Tuesday, March 13, 2012

Suicide attempts and sex

Another topic to research. It seems it is understood that while men kill themselves more often than women, women do attempt suicide more often. Using what some redditor found I look a bit into the numbers. Mostly CDC data though:

Suicidal Thoughts and Behaviors Among Adults Aged ≥18 Years --- United States, 2008-2009 - CDC

The National Survey on Drug Use and Health (NSDUH) is a national- and state-level survey of a representative sample of the civilian, noninstitutionalized U.S. population aged ≥12 years. NSDUH collects data on health-risks related to the use of illicit drugs, alcohol, and tobacco; initiation of substance use; substance use disorders and treatment; health care; and mental health. This report summarizes data on responses to questions concerning suicidal thoughts and behaviors contained in the mental health section among sampled persons aged ≥18 years in all 50 states and the District of Columbia. This report analyzes data on the prevalence of suicidal thoughts, planning, and attempts by age, sex, race/ethnicity, and state from 92,264 respondents in the 2008 and 2009 NSDUH.

[...] An estimated 2.2 million (annual average) adults in the United States (1.0% of the adult U.S. population) reported having made suicide plans in the past year. [...] The prevalence of suicidal thoughts was significantly higher among females than it was among males, but there was no statistically significant difference for suicide planning or suicide attempts.

[...]During 2008-2009, an estimated 3.8 million (annual average) adult males in the United States had suicidal thoughts in the past year (3.5% of the adult male population). Among males, the prevalence ranged from 1.3% in Mississippi to 7.1% in Rhode Island. During 2008-2009, an estimated 4.6 million (annual average) female adults in the United States (3.9% of the adult female population) had suicidal thoughts in the past year. Among adult females, prevalence ranged from 1.5% in Georgia to 9.1% in Nevada.

[...]During 2008-2009, an estimated 1.0 million (annual average) adult males in the United States (1.0% of the adult male population) made suicide plans in the past year. Among males, prevalence ranged from 0.1% in Georgia to 4.1% in Rhode Island. During 2008-2009, an estimated 1.2 million (annual average) adult females in the United States (1.0% of the female population) made suicide plans in the past year. Among females, prevalence ranged from 0.1% in Georgia to 3.1% in Nevada.

[...]During 2008-2009, an estimated 442,000 (annual average) adult males in the United States (0.4% of the adult male population) attempted suicide in the past year. Among males, prevalence ranged from <0.1% in Alaska, the District of Columbia, and Georgia to 2.2% in Rhode Island. During 2008-2009, an estimated 616,000 (annual average) adult females in the United States (0.5% of the adult female population) attempted suicide in the past year. Among females, prevalence ranged from <0.1% in Montana and Virginia to 1.3% in Connecticut.

According to this, not a huge difference between men and women, there is however other data and it might be the lifetime rate that is very different:

Suicide Facts at a Glance - CDC

• More than 34,000 suicides occurred in the U.S. This is the equivalent of 94 suicides per day; one suicide every 15 minutes or 11.26 suicides per 100,000 population.1
• Males take their own lives at nearly four times the rate of females and represent 78.8% of all U.S. suicides.1
• During their lifetime, women attempt suicide about two to three times as often as men.5
• Suicide is the seventh leading cause of death for males and the fifteenth leading cause for females.1
• Suicide rates for males are highest among those aged 75 and older (rate 36.1 per 100,000).1
• Suicide rates for females are highest among those aged 45-54 (rate 8.8 per 100,000 population).1
• Firearms are the most commonly used method of suicide among males (55.7%).1
• Poisoning is the most common method of suicide for females (40.2%).1

In 2009:
• 13.8% of students in grades 9-12 seriously considered suicide in the previous 12 months (17.4% of females and 10.5% of males).4
• 6.3% of students reported making at least one suicide attempt in the previous 12 months (8.1% of females and 4.6% of males).4
• 1.9% of students had made a suicide attempt that resulted in an injury, poisoning, or an overdose that required medical attention (2.3% of females and 1.6% of males).4

1. Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. (2010). National Center for Injury Prevention and Control, CDC (producer). Available from URL: www.cdc.gov/injury/wisqars/index.html.
4. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance—United States, 2009. Surveillance Summaries, June 4. MMWR 2010; 59(No. SS-5).
5. Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R, editors. World report on violence and health. Geneva: World Health Organization; 2002.

Now this is confusing. While most of the data is CDC data, the only data that shows us a huge difference between attempts is by the WHO. So let us look at that:

World report on violence and health - WHO - Etienne G. Krug, Linda L. Dahlberg, James A. Mercy, Anthony B. Zwi and Rafael Lozano - 2002 / Chapter 7 - Self-directed Violence

Also, as a general trend, rates of non-fatal suicidal behaviour tend to be 2–3 times higher in women than in men. Finland, though, is a remarkable exception to this pattern (35). [...] There is evidence that women, including those in old age, are more prone to suicidal thoughts than are men (37). Overall, the prevalence of suicidal ideation among older adults of both sexes has been estimated at between 2.3% (for those having had suicidal thoughts in the past 2 weeks) and 17% (for those ever having had suicidal thoughts) (38). However, compared with other forms of suicidal behaviours, such as attempted suicide, suicidal ideation may not be a useful indicator of which adolescents or adults are most in need of preventive services.

35. Schmidtke A et al. Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatrica Scandinavica, 1996, 93:327–338.
37. Linden M, Barnow S. The wish to die in very old persons near the end of life: a psychiatric problem? Results from the Berlin Ageing Study (BASE). International Psychogeriatrics, 1997, 9:291–307.

Hopping from study to study:

Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989-1992. Results of the WHO/EURO Multicentre Study on Parasuicide. - Schmidtke A, Bille-Brahe U, DeLeo D, Kerkhof A, Bjerke T, Crepet P, Haring C, Hawton K, Lönnqvist J, Michel K, Pommereau X, Querejeta I, Phillipe I, Salander-Renberg E, Temesváry B, Wasserman D, Fricke S, Weinacker B, Sampaio-Faria JG. - Psychiatric Department, University of Wuerzburg, Germany.

The World Health Organization/EURO Multicentre Project on Parasuicide is part of the action to implement target 12 of the WHO programme, "Health for All by the Year 2000', for the European region. Sixteen centres in 13 European countries are participating in the monitoring aspect of the project, in which trends in the epidemiology of suicide attempts are assessed. The highest average male age-standardized rate of suicide attempts was found for Helsinki, Finland (314/100,000), and the lowest rate (45/100,000) was for Guipuzcoa, Spain, representing a sevenfold difference. The highest average female age-standardized rate was found for Cergy-Pontoise, France (462/100,000), and the lowest (69/100,000) again for Guipuzcoa, Spain. With only one exception (Helsinki), the person-based suicide attempt rates were higher among women than among men. In the majority of centres, the highest person-based rates were found in the younger age groups. The rates among people aged 55 years or over were generally the lowest. For the majority of the centres, the rates for individuals aged 15 years or over decreased between 1989 and 1992. The methods used were primarily "soft' (poisoning) or cutting. More than 50% of the suicide attempters made more than one attempt, and nearly 20% of the second attempts were made within 12 months after the first attempt. Compared with the general population, suicide attempters more often belong to the social categories associated with social destabilization and poverty.

The rest was behind a paywall. Luckily, another study which is available online used the same data:

Relation between attempted suicide and suicide rates among young people in Europe - K Hawton, E Arensman, D Wasserman, A Hultén, U Bille-Brahe, T Bjerke, P Crepet,
E Deisenhammer, A Kerkhof, D De Leo, K Michel, A Ostamo, A Philippe, I Querejeta, E Salander-Renberg, A Schmidtke, B Temesváry - 1998

Study objective—To determine if there are associations between rates of suicide and attempted suicide in 15–24 year olds in different countries in Europe. Design—Attempted suicide rates were based on data collected in centres in Europe between 1989 and 1992 as part of the WHO/EURO Multicentre Study of Parasuicide. Comparison was made with both national suicide rates and local suicide rates for the areas in which the attempted suicide monitoring centres are based.
Setting—15 centres in 13 European countries. Patients—Young people aged 15–24 years who had taken overdoses or deliberately injured themselves and been identified in health care facilities. Main results—There were positive correlations (Spearman rank order) between rates of attempted suicide and suicide rates in both sexes. The correlations only reached statistical significance for male
subjects: regional suicide rates, r = 0.65, p < 0.02; national suicide rates, r = 0.55, p < 0.02. Conclusions—Rates of attempted suicide and suicide in the young covary. The recent increase in attempted suicide rates in young male subjects in several European countries could herald a further increase in suicide rates. [...] Attempted suicide was defined according to the proposed ICD-10 definition: “An act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences”. [...] Why should the association between suicide and attempted suicide in 15–24 year olds be stronger in male than female subjects? The findings must be interpreted against a background of generally much higher rates of attempted suicide in young female subjects than male subjects and the reverse for suicide. One reason is that the motivation, especially suicidal intent, involved in suicide attempts by young male subjects may show some differences from that of young female subjects, with the behaviour by male subjects being more clearly related to suicide in the sense of showing higher suicidal intent.12 On the other hand, such acts by female subjects often involve lower suicidal intent and are more usually associated with motives such as communication of despair and influencing others. A second reason is that the risk of suicide after attempted suicide in the young is much greater in male subjects than female subjects.13 14 References: 12 Bancroft JHJ, Skrimshire AM, Simkin S. The reasons people give for taking overdoses. Br J Psychiatry 1976;128: 538–48. 13 Otto U. Suicidal acts by children and adolescents. Acta Psychiatr Scand 1972;suppl 233. 14 Goldacre M, Hawton K. Repetition of self-poisoning and subsequent death in adolescents who take overdoses. Br J Psychiatry 1985;146:395–8.

Notice how wide the definition of attempted suicide is (causing self-harm instead of causing, well, death) and how the suicidal intend for men seem to be higher. Despite that, it is questionable how much relevance a 20 year old study from Europe that is not based on a randomized sample has for the USA. I am a bit surprised that the CDC cited it at all. Well maybe they did not correct their fact sheet after their recent survey.

To cite a relevant Science Daily article:

Why Women Are Less Likely Than Men To Commit Suicide

ScienceDaily (Nov. 12, 1998) — Many studies have identified a strong link between suicide and diagnosable mental illness, especially depression. So because women suffer from depression at a much higher rate than men, they would seem to be at higher risk for suicide. But women actually commit suicide about one-fourth as often as men.

Writing in the journal Comprehensive Psychiatry, George E. Murphy, M.D., an emeritus professor of psychiatry at Washington University School of Medicine in St. Louis, says that women may be protected because of the way they think about problems and interact with others.
"Women process their experiences with friends. They discuss their feelings, seek feedback and take advice," Murphy says. "They are much more likely to tell a physician how they feel and cooperate in the prescribed treatment. As a result, women get better treatment for their depression."
That treatment may help protect them from suicide, but Murphy says there is more to it. The approach to problem-solving is what lands a woman in a psychiatrist's office in the first place. And that approach may be keeping female suicide rates lower than those of men.

Suicide vs. attempted suicide
There are roughly 30,000 suicides in the United States each year, and three-fourths of those are men. But the number of attempted suicides is at least 10 times that, and even that estimate may be low because many suicide attempts are euphemistically classified as lacerations or accidental poisonings when patients receive treatment in hospital emergency rooms.
Although suicide rates are lower among women, women lead men two to one in suicide attempts. So, Murphy says at least 200,000 women are involved in suicide attempts annually. But he points out that attempted suicide most often is not an attempt to actually end one's life. Its purpose, he says, is to survive with changed circumstances.
"An attempted suicide is not really an attempt at suicide in about 95 percent of cases. It is a different phenomenon. It's most often an effort to bring someone's attention, dramatically, to a problem that the individual feels needs to be solved. Suicide contains a solution in itself," he says.
In attempted suicide, both men and women tend to use methods that allow for second thoughts or rescue. Murphy says that when people intend to survive, they choose a slowly effective, or ineffective, means such as an overdose of sleeping pills. That contrasts to the all-or-nothing means like gunshots or hanging used by actual suicides.
In the past, researchers who looked at the high rate of attempted suicide in women concluded that women were just not as efficient as men at taking their own lives. Murphy calls that "sexist baloney" and points to statistics that show that like men, women who commit suicide most often use guns. However, even as the number of women using the most lethal means increases, the suicide rate in women has slowly declined.
"So it really goes back to the same thing -- that women, when they intend to do it, can be just as effective as men in committing suicide. But they aren't so inclined," Murphy says.

Cognitive differences
Murphy believes women are less inclined to commit suicide because their thinking is more inclusive. While a man might tend to throw aside seemingly peripheral issues to get to the core of a problem, a woman might take more things into account. She may continue to seek input and process problems long after the point where men decide on a course of action.
"She'll consider not just her feelings but also the feelings of others -- her family, the children, even acquaintances, and how those people will be affected by a decision like suicide," Murphy says. "A man is much less likely to take those things into account. He makes his decision, and it's about him, so he doesn't feel the need to share it with anyone else."
But before they ever get to the point of considering suicide, Murphy says, women are much more likely to seek help with their problems. The classic example is asking for directions when driving. Many men refuse to do that, perhaps seeing it as an admission of weakness. They believe they are supposed to be competent in all areas. Because they are not, they are at risk. Women, on the other hand, are much more likely to seek advice and take it.
Even though depressed or alcoholic men are less likely to look for help, it still may be possible to prevent many suicides, Murphy believes. He says alert physicians might be able to pick up on risk factors and refer men into treatment to help them look for ways to solve their problems without ending their lives.
"Half of all people who commit suicide have seen a physician within a month of their fatal act," he says. "Mostly they didn't get diagnosed, and if they did, they didn't get treated very vigorously."
That requires recognition that depressed men may understate their pain or their difficulty with a particular problem. Murphy says such recognition is essential if men are ever to benefit from the treatments that protect women from suicide. Murphy and the late Eli Robins, M.D., conducted the first comprehensive study of suicide 40 years ago, studying every suicide that occurred in St. Louis and St. Louis County during a one-year period.

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