Research Trends. Why Has Suicide Increased in Young Males? Keith Hawton

Transcription

1 Research Trends 119 Why Has Suicide Increased in Young Males? Keith Hawton Several countries in the Western hemisphere have experienced a marked increase in suicide rates in young males in recent years. This article considers this phenomenon largely from the perspective of the United Kingdom, where rates of suicide in year-old males nearly doubled in just over a decade. The possible reasons for this are considered, particularly in the context of relative stability of suicide rates in young females. Keywords: Suicide, deliberate self-harm, young males, prevention. Major changes in the patterns of suicide have occurred in recent years in several Western countries. The main trend has been toward an increase in suicide rates in young males. A marked change occurred in the USA between the 1960s to 1980s, with suicide rates in American males aged years nearly doubling during that timespan [Hollinger, 1989]. Rates in females in the same age group also increased, though to a lesser extent. Increased rates of suicide in young males have also been reported more recently from several European countries, including especially Portugal, Spain, and Greece [Pritchard, 1992]. This phenomenon has now also occurred in Australia [Kosky, 1987; Baume & McTaggart, 1998] and New Zealand [Skegg & Cox, 1991], the latter presently having the highest rate of suicide in year-olds in the world. This recent pattern has also been marked in the United Kingdom. Between 1980 and 1992, the suicide rate for year-old males in England and Wales increased by more than 80% [Hawton, 1992]. The rate for deaths from undetermined cause the majority of which are known to be suicides increased even more: by 100%. Combining both rates for suicide and deaths from undetermined cause ( open verdict ) revealed an overall rise of 86.3%. In contrast, the combined rates of suicide and undetermined deaths in year-old females changed very little over this period ( 5.5%). While suicide rates in young males have levelled off and even declined a little in the past three or four years [Kelly & Bunting, 1998], suicide is now the second most common cause of death in young males (after accidents). In fact, in a number of countries (e. g., Sweden) it is now even the leading cause of death in this age group. Suicide is rare under 15 years of age in the United Kingdom, although the extent to which deaths from suicide might be concealed by being given other verdicts (in this and other countries) must raise doubts about the accuracy of official statistics. Patterns of attempted suicide in the United Kingdom have shown similar changes with a very large recent increase in rates in young males [McLoone & Crombie, 1996; Bialas et al., 1996; Hawton et al., 1997]. Crisis, 19/3 (1998) 1998 Hogrefe & Huber Publishers

2 120 Research Trends In Oxford, for example, rates of deliberate self-harm in year-old males increased by 194.1% between 1985 and 1995, while rates in young females changed very little [Hawton et al., 1997]. In a study arising from the multicenter WHO: EURO Study on Parasuicide we showed that rates of attempted suicide and completed suicide in year-olds in individual centers and countries in Europe are correlated, particularly in males [Hawton et al., 1998]. Given the considerable risk of suicide after attempted suicide in the young [Otto 1972; Goldacre & Hawton, 1985], any changes in attempted suicide rates in the young can have serious implications for subsequent suicide rates. Before considering the possible explanations for these changes in suicide rates, we need to highlight the recognized factors to which changes in rates are usually attributed. These include societal factors such as war, population shifts, and socio-economic changes; variations in the availability of commonly used methods for suicidal acts also seem to be important. Suicidal behavior is strongly linked to psychiatric disorders, especially depression, so any changes in their population prevalence are also relevant. Exposure to suicide in others, either directly or via the media, genetic and biological factors are also known to be contributors to suicidal acts. The rest of this article is about possible reasons that might explain the rise in youth suicidal behavior, particularly suicide, with consideration of how these might operate given the gender differences noted above. Possible Reasons The focus of this article is primarily on the possible reasons for the increases in suicide and attempted suicide in young males in the United Kingdom. The term young will include both teenagers and people in their early twenties. Several possible explanations for the changing pattern of suicide have been suggested [Hawton, 1992], but at present there is no certainty about any of them. The following discussion is therefore largely speculative. When evaluating the explanations that have been suggested one should bear in mind the fact that young females have not shown this dramatic increase in rates. Thus, to be valid, explanatory factors must either have occurred to different extents in the two sexes or they have had very marked differential effects on males and females. Unemployment It has long been recognized that there are fairly strong statistical associations between rates of unemployment and rates of both suicide and attempted suicide [Platt, 1984; Platt & Kreitmen, 1984; Hawton & Rose, 1986; Hawton et al., 1988; Pritchard, 1992]. Yet, the nature of this association is unclear. While it seems unlikely that unemployment itself more than occasionally directly leads to suicidal behavior, there may be indirect casual links, perhaps via, for example, poverty, social deprivation, domestic difficulties, depression, and hopelessness. On the other hand, the statistical association may be explained by people at risk for suicidal behavior, especially those with chronic mental illness, being more likely to be unemployed. A recent case control study of serious suicide attempts in New Zealand questioned the role of unemployment in suicide: When other factors were controlled for, the statistical relationship between suicide attempt risk and unemployment became nonsignificant [Beautrais et al., 1998]. Also, there are difficulties in attributing the recent increase in suicide rates in young males in the United Kingdom to unemployment. Thus, while suicide rates rose steadily during the 1980s and early 1990s, the unemployment rate declined in the later 1980s. Furthermore, unemployment rates have also risen in females. One can argue with some justification, however, that the impact of unemployment on males may be somewhat different than on females, particularly in terms of its greater implications for the self-esteem and social standing of males and its effects on their families and domestic circumstances. The self-esteem of many young females may be less dependent on employment status and more related to other factors, such as personal relationships. Any relationship between suicide and occupational status may reflect not just unemployment, but also the increasing tendency in many young people for employment to be temporary and insecure, and for a lack of a clear career path. Uncertainty about future employment and work role may increase an individual s lack of sense of purpose, particularly in the face of other adverse factors. Crisis, 19/ 3 (1998)

3 Research Trends 121 Alcohol and Drug Abuse It is well-recognized that suicide risk is strongly associated with both alcohol [Murphy, 1992] and drug abuse [Fowler et al., 1986]. Furthermore, rates of both types of abuse have generally risen in young people, at least in the United Kingdom. However, the increase in substance abuse has occurred in both sexes. Substance abuse may be an increasing factor in young suicides but differentially affects the two sexes because of its interaction with other factors (e. g., differences between the two sexes in ability to seek help for emotional problems). In psychological autopsy studies of series of young suicides, substance abuse seems to be a more important factor in males [Martunnen et al., 1993]. This was also found in a recent major psychological autopsy study of young suicides in New York [Shaffer et al., 1996]. While depression was also common, interestingly this often appeared to be the result of substance abuse rather than the cause of it. A history of conduct disorder often preceded the substance abuse. Increased Availability of Methods Used for Suicide It is also well known that availability of methods for committing suicide affects suicide rates, the best example being the large decline in suicides in the United Kingdom paralleling the introduction of nontoxic North Sea gas during the 1960s [Kreitman, 1976]. Nowadays, car-exhaust poisoning is one of the two most frequent methods used for suicide by young men in the United Kingdom. Could the increased number of young car owners, especially males, plus the publicity about such deaths, be a partial explanation for the increased number of suicide deaths? The recent small downturn in suicide rates in young males in England and Wales might in part reflect the increase in the number of cars with catalytic converters [Kelly & Bunting, 1998]. There is evidence from Sweden that the introduction of catalytic converters can influence suicide rates [Öström et al., 1996]. The other most common method of suicide in the young in the United Kingdom is by hanging, a method that has increased in both genders and for which prevention is difficult. Recently attention has been paid to the significant number of deaths each year because of paracetamol self-poisoning [Gunnell et al., 1997], an overdose of paracetamol carrying a risk of liver damage. Paracetamol is very readily available in the United Kingdom. Legislation has been announced that will limit pack sizes from the summer of Our research team will be investigating whether this has any significant effects. In North America handguns are particularly important in youth suicide [Brent et al., 1991] but play only a small role in the United Kingdom except in certain occupational groups, especially farmers [Malmberg et al., 1997]. Nevertheless, recent legislation on firearm registration and storage may have had some impact on this method of suicide in England and Wales [Hawton et al., submitted for publication]. AIDS and HIV Infection Suicide rates are considerably elevated in people with AIDS and HIV infection [Marzuk et al., 1988; Pugh et al., 1993], although some of the increased risk may be explained by other factors, especially drug abuse. However, AIDS cannot have contributed greatly to the increase in male suicide rates because, first, the increase in rates began well before AIDS was recognized in 1984; and secondly, the number of AIDS-related suicides would have been far less than the increase in the number of male suicides that has actually occurred [Buehler et al., 1990]. Also, the increase in suicide rates in England and Wales in the 1980s was not particularly correlated with the main high prevalence HIV areas [Kelly & Bunting, 1998]. Media Exposure There is reasonable evidence that media portrayal of suicide can influence suicide in other people, especially in the young. The best example is where a major increase in railway suicides occurred in Germany following the double showing of a serial on TV in which a 19-year-old boy committed suicide on a railway [Schmidtke & Häfner, 1988]. This increase, which particularly affected young males, was not accompanied by a fall in the use of other methods of suicide. Evidence of imitation effects in the young following suicide portrayal on television has also been found in the USA [Gould & Shaffer, 1986]. Relatively little evidence has so far been found in the United Kingdom of an influence of media portrayal of self-poisoning on rates Crisis, 19/3 (1998)

4 122 Research Trends of deliberate self-poisoning [Platt, 1987; Simkin et al., 1995], although this has been subjected to less research than elsewhere. Nevertheless, the positive evidence from studies in other countries makes one concerned about the potential effects of dramatic reporting of actual suicides or media portrayal of fictional suicides on the suicide potential of vulnerable young people. However, apart from the study in Germany, there is little evidence to suggest that males might be more vulnerable to media influences than females. Family Breakdown This is relevant to risk of suicidal behavior in the young in two major ways. First, there are the possible longterm effects of parental marital breakdown on children. Thus, the rapid rise in rates of marital breakdown and divorce in recent years may have increased the vulnerability of today s young people to experience emotional difficulties and hence suicidal behavior [Dorpat et al., 1965; Bulusu & Alderson, 1984]. Second, the increased rate of breakdown of relationships in young people today may have contributed to their increased risk of suicide. A broken relationship is a common life event preceding both suicide and attempted suicide. Since broken relationships occur with equal frequency in males and females, how might one explain the fact that rates of suicide in young males are increasing while those in females remain relatively stable? A possible explanation is that the considerable social changes of the last two decades, particularly the liberation of females, have differently affected the relative vulnerability of males and females to the effects of broken relationships. Nowadays, for example, it is far easier for women to live independently than was the case in, say, the 1960s. Also, females are generally more able to seek and find support from other females when facing emotional difficulties, such as following a broken relationship, whereas many males may find this difficult. Increase in Psychiatric Disorders The association of suicide in young people with psychiatric disorders, especially depression, is well documented [e. g., Runeson, 1989; Martunnen et al., 1993; Brent et al., 1993; Shaffer et al., 1996] It is therefore of some relevance to the present discussion that there is evidence that an increase in youth and young adult rates of depression has occurred in recent years [Klerman, 1988]. Yet, the underlying reasons for this are unclear. There is some evidence of a decrease in the usual female to male gender difference in prevalence of depression [Klerman, 1988]. Male Reluctance to Seek Help An added factor that increases the vulnerability of many males to suicide is their relative reluctance to seek help when distressed. In studies of suicides, young people (mostly males) had contacted their general practitioners in the week before the death far less often than had older suicides [e. g., Vassilas & Morgan, 1993]. Of course, such data do not tell us about how many people sought help and were then prevented from committing suicide. Nonetheless, there is general agreement that reluctance to seek help is common in males, especially young men. One wonders to what extent the deinstitutionalization of psychiatry has left some young males (and females) with chronic mental disorders less protected than previously. Reduction in psychiatric hospital beds also means that hospitals have a much reduced capacity to provide crisis admission, which can be an important source of protection especially for males at times of high suicide risk. Greater Acceptability of Suicide as an Option An additional factor may be that suicide may have become a more acceptable option for young people. I know of no evidence to support this notion and certainly none to suggest that an altered gender difference in acceptability has occurred. Nevertheless, it is a possibility and one that perhaps warrants the attention of social scientists. Conclusion My personal belief is that the most likely explanation for the increase in suicide rates in young males lies in social changes, particularly in terms of perceived or actual reduction in role opportunities, which have differentially affected the relative vulnerability of males Crisis, 19/ 3 (1998)

5 Research Trends 123 and females to emotional difficulties; compounded by hopelessness, particular in response to other stress factors such as unemployment and broken relationships, with substance abuse and difficulty in help-seeking being additional contributory factors. There is, however, a pressing need for more research to unravel the explanatory factors and hence to enable preventive strategies to be developed on the basis of sound knowledge. This should consist of further psychological autopsy studies of young suicides, with a particular focus on social issues, together with sophisticated epidemiological studies. In other words, we now need a second generation of studies, such as that by Gould et al. [1996], to extend beyond facts such as the influence of mental illness and to try to identify other specific causal factors (including psychosocial characteristics) that contribute to the suicide process in the young. The extent to which this is feasible in studying actual suicides may be limited, and we now need to focus more on failed suicides where it should be possible to study the suicide process in more detail. References Baume P, McTaggart P. Suicide in Australia. In R J Kosky, HS Eshkevan, RD Goldney, R Hassan (eds), Suicide prevention: The global context. New York: Plenum Press, Beautrais AL, Joyce PR, Mulder RT. Unemployment and serious suicide attempts. Psychological Medicine 1998; 28: Bialas MC, Reid PG, Beck JH, Lazarus JH, Scorer PM, Routledge PA. Changing patterns of self-poisoning in a UK health district. Quarterly Journal of Medicine 1996; 89: Brent DA, Perper JA, Moritz G, Allman C, Friend A, Roth C, Schweers J, Balach L, Baugher M. Psychiatric risk factors for adolescent suicide: a case-control study. Journal of the American Academy of Child and Adolescent Psychiatry 1993; 32: Buehler J, Devine O, Berkelman R, Chevarley F. Impact of human immunodeficiency virus epidemic on mortality trends in young men, United States. American Journal of Public Health 1990; 80: Bulusu L, Alderson M. Suicides Population Trends 1984; 35: Dorpat T L, Jackson JK, Ripley HS. Broken homes and attempted suicide. Archives of General Psychiatry 1965; 12: Fowler RC, Rich CL, Young D. San Diego suicide study. II: Substance abuse in young cases. Archives of General Psychiatry 1986; 43: Goldacre M, Hawton K. Repetition of self-poisoning and subsequent death in adolescents who take overdoses. British Journal of Psychiatry 1985; 146: Gould MS, Fisher P, Parides M, Flory M, Shaffer D. Psychosocial risk factors of child and adolescent completed suicide. Archives of General Psychiatry 1996; 53: Gould M, Shaffer D. The impact of suicide in television movies: evidence of imitation. New England Journal of Medicine 1986; 315: Gunnell D, Hawton K, Murray V, Garnier R, Bismuth C, Fagg J, Simkin S. Use of paracetamol for suicide and non-fatal poisoning in the UK and France: Are restrictions on availability justified? Journal of Epidemiology and Community Health 1997; 51: Hawton K. By their own young hand. British Medical Journal 1992; 304:1000. Hawton K, Arensman E, Hultén A, Wasserman D, Schmidtke A, Bille-Brahe U, DeLeo D, Kerkhof A, Bjerke T, Crepet P, Haring C, Lönnqvist J, Michel K, Querejeta I, Phillipe I, Salander-Renberg E, Temesváry E. The relationship between attempted suicide and suicide rates among young people in Europe. Journal of Epidemiology and Community Health 1998; 52: Hawton K, Fagg J, Simkin S, Bale E, Bond A. Trends in deliberate self-harm in Oxford, , and their implications for clinical services and the prevention of suicide. British Journal of Psychiatry 1997; 171: Hawton K, Fagg J, Simkin S. Female unemployment and attempted suicide. British Journal of Psychiatry 1988; 152: Hawton K, Fagg J, Simkin S, Harriss L, Malmberg A. Methods used for suicide by farmers in England and Wales: The contribution of availability and its relevance to prevention. Submitted for publication. Hawton K, Rose N. Unemployment and attempted suicide among men in Oxford. Health Trends 1986; 18: Hollinger PC. Epidemiologic issues in youth suicide. In C Pfeffer (ed), Suicide among youth: Perspectives on risk and prevention. Washington DC: American Psychiatric Press, Kelly S, Bunting J. Trends in suicide in England and Wales Population Trends 1998; Summer: Klerman GL. The current age of youthful melancholia: evidence for increase in depression among adolescents and young adults. British Journal of Psychiatry 1988; 152:4 14. Kosky R. Is suicide increasing among Australian youth? Medical Journal of Australia 1987; 147: Kreitman N. The coal gas story: UK suicide rates British Journal of Preventative and Social Medicine 1976; 30: McLoone P, Crombie IK. Hospitalisation for deliberate self-poisoning in Scotland from 1981 to 1993: Trends in rates and types of drug used. British Journal of Psychiatry 1996; 169: Malmberg A, Hawton K, Simkin S. A study of suicide in farmers in England and Wales. Journal of Psychosomatic Research; 43: Martunnen M J, Aro HM, Lönnqvist J K Adolescence and suicide: A review of psychological autopsy studies. European Child and Adolescent Psychiatry 1993; 2: Marzuk P, Tierney H, Tardiff K, Gross EM, Morgan EB, Hsu M, Mann JJ. Increased risk of suicide in persons with AIDS. Journal of the American Medical Association 1988; 259: Murphy GE. Suicides in alcoholism. New York: Oxford University Press, Öström M, Thorson J, Eriksson A. Carbon monoxide suicide from car exhausts. Social Science and Medicine 1996; 42: Otto U. Suicidal acts by children and adolescents. Acta Psychiatrica Scandinavica 1972 (Supplement 233). Crisis, 19/3 (1998)

6