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1 Kent Aademi Repository Full text doument (pdf) Citation for published version Varnik, A. and Kolves, K. and van der Felz-Cornelis, Christina M and Marusi, Andrej and Oskarsson, H. and Palmer, Ann P. and Reish, Thomas and Sheerder, G. and Arensman, Ella and Aromaa, Esa and Giupponi, Gianarlo and Gusmão, Riardo and Maxwell, Margaret and Pull, Charles and Szekely, A. and Perez Sola, V. and Hegerl, Ulrih (2008) Suiide methods in Europe: a gender-speifi DOI Link to reord in KAR Doument Version UNSPECIFIED Copyright & reuse Content in the Kent Aademi Repository is made available for researh purposes. Unless otherwise stated all ontent is proteted by opyright and in the absene of an open liene (eg Creative Commons), permissions for further reuse of ontent should be sought from the publisher, author or other opyright holder. Versions of researh The version in the Kent Aademi Repository may differ from the final published version. Users are advised to hek for the status of the paper. Users should always ite the published version of reord. Enquiries For any further enquiries regarding the liene status of this doument, please ontat: researhsupport@kent.a.uk If you believe this doument infringes opyright then please ontat the KAR admin team with the take-down information provided at

2 Researh report Suiide methods in Europe: a gender-speifi analysis of ountries partiipating in the European Alliane Against Depression AVärnik, 1,2 KKõlves, 1 C M van der Feltz-Cornelis, 3 A Marusi, 4 H Oskarsson, 5 A Palmer, 6 T Reish, 7 G Sheerder, 8 E Arensman, 9 E Aromaa, 10 G Giupponi, 11 R Gusmäo, 12 M Maxwell, 13 C Pull, 14 A Szekely, 15 VPérez Sola, 16 U Hegerl 17 1 Estonian-Swedish Mental Health and Suiidology Institute, Estonian Centre of Behavioural and Health Sienes, Estonia; 2 Tallinn University, Estonia; 3 Trimbos-Instituut/Utreht and VU Medial Centre, Institute of Extramural Researh, Amsterdam, The Netherlands; 4 University of Primorska, Koper, Slovenia; 5 Diretorate of Health Campaign Against Depression and Suiide, Seltjarnarnes, Ieland; 6 Centre for Health Servies Studies, University of Kent, UK; 7 University of Bern, Department of Psyhiatry, Bern, Switzerland; 8 Katholieke Universiteit Leuven, LUCAS- Centre, Leuven, Belgium; 9 National Suiide Researh Foundation, Cork, Ireland; 10 Vaasa Central Hospital, Psyhiatri Unit, Vaasa, Finland; 11 S Maurizo Hospital Bolzano, Bozen, Italy; 12 Universidade Nova de Lisboa, Fauldade de Ciênias Médias, Lisbon, Portugal; 13 Department of Applied Soial Sienes, University of Stirling, UK; 14 Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg; 15 Semmelweis University Budapest, Institute of Behavioural Sienes, Budapest, Hungary; 16 Hospital de la Santa Creu i Sant Pau, Barelona, Spain; 17 University of Leipzig, Department of Psyhiatry, Leipzig, Germany Correspondene to: DrAVärnik, Estonian-Swedish Mental Health and Suiidology Institute, Õie 39, Tallinn 11615, Estonia; airiv@online.ee; airi.varnik@ipm.ki.se Aepted 13 July 2007 This paper is freely available online under the BMJ Journals unloked sheme, see jeh.bmj.om/info/unloked.dtl ABSTRACT Objetive: To identify the most frequent gender-speifi suiide methods in Europe. Design: Proportions of seven predominant suiide methods utilised in 16 ountries partiipating in the European Alliane Against Depression (EAAD) were reported in total and ross-nationally. Relative risk (RR) relating to suiide methods and gender was alulated. To group ountries by pattern of suiide methods, hierarhial lustering was applied. Setting and partiipants: Data on suiide methods for male and female ases in /5 from 16 EAAD ountries, overing 52% of European population were obtained. Results: Hanging was the most prevalent suiide method among both males (54.3%) and females (35.6%). For males, hanging was followed by firearms (9.7%) and poisoning by drugs (8.6%); for females, by poisoning by drugs (24.7%) and jumping from a high plae (14.5%). Only in Switzerland did hanging rank as seond for males after firearms. Hanging ranked first among females in eight ountries, poisoning by drugs in five and jumping from a high plae in three. In all ountries, males had a higher risk than females of using firearms and hanging and a lower risk of poisoning by drugs, drowning and jumping. Grouping showed that ountries might be divided into five main groups among males; for females, grouping did not yield lear results. Conlusions: Researh on suiide methods ould lead to the development of gender-speifi intervention strategies. Nevertheless, other approahes, suh as better identifiation and treatment of mental disorders and the improvement of toxiologial aid should be put in plae. An important task for researhers and publi health offiials is to seek effetive intervention strategies for suiide prevention. Studies about the methods of suiide in relation to different ultural, ethni, gender and age groups an provide useful information for developing effetive prevention and intervention programmes. 1 A review 2 examining effetiveness of speifi suiide-preventive interventions based on a omprehensive literature survey performed via eletroni searhes onsidered only two types of interventions as evidene based: eduating physiians to reognise and treat depression and restriting aess to lethal means. Methods that individuals hoose in suiide vary widely in their probability of resulting death. At least two general fators determine lethality by a partiular method. Firstly, the time span between the initiation of a suiidal at and expeted death is ruial for outome. Highly lethal suiide methods are fairly quik, reduing the possibility of detetion and intervention. Lethality is lower if the method hosen gives time for intervention, as well as the possibility of hanging one s mind and seeking help. Also ritial for outome is the availability of medial aid and its quality related to the method used. 3 Male suiide rates greatly exeeded female rates in all European ountries ( int/hfamdb/). Several studies have suggested that a primary reason for gender differenes in ompleted suiides is the result of differenes in methods used by the two groups. 4 7 A number of fators may influene an individual s deision regarding method in a suiide at. Hendin 8 attributes hoie of method to a form of final ommuniation of both personal and soial needs: a last message. He believes that this message is an expression of the life left behind and the individual s hopes to resolve the onflits that plagued him or her in life. Different methods yield mixed results in terms of lethality. Therefore, there is no single answer to the question whether method hoie an be used as a measure of suiidal intent. Similarly, a review of the literature reveals disparate onlusions. Some have found no signifiant gender differenes between the level of suiidal intent, others have argued that women tend to use less lethal methods beause they have less desire to kill themselves Gender differenes in the utilisation of suiide methods may depend on beliefs about ulturally aeptable gender-speifi self-destrutive behaviours. If ompleted suiide is viewed as a masuline behaviour, then an attempted suiide does not suit the men s role. Following this rationale, suiidal males ould hoose violent methods, as it would make them more likely to sueed in their ation. 9 Some attribute women s use of less violent methods to their onern for bodily appearane how they will look in death. The EAAD (European Alliane Against Depression), an international partnership of 16 European ountries, established in 2004, aims to redue suiide rates in partiipating ountries by implementing evidene-based ations and reating reommendations for effetive interventions. 13 The EAAD intervention onept is partly based on J Epidemiol Community Health 2008;62: doi: /jeh

3 Researh report Table 1 Suiide methods in absolute numbers and perentages by gender in EAAD ountries ombined through the years /5* Male Female Total No % No % No % Poisoning by drugs (X60 X64) Poisoning by other means (X65 X69) Hanging (X70) Drowning (X71) Firearms (X72 X74) Jumping (X80) Moving objet (X81) Other methods Total *Available years summarised. experienes of the Nuremberg Alliane Against Depression, a model projet that has been shown to be effetive in reduing the number of suiidal ats. 14 The epidemiologial data on methods of suiide gathered in the ourse of this projet provide an opportunity to ontribute to the field of suiide prevention. The present study reports the gender-speifi suiide methods in 16 ountries partiipating in the EAAD, ompares the results between ountries and makes efforts to group ountries with similar patterns of suiide methods. METHODS Data were olleted from 16 European ountries partiipating in the European Commission funded projet European Alliane Against Depression. The United Kingdom is represented in the study by two ountries: England and Sotland. In Belgium, Estonia, Finland, Germany, Hungary, Ieland, Italy (South Tyrol), Luxembourg, The Netherlands, Portugal, Sotland, Slovenia, Spain and Switzerland, the method used in a suiide at was identified aording to the odes X60-X84 by the tenth revision of international statistial lassifiation of diseases and related health problems (ICD-10; World Health Organization, 1992). In the following ountries, suiide ats were identified by ICD-9 (World Health Organization, 1978) odes E950-E959 for some or all of the study period: England in 2000, Portugal in and Ireland for the entire study period. As data on method-speifi suiide are not available through the WHO databank, the data were obtained from the appropriate statistis institutions of the EAAD ountries. Speifially, the responsible institutions that provided the data are Belgium, Flemish Ministry of Health in ooperation with the National Institute of Statistis (Statistis Belgium); Estonia, Statistis Estonia (Statistikaamet) England, South East Publi Health Observatory (SEPHO) Finland, Statistis Finland (Tilastokeskus) Germany, Information System of the Federal Health Monitoring (Gesundheitsberihterstattung des Bundes) www. gbe-bund.de; Hungary, Hungarian Central Statistial Offie; Ieland, Statistis Ieland Ireland, Central Statistis Offie (CSO) Ireland Italy (South Tyrol), Publi Health Offie of S Maurizo Hospital Bolzano (Servizio Igiene Ospedale S Maurizio Provinia di Bolzano); Luxembourg, (Ministère de la Santé) The Netherlands, Statistis Netherlands (Centraal Bureau voor de Statistiek) Portugal, Statistis Institute (Instituto Naional de Estatístia) Sotland, General Register Offie for Sotland Slovenia, Institute of Publi Health and the Statistial Offie of the Republi of Slovenia; Spain, National Statistis Institute (Instituto Naional de Estatistia) es; Switzerland, Swiss Federal Statistial Offie (Bundesamt für Statistik) The EAAD database ontains suiide deaths registered with the above mentioned institutions responsible for health statistis of partiipating ountries for the following years: in Estonia, Finland, Germany, Italy (South Tyrol ounty), Luxembourg, The Netherlands, Sotland and Spain, in in Belgium (Flemish Region, 59% of entire population), England, Hungary, Ieland, Ireland, Portugal, Slovenia and Switzerland. All suiide methods were re-ategorised into eight groups using all ICD-10 X-odes (table 1). The ategory other inludes methods that aounted for less than 3% of the overall number of suiides: explosive material (X75), fire (X76), hot vapours (X77), utting/piering with sharp objet (X78), utting/piering with blunt objet (X79), rashing of motor vehile (X82), with other speified and lassifiable means (X83) and other unspeified means (X84). Statistial analysis Statistial analysis was performed with SPSS 14.0 and StatsDiret To ompare male and female suiide methods, relative risks (RR) with 95% onfidene intervals in all studied ountries were alulated separately and in total. For grouping ountries by their distribution of suiide methods, standardised for Z-sores (the Z-sore reveals how many units of the standard deviation a ase is above or below the mean) separately by gender hierarhial lustering using Ward method was applied. This proedure attempts to identify relatively homogeneous groups of ases (ountries) based on seleted harateristis (suiide methods), using an algorithm that starts with eah ase in a separate luster and ombines lusters until only one is left (SPSS 14.0). The level of statistial signifiane was set at a = RESULTS This report is based on suiide ases, (74%) males and (26%) females, who ommitted suiide in 16 European ountries during the years /5. The most frequent suiide method for all studied EAAD ountries for both genders was hanging (54.3% among male and 35.6% among female suiidents ). For males, hanging was followed distantly and in almost equal plae by firearms (9.7%) and poisoning by drugs (8.6%). For females, poisoning by drugs (24.7%) and jumping from a high plae (14.5%) were the next most frequent methods (table 1). 546 J Epidemiol Community Health 2008;62: doi: /jeh

4 Researh report Table 2 Suiide methods in perentages in EAAD ountries by gender, annual means for the years /5 Poisoning by drugs Poisoning by other means Hanging Drowning Firearms Jumping Moving objet Other methods Belgium Males Females England Males Females Estonia Males Females Finland Males Females Germany Males Females Hungary Males Females Ieland Males Females Ireland Males Females Italy Males Females Luxembourg Males Females Netherlands Males Females Portugal Males Females Sotland Males Females Slovenia Males Females Spain Males Females Switzerland Males Females Total Males Females Hanging was the most frequent suiide method among males in all ountries exept in Switzerland, where firearms ranked first. Firearms were the seond most ommon suiide method among males in Belgium, Estonia, Finland, Germany and Slovenia. Use of firearms ranked lowest in Sotland (table 2). Hanging was the most ommon method among females in eight ountries: Belgium, Estonia, Germany, Hungary, Ireland, Netherlands, Portugal and Slovenia. Poisoning by drugs was the most frequent method for females in five ountries: England, Finland, Ieland, Sotland and Switzerland. Among females, jumping from a high plae ranked first in Italy (South Tyrol), Luxembourg and Spain (table 2). A omparison of male and female suiide methods showed that males have a statistially signifiantly higher risk than females of using firearms, hanging and poisoning by other means, and lower risk in poisoning by drugs, drowning and jumping (table 3). In all EAAD ountries, males had a higher risk of hanging than females. The situation was similar for firearms; only in Italy did the male-female differene not reah statistial signifiane. J Epidemiol Community Health 2008;62: doi: /jeh

5 Researh report Table 3 Relative risks by suiide methods in EAAD ountries omparing males to females Poisoning by drugs Poisoning by other means Hanging Drowning Firearms Jumping Moving objet Other methods Belgium RR 0.39* * 0.38* 3.20* 0.43* * 95% CI 0.33 to to to to to to to to 0.93 England RR 0.36* 2.54* 1.52* 0.46* 6.39* 0.73* * 95% CI 0.34 to to to to to to to to 1.69 Estonia RR 0.17* * 0.16* 5.14* 0.31* u{ % CI 0.10 to to to to to to to 2.35 Finland RR 0.34* 4.91* 1.61* 0.38* 11.68* 0.72* * 95% CI 0.32 to to to to to to to to 2.03 Germany RR 0.35* 1.32* 1.45* 0.29* 8.02* 0.55* * 95% CI 0.34 to to to to to to to to 0.90 Hungary RR 0.26* 0.77* 1.54* 0.31* 7.39* 0.52* % CI 0.24 to to to to to to to to 1.31 Ieland RR 0.50* * 0.38* u{ 1.97 u{ % CI 0.32 to to to to to to 4.77 Ireland RR 0.28* 2.31* 1.80* 0.63* 4.00* 0.51* 0.41* % CI 0.23 to to to to to to to to 2.31 Italy RR * 0.41* * % CI 0.12 to to to to to to to to 6.51 Luxembourg RR 0.34* * * 0.52* % CI 0.21 to to to to to to to to 1.80 Netherlands RR 0.44* 1.50* 1.43* 0.62* 8.67* 0.76* % CI 0.40 to to to to to to to to 1.36 Portugal RR 0.23* 0.61* 1.66* 0.33* 4.63* 0.49* % CI 0.17 to to to to to to to to 1.22 Sotland RR 0.38* 6.15* 1.69* 0.60* 19.47* % CI 0.34 to to to to to to to to 1.48 Slovenia RR 0.26* * 0.19* 11.62* 0.39* 0.42* % CI 0.18 to to to to to to to to 1.34 Spain RR 0.41* 0.68* 1.79* 0.57* 7.19* 0.49* 1.25* 0.86* 95% CI 0.36 to to to to to to to to 0.96 Switzerland RR 0.35* 1.46* 1.42* 0.30* 9.37* 0.62* 0.70* % CI 0.32 to to to to to to to to 1.36 Total RR 0.35* 1.26* 1.53* 0.39* 7.22* 0.54* % CI 0.33 to to to to to to to to 1.04 *p,0.05; {unalulable. Females more often used poisoning by drugs than males in all ountries. It was only in Italy that the higher risk of female poisoning by drugs was not statistially signifiant. Similarly, drowning was more ommon in females than in males in all ountries exept in Luxembourg. Females also had a higher risk of jumping than males, exept in Ieland. Other suiide methods varied by ountry (table 3). Grouping with hierarhial lustering using the Ward method showed that ountries might be divided into five main groups by suiide methods among males. The first group (Estonia, Slovenia, Hungary) had a very high proportion of hanging and low proportions of drowning and using a moving objet as a mean. The seond group (Finland and Switzerland) had the highest proportion of using firearms and the lowest of hanging in omparison with other ountries; also poisoning by drugs was above average. The third group (Germany, Belgium and The Netherlands) had average proportions of hanging and poisoning by drugs. In ountries in the fourth group (England, 548 J Epidemiol Community Health 2008;62: doi: /jeh

6 Researh report Sotland and Ieland), the proportion of poisoning by drugs was higher than in other ountries and poisoning with other means was above average. The fifth group (Italy, Spain, Luxembourg and Portugal) had a high proportion of jumping along with a low proportion of using a moving objet. Italy, Portugal and Spain also had low perentages of poisoning by drugs. Ireland ould not be grouped with any other ountries owing to its high proportion of drowning. For females, grouping with hierarhial lustering divided ountries into three triplets and three pairs. The first luster onsisted of England, Sotland and Hungary whih all had high proportions of poisoning by drugs, low perentages of jumping and below average proportions of drowning. The seond luster, Germany, Slovenia and The Netherlands, was similar to the overall average. Estonia had a very high proportion of hanging and very low proportions of drowning and use of a moving objet, onsequently Estonia ould not be grouped with any other ountries. Finland and Switzerland eah had high perentages of poisoning by drugs and low proportions of hanging. Belgium and Ireland had high proportions of drowning and low proportions of jumping. Italy, Luxembourg and Spain had very high proportions of jumping and low proportions of hanging. The last pair, Ieland and Portugal, ranked above average in drowning and low in the use of a moving objet. Hanging was ranked below average. DISCUSSION Methodologial onsiderations The present study is, to our knowledge, the first multisite epidemiologial examination of X-oded deaths in Europe desribing, omparing and analysing the pattern of the seven most frequent suiide methods by sex in 16 European ountries representing inhabitants, or 52% of the European population (Commonwealth of Independent States not inluded; The data reported is based on the average of five to six reent years. This reporting sheme eliminates temporary flutuations essential to small numbers harateristi of suiide mortality, partiularly when divided by gender and suiide methods. One of the limitations of the study was that two different lassifiations of auses of death were overed: in England, Ireland and Portugal the 9th revision of the ICD was used, whih was replaed by X-oded death using ICD-10 in the other ountries. To verify that the EAAD sample ould represent the whole of Europe in terms of suiide mortality, the average annual ageadjusted suiide rates between the years were ompared. For EAAD ountries ombined suiide rates 16.3 for males and 5.0 for females was lower against suiide mortality of the whole of Europe (Commonwealth of Independent States inluded) 28.9 for males and 6.1 for females. The respetive age-adjusted rates for 15 European Union member states (until 1 May 2004) 16.0 for males and 5.0 for females (average for ) were similar to that of the average of the EAAD ountries ombined. With respet to individual ountries, there were several ountries that were limited by non-representative samples: Belgium was represented only by the Flemish region and Italy was represented only by South Tyrol County. Also, two regions were reported separately in the United Kingdom. As England and Sotland are two separate sites in the EAAD study, they are reported here with aution as two separate ountries. To test the reliability of data obtained by EAAD partner ountries, male and female suiide numbers were ompared to WHO data in the European Mortality Database. There was agreement between the WHO data and the EAAD ompiled data in Estonia, Finland, Germany, Hungary, The Netherlands, Portugal, Slovenia and Spain. For ites where a region, rather than the whole ountry was studied (Belgium, Italy, England and Sotland), data were not omparable with WHO data. There were some notable differenes between EAAD and WHO data. The EAAD data for Ireland was 8.5% and for Luxembourg 1.8% higher than the WHO data. In ontrast, the EAAD data from Ieland and Switzerland were lower 2.9% and 0.5% respetively. Male and female suiide methods Although ompleted suiide rates are generally muh higher in men than in women with the exeption of some Asian ountries, there are more suiide attempts registered for females by the WHO/EURO Multientre Study in most of the partiipating ountries, 16 and muh more diagnosed depression in women relative to men This gender paradox alls into question the possible reasons for different prevalene rates in male-female ompleted suiides Several studies have addressed the issue of different patterns of methods used in male and female suiide populations as the primary reason for gender differenes in suiide mortality. Traditionally, women have seleted suiide methods that are less lethal and men have hosen tehniques that are more violent and whose onsequenes are irreversible. Spier et al 7 revealed that firearms, drowning and suffoation/ hanging were the most lethal methods and drug overdose/ poison ingestion and utting/piering were the least lethal methods. In Card s lassifiation, 21 in addition to the above mentioned methods jumping from a high plae and jumping in front of a moving objet were added to the highly lethal methods. Card qualified the use of fire as a less lethal suiide method. The present study found hanging to be the most predominant method of suiide in all EAAD ountries ombined. In fat, 54.3% of males and 35.6% of females in our study died from hanging. As hanging is universally available, it makes sense that it is the most ommon suiide method in many ountries worldwide 22 ; however, there is onsiderable variability internationally. A study of suiide methods in a large number of ases in Japan and the United States revealed that Japan had a very high proportion of hanging (70.4% for males and 60% for females); this proportion was muh lower (18.2% for males and 16.2% for females) in the United States. 23 Similarly, an Australian study reported hanging in 32% of its ases. 24 Hanging and self-poisoning with pestiides were the preferred means of suiide in south India. 25 Self-poisoning (X60 X69) ranked as the seond highest suiide method for both males (14.0%) and females (29.0%) in EAAD ountries ombined. In the EAAD this usually meant poisoning by drugs that is, mediation (X60 X64), in ontrast to worldwide trends, whih show that self-poisoning by pestiides is the frequently used method among other poisonings (X65 X69) in many Asian, Afrian and Latin Amerian ountries, aounting in rural areas for about a third of all suiides worldwide. 1 In fat, in rural China pestiide ingestion aounts for 58% of all suiides and aounts for 79% of all suiides among young females in rural areas. 26 Firearms, a highly lethal method, ranked the third among males (9.7%) and were rarely used among females (1.3%) in EAAD ountries ombined. In the United States, respetive proportions were muh higher 63.1% and 37.2%. 23 An J Epidemiol Community Health 2008;62: doi: /jeh

7 Researh report Australian study 24 reported the use of firearms in 22% of total suiides. In Japan 23 and China 27 the use of firearms as a means of suiide was rare. The literature on this topi shows that limiting aess to firearms has been found to be an effetive mean of reduing suiide mortality. Notwithstanding the similar rank order of suiide methods among males and females ombined, males had a 7.2 times higher risk of using firearms and a 1.5 times higher risk of hanging than females, while poisoning by drugs and drowning were methods predominated by females. Remaining methods had different male-female dominane in different ountries. Considering the lassifiation systems of Spier et al 7 and Card, 21 in European ountries males had a higher risk of using more lethal methods like hanging and firearms than females. What is already known on this subjet Two types of interventions by omprehensive overview of Mann et al 2 were proved to be evidene based in suiidepreventive interventions: eduating physiians to reognise and treat depression and restriting aess to lethal means. From studies of the previous literature hoie of method differs by gender and is influened by availability, lethality and aeptability. To our knowledge there are no reent data published for Europe on suiide methods. Analysis of methods is needed to elaborate effetive ollaborative suiide prevention strategies. Grouping ountries There was a strong similarity between Hungary, Slovenia and Estonia, based on very high shares of hanging both for males and females. In an effort to find an explanation, we note the following ommon features: reent soialist bakgrounds, rapid soio-politial and eonomi hanges in integrating into the European Union, very high alohol onsumption, high rates of alohol dependene and abuse among suiidents and high overall suiide rates. Referring to the luster analysis of male suiide methods, exluding the former Eastern blok ountries (Estonia, Hungary and Slovenia) and Finland and Switzerland, the remaining groups of ountries appear, at the first glane, to be similar in suiide methods by geographi proximity. In northwest Europe (England, Sotland and Ieland), high proportions of poisoning by drugs were found. Central Europe (Belgium, Germany and The Netherlands) was lose to the EAAD average onerning most methods and southern Europe (Italy, Portugal, Spain, inluding also Luxembourg) was haraterised by a very high proportion of jumping. Ireland ould not be grouped beause of the extremely high level of drowning. It was surprising to find an almost ongruent pattern of suiide methods for both genders in Switzerland and Finland haraterised by high rates of poisoning by drugs and firearms and also low proportions of hanging. Suh ommonalities were not present in females and female lusters were not identifiable. Prevention possibilities The high rate of hanging plaes onsiderable limitations on the redution of suiides through method restrition exept in institutional settings De Leo et al 24 assoiated hanging with having low impulse ontrol, being in short-term, suiidal risis and reeiving past or urrent psyhiatri treatment. They alled for further investigations to develop a deeper understanding of hanging and to develop appropriate prevention methodologies. Cantor and Baume 34 also pointed out that little researh has examined hanging and suggested hanging might be influened by hanging publi pereptions of the soial aeptability of suiide by hanging Self-poisoning, as a potentially preventable method, should be the topi of further investigations regarding the promotion of suiide prevention poliy. X-lassifiation offers the opportunity to assess the use of self-poisoning as a suiide method. A ross-setional global publi health initiative with the overall goal of reduing morbidity and mortality related to pestiide poisoning has been announed by the WHO. 1 Selfpoisoning by drugs aounts for one fourth of female deaths in EAAD ountries and in some of the ountries almost a half of What this study adds The database of the present study ontains unique information about suiide methods employed during reent years in 15 ountries overing 52% of the European population. This paper, the first in a series of artiles in preparation, gives a gender-speifi overview and ompares suiide methods used in total and ross-nationally. In the European ountries studied ombined hanging and firearms were most prevalent for male suiides, while hanging and poisoning by drugs was ommon for females. However, there were differenes in the distribution of suiide methods between the ountries and groups of ountries, whih enhanes our understanding of suiide and provides the opportunity to develop prevention strategies. Poliy impliations Researh on suiide methods, taking into aount best praties in restrition of means, ould lead to the development of effetive intervention strategies. female suiides. As suh, self-poisoning deserves attention and the appliation of best praties in the field. There are remarkably few papers on suiide prevention addressing gender issues on method hoie. 37 Identifying and omparing patterns of methods of suiides used in different ountries by gender ould lead to the development of intervention strategies. The present study identifies groups of ountries with similar patterns of suiide methods by gender and enourages the researh and development of ollaborative suiide prevention strategies. Nevertheless, ontrol of aess to methods is but one of the strategies for suiide prevention. Other approahes, suh as better identifiation and treatment of mental disorders and the improvement of toxiologial aid, should be put in plae. Further analysis of other soiodemographi orrelates is warranted, partiularly the age distribution of the utilisation of suiide methods and a detailed analysis of poisoning by drugs as a preventable method to omplete suiide. Funding: The European Alliane Against Depression is funded by the European Commission, publi health exeutive ageny, grant number , by the Estonian Sientifi Foundation grants no 6799, The role of alohol in the suiide proess and in 550 J Epidemiol Community Health 2008;62: doi: /jeh

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