Scand J Soc Med, Vol. 20, No.2

Suicide among young people aged 10-29 in Sweden A. Hulten' and D. Wasserman/ J Department of Child and Adolescent Psychiatry, Giivle Hospital, S-803 28 Giiv!e, Sweden and lDepartmellt of Psychiatry, Karolinska Institute, Huddinge University Hospital, S-141 86 Huddinge, and Centre for Silicide Research and Prevention, Stockholm County Council, Karolinska Hospital, Sweden

Silicide among young people aged 10-29 ill Sweden. Hulten, A., Department of Child and Adolescent Psychiatry, Gavle Hospital, S-803 28 Gavle, Sweden and Wasserman, D., Department of Psychiatry, Karolinska Institute, Huddinge University Hospital, S-141 86 Huddinge, and Center for Suicide Research and Prevention Stockholm County Council, Karolinska Hospital, Sweden. Scam! J Soc /lied 1992, 2 (65-72).

This study analyses the incidence of suicide among children and young people aged between 10 and 29 in Sweden, during the period 1974-1986. The study comprises 4,624 individuals whose deaths were the outcome of verified, E95Q-E959 (II = 3,511) and undetermined, E98Q-E989 (II = 1,113) suicides. Regression analysis of different age groups separately and all age groups combined shows that the frequency of suicide among children and young people in Sweden did not increase in this period. Nonetheless, mortality figures are high, especially for boys and young men aged 15-29. The maximum suicide-mortality rate (43.2 per 100,000) is noted for young men aged 25-29 in 1984. The male-female ratio with respect to deaths from suicide is 2.5 for the entire group, the smallest difference being in the 15-19 age group (1.7) and the largest in the 25-29 age group (2.8). Methods of committing suicide vary between the sexes and the various age groups. Boys and young men use violent methods more often, and this situation has remained stable throughout the 13-year period. Girls use non-violent methods to a greater extent, but young women aged 18-29 use violent and non-violent methods to almost the same extent. During the 13-year period studied, a change took place in the girls' and young women's choice of methods towards more violent methods in the 1980scompared with the 1970s. Regardless of sex, there are significantly (p < 0.001) fewer married and more divorced people among those committing suicide compared with corresponding age groups in the overall population. Key words: suicide, children, adolescents, young people, trends, methods, marital status, Sweden, 1974-1986.

INTRODUCTION The incidence of suicide rose in several Western European countries during the period 1972-1982 (1). Platt (2) reports, in a survey of suicide trends in 24 European countries between the years 1972-73 and 1983-84, that most of the countries showed ris-

ing suicidemortality rates for men of all age groups between 15 and 54 and for women in the 25-34 age group. An investigation in the USA covering the years 1961-1975 (3) shows suicide to be the leading cause of death after accidents and homicide for the 15-24 age group. A 1978 survey duplicates this finding (4). In England and Wales, an increase in suicide mainly among boys aged 15-19, but also among girls aged 10-14 - emerged from a comparison between trends in 1941-50 and 1971-80 (5). In Belgium, a rise in suicides after 1970 was shown among males in the 20-24 age group (6). Norway, where the suicide rate was previously low, has witnessed a fivefold increase with respect to the 15-24 age group over the past two decades and is now on a par with Sweden and Denmark (7-9). According to a Finnish survey by Lonnqvist & Kotila, the incidence of suicide is especially high among boys aged 15-19 (10). Hansen & Wang also report high figures for suicide attempts and suicides among young people in Denmark (11). Very few children under the age of 10 commit suicide in Sweden. With advancing age, however, suicide becomes more frequent, especially among boys and young men aged 15-29. After road accidents and cancer, suicide is the most common cause of death for boys and young men in this age group (12). A study of birth cohorts of all people born in Sweden between 1877 and 1966 who committed suicide in the period 1952-1981 shows that, for men aged 20-24, the risk of suicide has increased 3.6 times (13)_ On the other hand, Barraclough reports (14) that the annual suicide rates in 70 member states of WHO show a reasonable consistency over the period 1972-1984 in the 15-24 age group. It is therefore of interest to investigate the current suicide trend for young people in Sweden. Scand J Soc Med 20

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66

A. HIIllell

The purpose of this investigation is to carry out a statistical analysis of the suicide frequency among children and young people aged 10-29 in Sweden during the period 1974-1986, in order to determine whether the upward trend is continuing. This review is envisaged as an introductory survey, to be followed up by a detailed examination of the contacts of this group with psychiatric in-patient care and their psychiatric morbidity and diagnoses, their suicidal communication and the assistance provided by the health services to young people on the verge of suicide. QUESTIONS The following questions are elucidated in this survey. (1) How did the frequency of verified and undetermined suicides change among children and young people (classified in the 10-14, 15-19, 20-24 and 25-29 age groups) in the period 19741986? (2) What differences in the incidence of verified and undetermined suicides emerge from comparisons between the sexes, and between each of the various age groups and the suicide population as a whole? (3) What is the predominant method of suicide for various age groups and for each sex? (4) What is the distribution of suicide over the various months of the year? (5) What difference is there in marital status between young people (aged 20-29) committing suicide and young people in the overall population?

METHODS AND MATERIAL This investigation comprises 3,511 children and young people aged 10-29 who died in Sweden between 1974 and 1986 as a result of verified suicide (according to the ICD-9 classification: E950-E959: E950 Suicide and self-inflicted poisoning by solid or liquid substances, E951 Suicide and self-inflicted poisoning by gases in domestic usc, E952 Suicide and self-inflicted poisoning by other gases and vapours, E953 Suicide and selfinflicted injury by hanging, strangulation and suffocation, E954 Suicide and self-inflicted injury by submersion [drowning], E955

Suicide and self-inflicted injury by firearms and explosives, E956 Suicide and self-inflicted injury by cutting and piercing instruments, E957 Suicide and self-inflicted injuries by jumping from high place, E958 Suicide and self-inflicted injury by other and unspecified means, and E959 Late effects of selfinflicted injury), and 1,113 children and young people for whom the diagnosis of undetermined suicide was made (according to the ICD-9 classification: E980-E989: these diagnoses correspond to the E950-E959 diagnoses listed above, but are applied to deaths in which there is some doubt as to whether the mortal injury was accidental or self-inflicted, i.e. undetermined suicides). The material is taken from the official Statistics of Sweden, Register of the causes of death (12). Since 1969, all cases of deaths for which it has been impossible to establish a specific cause and intent have been registered by the numbers E980E989. In 1981, Horte (15) found in his survey based on an analysis of autopsy reports and hospital journals, that 70% of the cases classified as undetermined suicides in Sweden were probably suicides. These observations were confirmed in an investigation carried out recently (16). It is therefore important to investigate trends of undetermined suicides, but to separate these from verified suicides in order to avoid any distortions in the analysis. A distinction is drawn between non-violent and violent suicide methods. Poisoning by solid or liquid substances or household gas is categorised as a nonviolent method, and designated by the ICD number E950-E952. Suicide by means of hanging, use of firearms or knives, jumping from a height or running out in front of vehicles and suicide through drowning are counted as violent methods and designated by ICD Nos. E953-E957. With regard to undetermined suicides, non-violent methods are labelled ICD E980-E982 and violent ones E983-E987. E958-E959 form a separate group that cannot be termed either non-violent or violent with respect to suicide method, but are rather classified as "suicides by other methods or LOS" (lacking detailed specification) or "delayed-effect suicides". E988-E989 make up the corresponding group for undetermined suicides. The marital-status distribution of individuals who committed suicide was also investigated. The number of individuals in various marital-status groups, in the 20-29 age group, who committed suicide have

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Suicide among young people ill Sweden o o •

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e~ 11 '2 IJ h 1\ "r"" '6 " Fig. 1. Annual absolute number of suicides among young people (aged 10-29) in Sweden, 1974-1986.

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been compared with corresponding marital-status and age groups in the total Swedish population. The average figures for the 13 years concerned have been used as figures for the whole population. ETHICAL ASPECTS Permission for the investigation was obtained from the regional Ethis Committee at the Uppsala University. STATISTICAL PROCESSING Since the suicide trends in Sweden were linear after 1970 (17-18), there was no reason to use non-parametric trend tests. Linear regression analysis (19) of the agespecific suicide and undetermined-suicide rates (per 100,000 individuals in Sweden), for various age groups and both sexes, was therefore performed. The two-tailed t-test was carried out to test the hypothesis of a significant slope. RESULTS

Absolute numbers of verified and undetermined suicides ill the years 1974-1986 Verified suicides in the 10-29 age group in 19741986 numbered 3,511; of these, 2,536 were boys and young men and 975 girls and young women. This gives an average number of verified suicides in this age group of 270 a year. The number of undetermined suicides was 1,113: 812 boys and young men and 301 girls and young women; and the annual average for undetermined suicides was 86. The lowest absolute number of verified suicides was recorded in 1981 (11 = 204) and the highest number in 1976 (11 = 309) (Fig. 1).

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Fig. 2. Annual absolute number of undetermined suicides among young people (aged 10-29) in Sweden, 197-1---1986.

The number of undetermined suicides was some 100 a year for the period up to 1981; subsequently, it declined to a relatively constant 65 or so a year (Fig. 2). Combining the number of verified and undetermined suicides among young people, the minimum was in 1982 (11 = 295) and the maximum in 1975 (11 = 408).

Absolute number of suicides and undetermined suicides ill various age groups In the 10-14 age group there were 40 suicides and 24 undetermined suicides (47 males, 17 females); in the 15-19 age group 499 suicides and 172 undetermined suicides (433 males and 238 females); in the 20-24 age group 1,311 suicides and 395 undetermined suicides (1,246 males and 460 females); and in the 25-29 age group 1,661 suicides and 522 undetermined suicides (1,622 males and 561 females). Figure 3 shows the distribution of the absolute numbers of verified suicides among age groups and between boys and young men on the one hand and girls and young women on the other. The absolute

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Fig. 3. Number of suicides among young people in Sweden by age and sex, during the period 197-1---1986. Scand J Soc !>ted20

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A. Hulten

68

'" 1 o 0 •

Female Male Total

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Fig. 4. Number og undetermined suicides among young people in Sweden by age and sex, during thc period 19741986.

number of suicides rises up to the age of 23 and then remains broadly constant. Among boys, the increase may be seen as early as the in upper teens, while the highest rates are among those aged 25-27. The corresponding curve for girls shows a steep increase in suicide at the age of 15, followed by a steady increase up to the age of 22 and levelling off thereafter. Figure 4 shows the distribution of undetermined suicides among age groups and between the sexes. The absolute number of undetermined suicides increases slightly after the teens. For boys, the increase takes place at the age of 19; for girls, a rise is found at 17, followed by a fairly level trend. The ratio of verified to undetermined suicides is 3:2, and is stable in all age groups,

Age-specific suicide rates for boys and young men and girls and young women aged 10-29: mortality rates and regression analysis Mean age-specific suicide rates for the years 19741986 are presented in Table 1, which shows that suicide rates rise for each successive age group. The maximum suicide rate (43.2) was noted for young men aged 25-29 in 1984. The suicide-mortality rate, i.e, the number of deaths from suicide per 100,000 individuals of the corresponding age, remained fairly stable for the age groups investigated in the period 1974-1986. The figures were somewhat higher at the end of the 1970s; a decline in early 1980 was followed by another rise in the years 1984-1986. However, these differences arc not significant (with the exception of undetermined suicides among young women aged 20-24). This is shown by the results of linear regression analysis of the age-specific suicide and undetermined-suicide rates in different age groups separately and all age groups combined over the 13-year period. These results are presented in Table 2, summarised in the form of slope coefficients and their degrees of significance. Male and female suicide rates ill Sweden, 19741986 In the entire group investigated, there were 2.5 as many suicides among boys and young men as among girls and young women, the smallest difference being in the 15-19 age group (1.7) and the largest among persons aged 10-14 and 25-29 (2.8) (Table

1).

Table I. Age-specific suicide rates (per 100 000 inhabitants) among young people (aged 10-29) of both sexes in Sweden 1974-1986, by 5-year age group. Means and male-female ratios Rate per 100 000 Mean Cor years 1974-1986 Ratio

Agc group

Boys

Girls

10-14 15-19 20-24 25-29

0,78 8,30 25,40 31,40

0,28 4,90

10,10 11,10

2,8 1,7 2,5 2,8

10-29

16,47

6,60

2,5

Suicide method In the lowest age group, 10-14 years, violent methods of suicide were chosen by all boys, while girls used violent and non-violent methods in almost equal proportions (Table 3). Violent methods also predominated for undetermined suicides among boys in this age group: such methods were chosen by 13, against 3 using nonviolent methods. None of the girls used a violent method. In the other age groups investigated, approximately twice as many young men used violent methods in verified suicides, while young women slightly more often used non-violent methods. For verified suicides, the proportions of non-violent and violent methods were stable over the 13

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Suicide among young people in Sweden

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Table II. Linear regression of age-specific suicide and undetermined suicide rates (per 100 000 inhabitants) among young people (aged 10-29) of both sexes in Sweden, 1974-1986 Suicide

Undetermined suicide

Age

Slope

Significance

Slope

Significance

Girls

10--14 15-19 20--2-1 25-29

-0.0-1 -0.29 -0.16 +0.07

n.s. n.s, n.s, n.s.

-0.0-1 -0.40 -0.42 +0.15

n.s. n.s. p

Suicide among young people aged 10-29 in Sweden.

This study analyses the incidence of suicide among children and young people aged between 10 and 29 in Sweden, during the period 1974-1986. The study ...
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