590630 research-article2015
ANP0010.1177/0004867415590630ANZJP DebateSnowdon
Debate Australian & New Zealand Journal of Psychiatry 1–3 DOI: 10.1177/0004867415590630
Why have Australian suicide rates decreased?
© The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
John Snowdon
There have recently been suggestions in the media that there is an epidemic of suicide in Australia. Such statements are evidently aimed at persuading the government to increase hospital and community resources in order to avert preventable suicides. There have indeed been suicides that could have been prevented if only mental health staff had been alert, perceptive and trained to recognise risks and take appropriate action. However, we should not seek resources by distorting facts. There has not been a suicide epidemic. Australian suicide rates (recorded per 100,000 population) rose to a peak in 1997 (male 23.6, female 6.2), and the main increase was among young men (42.8 in the 20–24 year age group, 40.5 at age 25–29). Figure 1 shows the suicide rates (male and female) for the 5-year period 1994–1998, of all 5-year age groups from 10–14 to 80–84, plus the rate for people aged 85 years and more. This age pattern is compared with corresponding 2009–2013 data (dotted line). The suicide rate had dropped to 16.7 (male) and 5.3 (female) per 100,000. The 2013 rates are shown separately (continuous line) in Figure 1. The suicide rate of males aged 20– 24 halved between 1994–1998 and 2009–2013 (Figure 1), although the male rate at age 45–49 was about the same in 2013 as it had been in 1994– 1998. In 2009–2013, male suicide rates were incrementally higher from boyhood through age 25–29 and up to age 45–49, whereas in 1994–1998, the rate was progressively lower across the age range from 25–29 to 45–49.
Between 1994–1998 and 2009–2013, there was a considerable decrease in the suicide rates of men in late middle age or older. The suicide rate in 2013 of men aged 65–74 years (16.2) was the lowest of all adult male age groups – and that of older women was lower than that of younger women (Figure 1). ‘Old old’ males are more likely than others to kill themselves. For many years, the suicide rate of each age group older than 70–74 has been incrementally higher: in 2009– 2013, the peak male suicide rate (at age 85+ years) was 33.8 per 100,000 (38.3 in 2013). Examination of Australian male suicide data from the 1950s and 1960s shows no age peak among young men. At that time, as in 2009–2013, the suicide rate of men aged 20–29 was less than 20 per 100,000 (Snowdon, 1997). By the early 1980s, the suicide rate of men aged 40–79 years had decreased from a mean of over 35 to about 25 per 100,000, but the 20–29 years rate had risen to just over 25 per 100,000, en route for its 1997 peak. Examination of Australian female suicide data from the 1950s (Snowdon, 1997) showed a peak of 11 per 100,000 at age 55–64 years, but in 1964–1968, the peak was higher, varying between 23 and 20 per 100,000 across the age range 45 to 69 years. By 1979–1983, the rate had halved, with a small peak (just over 10) at 45– 59 years. Figure 1 shows the female age pattern of suicide to have remained remarkably constant between 1994– 1998 and 2009–2013, varying between about 6.5 and 8.5 across the age range 20–59 years. The rates were only a little lower between 60 and 84 years
(Figure 1), and there was no peak in late old age to match the male late life peak.
Why are fewer Australians killing themselves? Questions arise. First, have there been changes in the way suicide data are gathered? Have changes in the way deaths are categorised affected the recorded rates? The proportion of Australian deaths registered as being of undetermined cause has risen from 3% to 10% but fluctuates. In England and Wales, the ‘open verdict’ rate is much higher. Such variations may partly account for differences in suicide rates between countries and across time. Keeping these in mind, questions about differences between genders and between age groups in suicide rates, and changes over time, could help in understanding suicide causation. Australian studies show that about 80% of suicide decedents had mental disorders, the percentage being lower among older people. Pridmore (2015) criticised those who believe that suicide is usually attributable to mental
S ydney Medical School and Sydney Local Health District, Jara Unit, Concord Hospital, Sydney, NSW, Australia Corresponding author: John Snowdon, Sydney Medical School and Sydney Local Health District, Jara Unit, Concord Hospital, Sydney, NSW 2139, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry
Downloaded from anp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
2
ANZJP Debate
Figure 1. The age patterns of Australian suicide rates in 1994–1998, 2009–2013 and 2013.
AUSTRALIAN SUICIDE RATE Male & Female
1994-1998 Male
1994-1998 Female
2009-2013 Male
2009-2013 Female
2013 Male
2013 Female
45 40 35 1994-98 Suicide rate per 100,000
30
Male
25 20
2013
15 10 5
Female 0
10 to 14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
5-year age-groups
disorder. He believes that more often it results from psychosocial stressors. The general view is that suicide results from a complex interplay of factors, one being psychological distress. Shneidman (1999) argued that suicide occurs when psychache (intensely felt psychological pain) becomes unbearable. The data presented above show relatively huge variations in suicide rates. Can these be explained as being due to varying levels and types of stress? If so, did the stressors lead to suicide, or did they lead to mental disorders that led to suicide? Anguish and distress are forms of mental perturbation, but what features and duration would be needed in order to regard this as mental disorder?
The data show (Figure 1) that in Australia, as in most countries, the male suicide rate is much higher than that of females. Pridmore (2015) contends that a 3:1 gender difference is evidence against a belief that suicide is usually the consequence of mental disorder (the overall prevalence of which is no higher in males). In China’s urban populations, male and female suicide rates are similar, and the age pattern is very different from that recorded in Australia. Yang et al. (2005) showed that 63% of suicide victims had a mental illness (67% of males, 58% of females), the lowest prevalence being in young rural females (39%), many of whom used pesticides impulsively. Gender
roles vary between cultures, across age groups and between families. Personality factors doubtless affect the way roles affect self-esteem, life satisfaction and emotions. Why, in Australia, over the 1970s to 1990s, did the suicide rate of young adult males more than double? Why did it then decrease? Was it attributable to increased use of recreational drugs? Did the drugs cause depression? Were there increased feelings of disconnectedness in that generation? But how do we account for the subsequent decrease? Why does the early peak in male suicide rate now occur 20 years later than it did in 1994–1998? This is probably a cohort/period effect, resulting
Australian & New Zealand Journal of Downloaded Psychiatry from anp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
3
Snowdon from environmental influences (society, peer-group, culture). Why did the suicide rate of middleaged females double in the 1960s and then fall? Sedative over-availability has been blamed. Why has there been such a big and continuing fall in the suicide rate of older men in Australia, other than of those aged 85+? Is it due to improved recognition and treatment of physical and mental disorders? Improved socioeconomic conditions? Why has the suicide rate of very old Australian males remained so high in contrast to very old women? Are women more tolerant of age-related frailty? Are men more prone to loss of self-esteem related to disability and inability to adapt? Are they keen to avoid being a burden on others? Compared to men aged 65–79, the suicides of those aged over 80 years
have been rated more often as understandable/rational (42% vs 18%; Snowdon and Baume, 2002). It is hoped that this article provokes discussion concerning factors that may contribute to suicidal thinking. Understanding reasons for variations in age patterns of suicide will clearly prove useful when discussing causation and prevention strategies. How should National Suicide Prevention resources be used to best effect? Acknowledgements The Australian Bureau of Statistics kindly provided suicide numbers and population data, thus allowing calculation of suicide rates. The 2013 suicide data were released on 31 March 2015.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References Pridmore S (2015) Mental disorder and suicide: A faulty connection. Australian and New Zealand Journal of Psychiatry 49: 18–20. Shneidman E (1999) Perturbation and lethality. In: Jacobs DG (ed.) The Harvard Medical School Guide to Assessment and Intervention. San Francisco, CA: Jossey-Bass, pp. 83–97. Snowdon J (1997) Suicide rates and methods in different age groups: Australian data and perceptions. International Journal of Geriatric Psychiatry 12: 253–258. Snowdon J and Baume P (2002) A study of suicides of older people in Sydney. International Journal of Geriatric Psychiatry 17: 261–269. Yang GH, Phillips MR, Zhou MG, et al. (2005) Understanding the unique characteristics of suicide in China: National psychological autopsy study. Biomedical and Environmental Sciences 18: 379–389.
Australian & New Zealand Journal of Psychiatry
Downloaded from anp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
ANP0010.1177/0004867415590630ANZJP DebateSnowdon
Debate Australian & New Zealand Journal of Psychiatry 1–3 DOI: 10.1177/0004867415590630
Why have Australian suicide rates decreased?
© The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
John Snowdon
There have recently been suggestions in the media that there is an epidemic of suicide in Australia. Such statements are evidently aimed at persuading the government to increase hospital and community resources in order to avert preventable suicides. There have indeed been suicides that could have been prevented if only mental health staff had been alert, perceptive and trained to recognise risks and take appropriate action. However, we should not seek resources by distorting facts. There has not been a suicide epidemic. Australian suicide rates (recorded per 100,000 population) rose to a peak in 1997 (male 23.6, female 6.2), and the main increase was among young men (42.8 in the 20–24 year age group, 40.5 at age 25–29). Figure 1 shows the suicide rates (male and female) for the 5-year period 1994–1998, of all 5-year age groups from 10–14 to 80–84, plus the rate for people aged 85 years and more. This age pattern is compared with corresponding 2009–2013 data (dotted line). The suicide rate had dropped to 16.7 (male) and 5.3 (female) per 100,000. The 2013 rates are shown separately (continuous line) in Figure 1. The suicide rate of males aged 20– 24 halved between 1994–1998 and 2009–2013 (Figure 1), although the male rate at age 45–49 was about the same in 2013 as it had been in 1994– 1998. In 2009–2013, male suicide rates were incrementally higher from boyhood through age 25–29 and up to age 45–49, whereas in 1994–1998, the rate was progressively lower across the age range from 25–29 to 45–49.
Between 1994–1998 and 2009–2013, there was a considerable decrease in the suicide rates of men in late middle age or older. The suicide rate in 2013 of men aged 65–74 years (16.2) was the lowest of all adult male age groups – and that of older women was lower than that of younger women (Figure 1). ‘Old old’ males are more likely than others to kill themselves. For many years, the suicide rate of each age group older than 70–74 has been incrementally higher: in 2009– 2013, the peak male suicide rate (at age 85+ years) was 33.8 per 100,000 (38.3 in 2013). Examination of Australian male suicide data from the 1950s and 1960s shows no age peak among young men. At that time, as in 2009–2013, the suicide rate of men aged 20–29 was less than 20 per 100,000 (Snowdon, 1997). By the early 1980s, the suicide rate of men aged 40–79 years had decreased from a mean of over 35 to about 25 per 100,000, but the 20–29 years rate had risen to just over 25 per 100,000, en route for its 1997 peak. Examination of Australian female suicide data from the 1950s (Snowdon, 1997) showed a peak of 11 per 100,000 at age 55–64 years, but in 1964–1968, the peak was higher, varying between 23 and 20 per 100,000 across the age range 45 to 69 years. By 1979–1983, the rate had halved, with a small peak (just over 10) at 45– 59 years. Figure 1 shows the female age pattern of suicide to have remained remarkably constant between 1994– 1998 and 2009–2013, varying between about 6.5 and 8.5 across the age range 20–59 years. The rates were only a little lower between 60 and 84 years
(Figure 1), and there was no peak in late old age to match the male late life peak.
Why are fewer Australians killing themselves? Questions arise. First, have there been changes in the way suicide data are gathered? Have changes in the way deaths are categorised affected the recorded rates? The proportion of Australian deaths registered as being of undetermined cause has risen from 3% to 10% but fluctuates. In England and Wales, the ‘open verdict’ rate is much higher. Such variations may partly account for differences in suicide rates between countries and across time. Keeping these in mind, questions about differences between genders and between age groups in suicide rates, and changes over time, could help in understanding suicide causation. Australian studies show that about 80% of suicide decedents had mental disorders, the percentage being lower among older people. Pridmore (2015) criticised those who believe that suicide is usually attributable to mental
S ydney Medical School and Sydney Local Health District, Jara Unit, Concord Hospital, Sydney, NSW, Australia Corresponding author: John Snowdon, Sydney Medical School and Sydney Local Health District, Jara Unit, Concord Hospital, Sydney, NSW 2139, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry
Downloaded from anp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
2
ANZJP Debate
Figure 1. The age patterns of Australian suicide rates in 1994–1998, 2009–2013 and 2013.
AUSTRALIAN SUICIDE RATE Male & Female
1994-1998 Male
1994-1998 Female
2009-2013 Male
2009-2013 Female
2013 Male
2013 Female
45 40 35 1994-98 Suicide rate per 100,000
30
Male
25 20
2013
15 10 5
Female 0
10 to 14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
5-year age-groups
disorder. He believes that more often it results from psychosocial stressors. The general view is that suicide results from a complex interplay of factors, one being psychological distress. Shneidman (1999) argued that suicide occurs when psychache (intensely felt psychological pain) becomes unbearable. The data presented above show relatively huge variations in suicide rates. Can these be explained as being due to varying levels and types of stress? If so, did the stressors lead to suicide, or did they lead to mental disorders that led to suicide? Anguish and distress are forms of mental perturbation, but what features and duration would be needed in order to regard this as mental disorder?
The data show (Figure 1) that in Australia, as in most countries, the male suicide rate is much higher than that of females. Pridmore (2015) contends that a 3:1 gender difference is evidence against a belief that suicide is usually the consequence of mental disorder (the overall prevalence of which is no higher in males). In China’s urban populations, male and female suicide rates are similar, and the age pattern is very different from that recorded in Australia. Yang et al. (2005) showed that 63% of suicide victims had a mental illness (67% of males, 58% of females), the lowest prevalence being in young rural females (39%), many of whom used pesticides impulsively. Gender
roles vary between cultures, across age groups and between families. Personality factors doubtless affect the way roles affect self-esteem, life satisfaction and emotions. Why, in Australia, over the 1970s to 1990s, did the suicide rate of young adult males more than double? Why did it then decrease? Was it attributable to increased use of recreational drugs? Did the drugs cause depression? Were there increased feelings of disconnectedness in that generation? But how do we account for the subsequent decrease? Why does the early peak in male suicide rate now occur 20 years later than it did in 1994–1998? This is probably a cohort/period effect, resulting
Australian & New Zealand Journal of Downloaded Psychiatry from anp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
3
Snowdon from environmental influences (society, peer-group, culture). Why did the suicide rate of middleaged females double in the 1960s and then fall? Sedative over-availability has been blamed. Why has there been such a big and continuing fall in the suicide rate of older men in Australia, other than of those aged 85+? Is it due to improved recognition and treatment of physical and mental disorders? Improved socioeconomic conditions? Why has the suicide rate of very old Australian males remained so high in contrast to very old women? Are women more tolerant of age-related frailty? Are men more prone to loss of self-esteem related to disability and inability to adapt? Are they keen to avoid being a burden on others? Compared to men aged 65–79, the suicides of those aged over 80 years
have been rated more often as understandable/rational (42% vs 18%; Snowdon and Baume, 2002). It is hoped that this article provokes discussion concerning factors that may contribute to suicidal thinking. Understanding reasons for variations in age patterns of suicide will clearly prove useful when discussing causation and prevention strategies. How should National Suicide Prevention resources be used to best effect? Acknowledgements The Australian Bureau of Statistics kindly provided suicide numbers and population data, thus allowing calculation of suicide rates. The 2013 suicide data were released on 31 March 2015.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References Pridmore S (2015) Mental disorder and suicide: A faulty connection. Australian and New Zealand Journal of Psychiatry 49: 18–20. Shneidman E (1999) Perturbation and lethality. In: Jacobs DG (ed.) The Harvard Medical School Guide to Assessment and Intervention. San Francisco, CA: Jossey-Bass, pp. 83–97. Snowdon J (1997) Suicide rates and methods in different age groups: Australian data and perceptions. International Journal of Geriatric Psychiatry 12: 253–258. Snowdon J and Baume P (2002) A study of suicides of older people in Sydney. International Journal of Geriatric Psychiatry 17: 261–269. Yang GH, Phillips MR, Zhou MG, et al. (2005) Understanding the unique characteristics of suicide in China: National psychological autopsy study. Biomedical and Environmental Sciences 18: 379–389.
Australian & New Zealand Journal of Psychiatry
Downloaded from anp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
