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Seminar
1372
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Vol 373 April 18, 2009
Suicide
Keith Hawton, Kees van Heeringen
Suicide receives increasing attention worldwide, with many countries developing national strategies for prevention.Rates of suicide vary greatly between countries, with the greatest burdens in developing countries. Many moremen than women die by suicide. Although suicide rates in elderly people have fallen in many countries, those inyoung people have risen. Rates also vary with ethnic origin, employment status, and occupation. Most people whodie by suicide have psychiatric disorders, notably mood, substance-related, anxiety, psychotic, and personalitydisorders, with comorbidity being common. Previous self-harm is a major risk factor. Suicide is also associatedwith physical characteristics and disorders and smoking. Family history of suicidal behaviour is important, as areupbringing, exposure to suicidal behaviour by others and in the media, and availability of means. Approaches tosuicide prevention include those targeting high-risk groups and population strategies. There are, however, manychallenges to large-scale prevention, especially in developing countries.
Background and epidemiology
The estimated global burden of suicide is a milliondeaths per year,
1
and an international policy statementby WHO in response to the large burden
2
has promptedmany countries to initiate suicide prevention policies.Estimated annual mortality is 14·5 deaths per100 000 people, which equates to one death every 40 s.
1
 Self-inflicted death accounts for 1·5% of all deaths andis the tenth leading cause of death worldwide.
3
Suiciderates vary according to region, sex, age, time, ethnicorigin, and, probably, practices of death registration.In some countries many deaths (eg, 15% in China
4 
)are probably unreported, and procedures for recordingdeaths as suicide are far from uniform. Countries differin their death certification procedures for unexpecteddeaths and in their requirements for a death to berecorded as suicide. Certification of the cause of unexpected death is made by different bodies, includingthe police (eg, Finland), physicians (eg, China), coroners(eg, England and Wales), coroners and medicalexaminers (eg, USA), or equivalent offi cials (eg,Procurator Fiscal in Scotland). The requirements for adeath to be recorded as suicide also differ, with externalevidence of intent, such as a suicide note being requiredin some countries (eg, Luxembourg); in others a verdictof suicide can be reached on a basis of judgment of intent, as long as there is certainty that the death wasself-inflicted (eg, England and Wales). The decisionabout the cause of death will be made in private in mostcountries where police or physicians are responsible forthe verdict and in the case of the Procurator Fiscal inScotland, although in England and Wales coroners’hearings happen in public.Different procedures and cultural and social practicesand values probably have profound effects on deathrecords and lead to misclassification of suicide(eg, as undetermined death or death due to accident orillness). Some countries (eg, Finland, France, Portugal,and Sweden) have very high combined rates of suicideand undetermined death compared with rates of suicide,whereas other countries (eg, Belgium, Denmark,Germany, and the UK) have moderately high combinedrates.
5
Detailed independent investigation (verbalautopsy) of unnatural deaths in rural areas of India,where suicide is illegal, suggested a nine-fold to ten-foldunderestimation of suicide in reported rates.
6
Suchfindings suggest that offi cial counts for the globalburden of suicide
1
are substantial underestimates. Inmany Islamic countries, the view of suicide as a criminaloffence might affect registration practices. Epidemio-logical data on suicide in Africa are scarce.Rates of suicide vary substantially between regions andcountries (figure 1). Within Europe, rates are generallyhigher in northern countries than in southern countries.An effect of latitude on suicide rates was found in Japan,suggesting an influence of the daily amounts of sunshineon suicide.
7
However, countries at about the samelatitude, such as the UK and Hungary, can havesubstantially different rates of suicide. Suicide is a majorconcern in former Soviet states.
1
More than 30% of suicides worldwide happen in China, where 3·6% of alldeaths are by suicide.
4 
Few countries provide nationalsuicide rates segregated by residence, and these datashow no clear pattern; although, in China, suicide ratesare three-times higher in rural than in urban settings.
4 
In developed countries, the male-to-female ratio forsuicide is between two and four to one, and this seems
Lancet
2009; 373: 1372–81Centre for Suicide Research,University Department of Psychiatry, Warneford Hospital,Oxford, UK
(Prof K Hawton DSc)
;and Unit for Suicide Research,University Department of Psychiatry, UniversityHospital, Gent, Belgium
 (Prof K van Heeringen PhD)Correspondence to:Centre for Suicide Research,University Department of Psychiatry, Warneford Hospital,Oxford OX3 7JX, UK
keith.hawton@psych.ox.ac.uk
Search strategy and selection criteria
We searched the Cochrane Library, Psycinfo, Medline(January, 2003, to July, 2008), and Embase (January, 2003,to July, 2008). We used the search term “suicide” incombination with the terms “aetiology”, “epidemiology”,“prevention”, and “psychological autopsy”. Index terms wereused in preference to free text search terms wheneverpossible; no language restrictions were applied to thesearch. We commonly referenced older publications. We alsosearched the reference lists of articles identified in thissearch strategy and selected relevant articles. Reviews andbook chapters are cited to provide readers with furtherreading. Our reference list was modified on the basis of comments from peer reviewers.
 
Seminar
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Vol 373 April 18, 2009
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to be increasing.
1
Asian countries typically show muchlower male-to-female ratios, but these might also beincreasing;
8
although in China more women than mendie by suicide.
4 
 Suicide rates are highest in elderly people in mostcountries. However, over the past 50 years, rates haverisen in young people, in particular in men,
9
anddecreased in elderly people.
10
More recently, suiciderates in young males have decreased in some developedcountries in which they had previously risen.
11
Suicide rates also vary with season, peaking in spring,particularly among men, although this associationseems to change over time.
12
Suicide rates are also highamong people, in particular women, born in spring andearly summer.
13
Clear ethnic patterns in suicide rates exist. Theseinclude lower rates of suicide in Hispanic and AfricanAmericans than in European Americans;
14 
although thehistorically large gap in suicide rates in black peoplecompared with those in white people in the USA hasnarrowed because of a substantial increase in suicidesin young black people.
11
 Within countries, variations in rates are seen betweendifferent ethnic groups.
15
In the UK, for example, youngIndian women in London have a higher suicide ratethan other women, whereas young Afro-Caribbeanwomen have very low rates, and men of Indian andAfrican origin have lower rates than do white men.
16
 There are also differences in methods of suicide, withwomen in south Asia commonly using setting fire tothemselves as a method of suicide.
17
Suicide rates withinethnic groups seem to vary inversely according torelative population density of each group, suggestingthat presence of cultural supports and networks mightbe protective.
16
However, suicide rates in populations of immigrants also tend to co-vary with rates in country of birth.
18
Indigenous populations in several countries havehigh suicide rates compared with the rest of thepopulation, for example Native American people in theUSA, Métis and Inuit in Canada, Australian Aborigines,and Maori in New Zealand all have high rates of suicide.
15
Factors that might contribute includemarginalisation, disintegration of traditional socialsupport networks and cultural values, socioeconomicdeprivation, and alcohol misuse.Suicide rates are high in unemployed people;
19
 although the reasons for this association are complex.In part, high rates are associated with mental illness,which contributes to risks of both unemployment andsuicide.
20
Among people in employment, someoccupational groups are at increased risk of suicide.Medical practitioners have a high risk in most countries,but female doctors are generally most at risk.
21,22
Nursesalso have a high risk.
23
In both these professionalgroups, access to poisons seems to be an importantfactor in determining the high rates.
23
Among doctors,anaesthetists are particularly at risk, with anaestheticdrugs being used in many suicide deaths.
21
Severalother high-risk occupational groups (eg, dentists,pharmacists, veterinary surgeons, and farmers) alsohave easy access to means for suicide.
24 
Suicide rates are high in prisoners in countries thatrelease data.
25
Major risk factors are being confined to asingle prison cell, previous attempted suicide, recentsuicidal ideation, and psychiatric disorder or history of 
AggregatedNorth AmericaAustralasiaEuropeSouth and east AsiaMiddle East and central AsiaAfricaLatin America
   E   u  r  o   p  e  a  n     U  n   i  o  n    (    1   9   9   8    )    ³    U   S   A    (    2   0   0   2    )   C  a  n  a  d  a    (    2   0   0   2    )   A   u  s   t  r  a    l   i  a    (    2   0   0   3     )    N  e   w     Z  e  a    l  a  n  d    (    2   0   0   3     )   G  r  e  e  c  e    (    2   0   0  4    )    U    K    (    2   0   0  4    )   F   i  n    l  a  n  d    (    2   0   0  4    )   L  a   t   v   i  a    (    2   0   0  4    )    H   u  n  g   a  r   y    (    2   0   0   3     )   L   i   t    h   u  a  n   i  a    (    2   0   0  4    )   S  r   i    L  a  n    k  a    (    1   9   9   6    )   C    h   i  n  a    (    2   0   0   0    )   J  a   p  a  n    (    2   0   0  4    )    I  r  a  n    (    1   9   9   1    )   E  g    y   p   t    (    1   9   8    7    )    I  s  r  a  e    l    (    2   0   0   3     )    K  a   z  a    k    h  s   t  a  n    (    2   0   0   3     )    Z   i  m    b  a    b   w  e    (    1   9   9   0    )   S  e   y  c    h  e    l    l  e  s    (    1   9   9   8    )   M  e   x   i  c  o    (    2   0   0   3     )    B  r  a   z   i    l    (    2   0   0   2    )   C   u    b  a    (    2   0   0  4    )
0510152025
    S   u    i   c    i    d   e   s   p   e   r    1    0    0
 
    0    0    0    p   e   o   p    l   e
30354045
    W  o  r    l  d    (    2   0   0   0    )    ¹
Figure 1:
Suicide rates in selected regions and countries
 
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Vol 373 April 18, 2009
alcohol problems.
26
Rates of attempted suicide inhomosexual and bisexual men and women are high,but evidence is lacking for suicide.
27
Methods of suicide
When a person is contemplating suicide, access tospecific methods might be the factor that leads totranslation of suicidal thoughts into action. The dangerof available methods might determine whether theoutcome is fatal or not. In general, men tend to choosemore violent means (eg, hanging or shooting) andwomen less violent methods (eg, self-poisoning).
28
Availability of specific means for suicide affectsnational patterns in the methods used. In the USA,firearms are used in most suicides, with risk of their usebeing highest where guns are kept in households.
29
Inrural areas of many developing countries, ingestion of pesticides is the main method of suicide,
30
reflectingtoxicity, easy availability, and poor storage. As many as30% of global suicide deaths might involve ingestion of pesticides.
30
Contributory factors
Numerous factors contribute to suicide, which is neverthe consequence of one single cause or stressor. Thesefactors can be categorised as state-dependent ortrait-dependent, or as distal or proximal factors (panel).The relation between risk factors can be described inexplanatory models of suicide, such as the stress–diathesis model (figure 2).Acute psychosocial crises and psychiatric disordersare commonly the proximal stressors leading to suicidalbehaviour, while pessimism or hopelessness and aggres-sion or impulsivity are components of the diathesis forsuicidal behaviour. Familial or genetic factors, childhoodexperiences, and other factors, including cholesterolconcentrations, influence the diathesis.
31
The stress–diathesis model is compatible with recent gene–environ-ment interaction models,
32
but prospective studies of itspredictive value are needed.
Psychiatric disorders
The classic method of investigating characteristics of individuals who have died by suicide is through psycho-logical autopsy, involving interviews with key informantsand examination of offi cial records.
33
This approach hasshown that psychiatric disorders are present in about90% of people who kill themselves and contribute47–74% of population risk of suicide.
34 
Such studies havemostly been done in developed countries. Similar findingshave come from India.
35
In China, however, a much lowerproportion of people who die by suicide seem to havepsychiatric disorders, especially women and girls in ruralareas.
36
Affective disorder is the most common psychiatricdisorder, followed by substance (especially alcohol)misuse and schizophrenia. Comorbidity of disordersgreatly increases risk of suicide.
34 
The mortality risk for suicide associated withdepression is many times the general population risk.
37
 More than half of all people who die by suicide meetcriteria for current depressive disorder;
34 
although theassociation seems weaker in Asia. About 4% of depressedindividuals die by suicide, but the risk is greatest inmales and in those who have needed psychiatrichospitalisation, especially for suicidality.
38
Clinicalpredictors of suicide in people with major depressivedisorder also include a history of attempted suicide,high levels of hopelessness, and high ratings of suicidaltendencies.
38
Suicide in major depressive disorder ismost likely to occur during the first episode, and thisseems to be related to alcohol misuse and impul-sive-aggressive personality traits. The effect of im-pulsive-aggressive traits is present in child andadolescent suicide and decreases with age.
39
10–15% of patients with bipolar disorder die bysuicide, commonly early in the illness course.
40
Riskfactors for suicidal behaviour include previousself-harm, family history of suicide, early onset andincreasing severity of the disorder, depressive symptoms(including hopelessness), mixed affective states, rapidcycling, comorbid psychiatric disorder, and misuse of alcohol or drugs.
41
Recent estimates suggest that lifetime suicide risk inschizophrenia is 4–5%, the risk being highest relativelyearly after onset of the disorder.
42
Risk is associated lesswith the core symptoms of schizophrenia, such asdelusions and hallucinations, but more with depressionand specific affective symptoms (eg, agitation, sense of worthlessness, and hopelessness). Other factors includeprevious suicide attempts, drug misuse, fear of mentaldisintegration, recent loss, and poor adherence totreatment.
43
Alcohol misuse, particularly dependence, is stronglyassociated with suicide risk.
44 
The severity of thedisorder, aggression, impulsivity, and hopelessnessseem to predispose to suicide. Key precipitating factorsare depression and stressful life events, particularlydisruption of personal relationships.
44 
Panel:
Risk factors for suicideDistal
• Genetic loading• Personality characteristics (eg, impulsivity, aggression)• Restricted fetal growth and perinatal circumstances• Early traumatic life events• Neurobiological disturbances (eg, serotonin dysfunctionand hypothalamic-pituitary axis hyperactivity)
Proximal
• Psychiatric disorder• Physical disorder• Psychosocial crisis• Availability of means• Exposure to models
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