Journal oI Public Health

ZeitschriIt Iür GesundheitswissenschaIten
© Springer-Verlag 2010
10.1007/s10389-010-0372-4
OriginaI ArticIe
EpidemioIogicaI issues regarding suicides
in Ecuador: an 8-year report
Fabricio González-Andrade
1
, Ramiro López-Pulles
2
, Santiago Gascón
3
and
1avier García Campayo
4

(1) Faculty of Medical Sciences, Central University of Ecuador, Sodiro N14-121 e Ìquique,
Quito, Ecuador
(2) Biomedical Center, Central University of Ecuador (Quito) and UniAndes (Ambato), Quito,
Ecuador
(3) Forensic Medicine Department, Faculty of Medicine, University of Zaragoza, Zaragoza,
Spain
(4) Department of Psychiatry, "Miguel Servet¨ University Hospital, Zaragoza, Spain

abricio GonzáIez-Andrade
EmaiI: Iabriciogonzaleza¸yahoo.es
#eceived: 23 April 2010 Accepted: 20 September 2010 PubIished onIine: 15 October 2010
Abstract
Aim
The aim oI this study was to analyze the epidemiological issues related to suicide in
Ecuadorians.
Subfect and methods
This is an observational, descriptive, and epidemiological study. The data used in this
study arise Irom the National Institute oI Statistics and Censuses register. The study
analyzed gender, sex, and method used in suicide and undeIined cases.
Results
Every year in Ecuador 801 individuals die by suicide, with a prevalence rate (PR) oI
60.55 deaths per million population (pmp). Suicide is the cause oI 1.4° oI all deaths in
Ecuador. By gender, men account Ior 70.96° (PR÷42.49 pmp), while the
percentage in women is only 29.04° (PR÷17.58 pmp). The male to Iemale ratio is
~2:1; 76.79° oI all the cases involved individuals between 15 and 50 years oI age. The
most common method oI suicide is hanging, strangulation, or suIIocation (44.35°),
Iollowed by unspeciIied chemicals (20.37°) and pesticide poisoning (20.07°). Every
year in Ecuador 352.6 individuals die by unspeciIied events or undetermined intents.
These events could be a source oI hidden suicides. By gender, men account Ior 76.39°
(PR÷20.35 ppm). The male to Iemale ratio is ~3:1.
Conclusion
Suicide in Ecuador has increased in a constant and progressive way, even though there
is major underreporting oI these cases. The main method to commit suicide was
hanging Iollowed by pesticide poisoning. Suicide prevalence rates were similar to
neighboring countries in South America, with the exception oI Uruguay. UnspeciIied
events or undetermined intents could be a source oI hidden suicides, a Iact that needs
Iurther analysis.
eywords Suicide Ecuador Epidemiology Public health UnspeciIied event
Pesticides
Abbreviations !R
Prevalence rate
- pmp
Per million population
- !R
Proportionate mortality ratio

ntroduction
Suicide in Ecuador has long been neglected and poorly understood by the Ecuadorian
society which has been very conservative in dealing with this problem. It has been in
the last decade when the community has begun to discuss this topic and other related
issues in an open and honest way, especially to promote the health oI marginalized
populations (Lopez-Cevallos and Chi 2010) and to reduce the socioeconomic inequality
in Ecuador that aIIects access to health care (Parkes et al. 2009).
Suicide is the result oI an act deliberately initiated and perIormed by a person in Iull
knowledge or expectation oI its Iatal outcome (Brundtland 2001). According to a 2006
report oI the World Health Organization (WHO) over 1 million people commit suicide
every year, which is more than the combined annual deaths Irom homicides and wars
(CIS 2009). Suicide accounts Ior roughly 877,000 lives worldwide (Mann et al. 2005),
which represents 1.51.8° oI the global burden oI disease (Joe et al. 2006), and it is
expected to increase to 2.4° by the year 2020 (Bertolote and Fleischmann 2002).
Lowering suicide rates has become a key mental health target in many developed
countries (Paton et al. 2001; Hansen and Pritchard 2008; Joe et al. 2008).
Suicide is a major health concern in Latin America also (World Health Organization
2009a), despite reporting regionally the lowest suicide rate in the world with a rate oI
65 per million population (pmp), in comparison with Eastern Europe which has the
highest annual rates, where ten countries reported more than 270 pmp, and the USA
which reported a rate oI 110 pmp (World Health Organization 2009b).
Some authors (Pritchard and Hean 2008) reported signiIicant diIIerences in the patterns
oI male and Iemale younger aged suicide vs undetermined deaths in Ecuador and other
Latin American countries and highly signiIicant patterns oI suicide to undetermined
deaths compared to the average developed country. In that study, Ecuador showed a
suicide rate oI 85 pmp in male and 46 pmp in Iemale young adults between 25 and
34 years and a rate oI undetermined deaths oI 202 pmp in men and 26 pmp in women,
with a ratio oI suicide to event oI undetermined intent oI 2.38 in men and 0.57 in
women during the 3-year period analyzed (19982000). This study suggests that there is
a strong possibility oI hidden suicides among these high levels oI events oI
undetermined intent (Pritchard and Amanullah 2007).
Furthermore, these calculations are based on oIIicially reported data; hence, suicide data
are hidden and underreported Ior variable reasons such as the prevalence oI social and
cultural attitudes. Underreporting oI suicide worldwide ranges between 20 and 100°,
which underlines the importance oI bringing about corrections and improvement oI this
approach (Bertolote and Fleischmann 2002). Almost 85° oI suicides occurred in low
and middle income countries, such as AIrican, Asian, and Latin American countries
(Krug et al. 2002).
Suicide is a preventable cause oI death and attempted suicide can be up to 40 times
more common than completed suicide (Hulten et al. 2000); up to 83° oI suicide
patients previously visited a primary care physician within a year beIore oI their death
(Luoma et al. 2002) and up to 66° within a month (Andersen et al. 2000). Many oI
those who attempt suicide require medical attention and they are at high risk oI
completing suicide (Bennewith et al. 2002). Suicide aIIects everyone, but some groups
are at higher risk than others. Men are Iour times more likely than women to die Irom
suicide. However, three times more women than men report attempting suicide. In
addition, suicide rates are high among young people and those over the age oI 65
(Centers Ior Disease Control and Prevention 2008).
Major depressive disorders and bipolar disorders are associated with about 60° oI
suicides (Bertolote et al. 2003). Other related Iactors include alcohol and drug abuse,
lack oI access to psychiatric treatment, attitudes toward suicide, help-seeking behavior,
physical illness, marital status, age, and sex (Lewine and Shriner 2009). According to a
national report (PAHO/OPS 2007), the main reasons Ior psychiatric consultation in
Ecuador were violence and abuse, alcoholism, and suicide attempts.
There are a number oI possible explanations Ior these rising suicide trends: loss oI
social cohesion, breakdown oI traditional Iamily structure (Wasserman et al. 2005),
growing economic instability and unemployment (Hintikka et al. 2009), and Iinally,
rising prevalence oI depressive disorders (Kelly et al. 2009).
The aim oI this study is to analyze the epidemiological aspects related to suicide in
Ecuadorian victims and to identiIy a pattern oI this problem that allows health
authorities to improve Iuture programs oI prevention.

ateriaI and methods
Study design
This is an observational, descriptive, and epidemiological study oI case series.
Source of information
The data used in this study arise Irom the National Register oI Hospital
Admissions/Discharges and the National Mortality Register, both administered by the
National Institute oI Statistics and Censuses (INEC 2010). This register is nationally
based, run and Iunded by the government. The data collected cover an 8-year period
between 2001 and 2008. The register has been extensively used in Iormer
epidemiological studies (Gonzalez-Andrade and Lopez-Pulles 2010a, b).
Study variables
The study analyzed gender, sex, mechanism oI death, and ethnic group. The cause oI
death was described according to the nternational Classification of Diseases, Tenth
Revision (ICD-10) (World Health Organization 2007).
Definitions used
Suicide is deIined as a death resulting Irom the use oI Iorce against oneselI when a
preponderance oI the evidence indicates that the use oI Iorce was intentional. This
category includes deaths oI persons who intended only to injure rather than kill
themselves, deaths associated with risk-taking behavior that is associated with a high
risk Ior death without clear intent to inIlict Iatal injury (e.g., 'Russian roulette¨), and
suicides involving only passive assistance to the decedent (e.g., supplying the means or
inIormation needed to complete the act). The category does not include deaths caused
by chronic or acute substance abuse without the intent to die or deaths attributed to
autoerotic behavior (e.g., selI-strangulation during sexual activity). Suicidal behavior is
any deliberate action with potentially liIe-threatening consequences, such as taking a
poison or deliberately using a Iirearm. Undetermined intent is used when a death results
Irom the use oI Iorce or power against oneselI or another person Ior which the evidence
indicating one manner oI death is no more compelling than evidence indicating another.
Unintentional firearm is used when a death results Irom a penetrating injury or gunshot
wound Irom a weapon that uses a powder charge to Iire a projectile and Ior which a
preponderance oI evidence indicates that the shooting was not directed intentionally at
the decedent.
The Iollowing deIinitions were used Ior methods of infury. Firearm, method that uses a
powder charge to Iire a projectile; sharp instrument: kniIe, razor, machete, pointed
instrument (e.g., chisel or broken glass); blunt instrument: club, bat, rock, or brick;
poisoning: street drug, alcohol, pharmaceutical, carbon monoxide, gas, rat poison, or
insecticide; hanging/strangulation/suffocation: hanging by the neck, manual
strangulation, or plastic bag over the head; personal weapons: hands, Iists, or Ieet; fall:
being pushed or jumping; drowning is inhalation oI liquid in a bathtub, lake, or other
source oI water/liquid; fire/burn is inhalation oI smoke or the direct eIIects oI Iire or
chemical burns; shaking: shaking a baby, child, or adult; motor vehicle: car, bus, or
motorcycle; other transport vehicle like train or airplane; intentional neglect like
starvation, lack oI adequate supervision, or withholding oI health care; any method
other than those listed above and method not reported or not known.
Statistical analysis
Mortality rate was calculated with the Iormula deaths/population × 1,000; and
proportionate mortality ratio (PMR) was calculated with the Iormula deaths by
suicide/total deaths × 100. The prevalence rate (PR) was calculated per million
population.

#esuIts
Table 1 shows deaths by suicide or intentional selI-harm, method used, and year (codes
X60X84). Table 2 details the deaths by event oI undetermined intent or unintentional
homicides (codes Y10Y34). Table 3 shows the distribution oI deaths by gender and
age group. In all cases . the PR was calculated. Finally Table 4 provides a comparison
oI suicide PR by gender and by country.
TabIe 1 Distribution of deaths by suicide, method used, and year
Ran
k
IC
D
Causes 2001 2002 2003 2004 2005 2006 2007 2008
Tota
l
º
1 X70
Hanging,
strangulation
, or
suIIocation
202 204 240 369 447 429 517 436
2,84
4
44.3
5
2 X69
Other and
unspeciIied
chemicals
and noxious
substances
a

113 112 170 147 132 168 227 237
1,30
6
20.3
7
3 X68 Pesticides 131 134 162 172 215 190 159 124
1,28
7
20.0
7
4 X74
Other Iire
weapons
unspeciIied
89 95 72 70 84 52 57 65 584 9.11
5 X84
UnspeciIied
methods
17 13 11 9 22 20 12 12 116 1.81
6 X65
Ethanol and
related
products
1 4 1 5 26 16 17 24 94 1.47
7 X78
With sharp
objects
3 2 4 11 0 4 2 7 33 0.51
8 X64
UnspeciIied
drugs
7 2 4 5 2 2 3 5 30 0.47
9 X67
Smoke and
steam
3 0 7 0 3 3 1 1 18 0.28
10 X71
Drowning
and
submersion
5 4 0 0 0 4 1 1 15 0.23
11 X72
By gunshot
with small
weapon
5 1 0 2 1 2 0 4 15 0.23
12 X61
Antiseizure,
hypnotic,
antiparkinso
n, and
psychotropic
drugs
3 2 0 1 2 1 1 1 11 0.17
13 X66
Organic
solvents and
halogenated
hydrocarbon
s
0 2 0 0 0 2 5 0 9 0.14
14 X79 With dull 0 0 0 2 4 0 1 2 9 0.14
Ran
k
IC
D
Causes 2001 2002 2003 2004 2005 2006 2007 2008
Tota
l
º
objects
15 X62
Narcotics
and related
drugs
0 0 1 2 1 2 0 1 7 0.11
16 X75 Explosives 2 2 0 0 0 2 0 1 7 0.11
17 X73
By gunshot
with riIle or
long weapon
1 1 0 0 2 0 0 3 7 0.11
18 X80
By jumping
oII a high
place
0 0 0 0 2 0 3 1 6 0.09
19 X76
By smoke,
Iire, and
Ilames
2 0 0 0 0 0 0 3 5 0.08
20 X60 NSAIDs 1 1 0 0 0 1 0 0 3 0.05
21 X83
Other
methods
0 0 2 0 0 1 0 0 3 0.05
22 X81
By throwing
or placing in
Iront oI
moving
object
0 0 1 1 0 0 0 0 2 0.03
23 X77
Water vapor,
steam, and
hot object
0 0 0 0 0 1 0 0 1 0.02
585 579 675 796 943 900 1006 928
6,41
2

PMR 1.06 1.04 1.26 1.45 1.66 1.55 1.73 1.55 1.42
PR (pmp)
45.4
2
44.1
6
52.5
6
61.0
7
71.3
6
67.1
2
73.9
4
67.2
2
60.5
5

ÌNEC data elaborated by the authors
NSAIDs nonsteroidal anti-inflammatory drugs, PMR proportionate mortality ratio, PR prevalence
rate, pmp per million population
a
X69 category includes: corrosive aromatics, acids, and caustic alkalis, glues and adhesives,
metals including fumes and vapors, paints and dyes, plant foods and fertilizers, poisonous
foodstuffs and poisonous plants, soaps, and detergents. ÌCD codes X60÷X84: intentional self-
harm
TabIe 2 Distribution of deaths by unspecified event or undetermined intent (as a likely source of
hidden suicides), method used, and year
Ran
k
IC
D
Causes 2001 2002 2003
200
4
2005 2006
200
7
2008
Tota
l
º
1 Y34
Event not
speciIied, no
321 192 132 19 44 54 36 294
1,09
2
22.6
5
Ran
k
IC
D
Causes 2001 2002 2003
200
4
2005 2006
200
7
2008
Tota
l
º
speciIic
intention
2 Y18 Pesticides 112 80 71 32 39 46 52 29 461 9.56
3 Y22
Gunshot with
small
weapon
119 131 63 13 0 0 0 1 327 6.78
4 Y19
Poisoning
with other
chemical
substances
71 46 23 47 60 48 23 70 388 8.05
5 Y20
Hanging,
strangulation,
or
suIIocation
35 31 27 12 14 21 1 31 172 3.57
6 Y24
By other Iire
weapons
unspeciIied
51 22 12 1 1 4 2 14 107 2.22
7 Y28 Sharp objects 32 8 5 0 1 5 0 9 60 1.24
8 Y21
Drowning
and
submersion
14 9 3 1 1 0 0 10 38 0.79
9 Y26
Smoke, Iire,
and Ilames
3 13 1 1 10 0 0 11 39 0.81
10 Y33
Aggressions
with other
methods
8 11 2 0 0 0 0 0 21 0.44
11 Y14
By other
drugs,
medicines, or
biological
substances
6 0 2 0 5 2 1 4 20 0.41
12 Y17
Smoke and
steam
3 4 0 1 2 3 3 3 19 0.39
13 Y15
Poisoning by
ethanol and
related
products
4 2 2 1 2 0 0 19 30 0.62
14 Y29 Dull objects 5 1 1 1 0 0 0 3 11 0.23
15 Y12
Poisoning by
narcotics and
related drugs
3 1 1 0 1 0 0 0 6 0.12
16 Y30
By boost
Irom a high
1 1 0 0 1 2 1 2 8 0.17
Ran
k
IC
D
Causes 2001 2002 2003
200
4
2005 2006
200
7
2008
Tota
l
º
place
17 Y23
By gunshot
with riIle or
long weapon
3 0 1 0 1 0 0 0 5 0.10
18 Y11
Poisoning by
antiseizure,
hypnotic,
antiparkinson
, and
psychotropic
drugs
0 1 0 1 1 0 1 0 4 0.08
19 Y25 Explosives 0 2 0 0 1 0 0 2 5 0.10
20 Y31
By Ialling,
staying, or
running
Iorward on
moving
object
2 0 0 0 0 0 0 1 3 0.06
21 Y10
Poisoning by
NSAIDs
0 0 0 0 1 0 0 0 1 0.02
22 Y13
Poisoning by
drugs that act
on
autonomous
CNS
0 0 0 0 0 0 1 1 2 0.04
23 Y16
Poisoning by
organic
solvents and
halogenated
hydrocarbons
0 0 0 0 0 0 1 0 1 0.02
24 Y27
Water vapor,
steam and
hot object
0 0 0 0 0 1 0 0 1 0.02
793 555 346 130 185 186 122 504
2,82
1

PMR 1.94 1.00 0.65 0.24 0.33 0.32 0.21 0.84 0.62
PR (pmp)
61.5
7
42.3
3
26.9
4
9.97
14.0
0
13.8
7
8.97
36.5
1
26.6
4

ÌNEC data elaborated by the authors. ÌCD codes Y10÷Y34: unspecified event or undetermined
intent
NSAIDs nonsteroidal anti-inflammatory drugs, PMR proportionate mortality ratio, PR prevalence
rate, pmp per million population
TabIe 3 Distributions of deaths by category, gender, and main age groups
2001 2002 2003 2004 2005 2006 2007 2008 Overall
To
tal
Suicides
Age/g
ender
M F M F M F M F M F M F M F M F M ° F °
515 15 17 16
2
3
11 20 30 30 34 26 29 28 45 23 24 22
20
4
51
.9
1
18
9
48
.0
9
39
3
1550
31
4
15
1
34
9
1
4
8
34
3
18
7
41
8
18
2
50
9
21
8
44
4
24
0
54
0
22
6
50
6
19
9
3,
37
3
68
.5
0
1,
55
1
31
.5
0
4,
92
4
5065 39 14 55 7 64 7 67 14 89 11 79 19 96 15 81 26
57
0
83
.4
6
11
3
16
.5
4
68
3
_ 65 31 4 28 3 35 8 4 11 51 5 50 11 51 10 63 8
31
3
83
.9
1
60
16
.0
9
37
3
Total
39
9
18
6
44
8
1
3
1
45
3
22
2
55
9
23
7
68
3
26
0
60
2
29
8
73
2
27
4
67
4
25
4
4,
55
0
70
.9
6
1,
86
2
29
.0
4
6,
41
2
PR
(pmp)
30
.9
8
14
.4
4
34
.1
7
9.
9
9
35
.2
7
17
.2
9
42
.8
9
18
.1
8
51
.6
8
19
.6
7
44
.9
0
22
.2
3
53
.8
0
20
.1
4
48
.8
2
18
.4
0
42
.4
9

17
.5
8

60
.5
5
Undetermined intent or unspeciIied event
_ 1 2 3 1 3 2 0 0 0 1 2 1 2 2 1 12 6 21
52
.5
0
19
47
.5
0
40
15 10 10 12 4 7 2 2 1 6 6 5 6 4 3 10 4 56
60
.8
7
36
39
.1
3
92
515 24 18 23
1
3
11 11 4 3 12 5 8 5 3 8 9 8 94
56
.9
7
71
43
.0
3
16
5
1550
46
3
93
29
9
7
5
18
1
49 61 33 60 39 73 39 47 20
24
5
57
1,
45
0
78
.2
5
40
3
21
.7
5
1,
85
3
5065 66 15 61 5 43 3 13 1 21 3 21 3 15 2 62 12
30
2
87
.2
8
44
12
.7
2
34
6
_ 65 69 20 44
1
5
33 4 11 1 17 13 10 13 14 3 55 24
25
3
73
.1
2
93
26
.8
8
34
6
Total
63
4
15
9
44
0
1
1
5
27
7
69 91 39
11
7
68
11
8
68 85 37
39
3
11
1
2,
15
5
76
.3
9
66
6
23
.6
1
2,
82
1
2001 2002 2003 2004 2005 2006 2007 2008 Overall
To
tal
PR
(pmp)
49
.2
3
12
.3
5
33
.5
6
8.
7
7
21
.5
7
5.
37
6.
98
2.
99
8.
85
5.
15
8.
80
5.
07
6.
25
2.
72
28
.4
7
8.
04
20
.3
5

6.
29

26
.6
4
ÌNEC data elaborated by the authors. Age in years
PR prevalence rate, pmp per million population
TabIe 4 Comparison of suicide prevalence rates by gender and by country
Country (WHO data) Year
a
Male Female Total
Belarus 2003 633 103 351
Lithuania 2008 559 91 307
Kazakhstan 2007 462 90 269
Uruguay 2004 260 63 158
Canada 2004 173 54 113
USA 2005 177 45 110
Chile 2005 174 34 103
Costa Rica 2006 132 25 80
Argentina 2005 127 34 79
Spain 2005 120 38 78
Ecuador (WHO) 2005 104 40 72
Ecuador (our data) 2005 51 19 71
Ecuador (our data) 2008
b
42 18 61
Colombia 2005 78 21 49
Brazil 2005 73 19 46
Paraguay 2004 55 27 41
Mexico 2006 68 13 40
Venezuela 2005 61 14 38
Guatemala 2006 36 11 23
Peru 2000 11 6 9
HO country reports and charts (orld Health Organization 2009a, b); elaborated by the
authors. Age in years
PR prevalence rate, pmp per million population
a
Last year reported
b
Average of period 2001÷2008
Suicide
Every year in Ecuador 801 individuals die by suicide, with a PR oI 60.55 deaths pmp.
Suicide is the cause oI 1.4° oI all deaths in Ecuador. By gender, men account Ior
70.96° with a PR oI 42.49 pmp, while the percentage in women is only 29.04° oI the
total, with a PR oI 17.58 pmp. The male to Iemale ratio is ~2:1; 76.79° oI all the cases
involved individuals between 15 and 50 years oI age. The most common method oI
suicide is hanging, strangulation, or suIIocation (44.35°), Iollowed by unspeciIied
chemicals (20.37°) and pesticide poisoning (20.07°).
Unspecified event or undetermined intent
Every year in Ecuador 352.6 individuals die by unspeciIied events or undetermined
intents. These events could be a source oI hidden suicides. By gender, men account Ior
76.39° with a PR oI 20.35 ppm, while women account Ior only 23.61° with a PR oI
6.29 ppm. The male to Iemale ratio is ~3:1; 65.69° oI all the cases involved individuals
between 15 and 50 years oI age. In relation to method oI death the unspeciIied events
are the most common method used (22.65°), Iollowed by pesticides (9.56°) and
gunshot with a small weapon (6.78°). The suicide/undetermined intent rate Ior all ages
is 2.27 (6,412/2,821).
Suicide pattern
The proIile oI Ecuadorian suicide is a man, Mestizo (admixture between a white and a
Native Amerindian), between 15 and 49 years oI age, who selI-destructs by hanging,
strangulation, or suIIocation Iirstly, or by using chemicals or pesticides, in his own
residence. Problems related to mental health, employment, Iinances, or relationships
also might have contributed to the high rates oI suicide in this age group. Current
mental health and/or substance abuse problems, relationship problems and losses, and
recent socioeconomic crises were Irequent precipitants Ior suicide. These Iactors have
been documented also in other studies as important risk Iactors Ior suicide.
Alcohol and drug abuse in persons with and without aIIective mood disorders both were
associated with suicidal behavior. However, this relation is quite complex; Ior instance,
alcohol abuse might lead directly to depression or indirectly through the sense oI
decline and Iailure that is experienced by the majority oI persons who are dependent on
alcohol. Alcohol also might be a Iorm oI selI-medication to alleviate depression.
A previous suicide attempt is an important predictor oI subsequent Iatal suicidal
behavior. Disclosure oI intent also is an important warning sign oI suicidal intentions,
although persons in close contact with potential victims oI suicide are oIten unaware oI
the signiIicance oI these warnings or unsure oI how to act on them.

iscussion
This manuscript reIlects the urgent need to understand this phenomenon and raise
eIIective prevention policies, as well as begin a new stage in the proper management oI
mental health. This is the Iirst Iormal study published on the epidemiology oI suicide in
Ecuador. Similar research has been carried out widely in English-speaking developed
countries, so this study oIIers an opportunity to analyze possible cultural inIluences on
the prevalence oI these phenomena.
Strengths and Iimitations of this study
The Iindings provided in this report are subject to a Iew limitations. First, the
availability, completeness, and timeliness oI data are dependent on data sharing among
institutions involved in gathering inIormation. This is challenging in some small
provinces, where not enough resources exist to monitor these cases. Data Irom these
remote regions are not expected to be as accurate as in large cities, so the results could
be biased. The abstractors are limited to the data included in the reports that they
receive. Also some reports do not reIlect all inIormation known about an event,
particularly in the case oI violence, where data are less readily available until aIter
prosecutions are complete. In other cases, death deIinitions present challenges when a
single death is classiIied in a diIIerent way or some variations in coding might occur
depending on the abstractor`s level oI experience. Despite this, the national register is
the only inIormation available until now and it is the major source oI inIormation.
On the other hand, underrecording oI suicides is a usual problem existing in most oI the
countries around the region, owing to the variety oI ways these causes are coded and
analyzed, insuIIicient Iunding Ior inIormation management, lack oI trained personnel
and coordinated data collection, and the existence oI a non-centralized system Ior
issuing reports. The morbidity and mortality statistics compiled by the services do not
reIlect the whole magnitude oI this problem which could be higher. In addition, victims
oIten do not seek support services at health institutions so that the events oI
undetermined attempts could be a source oI hidden suicides.
Sociodemographic factors
The methods oI suicide Iound in this study were similar to others reported in the world
(Ajdacic-Gross et al. 2008). There are well-known diIIerences between men and
women. Violent and highly lethal methods such as Iirearm suicide and hanging are
more Irequent among men, whereas women oIten choose poisoning or drowning, which
are less violent and less lethal (Ajdacic-Gross et al. 2008). Hanging was the most
Irequent method when no other major method was available, Iollowed by unknown
poisons and pesticides; iI these last two are added, the second most common method oI
suicide in Ecuador is poisoning in general.
The proportion oI hangings typically decreases as either pesticide suicide or Iirearm
suicide increases. Pesticide suicide has been recognized as a major public health
problem in Ecuador as has been demonstrated in Iormer studies (Gonzalez-Andrade et
al. 2010). A very common substance used to commit suicide is white phosphorus (WP),
in a commercially produced Iirecracker called little devil. Little devils are explosive
tablets that Ilame by violent Iriction, cost US $0.25 each, and have a mortality rate that
ranges between 20 and 90°, a Iast, cheap, and secure way to kill oneselI (Gonzalez-
Andrade et al. 2002). Other common known substances are organophosphates and
carbamates that cause death by inhibition oI acetylcholinesterase and are Irequent as
pesticides in banana and Ilower plantations in Ecuador.
Firearm suicide was not Irequent in our country because the private use oI Iirearms is
Iorbidden. However, in recent years a very important increase in the illegal circulation
oI Iirearms has increased the levels oI violence, and it is thought that this will increase
the homicide and suicide rate Ior Iirearms.
The most Irequent age to commit suicide ranged Irom 15 to 50 years; there was no
speciIic risk group aIIected in our study mainly due to a lack oI speciIic inIormation on
this issue. These Iindings do not coincide with other studies that have shown a notorious
increase oI suicide in adolescents in Latin America, or in the case oI some developed
countries, in elderly people. Further studies are necessary to clariIy this aspect. On the
other hand, men committed suicide more Irequently than women, a circumstance that
does not diIIer Irom other regional analyses.
The circumstances are quite diIIerent regarding unspeciIied events or undetermined
intent. In the majority oI cases the method used was unknown, which made it diIIicult to
establish a pattern. The second most Irequent method in this group was the use oI
pesticides, Iollowed by gunshot with a small weapon. These Iindings indicate that there
is a conIounding Iactor in the etiology oI the problem between suicides and homicides.
However, it is clear that more studies are needed on the cause oI the death at a crime
scene. It could be inIerred that using pesticides or other related substances, hanging and
the use oI a Iirearm are similar methods seen in suicide cases, and thereIore they could
be hidden cases oI suicides. On the other hand, there were a variety oI methods used to
commit suicide, some oI them very creative but not very eIIective. A great quantity oI
them do not seek to kill themselves in a very precise way. It is possible that a Iew cases
were only suicide attempts that Iailed unIortunately.
Psychiatric issues
Suicidal behavior exists along a continuum Irom thinking about ending one`s liIe, to
developing a plan, to nonIatal suicidal behavior, to ending one`s liIe. Suicidal behaviors
almost always occur in people with depression, bipolar disorder, schizophrenia, and
alcohol dependence. According to the Ministry oI Public Health (MPH 2010), every
year there are 1,750 suicide attempts in Ecuador (PR÷133.7 ppm), and the ratio oI
suicide attempt to suicide is 19:1.
People who attempt suicide are oIten trying to get away Irom a liIe situation that seems
impossible to deal with. Many who make a suicide attempt are seeking relieI Irom bad
thoughts or Ieelings, Ieeling ashamed, guilty, or like a burden to others, Ieeling like a
victim or Ieelings oI rejection, loss, or loneliness. In our study, this standard pattern
could not be recognizable because all our data were retrieved Irom hospitalization
registers.
Analyzing the same data, oIIicial records also show an increase oI the rate oI suicides
across time in the last 40 years, Irom a PR oI 23 pmp in 1971 to 67 pmp in 2008,
accounting Ior a total increase oI 190°. Similar data were Iound in this study: a
constant, yearly, and progressive increase in the suicide PR (MPH 2010).
Some authors (Pritchard and Hean 2008) believe that the deaths by undetermined intent
could be an important source oI hidden suicides, particularly in countries where
Catholicism is the primary religion. It is known that according to the Catholic religion, a
person who commits suicide cannot attain divine status aIter death. So many Iamilies at
the time oI Iilling out the paperwork ask that suicide not be mentioned as the cause oI
death and preIer to use the term accident.
On the other hand, suicide involves opening a criminal investigation by prosecutors
seeking to establish the motive and the speciIic cause oI death. Similarly, many
traditional Iamilies are opposed to legal intervention in these cases and hide behind the
word accident in cases oI a possible suicide. It is worth mentioning that assisted suicide
is not allowed in Ecuador. This religious inIluence has Iorced many Iamilies to keep this
issue within their Iamilies without seeking the support oI the specialized mental health
programs in this Iield.
This is an important aspect that deserves Iurther and complex studies. Regarding this
issue, in the category oI unspeciIied events the most common method oI death was also
the use oI pesticides, and it is still unknown whether these deaths were related to
unintentional poisonings or deliberate suicides.
#egionaI comparisons
As the reader can see in Table 4, the suicide PR was similar to the neighboring countries
in South America, with the exception oI Uruguay and Chile which show a higher PR. II
the PR is divided into Iour main groups, Guatemala and Peru have the lowest PR (less
than 30 pmp), the next group (between 30 and 100 pmp) comprises Ecuador and Central
and South America, the third group (between 100 and 150 pmp) covers North America,
and Iinally the Iourth group (over 150 pmp) involves the Eastern European region. It is
not possible to determine which Iactors aIIected these regional diIIerences, especially in
Uruguay, but deIinitely the world economic crisis in recent years is an important Iactor
to consider.
Prevention opportunities
Many prevention opportunities are available to reduce suicide deaths. Risk and
protective Iactors Ior interpersonal and selI-directed violence operate at multiple levels
oI social inIluence. Prevention programs can beneIit Irom considering both the best way
to address individual-level Iactors and the Iactors within Iamilies, peer groups, schools,
and communities that contribute to suicidal behavior. In general, prevention approaches
that address multiple domains oI inIluence on behavior are more likely to have a
preventive impact than those that Iocus on a single risk Iactor. Programs designed to
enhance social problem-solving and coping skills to deal with stressIul liIe events,
health and Iinancial problems, or other problems that occur within interpersonal
relationships can potentially reduce the suicide rate.
In addition to demonstrating the need to address situational stressors, the Iindings in this
report underscore the importance oI changing cultural and social norms and addressing
the social and economic conditions within communities. Mental health problems also
were prevalent among suicide decedents who did not receive treatment previously.
Again, these results highlight the importance oI knowing the signs and symptoms oI
suicidal behavior, reaching out to those with problems, reducing the stigma oI mental
illness, and increasing the accessibility oI treatment which can contribute to preventing
suicide.

ConcIusion
Suicide in Ecuador has increased in a constant and progressive way, even though there
is major underreporting oI these cases. The main method to commit suicide was
hanging Iollowed by pesticide poisoning. Suicide prevalence rates were similar to
neighboring countries in South America, with the exception oI Uruguay. UnspeciIied
events or undetermined intents could be a source oI hidden suicides, a Iact that needs
Iurther analysis.
Aknowledgements This study is part oI a research network and the initiative called
iomedical Research and !ublic Health in Ecuador (INBIOSEC, Investigacion
Biomedica y Salud Publica en Ecuador) which aims to improve health policies through
targeted research. The authors are grateIul to the researchers and health authorities that
support this initiative.
Contribution of the authors
All authors contributed equally to the conception, design, analysis and interpretation oI
data, draIting the article, Iurther revision oI this paper, and critical review oI the content.
Funding
None.
Conflict of interest
The authors declare that they have no conIlict oI interest.

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