Research report
Preference of lethal methods is not the only cause for higher suicide rates in males

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Abstract

Background

In most countries worldwide suicide rates are higher for males whereas attempted suicide rates are higher for females. The aim is to investigate if the choice of more lethal methods by males explains gender differences in suicide rates.

Methods

Data on completed and attempted suicides were collected (n = 3235, Nuremberg and Wuerzburg, years 2000–2004). The research question was analyzed by comparing the method-specific case fatality (= completed suicides / completed + attempted suicides) for males and females.

Results

Among the events captured, men chose high-risk methods like hanging significantly more often than women (φ =  0.27; p < 0.001). However, except for drowning, case fatalities were higher for males than for females within each method. This was most apparent in “hanging” (men 83.5%, women 55.3%; φ =  0.28; p < 0.001) and “poisoning by drugs” (men 7.2%, women 3.4%; φ =  0.09; p < 0.001).

Limitations

The sample size (n = 3235) was not enough for comparing method and gender specific case fatalities with a fine-meshed stratification regarding age.

Conclusions

Higher suicide rates in males not only result from the choice of more lethal methods. Other factors have to be considered.

Introduction

Approximately 1 million people worldwide die of suicide every year and the number of attempted suicides is estimated to be 10 to 20 times higher (World Health Organization, 2003). In Europe and most countries rates of completed suicides differ profoundly by gender with a global average male/female ratio of 2.9:1 (Värnik et al., 2008). Opposite to the rate of completed suicides, females outnumber males with respect to the number of attempted suicides. Results from the WHO/EURO Multicentre Study on parasuicide show a male/female ratio for non-fatal suicide acts of 1:1.5 (Schmidtke et al., 1996). Given the high numbers of annual suicides, prevention has been an important issue worldwide. In Western countries, high male suicide rates are of specific concern. Thus, an essential matter for improving suicide prevention is to find out more about the reasons for gender differences in suicide and especially about suicide patterns in males.

Several reasons for gender differences in suicidal behavior have been discussed. Depression as a major cause of suicidality (Bertolote and Fleischmann, 2002, Lönnqvist and Koskenvuo, 1988) has about half the prevalence in males compared to females. This could be a contributing factor to the lower rates of suicidal acts in total (completed + attempted suicides) in males, but does not explain why more males have higher completed-suicide rates. Further factors possibly contributing to the high male suicide rate are psychosocial factors: men are more reluctant to seek professional help compared to women when feeling depressed, hopeless or suicidal (Houle et al., 2008, Möller-Leimkühler, 2003), they often have less social support than women (Houle et al., 2005, Houle et al., 2008), unemployment seems to be a major threat especially to males (Andres et al., 2010, Stuckler et al., 2009), and a strong link between alcohol dependence and depression in men increases their suicide risk (Houle et al., 2008, Möller-Leimkühler, 2003). Furthermore, the choice of more or less lethal methods appears to be an important factor. While males in total carry out less suicidal acts, they choose more high-risk methods than women as shown by various studies (Hawton, 2000, Houle et al., 2008, Large and Nielssen, 2010, Schrijvers et al., 2011). High-risk methods have been defined as being more violent and immediately lethal in comparison to low-risk methods (Denning et al., 2000). Methods with the highest case fatality are firearms and hanging. In a recent study analyzing 16 European countries, Värnik et al. (2008) have shown that males are at greater risk of choosing highly lethal suicide methods such as hanging and firearms whereas females are at less risk with mostly choosing self-poisoning.

Additionally, age patterns seem to play an important role in suicidal behavior. In Germany, suicide rates follow the so-called Hungarian pattern, with higher numbers of completed suicides within the elderly, specifically males (Schmidtke et al., 2008). However, in other parts of Europe, e.g. in Scandinavian countries and Poland, suicide rates are highest between the ages of 45–55 years (Lester, 1982). Importantly, the age at which a suicidal act is carried out influences case fatality. For instance, self-poisoning with psychotropic drugs might be survived by a young person, but can be lethal at an older age. Thus, age needs to be taken into account when disentangling the factors explaining gender differences in suicidality.

If the preference for certain methods is the dominant factor explaining gender differences in suicide rates, then within the same method case fatalities should be similar in males and females, even after accounting for age effects (highest rates of attempted suicides in young females, highest rates of completed suicides in old males). If case fatalities differ by gender, other factors beyond the choice of method must be considered to explain higher male suicide rates.

We wanted to investigate why completed suicides occur more frequently in males although the number of suicidal acts in total is higher in females. Thus, we analyzed whether the choice of methods fully explains higher rates of completed suicide in males answering the following questions: 1. Are there gender differences in case fatality within the same suicide method? 2. Can possible gender differences in case fatality be explained by the influence of age?

Section snippets

Methods

Data used in the present study were assessed during a suicide prevention project, the “Nuremberg Alliance Against Depression”, “a 2-year, four-level, multifaceted, community-based intervention with evaluation with respect to both a baseline year and a control region” (Hegerl et al., 2006; p. 1230). The data on completed and attempted suicides from 2000 to 2004 were collected in the city of Nuremberg (480,000 inhabitants) and the region of Wuerzburg (260,000 inhabitants) in Bavaria, Germany.

Results

In Nuremberg and Wuerzburg 3235 cases of suicidal acts occurred during the study time, 656 completed suicides and 2579 attempted suicides. In total, there were 1766 women and 1469 men. Similar to national data and data of previous studies, men had higher rates of completed suicides (n = 478, 72.9%, 95% C.I.: 69.3%–76.2%) than women (n = 178, 27.1%, 95% C.I.: 23.8%–30.7%). Females had higher rates of attempted suicides (n = 1588, 61.6%, 95% C.I.: 59.7%–63.5%) than males (n = 991, 38.4%, 95% C.I.:

Main findings

Consistent with prior studies (Denning et al., 2000, Elnour and Harrison, 2008, Kposowa and McElvain, 2006), suicidal acts were associated with higher lethality in males than in females. Since underlying reasons are only partly understood, gender differences in case fatality with respect to different methods were analyzed. It was found that for all suicide methods except for drowning case fatality was higher in men. This was most apparent for methods like hanging (men: 83.5%; women: 55.3%) and

Role of funding source

This project was supported by the German Ministry for Education and Research within the promotional emphasis “German Research Network on Depression and Suicidality”. The sponsor had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

The authors have no relevant financial relationships to disclose.

Acknowledgments

We would like to thank all investigators who participated in this study. Moreover, we want to thank Dipl.-Psych. Jörg Kunz for methodological advice.

This project was supported by the German Ministry for Education and Research within the promotional emphasis “German Research Network on Depression and Suicidality”. The authors report no financial or other relationship relevant to the subject of this paper.

The sponsor was not involved in study design, in the collection, analysis and interpretation

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