What are reasons for the large gender differences in the lethality of suicidal acts? An epidemiological analysis in four European countries

Mergl, Roland; Koburger, Nicole; Heinrichs, Katherina; Szekely, Andras; Toth, Monika Ditta; Coyne, James C.; Quintao, Sonia; Arensman, Ella; Coffey, Claire; Maxwell, Margaret; Vaernik, Airi; Van Audenhove, Chantal; McDaid, David; Sarchiapone, Marco; Schmidtke, Armin; Genz, Axel; Gusmão, Ricardo; Hegerl, Ulrich

What are reasons for the large gender differences in the lethality of suicidal acts? An epidemiological analysis in four European countries

dc.contributor.author	Mergl, Roland
dc.contributor.author	Koburger, Nicole
dc.contributor.author	Heinrichs, Katherina
dc.contributor.author	Szekely, Andras
dc.contributor.author	Toth, Monika Ditta
dc.contributor.author	Coyne, James C.
dc.contributor.author	Quintao, Sonia
dc.contributor.author	Arensman, Ella
dc.contributor.author	Coffey, Claire
dc.contributor.author	Maxwell, Margaret
dc.contributor.author	Vaernik, Airi
dc.contributor.author	Van Audenhove, Chantal
dc.contributor.author	McDaid, David
dc.contributor.author	Sarchiapone, Marco
dc.contributor.author	Schmidtke, Armin
dc.contributor.author	Genz, Axel
dc.contributor.author	Gusmão, Ricardo
dc.contributor.author	Hegerl, Ulrich
dc.contributor.funder	Seventh Framework Programme
dc.contributor.funder	Deutsche Forschungsgemeinschaft
dc.contributor.funder	Universität Leipzig
dc.date.accessioned	2016-02-17T10:07:57Z
dc.date.available	2016-02-17T10:07:57Z
dc.date.issued	2015
dc.description.abstract	Background: In Europe, men have lower rates of attempted suicide compared to women and at the same time a higher rate of completed suicides, indicating major gender differences in lethality of suicidal behaviour. The aim of this study was to analyse the extent to which these gender differences in lethality can be explained by factors such as choice of more lethal methods or lethality differences within the same suicide method or age. In addition, we explored gender differences in the intentionality of suicide attempts. Methods and Findings: Methods. Design: Epidemiological study using a combination of self-report and official data. Setting: Mental health care services in four European countries: Germany, Hungary, Ireland, and Portugal. Data basis: Completed suicides derived from official statistics for each country (767 acts, 74.4% male) and assessed suicide attempts excluding habitual intentional self-harm (8,175 acts, 43.2% male). Main Outcome Measures and Data Analysis: We collected data on suicidal acts in eight regions of four European countries participating in the EU-funded "OSPI-Europe"-project (www.ospi-europe.com). We calculated method-specific lethality using the number of completed suicides per method * 100 /(number of completed suicides per method + number of attempted suicides per method). We tested gender differences in the distribution of suicidal acts for significance by using the chi(2)-test for two-by-two tables. We assessed the effect sizes with phi coefficients (phi). We identified predictors of lethality with a binary logistic regression analysis. Poisson regression analysis examined the contribution of choice of methods and method-specific lethality to gender differences in the lethality of suicidal acts. Findings Main Results: Suicidal acts (fatal and non-fatal) were 3.4 times more lethal in men than in women (lethality 13.91% (regarding 4106 suicidal acts) versus 4.05% (regarding 4836 suicidal acts)), the difference being significant for the methods hanging, jumping, moving objects, sharp objects and poisoning by substances other than drugs. Median age at time of suicidal behaviour (35-44 years) did not differ between males and females. The overall gender difference in lethality of suicidal behaviour was explained by males choosing more lethal suicide methods (odds ratio (OR) = 2.03; 95% CI = 1.65 to 2.50; p < 0.000001) and additionally, but to a lesser degree, by a higher lethality of suicidal acts for males even within the same method (OR = 1.64; 95% CI = 1.32 to 2.02; p = 0.000005). Results of a regression analysis revealed neither age nor country differences were significant predictors for gender differences in the lethality of suicidal acts. The proportion of serious suicide attempts among all non-fatal suicidal acts with known intentionality (NFSAi) was significantly higher in men (57.1%; 1,207 of 2,115 NFSAi) than in women (48.6%; 1,508 of 3,100 NFSAi) (chi(2) = 35.74; p < 0.000001). Main Limitations of the Study: Due to restrictive data security regulations to ensure anonymity in Ireland, specific ages could not be provided because of the relatively low absolute numbers of suicide in the Irish intervention and control region. Therefore, analyses of the interaction between gender and age could only be conducted for three of the four countries. Attempted suicides were assessed for patients presenting to emergency departments or treated in hospitals. An unknown rate of attempted suicides remained undetected. This may have caused an overestimation of the lethality of certain methods. Moreover, the detection of attempted suicides and the registration of completed suicides might have differed across the four countries. Some suicides might be hidden and misclassified as undetermined deaths. Conclusions: Men more often used highly lethal methods in suicidal behaviour, but there was also a higher method-specific lethality which together explained the large gender differences in the lethality of suicidal acts. Gender differences in the lethality of suicidal acts were fairly consistent across all four European countries examined. Males and females did not differ in age at time of suicidal behaviour. Suicide attempts by males were rated as being more serious independent of the method used, with the exceptions of attempted hanging, suggesting gender differences in intentionality associated with suicidal behaviour. These findings contribute to understanding of the spectrum of reasons for gender differences in the lethality of suicidal behaviour and should inform the development of gender specific strategies for suicide prevention.	en
dc.description.sponsorship	European Commission (Seventh Framework Programme Grant Agreement No. 223138); Universität Leipzig, Germany (Open Access Publishing program)	en
dc.description.status	Peer reviewed	en
dc.description.version	Published Version	en
dc.format.mimetype	application/pdf	en
dc.identifier.articleid	e0129062
dc.identifier.citation	Mergl R, Koburger N, Heinrichs K, Székely A, Tóth MD, Coyne J, et al. (2015) What Are Reasons for the Large Gender Differences in the Lethality of Suicidal Acts? An Epidemiological Analysis in Four European Countries. PLoS ONE 10(7): e0129062. doi:10.1371/journal.pone.0129062
dc.identifier.doi	10.1371/journal.pone.0129062
dc.identifier.issn	1932-6203
dc.identifier.issued	7	en
dc.identifier.journaltitle	PLOS ONE	en
dc.identifier.uri	https://hdl.handle.net/10468/2302
dc.identifier.volume	10	en
dc.language.iso	en	en
dc.publisher	Public Library of Science	en
dc.relation.project	info:eu-repo/grantAgreement/EC/FP7::SP1::HEALTH/223138/EU/Optimizing suicide prevention programs and their implementation in Europe/OSPI-EUROPE
dc.rights	© 2015 Mergl et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited	en
dc.rights.uri	http://creativecommons.org/licenses/by/4.0/	en
dc.subject	Case fatality rates	en
dc.subject	Behavior	en
dc.subject	Deaths	en
dc.subject	Multicenter	en
dc.subject	Depression	en
dc.subject	Alliance	en
dc.subject	States	en
dc.title	What are reasons for the large gender differences in the lethality of suicidal acts? An epidemiological analysis in four European countries	en
dc.type	Article (peer-reviewed)	en