Suicide mortality trends in the Nordic countries 1980-2009

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DOI: 10.3109/08039488.2012.752036 · Source: PubMed
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Abstract
Background and aim: The Nordic countries provide a suitable setting for comparing trends in suicide mortality. The aim of this report is to compare suicide trends by age, gender, region and methods in Denmark, Finland, Iceland, Norway and Sweden 1980-2009. Methods: Suicide statistics 1980-2009 were analyzed for men and women aged 15 years and above and the age group 15-24 years. Regional suicide rates in 2009 were presented in maps. Results: The suicide rates across the Nordic countries declined from 25-50 per 100,000 in 1980 to 20-36 in 2009 for men and from 9-26 in 1980 to 8-11 in 2009 for women. The rates in Finland were consistently higher than those of the other countries. A significant increase of suicides in young women in Finland and Norway and a lack of a decline among young women in Sweden were noted. The male- female ratio of suicide converged to approximately 3:1 across the region during the study period. Rural areas in Finland, Norway and Sweden saw the highest suicide rates, whereas the rates in the capital regions of Denmark, Norway and Sweden were lower than the respective national rates. Conclusions: We hold that the overall decline of suicide rates in the Nordic countries reflects the socio-economic development and stability of the region, including the well-functioning healthcare. The increasing rates in Finland and Norway and the unchanged rate in Sweden of suicide in young women are an alarming trend break that calls for continued monitoring.
Suicide mortality trends in the Nordic
countries 1980 – 2009
DAVID TITELMAN , H Ø GNI OSKARSSON , KRISTIAN WAHLBECK ,
MERETE NORDENTOFT , LARS MEHLUM , GUO-XIN JIANG ,
ANNETTE ERLANGSEN , LATHA NRUGHAM , DANUTA WASSERMAN
Titelman D, Oskarsson H, Wahlbeck K, Nordentoft M, Mehlum L, Jiang G-X, Erlangsen A,
Nrugham L, Wasserman D. Suicide mortality trends in the Nordic countries 1980 2009.
Nord J Psychiatry 2013;Early Online:1 – 10.
Background and aim: The Nordic countries provide a suitable setting for comparing trends in
suicide mortality. The aim of this report is to compare suicide trends by age, gender, region and
methods in Denmark, Finland, Iceland, Norway and Sweden 1980 2009. Methods: Suicide statistics
1980 2009 were analyzed for men and women aged 15 years and above and the age group 15 24
years. Regional suicide rates in 2009 were presented in maps. Results: The suicide rates across the
Nordic countries declined from 25 50 per 100,000 in 1980 to 20 36 in 2009 for men and from
9 26 in 1980 to 8 11 in 2009 for women. The rates in Finland were consistently higher than those
of the other countries. A signifi cant increase of suicides in young women in Finland and Norway
and a lack of a decline among young women in Sweden were noted. The male female ratio of
suicide converged to approximately 3:1 across the region during the study period. Rural areas in
Finland, Norway and Sweden saw the highest suicide rates, whereas the rates in the capital regions
of Denmark, Norway and Sweden were lower than the respective national rates. Conclusions: We
hold that the overall decline of suicide rates in the Nordic countries refl ects the socio-economic
development and stability of the region, including the well-functioning healthcare. The increasing
rates in Finland and Norway and the unchanged rate in Sweden of suicide in young women are an
alarming trend break that calls for continued monitoring.
Nordic countries , Social factors , Suicide , Suicide in the young , Young women
David Titelman, Ph.D., Associate professor, NASP, Karolinska Institutet, 17177 Stockholm,
Sweden, E-mail: david.titelman@ki.se; Accepted 18 November 2012.
© 2013 Inform a Healthcare DOI : 10.3109/ 08039 488.2012 .752036
S uicide is an important public health problem and one
of the leading causes of death in young people
around the world (1 3). In the ve Nordic countries,
Denmark, Finland, Iceland, Norway and Sweden, suicide
is the second most common cause of death in the age
group 15 24 years, except for Finnish women among
whom it is the fi rst (4).
In 2009, the populations of these countries were:
Denmark, 5.5 million; Finland, 5.3 million; Iceland, 0.3
million; Norway, 4.8 million; and Sweden, 9.3 million
(5). As part of their social welfare model, they have
comparable, tax-funded healthcare systems that are acces-
sible to all citizens and permanent residents. In all fi ve
countries, suicide has been targeted in national prevention
action plans: Finland, 1991 (6), Norway, 1994 (7), Swe-
den, 1995/2008 (8, 9), Denmark, 1998 (10) and Iceland,
2003 (11). The well-regulated and transparent economic,
social and political conditions of the Nordic region
provide a basis for a benchmarking exercise comparing
trends in suicide mortality between its countries.
Aims
The rst aim of this paper is to describe the trends in
suicide rates among men and women in the Nordic coun-
tries 1980 to 2009 in the adult population (15 years and
above) and in the age group 15 24 years. A second aim
is to investigate the regional distribution of suicide and
the patterns of suicide methods.
Methods
Annual gures of suicide 1980 2009 for both genders,
ages 15 years and above and 15 24 years, were collected
from the national cause-of-death registers in the fi ve
countries. In all of them, unnatural causes of death are
determined by appointed medical doctors. There was
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Suicide rates were calculated as the number of suicides
divided by the mean population in the same age range in
each year. Rates and percentile distributions were calcu-
lated separately for men and women. Regional suicide
rates in the adult population of the fi ve countries in 2009
were illustrated on maps retrieved from the Nordic Centre
for Spatial Development (Nordregio). Five levels of sui-
cide rates are applied (the levels for men were 20.0,
20.0 25.0, 25.0 30.0, 30.0 35.0 and 35.0 suicides per
100,000; the levels for women were 5.0, 5.0 7.5, 7.5 10.0,
10.0 – 12.5 and 12.5).
Trends in suicide rates over time were tested using
univariate linear regression analysis by gender and coun-
try. Single calendar-year increments were the independent
variable. T -tests and two-tailed P -values were applied to
no major change of the practice of ascertaining suicide
during the examined period.
Causes of death were documented according to the
8th, 9th and 10th revisions of the International Statistical
Classifi cation of Diseases and Related Health Problems
(ICD). In ICD-8 and ICD-9, suicide included suicide
and self-infl icted injury (E950 E959). In ICD-10, suicide
is defi ned as intentional lethal self-harm or a sequel
thereof (X60 X84, Y87.0).
Based on the ICD-10 codes, the documented suicide
methods for 2009 were divided into the following catego-
ries: poisoning (X60 X69), hanging (X70), rearms (X72
X74), drowning (X71), jumping from a high place (X80),
moving object (X81 X82), the use of sharp objects (X78)
and other methods (X75 X77, X79, X83 X84, Y87.0).
Fig. 1 . (a) Suicide rates per 100,000 (5-year averages) in the Nordic countries during 1980 2009, ages 15 years and above; (b) suicide
rates per 100,000 (5-year averages) in the Nordic countries during 1980 2009, ages 15 24 years.
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SUICIDE TRENDS IN THE NORDIC COUNTRIES 1980−2009
NORD J PSYCHIATRY·EARLY ONLINE·2013 3
Finnish suicide rates were the highest in the Nordic
region during most of the study period. In all countries,
the male rate was markedly higher than the female rate.
Men, 15 years and above
In 2005 09, the suicide rates for men in Denmark,
Norway, Iceland and Sweden converged to a common
annual level of about 20 suicides per 100,000 inhabitants.
The most dramatic decline of the male suicide rate
occurred in Denmark. From 1980 to 2009, it dropped
from nearly 50 to about 20 per 100,000.
After rising to a peak of more than 60 suicides per
100,000 in the early 1990s (Table 1a), the male suicide
rate in Finland started to fall and continued to do so dur-
ing the rest of the study period. In 2005 09, it had reached
a level of approximately 35. Despite this signifi cant
assess statistical signifi cance. The signifi cance level was
set at 0.05.
Results
The changes in the suicide rate in the adult and young
population in each of the Nordic countries are illustrated
in Figures 1a and 1b. Crude annual suicide rates for each
country are found in Tables 1a and 1b. Across the Nordic
region, the suicide rates in the youngest age group devi-
ated from the overall, declining trend: a signifi cant
decline in the suicide rate was noted for both men and
women (all age groups) in all countries except Iceland
and for young women in Finland, Norway and Sweden
(Table 2); the suicide rates in Iceland were the lowest of
the fi ve countries for all groups except young men. The
Fig. 1 . (Continued)
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4 NORD J PSYCHIATRY·EARLY ONLINE·2013
as that of the other countries 1980 84, from 2000 and onward
it was between 6 and 9 per 100,000, that is, within the same
range as that seen in Norway, Iceland and Sweden.
A moderate decline occurred among women (all age
groups) in Finland, Norway and Sweden during the study
period, albeit that the female rate in Finland remained
slightly higher than that in the other countries ( 10 vs.
6
9 per 100,000 during 1995 2009).
Young people, 15 24 years
Suicide rates in the age group 15 24 years are seen in
Figure 1b. As in the population at large, the decline of
the suicide rate during the study period was signifi cant
for young men in Denmark, Finland, Norway and Swe-
den but not in Iceland. Again, the rates were higher in
Finland than in the other Nordic countries. The suicide
rate for young men in Finland decreased from above 40
per 100,000 in 1990 94 to approximately 25 in 2005 09.
The rate for young men in Norway dropped in the last
two decades from 24 in 1990 94 to approximately 18 in
2005 09. The decline of the suicide rate in
young men in Denmark started earlier. It fell from
decline, the Finnish male suicide rate remained almost
twice as high as that of the other countries for a majority
of years.
Similar to the Finnish trend, the suicide rate for men in
Norway went up to a range of 23 30 suicides per
100,000 until 1988. After this peak, the rate gradually
declined to approximately 20 per 100,000 in 2005 09. The
downward trend of the male suicide rate in Sweden during
the study period was not as pronounced as that in Denmark
and Finland. It started from a lower level in 1980 and with-
out the increase prior to 1990 seen in Finland and Norway.
Iceland had the lowest and most stable male suicide
rate during the study period. The relative dramatic annual
uctuations of the Icelandic rates (e.g., a male rate of
10.3 in 1981 and 30.6 in 2000) refl ect the small popula-
tion and low numbers of actual cases and are concealed
in the 5-year averages in Figures 1a and b.
Women, 15 years and above
Like the trend for men, the decline of the female suicide
1980 2009 rate was most prominent in Denmark. Although
the initial female suicide rate in Denmark was twice as high
Table 1a. Suicide rates per 100,000 by gender in Nordic countries 1980 2009, ages 15 years and above .
Year
Denmark Finland Iceland Norway Sweden
Male Female Male Female Male Female Male Female Male Female
1980 52.5 28.0 52.9 13.2 12.2 9.7 23.5 8.4 34.3 13.8
1981 49.2 26.6 49.2 11.9 10.3 4.4 24.7 8.3 30.5 12.9
1982 46.6 26.1 48.6 13.0 12.7 6.0 26.3 9.4 34.3 13.6
1983 46.2 25.0 50.1 12.1 27.6 5.9 26.8 10.2 33.5 13.2
1984 45.4 25.8 51.9 12.3 30.7 5.9 27.7 9.0 33.5 14.3
1985 43.5 25.1 50.9 11.9 20.6 5.8 26.2 9.2 30.6 13.9
1986 43.8 24.1 53.9 13.8 20.5 9.9 25.2 9.4 32.9 12.1
1987 44.3 24.1 55.8 14.4 17.8 11.4 29.3 9.4 31.7 13.1
1988 40.6 22.8 58.1 14.1 23.9 4.0 30.3 11.3 32.1 13.8
1989 41.9 23.5 58.2 14.1 12.6 4.8 28.6 10.2 32.6 12.7
1990 39.0 19.6 61.7 15.2 27.4 3.9 28.8 9.8 29.4 12.5
1991 36.3 18.0 61.1 14.4 22.4 6.2 29.3 10.0 29.7 12.3
1992 35.2 18.1 58.9 13.9 17.6 3.8 26.2 9.4 26.9 11.5
1993 35.5 18.6 56.0 13.6 14.4 5.3 26.1 7.8 27.4 11.5
1994 32.1 14.5 54.5 14.3 15.7 3.0 21.8 8.4 26.4 10.7
1995 29.5 13.6 54.1 14.4 16.4 3.7 23.5 7.6 26.8 11.3
1996 29.7 11.8 48.1 13.0 20.8 3.7 22.2 7.0 24.6 10.3
1997 26.2 11.6 51.5 13.0 19.1 5.2 22.2 8.1 24.1 9.2
1998 25.6 9.8 47.4 12.2 16.8 5.1 22.7 8.2 24.8 9.4
1999 26.3 9.0 46.8 11.5 17.3 5.8 24.6 8.4 24.2 9.7
2000 25.0 8.8 42.7 13.2 30.6 5.7 23.0 7.2 22.5 8.8
2001 23.7 9.9 45.2 12.3 19.6 5.6 23.2 7.5 23.2 9.7
2002 23.5 8.3 39.7 12.3 13.2 6.3 20.3 7.2 23.8 8.4
2003 22.4 6.9 39.0 11.7 14.5 4.2 20.6 6.7 21.3 8.8
2004 21.7 8.5 38.7 11.3 13.0 6.9 19.9 9.0 22.7 8.4
2005 21.1 7.8 34.4 12.0 22.1 8.4 19.6 9.2 22.5 10.0
2006 21.8 7.9 37.8 11.5 19.6 9.1 21.2 7.4 22.0 9.9
2007 18.3 8.0 35.1 10.8 25.5 6.3 17.9 7.8 21.2 8.4
2008 19.0 8.1 37.2 10.1 22.2 9.6 18.3 8.2 22.5 8.0
2009 21.4 6.3 35.2 11.9 23.7 6.0 21.5 7.9 23.1 8.9
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SUICIDE TRENDS IN THE NORDIC COUNTRIES 1980−2009
NORD J PSYCHIATRY·EARLY ONLINE·2013 5
In young women, a steady decline of suicides was
documented in Denmark, from a rate of approximately 6
per 100,000 in 1980 84 to 2 in 2005 09. However, the
rates for young women in Finland, Norway and Sweden
rose from 6.1, 4.0 and 5.7 in 1980
84 to 8.5, 6.4 and 7.2,
respectively, in 2005 09 — a statistically signifi cant trend in
approximately 17 per 100,000 in 1980 84 to 7 in
2005 09. In Sweden and Iceland, the suicide rates for
young men were relatively stable: it was above 15 in
Sweden until 1985 89, with a signifi cant decline to below
15 in 2000 09, and to between 20 and 30 in Iceland
without any signifi cant change over time.
Table 1b. Suicide rates per 100,000 by gender in Nordic countries 1980 2009, ages 15 24 years.
Year
Denmark Finland Iceland Norway Sweden
Male Female Male Female Male Female Male Female Male Female
1980 16.4 7.8 37.5 9.1 6.4 3.6 20.4 3.3 16.8 5.8
1981 17.2 5.0 32.2 4.6 12.9 3.6 20.3 3.3 14.2 4.1
1982 21.2 6.8 29.9 5.4 9.7 0.0 19.2 4.9 13.9 6.4
1983 15.4 5.2 35.0 6.8 22.6 0.0 21.5 3.5 16.0 6.2
1984 16.1 4.1 37.5 4.7 38.8 0.0 25.5 5.1 16.3 6.2
1985 17.0 8.0 37.3 6.2 22.8 0.0 22.0 7.6 14.2 7.5
1986 16.6 5.2 35.1 8.9 19.7 3.7 20.6 3.8 19.5 7.9
1987 16.5 8.3 37.9 7.6 16.4 0.0 23.7 3.7 16.8 5.5
1988 15.7 5.5 39.6 7.5 26.3 0.0 26.7 6.5 18.1 5.9
1989 14.5 4.2 50.4 6.5 19.9 0.0 25.8 6.2 19.8 8.3
1990 14.0 4.0 50.9 11.0 33.5 3.8 22.0 6.2 14.6 5.2
1991 11.9 3.5 42.2 7.3 43.5 7.5 27.1 4.4 16.9 5.0
1992 12.4 3.3 35.2 8.3 13.3 0.0 27.9 5.1 10.0 6.7
1993 13.3 2.3 33.0 3.2 16.6 0.0 21.6 5.9 12.0 6.6
1994 9.9 3.7 45.5 7.8 16.6 3.7 20.5 4.3 13.1 3.5
1995 13.1 2.3 36.6 8.4 13.3 0.0 22.4 5.5 13.5 5.3
1996 13.0 2.4 33.9 6.8 20.0 3.7 20.9 5.6 12.0 4.5
1997 13.1 5.1 39.1 7.0 10.1 3.8 20.0 4.6 11.6 6.5
1998 10.2 2.8 29.5 7.9 16.9 3.8 23.6 7.7 10.7 5.5
1999 12.3 2.2 36.3 5.9 16.7 7.5 28.2 8.9 14.8 6.3
2000 12.4 2.9 31.1 8.1 46.1 7.4 25.2 5.2 12.0 5.2
2001 12.4 2.4 27.7 6.8 26.0 0.0 22.1 7.6 11.2 3.6
2002 13.2 2.0 29.1 7.2 9.7 0.0 17.7 5.7 14.6 4.5
2003 7.9 2.0 28.6 8.5 16.0 0.0 20.8 6.3 11.0 6.7
2004 10.9 3.8 33.1 9.7 15.9 3.6 20.5 7.4 16.2 6.0
2005 6.9 2.4 20.4 10.3 15.2 0.0 17.4 7.3 11.9 6.6
2006 7.8 3.0 32.2 5.9 30.0 0.0 23.2 6.4 12.5 9.2
2007 4.7 2.0 26.5 9.6 35.1 5.1 15.9 4.9 11.4 6.1
2008 9.2 2.6 24.1 8.1 18.8 0.0 15.6 7.2 15.5 6.8
2009 7.1 1.2 26.4 8.7 9.2 0.0 16.2 6.0 14.4 7.2
Table 2. Regression trend by calendar year 1980 2009, ages 15 years and
above and 15 24 years.
Age 15 years Age 1524 years
B (df) t -stat P -value B (df) t -stat P -value
Males
Denmark 1.17 (1) 28.25 0.0001 0.37 (1) 16.94 0.0001
Finland 0.71 (1) 6.02 0.0001 0.44 (1) 4.62 0.0001
Iceland 0.15 (1) 1.01 0.323 0.16 (1) 0.82 0.419
Norway 0.30 (1) 6.24 0.0001 0.14 (1) 2.80 0.009
Sweden 0.48 (1) 15.31 0.0001 0.15 (1) 4.28 0.000
Females
Denmark 0.83 (1) 20.59 0.0001 0.18 (1) 10.47 0.0001
Finland 0.07 (1) 3.14 0.004 0.06 (1) 3.10 0.004
Iceland 0.09 (1) 1.66 0.109 0.02 (1) 0.50 0.618
Norway 0.07 (1) 3.66 0.001 0.09 (1) 6.39 0.0001
Sweden 0.21 (1) 13.45 0.0001 0.01 (1) 0.62 0.539
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6 NORD J PSYCHIATRY·EARLY ONLINE·2013
and Pirkanmaa regions in western and central Finland,
and in eastern Uusimaa in the south of Finland. (The
mortality rates for women in the Å land archipelago in
Finland, which were high in 2009, vary dramatically from
year to year due to the small number of inhabitants of
this area, and conclusions cannot be drawn from the
gures from 1 year only.) High female suicide rates were
also documented in two separate areas in Vest-Agder and
Vestfold in southern Norway and in G ä strikland
and H ä lsingland counties on the northern east coast of
Sweden.
The distribution of suicide rates was more even across
Denmark and Iceland: 20 25 per 100,000 men in Den-
mark and lower than 20 per 100,000 in Iceland. The
rates for Danish and Icelandic women were 5 7.5 and
lower than 5, respectively.
With regard to rural versus urban rates, it is notable that
the current suicide rates in the capital regions of Copenha-
gen, Oslo and Stockholm are lower than the respective
national rates in Denmark, Norway and Sweden.
Suicide methods
Categories of suicide methods used by men and women
(15 years and older) during 2009 are listed as rates and
percentages in Table 3. Self-poisoning and hanging
were the most frequent methods and accounted for
more than two-thirds of all suicides in the fi ve Nordic
countries.
Hanging was the most common method for men,
while self-poisoning was the method most commonly
used by women in all countries except Norway, where
hanging accounted for approximately 40% of female as
well as male suicides.
Finland and Norway but not in Sweden. With a notable
peak of about 5.5 in 1995 99, the female suicide rate in
Iceland stayed at a level of 1 2 per 100,000 and was the
lowest over time in the Nordic countries.
The gender ratio
In all fi ve countries, across all age groups, the male suicide
rate was higher than the female rate over time (Fig. 2). In
Finland, the gender ratio was steadily above 4 male per
1 female suicide until 1990 94, after which the ratio gradu-
ally decreased to just above 3. In Iceland, too, the gender
ratio went down from its highest level, 4.5, in 1990 94 to 3
in 2005 09. The change in Norway was from about 3 dur-
ing most of the study period to less than 2.5 in 2005 09.
Sweden s gender ratio was around 2.5 during the entire
study period. Denmark had the lowest initial ratio, below 2
between 1980 and 1990 94, when a gradual increase started;
the Danish gender ratio appears to have stabilized at approx-
imately 2.5. Thus, since 1990, the Nordic countries have
seen converging ratios of male and female suicide rates,
with a current range of 2.5 3.2.
The geographic distribution of suicide rates
Regional overall suicide rates within the fi ve countries
are illustrated in Figure 3.
Regional differences were pronounced in Norway,
Sweden and Finland. The highest annual rates for men
( 35 per 100,000) were found in northern and eastern
Finland, in the adjoining Finnmark county in the north of
Norway and in two delimited central regions, Buskerud
and Telemark in Norway and V ä rmland in Sweden.
For women, the highest rates ( 12.5 per 100,000)
were found in northern and eastern Finland, in Satakunta
Fig. 2 . Ratio (5-year averages) of suicide rates between males and females in the Nordic countries during 1980 2009, ages 15 years
and above.
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SUICIDE TRENDS IN THE NORDIC COUNTRIES 1980−2009
NORD J PSYCHIATRY·EARLY ONLINE·2013 7
Fig. 3 . Regional distribution of suicide rates per 100,000 for males and females in the Nordic countries in 2009, ages 15 years and
above.
The use of fi rearms was the third leading method for
men in all countries. It accounted for approximately 23%
of all male suicides in Norway and Finland.
Discussion
Suicide trends in the adult population
Declining suicide rates in men and women, all ages, were
seen in Denmark, Finland, Norway and Sweden. Were the
rates of the youngest age group (15 24 years) to be
removed from the overall trend, the decline would be
even starker. The range of the annual suicide rate for men
decreased from 25 50 per 100,000 in 1980 to 20 36 in
2009. The corresponding decline of the suicide rates for
women was from 9 26 to 8 11. Iceland had the lowest
suicide rates for all ages and both genders during the
study period. The fl uctuations of the Icelandic rates,
which are noticeable even in the 5-year averages of
Figures 1a and b, were not statistically signifi cant.
In 1980 84, Denmark and Finland had the highest
suicide rates in the Nordic region. The decline of the
combined rate in Denmark and the male rate in Finland
during the study period is notable. The only known
comparable development in the history of the documen-
tation of suicide rates in the Nordic countries occurred
in Denmark and Sweden during the First World War
(12 14). The overall downward trend of the Nordic
suicide rate appears to have fl attened out in the last
decade.
The Finnish suicide rates remain higher than those in
the other Nordic countries. In a nationwide psychological
autopsy study, Henriksson et al. (15) showed that more
than 90% of suicides in Finland are linked to a mental
disorder, mainly depressive disorder (59%) and alcohol
dependence or abuse (43%). That more than one in three
male suicide victims in Finland were given a diagnosis of
alcoholism reaffi rms that alcohol problems are a major
determinant of suicide, there as elsewhere (16, 17). How-
ever, a general socio-economic factor most likely overlaps
with the impact of alcohol: suicide among Finnish male
unskilled workers is 2.3 times more frequent than it is
among non-manual, white-collar employees, whose suicide
rate does not differ signifi cantly from the overall Nordic
male suicide rate (18).
Representing different trends in suicide rates during
the study period, the national ratios of male and female
suicide rates converged to a range of 2.5 3.2. The declin-
ing male suicide rate in Finland during the last two
decades explains the narrowing gender ratio there, while
the sharp decline of the female suicide rate in Denmark
is refl ected in a widened ratio.
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D TITELMAN ET AL.
8 NORD J PSYCHIATRY·EARLY ONLINE·2013
countries. However, the ownership rate of weapons is not
higher in Norway than in Sweden (25), where the docu-
mented annual rate of suicides by fi rearms for men is
about 14.4% (and 1.4% for women). It is conceivable that
this is explained by varying safety precautions for storing
weapons: when legislation and education about the safe
storage of fi rearms were implemented in Norway, the
proportion of fi rearm suicide decreased by 57% (26). A
similar trend was seen in Iceland, where, following new
legislation concerning the storage of weapons, suicides by
rearms decreased from 20.9% in 1980 84 to 11.1% in
2009 (data available from authors on request).
Regional differences
The high suicide rates of certain rural parts of the Scandi-
navian peninsula and Finland attest to earlier fi ndings on
the association of male suicide with a high availability of
suicide means, a low utilization rate of mental healthcare,
a shortage of such facilities and social isolation (27, 28).
However, it has also been shown that rural residence is
associated with suicide, only when adjusting for socio-
economic characteristics and psychiatric status (29).
An explanation of the noted lower suicide rates of
Copenhagen, Oslo and Stockholm, compared with the
respective national rates, may be the infl ux to these cities
of immigrant groups from Muslim countries that report
low suicide rates. A comparable shift of suicide rates,
moving from top to bottom of the hierarchy of regional
rates, was reported in other metropolitan areas of the
Western world with similar demographic changes (30).
Suicide rates in young people, 1524 years
The upward trend of the suicide rate among young women
in Finland and Norway over the last 30 years and the
unchanged level in young women in Sweden and in young
men in Iceland stand in contrast to the general decline of
the suicide rate in the Nordic countries. It is also notable
that the suicide rate of Icelandic young men is the only
instance of Iceland not showing lower rates than those in
the other Nordic countries. Together with current reports
of increasing numbers of attempted suicide among the
young (19, 20) and with the known association between
attempted and completed suicide, particularly in the
socially disadvantaged (21), these observations call for
continued monitoring of vulnerable young people.
Suicide methods
In all fi ve countries, violent methods such as hanging and
the use of fi rearms were more common among men than
among women. The lethality of hanging and fi rearms may
partly explain the higher male suicide rate. Conversely,
suicide attempts by poisoning may be less likely to have
fatal outcomes in developed societies due to lower dos-
ages after the introduction of blister packaging (22) and
to a high likelihood of being rescued by accessible emer-
gency care (23). A recent study indicates that the increase
in suicides among young women in Finland is linked to a
switch to more violent and lethal methods (24).
The relatively high incidence of fi rearm suicides in Fin-
land and Norway, about 23% for both men and women,
may be linked to household ownership of weapons in these
Table 3. Rates and percentages of suicide methods per 100,000 for men and women, ages 15 years and
above.
Category
Denmark Finland Iceland Norway Sweden
Rate % Rate % Rate % Rate % Rate %
Males
Poisoning (X60 – X69) 3.7 17.3 7.4 21.0 6.3 27.6 3.2 14.7 4.3 18.8
Hanging (X70) 10.3 48.2 11.7 33.2 9.4 41.4 8.5 39.3 10.9 47.1
Drowning (X71) 1.1 5.0 1.6 4.6 0.8 3.4 1.6 7.3 0.8 3.6
Firearms (X72 – X74) 2.9 13.7 8.0 22.9 3.1 13.8 5.0 23.2 3.3 14.4
Sharp object (X78) 1.0 4.4 0.7 2.1 2.4 10.3 0.7 3.4 0.5 2.0
Jumping from a high place (X80) 0.7 3.4 2.2 6.2 0.8 3.4 0.8 3.8 1.1 4.9
Moving object (X81 X82) 1.1 5.0 2.6 7.5 0 0.0 0.7 3.1 1.5 6.3
Other methods 0.6 3.0 0.9 2.5 0.0 0.0 1.1 5.3 0.7 2.9
Total 21.4 100.0 35.2 100.0 22.7 100.0 21.5 100.0 23.1 100.0
Females
Poisoning (X60 – X69) 2.7 43.1 6.8 56.8 2.4 42.9 2.9 37.0 4.0 44.9
Hanging (X70) 2.0 32.0 2.5 21.2 1.6 28.6 3.3 41.8 2.4 26.6
Drowning (X71) 0.7 10.5 0.7 6.2 1.6 28.6 0.8 10.3 0.8 8.6
Firearms (X72 – X74) 0.0 0.6 0.3 2.6 0 0.0 0.1 0.6 0.1 1.4
Sharp object (X78) 0.2 2.7 0.1 0.7 0 0.0 0.1 1.3 0.1 1.1
Jumping from a high place (X80) 0.4 6.2 0.4 3.7 0 0.0 0.3 3.2 0.6 6.6
Moving object (X81 X82) 0.2 3.5 1.0 8.1 0 0.0 0.2 2.6 0.8 9.1
Other methods 0.1 1.4 0.1 0.7 0.0 0.0 0.3 3.2 0.2 1.7
Total 6.3 100.0 11.9 100.0 5.6 100.0 7.8 100.0 8.9 100.0
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SUICIDE TRENDS IN THE NORDIC COUNTRIES 1980−2009
NORD J PSYCHIATRY·EARLY ONLINE·2013 9
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A gender-specifi c analysis of countries participating in the
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Health 2008 ; 62 : 545 – 51 .
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trends, levels, and life expectancy differences . Scand J Public Health
2007 ; 35 : 387 – 95 .
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Akademisk Forlag ; 2007 .
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School of Public Health; 2009 .
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non-fatal self-harm? A multicentre study of risk factors. Psychol Med
2012 ; 42 : 727 – 41 .
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long term effect on poisonings . BMJ 2004 ; 329 : 1076 .
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study . BMC Emerg Med 2010 ; 10 : 13 .
Lahti A , R ä s ä nen P , Riala K , Ker ä nen S , Hakko H . Youth suicide 24. trends in Finland, 1969 2008 . J Child Psychol Psychiatry
2011 ; 52 : 984 – 91 .
Civilian gun ownership for 178 countries, in descending order of 25. averaged fi rearms . Oxford University Press 2007 [cited 2012 Aug
17] . Available from: http://www.smallarmssurvey.org/publications/
by-type/yearbook/small-arms-survey-2007.html#c3541
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David Titelman, National Center of Suicide Research and Prevention of
Mental Ill-Health (NASP), Karolinska Institutet, Stockholm, Sweden.
H ø gni Oskarsson, Icelandic Alliance Against Depression, Reykjavik,
Iceland .
Conclusions
In addition to confi rming an overall decline of suicide rates
in the Nordic countries 1980 2009, we noted differences in
trends and levels of suicide rates between countries, regions
within countries, genders, age groups and suicide methods.
It is possible that the converging suicide rates in the
Nordic region, but also the consistently high rates in Fin-
land, are accounted for by variations in stages or posi-
tions in a fundamentally common social process or by a
cohort effect (31). The impact of socio-economic fac-
tors on vulnerable groups needs to be better understood
in the context of suicide prevention. The psychosocial
impact of migration and cultural factors on mental health
and suicide is a relevant perspective in future studies.
The rise of the suicide rate among young women,
aged 15 24 years, in Finland and Norway and the lack
of a signifi cant decline of suicide rates in this group in
Sweden warrant continued monitoring.
Acknowledgements This study was initiated in discussions of the
Nordic Consortium for Suicide Prevention, in which all of the
collaborating centers and university departments are active. During
2010 2012, the consortium meetings were coordinated with the activi-
ties of a Nordic research network focusing on the theme Mental health
and evidence: linking research to practice . The network was conjointly
led by Danuta Wasserman, NASP, and Lars Fred é n, the Nordic School
for Public Health in Gothenburg, and supported by a grant from
NordForsk.
Declaration of interest: The authors report no confl icts of
interest. The authors alone are responsible for the content
and writing of the paper.
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D TITELMAN ET AL.
10 NORD J PSYCHIATRY·EARLY ONLINE·2013
Annette Erlangsen, Mental Health Centre, Capital Region of Denmark,
Denmark .
Latha Nrugham, National Centre for Suicide Research and Prevention,
Institute of Clinical Medicine, Medical Faculty, University of Oslo,
Oslo, Norway .
Danuta Wasserman, National Center of Suicide Research and
Prevention of Mental Ill-Health (NASP), Karolinska Institutet,
Stockholm, Sweden .
Kristian Wahlbeck, Mental Health Services, National Institute for
Health and Welfare, Helsinki, Finland .
Merete Nordentoft, Mental Health Centre, Capital Region of Denmark,
Denmark.
Lars Mehlum, National Centre for Suicide Research and Prevention, Institute
of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.
Guo-Xin Jiang, National Center of Suicide Research and Prevention of
Mental Ill-Health (NASP), Karolinska Institutet, Stockholm, Sweden.
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    Acute poisonings are common and are treated at different levels of the health care system. Since most fatal poisonings occur outside hospital, these must be included when studying characteristics of such deaths. The pattern of toxic agents differs between fatal and non-fatal poisonings. By including all poisoning episodes, cause-fatality rates can be calculated. Fatal and non-fatal acute poisonings in subjects aged > or =16 years in Oslo (428 198 inhabitants) were included consecutively in an observational multi-centre study including the ambulance services, the Oslo Emergency Ward (outpatient clinic), and hospitals, as well as medico-legal autopsies from 1st April 2003 to 31st March 2004. Characteristics of fatal poisonings were examined, and a comparison of toxic agents was made between fatal and non-fatal acute poisoning. In Oslo, during the one-year period studied, 103 subjects aged > or =16 years died of acute poisoning. The annual mortality rate was 24 per 100 000. The male-female ratio was 2:1, and the mean age was 44 years (range 19-86 years). In 92 cases (89%), death occurred outside hospital. The main toxic agents were opiates or opioids (65% of cases), followed by ethanol (9%), tricyclic anti-depressants (TCAs) (4%), benzodiazepines (4%), and zopiclone (4%). Seventy-one (69%) were evaluated as accidental deaths and 32 (31%) as suicides. In 70% of all cases, and in 34% of suicides, the deceased was classified as drug or alcohol dependent. When compared with the 2981 non-fatal acute poisonings registered during the study period, the case fatality rate was 3% (95% C.I., 0.03-0.04). Methanol, TCAs, and antihistamines had the highest case fatality rates; 33% (95% C.I., 0.008-0.91), 14% (95% C.I., 0.04-0.33), and 10% (95% C.I., 0.02-0.27), respectively. Three per cent of all acute poisonings were fatal, and nine out of ten deaths by acute poisonings occurred outside hospital. Two-thirds were evaluated as accidental deaths. Although case fatality rates were highest for methanol, TCAs, and antihistamines, most deaths were caused by opiates or opioids.
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    Suicide is the third leading cause of death among young people in the U.S. and represents a significant public health problem worldwide. This review focuses on recent developments in our understanding of the epidemiology and risk factors for adolescent suicide and suicidal behavior. The suicide rate among children and adolescents in the U.S. has increased dramatically in recent years and has been accompanied by substantial changes in the leading methods of youth suicide, especially among young girls. Much work is currently underway to elucidate the relationships between psychopathology, substance use, child abuse, bullying, internet use, and youth suicidal behavior. Recent evidence also suggests sex-specific and moderating roles of sex in influencing risk for suicide and suicidal behavior. Empirical research into the causal mechanisms underlying youth suicide and suicidal behavior is needed to inform early identification and prevention efforts.