Why is Brazil losing the race against youth suicide?

EDITORIAL

Why is Brazil losing the race against youth suicide?

José Manoel Bertolote, MD

Professor, Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Australia. Voluntary Professor. Faculdade de Medicina de Botucatu, Universidade Federal de São Paulo. Botucatu, Brazil

In Brazil, suicide mortality represents an important toll: about 10,000 lives are lost to suicide every year, nearly the same number of people dying from AIDS. Three papers in this issue of Revista Brasileira de Psiquiatria address suicide from different perspectives, in different Brazilian states with solid epidemiologic methodology. This is a positive sign of researchers' and editors' interest in this complex issue.

The paper of Macente et al.¹ uses a geopositioning approach to identify high risk areas of suicide mortality in the state of Espírito Santo. They confirmed the limited value of aggregate rates, by highlighting major differences in suicide mortality across neighbouring areas.

Bando et al.² points out in their paper a more worrisome issue, the recent disproportionate increase of suicide mortality among young people in São Paulo, Brazil's largest city. Using joint point regression analysis, they identified an annual percentage increase of 8.6 for males aged 24-44 years between 2002 and 2009, period during which it decreased for all other male age groups as well as for all female age groups. Migrants were also identified as a high-risk group.

Yet another high-risk group was studied by Tavares et al.³ in Pelotas, RS. Postpartum women were analysed not for suicide mortality, but for their risk of suicidal behaviour. Mental disorders, particularly bipolar disorder emerged as having the highest impact on suicide risk.

A couple of lessons useful for clinicians, researchers and health planners and authorities can be drawn from these papers:

1. Planning for interventions at a local level based on rates from elsewhere can be seriously misleading. This is confirmed by a study in a micro region of São Paulo state hinterland (Botucatu and Avaré): against a national average of overall suicide mortality rates in the same period in Brazil of 4 to 5.6 deaths per 100,000 and in São Paulo city of 5.9 to 6.7 deaths per 100,000, corresponding rates were 17.1/100,000 in Botucatu (2009), and 17.8/100,000 and 22.9/100.000 in Avaré (2010 and 2011, respectively) (Bertolote et al.⁴).

2. In spite of the wide recognition of mental disorders as the highest risk factor for suicidal behaviour, the announcement in 2006 of a national strategy for suicide prevention by the Ministry of Health (Ministério da Saúde, 2006)⁵ never became a concrete action. Yet, wider access to the identification and treatment of major mental disorders is fundamental for the reduction of suicide behaviours. It is not unthinkable that the current unsatisfactory situation of mental health care in Brazil is contributing to the problem, rather than to its solution.

The recent publication of the WHO Intervention Guide for mental disorders⁶ with a specific chapter on Self-harm/ Suicide, already translated into Portuguese, to be released soon, can be a powerful contribution towards the reduction of suicidal behaviour, particularly in settings with limited specialized human resources, e.g. the primary health care level, including the Strategy of Family Health (PSF).

The ball is now in the authorities´ court: immediate and appropriate action must be taken at national, state and local levels lest suicide continue at unwanted rates, or worse, to increase in vulnerable groups (Bertolote, et al.⁷).

References

1. Macente L, Zandonade E. Spatial distribution of suicide incidence rates in municipalities in the state of Espírito Santo (Brazil), 2003-2007: spatial analysis to identify risk areas. Rev Bras Psiquiatr. 2012;34:[ePub ahead of print].

2. Bando D, Brunoni A, Fernandes T, Bensenor I, Lotufo P. Suicide rates and trends in São Paulo, Brazil according to gender, age and demographic aspects: a joinpoint regression analysis. Rev Bras Psiquiatr. 2012;34:[ePub ahead of print].

3. Tavares D, Quevedo L, Jansen K, Souza L, Pinheiro R, Silva R. Prevalence of suicide risk and comorbidities in postpartum women in Pelotas. Rev Bras Psiquiatr. 2012;34:[ePub ahead of print].

4. Bertolote JM, Pinheiro Machado M, Ribeiro M. Determinants of suicide in a countryside region of São Paulo State, Brazil [submitted to Rev Bras Psiquiatr] .

5. Ministério da Saúde (2006). Diretrizes Nacionais para a Prevenção do Suicídio (Portaria 1.876/06). Diário Oficial da União, Seção 1, 15.08.2006: pp. 65.

6. World Health Organization (2010). mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva, World Health Organization.

7. Bertolote JM, Botega N, De Leo D. Inequities in suicide prevention in Brazil. Lancet, 2011;378(9797):1137.

• 4. Bertolote JM, Pinheiro Machado M, Ribeiro M. Determinants of suicide in a countryside region of São Paulo State, Brazil [submitted to Rev Bras Psiquiatr]
• 5. Ministério da Saúde (2006). Diretrizes Nacionais para a Prevenção do Suicídio (Portaria 1.876/06). Diário Oficial da União, Seção 1, 15.08.2006: pp. 65.
• 6. World Health Organization (2010). mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva, World Health Organization.
• 7. Bertolote JM, Botega N, De Leo D. Inequities in suicide prevention in Brazil. Lancet, 2011;378(9797):1137.

Publication Dates

• Publication in this collection
  14 Nov 2012
• Date of issue
  Oct 2012