Epidemiological profile of suicide in the west of the State of Santa Catarina, Brazil

Abstracts

INTRODUCTION: The State of Santa Catarina is located in Southern Brazil. The suicide rate in this state is one of the largest in the country. Preliminary studies showed that the westernmost region of Santa Catarina has the largest rate in the state. Descriptive studies about suicide epidemiological profile in this area are not available. METHOD: A descriptive study of suicide rate in the west of Santa Catarina was performed, stratified by gender and age from 1980 to 2005. Methods of suicide are also described. The data were collected from the Departamento de Informática do Sistema Único de Saúde (Information Technology Department of the Brazilian Unified Health System - DATASUS). RESULTS: Mean suicide rate was 10 cases/100,000 inhabitants in western Santa Catarina. The male rate was three times higher than that of females. There was a 50% increase in suicide rates during the study period, independent of gender or age. Hanging accounted for 76% of male and 73% of female deaths. CONCLUSIONS: This study confirms that the westernmost region of Santa Catarina has suicide rates higher than the state and national levels, comparable to the highest rates in the country. The epidemiological profile has similarities with the State of Rio Grande do Sul and it should be investigated in further studies.

Suicide; epidemiology; Santa Catarina; Brazil

INTRODUÇÃO: O estado de Santa Catarina está localizado na Região Sul do Brasil. O coeficiente de mortalidade nesse estado é um dos maiores do país. Estudos preliminares indicam que a região do extremo oeste de Santa Catarina apresenta os maiores índices estaduais. Inexistem estudos descritivos sobre o perfil epidemiológico do suicídio nessa região. MÉTODO: Estudo descritivo, calculando o coeficiente bruto de mortalidade por suicídio no extremo oeste catarinense, assim como os coeficientes padronizados por gênero e faixa etária no período entre 1980 e 2005. Descrição dos meios empregados para o suicídio. Os dados foram coletados do Departamento de Informática do Sistema Único de Saúde. RESULTADOS: O coeficiente médio de suicídios no extremo oeste foi de 10 casos para cada 100.000 habitantes. A proporção entre homens e mulheres foi de 3:1. Os índices apresentaram aumento de mais de 50% em ambos os sexos e em todas as faixas etárias no período estudado. O enforcamento representa 76% dos casos entre os homens e 73% entre as mulheres. CONCLUSÕES: O extremo oeste catarinense apresenta coeficientes de mortalidade por suicídio acima da média nacional e estadual, sendo comparável aos maiores do país. O perfil epidemiológico da região guarda semelhanças com o Rio Grande do Sul que devem ser investigadas em estudos seguintes.

Suicídio; epidemiologia; Santa Catarina; Brasil

en_v30n2a07

ORIGINAL ARTICLE

Epidemiological profile of suicide in the west of the State of Santa Catarina, Brazil

Ricardo Schmitt^I; Maria Gabriela Lang^II; João Quevedo^III; Talita Colombo^II

^IMSc. Professor, Centro de Ciências da Saúde, Universidade Comunitária Regional de Chapecó (UNOCHAPECÓ), Chapecó, SC, Brazil. Coordinator, Research Group on Clinical Epidemiology (EPICLIN), Chapecó, SC, Brazil.

^IIMedical student, UNOCHAPECÓ. Researcher, EPICLIN.

^IIIPhD in Biological Sciences: Biochemist. Professor and coordinator, Graduation Program in Health Sciences, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense (UNESC), Criciúma, SC, Brazil.

Correspondence

ABSTRACT

INTRODUCTION: The State of Santa Catarina is located in Southern Brazil. The suicide rate in this state is one of the largest in the country. Preliminary studies showed that the westernmost region of Santa Catarina has the largest rate in the state. Descriptive studies about suicide epidemiological profile in this area are not available.

METHOD: A descriptive study of suicide rate in the west of Santa Catarina was performed, stratified by gender and age from 1980 to 2005. Methods of suicide are also described. The data were collected from the Departamento de Informática do Sistema Único de Saúde (Information Technology Department of the Brazilian Unified Health System - DATASUS).

RESULTS: Mean suicide rate was 10 cases/100,000 inhabitants in western Santa Catarina. The male rate was three times higher than that of females. There was a 50% increase in suicide rates during the study period, independent of gender or age.

Hanging accounted for 76% of male and 73% of female deaths.

CONCLUSION: This study confirms that the westernmost region of Santa Catarina has suicide rates higher than the state and national levels, comparable to the highest rates in the country. The epidemiological profile has similarities with the State of Rio Grande do Sul and it should be investigated in further studies.

Keywords: Suicide, epidemiology, Santa Catarina, Brazil.

INTRODUCTION

Data published by the World Health Organization (WHO) indicate that deaths from suicide have increase over the past 45 years; mortality coefficient from suicide worldwide in 1995 was 16 cases/100,000 inhabitants.¹ WHO estimates that about 1 million people committed suicide in 2000, which represents one death every 40 seconds.²

Description of the epidemiological profile in Brazil has been growing significantly over the past decades. In 2005 Mello-Santos et al. published a study on Brazilian suicide rates from 1980 through 2000. The authors found an average of three to four suicides/100,000 inhabitants in Brazil, and the incidence was four times higher in men, with growing rates in younger age groups.³ In that same year the Brazilian Department of Health concluded a study replicating these findings and also showed regional differences in suicide rates across the country. Results revealed that the South Region, and more specifically the State of Rio Grande do Sul (RS) had the highest mortality coefficients from suicide in Brazil, reaching 11/100,000 inhabitants.⁴ Suicide specificities in RS have been studied for over a decade by the group "Agrochemicals and other risk factors for suicide in RS."^5,6 These researchers published a detailed study on suicide epidemiological profile in RS, indicating an increase in death coefficients from suicide from 1980 to 1999.^6,7 Studies also showed that, for each actual suicide, there were at least 10 serious attempts, which demanded medical care and increase in costs for the public system.^2,3

The State of Santa Catarina (SC) belongs to the Brazilian South Region. Available studies show that the mortality coefficient from suicide in this state is around 7/100,000 inhabitants, which represents almost twice the national average. As in Brazil, suicide death rates in SC also have significant regional variations. A study published by the State Department of Health showed that mortality from suicide in the far west region of SC had a coefficient of 11/100,000 inhabitants in 2001, higher than the homicide death coefficient in that region.⁸

For administrative purposes, the State Department of Health divided the territory of SC into eight health regions: far west, middle west, mountainous plateau, south, Florianópolis, Itajaí Valley, north plateau and northeast⁹ (Figure 1). The far west had a population estimated in 689,521 inhabitants in 2007 and agribusiness is its main economic component.¹⁰ Its population is comprised of caboclo descendants (first colonizers in the region), but received the main migratory flow after the 1920's with the arrival of colonists coming from RS, most descendants of Italian and German immigrants.¹¹

However, despite the high indices of suicide in the region, few studies have been conducted in the sense of describing the phenomenon, whether in the medical, epidemiological or social aspect. The Universidade Comunitária Regional de Chapecó (UNOCHAPECÓ) has recently created a research group in clinical epidemiology that, among other objectives, aims at outlining the epidemiological profile of suicide deaths and suicidal behavior in the region.

This study aims at outlining some epidemiological characteristics of suicide deaths in the far west of SC from 1980 through 2005. This intends to create evidence subsidizing further research in the area, and also serves as an aid in the creation of public policies to deal with this problem.

METHOD

This is a descriptive study of the following epidemiological characteristics of suicide deaths in the far west of SC from 1980 through 2005: a) raw mortality coefficient; b)proportional and standardized coefficient according to gender; c) proportional and standardized coefficient according to age group; and d) description of the means used for suicide. In addition, mortality coefficient from suicide was calculated in eight regions of SC to compare with the indices of the region under investigation. The far west was defined according to the division of health regions of the State Department of Health of Santa Catarina,⁹ properly discriminated by the Department of Information Technology of the Brazilian Unified Health System (DATASUS) and by the Brazilian Institute of Geography and Statistics (IBGE).

The data were extracted from the Information System on Mortality (SIM), published by DATASUS and available at the Department of Health website.¹² The population data were obtained from the IBGE website.¹⁰

The International Classification of Diseases Ninth Revision (ICD-9) was used to calculate the number of suicides from 1980 to 1995, including the following characteristics:

- E950 - suicide by solid or liquid substances;

- E951 - suicide by gases in domestic use;

- E952 - suicide by other gases and vapors;

- E953 - suicide by hanging, strangulation and suffocation;

- E954 - suicide by submersion (drowning);

- E955 - suicide by firearms and explosives;

- E956 - suicide by cutting and piercing instruments;

- E957 - suicide by jumping from high place;

- E958 - suicide by other and unspecified means;

- E959 - late effects of self-inflicted injury.

For the period from 1996 to 2005, the International Classification of Diseases Tenth Revision (ICD-10), including the categories X60 to X84 (intentional self-harm) and Y87.0 (sequelae of intentional self-harm). The ICD-10 describes intentional self-harm as follows:

- X60: intentional self-poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics;

- X61: intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotic, anti-Parkinsonism and psychotropic drugs, not elsewhere classified;

- X62: intentional self-poisoning by and exposure to narcotics and psychodysleptics (hallucinogens), not elsewhere classified;

- X63: intentional self-poisoning by and exposure to other drugs acting on the autonomic nervous system;

- X64: intentional self-poisoning by and exposure to other and unspecified drugs, medicaments and biological substances;

- X65: intentional self-poisoning by and exposure to alcohol;

- X66: intentional self-poisoning by and exposure to organic solvents and halogenated hydrocarbons and their vapors;

- X67: intentional self-poisoning by and exposure to other gases and vapors;

- X68: intentional self-poisoning by and exposure to pesticides;

- X69: intentional self-poisoning by and exposure to other and unspecified chemicals and noxious substances;

- X70: intentional self-harm by hanging, strangulation and suffocation;

- X71: intentional self-harm by drowning and submersion;

- X72: intentional self-harm by handgun discharge;

- X73: intentional self-harm by rifle, shotgun and larger firearm discharge;

- X74: intentional self-harm by other and unspecified firearm discharge;

- X75: intentional self-harm by explosive material;

- X76: intentional self-harm by smoke, fire and flames;

- X77: intentional self-harm by steam, hot vapors and hot objects;

- X78: intentional self-harm by sharp object;

- X79: intentional self-harm by blunt object;

- X80: intentional self-harm by jumping from a high place;

- X81: intentional self-harm by jumping or lying before moving object;

- X82: intentional self-harm by crashing of motor vehicle;

- X83: intentional self-harm by other specified means;

- X84: intentional self-harm by unspecified means.

Due to the differences between the ninth and tenth revision of the ICD, categorization of means used for suicide was organized based on clusters of similar categories. Therefore, categories E953 of ICD-9 and X70 of ICD-10 were defined as "hanging"; categories E955 and X72-75 as "firearm;" categories E950, E952 and X60-69 as "poisoning;" and the remaining categories as "other."

Historic series were built for the period from 1980 to 2005. This period was selected due to the availability of mortality and population data at DATASUS and IBGE. Age groups were described according to WHO standardization¹³ and grouped into four large groups: a) 10-19 years; b) 20-39 years; c) 40-59 years; d) 60 years or more. The data were analyzed using the TABWIN software of the Department of Health.

RESULTS

There were 1,669 suicides in the far west of Santa Catarina from 1980 through 2005. Of this total, 11 cases had age unknown (10 male and one female). These data were excluded from the analyses according to age group, but were used in the calculation according to gender.

During the study period (1980-2005) the State of SC had mean mortality coefficient from suicide of seven cases/100,000 inhabitants, whereas the Brazilian mean was not more than four deaths for each 100,000 inhabitants. The far west of SC accounted for 20% of the total suicides in the state during the 25 years of the study period (1,669 cases out of 8,248), secondary only to the Itajaí Valley, which accounted for 21% of deaths. Mean mortality coefficient in the far west indicated a rate of 10 deaths/100,000 inhabitants, the highest in the state (Table 1). All the regions had an increase in number of suicides during the study period, nearly doubling their indices between 1980 and 2005.

Coefficients in the far west ranged between six and 13 deaths/100,000 inhabitants, but since 1997 have been between 10 or more cases (Table 2). Male individuals accounted for 78% of the total number of suicides during the study period. The standardized coefficient according to gender ratio indicate a mean proportion of 31 between men and women, which is the same as that found in Brazilian studies.^3,4 However, the number of deaths and coefficient in women increased over the past 25 years and had mean higher than the Brazilian population; mean coefficient of suicides in women in the far west was 4/100,000 from 1980 to 2005.

In the analysis stratified by age group, the coefficient of deaths from suicide had progressively higher indices as age increases in all years and in both genders (Table 3). On the other hand, in absolute numbers, most deaths were in the age group of 20-49 years. Male coefficients ranged between 4/100,000 in the age group of 10-19 years and 60/100,000 in individuals over 60 years of age. These indices were calculated considering the number of suicides and the mean population of the study period for each age group.

In the evaluation stratified by age group and gender, there was a tendency to coefficient stabilization between 10 and 39 years, as well as a fall for ages over 40 years in males in the last 5 years of the study (2000-2005) (Figure 2). For the female gender, there was a tendency of growth in suicide rates between 20 and 59 years in the same period; age group between 40 and 59 years has the highest coefficients in the last years of the analysis, suggesting a change in profile of women who committed suicide in the far west (Figure 2).

The most widely used method for suicide in both genders was hanging, which accounted for more than 70% of deaths (category E953 of ICD-9 and category X70 of ICD-10) (Figure 3). Use of firearms accounted for 13% of deaths in males and 9% in females. Poisoning, in turn, accounted for 5% in men and 11% in women. Many other methods are recorded in DATASUS statistics, such as drowning and jumping from high place, but each accounted for around 1% and were then grouped as "others" (Figure 3).

DISCUSSION

The State of SC has one of the highest Brazilian mortality coefficients from suicide (7/100,000). However, distribution of these indices is not homogenous across the varied regions of the state. The far west of Santa Catarina had mean mortality from suicide of 10 cases for each 100,000 inhabitants from 1980 and 2005. Previous studies using more restricted historic series already indicated this trend.^8,14,15 That was the highest rate in the state. The State of SC, although having a relatively small territory, is characterized by a wide ethnic and cultural variation across its regions.^11,16 Its shore, for example, has a historic and political process of colonization and development that differs from the far west.^11,16 The far west has twice the suicide rate of Florianópolis and South region. It is not known to what extent these ethnic and/or cultural differences interfere with suicide rates, and a descriptive study cannot suggest causal relationships. However, this seems to be a pertinent issue for further studies.

As in the rest of the country, both the absolute number and the death coefficient from suicide in the far west have grown over the past 25 years. Since 1997, the annual coefficient has been between 10 and 13 cases/100,000. A study published by WHO classified mortality from suicide into four levels, according to expected coefficient¹⁷: 1) less than 5/100,000 - low; 2) between 5 and 15/100,000 - medium; 3) between 15 and 30/100,000 - high; and 4) over 30/100,000 - very high. Based on this classification, the far west indices are at a medium level, the same as in the State of RS. The explanations for such a high incidence in that region are not clear yet. An initial comparison with available evidence indicates that both the ethical profile (descendants of European immigrants) and economic activity (agribusiness) are present in areas with high suicide rates in RS and SC. Other variables, such as schooling, socioeconomic level and level of investment in health, also seem to be correlated to suicide rates.^7,18 The far west of SC has been showing an urbanization process over the past 10 years, according to data from the state government. The Index of Human Development (IHD), which consists of an average of income, education and longevity, is between medium and high level, one of the highest in the country.¹⁶ This study is a preliminary survey of the epidemiological profile of suicide in that region. A relevant issue is the need of investigating the possible correlation between these socioeconomic factors and suicide rates in the region.

Suicide rates according to age group and gender are similar to those found in the literature: incidence three to four times higher in males and increasing coefficients with age. When analyzed according to age group, mortality in females reaches coefficients of 7/100,000 in young adults and rises to 10/100,000 in middle age and old age, which can be considered medium based on the WHO classification. These data stand out because they show worsening of the suicide problem in a group (women) that traditionally has low incidence. Faria et al.⁷ found a correlation between increasing levels of suicide in female rural workers in RS. It is likely that the same phenomenon is repeated in the far west of SC, where there is predominance of family agriculture. Another highlight is the tendency, as shown in

, of suicide growth in young adult and middle-aged women (between 20-49 years), while the other age groups have a reduction in their coefficients. Among men there was a tendency to stabilization of rates over the past 5 years (2000-2005). Specifically in young adults (20-39 years), the men/female suicide ratio does not reach 31 from 2000 to 2005. Therefore, what stands out here is a "progression" of a female population layer in relation to the others. These findings also refer us to previous issues: what is the socioeconomic profile of this population?

The method used for suicide seems to be the most peculiar finding of the region. Hanging accounted for 76% of deaths in men and 73% in women. Use of firearms accounted for 13% of deaths in males and 9% in females. Poisoning was considerably high in women (11 vs. 5% in men). In Brazil the most widely used means in men, according to a study by the Brazilian Department of Health, is use of firearms (44%), and hanging in women (41%).⁴ An epidemiological study in RS found hanging as accounting for 62% of deaths in general.⁶ Therefore, hanging is the significantly most widely used means for suicide in the far west of SC, whereas other forms, such as firearms and poisoning, have a discrete participation, when compared with previous studies; in RS firearms account for more than 20% of suicides,⁶ while the Brazilian mean is around 25%;¹⁹ poisoning had 31% rates in a study in the municipality of Ribeirão Preto.²⁰ This is another issue that requires more detailed studies. The far west region of SC cannot be considered a zone free of firearms; on the contrary, the history of conflicts in the region is likely to make access to these firearms even easier. However, use of this means for suicide is low compared with other Brazilian regions. Similarly, because of its economic characteristic, use of pesticides could increase the number of poisonings, which preliminarily does not seem to occur. Therefore, cultural and anthropological aspects are likely to be involved in choice of hanging as the preferential form of suicide. Leal²¹ stresses that hanging is closely related to the culture of RS. According to the authors, suicide can be seen as an honored action by males in RS that somehow had their honor compromised, and hanging could be a "masculine" form of dying. Colonization of the far west of SC was strongly influenced by the culture of RS, as most colonizers who occupied the territory since the 20th century came from RS.¹¹ One possible hypothesis is that RS and the far west of SC are separated from the political and administrative perspective, but form a culturally homogeneous cluster that might have some influence on the epidemiological profile of suicides. The anthropological explanation, however, does not clarify why hanging is also the most common method chosen by women in the far west of SC.

The main limitation of this study refers to its descriptive characteristic. This type of study helps health diagnosis and data systematization, but lacks the ability of establishing associations and estimating risks. This is a brief report of the statistics available at DATASUS. Although important as a general "mapping" of the far west, the absence of more detailed analyses limits the ability to compare and identify statistical differences. Some authors claim that epidemiological studies on suicide in Brazil still need refined statistical methods and suggest adoption of econometric analyses as a form of improving the studies.¹⁸ Another limitation is the possible underreport of suicide cases in Brazil. Mortality data are based on death certificates, and their quality is much dependent on the subjective interpretation of the professional responsible for it. Meneghel⁶ states that suicides can be reported as ignored external cause due to the taboo surrounding this type of death.

CONCLUSION

Several studies indicated that SC has one of the highest Brazilian mortality coefficients from suicide. The findings of this study corroborated previous research indicating the far west of SC as having the highest mortality rate from suicide. This study has the additional characteristic of using an extensive historical series (1980-2005), which had not occurred in descriptive statistics on suicide in SC.

The epidemiological characteristics of this region are similar to those of RS, with a high raw coefficient (mean of 10/100,000 inhabitants) and hanging as the method used in the absolute majority of cases. As in most places worldwide, the incidence of suicides is about three times higher in men than in women and has increasing coefficients with age.

Over the past 5 years of our series, suicide rates, although high, have shown a tendency to stabilization or even fall. The reasons of this finding should be further investigated, but some studies suggested that dissemination of psychiatric treatments may be related to such reductions.¹ However, in women aged 20-49 years, suicide rates have been increasing over the same period.

These results may help develop new research about this phenomenon in that region. Many questions aroused from the findings of this study. Among them, the following stand out: what is the socioeconomic profile of suicide? Is there an endemic zone of suicides between RS and the far west of SC, since the epidemiological profile and cultural aspects are similar between the populations? Why is hanging the most widely used method in more than 70% of cases?

The results indicate that suicide is a relevant public health problem in this region of SC. Data from other studies showed that only traffic accidents have rates higher than suicide rates in mortality due to external causes in the far west of SC.⁸ Collaboration between researchers of varied areas, such as medicine, social sciences, anthropology and economy, may be useful to build scientifically based knowledge on suicide in the far west of SC.

REFERENCES

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  World Health Organization. Multisite intervetion study on suicidal behaviours. Geneva, 2002. Disponível em: http://www.who.int/mental_health/media/en/254.pdf (acessado em 20/01/08).
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• 15. Peixoto HCG, Souza ML. O indicador anos potenciais de vida perdidos e a ordenação das causas de morte em Santa Catarina 1995. Inf Epidemiol SUS. 1999;8(1):17-25.
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Publication Dates

• Publication in this collection
  06 Jan 2009
• Date of issue
  Aug 2008

History

• Accepted
  31 Mar 2008
• Received
  22 Feb 2008