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Brazilian Journal of Psychiatry

versão impressa ISSN 1516-4446versão On-line ISSN 1809-452X

Braz. J. Psychiatry vol.41 no.5 São Paulo set./out. 2019  Epub 18-Fev-2019

http://dx.doi.org/10.1590/1516-4446-2018-0230 

ORIGINAL ARTICLES

Trends in suicide rates in Brazil from 1997 to 2015

Cássio D. Rodrigues1 
http://orcid.org/0000-0003-3553-9316

Débora S. de Souza1 

Henrique M. Rodrigues1 

Thais C.R.O. Konstantyner2 
http://orcid.org/0000-0002-2289-1866

1Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil

2Departamento de Medicina Preventiva, UNIFESP, São Paulo, SP, Brazil


ABSTRACT

Objectives:

To analyze time trends of suicide rates in Brazil overall and in Brazilian states and compare the estimated suicide rates projected for 2020 with the World Health Organization (WHO) Mental Health Action Plan target.

Methods:

This was an ecological time-series study from 1997 to 2015, stratified by Brazilian states, specific age groups, and sex. Data were obtained from the Mortality Information System (Sistema de Informações sobre Mortalidade [SIM]) of the Brazilian Ministry of Health. Polynomial regression models were used to analyze the trends in suicide rates and to project suicide rates for 2020.

Results:

Considering 224 units of analysis, 21 (9.4%) showed a decreasing trend, 108 (48.2%) were stable, and 95 (42.4%) showed an increasing trend. Thus, 67% of units of analysis will not meet the WHO target in 2020. Mean suicide rates were higher in males than in females. People aged 60 years and older presented the highest suicide rates, while 84.7% of total deaths by suicide occurred among 15-to-59-year-olds.

Conclusion:

Overall, 90.6% of units of analysis had a stable or increasing trend in suicide rates from 1997 to 2015. If these trends remain, most of Brazil will fail to achieve the WHO-recommended reduction in suicide rates by 2020.

Key words: Suicide; epidemiology; community mental health; public health; time series

Introduction

Suicide is a serious public health problem and one of the leading causes of death worldwide. According to the World Health Organization (WHO), close to 800,000 people die by suicide every year,1 resulting in a global average rate of 10.6 per 100,000 individuals, which is projected to increase in the next decades.2 In Brazil alone, approximately 10,000 individuals die by suicide per year, resulting in a crude suicide rate of 5.5 per 100,000 in 2015. In an attempt to counter these disheartening projections, Brazil and other countries, guided by the latest WHO Mental Health Action Plan,3 have been working toward a 10% reduction in their suicide rate by 2020 (considering 2012-year or 2013-year suicide rates as baseline).

With a population of more than 200 million, Brazil is the fifth largest country in the world and the eighth richest by Gross Domestic Product (GDP).4 Furthermore, it also has one of the world’s highest levels of social and income inequality, which has a direct impact on population health and on causes of death such as suicide.5

It is known that suicide is a complex and multifactorial phenomenon that involves sociocultural, economic, psychological, biological, and environmental issues. Therefore, regional variations in suicide rates in a large, heterogeneous, developing country like Brazil are to be expected. In such settings, time-series ecological studies can be an important epidemiological tool for formulating regional explanatory hypotheses and indirectly evaluating the effectiveness of public policies, as they allow forecasting and provide information on the distribution of events.6

Within this context, the aims of our study were to analyze time trends of suicide rates in Brazil overall and in individual Brazilian states from 1997 to 2015 and to compare projected suicide rates for 2020 with the WHO Mental Health Action Plan target.

Methods

This ecological study was an analysis of the time trend in suicide rates in Brazil as a whole and in Brazilian states from 1997 to 2015, stratified by sex and by age groups (15-29 years, 30-39 years, 40-59 years, and 60 years and older). In total, 224 units of analysis were studied.

All data were obtained from official secondary sources. The number of suicides was obtained from the Mortality Information System (Sistema de Informações sobre Mortalidade [SIM]) database, maintained by the Brazilian Ministry of Health. The population of each state was obtained from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística [IBGE]); census data were used for years in which censuses were performed, and interpolated data for the other years. Both datasets are publicly available online.7

Suicide was defined as death resulting from intentional self-harm according to the ICD-10, which uses codes X60 to X84 and Y87 to identify this outcome.

The 1997-2015 time series was composed of annual suicide rates. These were calculated by dividing the total number of suicides by the number of population and multiplying the quotient by 100,000, for Brazil and each of its states. Analyzes stratified by sex and age group were performed. Values corresponding to unknown age were excluded.

To evaluate whether the trend in suicide rates increased, decreased, or remained stable during the study period, polynomial regression models were used (y = β0 + βx). Suicide rates were considered as dependent variables (y), and the calendar years as independent variables (x). To avoid self-correlation between the terms of the regression equation, the calendar years were transformed into a year-centralized variable (x minus the midpoint of the historical series). A trend was considered significant when its estimated model obtained p < 0.05. Homoscedasticity and normality of distribution were assumed.

Estimated suicide rates projected for 2020 (using polynomial regression models and the 1997-2015 time series) and the WHO Mental Health Action Plan 10% reduction target3 were compared, using 2013-year rates as baseline data instead of 2012-year rates because there were no relevant differences between them and because 2013 data are more recent. All analyses were carried out in Stata version 14.0.

In accordance with Brazilian National Health Council Resolution 466/2012,8 this study was exempt from evaluation by a research ethics committee, since it used only secondary data available from official Brazilian Ministry of Health databases.

Results

According to official data, from 1997 to 2015, 164,276 suicides occurred in people aged 15 years and over in Brazil. Men accounted for 79.3% of total deaths. Considering the age groups analyzed, 32.4% of deaths occurred among people aged 40-59, 30.7% among people aged 15-29, 21.6% among people aged 30-39, and 15.3% among people aged 60 years and over.

The mean rates in women ranged from 0.89 (Acre, age ≥ 60 years) to 6.54 per 100,000 population (Rio Grande do Sul, age ≥ 60), while in men, they ranged from 3.78 (Rio de Janeiro, age 15-29) to 37.45 per 100,000 (Rio Grande do Sul, age ≥ 60).

The mean rates were higher in men than women in all age groups and throughout the country (Tables 1 to 4). Except in men aged 15-29 in the states of Maranhão, Paraíba, Bahia, and Rio de Janeiro, the mean suicide rate in male surpassed 5.00 per 100,000.

Table 1 Trends in suicide rates among people aged 15-29, stratified by sex (Brazil, 1997 to 2015) 

Region Female Male
Mean* βx R2 p-value Trend Mean* βx R2 p-value Trend
Brazil 2.22 0.01 0.25 0.029 Increasing 8.23 0.09 0.74 < 0.001 Increasing
North
Acre 2.89 0.00 0.00 0.956 Stable 11.17 0.56 0.55 0.002 Increasing
Amapá 3.53 0.16 0.34 0.037 Increasing 14.55 0.10 0.01 0.061 Stable
Amazonas 2.47 0.12 0.54 0.002 Increasing 11.93 0.68 0.88 < 0.001 Increasing
Pará 2.13 -0.09 0.37 0.025 Decreasing 5.39 0.14 0.45 0.008 Increasing
Rondônia 3.12 -0.08 0.13 0.129 Stable 9.26 0.08 0.03 0.474 Stable
Roraima 5.68 -0.03 0.00 0.799 Stable 20.06 0.06 0.00 0.841 Stable
Tocantins 2.86 0.11 0.33 0.042 Increasing 9.82 0.43 0.72 < 0.001 Increasing
Northeast
Alagoas 1.93 0.05 0.24 0.03 Increasing 6.16 0.06 0.03 0.500 Stable
Bahia 1.10 0.03 0.31 0.014 Increasing 3.88 0.19 0.72 < 0.001 Increasing
Ceará 2.67 0.09 0.68 < 0.001 Increasing 10.69 0.18 0.64 < 0.001 Increasing
Maranhão 1.56 0.04 0.21 0.050 Increasing 4.98 0.39 0.84 < 0.001 Increasing
Paraíba 1.71 0.12 0.39 0.005 Increasing 4.86 0.30 0.76 < 0.001 Increasing
Pernambuco 2.32 -0.04 0.44 0.010 Decreasing 6.35 -0.05 0.13 0.129 Stable
Piauí 3.37 0.19 0.71 < 0.001 Increasing 9.85 0.56 0.83 < 0.001 Increasing
Rio Grande do Norte 1.83 -0.03 0.08 0.231 Stable 6.49 0.13 0.48 0.005 Increasing
Sergipe 2.92 0.12 0.46 0.007 Increasing 7.28 0.32 0.64 < 0.001 Increasing
Center-West
Distrito Federal 2.50 -0.00 0.00 0.881 Stable 9.23 -0.13 0.12 0.154 Stable
Mato Grosso 3.27 -0.11 0.48 0.005 Decreasing 9.68 0.05 0.02 0.554 Stable
Mato Grosso do Sul 5.44 0.04 0.03 0.461 Stable 17.29 0.39 0.53 0.002 Increasing
Goiás 2.89 -0.03 0.12 0.152 Stable 10.94 0.05 0.03 0.459 Stable
Southeast
Espírito Santo 1.76 0.05 0.21 0.051 Stable 6.34 -0.12 0.14 0.109 Stable
Minas Gerais 2.22 0.05 0.35 0.032 Increasing 8.64 0.17 0.61 < 0.001 Increasing
Rio de Janeiro 1.34 0.01 0.01 0.700 Stable 3.78 0.00 0.00 0.893 Stable
São Paulo 1.88 0.02 0.45 0.009 Increasing 8.35 0.01 0.38 0.023 Increasing
South
Paraná 3.08 -0.07 0.35 0.008 Decreasing 11.56 -0.17 0.51 0.001 Decreasing
Santa Catarina 2.71 -0.01 0.01 0.619 Stable 11.11 0.02 0.01 0.655 Stable
Rio Grande do Sul 3.37 -0.07 0.43 0.011 Decreasing 14.27 -0.18 0.44 0.009 Decreasing

*Mean per 100,000 population from 1997 to 2015.

Annual increase per 100,000 population.

Table 2 Trends in suicide rates among people aged 30-39, stratified by sex (Brazil, 1997 to 2015) 

Region Female Male
Mean* βx R2 p-value Trend Mean* βx R2 p-value Trend
Brazil 2.55 0.03 0.46 0.002 Increasing 11.16 0.09 0.74 < 0.001 Increasing
North
Acre 3.61 0.03 0.00 0.806 Stable 12.15 0.37 0.14 0.118 Stable
Amapá 1.36 0.00 0.00 0.990 Stable 10.71 0.25 0.31 0.049 Increasing
Amazonas 1.38 0.13 0.39 0.004 Increasing 8.72 0.40 0.79 < 0.001 Increasing
Pará 1.53 0.01 0.01 0.754 Stable 5.67 0.14 0.39 0.019 Increasing
Rondônia 2.82 0.17 0.26 0.025 Increasing 9.90 0.18 0.07 0.282 Stable
Roraima 4.18 0.16 0.06 0.307 Stable 13.81 -0.30 0.06 0.333 Stable
Tocantins 2.96 0.11 0.08 0.236 Stable 10.49 0.70 0.67 < 0.001 Increasing
Northeast
Alagoas 1.68 0.03 0.06 0.324 Stable 7.21 0.07 0.04 0.435 Stable
Bahia 1.19 0.04 0.26 0.027 Increasing 5.60 0.25 0.65 < 0.001 Increasing
Ceará 2.91 0.01 0.01 0.723 Stable 14.74 0.24 0.63 < 0.001 Increasing
Maranhão 1.65 0.05 0.12 0.146 Stable 5.90 0.38 0.86 < 0.001 Increasing
Paraíba 1.69 0.07 0.33 0.042 Increasing 8.22 0.47 0.68 < 0.001 Increasing
Pernambuco 2.07 -0.03 0.05 0.336 Stable 8.02 -0.12 0.15 0.096 Stable
Piauí 3.18 0.18 0.56 0.002 Increasing 12.53 0.72 0.66 < 0.001 Increasing
Rio Grande do Norte 2.20 0.03 0.03 0.468 Stable 10.72 0.04 0.01 0.686 Stable
Sergipe 2.59 0.06 0.40 0.017 Increasing 10.94 0.34 0.27 0.022 Increasing
Center-West
Distrito Federal 2.28 0.02 0.02 0.532 Stable 10.37 -0.03 0.00 0.777 Stable
Mato Grosso 3.44 -0.12 0.16 0.085 Stable 11.90 -0.07 0.03 0.464 Stable
Mato Grosso do Sul 4.10 0.09 0.23 0.040 Increasing 15.49 0.29 0.23 0.040 Increasing
Goiás 3.53 -0.01 0.00 0.831 Stable 12.90 -0.01 0.00 0.933 Stable
Southeast
Espírito Santo 2.70 0.14 0.58 0.001 Increasing 9.46 -0.04 0.04 0.397 Stable
Minas Gerais 3.12 0.07 0.52 0.003 Increasing 11.91 0.30 0.77 < 0.001 Increasing
Rio de Janeiro 1.84 0.00 0.00 0.822 Stable 5.40 0.02 0.61 0.001 Increasing
São Paulo 2.33 0.03 0.57 0.001 Increasing 10.87 0.11 0.70 < 0.001 Increasing
South
Paraná 3.44 -0.03 0.03 0.469 Stable 13.57 -0.20 0.47 0.001 Decreasing
Santa Catarina 3.81 0.15 0.60 0.001 Increasing 15.39 -0.28 0.56 0.001 Decreasing
Rio Grande do Sul 4.22 0.03 0.09 0.226 Stable 19.38 -0.21 0.36 0.007 Decreasing

*Mean per 100,000 population from 1997 to 2015.

Annual increase per 100,000 population.

Table 3 Trends in suicide rates among people aged 40-59, stratified by sex (Brazil, 1997 to 2015) 

Region Female Male
Mean* βx R2 p-value Trend Mean* βx R2 p-value Trend
Brazil 3.03 0.05 0.70 < 0.001 Increasing 11.68 0.04 0.36 0.030 Increasing
North
Acre 1.72 0.00 0.00 0.956 Stable 8.81 0.35 0.18 0.073 Stable
Amapá 2.08 0.03 0.01 0.753 Stable 9.51 -0.25 0.08 0.231 Stable
Amazonas 1.40 0.09 0.53 0.002 Increasing 6.73 0.11 0.17 0.078 Stable
Pará 1.39 -0.03 0.16 0.088 Stable 5.45 0.08 0.17 0.084 Stable
Rondônia 3.01 -0.03 0.02 0.566 Stable 9.69 -0.09 0.02 0.533 Stable
Roraima 2.12 0.03 0.00 0.824 Stable 12.24 -0.00 0.00 0.996 Stable
Tocantins 3.62 0.10 0.33 0.04 Increasing 11.83 0.28 0.37 0.024 Increasing
Northeast
Alagoas 1.79 0.05 0.34 0.037 Increasing 7.90 0.14 0.16 0.085 Stable
Bahia 1.39 0.06 0.44 0.002 Increasing 6.69 0.25 0.85 < 0.001 Increasing
Ceará 3.47 0.04 0.07 0.265 Stable 14.46 0.32 0.52 0.003 Increasing
Maranhão 1.47 0.09 0.65 < 0.001 Increasing 5.94 0.29 0.71 < 0.001 Increasing
Paraíba 2.11 0.13 0.50 0.004 Increasing 8.44 0.52 0.76 < 0.001 Increasing
Pernambuco 2.40 0.01 0.02 0.604 Stable 9.17 -0.11 0.22 0.041 Decreasing
Piauí 3.48 0.18 0.51 0.001 Increasing 12.83 0.82 0.80 < 0.001 Increasing
Rio Grande do Norte 2.48 0.02 0.01 0.706 Stable 11.88 0.26 0.35 0.030 Increasing
Sergipe 2.96 0.09 0.15 0.106 Stable 10.39 0.38 0.58 0.001 Increasing
Center-West
Distrito Federal 3.56 0.06 0.07 0.271 Stable 9.45 0.09 0.07 0.269 Stable
Mato Grosso 3.46 0.02 0.01 0.750 Stable 12.82 -0.21 0.17 0.080 Stable
Mato Grosso do Sul 3.42 -0.05 0.10 0.181 Stable 14.25 0.08 0.03 0.459 Stable
Goiás 3.88 0.04 0.08 0.250 Stable 13.85 -0.10 0.05 0.378 Stable
Southeast
Espírito Santo 3.62 0.15 0.50 0.004 Increasing 10.67 0.05 0.05 0.378 Stable
Minas Gerais 3.46 0.17 0.81 < 0.001 Increasing 12.17 0.38 0.79 < 0.001 Increasing
Rio de Janeiro 2.08 0.01 0.03 0.513 Stable 6.09 0.03 0.03 0.484 Stable
São Paulo 2.84 0.03 0.19 0.066 Stable 10.25 -0.05 0.65 < 0.001 Decreasing
South
Paraná 3.56 -0.01 0.01 0.751 Stable 14.76 -0.24 0.73 < 0.001 Decreasing
Santa Catarina 5.38 0.13 0.45 0.008 Increasing 21.24 -0.26 0.58 0.001 Decreasing
Rio Grande do Sul 5.94 0.03 0.31 0.049 Increasing 26.34 -0.35 0.61 < 0.001 Decreasing

*Mean per 100,000 population from 1997 to 2015.

Annual increase per 100,000 population.

Table 4 Trends in suicide rates among people aged ≥ 60 years, stratified by sex (Brazil, 1997 to 2015) 

Region Female Male
Mean* βx R2 p-value Trend Mean* βx R2 p-value Trend
Brazil 2.57 0.02 0.30 0.015 Increasing 13.84 0.03 0.07 0.285 Stable
North
Acre 0.89 -0.01 0.00 0.897 Stable 8.86 0.22 0.04 0.424 Stable
Amapá 1.46 -0.18 0.08 0.234 Stable 10.44 0.28 0.02 0.572 Stable
Amazonas 1.18 0.08 0.16 0.091 Stable 6.77 0.20 0.16 0.091 Stable
Pará 0.96 0.03 0.07 0.279 Stable 6.22 0.13 0.17 0.080 Stable
Rondônia 1.84 -0.00 0.00 0.982 Stable 10.02 -0.09 0.01 0.732 Stable
Roraima 2.71 0.31 0.10 0.196 Stable 14.25 -0.38 0.04 0.429 Stable
Tocantins 3.11 0.20 0.24 0.033 Increasing 14.75 0.75 0.33 0.010 Increasing
Northeast
Alagoas 1.60 0.05 0.07 0.273 Stable 8.96 0.30 0.24 0.035 Increasing
Bahia 1.22 0.06 0.29 0.017 Increasing 8.05 0.34 0.55 0.002 Increasing
Ceará 2.76 0.07 0.32 0.044 Increasing 14.97 0.44 0.62 0.001 Increasing
Maranhão 1.24 0.07 0.26 0.024 Increasing 6.49 0.61 0.81 < 0.001 Increasing
Paraíba 2.24 0.08 0.14 0.121 Stable 11.18 0.69 0.72 < 0.001 Increasing
Pernambuco 2.53 -0.07 0.54 0.002 Decreasing 11.37 -0.05 0.02 0.547 Stable
Piauí 3.74 0.27 0.54 0.002 Increasing 16.63 1.13 0.84 < 0.001 Increasing
Rio Grande do Norte 2.97 0.05 0.04 0.438 Stable 14.34 0.051 0.46 0.008 Increasing
Sergipe 3.14 0.16 0.24 0.034 Increasing 12.70 0.64 0.43 0.011 Increasing
Center-West
Distrito Federal 2.11 0.02 0.01 0.727 Stable 12.09 -0.12 0.02 0.570 Stable
Mato Grosso 2.86 -0.03 0.01 0.691 Stable 16.52 -0.03 0.00 0.858 Stable
Mato Grosso do Sul 3.80 -0.04 0.02 0.553 Stable 21.23 -0.62 0.41 0.015 Decreasing
Goiás 2.99 -0.01 0.00 0.896 Stable 18.66 0.06 0.02 0.532 Stable
Southeast
Espírito Santo 2.26 0.02 0.01 0.753 Stable 11.17 -0.00 0.00 0.976 Stable
Minas Gerais 2.08 0.11 0.68 < 0.001 Increasing 11.06 0.32 0.55 < 0.001 Increasing
Rio de Janeiro 1.63 0.01 0.01 0.730 Stable 8.06 -0.12 0.15 0.102 Stable
São Paulo 2.25 -0.00 0.00 0.903 Stable 11.30 -0.17 0.51 0.003 Decreasing
South
Paraná 2.63 -0.04 0.12 0.149 Stable 16.91 -0.45 0.55 0.002 Decreasing
Santa Catarina 5.33 0.06 0.07 0.265 Stable 30.03 -0.53 0.56 0.001 Decreasing
Rio Grande do Sul 6.54 -0.07 0.13 0.130 Stable 37.45 -0.59 0.59 0.001 Decreasing

*Mean per 100,000 population from 1997 to 2015.

Annual increase per 100,000 population.

Considering 224 units of analysis, 21 (9.4%) showed a decreasing trend in suicide rates, 108 (48.2%) were stable, and 95 (42.4%) showed an increasing trend in suicide rates (Tables 1 to 4).

A comparison between projected suicide rates for 2020 versus the WHO Mental Health Action Plan target is presented in Tables 5 and 6. Of the 224 units of analysis, 67% will not meet the WHO target by 2020. Considering only the 21 units of analysis that showed a decreasing trend, 14 will still not meet the WHO target by 2020.

Table 5 Comparison between projected suicide rates (per 100,000 population) for 2020* and the World Health Organization (WHO) Mental Health Action Plan target for women, stratified by age group 

Region 15-29 years 30-39 years 40-59 years ≥ 60 years
Projection 2020 WHO 2020 Projection 2020 WHO 2020 Projection 2020 WHO 2020 Projection 2020 WHO 2020
Brazil 2.36 2.02 2.97 2.24 3.73 3.19 2.85 2.80
North
Acre 2.89 4.93 3.61 3.15 1.72 0.00 0.09 0.00
Amapá 0.83 2.54 1.36 0.00 2.08 3.07 1.46 0.00
Amazonas 7.57 4.24 3.20 3.39 6.11 0.56 1.18 2.39
Pará 2.57 1.53 1.53 1.33 1.39 1.27 0.96 1.57
Rondônia 3.12 1.50 5.20 4.48 3.01 2.01 1.84 0.00
Roraima 5.68 5.09 4.18 5.03 2.12 2.23 2.71 7.61
Tocantins 2.79 3.54 2.96 2.35 0.00 1.30 5.91 1.53
Northeast
Alagoas 2.63 1.80 1.68 1.02 4.02 2.40 1.60 2.24
Bahia 1.52 1.13 1.75 1.34 2.23 1.95 2.06 2.46
Ceará 2.36 2.69 2.91 2.49 3.47 3.35 5.36 3.76
Maranhão 2.12 1.80 1.65 0.52 2.73 1.95 2.22 2.45
Paraíba 3.39 2.10 0.96 2.24 3.80 2.92 2.24 2.90
Pernambuco 0.13 1.64 2.07 0.83 2.40 1.89 4.84 1.81
Piauí 2.75 3.63 2.40 3.10 6.00 1.61 4.09 7.79
Rio Grande do Norte 1.83 1.00 2.20 1.68 2.48 2.64 2.97 3.18
Sergipe 1.30 3.26 0.00 1.99 2.96 4.23 5.38 2.52
Center-West
Distrito Federal 2.50 2.46 2.28 3.65 3.56 2.60 2.11 1.30
Mato Grosso 0.00 1.93 1.76 2.11 3.46 5.69 2.86 2.79
Mato Grosso do Sul 5.44 4.89 3.44 5.74 3.42 3.59 3.80 3.33
Goiás 2.89 2.36 3.53 2.33 3.88 4.37 2.99 3.36
Southeast
Espírito Santo 1.76 0.74 6.18 4.02 4.11 4.08 2.26 3.60
Minas Gerais 1.14 2.05 2.42 2.34 5.84 4.19 5.43 2.76
Rio de Janeiro 1.34 1.08 1.84 1.72 2.08 1.91 1.63 1.36
São Paulo 3.95 1.96 0.15 2.05 2.84 2.94 2.25 2.07
South
Paraná 2.03 1.78 3.44 2.40 3.56 3.52 2.63 2.68
Santa Catarina 2.71 1.70 7.58 3.67 10.45 6.75 5.33 5.70
Rio Grande do Sul 4.05 3.17 4.22 3.87 7.92 5.77 6.54 6.23

*Using polynomial regression models and a 1997-2015 time series.

WHO Mental Health Action Plan target: a 10% reduction in suicide rate by 2020, using 2013-year rates as baseline.

Table 6 Comparison between projected suicide rates (per 100,000 population) for 2020* and the World Health Organization (WHO) Mental Health Action Plan target for men, stratified by age group 

Region 15-29 years 30-39 years 40-59 years ≥ 60 years
Projection 2020 WHO 2020 Projection 2020 WHO 2020 Projection 2020 WHO 2020 Projection 2020 WHO 2020
Brazil 9.49 7.99 13.49 10.69 13.92 10.87 13.84 12.49
North
Acre 17.27 13.68 12.15 15.44 8.81 8.37 8.86 0.00
Amapá 14.55 19.15 25.81 11.42 9.51 8.43 10.44 15.36
Amazonas 29.77 17.11 22.52 11.35 6.73 5.97 6.77 5.21
Pará 8.97 5.34 10.8 6.77 5.45 5.72 6.22 7.39
Rondônia 9.26 9.35 9.90 13.16 9.69 8.59 10.02 7.18
Roraima 20.06 13.54 13.81 12.29 12.24 14.03 14.25 6.89
Tocantins 10.82 10.71 10.28 15.81 7.59 13.57 10.27 16.37
Northeast
Alagoas 6.16 8.84 7.21 8.62 7.90 9.19 13.16 13.01
Bahia 4.81 3.87 7.49 6.37 8.57 7.67 11.07 11.99
Ceará 6.56 11.11 8.11 14.41 12.21 14.63 14.56 17.84
Maranhão 12.16 6.52 14.66 7.96 10.00 7.79 18.30 10.61
Paraíba 9.06 6.02 14.8 10.92 17.35 12.92 15.74 14.58
Pernambuco 6.35 5.02 8.02 9.55 7.63 7.50 11.37 10.39
Piauí 14.46 12.19 9.97 12.17 19.46 17.23 32.45 18.48
Rio Grande do Norte 3.46 6.48 10.72 9.12 10.41 11.54 14.85 13.21
Sergipe 11.76 8.68 15.70 9.80 7.38 12.49 16.55 14.26
Center-West
Distrito Federal 9.23 8.96 10.37 8.91 9.45 9.23 12.09 8.86
Mato Grosso 9.68 9.41 11.90 8.76 12.82 10.62 16.52 14.86
Mato Grosso do Sul 16.07 17.45 19.55 15.34 14.25 15.34 15.80 15.77
Goiás 10.94 10.83 12.90 11.61 13.85 13.86 18.66 14.94
Southeast
Espírito Santo 6.34 4.10 9.46 8.43 10.67 9.67 11.17 4.85
Minas Gerais 9.36 8.38 12.72 10.57 15.95 11.73 15.54 11.84
Rio de Janeiro 3.78 2.73 10.75 6.00 6.09 5.03 8.06 6.03
São Paulo 11.76 8.02 18.92 12.11 14.60 9.40 10.53 8.62
South
Paraná 9.18 10.02 10.77 11.75 18.17 12.28 20.65 12.71
Santa Catarina 11.11 9.47 18.03 14.36 25.95 18.06 40.79 26.32
Rio Grande do Sul 10.00 10.69 16.44 16.92 21.44 22.78 30.90 29.19

*Using polynomial regression models and a 1997-2015 time series.

WHO Mental Health Action Plan target: a 10% reduction in suicide rate by 2020, using 2013-year rates as baseline.

Discussion

Our ecological study showed three main results. First, 90.6% of units of analysis had a stable or increasing trend in suicide rates from 1997 to 2015; if these trends are maintained, 67% of the 224 units of analysis will not achieve a 10% reduction in suicide rates by 2020 as recommended by WHO. Second, there was great variability in mean suicide rate among the Brazilian states. In general, the highest mean suicide rate was found among people aged 60 years and older. However, approximately 85% of suicides occurred in the young and adult population (15-59 years). Furthermore, mean suicide rates in men were always higher than in women, regardless of age group or state of Brazil.

The Brazilian mental health system was reorganized by a psychiatric reform that began in 1978. Since then, mental health care network services have been expanded to provide assistance in the community and to avoid hospitalization. However, only a small part of these services received training for suicide management. Only since 2006 has suicide been recognized as a priority challenge for public health in the country.9 In 2017, the Brazilian Ministry of Health, rectifying this concern, designed the 2017-2020 Strategic Action Agenda for Suicide Surveillance and Prevention and Health Promotion in Brazil (Agenda de Ações Estratégicas para a Vigilância e Prevenção do Suicídio e Promoção da Saúde no Brasil 2017-2020),10 based on the WHO Mental Health Action Plan.3 This document establishes a series of actions to improve the quality of health promotion, suicide surveillance, suicide prevention, and care to victims of attempted suicide and their relatives. Considering the projections of our study, it is essential that these strategies be quickly and effectively implemented throughout Brazil, with special emphasis on vulnerable groups and those with high suicide concentrations.

The variability in suicide rates and trends in Brazilian states evidenced by our study was expected, and had already been observed in previous investigations in the country.11,12 The literature has also shown heterogeneity in these rates within the country, which have been explained by cultural, environmental, and socioeconomic differences.13-17 It is worth noting that Brazil has one of the world’s largest GDPs and one of the highest rates of social and income inequality. In addition, its vast territory, populated by several ethnic groups and cultures from various parts of the world, account for this heterogeneous scenario.

Regardless of the Brazilian state analyzed, our findings have reinforced the magnitude of suicide in men and older adults. According to the WHO, men from richer countries are three times as likely to die by suicide than women, while the male-to-female ratio of suicide deaths in low- and middle-income countries is around 1.5. In addition, the suicide rate is highest in people aged 70 years and over, regardless of gender.1

Finally, the high absolute number of suicides that occurred in the young and adult population during the period of analysis is worrisome. It bears stressing that deaths in this age group have major economic and social costs,18 besides reflecting lower quality of life in the population. A previous Brazilian study highlighted the importance and impact of external causes of premature death and disability among the population and found that suicide was the sixth leading external cause of years of life lost to death or disability.19

Although ecological studies are useful for generating hypotheses, we acknowledge that the main limitation of our study was the possibility of ecological bias, that is, the failure in reasoning that arises when an inference is made about an individual based on aggregate data for a group. The specialized literature suggests some strategies to avoid this kind of bias, one of which is the use of smaller units of analysis to make groups more homogeneous in relation to exposures.20 Thus, we chose to stratify these rates by state, gender, and age groups, given the massive size of Brazil and the available official data on suicide. Furthermore, once this stratification was done, it gave us mathematical support to dismiss the standardized suicide ratio and use crude rates instead.

Another important limitation of our study was the use of data on suicide from a secondary database; specifically, the Brazilian Ministry of Health SIM. Although the coverage and quality of these data are regarded as satisfactory, underreporting and misclassification are known to occur, and tend to lead to underestimation of suicide rates, particularly in developing regions.21 However, a review indicates that underestimation is not sufficient to bias results in this type of analysis.22

The main strength of our study was the use of panel data. In settings with areas and populations as large as that of Brazil, an ecological time-series approach can quickly identify vulnerable groups to which resources should be allocated as a priority, as well as groups with low suicide rates, which can provide insights into best practices.23

Although the Brazilian scenario is alarming, we believe that suicide can be prevented by public health strategies and social policies.24 Therefore, our study contributes with well-founded data nationwide that strengthens the need for rapid implementation of actions for health promotion and prevention of this phenomenon, as provided for in the 2017-2020 Strategic Action Agenda for Suicide Surveillance and Prevention and Health Promotion in Brazil.

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Recebido: 24 de Julho de 2018; Aceito: 26 de Setembro de 2018

Correspondence: Cássio Dias Rodrigues, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, CEP 04023-062, São Paulo, SP, Brazil. E-mail: cassio.dias.rodrigues@gmail.com

Disclosure The authors report no conflicts of interest.

How to cite this article: Rodrigues CD, de Souza DS, Rodrigues HM, Konstantyner TCRO. Trends in suicide rates in Brazil from 1997 to 2015. Braz J Psychiatry. 2019;41:000-000. http://dx.doi.org/10.1590/1516-4446-2018-0230

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