Suicide and associated factors across life span

Objective: To assess the epidemiological and toxicological profile of all suicide victims in 2017 in Rio Grande do Sul, Brazil. Methods: The victims were classified by gender, age, parental absence, city, suicide form, death context, and toxicological results, using the police occurrences and the reports issued by the Instituto-Geral de Perícias do RS. Multiple correspondence analysis and the CochranMantel-Haenszel X2 test were used to evaluate associations between the parameters studied. Results: There were 1,284 suicides (11.3 cases/100,000 inhabitants) in RS in 2017, 80% of which were men and 46% were young and old. Porto Alegre had the highest number of victims and the region of the Vale do Rio Pardo, the highest rate (20.8 cases/100,000 inhabitants). The hanging was the most used medium and the depression, the most mentioned context in the occurrences. The presence of ethanol was observed in 30% of the samples analyzed, with an adult male profile associated with the presence of other psychotropic substances, whose class was most frequently detected with anxiolytics. The nitrite was the most detected poison among the samples sent for this purpose. There was an association between parental absence and young people, between suicidal intoxication method and women and among young people and the presence of illicit compounds. Conclusion: Mortality due to suicide continues to increase in RS, which, historically, has the highest Brazilian index. The information obtained in this study supports new research, promoting awareness raising, guidance to health services and the elaboration of more preventive public policies.


INTRODUCTION
Suicide is one of the most preventable causes of violent death in modern society, becoming a public health problem 1 . Worldwide, around 800,000 people commit suicide every year 2 , with 65,000 in the Americas region 3 . According to the World Health Organization (WHO), suicide prevention is a global goal, aiming at a 10% reduction by 2020 4,5 . In addition, it is also among the United Nations health indicators, whose goal of sustainable development is to reduce, by 2030, premature mortality from non-communicable diseases by preventing, treating and promoting mental health and well-being 5 .
In Brazil there were 8,000 cases of suicide in 2004 and more than 10,000 in 2014 6,7 . While the Brazilian population increased by 17.8% between 1998 and 2008, the number of deaths from suicide increased by 33.5% 8 . The average case rate per 100,000 inhabitants/year in 2016 in Brazil was 6.19 and this national average hides important regional variations 8,9 , indicating the need for local monitoring and control processes aligned with governmental preventive measures 5 .
The state of Rio Grande do Sul (RS) has, historically, had the highest Brazilian suicide rate 10-12 , with an annual average (2016) of 11.0 cases per 100,000 inhabitants 10 . In this sense, the objective of this study was to characterize the epidemiological and toxicological profile of all RS suicide victims in 2017, in order to support the elaboration of preventive strategies directed to the regions and the population most vulnerable to this psychosocial problem.

METHODS
The occurrences of the Polícia Civil do RS, the reports of the Department of Forensic Medicine and the examinations performed by the Department of Laboratory Forensics related to all deaths by suicide, submitted to necropsy by the Instituto-Geral de Perícias do RS, from January 1st to December 31, 2017, were included in this work.
Victims were classified by gender, age, parental absence in the birth certificate, city, region 13 , macroregion 14 , suicide form, death context, and toxicological findings. Alcoholic dosages were performed on whole blood samples and qualitative analyzes of psychotropics and poisons on urine, vitreous humor, stomach and contents, liver and/or brain.
The study was retrospective and descriptive, and suicide rates for every 100,000 inhabitants were calculated from population data estimated for 2017 by the Instituto Brasileiro de Geografia e Estatística 15 .
Multiple correspondence analysis, Cochran-Mantel-Haenszel X 2 with continuity correction (CMH) and Breslow-Day tests were performed using the free software R ® version 3.5.1, with a significance level of 0.05%, excluding observations with missing data.
The study project was approved by the Research Ethics Committee of the Federal University of Rio Grande do Sul, under number 2 532 550.

RESULTS
A total of 1,284 deaths from suicide in RS were recorded in 2017, corresponding to the rate of 11.3 cases per 100,000 inhabitants.
In 302 (60.8%) of the 497 cities of RS, there were cases of suicide. The state's capital, Porto Alegre, had the highest number of victims (n = 120), with a rate of 8.1 cases/100,000 inhabitants. Already the André da Rocha city, had the highest state rate, 153.1/100,000 inhabitants.
In figure 1, it can be observed that Passo Fundo and Caxias do Sul macroregions, had the highest suicide rates, both with 13.9 cases/100,000 inhabitants.
The region with the highest rate in the state (20.8 cases/100,000 inhabitants) was the Vale do Rio Pardo. Figure 1 also shows the rates by city that makes up this region. The highest rate in the region was observed in the Vale Verde city.
Most victims were born and committed suicide in different cities (57.2%), but in the same region (66.3%) or macroregion (75.5%). In 63 cases (4.9%), birth occurred in other states or countries, including South Korea, the United States, Russia, and Germany, among others.
According to table 1, the ratio between men and women was 4:1, with the obtained rates of 19.9 cases/100,000 male and of 4.5, female.
Parental absence was observed in 76 cases, corresponding to 5.6% of women and 6.0% of men.
The average age of the victims was 47.6 ± 18.3 years, ranging from 7 to 101 years.
In 2017 in RS, young people (15 to 29 years old) accounted for 18.8% (n = 241) of suicide victims, providing a rate of 9.1 cases/100,000 inhabitants. The elderly (60 years or older), at 26.9% (n = 345), with a rate of 23.6 cases/100,000 inhabitants of this age group.
Concerning seasonality, winter was the period of the year where there were most cases of suicide (26.1%), regardless of gender. According to the age group, the elderly committed suicide more in the summer (29.6%) and young people more in the spring (30.7%). It was also observed that most suicides occurred on Wednesdays (15.5%), the morning shift (34.2%) and the second half of the month (50.2%).
With respect to way to commit suicide (Table 1), hanging corresponded to 72.3% of cases, followed by firearm (14.7%), intoxication (6.1%) and high fall (2.9%). In addition to these forms, suicides involving stabbing, drowning, burns, traffic accidents, brain trauma, electroplession and blunt instrument were also recorded. It was also observed that only in cases of poisoning there was a higher number of female victims.
Of the cases involving the use of firearms (n = 189), 69.3% (n = 131) underwent residuographic examinations to detect the presence of lead, barium and antimony in the hands of the victims 16 , obtaining 65.6 % of positive results (n = 86). In 58 cases (30.7%), there was no collection of the necessary material to perform this exam.
Although additional information was not available in all cases (Figure 2), it was observed that 34.1% of women and 20.6% of men had depression, totalling 23.2% of victims.
Taking into account the age group (Table 1), the elderly were more frequent victims than young people between occurrences related to depression and warning of the intention to commit suicide. On the other hand, when previous suicide attempts were recorded, young people were more frequent than the elderly.
It is also noted ( Figure 2) that there were practically no female suicides related to alcoholism, financial problems, homicide followed by suicide or cases in which the victim was deprived of her freedom.
In only one case (female, 24 years old) was the victim's participation recorded in the internet game called "blue whale", where the person is encouraged to perform selfdestructive actions whose ultimate goal is to end his or her own life 17 .   Regarding toxicological assessments, suicide deaths in RS in 2017 required a total of 2,051 expert analysis in biological samples collected from 980 victims, and no laboratory tests were requested in 23.7% (n = 304) of the cases.
The presence of ethanol was detected in 29.9% (n = 282) of the samples referred for this analysis (n = 943). In 29 cases, the blood alcohol concentration was impaired due to problems of coagulation, leakage or use of expired vial for sample packaging. Mean blood ethanol concentration among men was 14.6 ± 10.4 dg/L (0.5 to 85.3 dg/L) and among women was 10.4 ± 8.2 dg/L (0.6 to 36.2 dg/L).
About the positive results for alcohol (Table 1), the ratio between men and women was 8:1, with the highest frequency in the Porto Alegre macroregion (n = 109), followed by Passo Fundo (n = 69). The prevalence ratio of ethanol positive results among men was 2.5 times higher than among women (95% CI 1.6-3.8), regardless of macroregion (p = 3.38) or age (p = 0.41).
Detection of other psychotropic substances was observed in 31.2% (n = 268) of the samples analyzed for this purpose (n = 858). Among the positive results, the ratio between men and women was 2:1.
According to table 1, the most present class of psychotropic (except ethanol) in the samples was anxiolytics (40.3%, n = 108), in which diazepam, nordazepam and midazolam were the most detected benzodiazepines. Secondly, compounds with stimulating properties were found, corresponding to 30.6% of the positive results (n = 82), where cocaine was the most frequent substance (n = 79).
Antidepressants were observed in 23.5% (n = 63) of the positive cases, including fluoxetine (n = 15), sertraline (n = 13), amitriptyline (n = 12) and citalopram (n = 11). When some antidepressant medication was detected, 41.3% (n = 26) presented depression, according to police occurrences. However, evaluating the records where depression was reported, in 64.8% (n = 193) of the cases no antidepressant was found and 26.5% (n = 79) of these victims did not have their biological samples collected for laboratory tests.
Considering other illicit compounds 18 , tetrahydrocannabinol (THC) was detected in 21 samples, corresponding to 7.8% of positive results (n = 268) and methylenedioxymethamphetamine (MDMA) to 1.5% (n = 4). The victims who presented at least one illicit substance (n = 92), were young people in 42.4% of the cases, the male to female ratio was 9:1 and the highest frequency occurred in Porto Alegre macroregion (n = 45), followed by Caxias do Sul (n = 16).
In all victims that MDMA was present, at least one other psychotropic drug was detected simultaneously, including ethanol, cocaine, ketamine and/or THC. In only one of the positive cases for MDMA, the means used by the victim was intoxication.
Simultaneous consumption of ethanol and some other psychoactive compound (Table 1) was observed in 29.9% (n = 75) of the samples with positive results for any psychotropic substance (n = 251), being 8:1 the proportion between men and women and 32.0% (n = 24) involving young people.
Detection of some poison occurred in 14.9% (n = 17) of the samples sent for this purpose (n = 114). Considering the positive results (Table 1), the ratio between men and women was 2:1, the highest frequency was found in the Caxias do Sul macroregion (n = 10), followed by Passo Fundo (n = 3). The elderly victims corresponded to 29.4% of the cases and the young to 23.5%. Nitrite ion was detected in 47.1% (n = 8) of the positive results, followed by carbofuran (n = 3), fention, acephate, carbon monoxide, butane, paraquat and 2.4 D.
The suicidal form was associated with the presence of psychotropic drugs (Figures 3, 4 and 5), but there was no association between the macroregion and detection of ethanol, regardless of age or gender.
The intoxication, female victims and negative results for ethanol categories were in the same quadrant in figure 4, as well as illicit compounds, parental absence and young. By evaluating the data in figure 5, it was observed that there was an association between gender and cause of death, between gender and the presence of ethanol and between parental absence and age; however, it was not observed between parental absence and illicit drugs.

DISCUSSION
The number of suicide victims in RS in 2017 increased by 10% over the previous year, where 1,166 cases were reported, and the rate obtained was almost double the Brazilian rate in 2016 10 . These results may be even higher considering underreporting cases, where suicides are concealed by other types of death, such as traffic accidents, drowning, accidental poisoning, or deaths of undetermined cause 8,11 . The social impact of this problem goes far beyond the actual number of deaths, since it is estimated that for each suicide there are, on average, 5 or 6 people close to the victim who suffer emotional, social and economic consequences 1,6,19 .
One parameter that is used to identify and compare cities regarding the incidence of suicides is the case rate per 100,000 inhabitants. This assessment, however, should consider that in cities with less than 200,000 people, few deaths can substantially increase the mortality coefficient 9 . For example, André da Rocha city, located in the northeast region, registered only 2 cases in a population of 1 306 people and Vale Verde city, 4 cases with 3 461 inhabitants.
The RS state has 22 regions 13 organized in 5 macroregions 14 . The region of the Vale do Rio Pardo, which had the highest state suicide rate, is in the Caxias do Sul macroregion, whose main urban centers are the cities of Santa Cruz do Sul and Venâncio Aires 15,20 , concentrates 4% of the population state, has a demographic density (2010) of 32.7 inhabitants/km² and is where predominantly tobacco is grown. One of the factors that may be related to the incidence of suicides in this region is the prospect of tobacco saturation, which concerns the local economic base, including the level of employment in the industry linked to this segment 20 .
In 2012, the Vale do Rio Pardo region had a socioeconomic development index of 0.725 (middle level) with a gross domestic product of approximately R$ 10.8 billion (3.9% of the total RS). With regard to educational indicators, this region has the sixth lowest value among all other regions, with the lowest enrollment rate in state high school. In addition, the percentage of households with internet access and fixed and mobile telephones is below state averages 20 .
According to WHO data (2000), people who move, mainly from rural to urban areas, or between different regions or countries, are more vulnerable to suicidal behavior 1 . In RS, in 2017, the data obtained confirmed this feature, except for the rural and urban issue, which was not evaluated.
In 2016, the suicide rates recorded in RS were 17.8 cases/100,000 male inhabitants and 4.5 among women 10 . The results found in this study showed an increase of 11% among men, while the rate among female victims remained constant. In general, suicide mortality among men is higher 1,10,11,21-23 . According to Meneghel (2004), men behave more competitively, impulsively, have more access to firearms and, in some cultures, suffer stress and frustration due to the obligation to perform traditional gender roles, as family economic provider 10, 11 . In contrast, women would commit suicide less because they have stronger social protection networks and engage more easily in domestic and community activities, developing a greater sense of connection 5,11,19 . Nevertheless, in Brazil between 1994 and 2004, the proportional increase in suicide rates was 16.4% for men and 24.7% for women 6 .
In relation to suicides in adolescence, must keep in mind that this period of life is characterized by profound changes in physiological, psychological and social order, including the moment when psychoactive drugs consumption begins 22 . Parents and teachers, because they are close, should give young people an opportunity to understand the process they are going through, to encourage them to make decisions and to feel able to deal with their own problems 24 .
Suicide is the second leading cause of death among young people (15-29 years), according to WHO 2 . This age group represented approximately 1 case per 5 suicides in RS in 2017. Suicide death rates among young individuals have increased in countries such as Australia, Canada, Kuwait, New Zealand, Sri Lanka and the United Kingdom. In Brazil, between 1979 and 1998, there was an increase in these rates in 11 capitals, with the highest values recorded in Porto Alegre and Curitiba 25 .
Although it was not possible to assess the absence of parents throughout the victims' lives, the registration of only one parent on the birth certificate proved to be a risk factor for suicide among young people, confirming other published data 6 .
Considering the chosen way to commit suicide, hanging was the most frequent means among RS victims in the studied period, as already reported in several other states or countries 8,11,21,23,26,27 .
When firearms are used, the combustion of explosives present in the ammunition generates metallic waste, which passes through the holes of the instrument, depositing itself in the hands of the shooter 16 . Approximately 34% of the residuographic examinations were negative for these metals in the hands of firearm suicide victims. Regardless of the police investigation into the veracity of death by suicide, two factors may be associated with negative results in this type of examination. One of them refers to the fact that these metals are easily removed from the skin and the other takes into account that pistols, when compared to revolvers, release less waste because they are more closed systems 16 . In any case, the collection of these samples should be mandatory in all firearm suicides.
Although the police record of suicides is not standardized, in many cases lacking information regarding the context of death or its possible causes, the data obtained in this study showed that many victims were at risk because they showed signs that they needed help, depression symptoms, reports of intent to commit suicide and even previous suicide attempts. Often, these behaviors are not properly recognized, generating feelings of guilt and indicating the unpreparedness of professionals and family members 24 . According to Botega (2014), when these victims are properly identified, referred to health services, with careful registration and follow-up, including psychosocial interventions, motivational approaches and regular contact (telephone, for example), there may be a decrease in up to 10 times in the number of cases effected 8 .
About toxicological findings, the lack of biological sample collection of approximately 24% of the victims revealed problems of standardization in the medical-legal conduct, hindering the obtaining of complete data, as well as the exact evaluation of which substances are related to the cases suicide. Even so, the percentage obtained from samples containing ethanol corroborated the data released by WHO (2000), that approximately one third of suicide cases are related to alcohol consumption 1 .
Regarding the detection of antidepressants in the samples, it is known that, regardless of the class used, in the first weeks of treatment, some patients may present an intensification of suicidal ideas 6 . Consumption of selective serotonin reuptake inhibitors such as fluoxetine, sertraline and citalopram may increase the risk of suicide among young people. Some studies associate the increased use of antidepressant drugs by the population with the higher incidence of suicide cases, but it is necessary to assess whether this increase occurred among treated people or not 31 . For a correct assessment of this kind, police records should be standardized, as well as biological sampling should be mandatory in all suicide cases.
Obtaining positive MDMA results in the presence of other psychotropic substances showed similarity to the findings of Fernando et al. (2012), that is, recreational levels of this amphetamine derivative are found in cases of suicide in combination with other drugs, such as ethanol and ketamine. Suicide forms are governed by accessibility and also by understanding the potential lethality of a particular action or substance. The low ingestion rate of MDMA alone as a suicidal form may be due to the rare adverse reactions manifested by its use, leading to a belief that this substance is not toxic enough to reliably cause death. Chronic use of MDMA has been shown to lead to severe depression with suicidal ideation due to serotonergic neurotoxicity 32 .
With regard to poisons, the most frequently detected compound was nitrite. One source of this anion is nitrate reduction (saltpeter or salitre), which are preservative salts used in the food industry to preserve the color of canned meat and sausages, as well as to prevent the spread of botulism-causing bacteria. Nitrite toxicity is attributed to hemoglobin oxidation to methemoglobin, rendering it unable to bind to oxygen 33 . In the Caxias do Sul macroregion, located in the Serra Gaúcha, there are a large number of family agribusinesses of animal products, which may have facilitated victims' access to nitrite.
Assessments of the relationship between multivariate qualitative parameters can be performed by multiple correspondence analysis. This statistical tool allows to graphically analyze possible associations between more than two variables by reducing the dataset's dimensionality 34 . Interpretation is based on the proximity between variables, or categories, in the same region of space; however, the distances between the points do not have a direct relation in this evaluation 35 , which makes it necessary, therefore, the complementary use of other statistical tests, such as the CMH, which verifies the existence of conditional associations between two binary variables in the presence of a third one, categorical.
Finally, suicide is a behavior with multifactorial determinants, the result of a complex psychological, genetic, cultural and socio-environmental interaction 11,19,21 . Therefore, a multidisciplinary approach is needed, combining government efforts and rescuing the potential of existing networks in the family, school and community, according to the circumstances of each location 5,24 .
Sharing data related to suicide, as has happened in the past, with sexually transmitted diseases or cancer, can make prevention more successful 36 . Access to accurate and impartial public information is an inherent right to the condition of life in society and is the duty of the media, as these media promote reflection, dialogue, collective analysis and, potentially, social representations. Discussions about suicide culminated in the development of a handbook for media professionals on how to disseminate this data and reduced the number of suicide events on the Austrian subway between 1986 and 1991, for example. Through these actions, people could have access to the symptoms of mental illness most linked to suicide and a list of places where they could find treatment, also clarifying the consequences and impact that suicide has on both family and community 10, 37 .
In addition, restricting access to lethal means, including regulation of the trade in pesticides, alcohol, psychotropic drugs and firearms, as well as stimulating safe architecture in public places, could be effective strategies to prevent suicide 1,8,19,30 .

CONCLUSIONS
Suicide victims in RS in 2017 were mostly male, with 46% of cases involving young and elderly. The most used means was hanging and the most frequent context was depression. About 30% of the samples analyzed showed ethanol, a variable that was associated with adult men, as well as the consumption of other psychotropic substances, including illicit drugs. The Vale do Rio Pardo region had the highest case rate in the state. The information obtained in this work supports new research, because knowledge of local reality allows the development of targeted actions, assists health professionals, psychosocial services and education in identifying the most vulnerable individuals, playing a critical role in reducing new cases and in the elaboration of more preventive public policies.

INDIVIDUAL CONTRIBUTIONS
Maria Cristina Franck -Conception, project, design, data acquisition, analysis, interpretation of results, writing the article, and approval of the version to be published.