Youth suicide in New South Wales: urban-rural trends

Male suicide mortality in eastern Finland - urban - rural changes during a 10-year period between 1988 and 1997

Aims: To investigate urban -rural differences in male suicide mortality between 1988 and 1997 in the province of Kuopio in eastern Finland. Methods: Male suicide mortality between 1988 and 1997 was studied in eastern Finland. The data were collected from official autopsy reports. Age, marital status, household type, place of death, method of suicide and the region within the county were analysed. Results: The age-adjusted male suicide mortality remained quite constant at 67 and 65/100,000 (>15 years of age) in 1988 and 1997, respectively. In urban areas, a decline in suicide rates was noted in all age groups of men, whereas in rural areas, after an initial decline, a marked increase took place during the last years of the study period, especially among middle-aged and elderly men. This coincided with the time of recovery from an economic recession in Finland that particularly affected rural areas. Conclusion: Male suicide mortality may be regionally diverging in Finland.

Suicide in Australia: Do We Really Have A Problem?

In 1995, 2367 Australians lost their lives through suicide, and up to 100 times this number may attempt each year: Suicide has now become a major public health problem in Australia, which has seen the suicide rates in young males quadruple over the last 35 years or so. An analysis of current research on suicide and suicidal behaviour exploring possible causes and crosscultural issues, is discussed. As well, an extended definition of suicide as an intentional death and its antecedents provides the foundation for a discourse on the views now held by our corntemporary society. The paper argues that suicide not only is one of the most extreme consequences of personal psychosocial distress but also is often also an indicator of previous life events and environmental factors that potentiates for personal vulnerabilities.

Completed suicide in childhood

Suicide in children and young adolescents up to 14 years of age has increased in many countries, warranting research and clinical awareness. International reported suicide rates per 100,000 in this young population vary between 3.1 and 0 (mean rate worldwide, approximately 0.6/100.000; male-female ratio, 2:1). Suicide occurs only in vulnerable children; this vulnerability begins with parental mood disorder and impulsive aggression, and family history of suicide. Childhood affective and disruptive disorders and abuse are the most often reported psychiatric risk factors. Suicide becomes increasingly common after puberty, most probably because of pubertal onset of depression and substance abuse, which substantially aggravate suicide risk. Biologic findings are scarce; however, serotonergic dysfunction is assumed. The most common precipitants are school and family problems and may include actual/anticipated transitions in these environments. Suicides in children and young adolescents up to 14 years of age often follow a brief period of stress. Cognitive immaturity/misjudgment, age-related impulsivity, and availability of suicide methods play an important role. Psychologic autopsy studies that focus on suicides in this age group are needed.

Further increases in rural suicide in young Australian adults: Secular trends, 1979–2003

This study investigates changes in Australian urban-rural suicide differentials over time in the context of overall declines in (male) suicide in the late 1990s, and determines the extent to which differences in socio-economic status (SES) account for observed urban-rural trends. Suicide data were stratified for the period 1979-2003 by metropolitan, rural and remote areas and examined across five quinquennia, centred on each Australian census from 1981 to 2001. Suicide rates (per 100,000) were adjusted for confounding by sex, age, country-of-birth and the mediating effects of area SES, using Poisson regression models. Male suicide rates in metropolitan, rural and remote areas diverged significantly over time, especially in young males (15-24 years). Young male suicide rates increased significantly in metropolitan, rural and remote areas over 1979-1998, and in the most recent period (1999-2003) increased further in remote areas from 38.8 (per 100,000) to 47.9 (23% increase). In contrast suicide rates in rural areas decreased from a peak of 27.5 to 19.8 (28% decrease), and in metropolitan areas from a peak of 22.1 to 16.8 (24% decrease). Similar divergence in the 1999-2003 quinquennium, though of a lesser magnitude, was also evident for males aged 25-34 years. Female suicide rates in the earlier part of the period were significantly lower in rural and remote areas than in metropolitan areas, particularly for those aged 25-34 years, then increased in rural and remote areas to converge with female suicide rates in metropolitan areas. Adjusting for SES in addition to age and country-of-birth reduced urban-rural suicide differentials in both males and females, consistent with SES being an intermediary between rural residence and suicide. Nevertheless, urban-rural differences remained statistically significant. These results show that the largest urban-rural male suicide differentials for the 25-year study period occurred in the most recent period (1999-2003), in the context of decreasing male suicide rates overall.

Have urban/rural inequalities in suicide in New Zealand grown during the period 1980-2001?

Previous studies have noted that in many countries there has been a disproportionate increase in suicide in rural areas, contributing to greater urban/rural inequalities in health. This paper evaluates whether this trend was also apparent in New Zealand during the 1980s and 1990s, a period of rapid social and economic change. Using suicide incidence data for the period 1980-2001, we investigate whether urban/rural status had an effect upon rates of suicide independently of socioeconomic deprivation. While both male and female suicide rates were significantly higher in urban than rural areas in 1980-1982, by the end of the 1990s, urban/rural differences in suicide rates were not significant. The narrowing of urban/rural differences was, to some extent, a result of the growth in suicide rates in more isolated rural communities and small rural service centres. Recent geographical variations in suicide in New Zealand are therefore to a large extent similar to trends observed elsewhere, but are less marked. Potential explanations are offered for the fluctuating urban/rural inequalities in suicide including compositional arguments, rural restructuring and economic decline, social isolation and health service utilisation.

Service utilisation by rural residents with mental health problems

OBJECTIVE

To examine the level and type of service utilisation by rural residents for mental health problems, and to explore the influence of level of need, sociodemographic factors and town size on such service use.

METHOD

This was a cross-sectional, community-based study. Subjects were recruited from three locales in rural north-west Victoria: a large regional centre, towns of 5,000-20,000 population and towns of <5,000 population. Three hundred and ninety-one individuals (54% females) participated. A logistic regression analysis was used to investigate which factors (i.e. need, sociodemographic and town size) predicted lifetime help-seeking for emotional or mental problems from formal health providers in the study sample.

RESULTS

Factors that predicted having ever sought help from a formal health provider for emotional or mental health problems were: a lifetime and/or current psychiatric disorder, being female, being separated, divorced or widowed, and living in medium sized towns (population 5,000-20,000).

CONCLUSIONS

While traditionally known predictors of help-seeking, i.e need and gender, were associated with help seeking in this study, help seeking for mental health problems was also more common amongst individuals living in medium sized rural towns than those living in a large regional city. Possible explanations include availability, accessibility and organisation of services, and individual and/or community attitudes towards help seeking.

A review of the literature on rural suicide: risk and protective factors, incidence, and prevention

BACKGROUND

Suicide is a major cause of mortality worldwide. Differences in rates of suicide exist between urban and rural areas; however, little rigorous research has examined the phenomena of rural suicide.

OBJECTIVE

This review examines the current body of literature on rural suicide and investigates differences between rural and urban suicide, including socioeconomic, psychological, and cultural variables. Prevention and intervention strategies specific to rural communities are discussed. DESCRIPTION OF STUDIES: All empirical and epidemiological studies of rural suicide were included in the review regardless of study design or methodology.

RESULTS

Although findings are mixed, research and epidemiological data indicate that suicide is a public health concern in rural areas, with suicide rates often greater than in urban areas.

DISCUSSION

Rural locale may create geographic, psychological, and sociocultural barriers to treatment of suicide. A better understanding of the role of rurality in the development and maintenance of suicidal thoughts and behaviors is needed and may inform prevention and intervention efforts.

Suicide in Austrian children and young adolescents aged 14 and younger

INTRODUCTION

Research on suicide in childhood and early adolescence is sparse. We investigated suicide cases of children and young adolescents in terms of prevalence, gender differences, suicide methods and monthly distribution during a period of 32 years.

METHODS

Registered suicides aged 14 or younger occurring between 1970 and 2001 (n = 275) in Austria were studied.

RESULTS

The mean suicide rate for 10 to 14-year-olds was 1.4 per 100,000 with a male-female ratio of 3.1:1. The total child and young adolescent suicide rate and boys' suicide rates decreased over the study period. However, there was no significant fluctuation in girls' suicide rates. Hanging was the predominant suicide method in both genders. Use of this method decreased steadily over the study period, whereas the percentage of suicides by other methods, i.e., jumping and firearms suicides increased. Greater number of suicides in children and young adolescents was observed during the months of April/May and October/November.

CONCLUSION

Suicide rates of children and young adolescents in Austria are on the decrease, in accordance with a reported decrease in the general suicide rate in Austria.

Rural suicide--people or place effects?

OBJECTIVE

To examine factors that may contribute to elevated rates of suicide among rural communities in Australia.

METHOD

A wide-ranging literature search reviewed possible factors that may contribute to the geographical variation in suicide. Literature was organized to enable examination of compositional and contextual explanations, as well as collective social functioning and social practices.

RESULTS

A variety of factors may contribute to elevated rates of suicide in rural compared with urban areas. Collective and contextual (place) factors seem to be of particular importance as possible contributors to the elevated rate of suicide among rural males. These include rural socioeconomic decline; facilitators and barriers to service utilization such as service availability and accessibility, rural culture, community attitudes to mental illness and help seeking; and exposure to firearms.

CONCLUSIONS

Compositional, contextual and collective factors are hypothesized to influence the elevated rate of suicide in rural compared with urban areas. These factors need to be tested in empirical studies that consider both individual and community-based risk factors, and are designed to enable exploration of likely within-rural differences.

'Big build': hidden depression in men

OBJECTIVE

To investigate men's experience of depression.

METHOD

A sample of male and female teachers and students was recruited from four sites of a tertiary education institution to a series of focus groups. A grounded theory approach to qualitative data analysis was used to elucidate men's experience of depression. Content analysis was applied to the women's data to examine similarities and contrasts with the men. Standard measures of mood and dispositional optimism confirmed the non-clinical status of the group.

RESULTS

The findings suggest that some men who are depressed can experience a trajectory of emotional distress manifest in avoidant, numbing and escape behaviours which can lead to aggression, violence and suicide. Gender differences appear not in the experience of depression per se, but in the expression of depression.

CONCLUSION

Emotional distress, constrained by traditional notions of masculinity, may explain why depression in men can often be hidden, overlooked, not discussed or 'acted out'. There are implications for the types of questions asked of men to detect depressive symptoms.

Suicide risk in relation to level of urbanicity—a population-based linkage study

BACKGROUND

The extent to which the high suicide rate in urban areas is influenced by exposures to risk factors for suicide other than urbanicity remains unknown. This population-based study aims to investigate suicide risk in relation to the level of urbanicity in the context of other factors, and to study the risk variation in a sex, age, and calendar year perspective.

METHODS

The study is a nested case-control study comprising 21 169 suicides and 423 128 population controls matched for age and sex. Personal data on place of residence, socioeconomic status and psychiatric history were retrieved from various Danish longitudinal registers. Data were analysed with conditional logistic regression.

RESULTS

This study confirms that people living in more urbanized areas are at a higher risk of suicide than their counterparts in less urbanized areas. However, this excess risk is largely eliminated when adjusted for personal marital, income, and ethnic differences; it is even reversed when further adjusted for psychiatric status. Moreover, the impact of urbanicity on suicide risk differs significantly by sex and across age. Urban living reduces suicide risk significantly among men, especially young men, but increases the risk among women, especially women aged 24-35 or >65 years. In addition, during 1981-1997, the suicide risk associated with urbanicity remained rather constant among women, whereas it dropped significantly among men, a trend that seemingly gained strength during the last part of this period.

CONCLUSIONS

Suicide risk associated with urbanicity varies significantly by sex and age groups and recent years have seen a decline in the urban-rural disparities among men. The increased risk in urban areas can largely be explained by the effects of marital status, ethnics, income, and psychiatric status.

Toward understanding youth suicide in an Australian rural community

Australia has one of the highest rates of youth suicide in the western world, especially among rural men. This paper discusses the social construction of this issue in Australia and explores the issue through interviews with 30 young people and 12 key informants from a rural town in NSW. Findings suggest that young people struggle to deal with conflict in social relationships, that community discourses shape young people's understandings and that suicide is talked about in reference to depression. Implications for youth suicide prevention in Australian rural communities are discussed.

Rural secondary school students living in a small community: their attitudes, beliefs and perceptions towards general practice

OBJECTIVE

To study the attitudes and beliefs towards general practice of rural secondary school students, in particular, their perception of the barriers to the effective delivery of primary health care.

SETTING

Students attending a government-funded secondary school in a rural community of less than 4000 people.

SUBJECTS

250 students in years 7-12 were surveyed, with 177 (71%) replying, 45% of these being male.

DESIGN

Cross-sectional, self-administered questionnaire survey.

RESULTS

The study found that most students value general practitioners (GPs) as valuable sources of health care, feel they have reasonable access to care and in most instances appear to attend appropriately for their health problems. Most felt their doctor would be an empathetic listener, would provide sufficient time to provide effective care and communicated in a language they could understand. Confidentiality issues were considered important, especially by females.

CONCLUSION

Although students have very positive attitudes about general practice, the findings could be used to improve a number of GP services for young people in small rural communities. This is particularly so for presentations which require a high degree of confidentiality and skillful counselling, such as psychological problems and risk-taking behaviours.

Rural-urban differences in reasons for living

OBJECTIVE

The suicide rate in Australia is cause for concern, especially the increase in attempted and completed suicides in rural and regional locations. The present study examined reasons for choosing not to commit suicide as a function of residential location.

METHOD

The study involved 655 Victorian residents from four population-based strata; urban, regional city, regional town, and rural.

RESULTS

Results from the Reasons for Living Inventory revealed significant differences as a function of residential location. Overall, residents in rural locations reported having significantly more to live for than their urban counterparts. Further analysis of six reasons for living (child, family, moral, social, coping and death-related concerns) showed a pattern whereby residents in rural locations reported having the most to live for, followed by regional residents, and urban residents who reported having the least to live for.

CONCLUSIONS

These findings are in contrast to increase of suicide rates in rural areas, and highlight the need for a greater understanding of the mechanisms underlying suicidal behaviour.

Suicide differentials in Australian males and females by various measures of socio-economic status, 1994-98

OBJECTIVES

To investigate Australian suicide differentials in males and females by three area-based measures of socio-economic status (SES).

METHODS

Suicide data for 1994-98 were used to investigate area-based gradients of SES for the Index of Relative Socio-Economic Disadvantage (IRSED) (an overall measure of SES), the Index of Economic Resources (IER), and the Index of Education and Occupation (IEO), using Poisson regression models adjusting for age, country-of-birth and urban-rural residence.

RESULTS

After adjusting for age, country-of-birth and urban-rural residence, significant increasing linear trends in suicide risk from high to low quintiles of SES were evident in males for the IRSED (an average multiplicative increase in suicide risk of 8% per quintile), IER (9% increase) and IEO (5% increase). For females, there was no evident SES gradient for the IRSED after adjusting for age, country-of-birth and urban-rural residence, but a significant positive linear trend from high to low quintiles of SES was found for the IER (6% increase per quintile). A significant decreasing linear trend (increasing suicide risk with increasing SES) was evident for the IEO (30% per quintle).

CONCLUSION

Male suicide is positively associated with all three measures of SES examined. Female suicide is significantly associated with the IER (positive association) and IEO (negative), and because of this is not associated with the overall measure of SES. These findings partly explain why female suicide has been found to be poorly correlated with area-based measures of SES.

IMPLICATIONS

Specific components of area-based socio-economic status provide a clearer picture of socio-economic suicide differentials in Australian females, with implications for population-based preventive strategies.

A global view of suicidal behaviour

Suicidal behaviour is a major public health problem. There is no one explanatory theory of suicidal behaviour, and various combinations of sociological and biological/medical interventions are required to reduce associated mortality and morbidity. The importance of primary prevention varies from community to community, and may have an impact at the population level. However, individual suicidal persons always require optimum assessment and management and that is usually provided by primary care and emergency physicians. This paper provides an overview of issues to be addressed in the assessment and management of suicidal patients.

Suicide in Australian farming, 1988-1997

OBJECTIVES

To identify and describe suicide data for occupational classifications relating to farm managers and agricultural labourers for Australia for the period 1988 to 1997, and to relate resultant suicide rates to farmers' terms of trade.

METHOD

Descriptive and linear regression analysis of aggregated mortality data.

RESULTS

In the period 1988 to 1997, 921 suicides were identified. The majority of these suicides were farm managers (67.4%). Farm manager suicides occurred predominantly in older age groups (55 + years). In comparison agricultural labourer suicides were younger, with the majority of suicides occurring in the 15-39 years age group. The most common methods for both groups were firearms (particularly hunting rifles and shot guns), hanging and motor vehicle exhaust gas. These methods accounted for approximately 81% of all male farm suicides. Firearms accounted for 51% of male farm suicide, in comparison to 23% for the wider Australian male population for the same period. Estimated age standardized rates per 100 000 for male farm managers for the 10-year period ranged from 24.8 to 51.4. For male agricultural labourers these rates ranged from 23.5 to 41.9. Analyses also revealed a negative correlation (r = -0.75, p < 0.01) between farm manager suicide rates and farmers' terms of trade.

CONCLUSION

Male farm manager and agricultural labourer suicide rates are higher than male national rates and rates in the wider rural population, particularly in the later years of the period investigated. Firearms prefigure as the most common method of suicide, despite decreases in this method in the wider rural population. Establishing more accurate denominator data for the farming community is a priority, as is preventative action that accounts for unique aspects of farm life.

The epidemiology of suicide and attempted suicide among young Australians

OBJECTIVE

This paper summarises a report to the NHMRC the objectives of which were to review research into the epidemiology of youth suicide in Australia and identify gaps in research.

METHOD

Literature searches were conducted. A limited amount of new data analysis was included to shed light on reliability issues of official Australian suicide data.

RESULTS

The review examined suicide data systems, including issues to do with coroners, the Australian Bureau of Statistics and alternative systems. The epidemiological areas reviewed included: all ages, youth, age and gender, geographical, socioeconomic, marital, indigenous, migrants, suicides in custody and gay and lesbian suicides.

CONCLUSION

While much is known about the epidemiology of youth suicide, much remains to be clarified. Study of indigenous issues is perhaps the most neglected area; study of family issues may be potentially be the most productive.

A study of suicides in Ballarat, Victoria, Australia

OBJECTIVE

To study suicides occurring in Ballarat with regard to incidence, demographic variables, possible causal factors, and association with psychiatric disorders over a period of 5 years.

METHOD

A detailed review of the coroner's record of every suicide occurring during 1992-1996 was undertaken. Information was obtained on socio-demographic variables, method and circumstances of suicide, and associated psychiatric disorders in each case and subjected to psychological autopsy.

RESULTS

75 suicides were recorded. The male to female ratio was 4:1 and average age was 43 years. 60% had associated psychiatric illnesses, mainly affective disorders. Carbon monoxide self-poisoning accounted for 40%, firearms for 30%, and hanging, overdose, asphyxia and other methods for the remaining 30%. It was statistically significant that the younger age group preferred firearms to other methods, and that their suicides were precipitated by interpersonal conflicts. Social and personal difficulties were associated in 33%, and triggering factors were present in 40%. Previous suicide attempts were present in 28%, while 32% had manifest behavior changes preceding suicides or verbalized their intent to suicide.

CONCLUSIONS

Suicide rates in Ballarat were higher than the average overall Victorian and Australian rates. After a consistent decline over 4 years an increase occurred in 1996. The preferred method of suicide was carbon monoxide, although the young preferred firearms. Demographic and other psychosocial factors were similar to the rest of Australia. Unemployment was not a significant factor. Psychiatric conditions, personal and social problems figured prominently as factors of etiological significance in suicide subjects.

Urban and rural suicide differentials in migrants and the Australian-born, New South Wales, Australia 1985--1994

We estimated risk of suicide in adults in New South Wales (NSW) by sex, country of birth and rural/urban residence, after adjusting for age; we also examined youth suicide (age 15-24 years). The study population was the entire population of NSW, Australia, aged > or =15 years during the period 1985-1994. Poisson regression was used to examine the relationship between predictor variables and the risk of suicide, with the focus on migrant status and area of residence. A significantly higher risk of suicide was found in male migrants from Northern Europe and Eastern Europe/former USSR, compared to Australian-born males; a significantly lower suicide risk occurred in males from Southern Europe, the Middle East and Asia. In female migrants, those from UK/Eire, Northern Europe, Eastern Europe/former USSR and New Zealand exhibited a significantly higher risk of suicide compared to Australian-born females. A significantly lower risk of suicide occurred in females from the Middle East. Male migrants overall were at significantly lower risk of suicide than the Australian-born, while female migrants overall had a significantly higher risk of suicide than Australian-born females. Among migrant males overall, the rural-urban suicide risk differential was significantly higher for those living in non-metropolitan areas (RR = 1.9; 95% CI: 1.7-2.1). Suicide risk was significantly higher in non-metropolitan male immigrants from the UK/Eire (RR = 1.4; 95% CI: 1.1-1.7), Southern Europe (RR = 1.7; 95% CI: 1.2-2.4), Northern/Western Europe (1.5; 95% CI: 1.2-1.9), the Middle East (RR = 3.8; 95% CI: 1.9-7.8), New Zealand (RR = 1.4; 95% CI: 1.0-1.8) and 'other' (RR = 2.6; 95% CI: 1.9-3.5), when compared to their urban counterparts. There was no statistically significant difference in suicide risk between rural and urban Australian-born males. For female suicide, significantly lower risk was found in female immigrants living in non-metropolitan areas who were from Northern/Western Europe (RR = 0.7; 95% CI: 0.4-0.96), as well as the Australian-born (RR = 0.7; 95% CI: 0.6-0.8), when compared to their urban counterparts. The non-metropolitan/metropolitan relative risk for suicide in female migrants overall was not significantly different from one. Among male youth there was a significantly higher suicide risk in non-metropolitan areas, with a relative risk estimate of 1.4 for Australian-born youth (95% CI: 1.2-1.5) and 1.7 for migrant youth (95% CI: 1.2-2.4), when compared with metropolitan counterparts. We conclude that suicide among migrant males living in non-metropolitan areas accounts for most of the excess of male suicide in rural NSW, and the significantly lower risk of suicide for non-metropolitan Australian-born women does not apply to migrant women.

Suicide in urban New South Wales, Australia 1985-1994: socio-economic and migrant interactions

Variation of suicide with socio-economic status (SES) in urban NSW (Australia) during 1985-1994, by sex and country or region of birth, was examined using Poisson regression analysis of vital statistics and population data (age >¿ approximately 15 yr). Quintiles of SES were defined by municipality of residence and comparisons of suicide by SES were adjusted for age and country (or region) of birth (COB), and examined by COB. Risk of suicide in females was 28% that of males for all adults and 21% for youth (age 15-24 yr). Suicide risk was lower in males from southern Europe, Middle East and Asia, and higher in northern and eastern European males, compared to the Australian-born. Risks for suicide increased significantly with decreasing SES in males, but not in females. The relationship of male suicide and SES was stronger when controlled for COB. For males, the relative risk of suicide, adjusted for age and COB, was 66% higher in the lowest SES quintile compared to the highest quintile. and 39% higher for youth (age 15-24 yr). For male suicide, the population attributable fraction for SES (less than the highest quintile) was 27%. Analysis of SES differentials in male suicide according to COB indicated a significant inverse suicide gradient in relation to SES for the Australian-born and those born in New Zealand and the United Kingdom or Eire, but not in non-English speaking COB groups, except for Asia. For Australian-born males, suicide risk was 71% higher in the lowest SES group (compared to the highest), adjusted for age. These findings indicate that SES plays an important role in male suicide rates among the Australian-born and migrants from English-speaking countries and Asia, and among youth; but not in female suicide, nor suicide in most non-English speaking migrant groups. Reduction in SES differentials through economic and social policies may reduce male suicide in lower SES groups and should be seen to be at least as important as individual level interventions.

Firearm suicides and homicides in the United States: regional variations and patterns of gun ownership

Among industrialized countries, the United States has the highest rates of firearm suicide and homicide, as well as the highest rate of gun ownership. The present study compares the differential impact of gun availability on firearm suicides and homicides in the U.S. Using data from the NCHS Mortality Detail Files (1989-1991), the 1990 U.S. census population estimates, and the General Social Surveys (1989-1991) for nine geographic divisions, we computed rates of firearm and non-firearm suicides and homicides as well as rates of gun ownership for four gender-race groups. We tested the strength of the associations between gun availability and firearm suicide and homicide rates by computing the Spearman correlation coefficients. To help elucidate the role of method substitution, we conducted similar analyses on non-firearm suicide and homicide. The results show that gun ownership has a stronger impact on firearm suicides than homicides. These findings held up after stratifying by gender and race. The study suggests that reducing the aggregate level of gun availability may decrease the risk of firearm-related deaths.

Coroners' records of rural and non-rural cases of youth suicide in New South Wales

OBJECTIVE

The aim of this study is to compare the frequency of certain putative risk factors for youth suicide in New South Wales (especially use of alcohol, social class, unemployment, and internal migration) in metropolitan and rural settings.

METHOD

A review of 137 files for 10-19-year-old subjects judged by the Coroner to have committed suicide in 1988-1990 was carried out.

RESULTS

One hundred and fifteen males and 21 females were identified (one subjects sex was unavailable). The male-female ratio was higher in rural (13.0) areas than non-rural (4.9 chi 2 = 12.14, p < 0.01). Of 27 subjects migrating within Australia, most migrated in a rural direction, and most to rural shires. Unemployment was somewhat more common among rural (38.5%) than non-rural (28.9%) subjects (chi 2 = 0.75, p = 0.39). Eleven of 50 non-rural parents of the deceased, but none of the 11 rural parents, were ranked as being in social classes 2 or 3. Alcohol consumption appeared more common in rural shires (44%) than metropolitan areas (32.9%), but this was not statistically significant. Medical services were less utilised prior to death in rural (15%) than non-rural (25%) areas (chi 2 = 1.69, p = 0.19), and a psychiatric diagnosis was recorded more commonly in non-rural areas.

CONCLUSIONS

Incomplete coronial file data and relatively small numbers limit this study's conclusions. Male suicides, principally by firearms, predominated in rural areas. Youth firearm access remains highly relevant to rural communities. Possible trends among rural subjects toward rural migration, higher unemployment, lower social class and lower medical attendance may point to resource deprivation among this group; these matters require further investigation.

Violence against children and adolescents. International perspectives

Selected topics of violence against children and adolescents that occur in countries outside of the United States are discussed. Focus is given to middle-income and low-income countries and emphasis is placed on the epidemiology of this pressing public health problem, particularly on conditions that are peculiar to children and adolescents in international settings, such as female genital mutilations, wars, displacements, and land mines. The discussion of child maltreatment is presented in the context of child rearing and discipline in different cultures. Recommendations for action and violence prevention are offered in the light of vast cultural differences.

Hunting guns in homes and suicides in 15-24-year-old males in eastern Finland

OBJECTIVE

The aim of this study was to investigate the associations between firearm ownership, the presence of guns in homes, the use of psychiatric services and suicides in 15-24-year-old males in Eastern Finland.

METHOD

Police and medicolegal records of all suicides (n = 68) performed by 15-24-year-old males in the Kuopio province, Eastern Finland, in 1988-1995 were studied. Information was sought about firearm ownership, legality and purposes of use. Information was also sought about recent contacts with psychiatric services. Firearm suicides were compared with suicides by other methods.

RESULTS

The annual suicide rate for 15-24-year-old males was 51/100 000. Sixty-two percent of suicides were committed by shooting. In 74% of these, licensed hunting guns were used. The proportion of suicides committed by legal hunting guns stored in the homes of victims was 60% of all firearm suicides. Sixty-two percent of firearm suicides were committed in homes of victims or in someone else's residence where guns were present. Only 2% of those who shot themselves were seen in psychiatric consultation during the 3 months prior to death.

CONCLUSIONS

The presence of hunting guns in homes means easy access to a most lethal suicide method and is associated with a high suicide rate for 15-24-year-old males in Eastern Finland.

Evaluation of a diabetes education program in Newcastle, NSW

OBJECTIVE

To assess the level of coverage and effectiveness of diabetes education provided by the Newcastle Diabetes Education and Stabilisation Centre (DESC) to people taking insulin.

RESEARCH DESIGN AND METHODS

A community based survey of people presenting a prescription for insulin to retail pharmacies in the Hunter Region. The study characterised participants and non-participants in the DESC program by social and demographic factors and assessed the knowledge, blood glucose control and symptoms of diabetic complications they reported. The study also assessed their attitude towards diabetes and diabetic self-care and their feelings towards and use of clinical services.

RESULTS

There were 229 respondents, 75% had attended the DESC course, however single males living in rural areas were significantly less likely to attend. Course attenders were more likely to do blood tests and visit an ophthalmologist and podiatrist than non-attenders, but were not more knowledgable about diabetes or reported fewer complications. Despite high levels of use of health care services including eye care, by people with diabetes, and an overall positive attitude to diabetes management, the study revealed a widespread ignorance of the serious consequences of diabetes.

CONCLUSIONS

People with diabetes taking insulin in the Hunter Region have an overall positive attitude to diabetes and a high level of participation in a formal diabetes education program. Attendance was associated with increased use of eye care and foot care services, despite little demonstrable effect on knowledge or self-reported diabetes control.

Social and cultural patterns of suicide in young people in rural Australia

The purpose of this paper is to describe patterns of suicide in young people in rural communities. Australian Institute for Suicide Research and Prevention and Australian Bureau of Statistics data are used to discuss regional and gender differences in suicide rates, with particular attention to completed suicides in young people. The regional distribution completed suicide in young people and gender differences in suicide rates are identified. Trends in the methods of suicide chosen by young people are also described. Patterns of male self-destructive behaviour are emphasised. The paper, as a whole, draws attention to the complex factors that influence deaths by suicide in young people. The factors implicated are associated mainly with suicide in young males, but much of the literature speculates on rather than demonstrates their influence. As the competing explanations have not been systematically evaluated, further research is required to establish the causal processes involved and to provide a firmer foundation for suicide prevention programs and services for those who live in suicide's aftermath.

Suicide among young rural Australians 1964-1993: a comparison with metropolitan trends

The study tested hypotheses that from 1964 to 1993: (1) suicide rates among Australian 15- to 24-year-old males rose more sharply in rural than metropolitan areas; (2) firearm suicide rates among 15- to 24-year-old males, declining throughout Australia recently, rose continuously in rural areas; (3) suicide rates among 15- to 24-year-old females did not change significantly in either metropolitan or rural areas. Suicides of those aged 10-24 years recorded by the Australian Bureau of Statistics (ABS) were classified according to the subject's residential grouping. Rates were calculated using ABS population data corresponding to these groupings. Results were analysed using log-linear analysis and chi-square statistics. The results supported the first two hypotheses, but not the third. Suicide rates for 15- to 24-year-old males rose by a factor of 2.2 in metropolitan areas, by 4-fold in towns with populations between 4,000 and 25,000, and by 12-fold in towns with populations less than 4,000. Male firearm suicide rates continued to rise in rural areas, and the greatest proportion of deaths in those locations were by firearms, though male hanging rates increased most in recent years in all locations. Female youth suicide rates did not change overall, but in towns with populations less than 4,000, they increased 4.5-fold. Possible explanations for this epidemic, which are mostly speculative and require confirmation, are discussed.

A regional profile of suicide in Queensland

A regional profile of suicide in Queensland follows on from earlier work which failed to find urban-rural differences in suicide rates. Suicide rates were higher in the north of the state and lower in the more developed south Rural Queensland health regions displayed both the lowest (Darling Downs and Mackay) and the highest (Peninsula) suicide rates. Socioeconomic factors correlated with these differences in some regions. Suicide rates for Aboriginal and Torres Strait Islanders, especially the young, were high, and may have contributed to elevated suicide rates in northern Queensland, but the numbers were insufficient to account for observed differences.

Access to firearms and the risk of suicide: a case control study

OBJECTIVE

This study examined the association between access to a firearm and risk of suicide in a consecutive sample of individuals who had made serious suicide attempts.

METHOD

The study used a case control design in which a sample of 197 individuals who died by suicide and 302 individuals who made medically serious suicide attempts was contrasted with 1028 randomly selected community control subjects.

RESULTS

Suicide attempts by gunshot accounted for 1.3% of all serious suicide attempts (with non-fatal outcome) and 13.3% of suicides. However, among those making serious suicide attempts, gunshot had a high rate of fatality (83.3%). While access to a firearm was associated with increased risks that gunshot would be chosen as the method of suicide attempt (OR = 107.9; CI = 24.8-469.5), this access was not associated with significant increases in the risk of suicide (OR = 1.4; CI = 0.96-1.99).

CONCLUSIONS

For this sample, access to a firearm was not associated with a significant increase in the risk of suicide, although such access was associated with an increased probability that gunshot would be chosen as the method of suicide attempt.

Arguments for and against teaching suicide prevention in schools

OBJECTIVE

To present arguments for and against the provision of curriculumbased suicide prevention programs in schools.

METHOD

The authors developed their arguments independently, based on the available literature on school-based programs, prior to debating the topic at a national conference on suicide prevention.

RESULTS

The rationale for school-based programs is that the school has the responsibility: to resolve problems that interfere with education; to teach health education; and to acknowledge a duty of care to parents and to the community as well as to youth. Primary prevention programs in schools are not aimed at so-called 'at-risk' students, but potential 'helpers', based on the knowledge that peers are a primary support for troubled adolescents. One measure of the efficacy of school-based prevention programs must be the extent to which there is an increase in the tendency for adolescents to turn to adults for help. There is ample evidence that increasing the tendency for adolescents to approach adults for help is achievable. The argument against such programs is that evidence from evaluation research suggests that they are ineffective, inefficient, not universally acceptable, and of questionable safety.

CONCLUSIONS

Those persuaded by the positive argument will wish to see these programs adopted in all Australian secondary schools. Those persuaded by the negative argument will recommend that suicide prevention resources be allocated to activities other than school-based suicide education programs.

Jumping the gun: firearms and the mental health of Australians

OBJECTIVES

The aims of this study were to (i) survey mental health-related correlates of firearms ownership and availability in Australia, and (ii) assess possible causal relationships between civilian gun deaths, gun availability and mental disorders.

METHOD

Available data regarding firearms ownership, injuries and deaths were reviewed as well as studies of (i) gun ownership, suicide and homicide, and (ii) gun control laws and suicide.

RESULTS

Findings indicated that 85% of firearm deaths are triggered by distress, as opposed to crime. Most firearm homicides are intrafamilial or involve familiar persons. Firearm suicide rates, although tapering off in recent years, continue to rise among certain groups. It was also found that: (1) Beyond reasonable doubt, a causal relationship exists between gun ownership and firearm suicides and homicides. The role of method substitution is controversial, but is probably less important among the young. (2) Outside the United States, legislation may be useful in reducing firearm and possibly overall suicide rates. (3) If firearm owners are representative of the community, then 15-20% suffer from a psychiatric disorder at any time. While a modest increase in risk of firearms misuse exists for this group, especially those with a history of substance abuse or violence, concern also arises regarding those with mental disorders who access firearms because owners have not secured them. No uniform definition or way of verifying self-reports exists for gun licence applicants regarding these issues.

CONCLUSIONS

Further regulation of firearm safety and availability is warranted. Public health measures include improved surveillance regarding firearm events, advocacy for appropriate firearm legislation, and better education and communication about firearms.

An analysis of age and gender influences on the relative risk for suicide and psychotropic drug self-poisoning

Psychiatric illness is a significant risk factor for both attempted and completed suicide and psychotropic medications account for 80% of all drug overdoses involving prescription medications. One challenge facing clinicians is to balance the benefit of treatment against the risk of drug overdose. The aim of the present study was to compare the age and gender distribution of patients prescribed psychotropic drugs with patients attempting and completing suicide with these drugs. Data were obtained from the Australian census and studies of general practitioner prescribing, patients who committed suicide or presented with self-poisoning within a defined geographic area. The characteristics of these populations were compared to calculate odds ratios for attempting or completing suicide with psychotropic drugs, before and after correction for rates of prescription, in different age and gender groups. The odds ratios (ORs) for self-poisoning were higher for those aged less than 45 years and yet this group was least likely to be prescribed psychotropic drugs. Men had a much higher rate of completed suicide using more lethal methods. The ORs for self-poisoning and suicide with psychotropic drugs, after correction for prescription rates, for those aged 15 to 24 years were 11.1 and 1.7, respectively. Those aged 25 to 44 years had ORs of 4.9 and 4.3, and, by contrast, those over 75 years had ORs of 0.03 and 0. Women were slightly more likely to poison themselves with psychotropic drugs (OR 1.2). However, the situation reversed after correction for prescription rates (OR 0.69). It is concluded that greater caution should be exercised in prescribing for those under 45 years of age, given their relatively higher risk of drug overdose, and that the least toxic compounds should be used. The risk (of self-poisoning) among the elderly may have been overstated, so that some patients may have been denied the benefit of adequate treatment.

Socioeconomic and spatial differentials in mortality and means of committing suicide in New South Wales, Australia, 1985-91

Analysis of suicide mortality in New South Wales, Australia is undertaken with reference to marital status and occupational status between 1986-89/90 and with reference to the principal means of committing suicide. Not currently married male manual workers were particularly at risk although marital status variations were significant with both genders and at different ages. Between 1985-91 male suicide mortality rates were significantly higher in inland non-metropolitan regions, especially among younger men, and were higher in inner areas of metropolitan Sydney. While there were no significant variations by marital status in the means of committing suicide there were variations between genders, and there were regional and social class variations in the use of guns with males. The use of guns was a factor in the elevated suicide mortality levels among inland rural youth and men, and among farmers and transport workers while the use of poisons was also significant with these occupational groups. The use of poisons was greater among persons committing suicide in the areas of elevated mortality in inner Sydney and the use of guns much lower.

The impact of firearm control legislation on suicide in Queensland: preliminary findings

OBJECTIVE

To examine the effect of specific firearm control legislation on firearm and overall suicide rates.

DESIGN

Retrospective survey of data from the Register of the Suicide Research and Prevention Program, Queensland Department of Health. The hypothesis was tested that the legislation would reduce firearm and overall suicides more in metropolitan and provincial city areas than in rural areas, where firearm ownership is higher.

SETTING

State of Queensland 1990-1993.

OUTCOME MEASURES

Suicide rates by age, sex and method for metropolitan, provincial city and rural areas in the two years before (1990-1991) and after (1992-1993) legislation.

RESULTS

Mean annual firearm suicide rates declined significantly (P < 0.05) in metropolitan and provincial city areas after legislation (from 3.6 to 2.3 per 100,000 and from 5.2 to 3.1 per 100,000, respectively), with significant declines among men and in the 15-29 years age group. Rates increased slightly in rural areas (from 7.2 to 8.2 per 100,000). Overall suicide rates declined in provincial areas only, with minimal change in metropolitan areas and a slight rise in rural areas.

CONCLUSION

These results provide preliminary evidence that firearm control legislation, including a 28-day "cooling-off" period before firearm purchase, reduces suicide rates, especially among younger adult men.

Differential and spatial aspects of suicide mortality in New South Wales and Sydney, 1980 to 1991

Occupational and marital status dimensions of suicide mortality in New South Wales were examined for the periods 1980 to 1985 and 1986 to 1989-90 respectively, and marital status and birthplace group mortality profiles were examined in relation to grouped occupations, with a view to identifying the relative influence of these differentiating factors on suicide mortality. Spatial analysis was undertaken for different ages, in major regions of New South Wales and statistical local areas in Sydney for the period 1985 to 1991, and associations with socioeconomic characteristics of geographic areas were investigated. Despite residential revitalisation in inner city areas, higher mortality in several inner city localities has persisted over time while levels have risen in some outer areas. Never-married and divorced men in manual work were most at risk of committing suicide and never-married and divorced women had elevated suicide levels. Male suicide levels were elevated among farmers and related workers, and youth and adult male suicide levels were elevated in inland regions of the state. Possible explanations for the variations are discussed.

Is there a rural suicide problem?

Suggestions that youth suicide rates are disproportionately higher in rural areas were explored using Queensland cause-of-death data supplied by Queensland Health for the years 1986 to 1990. Standardised mortality ratios (SMRs) were compared across three zones: urban, provincial and rural, for three age bands: all ages, 15 to 19 years and 20 to 29 years, for each sex. This Queensland study did not find a statistically significant excess of rural youth suicides. Further study of this phenomenon involving other states is called for.

Adolescent suicide clusters: evidence, mechanisms and prevention

Cluster suicides account for an estimated 5% of all teenage suicides in the USA. Not all hypothesised clusters are verified, however, when submitted to statistical analysis. This paper reviews possible mechanisms underlying adolescent cluster suicides using the "infectious disease model", key concepts of which are host susceptibility, modes of transmission, degree of virulence, and dose dependency. Preventive measures against cluster suicides are reviewed, including primary prevention against youth suicide, tempered media reporting of suicide, and "postvention strategies" directed to communities affected by suicide.

Suicide and unemployment in Australia 1907-1990

Ever since Durkheim postulated a relationship between economic change and suicide there has been evidence of a general association between aggregate data on unemployment and the frequency of suicide. Quantitatively, however, the association has been variable and it is clear that due to differing cultural, social and individual determinants of suicide, the relationship is complex. Methodological difficulties abound with interpretation of aggregate data. Australian records for most of the present century are suitable for examining secular trends in suicide and unemployment by age group and gender to gain an indication of the extent to which both parameters may be causally related. An aggregate/ecological study was designed to incorporate quantitative and qualitative strategies. Annual age-adjusted male and female suicide rates and annual unemployment rates were derived for the period 1907-1990. Female suicide rates were generally stable throughout the period, whereas those for males demonstrated sharp fluctuations with the peaks coinciding with times of high unemployment. The association between suicide and unemployment for 15-24 year old males was comparatively high for the recent period, 1966-1990. The increasingly youthful contribution to male suicide was demonstrated by a rise in the loss of life years during 1973-1984. Despite the inability of any investigation based on aggregate data to establish an unequivocable causal relationship, no evidence was detected to suggest that relatively high population levels of unemployment were not related to the occurrence of suicide.

Suicide in the young

Suicide in the young is not a new phenomenon. There have been increases in young males but not young females, and the geographic distribution varies. Although sociological issues are of importance, there are substantial data attesting to the presence of psychiatric illness in the overwhelming majority of those who commit suicide. While such illness may not be a sufficient cause for suicide to occur, it would appear to be a necessary one. Treatments are available.