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 Informaçoes 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.
Suicide; epidemiology; community mental health; public health; time series
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 Informaçoes 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 Maranhao, Paraíba, Bahia, and Rio de Janeiro, the mean suicide rate in male surpassed 5.00 per 100,000.
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.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 Açoes Estratégicas para a Vigilância e Prevençao do Suicídio e Promoçao 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.DISCLOSURE
The authors report no conflicts of interest.REFERENCES
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