Suicide trends and characteristics in Brazil.

Brazil is the largest and most populous country in South America (in 2002 the population was approximately 175 million). Although life expectancy in Brazil has increased, suicide and other forms of injury-related mortality, such as homicide and accident, have increased as a proportion of overall mortality (Oswaldo Cruz Foundation, 1984; Brazil Ministry of Health, 2001). The suicide rate in Brazil (3.0-4.0 per 100 000 inhabitants) is not considered high in global terms (World Health Organization, 1999). Nevertheless, it has followed the world tendency towards growth: during 1980-2000, the suicide rate in Brazil increased by 21%. Elderly people present the highest suicide rates in absolute numbers, but the alarming finding in the Brazilian data is that the youth population is increasingly dying by suicide (Mello-Santos et al, 2005). This statistic partially confirms a forecast by Diekstra & Guilbinat (1993) that the number of deaths by suicide would dramatically increase over the next decades, mainly in developing countries, including Latin America. In these regions, socio-economic factors (such as an increase in divorce and unemployment and a decrease in religiosity) increase the risk of self-harm. We discuss the reasons for the low suicide rate in Brazil and highlight the socio-economic factors affecting its increase among the youth population in particular.

Low suicide rate in Brazil: fact or artefact?

It is important to determine whether there was an actual increase in suicide rates in Brazil or whether it represents only a methodological artefact arising from the improvement in data collection at national level. The tendency for not all deaths to be notified in Brazil is common to other Latin American countries as well; the problem is compounded by the authorities’ disregard (Grossi & Vassan, 2002). The Brazilian Mortality Information System, operated by the Ministry of Health, may be capable of tracing only about 80% of total deaths in Brazil, since 20% of deaths are not registered (Mello-Jorge et al, 1997).

Elderly people present the highest suicide rates in absolute numbers, but the alarming finding in the Brazilian data is that the youth population is increasingly dying by suicide.

Some peculiarities of the Brazilian health system may have affected the national statistics. One methodological problem of registering death is the difficulty of distinguishing suicide from other violent deaths, such as homicide and accident. Frequently, coroners do not record the basic cause of death on the death certificate, but instead explain only the nature of the lesion. In Brazil, suicide cases are registered according to the classifications in the ‘external causes’ section of ICD–10 (World Health Organization, 1992), which classifies lethal events not arising from biological diseases as: those resulting from violence, those resulting from fatal accidents, and suicide. This procedure hampers the gathering of conclusive data on the nature of the death, such as the non-accidental cases (e.g. exogenous intoxication in the case of alcohol-related car accidents). Brazilian authorities are more concerned with the registering of accidents and homicides than with the accuracy of suicide statistics, as homicide is the largest single cause of death in Brazil. During 1980–2002, the homicide rate in Brazil more than doubled, from 11.4 per 100 000 population to 28.4 (Gawryszewski & Mercy, 2004).

Brazilian authorities are more concerned with the registering of accidents and homicides than with the accuracy of suicide statistics, as homicide is the largest single cause of death in Brazil.

Relatives and even the authorities often conceal the suicide for fear of judicial disputes or retaliation. There is a social prejudice against suicide and this results in non-disclosure (Mello-Jorge, 1988; Souza, 1991).

On the other hand, obtaining access to the means of suicide is easy in Brazil. The sale of psychotropics on the black market, the non-regulated and illegal carrying of guns, the ambiguous policy in relation to alcoholism, and the sale of caustic soda and rat poison in supermarkets are some examples. These are the major means of attempting suicide. Pesticides are commonly used in rural areas. The recent disarmament campaign, the withdrawal of inflammable products from supermarket shelves, a prohibition of the sale of some types of rat poison and stricter pesticide sales regulations reflect increasing concern. However, the Brazilian government still has not adequately tackled the recent increase in suicide rates through control of the means of suicide.

Recent data indicate that Brazilian youths are dying more from violent causes than from biological ones.

Suicide among Brazilian youth: the role of socio-economic factors

The significant increase in suicide among Brazilian youths (those aged 15–24 years) is in line with a world tendency, in which the majority of suicides occur in the population aged 5–44 years (Bertolote & Fleischmann, 2002). From 1980 to 2000, the suicide rate in this age-group increased 1000% in Brazil. Female suicide within the same age-group increased only 400%, while the male increase was about 2000% (Mello-Santos et al, 2005). Our own data for the city of São Paulo, the largest and most important Brazilian city, can be used to illustrate the national findings: from 1996 to 2000, 66% of all suicides were by persons aged 5–44 years. Recent data indicate that Brazilian youths are dying more from violent causes than from biological ones. In nine Brazilian capitals surveyed, Souza et al (2002) noted a 27.6% increase between 1979 and 1998 in deaths due to external causes among individuals aged 15–24 years. Suicide was ranked sixth among the external causes.

The analysis of the young people who have died by suicide reveals a population in crisis. The common characteristics are being male, single and a non-specialised worker with low educational attainment (Souza et al, 2002). These factors, together with the highly competitive market economy, limited employment opportunities and low governmental incentives, further combined with professional and economic instability, make the young population vulnerable. Accordingly, these factors are related to feelings of hopelessness among the younger generation, which encourages their suicidal behaviour. However, more studies are necessary to clarify the relationship between socio-economic factors and suicide among Brazilian youths.

The male:female ratio for suicide is 3:1, which is consistent with the findings of international studies…. However, this ratio is reversed when we study suicide attempts: women are three times more inclined to attempt suicide than men.

Suicide methods and gender

The male:female ratio for suicide is 3:1, which is consistent with the findings of international studies (Bertolote & Fleischmann, 2002). However, this ratio is reversed when we study suicide attempts: women are three times more inclined to attempt suicide than men (Teixeira & Villar Luis, 1997).

The difference in gender also reflects the lethality of the methods chosen. Women opt for poisoning or overdose, whereas men look to violent and more lethal methods, such as hanging and the use of firearms (Teixeira & Villar Luis, 1997) – the two most common methods in Brazil (Souza et al, 2002; Grossi & Vassan, 2002). In Brazil, two important suicide methods, mainly used by women, should be mentioned: the use of methyl alcohol for self-immolation (Marchesan et al, 1997; Souza et al, 1998) and the ingestion of carbamate (a rat poison) (Lima & Reis, 1995). Men die by suicide typically because they seek a drastic solution to a personal problem; women generally attempt suicide in an attempt to improve adverse conditions (Teixeira & Villar Luis, 1997).

Information on family problems, religiosity and divorce are not available in the routinely collected data for suicide.

Conclusion

Even though their reliability can be questioned, the Brazilian data on suicide rates allow the identification of risk groups among the general population. The increase in the youth suicide rate is a worldwide phenomenon, not exclusive to Brazil. In spite of the low suicide rates among Brazilian youths, its steady increase over the last two decades is a reason for concern. The young population, who have few opportunities, are vulnerable to socio-economic factors. Preventive strategies directed at this population should be implemented in order to reverse this trend. Intervention studies with high-risk populations are tasks for Brazilian researchers and a challenge for the public health authorities.