Comparing rates and patterns of male suicide and ''hidden suicide'' between nations and over time
1Discipline of Psychiatry, Sydney Medical School, Concord Hospital, 2139 Sydney, Australia
Submitted: 12 March 2021 Accepted: 28 April 2021
Online publish date: 31 July 2021
Rates and age patterns of suicide differ between nations and population groups. The accuracy of data provided by national statistics oﬃces has been questioned. This paper (1) compares recent high quality data regarding suicide rates in larger countries, and (2) explores differences between countries in proportions of male deaths coded as ''undetermined''. Data were obtained from the WHO Mortality Database regarding deaths in ten larger nations in 2015, coded (using ICD-10) as due to suicide, Event of Undetermined Intent (EUI), ill-deﬁned or unknown cause (R99), or accidental poisoning or drowning. Numbers in 5-year age groups were recorded and rates calculated using population ﬁgures. Male suicide rates per 100,000 in the ten nations were found to vary between 8.40 (Mexico) and 37.52 (Korea). Most Western nations had bimodal male age patterns, US and Japan trimodal, and Korea's was upward-sloping. Male EUI rates varied: those in Mexico and Japan progressively increased across the age-range. The UK's male R99 cross-age rate was nearly zero; the other 9 countries had high rates, largely with exponential rises in late life. England & Wales publish combined suicide and EUI rates as their ''oﬃcial'' suicide ﬁgures. Other countries, too, have been shown to code many suicides as ''undetermined deaths''. Partly this could be because of lack of resources to adequately investigate deaths. Accuracy of data would be improved by increased use of verbal autopsies. Comparisons of male age patterns of suicide, examining associations between period effects and sociocultural differences, could help identify reversible causative factors.
Suicide; Undetermined deaths; Rates; Age patterns; Gender ratio
John Snowdon. Comparing rates and patterns of male suicide and ''hidden suicide'' between nations and over time. Journal of Men's Health. 2021.doi:10.31083/jomh.2021.083.
 Bachmann S. Epidemiology of suicide and the psychiatric perspective. International Journal of Environmental Research and Public Health 2018; 15: 1425.
 World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines (CDDG). WHO, Geneva. 1992.
 WHO. The Global Health Observatory. WHO Mortality Database. 2020. Available at: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/download-the-raw-data-files-of-the-who-mortality-database (Accessed: 30 September 2020).
 Sveticic J, McPhedran S, De Leo D. Reviewing the revisions: what are the Australian Bureau of Statistics suicide figures really telling us?Meical Journal of Australia 2013; 198: 478.
 Rockett IRH, Kapusta ND, Bhandari R. Suicide misclassification in an international context: revisitation and update. Suicidology Online 2011; 2: 48–61.
 WHO. Suicide worldwide in 2019: global health estimates. Geneva: World Health Organization, 2021. Licence: CC BY-NC-SA 3.0 IGO (Accessed: 26 June 2021).
 Mikkelsen L, Phillips DE, AbouZahr C, Setel PW, de Savigny D, Lozano R, et al. A global assessment of civil registration and vital statistics systems: monitoring data quality and progress. Lancet. 2015; 386: 1395–1406.
 World Health Organization Geneva. Primary prevention of mental, neurological and psychosocial disorders. 1998. Available at: https://apps.who.int/iris/bitstream/handle/ 10665/42043/924154516X_eng.pdf (Accessed: 26 June 2021).
 Tøllefsen IM, Helweg-Larsen K, Thiblin I, Hem E, Kastrup MC, Nyberg U, et al. Are suicide deaths under-reported? Nationwide re-evaluations of 1800 deaths in Scandinavia. BMJ Open. 2015; 5: e009120.
 Gunnell D, Bennewith O, Simkin S, Cooper J, Klineberg E, Rodway C, et al. Time trends in coroners’ use of different verdicts for possible suicides and their impact on officially reported incidence of suicide in England: 1990–2005. Psychological Medicine. 2013; 43: 1415–1422.
 Palmer BS, Bennewith O, Simkin S, Cooper J, Hawton K, Kapur N, et al. Factors influencing coroners’ verdicts given in 12 coroners’ districts to researcher-defined suicides in England in 2005. Journal of Public Health. 2014; 37: 157–165.
 Li F, Lu X, Ou Y, Yip PSF. The influence of undetermined deaths on suicides in Shanghai, China. Social Psychiatry and Psychiatric Epidemiology. 2019; 54: 111–119.
 Naghavi M, Global Burden of Disease Self-Harm Collaborators. Global, regional and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016. British Medical Journal 2019; 364: l94.
 Pritchard C, Hansen L. Examining undetermined and accidental deaths as source of ’under-reported-suicide’ by age and sex in twenty Western countries. Community Mental Health Journal. 2015; 51: 365–376.
 Rockett IRH, Hobbs GR, Wu D, Jia H, Nolte KB, Smith GS, et al. Variable Classification of Drug-Intoxication Suicides across us States: a Partial Artifact of Forensics? PLoS ONE. 2015; 10: e0135296.
 Chan CH, Caine ED, Chang SS, Lee WJ, Cha ES, Yip PSF. The impact of improving suicide death classification in South Korea: a comparison with Japan and Hong Kong. PLoS ONE. 2015; 10: e0125730.
 Pritchard C, Iqbal W, Dray R. Undetermined and accidental mortality rates as possible sources of underreported suicides: population-based study comparing Islamic countries and traditionally religious Western countries. British Journal of Psychiatry Open. 2020; 6: e56.
 Chang S-S, Sterne JAC, Lu T-H, Gunnell D. ‘Hidden’ suicide amongst deaths certified as undetermined intent, accident by pesticide poisoning and accident by suffocation in Taiwan. Social Psychiatry and Psychiatric Epidemiology. 2010; 45: 143–152.
 Population Pyramid. 2020. Available at: www.populationpyramid. net (Accessed: 25 June 2021).
 Snowdon J, Phillips J, Zhong B, Yamauchi T, Chiu HFK, Conwell Y. Changes in age patterns of suicide in Australia, the United States, Japan and Hong Kong. Journal of Affective Disorders. 2017; 211: 12–19.
 Snowdon J, Chen Y, Zhong B, Yamauchi T. A longitudinal comparison of age patterns and rates of suicide in Hong Kong, Taiwan and Japan and two Western countries. Asian Journal of Psychiatry. 2018; 31: 15–20.
 Snowdon J. Suicide and ‘hidden suicide’: a comparison of rates in selected countries. Australasian Psychiatry. 2020; 28: 378–382.
 Snowdon J. Indian suicide data: what do they mean? Indian Journal of Medical Research. 2019; 150: 315–320.
 Dandona R, Kumar GA, Dhaliwal RS, Naghavi M, Vos T, Shukla DK, et al. Gender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016. The Lancet Public Health. 2019; 3: e478–e489.
 Zhong B, Chiu HFK, Conwell Y. Elderly suicide trends in the context of transforming China, 1987–2014. Scientific Reports. 2016; 6: 37724.
 Sha F, Chang Q, Law YW, Hong Q, Yip PSF. Suicide rates in China, 2004–2014: comparing data from two sample-based mortality surveillance systems. BMC Public Health. 2018; 18: 239.
 Snowdon J. Differences between patterns of suicide in East Asia and the West. the importance of sociocultural factors. Asian Journal of Psychiatry. 2018; 37: 106–111.
 Chen Y, Wu KC, Yousuf S, Yip PSF. Suicide in Asia: opportunities and challenges. Epidemiologic Reviews. 2012; 34: 129–144.
 Ritchie H, Roser M, Ortiz-Ospina E. Suicide. 2018. Available at: https://ourworldindata.org/suicide?country= (Accessed: 25 June 2021).
 Jeon SY, Reither EN, Masters RK. A population-based analysis of increasing rates of suicide mortality in Japan and South Korea, 1985–2010. BMC Public Health. 2016; 16: 356.
 Park BCB. Cultural ambivalence and suicide rates in South Korea. Suicide and Culture. In E. Colucci & D. Lester (eds.) Cambridge, USA: Hogrefe. 2013.
 Suh G, Gega L. Suicide attempts among the elderly in East Asia. International Psychogeriatrics. 2017; 29: 707–708.
 Chang S, Gunnell D, Sterne JAC, Lu T, Cheng ATA. Was the economic crisis 1997–1998 responsible for rising suicide rates in East/Southeast Asia? a time–trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Social Science & Medicine. 2009; 68: 1322–1331.
 Pritchard C, Amanullah S. An analysis of suicide and undetermined deaths in 17 predominantly ‘Islamic countries’ contrasted with the United Kingdom. Psychological Medicine 2007; 37: 421–430.
 Polprasert W, Rao C, Adair T, Pattaraarchachai J, Porapakkham Y, Lopez AD. Cause-of-death ascertainment for deaths that occur outside hospitals in Thailand: application of verbal autopsy methods. Population Health Metrics. 2010; 8: 13.
 Mikkelsen L, Moesgaard K, Hegnauer M, Lopez AD. ANACONDA: a new tool to improve mortality and cause of death data. BMC Medicine. 2020; 18: 61.
 Mikkelsen L, Iburg KM, Adair T, Fürst T, Hegnauer M, von der Lippe E, et al. Assessing the quality of cause of death data in six high-income countries: Australia, Canada, Denmark, Germany, Japan and Switzerland. International Journal of Public Health. 2020; 65: 17–28.
 Linsley KR, Schapira K, Kelly TP. Open verdict v. suicide—importance to research. The British Journal of Psychiatry. 2001; 178: 465–468.
 Ohberg A, Lonnqvist J. Suicides hidden among undetermined deaths. Acta Psychiatrica Scandinavica. 1998; 98: 214–218.
 Lachaud J, Donnelly P, Henry D, Kornas K, Fitzpatrick T, Calzavara A, et al. Characterising violent deaths of undetermined intent: a population-based study, 1999–2012. Injury Prevention. 2018; 24: 424–430.
 Bakst SS, Braun T, Zucker I, Amitai Z, Shohat T. The accuracy of suicide statistics: are true suicide deaths misclassified? Social Psychiatry and Psychiatric Epidemiology. 2016; 51: 115–123.
 Oquendo MA, Volkow ND. Suicide: a Silent Contributor to Opioid-Overdose Deaths. the New England Journal of Medicine. 2018; 378: 1567–1569.
 Skinner R, McFaull S, Rhodes AE, Bowes M, Rockett IRH. Suicide in Canada. the Canadian Journal of Psychiatry. 2016; 61: 405–412.
 Hsieh W, Wang C, Lu T. Drowning mortality by intent: a population-based cross-sectional study of 32 OECD countries, 2012-2014. BMJ Open. 2018; 8: e021501.
 Snowdon J. Changes in the age pattern of New Zealand suicide rates. New Zealand Medical Journal. 2017; 130: 18–26.
 Snowdon J, Baume P. A study of suicides of older people in Sydney. International Journal of Geriatric Psychiatry. 2002; 17: 261–269.
 Tong Y, Phillips MR. Cohort-specific risk of suicide for different mental disorders in China. The British Journal of Psychiatry. 2010; 196: 467–473.
 Pridmore S. Mental disorder and suicide: a faulty connection. Australian and New Zealand Journal of Psychiatry. 2015; 49: 18–20.
 Shneidman E. Perturbation and lethality. The Harvard Medical School Guide to Assessment and Intervention. In D. G. Jacobs (ed.) San Francisco: Jossey-Bass. 1999.
 Phillips JA, Robin AV, Nugent CN, Idler EL. Understanding recent changes in suicide rates among the middle-aged: period or cohort effects? Public Health Reports. 2010; 125: 680–688.
 Chang SS, Stuckler D, Yip P, Gunnell D. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. British Medical Journal. 2013; 347: f5239.
Science Citation Index Expanded Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.
Social Sciences Citation Index Social Sciences Citation Index contains over 3,400 journals across 58 social sciences disciplines, as well as selected items from 3,500 of the world’s leading scientific and technical journals. More than 9.37 million records and 122 million cited references date back from 1900 to present.
Current Contents - Social & Behavioral Sciences Current Contents - Social & Behavioral Sciences provides easy access to complete tables of contents, abstracts, bibliographic information and all other significant items in recently published issues from over 1,000 leading journals in the social and behavioral sciences.
Current Contents - Clinical Medicine Current Contents - Clinical Medicine provides easy access to complete tables of contents, abstracts, bibliographic information and all other significant items in recently published issues from over 1,000 leading journals in clinical medicine.
SCOPUS Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.
DOAJ DOAJ is a community-curated online directory that indexes and provides access to high quality, open access, peer-reviewed journals.
CrossRef Crossref makes research outputs easy to find, cite, link, assess, and reuse. Crossref committed to open scholarly infrastructure and collaboration, this is now announcing a very deliberate path.
Portico Portico is a community-supported preservation archive that safeguards access to e-journals, e-books, and digital collections. Our unique, trusted process ensures that the content we preserve will remain accessible and usable for researchers, scholars, and students in the future.