Suicide rates in Fortaleza increased 157% in ten years

Objective: to analyze suicide rates between 2000-2009 in Fortaleza, Ceará, Brazil. Methodology: Data was obtained from Ceará’s Institute of Forensic Medicine (PEFOCE). Estimated population by year was obtained from the Unified Health System (DATASUS). Results: A total of 1903 suicide cases were registered in Fortaleza, between 2000 and 2009. The distribution of methods was analyzed using the variables gender, age and year. Around 80% of the cases were male, corresponding to 4.3 male to female suicide rate. The most common suicide method was hanging, followed by poisoning, firearms, and jumping from heights. Among males, hanging was the most prevalent suicide method, followed by poisoning; while in females poisoning was the most prevalent method, followed by hanging. Almost half of all suicides in the study were by hanging. Conclusions: The classification of death as suicide is subject to interpretation of the coroner. Local published literature about this problem is sparse. Understanding suicide methods may provide support to more effective suicide prevention programs.

In contrast, female used more poisoning (n=50, 42.0%), following by hanging (n = 101, 28.3%). The most frequent methods in each age group according to sex are shown in Table 1. There was a significant change in suicide methods used by females within advancing age. Poisoning was the most prevalent method in groups below 55 years old. However, hanging was more common in the groups above 54 years. The problem of irregular and clandestine use of pesticides reaches other regions in Brazil. 14,15 Intoxication is the leading cause of hospitalization in Brazil due to suicide attempts and pesticides account for 46.7% of total deaths of suicide by exogenous intoxication in a time period between 1998 and 2009. 16 In South India, poisoning by pesticides was the most prevalent method (53%) also may be the result of ease of access to pesticides. 17 In Sri Lanka, where pesticides are the leading method of suicide, after the government banned several of the most highly toxic pesticides, the suicide rate fell by half. 18 In Fortaleza, among males, hanging was the most prevalent method followed by poisoning in all age groups, while in South India, in males, poisoning was prevalent in the age group 15-74 years, and hanging was more prevalent above 74 years. 17 In this city, female suicide methods vary with age. Poisoning predominated in women aged up to 54 years, while hanging was more prevalent in elder women (55 and over). A similar result was observed in South India, where poisoning was prevalent in females in the age group 0-74 years, and hanging was prevalent above 74 years. 17 In Europe and Korea, hanging was the most prevalent method in both genders. 7,8 A review of the World Health Organization (WHO) mortality database showed that violent and highly lethal methods, such as suicide by firearm and hanging, are more frequent among men, while women tend to choose poisoning, which is less violent and lethal. 4 Firearms were the third most used suicide method in Fortaleza. Suicide by firearms had a downward trend. This fact may be associated with restricting access implemented by the Disarmament Statute (Federal Law n. 10.826 of 22th December 2003). 18 This law prohibits carrying weapons by civilians, except for cases where there is proven need. The permission is allowed only for members of the armed forces, police, intelligence agents, tax auditors and private security agents. The availability of firearms is associated with higher rates of suicide with mounting evidence suggesting that restricting access to firearms may be an effective strategy for suicide prevention. 19,20 Many countries have witnessed significant falls in suicide rates that have paralleled gun law reforms. 21-23 One limitation of this study is the possible bias in the underreporting of death by suicide. This may have resulted in underestimation of certain suicide methods since death from overdose and drowning are more likely to be coded as undetermined deaths instead of suicide. 24 The classification of death as suicide or undetermined death is subject to the interpretation of the coroner. This can affect the reliability of official suicide statistics. Furthermore, changes at social and religious acceptability of suicide may lead to biased trend estimates. 25

DISCUSSION
Almost half of all suicides occurred in Fortaleza between 2000-2009 were by hanging, which mirrors the general trend in most countries in the world. Studies show hanging as main suicide method when no other major method is available. The proportion of hanging typically decrease as either pesticide suicide or firearm suicide increases. 4 In addition, in Fortaleza, there is a significant use of hammocks to rest or sleep. This cultural factor may increase suicide by hanging due to the easy availability of ropes.
The second most prevalent method was poisoning as well as many countries. [7][8][9] In Fortaleza, the high proportion of suicides by poisoning could had been caused by ingestion of carbamate and organophosphate as suggested in a preliminary report of the biggest emergency hospital of Fortaleza, that 80% of deaths observed in that hospital by suicide were associated with selfpoisoning by pesticides. 10 This phenomenon may be influenced by the easy access to these substances at the local market, which are usually sold as rat poison in urban and as pesticides in rural areas. Despite the Federal Law nº. 7802/89, which regulates the sale and use of these products, 11 unfortunately, there is no effective control over these substances. Brazilian regulatory agencies still suffer from institutional fragilities such as shortage of dedicated staff and funding. 12 Since 2008, Brazil is one of the largest pesticide markets in the world, with 19% of the total market share. While in the The diagnosis of a mental disorder, one of the most important risk factors for suicide, as well as other indicators of demographic and clinical facts that could be associated to suicidal behavior were not evaluated because the report Institute of Forensic Medicine of Ceará did not register these variables.
The preference of the suicide method is complex. The use of a method depends on the availability and accessibility of ways to commit suicide. Epidemiological evidence suggests that means restriction do not reduce only method-specific but also overall suicide rates, being an important assistance on suicide prevention. [26][27][28] In this sample, it was not possible to evaluate whether the restriction of firearms had an impact on the overall suicide rates in Fortaleza.
In conclusion, although suicide is an important public health issue, the local published literature about this problem is sparse. Therefore, understanding suicide methods may provide support to more effective public suicide prevention programs. There is a clear need to improve data registry of suicide, including demographic and clinical data as a way to develop more effective strategies.