Adli Tıp Dergisi 2009; 23(2): 1-10
Journal of Forensic Medicine
DO REGIONAL RISK FACTORS AFFECT THE CRUDE SUICIDAL
MORTALITY RATES IN TURKEY?
Mahmut AŞIRDİZER (MD) Assoc. Prof.1, M. Sunay YAVUZ (MD) Assoc. Prof.1, Serpil AYDIN DEMİRAĞ (MD) Assoc. Prof.2, Ertuğrul TATLISUMAK (MD) Assist. Prof.3
1
Department of Forensic Medicine, Celal Bayar University, School of Medicine, Manisa, Turkey.
2
Department of Family Medicine, Adnan Menderes University, School of Medicine, Aydin, Turkey.
3
Anatomy and Specialist of Family Medicine, Celal Bayar University, School of Medicine, Manisa, Turkey.
Abstract
Aims of this study were to reveal differences in suicidal deaths among various regions of Turkey and to evaluate effects of various demographic, socio-economic and socio-cultural factors on regional suicide rates. The crude data about suicidal deaths in 2006 were collected from the website of Turkish Statistical Institute (TURKSTAT) and other web pages and they were adopted for this study.
There were 2,829 suicidal deaths in Turkey in 2006. The crude suicidal mortality rate was found to be 3.88 per 100,000 people. The mean age of female and male victims was 30.4±16.7 years (median: 30.0 years) and 38.4±16.8 years (median: 37.7 years) respectively. The incidence of male and female victims was found to be 4.82 per 100,000 people and 2.91 per 100,000 people respectively.
In this study, even though regional rates of risk factors including to educational level, population density, net domestic migration rate, unemployment rate, GDP per capita, average age at marriage, crude marriage rate, fertility and crude divorce were not found to have a significant effect on crude suicide rates, these risk factors may individually affected on suicide victims. They were not causes of suicides, but were incentive on the persons who psychiatric predisposed to suicidal acts.
Keywords: Suicide, demographic characteristics, socio-economic factors, socio-cultural factors,
regional risk factors.
BÖLGESEL RİSK FAKTÖRLERİ, TÜRKİYE’DEKİ KABA İNTİHAR ÖLÜM ORANLARINI ETKİLİYOR MU?
Özet
Bu çalışmanın amacı, Türkiye’nin çeşitli bölgelerindeki intihar ölümlerinin farklılıklarını ortaya koymak ve bölgesel intihar oranları üzerinde çeşitli demografik, sosyo-ekonomik ve sosyo-kültürel etkileri değerlendirmektir. 2006 yılındaki intihar ölümleri hakkındaki kaba veriler, Türkiye İstatistik Kurumu’nun web sayfalarından ve diğer web sayfalarından elde edilerek, bu çalışma için uyarlanmıştır.
2006 yılında, Türkiye’de 2829 intihar ölümü bulunmaktaydı. Kaba intihar ölüm hızı, her 100000 kişi için 3.88 olarak bulundu. Kadın ve erkek kurbanların ortalama yaşları sırasıyla, 30.4±16.7 yıl (medyan: 30.0 yıl) ve 38.4±16.8 yıl (medyan: 37.7 yıl) idi. Kadın ve erkek kurbanların sıklığı, sırasıyla her 100000 kişi için 4.82 ve 2.91 olarak saptandı.
Bu çalışmada, her ne kadar eğitim seviyesi, nüfus yoğunluğu, net iç göç hızı, işsizlik oranı, kişi başı gayri-safi milli hasıla, ortalama evlilik yaşı, kaba boşanma ve doğum oranlarını içeren risk faktörlerinin bölgesel oranları, kaba intihar oranları üzerinde anlamlı bir etkide bulunmamış ise de, bu risk faktörleri intihar kurbanlarını kişisel olarak etkilemiş olabilir. Bu faktörler, intiharın nedenleri olmasa da, intihar eylemlerine psikiyatrik olarak yatkın olan kişilerde harekete geçirici etkenlerdir.
Anahtar Kelimeler: İntihar, demografik özellikler, sosyo-ekonomik faktörler, sosyo-kültürel
faktörler, bölgesel risk faktörleri.
Introduction
Worldwide, suicide claimed the lives of an estimated 815,000 people in 2000, for an overall age-adjusted rate of 14.5 per 100,000 people [1]. The suicidal mortality varies with gender, age, region and country and is affected by risk factors including psychiatric diseases, somatic illnesses, poor financial status, insufficient social support, Gross Domestic Product (GDP) per capita, unemployment and problems at work, divorce, familial conflicts, honor, fertility, alcohol consumption, inequalities, religion, political factors and cultural attitudes [1 - 5].
Therefore, suicide should be handled with a multidimensional approach: i.e. biological, psychological, genetic, sociological, philosophical and religious dimensions [6]. In many countries, suicide prevention programs are prepared and the results of these programs are submitted to the World Health Organization (WHO). The WHO recommends public health interventions which are traditionally characterized by three steps of prevention: (a) primary- approaches that aim to prevent suicide before it occurs, (b) secondary- approaches that focus on the more immediate responses to suicide, such as pre-hospital care, emergency services or treatment, (c) tertiary- approaches that focus on long-term care of the suicide survivors, such as rehabilitation and reintegration, and preventive attempts [1]. Unfortunately, there have not been any suicide prevention and care programs reported by Turkey to the WHO.
The aim of this study was to reveal differences in suicidal deaths between various regions of Turkey, which were classified according to economic, social and geographic features, regional development plans and their population, and to evaluate the effects of various demographic, socio-economic and socio-cultural factors on regional rates of suicidal deaths.
Material and Methods
Turkish Statistical Institute (TURKSTAT) of the Republic of Turkey has made a classification of “statistical regions” according to various statistical parameters. Based on this classification, there are three types of regions. The first group includes the regions in which the cities are located. The second group includes a few cities that represent the regions. All the cities are found in the third group of regions. Neighboring cities, which are similar in terms of economic, social and geographic features, regional development plans and population, are assigned to the second and the first groups of regions [7].
In this study, data about 12 regions, assigned to the first group of regions, were evaluated.
Data about population, suicidal death numbers, crude suicidal mortality rates, distribution of victims by gender and age groups, net migrations rates, unemployment rates, crude marriage rates, average age at marriage, crude divorce rates and areas of regions in 2006 were obtained from various web pages of TURKSTAT (http://www.turkstat.gov.tr). Based on the information provided in these web pages, the ratio of female to male victims, the mean ages of total, male and female populations and population density were calculated. Gross Domestic Product (GDP) per capita for 2006 could not be obtained from TURKSTAT web pages, but data about GDP in 2007 were obtained from a different source (http://www.milliyet.com.tr/2007/04/01/ekonomi/eko05.html).
For the assessment of educational levels, a percentile system was selected. Each 20% showed different levels of education. Five groups formed a total of 100%: the first group included the people who could not complete school, the second group included primary school graduates, the third group included the people who completed primary education or secondary (middle) school or vocational middle school, the forth group included high school graduates and the last group included the people who completed higher education. These rates were multiplied by the number of people with the same educational level, and the obtained number was divided by the number of total population in a given region.
In this study, informed consent was obtained from TURKSTAT via e-mail. Student T, Chi-square and Spearman correlation tests were used for statistical analyses. P< 0.05 was considered significant.
Results
There were a total of 2,829 suicidal deaths and the mid-year total population was estimated to be 72,974,000 in Turkey in 2006. The crude suicidal mortality rate was found to be 3.88 per 100,000 people. While most of the suicides were committed in the Aegean region (n=415, 14.7%), (p<0.0001), the West Marmara region (5.56 in 000%) had the highest crude suicidal mortality rates calculated per 100,000 people (Table 1).
There were 1,047 female victims (37%) and 1,782 male victims (63%). While the number of female victims was higher in the Mediterranean, Aegean, Central East Anatolia and South-east Anatolia regions (p<0.0001), male victims commonly occurred in the Aegean region, Istanbul and the Mediterranean region (p<0.0001).
The incidence of male and female suicidal deaths in the country was found to be 4.82 per 100,000 people and 2.91 per 100,000 people respectively. The West Marmara and Aegean regions had the highest rates of male victims (7.84 per 100,000 people and 6.13 per 100,000 people respectively). Nonetheless, the rate of female victims was higher in east regions except of East Black Sea Region of Turkey and it was higher than the rates of male victims (Table 1) (p<0.0001).
The mean age of all the victims was 34.7±17.2 years (median: 34.2) and the mean ages of male and female victims were 38.4±16.8 years (median: 37.7 years) and 30.4±16.7 years (median: 30.0 years) respectively. The distribution of mean ages of overall, male and female populations by the regions is shown in Figure 1. The South-east Anatolia region had the lowest mean age of the suicidal deaths (26.4 years) and the West Marmara region had the highest mean age of the suicidal deaths (41.0 years) (p>0.05). The South-east Anatolia and the East Marmara regions had the lowest (28.7 years) and highest (42.6 years) mean age of the male victims respectively (p>0.05). The Central East Anatolia and the West Marmara regions had the lowest (22.7 years) and highest mean age of female victims (38.9 years) respectively (p>0.05).
The educational level of Turkey was calculated to be 41.2%. The South-east Anatolia region had the lowest educational level (30 %) and the Istanbul had the highest educational level (47.2%). There was no significant relation between crude suicidal mortality rates and educational level (p=0.664, r=-0.140) (Figure 2).
The mean population density in Turkey was 93 people per square kilometer. Whilst the most crowded region was Istanbul (2248 people/km2), the most uncrowned region was North-east Anatolia (36 people/km2). The relation between crude suicidal mortality rates and population density was not significant (p=0.236, r=-0.371) (Figure 3).
Istanbul, West Marmara, Aegean, East Marmara, West Anatolia and Mediterranean regions had in-migration, the other regions had out-migration. There was no significant relation between crude suicidal mortality rates and net domestic migration rates (p=0.871, r=-0.053) (Table 2).
unemployment rate (14%). There was no significant relation between crude suicidal mortality rates of the overall population and the male population and the rates of unemployment (p=0.75, r=-0.531 for the overall population and for the male population: p=0.289, r=-0.334) (Table 2). Unlike males, among females the crude suicidal mortality rates increased as the unemployment rate decreased (p=0.002, r=-0.788).
GDP per capita in Turkey was 9,662 $ (USA). The highest GDP per capita was in the East Marmara region (14,802 $), and the lowest GDP per capita in the North-east Anatolia region (3,584 $). There was no significant relation between crude suicidal mortality rates and GDP per capita (p=0.779 r=-0.91) (Table 2).
The average age at marriage was 23.8 years and the crude marriage rate was 8.72 ‰ in Turkey. Central Anatolia had the lowest age at marriage (22.6 years) and the highest crude marriage rate (10.45 ‰). There was no significant relation between crude suicidal mortality rates and age at marriage and crude marriage rates (p=0.577, r=-0.179), (p=0.436, r=-24.9, respectively) (Table 3).
The total fertility rate and crude divorce rate in Turkey were 2.53 and 1.28 ‰ respectively. The regions, which had highest rates of fertility and crude divorce rates, were South-east Anatolia region (4.55) and Aegean region (1.86 ‰), respectively. The regional fertility and crude divorce rates did not seem to affect crude suicidal mortality rates (p=0.618, r=-0.161 and p=0.812, r=-0.77) (Table 3).
Table 1. The Distribution of Suicides and Crude Suicidal Mortality Rates (per 100,000 people) by Gender and Regions
REGIONS THE NUMBER OF SUICIDES CRUDE SUICIDAL MORTALITY RATES
(PER 100,000 POPULATIONS)
MALE/FEMALE RATIO
MALE FEMALE TOTAL MALE FEMALE TOTAL
Istanbul 254 108 362 4,30 1,89 3,11 2,28 West Marmara 121 45 166 7,84 3,12 5,56 2,51 Aegean 294 121 415 6,13 2,57 4,37 2,39 East Marmara 158 78 236 4,98 2,54 3,78 1,96 West Anatolia 146 104 250 4,10 2,98 3,55 1,38 Mediterranean 240 133 373 4,98 2,82 3,91 1,77 Central Anatolia 108 42 150 5,06 1,97 3,52 2,57
West Black Sea 121 77 198 5,26 3,25 4,24 1,62
East Black Sea 69 61 130 4,33 3,82 4,08 1,13
North East Anatolia 52 51 103 3,98 4,21 4,09 0,95
Central East Anatolia 101 119 220 4,84 6,12 5,46 0,79 South East Anatolia 108 118 226 2,87 3,28 3,07 0,88
Figure 1. The Distribution of the Mean Ages of Suicides by Gender and Regions
Figure 2. The Relationship between Crude Suicidal Mortality Rates (per 100,000 people) and Educational Level (%)
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Figure 3. The Relationship between Crude Suicidal Mortality Rates (per 100,000 people) and Population Density (per km2)
Table 2. The Relationship between Crude Suicidal Mortality Rates (per 100,000 people) and Net Domestic Migration Rates
(per 1,000 people) REGIONS CRUDE SUICIDAL MORTALITY RATES (PER 100,000) NET DOMESTIC MIGRATION RATES (‰) UNEMPLOYMENT RATES (PER 100) PER CAPITA GROSS DOMESTIC PRODUCT BY PROVINCES ($)
MALE FEMALE TOTAL MALE FEMALE TOTAL
Istanbul 4,30 1,89 3,11 46,1 10,5 13,9 11,2 12870 West Marmara 7,84 3,12 5,56 26,1 6,2 9,2 7,1 11693 Aegean 6,13 2,57 4,37 22,9 8,6 9,4 8,8 12413 East Marmara 4,98 2,54 3,78 15,9 8,2 11,2 9,0 14802 West Anatolia 4,10 2,98 3,55 15,9 9,9 17,0 11,6 10088 Mediterranean 4,98 2,82 3,91 0,4 11,7 12,8 12,0 8884 Central Anatolia 5,06 1,97 3,52 - 24,9 10,5 12,4 10,9 6902
West Black Sea 5,26 3,25 4,24 - 50,3 6,7 5,2 6,1 8500
East Black Sea 4,33 3,82 4,08 - 26,1 6,2 5,0 5,7 6459
North East Anatolia 3,98 4,21 4,09 - 49,8 6,5 2,4 5,3 3584 Central East
Anatolia 4,84 6,12 5,46 - 33,4 12,3 8,4 11,3 3998
South East Anatolia 2,87 3,28 3,07 -36,2 14,6 8,4 14,0 5263
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Table 3. The Relationship between Crude Suicidal Mortality Rates (per 100,000 people) and the Parameters of Crude Marriage
Rates (‰), Average Age at Marriage (years), Total Fertility Rates (per female) and Crude Divorce Rates (‰).
REGIONS
CRUDE
SUICIDAL MORTALITY RATES (PER 100,000) CRUDE MARRIAGE RATE (‰) AVERAGE AGE AT MARRIAGE TOTAL FERTILITY RATE CRUDE DIVORCE RATE (‰)
MALE FEMALE TOTAL
Istanbul 4,30 1,89 3,11 8,31 24,6 1,97 1,78 West Marmara 7,84 3,12 5,56 7,50 23,7 1,82 1,45 Aegean 6,13 2,57 4,37 8,34 24,1 2,03 1,86 East Marmara 4,98 2,54 3,78 8,34 23,8 2,01 1,32 West Anatolia 4,10 2,98 3,55 7,91 23,9 2,26 1,60 Mediterranean 4,98 2,82 3,91 8,79 23,9 2,53 1,29 Central Anatolia 5,06 1,97 3,52 10,45 22,6 2,68 1,25
West Black Sea 5,26 3,25 4,24 9,51 23,4 2,44 1,09
East Black Sea 4,33 3,82 4,08 6,97 23,4 2,38 0,63
North East Anatolia 3,98 4,21 4,09 9,68 23,2 3,73 0,43
Central East Anatolia 4,84 6,12 5,46 9,02 23,2 3,82 0,44 South East Anatolia 2,87 3,28 3,07 10,09 23,5 4,55 0,50 TOTAL 4,82 2,91 3,88 8,72 23,8 2,53 1,28 Discussion
The rates of suicidal deaths vary considerably among countries and regions. While the highest suicidal death rates in the world were in northern and eastern European countries, especially Baltic countries and Hungary, suicide rates were lower in the Mediterranean countries [8, 9]. The rate of suicidal deaths in Turkey was 3.88 per 100,000 people and the range of them varied between 3.07 per 100,000 people and 5.56 per 100,000 people in various regions of Turkey (Table 1).
In general population, rates of suicides in most countries are higher in females than in males [10, 11]. In contrast to the low rate of deliberate self-harm, the rate of suicidal deaths is higher in males. One of the main causes of this contradiction was the surplus of suicidal intent in males and deliberate self-harm based on non-suicidal motivation in females [11]. Qin et al. reported that the protective effect of marriage in women was largely due to having children; and the psychiatric history, socio-economic factors and demographics do not explain the higher suicide rates in males; there may be some other aspects such as genetic factors, personality characteristics, and stressful life events which increase suicide risks [10]. In the present study, the rate of male suicidal deaths (4.82 in 000%) was higher than the rate of female suicidal deaths (2.91 in 000%). The rate of female victims was higher than the rate of male victims in east regions except of East Black Sea Region of Turkey (Table 1). Alptekin et al. and Sır et al. also reported that the rate of female suicides increased in eastern regions of Turkey, especially in the South-east Anatolia region [12, 13]. This can be explained by severe oppression caused by rites and moral values on women living in these regions [12 - 14]. In China, the high female suicide rate is attributed to low economic status of females and insufficient rights in the socio-cultural environment [15].
In this study, the mean age of female victims (30.4±16.7, median: 30.0) was lower than that of male victims (38.4±16.8, median: 37.7) (Figure 1). The feeling of hopelessness reduces the abilities of
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solving and copes with problems in persons and the victims of suicides generally give up hope of live. This sense is clearly observed in youth victims [16]. The low mean ages of both male and female victims were in the Eastern Anatolia and South-east Anatolia regions had been affected schismatic terrorism of Turkey (Figure 1). Ergunes reported that there was a close relation between terrorism and posttraumatic distress syndrome. Additionally, he quoted that, there were a psychiatric disorder in 91% of victims of suicidal attempts and the most risky group was persons with posttraumatic distress syndrome [17]. In this study, lower educational level (Figure 2), higher domestic migration rate, higher unemployment rate and low GDP per capita (Table 2) were observed in those regions. However, the relation between crude suicidal mortality rates and such factors as educational level (p=0.664, 0.140) (Figure 2), net domestic migration rates (p=0.871, 0.053), unemployment rates (p=0.75, r=-0.531) and GDP per capita (p=0.779, r=-0.91) was not statistically significant (Table 2). We think that those suicidal risk factors may be affected on suicides when they accompanied with posttraumatic distress syndrome originating from terrorism, even if they were not separately affected on suicides.
In prior studies, social factors have shown to be predictive for suicide [18 - 21]. In a recent study by Lorant et al. on the role of socio-economic inequalities in suicide rates in some European countries, the crude suicidal mortality rate is higher in the group with a lower educational level and in all male populations, in particular [20]. Qin et al. found socio-economic inequalities to be a significant risk factor for suicides in the USA [10]; however, it was reported that socio-inequalities did not affect suicides in the UK [22] and Denmark [10]. Minoui et al. emphasized that unemployment and income inequality had a stronger impact on female suicides than on male suicides [23]. Inoue et al. reported that the unemployment was particularly associated with increased suicides among males in Japan and that suicide rates were less strongly associated with unemployment rates than a change in situation from employment to unemployment [19]. In the present study, there was no significant relation between crude suicidal mortality rates and educational level, net domestic migration rate, GDP per capita and unemployment rate. However, we could not access the statistical data about the change in situation from employment to unemployment. The reason why socio-economic factors had no effect on the suicide rates in Turkey may be religious factors and strong family ties. In fact, suicide is considered as a sin and persons who feel hopeless and helpless are provided support by their family members in Turkey. However, Palabiyikoglu et al. from Turkey defined the inequality in support, tolerance, love and affection in a family as suicide risks [24]. Ozkan et al. explained that the feelings of hopelessness and helplessness resulting from societal difficulties, effects of increasing societal loneliness and certain biological mechanisms triggered by these effects lead to suicide [6].
Before conduction of this study, we hypothesized that factors like age at marriage, fertility rate and divorce rate (Table 3) would affect the rates of youth suicides, and especially young female suicides. Although we did not find a statistically significant relation between crude suicidal mortality rates and some parameters such as average age at marriage (p=0.577, 0.179), fertility rate (p=0,001, r=-0,818) and crude divorce rate (p=0.812, r=-0.77) (Table 3), we think that young age at marriage might have had an effect on the lower mean ages of female suicides in the Eastern Anatolia and South-east Anatolia regions of Turkey (Figure-1). In the abovementioned regions, many women get married in childhood, which is illegal and is not available in statistical data. In those regions, the high fertility rate causes an increase in the number of children and in turn inequality in support, tolerance, love and affection in the family. Besides, the lower suicide rate in those regions may be explained by the ban of divorce. The families generally do not let their children get divorced even in the presence of big disagreements. However, this can be one of the main causes of suicides in the youth. Conflicting with this hypothesis, Kposowa revealed that risks of suicide increased among divorced and separated men but not among women [22]. We think that each hypothesis mentioned above is of value in the culture where it was created. In the present study, there was no significant relation between the crude
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marriage rates and crude suicidal mortality rates (p=0.436, r=-24,9) (Table 3).
There have been some controversies in the literature about the association between suicide rates and populations of cities. Whilst Mościcki showed a positive relation between suicide rates and populations of cities [25], McCall et al. reported that suicide rates in US cities towards the end of the twentieth century did not seem to vary with population [26]. In the present study, we found no significant relation between crude suicidal mortality rates and population density (p=0.236, r=-0.371) (Figure 3).
Conclusion
In this study, even though regional rates of risk factors including to educational level, population density, net domestic migration rate, unemployment rate, GDP per capita, average age at marriage, crude marriage rate, fertility and crude divorce in each region were not found to have a significant effect on crude suicide rates, these risk factors may individually affected on suicide victims such as previously reported by Asirdizer et al [27]. They were not causes of suicides, but were incentive on the persons who psychiatric predisposed to suicidal acts.
Acknowledgement
We thank TURKSTAT for providing the data. References
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Corresponding Author: Mahmut ASIRDIZER (MD) Assoc.Prof.
Associate Professor of Forensic Medicine, Chair, Department of Forensic Medicine, Celal Bayar University, School of Medicine, 45030, Manisa-Turkey. E-mail: masirdizer@yahoo.com
