INSERM Collective Expert Reports. Paris: Institut national de la santé et de la recherche médicale, 2004.
Suicide constitutes a major public health problem. It is a manifestation of self-destructive behavior that results from a crisis situation often not sufficiently recognized by relatives and friends or by the medical profession. It affects all age categories and both sexes. Suicide attempts are at least 10 times more frequent than fatal suicides and repeated attempts are common. According to the World Health Organization, approximately one million people die by suicide worldwide every year, and the phenomenon is constantly and globally on the increase. This plague affects all countries in varying degrees.
The suicide rate varies from 0.5/100,000 in Jamaica to 75.6/100,000 in Lithuania for men and from 0.2/100,000 in Jamaica to 16.8/100,000 in Sri Lanka for women. In France, the estimated number of suicides is about 11,000 per year. This represents 2% of the annual death toll, which is in the upper average relative to other European countries. It is the second cause of mortality among 15–44 year olds after road accidents and the first cause of mortality among 30–39 year olds. Although the proportion of suicides thereafter diminishes significantly with age, the number of deaths by suicide increases markedly. Indeed the rate of fatal suicides is 6 times higher among the aged over 85 than among 15–24 year olds. In 1999, the last year for which prevalence figures are known, suicide rates for the population as a whole were 26.1/100,000 for men and 9.4/100,000 for women. In addition, there are strong geographical discrepancies, with higher suicide prevalence in northwestern regions of France.
Analyzing mortality data enables one to evaluate the suicide situation in a particular country in relation to the rest of the international community or establish the suicide burden among the causes of death of certain population categories, such as teenagers. To do this, gathering statistical data on the population deceased by suicide requires that one takes into account the medical causes of death reported on death certificates. Should suicide not be explicitly mentioned, the prevalence of death by suicide may be underestimated. Sporadic investigations involving medico-legal institutions and conducted by INSERM’s CépiDC (Epidemiological Center for Mortality by Medical Causes) have evaluated that 1998 suicides in France were under-declared by 20%. Suicidal conduct presents a number of very heterogeneous phenotypes. “Suicidal behavior” usually refers to a whole variety of conducts that include suicide “attempts” (defined as an intentional gesture aimed at dying and requiring evaluation or medical treatment) and suicide as such. Suicidal behavior may be classified according to the subject’s intentionality (desire to escape, vengeance, altruistic suicide, risk taking, ordalic behavior, self-sacrifice), suicidal ideation, means of suicide (violent or non-violent), degree of lethality (with or without necessity for intensive care hospitalization), the degree of alteration of cognitive function (aggressive and impulsive behavior), aggravating or triggering circumstances (mental confusion, intoxication, specific sociodemographical context), and the presence of psychiatric or other comorbidities.
Predictability of suicidal action is very uncertain and numerous authors agree to say that it is impossible to draw a precise portrait of the suicidal subject. Nonetheless, various risk factors have been identified over time, in particular by using the technique known as psychological autopsy. This technique is practiced in a number of countries such as Canada, Great Britain and Finland but is still virtually unpublicized in France. The aim is to reconstitute the psychological, social and medical circumstances of death of a person who has committed suicide by collecting data, especially among friends and relatives. This can then be used in research efforts to improve our knowledge of risk factors in suicidal behavior and develop prevention.