title: What Are Reasons for the Large Gender Differences in the Lethality of Suicidal Acts? An Epidemiological Analysis in Four European Countries.
abstract: BACKGROUND
  In Europe, men have lower rates of attempted suicide compared to women and at the same time a higher rate of completed suicides, indicating major gender differences in lethality of suicidal behaviour. The aim of this study was to analyse the extent to which these gender differences in lethality can be explained by factors such as choice of more lethal methods or lethality differences within the same suicide method or age. In addition, we explored gender differences in the intentionality of suicide attempts.
  
  
  RESULTS
  Methods. Design: Epidemiological study using a combination of self-report and official data. Setting: Mental health care services in four European countries: Germany, Hungary, Ireland, and Portugal. Data basis: Completed suicides derived from official statistics for each country (767 acts, 74.4% male) and assessed suicide attempts excluding habitual intentional self-harm (8,175 acts, 43.2% male). Main Outcome Measures and Data Analysis. We collected data on suicidal acts in eight regions of four European countries participating in the EU-funded "OSPI-Europe"-project (www.ospi-europe.com). We calculated method-specific lethality using the number of completed suicides per method * 100 / (number of completed suicides per method + number of attempted suicides per method). We tested gender differences in the distribution of suicidal acts for significance by using the χ2-test for two-by-two tables. We assessed the effect sizes with phi coefficients (φ). We identified predictors of lethality with a binary logistic regression analysis. Poisson regression analysis examined the contribution of choice of methods and method-specific lethality to gender differences in the lethality of suicidal acts.
  Suicidal acts (fatal and non-fatal) were 3.4 times more lethal in men than in women (lethality 13.91% (regarding 4106 suicidal acts) versus 4.05% (regarding 4836 suicidal acts)), the difference being significant for the methods hanging, jumping, moving objects, sharp objects and poisoning by substances other than drugs. Median age at time of suicidal behaviour (35-44 years) did not differ between males and females. The overall gender difference in lethality of suicidal behaviour was explained by males choosing more lethal suicide methods (odds ratio (OR) = 2.03; 95% CI = 1.65 to 2.50; p < 0.000001) and additionally, but to a lesser degree, by a higher lethality of suicidal acts for males even within the same method (OR = 1.64; 95% CI = 1.32 to 2.02; p = 0.000005). Results of a regression analysis revealed neither age nor country differences were significant predictors for gender differences in the lethality of suicidal acts. The proportion of serious suicide attempts among all non-fatal suicidal acts with known intentionality (NFSAi) was significantly higher in men (57.1%; 1,207 of 2,115 NFSAi) than in women (48.6%; 1,508 of 3,100 NFSAi) (χ2 = 35.74; p < 0.000001).
  Due to restrictive data security regulations to ensure anonymity in Ireland, specific ages could not be provided because of the relatively low absolute numbers of suicide in the Irish intervention and control region. Therefore, analyses of the interaction between gender and age could only be conducted for three of the four countries. Attempted suicides were assessed for patients presenting to emergency departments or treated in hospitals. An unknown rate of attempted suicides remained undetected. This may have caused an overestimation of the lethality of certain methods. Moreover, the detection of attempted suicides and the registration of completed suicides might have differed across the four countries. Some suicides might be hidden and misclassified as undetermined deaths.
  
  
  CONCLUSIONS
  Men more often used highly lethal methods in suicidal behaviour, but there was also a higher method-specific lethality which together explained the large gender differences in the lethality of suicidal acts. Gender differences in the lethality of suicidal acts were fairly consistent across all four European countries examined. Males and females did not differ in age at time of suicidal behaviour. Suicide attempts by males were rated as being more serious independent of the method used, with the exceptions of attempted hanging, suggesting gender differences in intentionality associated with suicidal behaviour. These findings contribute to understanding of the spectrum of reasons for gender differences in the lethality of suicidal behaviour and should inform the development of gender specific strategies for suicide prevention.
authors.affiliation: Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Saxonia, Germany.
authors.forename: Roland
authors.initials: R
authors.lastname: Mergl
authors.affiliation: Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Saxonia, Germany.
authors.forename: Nicole
authors.initials: N
authors.lastname: Koburger
authors.affiliation: Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Saxonia, Germany.
authors.forename: Katherina
authors.initials: K
authors.lastname: Heinrichs
authors.affiliation: Institute of Behavioral Sciences, Semmelweis University Budapest, Budapest, Hungary.
authors.forename: András
authors.initials: A
authors.lastname: Székely
authors.affiliation: Institute of Behavioral Sciences, Semmelweis University Budapest, Budapest, Hungary.
authors.forename: Mónika Ditta
authors.initials: MD
authors.lastname: Tóth
authors.affiliation: Department of Health Psychology, University Medical Center, Groningen, the Netherlands.
authors.forename: James
authors.initials: J
authors.lastname: Coyne
authors.affiliation: CEDOC, Department of Psychiatry and Mental Health, Universidade Nova de Lisboa, Lisbon, Portugal.
authors.forename: Sónia
authors.initials: S
authors.lastname: Quintão
authors.affiliation: National Suicide Research Foundation and Department of Epidemiology and Public Health, University College Cork, Cork, Ireland.
authors.forename: Ella
authors.initials: E
authors.lastname: Arensman
authors.affiliation: National Suicide Research Foundation and Department of Epidemiology and Public Health, University College Cork, Cork, Ireland.
authors.forename: Claire
authors.initials: C
authors.lastname: Coffey
authors.affiliation: Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, Scotland, United Kingdom.
authors.forename: Margaret
authors.initials: M
authors.lastname: Maxwell
authors.affiliation: Estonian-Swedish Mental Health and Suicidology Institute and Tallinn University, Tallinn, Estonia.
authors.forename: Airi
authors.initials: A
authors.lastname: Värnik
authors.affiliation: LUCAS Center for care research and consultancy at Katholieke Universiteit Leuven, University of Leuven, Leuven, Belgium.
authors.forename: Chantal
authors.initials: C
authors.lastname: van Audenhove
authors.affiliation: London School of Economics, London, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: McDaid
authors.affiliation: Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy, National Institute for Health, Migration and Poverty, Rome, Italy & University "Gabriele d'Annunzio" Foundation, Chieti, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Sarchiapone
authors.affiliation: Department of Psychiatry, Psychosomatics and Psychotherapy, Universität Würzburg, Würzburg, Germany.
authors.forename: Armin
authors.initials: A
authors.lastname: Schmidtke
authors.affiliation: Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.
authors.forename: Axel
authors.initials: A
authors.lastname: Genz
authors.affiliation: Department of Psychiatry and Mental Health, CEDOC, Universidade Nova de Lisboa & ISPUP, Institute of Public Health, University of Porto, Porto, Portugal.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Gusmão
authors.affiliation: Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Saxonia, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Hegerl
mesh_terms: D016021:Epidemiologic Studies; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D012737:Sex Factors; D013405:Suicide