Keith Hawton, Kees van Heeringen
Lancet 2009; 373: 1372–81 Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK (Prof K Hawton DSc); and Unit for Suicide Research, University Department of Psychiatry, University Hospital, Gent, Belgium (Prof K van Heeringen PhD) Correspondence to: Centre for Suicide Research, University Departmentof Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK firstname.lastname@example.org
Suicide receives increasing attention worldwide, with many countries developing national strategies for prevention. Rates of suicide vary greatly between countries, with the greatest burdens in developing countries. Many more men than women die by suicide. Although suicide rates in elderly people have fallen inmany countries, those in young people have risen. Rates also vary with ethnic origin, employment status, and occupation. Most people who die by suicide have psychiatric disorders, notably mood, substance-related, anxiety, psychotic, and personality disorders, with comorbidity being common. Previous self-harm is a major risk factor. Suicide is also associated with physical characteristics anddisorders and smoking. Family history of suicidal behaviour is important, as are upbringing, exposure to suicidal behaviour by others and in the media, and availability of means. Approaches to suicide prevention include those targeting high-risk groups and population strategies. There are, however, many challenges to large-scale prevention, especially in developing countries.
The estimated global burden of suicide is a million deaths per year,1 and an international policy statement by WHO in response to the large burden2 has prompted many countries to initiate suicide prevention policies. Estimated annual mortality is 14·5 deaths per 100 000 people, which equates to one death every 40 s.1 Self-inﬂicted death accounts for 1·5% of all deaths and is the tenth leadingcause of death worldwide.3 Suicide rates vary according to region, sex, age, time, ethnic origin, and, probably, practices of death registration. In some countries many deaths (eg, 15% in China4) are probably unreported, and procedures for recording deaths as suicide are far from uniform. Countries diﬀer in their death certiﬁcation procedures for unexpected deaths and in their requirements for adeath to be recorded as suicide. Certiﬁcation of the cause of unexpected death is made by diﬀerent bodies, including the police (eg, Finland), physicians (eg, China), coroners (eg, England and Wales), coroners and medical examiners (eg, USA), or equivalent oﬃcials (eg, Procurator Fiscal in Scotland). The requirements for a death to be recorded as suicide also diﬀer, with external evidence of intent,such as a suicide note being required in some countries (eg, Luxembourg); in others a verdict
Search strategy and selection criteria We searched the Cochrane Library, Psycinfo, Medline (January, 2003, to July, 2008), and Embase (January, 2003, to July, 2008). We used the search term “suicide” in combination with the terms “aetiology”, “epidemiology”, “prevention”, and “psychological autopsy”.Index terms were used in preference to free text search terms whenever possible; no language restrictions were applied to the search. We commonly referenced older publications. We also searched the reference lists of articles identiﬁed in this search strategy and selected relevant articles. Reviews and book chapters are cited to provide readers with further reading. Our reference list was modiﬁedon the basis of comments from peer reviewers.
of suicide can be reached on a basis of judgment of intent, as long as there is certainty that the death was self-inﬂicted (eg, England and Wales). The decision about the cause of death will be made in private in most countries where police or physicians are responsible for the verdict and in the case of the Procurator Fiscal in Scotland, although...