Suicide in Hungary-an introduction
Suicide rates are high in large parts of Northern and Eastern Europe, and some of the highest figures have been reported in Hungary [
1,
10]. In addition to psycho-social factors, several lines of evidence indicate genetic and biological contributions to unexpectedly high Hungarian suicide rate [
12]. Within Europe, the countries with the highest suicide rate constitute a contiguous J-shaped belt from Finland through the Baltic countries, Russia, Belarus, and Ukraine to central Europe (Hungary, Slovenia, Austria) [
12]. Genetic similarities observed between populations of these countries led to the Finno-Ugrian suicide hypothesis which states that high suicide rates of these countries are the consequence of a shared genetic susceptibility [
12]. Genetic background of this phenomenon is very probable because other (e.g., cultural/socio-political/economic) features of these countries are quite different. Consonant with the theory about the genetic background of the high suicide rate of Hungary, Hungarian immigrants in the USA have the highest suicide rates of all immigrant groups [
11]. In addition, the existence of an unfortunate genetic/cultural susceptibility of Hungarians to suicidal behavior is further bolstered by the fact that suicide rates of those Romanian counties where the proportions of Hungarian people are high (e.g., Harghita, Covasna, Mures) were much higher than of those counties where the population percentages of Hungarians are low [
13].
Between 1960 and 2000 in the vast majority of years, the suicide rate of Hungary was the highest in the world. The reason of this very high suicide mortality of Hungary is not fully understood. It is one possibility is that the medical examiners in Hungary certify those deaths as suicide which would otherwise be labeled as undetermined death or as death related to other causes. However, the highest suicide rate of Hungarian immigrants in the USA [
11] and the similarly high suicide rate of ethnic Hungarians living in Romania [
13] contradict this possibility. Political or economic causes are also very unlikely, as between 1960 and 1990 the suicide rates of Poland, Bulgaria, Romania, and former Yugoslavia (countries with similar political and economic systems) were around one third of the Hungarian figure, and during the mentioned period, in the majority of the years, the suicide mortality of Denmark, Finland, Austria, and Sweden (with much more advantageous political and economic situations) have been among the top ten in the world. As mentioned above, the most established risk factor(s) of suicide are different forms of (untreated) major affective disorders. Although direct comparison of national epidemiological data on prevalences of affective disorders is not fortunate due to some methodological issues (e.g., different studies have frequently used different diagnostic instruments), it can be said that lifetime prevalence of ‘any’ bipolar disorder, which carries the highest risk of suicide [
14‐
16], is unusually high in Hungary (5.1%) [
17,
18]. Albeit, lifetime prevalence of major depressive disorder according to the DSM-IV criteria in the Hungarian population (15.1%) is similar to the corresponding data from other European countries and the USA, a recent study, assessing depressive symptoms using CES-D in the general population of 23 European countries, reported the highest mean scores in Hungary among all investigated countries [
19,
20]. In summary, these results raise the possibility that high prevalence of affective (especially bipolar) disorders (and possibly also subthreshold manifestations of bipolarity and bipolar spectrum disorders) in the Hungarian population may be one of the most important contributors to the markedly high suicide rate of Hungary.
Looking at European countries with the highest suicide rates 25 years ago (between 20 and 46 per 100,000 per year), the 26%–54% decline in the national suicide rates of Hungary, Denmark, Germany, Austria, Estonia, Switzerland, Sweden, and Finland in the last 2 decades is quite impressive [
3,
10,
21‐
23]. However, given the recent economic crisis, suicide rates are stabilized or show a slight increase in many European countries [
24,
25].
Decreasing suicide mortality in Hungary: what is beyond the figures?
Although the traditionally high suicide rate of Hungary is the second highest in the European community and the fifth to sixth highest in Europe, characteristics of suicidal behavior (gender, age, and urban–rural distribution, method of suicide, marital status, seasonality, rate of psychiatric morbidity) are very similar to those reported from other countries.
In spite of the fact that unemployment and alcohol consumption are well-accepted suicide risk factors [
6,
7,
24,
60], these two indices do not show a strong positive correlation with suicide rate in Hungary between 1992 and 2010. However, a significant positive correlation has been found between tobacco consumption and national suicide rate between 1985 and 2008 [
8], which may reflect that, as demonstrated also by our studies in Hungary, patients with mood disorders smoke much more frequently than members of the general population [
61] and smoking is a suicide risk factor [
6,
62]. Moreover, smokers are significantly more impulsive than nonsmokers [
63,
64], and it is well demonstrated that impulsive-aggressive personality features are powerful predictors of suicidal behavior [
65,
66].
Looking at the problem of suicide from the side of a given individual, there is no doubt that suicidal behavior is the result of the complex interplay between macro-social and personal suicide risk factors, the most powerful of them is current major depression [
3‐
5]. In agreement with international findings, several studies demonstrated the important role of depression in suicidal behavior in Hungary, as we will discuss below. This is particularly important from a practical point of view, as depression is one of most easily amendable suicide risk factor.
Investigating the regional distribution of recognized and treated depressions and suicide rates in 20 regions of Hungary in 1985, 1986, and 1987, the suicide rate showed a significant negative correlation with the rate of treated depressions in each of the 3 years: the higher was the rate of treated depressions and the lower was the suicide rate in the given region. It is also important to note that no such relationship was found regarding treated schizophrenic cases [
42].
In a psychological autopsy study conducted more than 25 years ago in Budapest, we have found that 63% of 200 consecutive suicide victims had current depressive disorders (almost half of them had bipolar depression), 9% schizophrenia, and 8% alcoholism [
14,
67]. More than half of the depressed suicide victims had medical contact during their last depressive episode, but less than 20% of them received antidepressants and/or mood stabilizers [
14]. In a most recent case, control psychological autopsy study in 194 suicide victims and 194 controls in Budapest [
6] we also found that 60% of victims (and 11% of controls) had current affective disorder, 26% of victims (and 38% of controls) had medical contact and 18% of suicides (and 8% of controls) took antidepressants in the last 4 weeks before the suicide or before the interview. This study also identified a number of societal factors that may be important determinants of the suicide risk in individuals. It has been found that lifetime history of psychiatric illness, such as separated/divorced/widowed marital status, lower educational level, unemployment, or long-term sick/disabled status, adverse life events within the previous 3 months, alcoholism, and current cigarette smoking, was significantly more common among suicide victims, while being responsible for a child less than 18 years of age and practicing a religion was significantly less frequent among the victims than among the controls [
6].
Two independent studies on nonviolent suicide attempters (drug overdose or poisoning) in Budapest showed that 69%–87% of the attempters had a current major depressive episode (in many cases with comorbid anxiety and/or substance-use disorders), and unemployment, living alone, and economically inactive status were overrepresented among them [
30,
68]. The strong relationship between suicide attempts and agitated/mixed depression has been also found both in population-based epidemiological [
15] and clinical samples [
69].
While the suicide rate of Hungary showed a steady (46%) decline between 1983 and 2006, most of the ‘post-communist’ countries (e.g., the Baltic States) exhibited decrease in their suicide mortality only from the mid 1990s, several years after the big political/economic changes started around 1990 (the suicide rate of some other ‘post-communist’ countries, e.g., Poland and Romania, has reached its zenith even later (in 2005 and 2000, respectively)) [
2]. On the other hand, however, the greatest decline in national suicide rate on the world (more than 65%) between the mid 1980s and 2010 were detected in Denmark, that is not a typical ‘post-communist’ country [
2]. This shows that political/economic change is probably not the main factor behind this favorable trend. At the same time, between 1983 and 2006, the prescription of antidepressants increased by tenfold. The negative correlation between antidepressant prescription and national suicide rate in Hungary between 1985 and 2011 is well demonstrated in several previously published papers showing that better recognition and more widespread treatment of depressive disorders, as reflected in the increasing antidepressant utilization, seems to be one of the main contributing factors in the markedly declined suicide rate of Hungary in the last 3 decades [
8,
21,
23,
29,
34,
70]. Similarly, a statistically significant correlation between increasing antidepressant utilization and decreasing national suicide rates have been reported recently from several countries [
35,
71], including Sweden, Denmark, Finland, Norway [
3,
72,
73], the USA [
74], Japan [
75] and, as mentioned above, Hungary [
8,
21,
23,
29,
34,
70]. Although ecological association does not mean causality, considering that
1)
there is a strong relationship between untreated major depression and suicide [
5,
76,
77];
2)
the appropriate acute and long-term treatment of patients with major depressive and bipolar disorders markedly reduces the suicide mortality even in this high-risk patient-population [
5,
76,
77] and initially suicidal depressives become nonsuicidal with antidepressant treatment [
5,
78]; and
3)
the annual prevalence of major depressive episode in the population is around 6%–8% [
18,
79].
It is logical to assume that more widespread treatment of depression is one of the main causes of declining suicide rates in countries where antidepressant utilization recently increased markedly. On the other hand, however, as national suicide rates are affected by many known (unemployment, divorce rate, alcohol consumption, living standard, etc.) and unknown factors [
80,
81], the isolation of the result of better treatment of depression in declining suicide rates is not easy.
The increase in antidepressant utilization, as reflected in antidepressant prescriptions, is only a proxy marker of greater access of patients to appropriate care, and higher population density of doctors in general [
82,
83] and psychiatrists and psychotherapists in particular [
21,
22,
83] are negatively associated with national and regional suicide rates. It is likely that many patients receiving antidepressants also receive a prescription of lithium and other mood stabilizers as well as they receive more frequently supportive or specific psychotherapy for depression. Between 1982 and 2000, the number of psychiatrists in Hungary increased from 550 to 850, as well as the number of outpatient psychiatric departments (from 95 to 139), and the number of S.O.S. telephone services (from 5 to 28) [
70]. It should be also noted that between 1990 and 2010, the number of telephones (the best mean for rapid communication even in the case of suicidal crisis) increased by fivefold in Hungary, and recently, the number of ordinary and mobile phones is over 11 million while the population of the country is 10 million. Although it is not possible to measure, it is very likely that the new democratic political system since 1990 (including freedom of religion and several newly founded civil organizations) plays also important role in this favorable process. Therefore, the decrease of suicide rates could reflect a general improvement in mental health care rather than being caused by increasing antidepressant sales alone. The robust increase of antidepressant prescription in Hungary remains the only consistent correlate of declining national suicide rate of Hungary in the last 25–30 years [
8,
21,
23,
34,
70], indicating that better recognition and treatment of depression is one, but not the only, important contributor to this favorable change. On the other hand, however, recently, we have suggested that increasing unemployment rate after 2005 might be one of the contributing factors that accounted for the disappearance of the strong decreasing trend from the Hungarian suicide rate that stabilized around 24/100,000 between 2006 and 2011 [
25]. The exact causes, the role of possible contributory factors as well as the relationship between them remain to be elucidated, yet it seems increasingly obvious that patterns and trends in suicide rates in Hungary are determined by a delicate interplay between various genetic, psychiatric, cultural, economic, political, social, and treatment-related factors specific for Hungary.
In spite of the great decline in the suicide rates of Hungary in recent decades most likely resulting from advancements in Hungarian healthcare well indicating the possibilities for suicide prevention, there is, unfortunately, no centrally directed, government-organized suicide prevention program in Hungary. However, in the last 20–25 years the importance of psychiatric disorders (particularly depression) in suicide and suicide prevention receives more and more attention in the training of medical students, residents, psychiatrists, and general practitioners. These regular trainings are organized by the four medical universities (Budapest, Pécs, Szeged, Debrecen), the Hungarian Psychiatric Association, the Association of Hungarian Neuropsychopharmacologists, and also by pharmaceutical companies. In spite of the fact that the decline of national suicide mortality in Hungary in the last 25 years (46%) is among the greatest decreases in the world, the suicide rate of Hungary is still very high (in 2011, 24.3/100,000), so much remains to be done.
In agreement with the findings of the Swedish Gotland Study [
84], our community-intervention suicide preventive project in the Kiskunhalas region of Hungary (68,000 inhabitants) between 2000 and 2005 showed that education of doctors, other healthcare professionals, and gatekeepers, as well as the public, is an effective method of reducing suicide mortality [
85]. The Hungarian Depression Recognition and Suicide Prevention Program in Szolnok between 2004 and 2006 (as a part of the European Alliance Against Depression program) directed by Maria Kopp also supported the key role of general practitioners and other gatekeepers (psychiatrists, psychologists, telephone help service providers, pharmacists, teachers, pastors, police officers, family nurses, geriatric care providers, etc.) in suicide prevention [
86].
Screening and also medical care for those at increased risk of suicide should be extended from psychiatric practices to all specialities of healthcare, especially to primary care, and primary care providers should not only be qualified to screen for depression and suicide risk, but should also provide subsequent care for previous suicide attempters since previous attempts are among the major risk factors for suicide. Also, in primary care practices, family suicide events, another important risk factor, should also be screened for [
87]. General practitioners are in the best position to detect if multiple important risk factors of the suicide constellation are present in case of their patients and could provide referral to mental health care or counselling services.
As psychosocial and community factors also play an important role in suicidal behavior, it is not only health care workers who are responsible for its prevention. Improving well-being and quality of life of people in general (including decreasing unemployment and providing more support for health and social services), restricting lethal suicide methods (e.g., reducing domestic and car exhaust gas toxicity and introducing stricter laws on gun control), and initiating more restricitve alcohol and smoking policies, which may also reduce suicide mortality [
4,
9,
88,
89], exceed the limits and jurisdiction of health and social care and are rather the leaders’ competence and responsibility at any level of the society. Individual programs developed and implemented in each level of the society, however, need to be coordinated by a unified, government-level central suicide prevention plan. A central prevention plan should appoint possible targets of prediction, prevention, and intervention, at multiple levels and building on multiple groups within the society. The suicide prevention plan should include guidelines for data collection concerning suicide and its risk factors; outline of necessary changes in medical training; training for workers in the social field; and also training for church associated persons as well as teachers and policemen; enhancing scientific research in related fields, tackling ethical, moral, and legal issues related to suicide; and changing legislation if necessary, designing and launching public campaigns, planning enlightenment campaigns, and creating possibilities for interventions in schools. Coordinators at all levels should also be appointed. However, for such a plan to be realized, first awareness concerning the burning issue of suicide in Hungary should be raised not only for the population but also for politicians, legislators, and health/social care decision makers.