The disease burden of suicide in Ecuador, a 15 years’ geodemographic cross-sectional study (2001–2015)

Suicide affects people from different backgrounds, ethnical groups, socio-economic status and geographical locations [1‐3]. Suicide can be defined as any deliberated act by which an individual’s death results directly or indirectly from a self-inflicted injury or poisoning [4, 5]. Suicide is a global health problem, ranking between 4th to 20th cause of mortality for any given region in the world [6, 7]. According to the World Health Organization (WHO),a person commits suicide every 40 s [1]. In 2012, suicide accounted for 1.4% of all deaths worldwide, the majority occurring in low- and middle-income countries [8, 9].

Suicide rates vary across countries, ranging from less than 1 per 100,000 deaths in Saudi Arabia and Belize to more than 40 per 100,000 deaths per year in Guyana or Lithuania [1, 10]. The Global Burden of Disease Group (GBD) reported that in 2013, more than 840,000 people died from self-harm worldwide [7]. According to this report, suicide was the 14th leading cause of years of life lost in the world [7].

Suicide is a multifactorial problem influenced by genetic, psychological, cultural and environmental factors [11].

Several risk factors for suicide have been clearly documented, e.g. male sex, younger age, having a psychiatric disorder such as depression and schizophrenia, hopelessness, marital status, white race, low income, owning firearms, incarceration, job loss and drug abuse [12‐18]. Recently, a positive association between altitude gradient and suicide has been described [19].

It is estimated that about 30% of suicides in the world are committed by poisoning with pesticides, hangings or firearms, and the means of suicide depend greatly on the availability and access to the lethal object used by the person [20, 21].

In Latin America, the highest mortality rate comes from Uruguay; a small country with a little more than three million people reported more than 15 per 100,000 deaths per year from suicide in 2012 [6, 22]. Other countries like Guatemala (2.5/100.000), Venezuela (3/100.000) or Peru (5.8/100.000), reported more lower rates, averaging 3.7 per 100,000 deaths in 2012 [6].

In South America suicide rates change according to cultural, behavioral and socioeconomic factors, however, data availability and under-ascertainment might also contribute to these differences. Adding up all the regional reports, it was estimated that more than 45,800 people commit suicide every year in this region [23].

Data about suicide is still scarce in Latin America, especially in smaller countries like Ecuador. In the last 20 years just very few reports have partially described this phenomenon in the country [24‐26].

The Observatory for Citizen Security in Quito carried out a study on the subject and determined that in 2014 in Ecuador there were 9 suicides per 100,000 inhabitants with similar results in 2015 [27]. The most recent scientific reports on Ecuadorian suicide epidemiology comes from 2011, with two descriptive analyses that offer an interesting demographic analysis of the problem, however, none of those reports included a detailed geodemographic and economic analysis of suicide, years of life lost, disability-adjusted life years (DALY) or risk analysis [24, 26].

In this sense, this document responds to the lack of data about the economic and public health impact of suicide in Ecuador, adding new insights about a problem that has been poorly described in Latin American countries will improve the capacity of policy makers to correctly approach this health problem.

In Ecuador, over a period of 15 years from 2001 to 2015, a total of 13,024 deaths were attributed to self-inflected injuries. Over this time period, suicide rate fluctuated between 4.3 to 7.1 per 100.000. The overall national suicide mortality rate in private and public healthcare systems averaged 7.5 per 100,000 deaths. Men were 3 times more likely than women to die by suicide. The highest rate of suicide was recorded in Carchi province (12.7 per 100,000) and the highlands provinces had higher rates than those located at sea level (9 vs 4.5 per 100.000). For the first time in history, the rate of suicide in 2015 (7.9 per 100,000) surpassed the homicide rate (6.3 per 100,000).

The results from this investigation demonstrate that suicide is one of the most important health issues in Ecuador. Adequate public policy needs to be pursued in order to generate effective public health prevention programs. The results in Ecuador accompany and support the WHO global epidemics [10, 33]. Nearly 13,500 deaths were attributed and officially reported as suicide in the last 15 years in Ecuador, averaging almost 890 deaths per year, with an average suicide rate of 7.1 per 100,000. In Ecuador, men are three times as likely to commit suicide than women; this relationship of 3:1 seems to be within the range described worldwide [10, 22, 34].

Suicide rates vary from region to region, affecting provinces located in the Andean region of Ecuador more than those located at lower altitudes. It is not well understood why this relationship is present in Ecuador, however, other reports have also suggested the positive relationship between altitude and suicide rates [19, 35].

The differences between highland and lowland communities have been well documented and include cultural, physical or socioeconomic variances [27, 36]. Although there is not much research on this subject it is speculated that altitude can increase psychiatric disorders, mood changes, risk of depression and risk to develop stroke [37‐40]. Greater access to firearms, isolation or reduced income have also been implicated as possible causes [35]. In Ecuador, high altitude provinces have more presence of indigenous groups than those provinces located at the coast. According to the latest National Census, this vulnerable population has less access to proper housing, education and health care [41]. The World Report on Violence and Health in 2002 found that suicide rates have increased among indigenous people [42]. Among the proposed risk factors, cultural differences, discrimination, poor adaptation to urban lifestyles, poverty and limited health access were identified [42, 43]. In this sense, Carchi and Azuay, two of the provinces with the highest suicide rates experienced a massive emigration from their young adults to the US and Europe in the year 2000 [44]. Immigration patterns are variables that increase the risk of suicide due to the apparition of broken families and children that were raised alone, make this group particularly vulnerable to depression, drug abuse and probably higher risk of suicide [45‐47]. On the other hand our results might indicate that living at high altitude could be considered a non-traditional risk factor, although the effect of hypoxia on suicidal thoughts or behavior has not been demonstrated yet, a slightly higher relative risk of committing suicide was demonstrated among high altitude dwellers when compared to those located at lower altitudes [19, 35].

Among Andean countries, Ecuador has the second highest suicide rate, ahead of Colombia (6.1/100.000) and Peru (5.8/100.000) and behind Bolivia (18.7/100.000) [6, 22]. The reasons of this situation are not well understood; multifactorial risk factors might contribute to these differences among similar countries, and there may also be methodological differences in data collection and registering death causes.

It is not clear why some countries within the same region have significantly different suicide rates [6]. The World Health Organization reports that from the 800,000 people committing suicide each year, 50% are from China and India, and the highest rates reported were from Guyana, Lithuania, Hungary and South Korea [21, 33, 48]. Other countries including Saudi Arabia, Syria, Jordan, Nepal and Jamaica reported some of the lowest rates worldwide [49, 50].

The data from rural and urban areas showed different characteristics regarding the means of the suicidal act [51]. The incidence of suicide between rural and urban areas varies around the world due to their cultural, socioeconomic and geographical particularities [52]. In Ecuador, most of the reports come from the cities, more than doubling the cases from rural communities. Social stress factors such as high unemployment rates, social isolation, divorce, drug abuse, excessive working and negative chronobiological or physical working conditions have been identified as risk factors in the urban area [53‐56]. Emotional conflicts occur in both rural and urban areas, but due to cultural and economic features, divorce as a reason for suicide is less frequent among the rural communities [57]. It has also been hypothesized that longer night shifts and busier lifestyles in urban areas can increase the risk of suicide [58]. There has been very little research on the effect of urbanization on the incidence of suicide. It has been identified that women perform more suicidal acts in urban areas than men, which may be due to job-related factors (quality, opportunity for promotions, etc.) and also vulnerability living in large cities [59].

It is not yet clear why men commit suicide more than women, despite knowledge that suicidal thoughts are more common in women than men, this proportion is observed across cultures. Certain factors have been identified that influence the suicide rate in men [60, 61]. For instance, the gender gap and the social pressure that is exerted on men because the image is generally linked to family support, which can cause economic failure to have a stronger negative impact on men. In Ecuadorian culture, men are commonly perceived or expected to be the primary head of household or even the family’s unique livelihood. They are expected to earn more than women counterparts so often times economic failure and feelings of inability to support one’s family can create an insurmountable pressure [62].

According to available literature, the means by which a man takes his own life appear to be more violent than those means utilized by women [17, 63]. In Ecuador, men use more violent methods than women, including death by firearms, hanging and sharp objects (Fig. 4). Interestingly, the landscape of means of suicide in Ecuador have changed in the last 15 years. Firearms used to account for 15% of the total causes of suicide in 2001, however in 2015, this number dropped to 5% (Fig. 5). This important reduction might be a consequence of better gun control and stronger national safety policy in Ecuador in the last 10 years [64]. For the first time ever in 2015 homicide rate dropped below the suicide rate, This trend might also be related with an important reduction in crime reported in Ecuador in the last years since suicide did not changed dramatically in the last 15 years. [65, 66].

An alarming discovery is that among adolescent women, suicide is the main cause of death, including all violent and non-violent causes. In the last years suicide has become a major public health problem among adolescents, specially in developed countries like the US [67]. Data from other countries shows that men adolescents are 2.6 times more likely to commit suicide than adolescent women [68]. In Ecuador, the proportion of suicide among adolescents account for more than 12% of the total causes of deaths, being this number higher in women (17%) than in men (10%). Similar reports have been published in other countries, showing that proportions are useful tools when estimating the impact of suicide among all other causes of the unnatural Death [69].

Suicide is usually preventable, especially in health systems where mental health services are readily available [70]. These preventable deaths need to be addressed to public health policy makers in order to plan and implement suicide prevention programs with a special focus on high-risk groups such as young adolescents women and single young men. Despite the fact that from 2001 to 2015 suicide rates in Ecuador were fairly stable, the health system and economic impacts are highly concerning due to premature mortality. Ecuador reported 4421 deaths registered as suicide, and the total years of healthy life lost exceeded 135,731 years. Using the human capital method, in 2001–2015 period, the total economic loss due to suicide was estimated to be $852.6 million international dollars (year 2010 base), almost 1% of the Ecuadorian gross domestic product (GDP) for 2015 [65].

This geodemographic study is the first of its kind in exploring the complete burden of suicide in Ecuador and its economic impact over the local health and productive system. In the last 15 years of available data, nearly 13,500 deaths were officially registered as suicide, putting the country above the regional average with a suicide rate of 7.1 per 100,000. Suicide largely is taking the life of younger people; especially adolescent women signifies that gender inequality may be a contributing factor. Some of the possible causes of higher suicide rate among younger people can be explained by chronic stressors such as family dysfunction, school failure, sexual abuse, alcohol, drug use and immigration patterns.

Despite the fact that some of the means of suicide has changed over time, the annual rate of suicide has not varied significantly in the last 15 years. In fact, while other means like firearms and pesticide consumption decreased in the last few years, hangings have increased over time.

Suicide seems to be more prevalent in high altitude provinces when compared to provinces at lower altitudes, however, this relationship does not demonstrate causality and further research is needed. Although this data is important, the analysis of risk factors and behavioral problems need to be addressed at a deeper level future studies.

The results of this study will provide an insight into the needs of authorities with regard to prevention programs and contributed to our understanding of suicide in Andean countries where information is scarce. Furthermore, it contributes to create the baseline data in order to publish guidelines for those involved in the medical practice of suicide specially those who are in charge of adolescents’ school-based education programs and gender inequality policies.