Suicide rates and income in São Paulo and Brazil: a temporal and spatial epidemiologic analysis from 1996 to 2008

Abstract

BackgroundIn a classical study, Durkheim noted a direct relation between suicide rates and wealth in the XIX century France. Since that time, several studies have verified this relationship. It is known that suicide rates are associated with income, although the direction of this association varies worldwide. Brazil presents a heterogeneous distribution of income and suicide across its territory; however, evaluation for an association between these variables has shown mixed results. We aimed to evaluate the relationship between suicide rates and income in Brazil, State of São Paulo (SP), and City of SP, considering geographical area and temporal trends.MethodsData were extracted from the National and State official statistics departments. Three socioeconomic areas were considered according to income, from the wealthiest (area 1) to the poorest (area 3). We also considered three regions: country-wide (27 Brazilian States and 558 Brazilian micro-regions), state-wide (645 counties of SP State), and city-wide (96 districts of SP city). Relative risks (RR) were calculated among areas 1, 2, and 3 for all regions, in a cross-sectional approach. Then, we used Joinpoint analysis to explore the temporal trends of suicide rates and SaTScan to investigate geographical clusters of high/low suicide rates across the territory.ResultsSuicide rates in Brazil, the State of SP, and the city of SP were 6.2, 6.6, and 5.4 per 100,000, respectively. Taking suicide rates of the poorest area (3) as reference, the RR for the wealthiest area was 1.64, 0.88, and 1.65 for Brazil, State of SP, and city of SP, respectively (p for trend <0.05 for all analyses). Spatial cluster of high suicide rates were identified at Brazilian southern (RR = 2.37), state of SP western (RR = 1.32), and city of SP central (RR = 1.65) regions. A direct association between income and suicide were found for Brazil (OR = 2.59) and the city of SP (OR = 1.07), and an inverse association for the state of SP (OR = 0.49).ConclusionsTemporospatial analyses revealed higher suicide rates in wealthier areas in Brazil and the city of SP and in poorer areas in the State of SP. We further discuss the role of socioeconomic characteristics for explaining these discrepancies and the importance of our findings in public health policies. Similar studies in other Brazilian States and developing countries are warranted.

Suicide and poverty in low-income and middle-income countries: a systematic review

“…Eight studies [59][60][61][62][63][64][65][66] were of low quality due to problems with risk of bias: performance, attrition and detection bias (interrupted-time series); selection bias, unclear case definitions, detection bias, lack of adjustment for confounding factors (case-control studies); detection bias, lack of adjustment for confounding factors (cross sectional and ecological studies). Table 4 summarises the relationships between SIB and poverty reported in 37 included studies (full details in appendix).…”

“…However, seven studies 33,40,44,45,47,60,66 investigated the relationship between suicide and national income. Three studies using bivariate analysis had mixed results: one 33 positive with the inflation rate in South Africa, one 45 negative with Purchasing Power Parity-adjusted GDP per capita across multiple countries, and one 60 unclear association with GDP per capita in Brazil.…”

Acute suicidal ideation in middle-aged adults from Brazil. Results from the baseline data of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

“…South America presents an historical (however recently increasing (Bando et al, 2012)) low rate of suicide (Hawton and van Heeringen, 2009), which is surprising given that the prevalence of mental disorders in this region seems to be higher than the world average (Bromet et al, 2011), although this can be partly explained by underreporting of suicide (Pritchard and Hean, 2008). Perhaps due to these low rates, data regarding suicide and suicidal ideation and behavior from South American countries are scarce and mainly ecological.…”

Spatial temporal analysis of mortality by suicide among the elderly in Brazil

“…In this context, in a country like Brazil with more than 200 million inhabitants and regions with different socioeconomic and cultural characteristics, the heterogeneous distribution of suicide mortality rates is expected 27 . Historically, the states of the south of the country, specifically Rio Grande do Sul, have the highest suicide rates, with an average of 10.2/100,000 inhabitants in 1980-1999 28 .…”