Section 1
Chapter
Global epidemiology of suicide
2 Pedro Ruiz
Introduction
Suicidal behavior certainly presents a major challenge to
humanity in all regions of the world. For centuries, the
phenomenon of suicide has been studied and examined
at all levels of sciences, and still is a major dilemma for
scientists and researchers (Nock et al., 2012a). Over the
years, suicidal behavior has definitely called the attention
of researchers, clinicians, and philosophers (Durkeim,
1951; World Health Organization, 2009). Recently, the
World Health Organization (WHO) has decided to look
at this phenomenon and is currently attempting to
understand it, and address it from a comprehensive
point of view. Indeed, suicide worldwide has already
become a major player as an important contributor to
the global burden of disease in every respect.
It is within this context that we decided to assess
the phenomenon of suicide from a global point of
view, focusing on an epidemiological perspective.
A United States perspective
In the USA alone, 11 persons in every 100 000 complete
suicide annually; additionally, in the USA 193 persons
suffering from bipolar and other mood disorders also
kill themselves in every 100 000 persons (Simon &
Hales, 2006). There is no evidence that “suicide con-
tracts” are honored by the patients and, thus, it has no
impact on the number of suicides that take place
(Simon, 2006). Several factors are well known to
increase suicide, among them, the presence of person-
ality disorders (Linelman et al., 2000); in this population
group, there is a seven times greater risk for suicide than
in the general population (Harris & Barraclough, 1997).
In the USA, there are significant racial differences with
respect to suicidal behavior: Native Americans have the
highest rates of completed suicide, followed by Whites.
African Americans have the lowest suicide rates; how-
ever, in recent years the African American suicide rate,
A Concise Guide to Understanding Suicide, ed. Stephen H. Koslow, Pedro Ruiz, and Charles B. Nemeroff. Published by
Cambridge University Press. © Cambridge University Press 2014.
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particularly among the African American youth, is
increasing (Gould et al., 2003). The focus on “youth”
in the USA is more intense than the focus on older
adults. The predominant cultural values are youth,
beauty, and a vigorous lifestyle; however, the highest
rate of suicide is observed among older adults
(US Public Health Service, 2001).
Males commit suicide at a rate three to four times
greater than females (Simon, 2006), and the highest
suicide rates for women occur among White females in
the age range 40 to 44 years old (Moscicki, 1999). Despite
the low rates of suicide among women in the USA, they
tend to have two of the most significant suicide risk
factors, that is, depression and suicide attempts.
A worldwide perspective
More than one million people died in 2000 worldwide
due to suicide. Despite the fact that most people who
commit suicide suffer from a mental illness, suicide
tends to occur during periods of social, economic, fam-
ily, and individual crisis (Horton, 2006). On many occa-
sions, even if persons who commit suicide suffer from
mental illness, especially depression and/or substance
abuse, the basic issues related to the suicidal behavior
are tied to social, cultural, economic, family, and/or
individual crisis (Delgado & Ruiz, 1985; GAP, 1989).
Unquestionably, suicidal behavior is a leading
cause of injury and death at a worldwide level and,
thus, addressing the epidemiology of such behavior is
very important from a policy-making viewpoint.
Approximately one million people worldwide die by
suicide, thus making it one of the leading causes of
death (Nock et al., 2012b).
Worldwide, suicide was ranked the 14th leading
cause of death globally in 2002, and is projected to
increase by 50% and become the 12th leading cause of
death by year 2030 (Mathers & Loncar, 2006). Despite
the fact that an association between early childhood
13
 Section 1: Understanding Suicide

abuse and later suicidal behavior has been reported in 100 000 persons, by country, year, and sex are as fol-
several studies (Stein et al., 2012), this assumption has lows (World Health Organization, 2011):
not been confirmed as yet (Bradsky & Stanley, 2008).
With respect to Latin America and the Caribbean, Country Year Males Females
it has been historically reported that the level of suicide Albania 2003 4.7 3.3
is lower than that in the rest of the world, especially Antigua and Barbuda 1995 0.0 0.0
when compared with European countries. It is impor-
Argentina 2008 12.6 3.0
tant to note that the suicide rate data for Latin America
are recent. Levels of suicide tend to fluctuate among Armenia 2008 2.8 1.1
the countries of Latin America (Kohn & Friedman, Australia 2006 12.8 3.6
2009), and thus, additional research efforts are needed Austria 2009 23.8 7.1
in this area. Azerbaijan 2007 1.0 0.3
It should be noted, however, that quite a few stud-
Bahamas 2005 1.9 0.6
ies on migration and suicide that focus on Mexican
Bahrain 2006 4.0 3.5
and Mexican-American populations have been con-
ducted in recent years (Ruiz, 1995, 1996a, b). In gen- Barbados 2006 7.3 0.0
eral, the suicide rate is lower in Mexico but it increases Belarus 2007 48.7 8.8
among Mexican-American migrants who settle in the Belgium 2005 28.8 10.3
USA as they become acculturated to the prevailing
Belize 2008 6.6 0.7
Anglo-Saxon culture.
Bosnia and 1991 20.3 3.3
One recent publication has focused on the topic of Herzegovina
suicide in Latin America. It focuses on all key aspects
Brazil 2008 7.7 2.0
of suicide in Latin American (Martinez et al., 2009),
A recent publication in Latin America primarily Bulgaria 2008 18.8 6.2
focuses on suicide among Latin American women, Canada 2004 17.3 5.4
addressing important areas such as the role of the Chile 2007 18.2 4.2
Hispanic family, the evolution from childhood to adult- China (Selected Rural & 1999 13.0 14.8
hood, and preventive aspects with regard to suicidal Urban Areas)
behavior among Latin American women. Cultural China (Hong Kong) 2009 19.0 10.7
aspects, the impact of substance abuse, the role of psy-
Colombia 2007 7.9 2.0
chotherapy, and family dynamics are discussed (Zayas,
Costa Rica 2009 10.2 1.9
2011).
Another recent book published in 2009 Croatia 2009 28.9 7.5
(Wasserman & Wasserman, 2009) offers an extensive Cuba 2008 19.0 5.5
“global perspective” on suicide and suicide prevention. Cyprus 2008 7.4 1.7
This text offers a worldwide understanding of the most Czech Republic 2009 23.9 4.4
important aspects of suicidal behavior and suicide
Denmark 2006 17.5 6.4
prevention, discussing the role of religion and culture,
and includes theories of suicidal behavior, its political Dominican Republic 2005 3.9 0.7
determinants, socioeconomic aspects, clinical and bio- Ecuador 2009 10.5 3.6
logical measures, public health components, and pre- Egypt 2009 0.1 0.0
ventive strategies. El Salvador 2008 12.9 3.6
Another recent book focuses on the preventive
Estonia 2008 30.6 7.3
aspects of suicide, including its clinical assessment
and management (Simon, 2011). Finland 2009 29.0 10.0
France 2007 24.7 8.5
Georgia 2009 7.1 1.7
An epidemiological perspective Germany 2006 17.9 6.0
In accordance with the World Health Organization
Greece 2009 6.0 1.0
(WHO) 2011 suicide data, the rates of suicide per

14
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 Chapter 2: Global epidemiology of suicide

Country Year Males Females Country Year Males Females

Grenada 2008 0.0 0.0 Saint Kitts and Nevis 1995 0.0 0.0
Guatemala 2008 5.6 1.7 Saint Lucia 2005 4.9 0.0
Guyana 2006 39.0 13.4 Saint Vincent and the 2008 5.4 1.9
Grenadines
Haiti 2003 0.0 0.0
Sao Tome and Principe 1987 0.0 1.8
Honduras 1978 0.0 0.0
Serbia 2009 28.1 10.0
Hungary 2009 40.0 10.6
Seychelles 2008 8.9 0.0
Iceland 2008 16.5 7.0
Singapore 2006 12.9 7.7
India 2009 13.0 7.8
Slovakia 2005 22.3 3.4
Iran 1991 0.3 0.1
Slovenia 2009 34.6 9.4
Ireland 2009 19.0 4.7
South Africa 2007 1.4 0.4
Israel 2007 7.0 1.5
Spain 2008 11.9 3.4
Italy 2007 10.0 2.8
Sri Lanka 1991 44.6 16.8
Jamaica 1990 0.3 0.0
Suriname 2005 23.9 4.8
Japan 2009 36.2 13.2
Sweden 2008 18.7 6.8
Jordan 2008 0.2 0.0
Switzerland 2007 24.8 11.4
Kazakhstan 2008 43.0 9.4
Syrian Arab Republic 1985 0.2 0.0
Kuwait 2009 1.9 1.7
Tajikistan 2001 2.9 2.3
Kyrgyzstan 2009 14.1 3.6
Thailand 2002 12.0 3.8
Latvia 2009 40.0 8.2
Tfyr Macedonia 2003 9.5 4.0
Lithuania 2009 61.3 10.4
Trinidad and Tobago 2006 17.9 3.8
Luxembourg 2008 16.1 3.2
Turkmenistan 1998 13.8 3.5
Maldives 2005 0.7 0.0
Ukraine 2009 37.8 7.0
Malta 2008 5.9 1.0
United Kingdom 2009 10.9 3.0
Mauritius 2008 11.8 1.9
United States of 2005 17.7 4.5
Mexico 2008 7.0 1.5 America
Netherlands 2009 13.1 5.5 Uruguay 2004 26.0 6.3
New Zealand 2007 18.1 5.5 Uzbekistan 2005 7.0 2.3
Nicaragua 2006 9.0 2.6 Venezuela 2007 5.3 1.2
Norway 2009 17.3 6.5 Zimbabwe 1990 10.6 5.2
Panama 2008 9.0 1.9
Paraguay 2008 5.1 2.0
Peru 2007 1.9 1.0
Conclusion
Philippines 1993 2.5 1.7
We addressed many important aspects of “suicidal
Poland 2008 26.4 4.1 behavior” and its “prevention”. In so doing, we focused
Portugal 2009 15.6 4.0 this very important clinical topic from a global point of
Puerto Rico 2005 13.2 2.0 view. This approach addresses key issues, such as cultural
Republic of Korea 2009 39.9 22.1
aspects, as well as religious, ethnic, racial, language,
and other culturally related factors; additionally, socio-
Republic of Moldova 2008 30.1 5.6
economic factors; age aspects; gender differences; clinical
Romania 2009 21.0 3.5 considerations, preventive approaches, public health
Russian Federation 2006 53.9 9.5 perspectives, educational interventions, factors related

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 Section 1: Understanding Suicide
to families, health-related factors, and political consider-
ations. Additional details are featured in the following
sections of this book.
In so doing, we focused on the most relevant and
recent literature related to this topic, with an empha-
sis on the global aspects of suicidal behavior and
suicide prevention. It is our expectation that this
chapter will positively add to our efforts in prevent-
ing suicidal behavior and effectively address suicide
attempts.
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