Epidemiology of suicide: from population to single cases

The new millennium was inaugurated with pessimistic figures on the epidemiology of suicide for years to come.Based on the collections of mortality rates from the World Health Organization (WHO), it was proposed that the one million deaths from suicide registered annually worldwide could rise to 1.56 million deaths annually by the year 2020 (Bertolote and Fleischmann, 2002).Such reports also showed the dramatic changes among year-groups, pointing to an increase in suicide rates among youths and young adults compared with people over the age of 45 years, who were the majority in the 1950s.As the years passed, such figures had to be corrected and there was a resizing of the original projections, with a reduction of suicide deaths worldwide (Bertolote and De Leo, 2012).In 2014, WHO (World Health Organization, 2014) released a comprehensive analysis of suicides in the world and indicated that 880 000 suicide deaths were registered annually.Of note, this report, which was awaited for some years, proposed basic but fundamental elements for suicide prevention, such as the difference between myths and fact about suicide.Such notions are well-known to suicidologists but are often neglected both in healthcare and among laypeople.For instance, a myth is 'Only people with mental disorders are suicidal', whereas the fact is 'Suicidal behaviour indicates deep unhappiness but not necessarily mental disorder.Many laypeople living with mental disorders are not affected by suicidal behaviour, and not all people who take their own lives have a mental disorder'; another myth is 'Most suicides happen suddenly without warning', whereas the fact is 'The majority of suicides have been preceded by warning signs, whether verbal or behavioural.Of course, there are some suicides that occur without warning.But it is important to understand what the warning signs are and look out for them.'Another major contribution to this report is the identification of key risk factors for suicide (factors related to society, community, relationships and the individual), which are aligned with the relevant interventions.Of note is the fact that mental disorders appear among many other circumstances and are also listed as individual risk factors.In the international literature, variables that may impact on individuals with different emphasis are generally left out of any discussion.New understanding of suicidal behaviour is now leading research beyond the statement that 90% of suicides were due to mental disorders.Incidentally, the phenomenon of suicide is much more complicated than the attribution of risk to a given disorder.It is more likely to be the result of a drama occurring in different ways for each unique individual.Therefore modern psychiatry is now changing such a paradigm and a different approach must be considered when it comes to suicide prevention, in line with recent epidemiological data.For instance, The Italian National Institute of Statistics (ISTAT, 2017) conducted a study on suicide in the Italian population for the 3 years 2011-2013, evaluating the presence of any physical or mental disorders.In the period considered there were 12,877 suicides (of which 10,065 were men), and about one in five suicides had significantly associated morbidities.In particular, in 737 suicides, the presence of relevant physical diseases was documented, of which 288 had a comorbid mental disorder.In 1664 cases, the study reported the presence of mental disorders without comorbidity from relevant organic diseases.However, in more than 80% of the cases, there were neither mental disorders nor relevant physical illnesses.Similarly, the Centers for Disease Control and Prevention in the USA (CDC) found a 30% increase in suicides across all age groups up to age 75 years between 1999 and 2016, indicating that about 54% of cases in 2015 were not associated with any mental disorder (Stone et al., 2018).Some scholars suggest that people with no psychiatric diagnosis did not have any chance to be assessed by mental health services.Nevertheless, the CDC has launched an information campaign to shed light on suicide, pointing to contributing factors other than mental illness (https:// www.cdc.gov/vitalsigns/suicide/index.html).They emphasised that any single factor rarely causes suicide and that the role of relationship problems, substance misuse, recent crisis and job, financial or legal stress should be taken into consideration.Such conclusions had been proposed much earlier by scholars who estimated that effective treatment of the psychiatric disorders commonly associated with suicide risk would have reduced suicide rates by only a small degree (Bertolote et al., 2003(Bertolote et al., , 2004)).These authors suggested broader evaluation of factors associated with such a risk and the implementation of several suicide prevention strategies.