The number of suicides is increasing in Brazil, reaching 11 per year.

Andreia Verdélio – reporter for Agência Brasil

Approximately 11 people die by suicide every year in Brazil. According to the first epidemiological bulletin on suicide, released today (21) by the Ministry of Health, between 2011 and 2016, 62.804 people took their own lives in the country, 79% of them men and 21% women. The release is part of the actions of Yellow September, a month dedicated to suicide prevention.

The suicide mortality rate among men was four times higher than that of women between 2011 and 2015. There were 8,7 suicides among men and 2,4 among women per 100 inhabitants.

According to Fátima Marinho, director of the Department of Surveillance of Non-Communicable Diseases and Health Promotion, this number is higher because there is a loss of diagnosis in suicide cases. She explained that in higher social classes there is a taboo surrounding the topic, issues related to life insurance, and diagnoses made by family doctors. "In general, we only detect the death of poorer people because they go to the IML [Forensic Medical Institute]," she explained.

Of the 1,2 million deaths in 2015, 17% had external causes. Of these, 40% are registered as having undetermined causes, according to Fátima. "There are still 6% of deaths where we haven't been able to determine the cause. That's about 10 deaths that were due to external, violent causes, but we don't know why. That's why we have this underdiagnosis of suicide," she said.

In Brazil, the elderly, aged 70 or older, presented the highest rates, with 8,9 suicides per 100 inhabitants, but, according to Fátima, in absolute numbers, the elderly population is increasing. Furthermore, they suffer more from chronic illnesses, depression, and family abandonment. She explains that this high suicide rate among the elderly is observed worldwide.

Data indicates that 62% of suicides were caused by hanging. Other methods used include poisoning and firearms. Fatima explains that in the United States, more suicides are recorded using firearms because access is easier.

The proportion of deaths by suicide was also higher among people who are not in a marital relationship; 60,4% are single, widowed, or divorced, and 31,5% are married or in a stable union. "And married men commit suicide less often. Marriage is a protective factor for men and a risk factor for women," said Fátima, explaining that there is an association between women's suicide attempts and domestic violence. She compares that women attempt suicide more often, and, on the other hand, men report it less, but they are the ones who die by suicide most often.

Between 2011 and 2015, the suicide mortality rate in Brazil was higher among the indigenous population, with 44,8% of indigenous suicides occurring in the 10-19 age group. For every 100 inhabitants, 15,2 deaths were recorded among indigenous people; 5,9 among whites; 4,7 among blacks; and 2,4 deaths among Asians.

For Fátima, the high risk of suicide among indigenous youth jeopardizes the future of these populations, since they also have a high risk of infant mortality.

According to the Special Secretary for Indigenous Health, Lívia Vitenti, there is a high number of indigenous people suffering from alcohol abuse, territorial disputes, and conflicts with family and the non-indigenous population. Among young people, there is a lack of life prospects. However, the problem of indigenous suicide is not distributed throughout the territory, being more frequent among the Guarani Kaiowá, Carajás, and Ticuna peoples.

Suicide attempts

Reporting of self-inflicted injuries became mandatory in 2011, and the number continues to rise. Between 2011 and 2016, 176.226 self-inflicted injuries were reported; 27,4% of them, or 48.204, were suicide attempts.

Suicide attempts are more frequent among women. Of the 48.204 people who attempted suicide between 2011 and 2016, 69% were women and 31% were men. The proportion of repeated suicide attempts is also higher among women. Between 2011 and 2016, of those who attempted suicide more than once, 31,3% were women and 26,4% were men.

The most common method used in suicide attempts was poisoning, at 58%. This was followed by sharp objects, at 6,5%, and hanging, at 5,8%.

Risk and protective factors

Risk factors for suicide include mental disorders such as depression, alcoholism, and schizophrenia; sociodemographic issues such as social isolation; psychological factors such as recent losses; and debilitating conditions such as disfiguring injuries, chronic pain, and malignant neoplasms. However, the Ministry of Health emphasizes that these aspects cannot be considered in isolation and each case must be treated individually.

According to the Ministry of Health, the existence of a Psychosocial Care Center (CAPS) in a municipality reduces the risk of suicide by 14%. In the analysis conducted, it is the only protective factor against suicide. Fátima emphasizes, however, that a better distribution of these centers is needed, especially in areas with a higher concentration of suicides. There are currently 2.463 CAPS in operation in Brazil.

Since suicide rates are high among indigenous people, being indigenous in itself is already a risk factor, explained Fátima. People who work in agriculture, who have access to pesticides, are also vulnerable to committing suicide by poisoning.

Suicides occur in almost every part of the country, but the Southern Region accounted for 23% of suicides between 2010 and 2015. According to Fátima, high income levels, low social inequality, and low poverty rates are characteristics of municipalities that concentrate more suicides.

She explains, however, that in the case of the Southern Region, there is an association between suicide cases and agriculture, specifically tobacco cultivation. According to Fátima, the green tobacco leaf can cause neurological intoxication in those who maintain very close contact with it, "the effect of this intoxication is called 'green tobacco leaf intoxication'."

Furthermore, the pesticide used in this crop contains manganese, which is absorbed and deposited in the central nervous system. Fátima emphasizes, however, that this is an association and that a causal link between this type of pesticide and cases of suicide has not yet been established.

"So we have occupational risk and social and economic pressure on family farmers. It's a combined exposure," said the director. She explained that incentive policies for crop diversification in the south of the country have not had a significant impact because tobacco is still very profitable.

In addition to the Southern Region and indigenous areas, this survey revealed new areas with high suicide rates, namely the border region between São Paulo and Minas Gerais and the state of Piauí. According to Fátima, these locations still require further study, but there is also an association with pesticide use and agriculture.

Global agenda

More than 800 people take their own lives each year worldwide. Therefore, in 2013, the World Health Organization developed a mental health action plan that aims to reduce the suicide rate by 10% by 2020.

The coordinator of Mental Health, Alcohol and Other Drugs, Quirino Cordeiro, said that the government had been promoting actions in the area of ​​suicide prevention, but now it is beginning to implement a policy focused on the issue. One of the strategic actions is the creation of the National Suicide Prevention Plan, to expand actions for vulnerable populations.

According to him, the Ministry of Health wants to expand the network of CAPS (Psychosocial Care Centers), including among the indigenous population, in addition to other mental health care strategies. It is also important to cross-reference maps to identify possible associations between causes of suicide, such as the association with pesticides. Other agencies and ministries will be invited to support future actions.

Quirino explains that suicide prevention policies should focus on two factors: mental disorders and the means of suicide. "We know that among the various factors contributing to suicide is the presence of untreated mental disorders, so having public policies focused on these disorders is important," he said.

Another area of ​​focus is controlling the means of suicide, according to Quirino, which has a significant impact on reducing these deaths. "Often, those who commit suicide are going through serious problems and end up attempting it out of desperation. But if they don't have a method at hand, that moment often passes and the person doesn't go through with it," he said, explaining that gun control is important in Brazil, for example, because restricting access to weapons reduces suicide cases.

Agreement with CVV

The Ministry of Health has partnered with the Center for Life Appreciation (CVV) since 2015, starting with a pilot project in Rio Grande do Sul. The CVV provides emotional support and suicide prevention, offering free and confidential assistance to anyone who wants or needs to talk, 24 hours a day, every day, via phone, email, chat, and VoIP.

The goal of the partnership is to gradually expand free calls to CVV, even from cell phones, through the number 188. In addition to Rio Grande do Sul, starting October 1st, people from eight more states will be able to call the service for free: Acre, Amapá, Mato Grosso do Sul, Piauí, Santa Catarina, Rio de Janeiro, Rondônia, and Roraima.

According to the Ministry of Health, 21% of the Brazilian population resides in the nine states to be served free of charge by CVV, which guarantees broad coverage. The agreement has already increased the number of calls, from 4,5 in September 2015 to 58,8 in August 2017. By 2020, the entire national territory will be able to count on the 188 helpline.

In the remaining states, CVV can still be reached by calling 141 or directly at the regional center. In cities without a CVV center, people can use the chat, Skype, and email services available on the CVV website.

The epidemiological bulletin on suicide is available on the Ministry of Health's website. The ministry also provides guidance materials for journalists, healthcare professionals, and the general public.