Suicides in two Scandinavian capitals — A comparative study

Forensic Science International 80 (1996) 211-219

ELSEVIER

Forensic Science lnterndii

Suicides in two Scandinavian capitals comparative study

A

Sidsel Rogde”‘“, Hans Petter Hougenb, Klaus Poulsenb ‘Institute

“Institute of Forensic Medicine, University of Oslo, Oslo, Norway of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark

Received 22 December 1995; accepted 2 February 1996

Abstract Suicides from the city and county of Copenhagen, Denmark, and from the two police districts Oslo and Asker and BErum, Norway, two comparable Scandinavian capital populations, were studied with regard to age, gender, suicide methods, marital status, nationality, month of year, somatic and psychiatric disease, previous suicidal attempts or suicidal threats, and suicide location. The incidence of suicides was higher in the Copenhagen material than in the Oslo material. In both cities the preferred method was intoxication by prescription drugs. In Copenhagen suffocation by means of a plastic bag was a frequently used method, while the Norwegians more often hanged or shot themselves. While hanging was very uncommon among the Copenhagen females, this was not the case in the Oslo population. Both materials had a male preponderance. Attention is also drawn to the well known phenomenon that the suicide rate may increase due to publicity about a suicide method. Keywords:

Suicide; Method; Capitals; Comparison

1. Introduction Denmark and Norway are two closely related Scandinavian countries. They share a great part of their history and there is little difference between the languages. Both countries have a well developed social welfare system with free *Corresponding author. Rettsmedisinsk institutt, Rikshospitalet, N-0027 Oslo, Norway. Tel.: +47 22 86 86 63; fax: +47 22 20 95 83. 0379-0738/96/$15.00 @ 1996 Elsevier Science Ireland Ltd. All rights reserved PZI SO379-0738(96)01918-4

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education and health care, and a high standard of living. The two countries are economically well consolidated small constitutional monarchies with multiparty Cabinet responsibility. Thus, the Danish and Norwegian populations are in many respects comparable. However, the way of life in the rural districts is rather different in the two Scandinavian countries. The city dwellers, and especially the populations in the two capitals, Copenhagen and Oslo, however, have comparable socioeconomic structures, the main difference being that the Copenhagen population is approximately twice as large as the Oslo population. We therefore wanted to investigate similarities and dissimilarities concerning various aspects of suicide in these two comparable populations. 2. Materials

and methods

All police and autopsy reports on suicides from Asker and Bzerum and from Oslo police districts from the year 1993 were reviewed retrospectively. In the same manner, all death certificates concerning suicides from the county of Copenhagen (including the city) in 1993 were reviewed. These wer : all death certificates issued on the premises of the Institute of Forensic Medicine on request of the police. In some casesthere were also autopsy reports which were reviewed. The following data were registered in each case: Gender, age, method (drug intoxication, carbon monoxide poisoning, other intoxication, hanging, gunshot, sharp injuries, burning, train, car, fall from a height, suffocation by means of a plastic bag, drowning, other), marital status (married or cohabitant, divorced, widowed, single, unknown), nationality, death month, psychiatric illness, previous suicidal behaviour or suicidal threats, somatic disease, and suicide location (at home, at work, hotel, hospital, prison, outdoor, other). Data concerning the general populations of the two cities were collected from the national bureaus of statistics in the two countries (Statistics Denmark and Statistics Norway, respectively). 3. Results

3.1. Population statistics In 1993, the population of Oslo and Asker and Barum was 612 366 (middle figure, Statistics Norway). The female proportion was 52%. Up to the age of 55-60, there were approximately equal amounts of males and females; the female proportion then rose gradually up to the age of 80 and above, where the female/male (F/M) ratio was 3.1:1; 18% of the Oslo population were below the age of 16; 67% between 16 and 66 and 1.5% above the age of 67. The 1993 population in the county of Copenhagen was 1 178 334 (middle figure, Statistics Denmark). Fifty percent were female. The percentage of females

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exceeded 50 in the age group 50-55 and rose gradually up to 80 and above where the F/M ratio was 2.7:1; 17% were 16 or younger, 66% between 17 and 65 and 17% above the age of 65. These data display a very similar age and sex distribution in the two populations. 3.2. Age and gender

The Norwegian suicide material, hereafter called the Oslo material, consisted of 89 individuals, 55 males and 34 females (M/F = 1.6:1). The Danish material, hereafter called the Copenhagen material, totalled 292; 168 males and 124 females (M/F = 1.4:1). The age distribution in the two materials is shown in Fig. 1. While the distribution among the age groups in the Oslo material was relatively even for both sexes, there was a tendency in the Copenhagen material towards a higher suicide incidence among elderly women. 3.3. Suicide methods

In both materials the method of choice was intoxication with prescription drugs. This method was used by 30% of the Danes (M/F = 0.6:1) and 26% of the Norwegians (M/F = 0.8:1). In the Oslo material 25% hanged themselves, while only 17% in the Copenhagen material used that method. Among the Danes who hanged themselves there was a huge male preponderance (M/F = 7.1:1), while the M/F ratio was 2:l among the Norwegians.

;o

Fig. 1. Diagrammatic females.

20 39

40 66

60 76

presentation

a 76

m

of the age distribution

:o

20 36

40 66

among the Copenhagen

60 79

> 76

fw

and Oslo males and

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Suicide by shooting was seen far more often among the Norwegian victims than among the Danish victims: 19% of the Norwegians had shot themselves but only 4.5% of the Danes. There was only one female victim (Norwegian). While 19% of the Danes chose suffocation by pulling a plastic bag over their heads, this method was not seen in the Oslo material. The M/F ratio was 0.7:1. There were 20 drownings in the total material, 10 in each population (3.4% of the Danes and 11.2% of the Norwegians). All the drowned Danes were females, while there were four males and six females among the Norwegians. A summary is given in Fig. 2. 3.4. Marital

status

One-hundred twenty-one of the victims were registered as married or cohabitant, i.e. 32% of the total material (Copenhagen males (MD): 31%, Copenhagen females (FD): 28%) Oslo males (MN): 40%, Oslo females (FN): 35%). Forty (10.2%) were divorced (MD: lo%, FD: 9%, MN: 15%, FN: 15%). Forty-six (11.8%) were widow(er)s (MD: ll%, FD: 16%, MN: 4%, FN: 18%). Onehundred fourteen (29%) were single (MD: 29%, FD: 31%, MN: 31%, FN: 29%). For 60 (18%) individuals (MD: 20%, FD: 16%, MN: ll%, FN: 3%) we had no indications of marital status. The data are summarized in Fig. 3. The group ctunknown, is markedly greater in the Copenhagen material. Apart from that, the distribution is similar in the two materials. Males Copenhagen

Males Oslo Drug intoxication

Drowning Hanging

Females Copenhagen

Females Oslo Drug intoxication

Drug intoxication

Hanging Dmvming Plastic

bag

Fig. 2. The various suicide methods among the Copenhagen and Oslo males and females. The group rotherw includes intoxication by agents other than prescription drugs, sharp injury, burning, train, car, fall from a height, and miscellaneous.

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80 (1996) 211-219 Males Oslo

Males Copenhagen

Married

or cohabitant

Females Oslo

Females Copenhagen

ingk

Fig. 3. Marital

status among the Copenhagen

and Oslo males and females.

3.5. Nationality

Very few of the victims had foreign names, indicating that they came from different cultures: in the Oslo material there were two such cases, in the Copenhagen material six cases. 3.6. Time of year

We investigated the numbers of suicides in each season. The lowest suicide incidence in any season in either material was 20% and the highest was 29%, i.e. the distribution was relatively even through the year in both populations. 3. Z Psychiatric

illness

Information on the death certificates or in the police reports of depression, psychosis, schizophrenia or neurosis was classified as psychiatric illness. Such information was found in 52% of the Danish and 45% of the Norwegian cases. 3.8. Suicidal threats andlor

earlier suicide attempts

Positive information of either or both was gathered in 16% of the Copenhagen material and 24% of the Oslo material.

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S. Rogde et al. I Forensic Science International Males Copenhagen

Males Oslo

Females Copenhagen

Females Oslo

Fig. 4. Suicide location

3.9.

Somatic

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for the Copenhagen

and Oslo male and female suicide victims.

disease

Positive information of somatic disease was obtained in 31% of the cases in both materials. 3.10. Suicide location In total, 251 individuals (65% of the total material) were found in their own home (MD: 63%, FD: 76%, MN: 51%, FN: 68%). Seventy-four individuals (19% of the total material) were found outdoors (MD: 20%, FD: 15%, MN: 25%, FN: 24%). Only seven individuals, all males, were found at work (three Danes and four Norwegians). Fifteen individuals (4%) committed suicide in hospital (MD: 2%, FD: 3%, MN: 9% FN: 9%). Only one individual (Norwegian male) was found in a hotel room. Five individuals, four MD and one MN committed suicide in prison. All hanged themselves. The suicide locations are illustrated in Fig. 4. 4. Discussion

In Norway the doctor who examines a deceased is obliged by law to report suicides to the police. Also by law, such deaths ought to be examined medicolegally (almost exclusively by a medicolegal autopsy). This rule is interpreted differently in the various police districts. However, in Oslo and the neighbouring

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municipalities Bzerum and Asker, all suicides that come to the knowledge of the police will undergo a medicolegal autopsy at the Institute of Forensic Medicine, University of Oslo. In Denmark, the suicides are also brought to the attention of the police by law. In all cases the police will require a medicolegal investigation, most often an external medicolegal examination. All suicidal deaths from the county of Copenhagen are thus examined at the Institute of Forensic Medicine - the cases from the municipality of Copenhagen by a forensic pathologist, the remainder of cases by the county medical officer. There will always be a police report, and highlights from this report and from the external examination are described on the death certificate, along with the cause of death. Selected cases are submitted for medicolegal autopsy. Thus, the Danish part of this study is based on external medicolegal examinations and/or autopsies, while the Norwegian material is based entirely on medicolegal autopsies. Therefore, data concerning alcohol and drug concentrations have not been compared. The basis for diagnosing drug intoxication in several cases in the Copenhagen material has been the circumstantial evidence. In both materials there is a clear male preponderance, in spite of the female surplus in the population, especially in the elderly population. There is, however, a greater male preponderance in the suicide rates for the nations as a whole (Norway 1993: 449 males and 141 females, i.e. M/F: 3.2:1; Denmark 1993: 749 males and 410 females, i.e. M/F: l&l, according to the official statistics of the two countries). Thus the sex distribution among the suicide victims in the capitals is more equal than in the countries as a whole. In both cities intoxication was the method of choice, especially among the women. No obvious difference can be found between the two populations in this respect. The difference between the two populations concerning suicidal hangings is enigmatic, especially concerning the sex distribution, as this method is far more common among the Oslo female victims than among the Copenhagen females. Shooting was also more used in the Oslo material. Both countries have strict weapon regulations, and we can offer no plausible explanation for this difference. Nineteen percent of the Danes committed suicide by covering nose and mouth with a plastic bag, while no such caseswere seen in the Norwegian material. There could be one reason for this: *Final Exit. The Practicalities of Self-Deliverance and Assisted Suicide fop. the Dying* (Derek Humphry) [l] is translated into Danish, but not into Norwegian. Although the languages are very similar, this book is practically unknown in Norway. In at least three casesof the Copenhagen suicides the book was observed close to the deceased. In this book the method of suffocation by means of a plastic bag covering nose and mouth is described in detail. The Danish translation was published in July 1992. The following year, the number of suicides with plastic bags rose from 19 to 55 in the Copenhagen area, but dropped to 14 in 1994. The total number of suicides in 1992 was 245 and in 1994 it was 272, i.e. 1993 had more suicides (292) than the neighbouring years, and this difference might be explained by the publicity concerning the plastic bag

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method. It is known from the literature that publicity about a suicide method may increase the overall suicide frequency, the so called Werther effect [2]. Concerning marital status our findings confirm what other investigators have previously shown: that suicide is less common among people who are married or cohabitant than among persons who live alone. The observation that information about somatic disease is obtained in the same proportion of cases in both materials is surprising, considering that the Copenhagen material is mainly based on external examination while the Oslo material is based on autopsies. The reason may be that in Copenhagen information from the deceased’s doctor is routinely collected by the police prior to the medicolegal examination. In the Oslo material such information is very sparse. In Denmark all persons are assigned their own general practitioner, while this is not the case in Norway, and thus medical information is more easily obtainable in Denmark. The Copenhagen suicide figures are considerably higher than the Oslo figures, and when taking the size of the population into consideration the suicide incidence in Oslo was 0.15 per 1000 and in Copenhagen 0.24 per 1000. The higher suicide index in Copenhagen is difficult to explain, as the populations are very similar. A higher unemployment rate in Copenhagen (Copenhagen unemployment rate 1993: 13.4%, Oslo unemployment rate 1993: 5.1% (sources: Statistics Denmark and Norway, respectively) could account for some of this difference. Platt (1985) has demonstrated a clear correlation between unemployment and suicides (reviewed by Diekstra and Gulbinat [3]). Differences in alcohol consumption could also be a factor. In a study from California, persons drinking six or more drinks daily were shown to have a sixfold increased suicide risk compared with non-drinkers [4]. The alcohol consumption in Denmark by far exceeds the Norwegian level. In Norway the registered alcohol consumption per person in 1993 was 3.7 1, calculated as litres of pure alcohol, while the registered consumption in Denmark was 10 1 [5]. It is, however, stipulated that the actual consumption of alcohol in Norway exceeds the official 3.7 1by some 25-35% [6]. The main contribution to this figure comes from import, smuggling and illicit distilling. The official Danish figure may also be underestimated, as the statistics are based on sales statistics. However, due to the increased availability of and considerably lower prices for alcohol in Denmark compared to Norway we believe that the unregistered alcohol consumption in Denmark is relatively moderate. The Norwegian suicide rate has for many years been relatively low compared to the other Nordic countries [7], and the tendencies for the country as a whole is obviously reflected in the capital figures. Bille-Brahe [8] has demonstrated that differences in suicide rates were connected with the degree of social integration, which was generally better in Norway than in Denmark. This discussion is, however, beyond the scope of this study. In conclusion, even in very similar populations both the incidence and methods of suicide may differ due to local environmental influences.

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References [I] D. Humphry, Sidste udvej, Lindhardt and Ringhof, Copenhagen, 1992. [2] A. Schmidtke and H. Hlfner, The Werther effect after television films: new evidence for an old hypothesis. Psychol. Med., 18 (1988) 665-676. [3] R.F.W. Diekstra and W. Gulbinat, The epidemiology of suicidal behaviour: a review of three continents. World Health Stat. Q., 46 (1993) 52-68. [4] A.L. Klatsky and M.A. Armstrong, Alcohol use, other traits, and risk of unnatural death: a prospective study. Alcohol. Clin. Exp. Res., 17 (1993) 1156-1162. [5] L. Grytten (ed.), Alcohol and Drugs in Norway, 199.5, The National Directorate for the Prevention of Alcohol and Drug Problems, Oslo, 1995. [6] K.T. Reinas, The Sources ofAlcohol, The National Directorate for the Prevention of Alcohol and Drug Problems, Oslo, 1991 (in Norwegian). [7] N. Retterstol, F. Gjertsen, H. Ekeland and J.H. Olving, Suicide among young persons at the age of 15-29 years in Oslo. Psychiatriki, l-2 (1994) 66-72. [S] U. Bille-Brahe, Suicide and social integration. A pilot study of the integration levels in Norway and Denmark. Acta Psychiatr. Stand., 76 (Suppl. 336) (1987) 45-62.