European Child & Adolescent Psychiatry

, Volume 23, Issue 1, pp 45–52

Northern excess in adolescent male firearm suicides: a register-based regional study from Finland, 1972–2009

Authors

    • Department of Psychiatry, Institute of Clinical MedicineUniversity of Oulu
  • Sirpa Keränen
    • Department of Psychiatry, Institute of Clinical MedicineUniversity of Oulu
  • Helinä Hakko
    • Department of PsychiatryOulu University Hospital
  • Kaisa Riala
    • Department of Psychiatry, Institute of Clinical MedicineUniversity of Oulu
    • Department of Adolescent PsychiatryHelsinki University Central Hospital
  • Pirkko Räsänen
    • Department of Psychiatry, Institute of Clinical MedicineUniversity of Oulu
Original Contribution

DOI: 10.1007/s00787-013-0422-x

Cite this article as:
Lahti, A., Keränen, S., Hakko, H. et al. Eur Child Adolesc Psychiatry (2014) 23: 45. doi:10.1007/s00787-013-0422-x

Abstract

There are more firearms in Northern Finland as compared to Southern Finland, and a positive association between suicide rates and the number of firearms in a given region has been demonstrated in previous literature. Accordingly, the authors compared firearm suicide rates of Finnish adolescent (under 18 years) males in the two geographic regions. Young adult (18–24 years) and adult (25–44 years) males were used as reference groups. National data on cases of suicide in Northern and Southern Finland between 1972 and 2009 were obtained from Statistics Finland. Firearm suicides (n = 5,423) were extracted according to ICD-classification (ICD-8/9: E955, ICD-10: X72-X75). The distribution of types of firearms (hunting gun, handgun, other) employed in suicides was also investigated. The adolescent male firearm suicide rate in Northern Finland was almost three times higher than that observed in Southern Finland, while there was no difference in rates of suicide by other methods. A northern excess in firearm suicide rates was also found among young adult and adult males. Hunting guns were the most common type of firearms employed in young male suicides, and their use was especially common in Northern Finland. Our results indicate that the use of firearms plays a major role in explaining the northern excess in young Finnish male suicide rates, and emphasize a need to advance suicide prevention according to specific regional characteristics.

Keywords

Adolescent Suicide Firearms Finland

Introduction

Finnish adolescent male suicide mortality is among the highest in Europe. In the first decade of the 21st century, only the Baltic countries and Ireland had young (15–19 years) male suicide rates exceeding those seen in Finland [1]. The use of firearms has been the most common method of suicide among young adolescent males since the 1960s in this country [2]. Considering these facts, the scarcity of research into suicide by firearms among the young Finnish male population is striking.

The possible relationship between suicide rates and geographic region is a subject of interest in the field of suicidology. Regional variations in rates of suicide may have important implications for clinical work, because suicide prevention measures, including psychiatric treatment, could be planned according to specific regional characteristics. Nevertheless, regional differences in youth suicide have gained relatively little attention in previous international research literature. In Finland, Näyhä [3] has shown that the suicide mortality of 15–24 year old males is higher in the province of Lapland, compared to the Finnish national suicide mortality among males of the same age. An Italian study reported a higher suicide rate among 15–19 year old males in the north of Italy (2.63/100,000) as compared to the central (2.07/100,000) and southern (2.19/100,000) parts of the country [4]. However, this regional difference was not found among 10–17 year old males in a later study [5]. Different methods of suicide were not analysed separately in any of these studies. In Australia, research has focused on rural–urban differences rather than large area variations. Dudley et al. [6] reported that suicide rates among 15–24 year old males doubled between the 1960s and 1990s in Australian metropolitan areas, while the rates in small rural communities increased 12-fold. With particular reference to firearm suicides, the authors showed that their rate declined in metropolitan areas but continued to rise in rural areas. More recently, Page et al. [7] illustrated that the rural–urban differential, with higher suicide rates in rural areas, has continued among young males in Australia. Similar findings have also been reported from Austria [8], and the US, where the overall suicide rates in 15–24 year old males living in rural areas were up to 60 % higher than those in males from urban areas [9]. Another study in the US revealed that firearm suicide rates among 10–19 year old adolescents were two times higher in rural compared to urban counties [10].

According to previous studies, there is a strong association between method availability and method-specific suicide rates [11]. In Finland, the relative number of firearms is greater in the northern as compared to the southern parts of the country (The Finnish Police, unpublished data). Our aim in this paper is to compare, for the first time, the rates of adolescent (under 18 years) male suicides committed using firearms in Northern and Southern Finland over a period of 38 years. Young adult (18–24 years) and adult (25–44 years) males are used as reference groups. We will also examine regional differences in the types of firearms (hunting guns, handguns, other) used in suicides.

Method

Suicide data

Our data, obtained from Statistics Finland, cover all suicides in Finland committed by persons in the age groups: under 18 years (later referred to as “adolescents”), 18–24 years (“young adults”) and 25–44 years (“adults”) between 1st January 1972 and 31st December 2009. The data consist of suicide frequencies classified by sex (male, female), year of death (1972–2009), age at death, cause of death (ICD-codes) and residence at death (Northern Finland, Southern Finland). A total of 24,050 suicides occurred in Finland among persons aged less than 45 years during the follow up period, of which 19,580 (81.4 %) were committed by males and 4,470 (18.6 %) by females.

Firearm suicides

Of all suicides in Finland between 1972 and 2009 among persons aged under 45 years, 23.6 % were committed using firearms (n = 5,671, males 95.6 %). For the purpose of this study, owing to the small number of female suicides involving firearms, only male subjects were studied. Suicide methods were classified according to codes E950-E959 in the 8th and 9th Revisions of the International Statistical Classification of Diseases and Related Health Problems (ICD-8 and ICD-9) between 1969–1995 and codes X60–X84 and Y87.0 of ICD-10 between 1996 and 2009. In ICD-8 and ICD-9, only one diagnostic code was used for firearm and explosive suicides (E9559 in ICD-8 and E955A in ICD-9), whereas after the year 1996, firearm suicides were classified according to ICD-10 as follows: handgun discharge (X72); rifle, shotgun and larger firearm discharge (X73); other and unspecified firearm discharge (X74); explosive material (X75). Since information of specific type of firearm was not recorded before 1996, type-specific firearm results can only be reported from that year onwards.

Characteristics of study regions

The study regions are illustrated in Fig. 1. Northern Finland covers 49 % of the land area of Finland [12]. In 2007, the population of Northern Finland accounted for 12 % of the total Finnish population, which was 5.4 million. Table 1 shows the essential geographical, sociodemographic and youth mental health characteristics of the study regions, as well as information on health care accessibility and rates for hunting permits and firearms.
https://static-content.springer.com/image/art%3A10.1007%2Fs00787-013-0422-x/MediaObjects/787_2013_422_Fig1_HTML.gif
Fig. 1

Study regions

Table 1

Characteristics of the study regions

 

Northern Finland

Southern Finland

Geographical characteristicsa

 Land area

150,000 km2

154,000 km2

 Population

663,000

4,739,000

 Population density

4.4 persons/km2

30.8 persons/km2

Sociodemographic characteristics

 Unemploymentb

9.2 %

7.6 %

 Educational qualificationc

68.5 %

67.6 %

 Divorcesd

13.5/1,000 persons

15.9/1,000 persons

Youth mental health characteristics

 Moderate or severe depressione

12.1 %

11.9 %

 Severely drunk at least once a monthe

21.2 %

23.0 %

 Psychiatric inpatient care (males)f

5.6/1,000 persons

5.5/1,000 persons

Health care accessibilityg

 Average (sd) distance to nearest health centre

4.9 (8.0) km

2.7 (3.3) km

 Distance to nearest health centre >20 km

5.7 %

0.3 %

Firearms and hunting

 All firearmsh

50/100 persons

27/100 persons

 Hunting gunsh

44/100 persons

21/100 persons

 Hunting permitsi

14/100 persons

5/100 persons

aIn 2011 [12]

bThe ratio of 15–74 year old unemployed persons to the active population (labour force) of the same age in 2011 [13]

cPercentage of population aged 15 or over with educational qualification in 2011 [14]

dThe average number of marriages that end up in a divorce among those aged 25–64 per 1,000 married persons of the same age in 1990–2011 [15]

eThe proportion of those who felt that they were at least moderately depressed (as measured by Raitasalo’s modification of the Beck Depression Inventory), or got severely drunk at least once a month, among Finnish pupils in year 8 and 9 of secondary school and year 1 and 2 of upper secondary school and vocational schools [16]

fPeriods of psychiatric inpatient care for males aged 13–17 per 1,000 persons of the same age in 1996–2009 [17]

gPopulation weighed average direct distance to nearest health centre. In Finland, mental health clinics are generally located within health centres. The population data are based on the Grid Database of Statistics Finland [18], which was linked with the information of the locations of health centres by the University of Oulu, Department of Geography [19]

hThe Finnish Police, unpublished data, 2012. The data are partly incomplete due to some missing information in the police firearms registry before the year 2002

iThe Finnish Hunters’ Association, unpublished data. Hunting permits redeemed in 1992–2010

To calculate the annual suicide rates per 100,000 of the population, the annual population estimates for males in each age group included in the study were obtained from Statistics Finland. For adolescent males, the reference population was 12–17 years, because suicides before the age of 12 years are extremely rare.

Statistical analyses

The suicide rates are visualised as 3-year moving average rates. The statistical significance of group differences in categorical variables was assessed using Pearson’s Chi square test or Fisher’s Exact test. Differences in suicide rates between Northern and Southern Finland were analysed with Independent Samples t test. Regression analysis was used to test the linear trend in suicide. The statistical software used in all analyses was PASW, version 18. All statistical tests were two-tailed, and the limit for statistical significance was set at p ≤ 0.05.

Results

Between 1972 and 2009, there were a total of 654 adolescent male suicides in Finland, of which 46.6 % (n = 305) were committed using firearms. Correspondingly, of all 4,252 suicides in young adult males, 36.0 % (n = 1,530) were committed using firearms, while firearm suicides accounted for 24.5 % (n = 3,588) of all 14,674 adult male suicides.

Difference in suicide rates between Northern and Southern Finland

Throughout the study period, 1972–2009, the mean rate of firearm suicides (per 100,000 population) among Finnish males aged under 45 years was statistically significantly higher in Northern Finland compared to Southern Finland (22.1 vs. 10.4, p < 0.001). Contrary to this, there was no statistically significant regional difference in the rate of suicides by all methods other than firearms in males aged less than 45 years (32.2 vs. 30.9, p = 0.277) (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs00787-013-0422-x/MediaObjects/787_2013_422_Fig2_HTML.gif
Fig. 2

Firearm suicide rates and rates of suicide by other methods per 100,000 population in Northern and Southern Finland, males under 45 years

With respect to age-specific firearm suicide rates, Fig. 3a shows that, during the 38-year period of review, the mean rates of adolescent male firearm suicides (per 100,000 population) were statistically significantly higher in Northern Finland compared to Southern Finland (8.7 vs. 3.1, p < 0.001). The difference in rates between regions was 2.8-fold. In young adult males, the regional difference was 2.6-fold (33.8 vs. 13.2, p < 0.001) (Fig. 3b) and in adult males 1.9-fold (22.0 vs. 11.4, p < 0.001) (Fig. 3c). In the rates of suicide by other methods, no regional differences were found among adolescent males (4.8 vs. 4.3, p = 0.176) or young adult males (26.8 vs. 28.7, p = 0.086), while a statistically significant difference was observed in adult males (43.2 vs. 38.7, p = 0.004).
https://static-content.springer.com/image/art%3A10.1007%2Fs00787-013-0422-x/MediaObjects/787_2013_422_Fig3_HTML.gif
Fig. 3

Male firearm suicide rates per 100,000 population in Northern and Southern Finland, by age groups

Proportion of suicides involving firearms

As illustrated in Fig. 4, the proportion of suicides involving firearms was statistically significantly higher in Northern Finland (64.2 %) compared to Southern Finland (41.0 %) among adolescent males (p < 0.001). A similar regional difference was also observed among young adult males (55.4 vs. 31.3 %, p < 0.001) and adult males (33.9 vs. 22.7 %, p < 0.001).
https://static-content.springer.com/image/art%3A10.1007%2Fs00787-013-0422-x/MediaObjects/787_2013_422_Fig4_HTML.gif
Fig. 4

Proportions of male firearm suicides in Northern and Southern Finland in 1972–2009, by age groups

Types of firearms

Table 2 describes the regional differences in types of firearms employed in firearm suicides by age group. Shotgun or rifle (i.e. a hunting gun) was the most commonly used weapon in firearm suicides in all age groups, both in Northern and Southern Finland. Among adolescent males, a hunting gun was involved in 87.5 % of all firearm suicides in Northern Finland, whereas the proportion was 67.2 % in Southern Finland (p = 0.060). The regional difference was similar among young adults (p < 0.001) and adult males (p < 0.001).
Table 2

Types of firearms used in firearm suicides among males in Northern and Southern Finland 1996–2009, by age groups

Age group

Type of firearm

Northern Finland (n = 366)

Southern Finland (n = 1,002)

Regional difference

n (%)

n (%)

p value

Adolescents,  <18 years

Handgun

2 (8.3)

16 (27.6)

0.06

Rifle/Shotgun

21 (87.5)

39 (67.2)

0.06

Explosive material + other/unspecified

1 (4.2)

3 (5.1)

0.85

Young adults, 18–24 years

Handgun

15 (12.7)

62 (26.5)

0.003

Rifle/Shotgun

100 (84.7)

156 (66.7)

<0.001

Explosive material + other/unspecified

3 (2.5)

16 (6.7)

0.09

Adults, 25–44 years

Handgun

45 (20.1)

254 (35.8)

<0.001

Rifle/Shotgun

177 (79.0)

399 (56.2)

<0.001

Explosive material + other/unspecified

2 (0.9)

57 (8.0)

<0.001

All, 0–44 years

Handgun

62 (16.9)

332 (33.1)

<0.001

Rifle/Shotgun

298 (81.4)

594 (59.3)

<0.001

Explosive material + other/unspecified

6 (1.6)

76 (7.6)

<0.001

ICD-8 and 9 includes only one diagnostic code for suicides by firearms or explosives. In ICD-10 since 1996, the exact type of firearm or use of explosive material is recorded

Discussion

Our study clearly demonstrated a marked regional difference in the firearm suicide rates of adolescent males, with significantly higher rates in Northern Finland compared to Southern Finland. The regional difference persisted for the entire 38-year study period. By contrast, the rates of suicide by all other methods did not show such differences between these two geographic regions. The excess in suicides among young males in Lapland, as compared to the national Finnish suicide rates, has been reported earlier [3], but different methods of suicide were not separately analysed in that study. Thus, our findings are novel and strongly indicate that the use of firearms, a violent and highly lethal method of suicide, plays a major role in explaining the northern excess in the suicide rates among young Finnish males.

In general, geographical variations in suicide rates have been explained by differences in various risk factors for suicide, such as sociodemographic factors, prevalence of mental disorders, alcohol consumption, availability of mental health services, or availability of lethal means [20]. However, as illustrated in Table 1, in Finland the only notable differences in these potential risk factors between the North and South are in the poorer accessibility to health centres (due to long distances) and the greater number of firearms per person in the North. Generally speaking, the greater the number of firearms, the higher is the rate of firearm suicides in a specific region, as shown in several studies [2125]. With specific relation to rural–urban differences in suicide rates, researchers have suggested that the rural excess in male suicides is related to easier access to firearms in rural settings [6, 9, 20, 26]. Since the prevalence of firearms in general, and hunting guns in particular, is substantially higher in Northern Finland as compared with Southern Finland, and since Northern Finland can generally be regarded as a more rural area than Southern Finland, based on the notably low population density, the findings of our study are consistent with the above-mentioned international studies. Although causality cannot be determined, we assume that if differences in some of the other risk factors, such as the weaker accessibility of mental health services in Northern Finland would explain our findings, regional differences should also have been observed in rates of suicide by other methods. This was not the case among adolescent and young adult males in our study.

The proportion of suicides involving firearms was very high among adolescent males from Northern Finland, as they accounted for almost two-thirds of all suicide cases. In comparison, only one-fifth of adult males from Southern Finland committed suicide using firearms. With regard to the specific types of firearms, hunting guns were employed the most commonly. Hunting is a popular sport among males of all age groups—including young adolescents—in Finland, particularly in the northern areas. In our study, males from Northern Finland showed greater preference for hunting guns than their peers in the South. It is of great concern that the proportion of firearm suicides involving hunting guns was the highest (almost nine out of ten firearm suicide cases) among adolescent males from Northern Finland. Due to our study design, it was not possible to determine who owned the firearms used in the suicides, but Hintikka et al. [27] have previously reported that 60 % of all firearm suicides among 15–24 year old males from Eastern Finland were committed using legal hunting guns stored in the victims’ homes.

Consistent with the other studies [24, 25, 28, 29], our results indicate that the association between greater availability of firearms and higher rates of firearm suicides is relatively more important in adolescent suicides than among older individuals. Miller et al. [25] have suggested that this might be due to greater impulsivity in the younger age group. Indeed, it has been shown that higher levels of impulsive-aggressive traits play a greater role in suicide occurring among younger individuals [30]. Further, even among adolescent suicides, younger persons have lower levels of intent [31]. However, the mechanism by which impulsivity confers risk in adolescent suicides is not well established. A study by Witte et al. [32] indicated that, contrary to the general view, the adolescents who plan their suicide attempts are more impulsive than those who attempt suicide without prior planning. Given the high lethality of firearms as a method of suicide, the lack of studies on near-lethal firearm suicide attempters is unsurprising, but one such study [33] found that most self-shooting survivors were young men who did not suffer from major depression or psychosis and had shot themselves impulsively in a crisis. However, subsequent findings from the same updated database [34] indicated that, while some patients fitted this picture (suicide attempt being a “spur of the moment” action), most in fact had longstanding personality difficulties and past history of substance abuse. Unfortunately, our data were based on suicide counts and thus statistical analysis at individual level was not possible. We are, therefore, unable to analyse the contribution of biopsychosocial factors, such as the victims’ psychiatric histories or level of impulsivity, to the suicides.

With regard to suicide prevention, evidence strongly suggests that means restriction (i.e. limiting access to suicide methods) is one of the few effective policies available [11]. More restrictive firearm control policies have been shown to lower the number of firearm suicides [11]. Brent et al. [35] suggested that prevention of suicides by the restriction of the availability and accessibility of firearms may be particularly important in adolescent suicide. Tighter firearms legislation has recently been implemented in Finland, but the impact of these changes on the rate of firearm suicides remains to be seen. Daigle [36] has proposed that individuals have a preference for a specific means, which makes method substitution unlikely. We estimated that, if firearm suicides among young males in Northern Finland could be reduced to the same level as in the South (i.e. by half), the overall rate of suicides among this age group would be 20 % lower in Northern Finland.

A Finnish study [37] found that firearm suicide victims were less likely to have received psychiatric treatment, or to have made previous suicide attempts, than suicide victims who used other methods of suicide. Further, only 2 % of young Finnish males who committed suicide using firearms had been in psychiatric consultation during the 3 months prior to suicide, as compared to 27 % of males who used other suicide methods [27]. From a psychiatric viewpoint, the prevention of suicides in young individuals who are at risk of suicide, but who do not actively seek help, is very challenging. The school health care system, which reaches virtually all adolescents in Finland, has a very important role in this respect. Better tools are required, such as adolescent-focused population level screening instruments that help us to recognize suicidality and explore adolescent’s attitude towards firearms. In our opinion, restrictions on the availability of and access to firearms are essential, but should be accompanied by improved availability of and access to adolescent mental health services in Finland. However, specific regional characteristics, such as the long distances in Northern Finland, may impose a range of challenges to this goal.

The results reported here should be interpreted in the light of some limitations. Adolescent suicide rates may be misclassified as accidental or other unnatural deaths, which may have caused some underestimation of their suicide rates [38]. Another limitation of our study was the relatively small number of suicides among adolescent males. Although the main findings are statistically robust, some degree of type II error may have occurred and some risk of spurious findings (i.e. type I error) also exists. In addition, the presence of firearms at the homes of suicide victims could not be verified in this study, and the type of firearm was not included in the diagnostic coding system until 1996, when ICD-10 was adopted.

Acknowledgments

This study was funded in part by grants from The Finnish Psychiatric Research Foundation, The Emil Aaltonen Foundation, The Otto A. Malm Foundation, and The Alma and K. A. Snellman Foundation, Oulu, Finland.

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Copyright information

© Springer-Verlag Berlin Heidelberg 2013