Spatial clusters of suicide in the municipality of São Paulo 1996–2005: an ecological study
In a classical study, Durkheim mapped suicide rates, wealth, and low family density and realized that they clustered in northern France. Assessing others variables, such as religious society, he constructed a framework for the analysis of the suicide, which still allows international comparisons using the same basic methodology. The present study aims to identify possible significantly clusters of suicide in the city of São Paulo, and then, verify their statistical associations with socio-economic and cultural characteristics.
A spatial scan statistical test was performed to analyze the geographical pattern of suicide deaths of residents in the city of São Paulo by Administrative District, from 1996 to 2005. Relative risks and high and/or low clusters were calculated accounting for gender and age as co-variates, were analyzed using spatial scan statistics to identify geographical patterns. Logistic regression was used to estimate associations with socioeconomic variables, considering, the spatial cluster of high suicide rates as the response variable. Drawing from Durkheim’s original work, current World Health Organization (WHO) reports and recent reviews, the following independent variables were considered: marital status, income, education, religion, and migration.
The mean suicide rate was 4.1/100,000 inhabitant-years. Against this baseline, two clusters were identified: the first, of increased risk (RR = 1.66), comprising 18 districts in the central region; the second, of decreased risk (RR = 0.78), including 14 districts in the southern region. The downtown area toward the southwestern region of the city displayed the highest risk for suicide, and though the overall risk may be considered low, the rate climbs up to an intermediate level in this region. One logistic regression analysis contrasted the risk cluster (18 districts) against the other remaining 78 districts, testing the effects of socioeconomic-cultural variables. The following categories of proportion of persons within the clusters were identified as risk factors: singles (OR = 2.36), migrants (OR = 1.50), Catholics (OR = 1.37) and higher income (OR = 1.06). In a second logistic model, likewise conceived, the following categories of proportion of persons were identified as protective factors: married (OR = 0.49) and Evangelical (OR = 0.60).
This risk/ protection profile is in accordance with the interpretation that, as a social phenomenon, suicide is related to social isolation. Thus, the classical framework put forward by Durkheim seems to still hold, even though its categorical expression requires re-interpretation.
- World Health Organization: World report on violence and health. In Self-directed violence. Geneva; 2002. http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap7.pdf
- World Health Organization: Suicide Prevention (SUPRE). Geneva; 2002. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/
- Bertolote JM, Fleischmann A: A global perspective in the epidemiology of suicide. Suicidologi 2002, 7:6–8.
- Lovisi GM, Santos SA, Legay L, Abelha L, Valencia E: Epidemiological analysis of suicide in Brazil from 1980 to 2006. Rev Bras Psiquiatr 2009, 31:86–94. CrossRef
- Brzozowski FS, Soares GB, Benedet J, Boing AF, Peres MA: Suicide time trends in Brazil from 1980 to 2005. Cad Saude Publica 2010, 26:1293–1302. CrossRef
- Morselli EA: Suicide: an essay on comparative moral statistics. New York: Appleton; 1882.
- Durkheim E: Suicide. London: Routledge; 1897. 1951
- Baller RD, Richardson KK: Social integration, imitation, and the geographic patterning of suicide. Am Sociol Rev 2002, 67:873–888. CrossRef
- Lester D, Charles C Thomas: Suicide from a sociological perspective. Springfield: Charles C Thomas; 1989.
- Iga M: The Thorn in the Chrysanthemum: Suicide and Economic Success in Modern Japan. Los Angeles: University of California Press; 1986.
- Middleton N, Sterne JAC, Gunnell DJ: An atlas of suicide mortality: England and Wales, 1988–1994. Health Place 2008, 14:492–506. CrossRef
- Gunnel D, Wheeler B, Chang S-S, Thomas B, Sterne JAC, Dorling D: Changes in the geography of suicide in young men: England and Wales 1981–2005. J Epidemiol Community Health 2012, 66:536–543. CrossRef
- Chang S-S, Sterne JAC, Wheeler BW, Lu T-H, Lin J-J, Gunnell D: Geography of suicide in Taiwan: spatial patterning and socioeconomic correlates. Health Place 2011, 17:641–650. CrossRef
- Halbwachs M: The causes of suicide. New York: Free Press; 1978.
- Baudelot C, Establet R: Suicide: The hidden side of modernity. Cambridge: Polity Press; 2008.
- Hawton K, van Heeringen K: Suicide. Lancet 2009,373(9672):1372–1381. CrossRef
- Rehkopf DH, Buka SL: The association between suicide and the socio-economic characteristics of geographical areas: a systematic review. Psychol Med 2006, 36:145–157. CrossRef
- Melinder KA, Andersson R: The impact of structural factors on the injury rate in different European countries. Eur J Public Health 2001, 11:301–308. CrossRef
- Gunnell DJ, Peters TJ, Kammerling RM, Brooks J: Relation between parasuicide, suicide, psychiatric admissions, and socioeconomic deprivation. Br Med J 1995, 311:226–230. CrossRef
- Cubbin C, LeClere FB, Smith GS: Socioeconomic status and the occurrence of fatal and non fatal injury in the United States. Am J Public Health 2000, 90:70–77. CrossRef
- Susser M: The logic in ecological: I The logic of analysis. Am J Public Health 1994, 84:825–829. CrossRef
- Instituto Brasileiro de Geografia e Estatística: Síntese de indicadores sociais confirma as desigualdades da sociedade brasileira. 2002.
- Sposati A: Mapa de exclusão/inclusão social na cidade de São Paulo – Brasil - 2000. São Paulo: Pontifícia Universidade Católica de São Paulo; 2000.
- IBGE (Instituto Brasileiro de Geografia e Estatística): Brasil tem 183,9 milhões de habitantes segundo Contagem da População do IBGE. 2007. http://www.ibge.gov.br/home/presidencia/noticias/noticia_visualiza.php?id_noticia=1028&id_pagina=1
- Viana MC, Teixeira MG, Beraldi F, Bassani IS, Andrade LH: São Paulo Megacity Mental Health Survey - a population-based epidemiological study of psychiatric morbidity in the São Paulo metropolitan area: aims, design and field implementation. Rev Bras Psiquiatr 2009, 31:375–386. CrossRef
- Kulldorff M: Information Management Services Inc: SaTScanTM v7.0: Software for the spatial and space-time scan statistics. 2007.
- Pan American Health Organization: World Health Organization, Ministério da Saúde do Brasil, Universidade Estadual de Campinas: Prevenção do suicídio: Manual dirigido a profissionais das equipes de saúde mental. Brasília: Ministério da Saúde; 2006.
- Stack S: Suicide: a 15-year review of the sociological literature Part II: modernization and social integration perspectives. Suicide Life Threat Behav 2000, 30:163–176.
- Vijayakumar L, Nagaraj K, Pirkis J, Whiteford H: Suicide in developing countries (1): frequency, distribution, and association with socioeconomic indicators. Crisis 2005, 26:104–111. CrossRef
- Diekstra RFW, Gulbinat W: The epidemiology of suicidal behaviour: a review of three continents. World Health Stat Q 1993, 46:52–68.
- Jackson MC, Huang L, Luo J, Hachey M, Feuer E: Comparison of tests for spatial heterogeneity on data with global clustering patterns and outliers. Int J Health Geogr 2009, 8:55. CrossRef
- Bando DH, Brunoni AR, Fernandes TG, Benseñor IM, Lotufo PA: Suicide rates and trends in São Paulo, Brazil according to gender, age and demographic aspects: a joinpoint regression analysis. Rev Bras Psiquiatr 2012, 34:237–244.
- Stack S: Gender, marriage, and suicide acceptability: a comparative approach. Sex Roles 1998, 38:501–520. CrossRef
- Cutright P, Stack S, Fernquist R: Marital status integration, suicide disapproval, and societal integration as explanations of marital status differences in female age-specific suicide rates. Suicide Life Threat Behav 2007, 37:715–724. CrossRef
- Masocco M, Pompili M, Vichi M, Vanacore N, Lester D, Tatarelli R: Suicide and marital status in Italy. Psychiatr Q 2008, 79:275–285. CrossRef
- Denney JT, Rogers RG, Krueger PM, Wadsworth T: Adult suicide mortality in the United States: marital status, family size, socioeconomic status, and differences by sex. Soc Sci Q 2009, 90:1167–1185. CrossRef
- Corcoran P, Nagar A: Suicide and marital status in Northern Ireland. Soc Psychiatry Psychiatr Epidemiol 2010, 45:795–800. CrossRef
- Kapusta ND, Gernot S: Suicides of men in Austria: an epidemiological analysis over a 30-year period. J Of Men’s Health 2004, 1:197–202.
- Liu HL: Epidemiologic characteristics and trends of fatal suicides among the elderly in Taiwan. Suicide Life Threat Behav 2009, 39:103–113. CrossRef
- Yamasaki A, Araki S, Sakai R, Yokoyama K, Voorhees AS: Suicide mortality of young, middle-aged and elderly males and females in Japan for the years 1953–96: time series analysis for the effects of unemployment, female labour force, young and aged population, primary industry and population density. Ind Health 2008, 46:541–549. CrossRef
- Yeh JY, Xirasagar S, Liu TC, Li CY, Lin HC: Does marital status predict the odds of suicidal death in Taiwan? A seven-year population-based study. Suicide Life Threat Behav 2008, 38:302–310. CrossRef
- Wyder M, Ward P, De Leo D: Separation as a suicide risk factor. J Affect Disord 2009, 116:208–213. CrossRef
- Jung H, Matei DB, Hecser L: Biostatistical study of suicide features in Mures County (Romania). Leg Med 2009, 11:S95-S97. CrossRef
- Voracek M, Loibl LM, Dervic K, Kapusta ND, Niederkrotenthaler T, Sonneck G: Consistency of immigrant suicide rates in Austria with country-of-birth suicide rates: a role for genetic risk factors for suicide? Psychiatry Res 2009, 170:286–289. CrossRef
- Almeida R: Religião na metrópole paulista. Braz J CiencSociais 2004, 56:15–27.
- Camurça PA: A realidade das religiões no Brasil no Censo do IBGE-2000. In As religiões no Brasil. Edited by: Teixeira F, Menezes R. Petrópolis: Vozes;
- Prandi R, Góes RCT, Justo JA: A renovação carismática e o pentecostalismo: proximidade e diferença. Edited by: Prandi R. São Paulo: Edusp; 1998:123–142.
- Bezerra Filho JG, Werneck GL, Almeida RLF, Oliveira MIV, Magalhães FB: Socio-demographic determinants of suicide in the State of Rio de Janeiro, Brazil, 1998–2002. Cad Saude Publica 2012, 28:833–844. CrossRef
- Sharma BR, Gupta AK, Sharma S, Gupta N, Relhan N, Singh H: Suicides in Northern India: comparison of trends and review of literature. J Forensic Leg Med 2007, 14:318–326. CrossRef
- Tondo L, Albert MJ, Baldessarini RJ: Suicide rates in relation to health care access in the United States: an ecological study. J Clin Psychiatry 2006, 67:517–523. CrossRef
- Fukuda Y, Nakamura K, Takano T: Cause-specific mortality differences across socioeconomic position of municipalities in Japan, 1973–1977 and 1993–1998: increased importance of injury and suicide in inequality for ages under 75. Int J Epidemiol 2005, 34:100–109. CrossRef
- Taylor R, Page A, Morrell S, Harrison J, Carter G: Mental health and socio-economic variations in Australian suicide. Soc Sci &Med 2005, 61:1551–1559. CrossRef
- Rezaeian M, Dunn G, Leger SS, Appleby L: Ecological association between suicide rates and indices of deprivation in the north west region of England: the importance of the size of the administrative unit. J Epidemiol Community Health 2006, 60:956–961. CrossRef
- Maki NE, Martikainen PT: Socioeconomic differences in suicide mortality by sex in Finland in 1971–2000: a register-based study of trends, levels, and life expectancy differences. Scand J Public Health 2007, 35:387–395. CrossRef
- Maki N, Martikainen PT: The role of socioeconomic indicators on non-alcohol and alcohol-associated suicide mortality among women in Finland. A register-based follow-up study of 12 million person-years. Soc Sciand Med 2009, 68:2161–2169. CrossRef
- Martiello MA, Giacchi MV: Ecological study of isolation and suicide in Tuscany (Italy). Psychiatry Res 2012. in press
- Pompili M, Innamorati M, Vichi M, Masocco M, Vanacore N, Lester D, Serafini G, Tatarelli R, De Leo D, Girardi P: Inequalities and impact of socioeconomic-cultural factors in suicide rates across Italy. Crisis 2011, 32:178–185. CrossRef
- Paugam S: Desqualificação social – ensaio sobre a nova pobreza. São Paulo: Educ & Cortez; 2003.
- Castel R: Metamorfoses da questão social. Rio de Janeiro: Vozes; 1998.
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/12/124/prepub
- Spatial clusters of suicide in the municipality of São Paulo 1996–2005: an ecological study
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- Online Date
- August 2012
- Online ISSN
- BioMed Central
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- Author Affiliations
- 1. University Hospital, University of São Paulo Medical School, São Paulo, Brazil
- 2. Department of Public Health, Aggeu Magalhães Institute, Oswaldo Cruz Foundation, Ministry of Health, Recife, Brazil
- 3. Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, Brazil
- 4. Department of Geography, School of Philosophy, Literature and Human Sciences, University of São Paulo, São Paulo, Brazil