Suicide among young people in selected
Brazilian State capitals
Suicídio de jovens nas principais
capitais do Brasil
1 Departam en to de Ep id em iologia e M étod os Qu an titativos em Saú d e, Escola N acion al d e Saú d e Pú blica, Fu n d ação Osw ald o Cru z . Ru a Leop old o Bu lh ões 1480, Rio d e Jan eiro, RJ 21041-210, Brasil. ed in ilsa@n u tecn et.com .br 2 Cen tro Latin o Am erican o d e Estu d os sobre Violên cia e Saú d e Jorge Careli, Escola N acion al d e Saú d e Pú blica, Fu n d ação Osw ald o Cru z . Av. Brasil 4036, Rio d e Jan eiro, RJ 21040-361, Brasil.
m cm [email protected] ju [email protected] z .br
Ed in ilsa Ram os d e Sou z a 1,2 M aria Cecília d e Sou z a M in ayo 2 Ju aci Vitória M alaqu ias 2
Abstract Th is stu d y an alyzes su icid e am on g you n g Braz ilian s (15-24 years old ) in n in e m etro-p olitan areas. Mortality d ata for 1979-1998 w ere obtain ed from th e Mortality In form ation Sys-tem of th e M in istry of Health . Ex tern al cau ses are th e m ain cau ses of d eath am on g you th , an d su icid e is th e sixth m ost frequ en t of th ese cau ses. Th e d istribu tion is h eterogen eou s, varyin g ac-cord in g to th e social stratu m , sp ecific age grou p, sex, an d m ean s u sed to com m it su icid e. All cities an alyz ed sh ow ed in creased su icid e rates from 1979 to 1998 (from 3.5 to 5.0 p er 100,000 in h abi-tan ts 15-24 years old ). Salvad or an d Rio d e Jan eiro h ad th e low est su icid e rates, w h ile Porto Ale-gre a n d Cu rit ib a h a d t h e h igh est . Th e p rin cip a l m ea n s u sed by you t h t o com m it su icid e w ere h an gin g, stran glin g, an d su ffocation (Porto Alegre), follow ed by firearm s an d ex p losives (Belo Horizon te).
Key words Beh aviou r; Mortality; Su icid e; Men tal Health
Introduction
Su icid e is a com p lex h u m an p h en om en on , an d sin ce it occu rs in all kn own an d research ed so-cieties, it is a lso co n sid ered u n iversa l. Its h is-to rica l in terp reta tio n h a s b een th e su b ject o f va rio u s a p p ro a ch es, ra n gin g fro m co m m o n sen se, wh ich views it as a beh avioral deviation , to Cath olicism , wh ich h istorically ju d ged it as an offen se again st God,den yin g a Ch ristian b u rial to th ose com m ittin g su icid e. Most con tem -p o ra r y th eo ries view it a s th e resu lt of m en tal disease, wh ile som e sch ools of p h ilosop h y view it, at th e lim it, as an act of su prem e freedom.
Wh ere d o su icid es fit in to th e so -ca lled grou p of extern al cau sesof m ortality as a wh ole? Sin ce th e classical work of Du rkh eim , Su icid e, wh ich d efin es th e p h en om en on as “all cases of d eath resu ltin g from a p ositive or n egative act of th e victim h im self, w h ich h e k n ow s w ill p ro-du ce th is resu lt” (Du rkh eim , 1982:16),th e su b -ject h a s b eco m e p a rt o f scien tific in q u iry a n d d eb a te. Th ree m a in exp la n a to r y m o d els n ow exist: (a ) th e so cio lo gica l m o d el, d ea lin g with su icid e with in th e h istorical an d cu ltu ral con -text; (b ) th e p sych ological m od el, con sid erin g it th e resu lt of in d ivid u al in tern al con flicts; an d (c) th e n osological m od el, viewin g th e p rob lem as an illn ess. All th ree in volve b oth sp ecific d is-cip lin ary lim itation s an d em p h asis on asp ects o f th e kn own a n d co m p lex rela tio n sh ip b e-tween in d ivid u a l a n d so ciety. Sin ce o u r stu d y a n a lyzes su icid e a m o n g yo u th , th ese th ree lin es of th ou gh t will b e ap p roach ed sp ecifically th rou gh th e litera tu re ta kin g th is socia l grou p as its referen ce.
The sociological model
Th e sociological m od el as con ceived by Du rk-h eim aim ed to con cep tu alize an d exp lain trk-h is social d ram a with in th e Eu rop ean con text p re-cisely 104 years ago, in th e late 19th cen tu ry. Al-th ou gh Al-th e n otion of in d ivid u al in ten t was p re-sen t in th e au th or’s own d efin ition , Du rkh eim p u rp osely failed to d eal with th e overlap p in g of th e so cia l issu e a n d in d ivid u a l m o tives, b e-cau se th e th eoretical fou n d ation s of h is th in k-in g co n sid ered su icid e a n em k-in en tly so cia l even t th at sh ou ld th u s b e stu d ied accord in g to th e ru les of th e sociological m eth od . Du rkh eim a sso cia ted wh a t h e term ed th e su icid ogen ic cu rren t,th a t is, th e p reva ilin g in crea se in su i-cid e rates, to th e p rofou n d tran sform ation s in th e m od e of p rod u ction a n d socia l la b or rela -tio n s th ro u gh o u t la te 19th cen tu r y Eu ro p e. Based on Qu ételet (1835), h e viewed su icid e as lin ked to so cia l fo rces th a t tra n scen d ed in d
ivid u a ls, d em o n stra tin g with d a ta th a t its in -crea se is in versely p ro p o rtio n a l to th e d egree o f a in d ivid u a l’s in tegra tio n in to so ciety a n d varies accord in g to cu ltu re: “each people h as its ow n tren d in relation to su icid e” (Du rkh eim , 1982:22). He con ten ded that in the case of you th , self-d estru ction is lin ked to su d d en ch an ges in th e social fab ric. You n g su icid e victim s ten d to in troject “an om ies”,a Du rkh eim ian con cep t re-ferrin g to socia l b rea kd own ; wh en th ere is ex-cessive rigid ity in th e m ilieu th ey freq u en t, or wh en th ey la ck referen tia l sch em es fo r th eir p resen t an d fu tu re con cern s an d social n eed s. Th e au th or also refers to an oth er form , altru is-tic su icide, an d its op p osite,egoistic su icide,in -d icatin g excessive su b m ission to cau ses, esp e-cially religiou s an d p olitical; th e op p osite case in vo lves d esp a ir ca u sed b y so cia l d ifficu lties (Du rkh eim , 1982; Sam p aio, 1991).
From th e m icro-sociological p oin t of view, va rio u s resea rch ers h igh ligh t th e im p o rta n ce o f th e fa m ily in stitu tio n a s a n extrem ely rele-van t n u cleu s for social eq u ilib riu m , n eu traliz-in g d istraliz-in tegration an d an om ic states, esp ecially d u rin g ad olescen ce an d you th . Th ey also in -d icate th e relevan ce of p rofession al an -d sch ool gro u p s fo sterin g th e exp ressio n o f p erso n a l ach ievem en t an d collective feelin gs in volvin g th e d evelop m en t of good s, valu es, an d in d ivid -u als again st th e d isr-u p tion of -u n em p loym en t, excessive com p etition , an d alien ation (Brid ge et al., 1997; Ch esn ais, 1981; Feld m an & Wilson , 1997; Go u ld et a l., 1996; Ka sh a n i et a l., 1989; Men n in ger, 1938).
The psychological model
Th e p sych o lo gica l m o d el, in q u a n tita tive a n d em p irical in vestm en t term s, is th e m od el th at h as received th e m ost th eoretical atten tion an d h as b een th e ob ject of ob servation an d clin ical atten tion sin ce Ésq u irol (1827), wh o d escrib ed su icid al in d ivid u als as alien ated , u n til th e p h e-n o m ee-n o lo gica l cu rree-n ts a e-n d p sych o a e-n a lysis, wh ich viewed su icid e a s th e resu lt o f m en ta l d isord er. Freu d (1917) con ten d ed th at su icid e is an aggression again st th e ob ject of an in tro-jected love with a n a m b iva len t in vestm en t. More recen t in tern a tion a l a n d Bra zilia n stu d -ies in th is field agree on th e p rin cip al risk fac-to rs fo r a d o lescen ts a n d yo u th , id en tified th ro u gh tren d a n a lyses, resea rch o n clin ica l treatm en t for relatives of su icid e victim s b ased o n p sych o lo gica l a u to p sies, o r q u a lita tive in -vestiga tio n with a cq u a in ta n ces o f victim s o f self-d estru ction .
(a ) first a n d fo rem o st, d ep ressive d iso rd ers. Hovey & Kin g (1996) p oin t ou t th at variou s rsearch ers h ave fou n d con n ection s b etween d e-p ression an d com m ittin g su icid e (Hob erm an &ame-p; Garfin kel, 1988); d ep ression an d su icid al id eas (Ha rter et a l., 1992); d ep ressio n a n d su icid o -gen ic b eh a vio r (Ro b b in s & Alessi, 1985); a n d la ck o f h o p e a s a sym p to m o r co m p o n en t o f d ep ressio n (Ca sso rla , 1984, 1987; Ca sso rla & Sm eke, 1994; Kash an i et al., 1989; Son en reich & Fried rich , 1984; Van san , 1987, 1988). Also cited a re th e weigh t o f d ifficu lties lin ked to m en ta l d evelop m en t an d cu m u lative stress; p osttrau -m atic disorder, especially caused by losses (Feld-m an &a(Feld-mp; Wilson , 1997); an d abuse of p sych oactive su b stan ces an d alcoh ol (Bren t et al., 1996; Cassorla & Sm eke, 1994; Coggan et al., 1997; Gold -sto n et a l., 1996; Go u ld et a l., 1996; Hovey & Kin g, 1996; Tu recki et al., 1999; Wilson , 1991).
Alth o u gh b a sed o n th e p sych o lo gica l ex-p la n a to r y m o d el, th e m a jo rity o f th e a b ove-m en tio n ed a u th o rs a lso lin k su icid e to so cia l in teraction , h igh ligh t th e relation al fam ily con -text a s n u clea r a n d fu n d a m en ta l to th e d evel-o p m en t evel-o f sevel-o cia liza tievel-o n a n d th e self-d estru c-tive p rocess. In 1987, Cassorla com m en ted th at b a sed o n h is stu d ies, m o st yo u n g in d ivid u a ls wh o com m it su icid e com e from b roken h om es. Th e sa m e o b ser va tio n wa s m a d e b y Va n sa n (1987, 1988); b a sed o n in ter views with fa m ily m em b ers a n d frien d s, h e id en tified 17 situ a -tion s th at cu lm in ated in th e in d ivid u als takin g th eir own lives.
In b oth th e n ation al an d in tern ation al con -text, as well as in d efen d in g or h igh ligh tin g an y of th e m od els, a ll of th e resea rch ers stress th e weigh t of fam ily p sych od yn am ics in relation to th e fo llowin g issu es: fa m ily h isto r y o f su icid e (Brid ge et a l., 1997); m u ltigen era tion a l fa m ily h istory with severe relation al p rob lem s su ch as d estru ctive b eh a vio r a n d vio len ce; d ivo rce, ab an d on m en t, lon g-lastin g con flict; em otion al ru p tu re, excessive fa m ily sym b io sis; rigid ity an d p olarization in relation s, real or im agin ary losses, low d egree of com m u n ication b etween p a ren ts th em selves a n d with th eir ch ild ren ; a n d exa cerb a ted a ggressiven ess. Su ch situ a tio n s en d u p iso la tin g yo u n g p eo p le fro m so -cia l gro u p s o f th eir own a ge a n d ca n ca u se o r a ggra va te p ro b lem s in sch o o l a n d la ck o f o r n ega tive p ersp ectives for th e fu tu re (Feld m a n & Wilso n , 1997; Go u ld et a l., 1996; Ka sh a n i et al., 1989). Th e latter au th ors fou n d a h igh in ci-d en ce of su icici-d e an ci-d attem p teci-d su icici-d e in very a ggressive yo u th a n d th o se with lega l p ro b -lem s, p ro d u cin g a so rt o f resp o n se to fla ws in affective relation s in volvin g loss, sep aration , or ab an d on m en t of wh ich th ey are victim s.
The nosological model
Th e n o so lo gica l m o d el views su icid e a s a d is-ease or th e resu lt of given illn esses. Som e in ter-p ret it as th e resu lt of ter-p sych oter-p ath ological d is-ord ers em ergin g over th e cou rse of m en tal illn ess, th u s as a sym p tom of th e u illn d erlyiilln g coilln -d ition . In recen t years variou s n eu rob iological stu d ies h ave sh own an association b etween re-d u cere-d sero to n in ergic a ctivity (th e p refro n ta l co rtex is in vo lved in execu tin g th e in h ib ito r y fu n ctio n ) a n d su icid a l b eh a vio r, esp ecia lly in cases with h eavy im p u lsive an d im p u lsiveaggressive traits. Based on a review of variou s au -th ors, Tu recki et al. (1999) fou n d -th at a red u c-tio n in p refro n ta l co rtica l a ctivity ca n p red is-p ose to self-d estru ction , sin ce su ch in d ivid u als ten d to a ct im p u lsively a n d self-a ggressively wh en exp osed to stressfu l situ ation s (Kraem er et a l., 1997; Ma n n et a l., 1998; Tu recki et a l., 1999; Va n sa n , 1988). Tu recki et a l. (1999) a lso ob served th at variou s gen etic/ ep id em iological stu d ies h a ve id en tified gen etic p ro b lem s th a t p rod u ce greater p red isp osition to su icid e, su ch as th e p resen ce of aggregation of certain fam ily typ es a ro u n d su icid a l id ea s, b eh a vio rs, a n d p ractices (Baech ler, 1975; Brid ge et al., 1997).
As o p p o sed to views o f su icid e b a sed o n a sin gle d iscip lin e, m ost su icid e research ers n ow ten d to con sid er it a com p lex p h en om en on d e-term in ed b y in tera ctio n s a m o n g va rio u s fa cto rs, a m o n gst wh ich th e b io lo gica l co n trib u -tion of in d ivid u als, th eir p erson al h istory, cir-cu m stan tial even ts, an d th e en viron m en t (Cas-sorla & Sm eke, 1994; Tu recki et al., 1999). Sev-eral au th ors q u estion th e existen ce of a sp ecif-ic p sych o d yn a m ecif-ic o r p erso n a lity a sso cia ted with su icid e. Fu rth erm ore, th ey gen erally an a-lyze th is p ro b lem a s a n esca p e fro m in ten se su fferin g, associated with fru strated n eed s in -volvin g a d ire stru ggle for su rvival an d u n b ear-ab le stress, a n arrowin g of op tion s, feelin gs of d esp air, h elp lessn ess, an d an irresistib le d esire to flee ( Ju ch em , 1998; Ka p la n et a l., 1997). An im p ortan t stu d y on ad olescen ts an d su icid e by Sam p aio (1991) calls atten tion to th e n eed for in terd iscip lin ary ap p roach es, with a system at-ic lin e co m b in in g so cia l, p sych o lo gat-ica l, a n d n osological d im en sion s, ob servin g an d an alyz-in g th e alyz-in teraction am on g factors an d th e d if-feren t co m b in a tio n a m o n g th em in ea ch sp e-cific case.
th e h ierarch y of d eath s in th is social grou p. In th e la st d eca d e th ey were resp o n sib le fo r a p -p roxim a tely seven o u t o f ten d ea th s a m o n g Brazilian you th in th e cou n try’s m ain cities.
Th erefore, th e m ain ob jective of th is stu d y is to an alyze su icid al b eh avior am on g you th in th e m ain u rb an areas of Brazil.
Material and methods
Th e ob jectives of th is article are as follows: (1) to p erfo rm a d escrip tive a n a lysis o f m o rta lity from su icid e in you n g p eop le 15 to 24 years of a ge in th e m a in Sta te ca p ita ls o f Bra zil fro m 1979 to 1998; (2) to id en tify th e sex a n d a ge gro u p s with th e h igh est in cid en ce o f su ch d ea th s; (3) to ch a ra cterize su ch su icid es b y typ e, m a rita l sta tu s, p la ce o f b irth , sch o o lin g, an d occu p ation ; (4) to com p are m ortality from su icid e a m o n g th e Bra zilia n Sta te ca p ita ls stu d ies (Belém , Fo rta leza , Na ta l, Recife, Sa l-va d o r, Belo Ho rizo n te, Vitó ria , Rio d e Ja n eiro, São Pau lo, Cu ritib a, an d Porto Alegre).
Th e so u rce o f m o rta lity d a ta wa s th e Mo r-ta lity In fo rm a tio n System (SIM) o f th e Bra zil-ia n Min istry of Hea lth (MS) (DATASUS, 1998). Th ese d a ta were co d ed b a sed o n th e In tern a -tion al Classifica-tion of Diseases (ICD), version s 9 (OMS, 1985) an d 10 (OMS, 1996). Th e p op u la-tion s u sed to calcu late th e rates were estim ated u sin g th e geom etric m eth od , b ased on th e 1980 an d 1991 n ation al cen su ses (IBGE, 1980, 1991).
We u sed Ep i In fo versio n 6.0 (CDC/ WH O, 1996) to ta b u la te th e d a ta a n d cro ss-a n a lyze th e va ria b les, Excel to co n stru ct m o rta lity sp rea d sh eets a n d p o p u la tio n p ro jectio n s, a s well as to calcu late statistical tests, an d Db ase III Plu s (Bo rla n d In tern a tio n a l, 1986) to rea d th e SIM d atab ase.
Th e d ata were an alyzed for th e years 1979, 1985, 1990, 1995, an d 1998 u sin g th e followin g in d icators: p rop ortion al m ortality from m ajor gro u p s o f ca u ses o f d ea th ; overa ll m o rta lity ra tes in th e 15 to 24-yea r a ge b ra cket; ra tes o f th e five p rin cip a l ca u ses o f d ea th ; m o rta lity rates for grou p s of sp ecific extern al cau ses; fre-q u en cies a n d p ro p o rtio n a l d istrib u tio n s o f d ea th s a cco rd in g to a ge b ra cket, sex, m a rita l statu s, an d sch oolin g. We calcu lated th e “t” sta-tistic to evalu ate d ifferen ces in relation to age b racket an d sex (Levin , 1985).
Results
As seen in Figu re 1, th e grou p of extern al cau s-es (also kn own as in ju ry an d p oison in g) sh owed a sign ifica n t p ro p o rtio n a l in crea se fro m 1979 to 1998.
From 1979 to 1998 th e p rop ortion of exter-n a l ca u ses o f m o rta lity fo r th e 15-24-yea r a ge b ra cket in crea sed fro m 58% to 74%, o r a n in -crea se o f 27.6%, in d ica tin g th a t yo u n g Bra zil-ian s are d yin g m ore from social cau ses th an b i-ological d iseases.
Injuries and poisoning 58%
Others 17%
Neoplasms 6%
Diseases of the respiratory system 5%
Diseases of the circulatory system 8%
Infectious and parasitic diseases 6%
1979 1998
Injuries and poisoning 74%
Diseases of the circulatory system 4%
Others 11%
Diseases of the respiratory system 3%
Infectious and parasitic diseases 4%
Neoplasms 4% Figure 1
Distribution of mortality among young people by major groups of causes in selected Brazilian State capitals* in 1979 and 1998.
Data in Tab le 1 sh ow th at m ortality rates for all cau ses (p er 100,000 in h ab itan ts) in th e 15 to 24-yea r a ge b ra cket in crea sed b y 39.7% fro m 1979 to 1998, from 138.0 to 192.8 in th e select-ed State cap itals. Th is in crease was d u e alm ost exclu sively to m o rta lity fro m in ju r y a n d p o i-so n in g, wh ich in crea sed b y 77.1% d u rin g th is p eriod , as com p ared to on ly 21.6% for th e over-all p op u lation .
Th is stu d y sh ows th at it was n ot on ly h om i-cid es th at in creased in Brazilian State cap itals, as h igh ligh ted by p reviou s stu d ies (Mello-Jorge et a l., 1997; So u za , 1995; Verm elh o, 1994). Alth ou gh Alth e ra tes a re rela tively low, su icid e in -crea sed b y 42.8% in th e selected ca p ita ls su rveyed fro m 1979 to 1998. Mea n wh ile, th e in -crease was on ly 27.3% in th e overall p op u lation . Da ta fro m Ta b le 2 sh ow th a t Sa lva d o r a n d Rio d e Jan eiro were th e cap itals with th e lowest su icid e rates, con trary to Belém , Cu ritib a, an d Po rto Alegre, wh ich sh owed th e h igh est ra tes d u rin g th e stu d y p eriod .
Ta b le 3 sh ows a n in crea se in th e a b so lu te n u m b er o f su icid es a n d m a le-to -fem a le m o r-tality ratio, i.e., in som e cases m ore th an th ree m ale su icid es p er fem ale su icid e from 1990 to 1995. Th ere wa s a lso a 54.7% in crea se in th e m ea n n u m b er o f su icid es p er m o n th over th e cou rse of th e p eriod stu d ied .
Accord in g to th e “t” test, su icid e on ly varied as a fu n ction of age in São Pau lo. In th is cap ital city, yo u n g p eo p le in th e 20-24-yea r b ra cket h ave a h igh er risk of d yin g from su icid e th an in th e 15-19-year b racket. Th is d ifferen ce was sta-tistically sign ifican t at th e 5% level.
Statistically sign ifican t differen ces (α= 0.05) were also ob served in m ortality from su icid e in
relation to gen d er on ly in th e cities of Fortale-za, Salvador, Belo Horizon te, Rio de Jan eiro, an d São Pau lo. In th ese cities th e risk of d yin g from su icid e was greater for m ales th an for fem ales.
In term s of socio-d em ograp h ic ch aracteris-tics, in keep in g with th e age b racket, m ore th an 80% o f th e yo u n g p eo p le wh o co m m itted su icid e were sin gle. Still, n early 10% were record -ed a s m a rri-ed (co n sid erin g th e yea rs 1979, 1985, a n d 1990). No te th a t so m e 1% were a l-rea d y wid owed (1990) o r lega lly sep a ra ted (1995), d esp ite th eir you n g age.
Fo r th e selected Sta te ca p ita ls a s a wh o le, th e vast m ajority of you n g su icid e victim s h ad o n ly p rim a r y sch o o lin g. However, in th e la st yea r stu d ied th eir wa s a p ro p o rtio n a l d ro p in th is gro u p, with a rise in th e p ro p o rtio n o f yo u n g p eo p le with m o re sch o o lin g. No te th e h igh p ercen ta ge o f u n available d atafo r th is variab le (ran gin g b etween 20% an d 30%, reach -in g 59% -in 1998), -in d ica t-in g th e p reca rio u s qu ality of th is in form ation . Con sid erin g th e 18-24-yea r a ge b ra cket, o n ly 3.5% o f th e yo u n g p eop le were en rolled in u n iversity, wh ile a fa r la rger p ro p o rtio n (49.0%) h a d o n ly p rim a r y sch o o lin g. Th is sh ows a h u ge gra d e/ a ge ga p am on g th ese you n g p eop le an d extrem ely low sch oolin g in th e grou p as a wh ole.
Th e m ajority of th e victim s (86%) were orig-in ally from th ese cap ital cities. As for occu p a-tion , th e m ajority were stu d en ts, with “m an u al la b o r” a s th e seco n d m o st freq u en t o ccu p a -tion . Over th e years th e p rop or-tion of u n avail-ab le d ata for th is variavail-ab le was som e 10%.
Tab le 4 lists in d ecreasin g ord er th e m ean s a n d p ro ced u res u sed b y yo u n g Bra zilia n s to com m it su icid e.
Table 1
Mortality rates* for young people 15 to 24 years old in selected Brazilian State capitals** according to major groups of causes.
Major groups of causes 1979 1998
no. Rate no. Rate
All causes 7,018 138.0 10,535 192.8
Injuries and poisoning 4,116 80.9 7,830 143.3
Suicide 177 3.5 275 5.0
Diseases of the circulatory system 545 10.7 374 6.8
Neoplasms 394 7.7 431 7.9
Infectious and parasitic diseases 387 7.6 454 8.3 Diseases of the respiratory system 374 7.4 325 5.9
Source: Mortality Information System, Ministry of Health (DATASUS, 1998). * Rates per 100,000 inhabitants 15 to 24 years old.
Accord in g to Tab le 4, h an gin g an d firearm s were th e first an d secon d m ost com m on m ean s u sed , resp ectively. Th ere was an in crease in th e u se o f firea rm s, su rp a ssin g h a n gin g in 1995 an d d rop p in g b ack to secon d p lace in 1998.
No te th e p reca rio u s n a tu re o f th e d a ta a s reflected by th e ca tego ry “oth er n on -sp ecified m ean s an d procedu res”, wh ich ap p ears in th ird place in the table, suggestin g in com plete record s on th e m ean s u sed to com m it su icid e.
Discussion
By wa y o f d iscu ssio n , th e fo llowin g rem a rks con cern th e in crease in su icid es am on g you n g Brazilian s, as ob served from th e d ata. First, we sh o u ld a sk wh eth er th is in crea se is rea l o r a n a rtifa ct, th e resu lt of im p roved q u a lity in d a ta rep ortin g an d record in g. Previou s stu d ies (MelloJorge, 1988; Sou za, 1991) h ave alread y h igh ligh ted p ro b lem s rela ted to d a ta q u a lity co n -cern in g th ese d eath s.
Th ere are several reason s for th e u n reliab il-ity o f th e d a ta , in clu d in g th e d ifficu lties th a t society an d in stitu tion s (esp ecially th e fam ily) h ave in d ealin g with th e issu e, ten d in g to avoid it, as well as tech n ical an d p rofession al sh ort-co m in gs in la w en fo rcem en t a gen cies a n d foren sic m ed ical facilities in d iagn osin g an d re-p o rtin g th is ca u se o f d ea th . In a d d itio n , Ca sso rla (1994) d iscu sses th e d ifficu lty in d istin -gu ish in g su icid e from th e overall set of violen t even ts, estim atin g th at th ere are actu ally som e ten tim es m ore su icid es in Bra zil th a n rep ort-ed . To o la n (1975) refers to th e sa m e situ a tio n in th e Un ited States, to th e p oin t of statin g th at 50% of d eath s rep orted as accid en tal are actu -a lly su icid es. His stu d ies, b -a cked b y o th ers, sh ow th a t som e a ccid en ts rep orted a s d rown -in g, m o to r veh icle co llisio n s, a n d p ed estria n d eath s m ay actu ally d isgu ise su icid es by you n g p eop le.
Su ch p rob lem s en d u p lead in g to an u n d er-estim ation of wh at are alread y trad ition ally low su icid e ra tes in Bra zil a n d certa in ly in flu en ce th e d ifferen t d istrib u tion s an d m agn itu d es ob ser ved fo r th e p h en o m en o n in th e cities a n a -lyzed h ere. Th u s, it is im p ossib le to sim p ly state th a t Sa lva d o r a n d Rio d e Ja n eiro h a ve lower ra tes, with o u t ta kin g in to a cco u n t th a t th ese two cities h a ve grea ter p ro b lem s in cla rifyin g th e cau se of d eath . Th is sam e im p act of qu ality o f in fo rm a tio n m a y h a ve led to a p p a ren tly h igh er rates in Porto Alegre an d Cu ritib a, sin ce th ese cities h a ve b etter d a ta o n d ea th s fro m su icid e.
Con sid erin g th e ab ove-m en tion ed d ifficu l-ties, it is clea r th a t a n y sta tem en t co n cern in g th e d a ta p resen ted h ere m u st b e m a d e with som e cau tion . With th is caveat, we p roceed to wo rk with th e h yp o th esis o f a rea l in crea se in su icid es a m o n g yo u n g p eo p le in th e m a in Brazilian State cap itals, a p h en om en on also in -d icate-d by Mello-Jorge & Gotlieb (2000).
As p ortrayed in th is stu d y, in u rb an areas of Brazil su icid e is th e sixth m ost freq u en t cau se of death am on g youn g p eop le, havin g in creased by 42.8% from 1979 to 1998. Th is sh ou ld b e em -p h asized es-p ecially d u e to its relevan ce for th e
Table 2
Suicide rates* among 15-24-years-old, by selected Brazilian State capitals.
Capital Year
1979 1985 1990 1995 1998
Belém 6.5 4.8 3.2 5.4 11.4
Fortaleza 5.3 2.9 3.8 6.0 5.3
Natal 3.1 1.8 4.0 5.0 1.4
Recife 2.2 2.2 4.8 6.1 3.9
Salvador 0.6 0.3 0.5 0.6 0.4 Belo Horizonte 3.7 2.9 5.8 5.8 7.2
Vitória 7.8 0.0 2.0 1.9 3.8
Rio de Janeiro 2.3 1.2 1.5 1.2 1.0 São Paulo 3.8 4.9 5.6 6.2 5.9 Curitiba 4.3 6.5 7.0 7.0 8.6 Porto Alegre 4.9 5.3 3.3 12.1 10.4
Total 3.5 3.4 4.0 4.9 5.0
Source: Mortality Information System, Ministry of Health (DATASUS, 1998). * Rates per 100,000 inhabitants 15 to 24 years old.
Table 3
Distribution of deaths from suicide according to sex, male-to-female ratio, and mean monthly suicides among 15-24-years-old in selected Brazilian State capitals*.
Deaths from suicide 1979 1985 1990 1995 1998
Sex
Male 110 128 156 208 201
Female 67 44 50 57 74
Total 177 172 206 265 275
Male-to-female ratio 1.6 2.9 3.1 3.6 2.7 Monthly mean 14.8 14.3 17.2 22.1 22.9
1524year age b racket, a fact in sisten tly h igh -ligh ted b y Ca sso rla in stu d ies ra n gin g fro m 1984 to 1998, callin g th e atten tion of th e Brazil-ian p u b lic sector an d society. Accord in g to on e stu d y (Ca ssorla , 1994), of a ll th e su icid e ca ses an alyzed in Cam p in as, São Pau lo State, 75% in -volved in d ivid u als u n d er 27 years of age.
Brazil d oes n ot h ave h igh su icid e rates in its overall m ortality p rofile as com p ared to official sta tistics fo r Eu ro p ea n co u n tries a n d even No rth Am erica n a n d so m e La tin Am erica n cou n tries (Mello-Jorge & Gotlieb, 2000). In th e Un ited States, for exam p le, su icid e is th e th ird m o st freq u en t ca u se o f d ea th a m o n g a d o les-cen ts an d you n g ad u lts. Ep id em iological d ata, wh o se rep o rtin g b a sis is o n e o f th e m o st cru -cia l p o in ts fo r d efin in g th e m a gn itu d e o f th e p h en om en on , in d icate th at su icid es rep resen t som e 4-5% of all violen t or accid en tal d eath s.
Alth o u gh sta tistica lly less sign ifica n t in Bra zil, su icid e h ere, a s in a n y so ciety, ca u ses d eep social com m otion , esp ecially wh en it oc-cu rs in th e you n g p op u lation . Viewin g th e p h e-n om ee-n oe-n ie-n term s of social p rocesses, th e sig-n ifica sig-n t isig-n crea se isig-n su icid e ra tes ca u ses grea t co n cern , sin ce it o ccu rred in th e sa m e a ge b ra cket a n d d u rin g th e sa m e p erio d in wh ich th ere was a m ajor in crease in h om icid e rates.
It is b elieved th a t th e gro u p o f yo u n g p eo -p le stu d ied h ere were su b ject to a d verse life circu m sta n ces, a s d em o n stra ted b y th e d a ta , m akin g th em m ore vu ln erab le to su icid e. Lim -ited sch o o lin g is o n e su ch ch a ra cteristic. Th e d a ta a n a lysis sh ows th a t th e va st m a jo rity o f th e you n g p eop le h ad on ly p rim ary sch oolin g, in d icatin g a large age/ grad e gap for stu d en ts or th e fact th at th ey h ad to leave sch ool to look for work.
Th e fact th at a p ortion of th e you n g su icid e victim s were u n skilled m a n u a l la b o rers is b acked by th eir low sch oolin g. Th ese com b in ed factors m ean a con text of lack of social p rosp ects a lo n g with jo b in secu rity, sin ce skilled p o si-tio n s in th e cu rren t la b o r m a rket req u ire th a t in d ivid u a ls h a ve a t lea st a seco n d a r y sch o o l d ip lom a or som e tech n ical/ vocation al cou rse.
Th e ch a ra cteristics o f low sch o o lin g a n d lowp aid occu p ation s in th e grou p stu d ied ap -p ear to in d icate th at th e weigh t of social -p ressu re co m b in ed with h a vin g to d ea l with stu d -ies, in creased job com p etition , an d an in crease in in form al over form al work is gen eratin g in -secu rity fo r th ese yo u n g p eo p le in term s o f th eir own su rviva l a n d in flu en cin g th eir d eci-sion to give u p livin g. At a m om en t of tran sition in th e form s of p rod u ction an d social relation s resu ltin g from th em , you th are th e m ost h eavi-ly jeo p a rd ized in th eir a ttem p t to p a rticip a te,
wh en th e econ om y is sp arin g lab or, wh en lab or rela tio n s a re flexib ilized , a n d wh en p ro sp ects for th e cou n try’s fu tu re h ave virtu ally b een re-d u cere-d to a n issu e o f in re-d ivire-d u a l co m p etitio n . Th u s, as d iscu ssed ab ove, it is n ecessary to u n -d erstan -d th e sim u ltan eou s occu rren ce of in -d i-vid u a l gen etic a n d p sych o lo gica l fa cto rs (i.e., wh a t exp la in s th e fa ct th a t n o t a ll th o se ex-p o sed to th e sa m e ex-p ro b lem s kill th em selves?) a ggra va ted b y so cio eco n o m ic, p o litica l, a n d cu ltu ra l fa cto rs in th e gen esis o f su icid e. Yet o n e sh o u ld a lso view th is a n a lysis with so m e ca u tio n , d u e to th e h igh p ro p o rtio n s o f u n -a v-a il-a b le d -a t-a fo r im p o rt-a n t v-a ri-a b les like sch oolin g an d occu p ation .
We feel th at fu rth er research is n eed ed as to wh eth er th e Bra zilia n p h en o m en o n o f a n in -creasin g n u m b er of fam ilies organ ized with ou t a fath er figu re (d u e to sep aration or d eath , of-ten vio len t) is a sso cia ted with in crea sin g su icid e rates am on g you th . Research is also n eed -ed to learn h ow th is exp erien ce of fam ily b reak-d own co m b in ereak-d with low sch o o lin g o f th ese yo u n g p eo p le a n d th eir lim ited o ccu p a tio n a l skills act join tly to fu el th eir feelin gs of d esp air an d lack of h op e for th e fu tu re. It wou ld also b e im p ortan t to in vestigate you n g Brazilian s’ cu r-ren t level of religiou s an d com m u n ity in tegra-tio n , th eir ca p a city fo r reco n cilia tegra-tio n a n d re-silien ce, an d th e relation sh ip am on g th ese var-io u s fa cto rs a n d su icid e. However, a n swers to th ese qu estion s are on ly p ossib le th rou gh qu al-itative ap p roach es or a com p arison of statistical con stru cts with com p reh en sive in form ation .
Wh at is u n an im ou s in th e literatu re is th at d ep ression in creases th e risk of con ceivin g, at-tem p tin g, an d com m ittin g su icid e. However, it wo u ld a m a jo r step fo r wa rd in kn owled ge o f th is p h en o m en o n if th e typ e o f d ep ressio n were sp ecified . Th e m a in a p p ro a ch to it h a s b een b io -p sych o lo gica l. It is wo rth wh ile h ere
Table 4
Distribution of principal means used by young Brazilians to commit suicide and State capitals where they were used most frequently, 1998.
Means used State capitals
1st Hanging, strangling, and suffocation Porto Alegre 2nd Firearms and explosives Belo Horizonte 3rd Other non-specified means and procedures Belém 4th Sharp and/or pointed instruments São Paulo 5th Solid or liquid substances Belém 6th Leaping off high places Vitória
to ch a llen ge th e lim ited so cia l fo cu s a d o p ted by p sych o-social stu d ies, virtu ally restricted to fam ily factors, an d to h igh ligh t th e n eed to ex-p a n d th is fo cu s. In gen era l, th ese a ex-p ex-p ro a ch es overlo o k th e effects th a t eco n o m ic a n d so cia l d ep ressio n ca n h a ve o n su icid a l b eh a vio r. In th e case of you n g Brazilian s, it is im p ortan t to a ttem p t to u n veil th e ro le o f serio u s so cia l p rob lem s (la ck of sch oolin g, lim ited work op -p o rtu n ities, -p overty, a n d th e risk o f d o m estic violen ce in th eir area of resid en ce, am on g oth -ers) in th e o ccu rren ce o f a n d in crea se in su i-cid es, an d h ow th ese m acrosocial factors act in the con scien ce an d subjectivity of youn g people. So m e d em o gra p h ic a n d ep id em io lo gica l h yp oth eses ap p eal to th e p op u lation stru ctu re a s a wa y o f u n d ersta n d in g th e d yn a m ic in ter-p la y o f vio len ce in flicted b y o th ers a n d o n e’s self. Accord in g to th is view, societies with old er p op u lation s ten d to h ave h igh er m ortality from su icid e, wh ile th ose with you n ger p op u lation s a re m o re p ro n e to h igh h o m icid e ra tes. In Brazil, wh ose p op u lation is m ostly you n g, th is b eh a vio r is exp ressed in th e h igh h o m icid e rates an d low su icid e rates.
In ep id em iological term s, it h as trad ition al-ly b een ob served th at cou n tries with h igh su i-cid e ra tes h a ve low h o m ii-cid e ra tes a n d vice versa. In th e first case violen ce is felt to b ecom e self-d irected d u e to greater rep ression an d th e in tro jected d em a n d s o f so cia l n o rm s, va lu es, a n d co n tro ls. In th e la tter ca se, o u twa rd ly d i-rected violen ce is m arked by fru strated asp ira-tion s an d exp ectaira-tion s, esp ecially am on g you n g p eop le, for wh om b asic righ ts an d n eed s are in -ad equ ately m et. Th e flaw in th ese argu m en ts is th eir m ech an istic ap p roach , sin ce th ey are n ot b a sed o n th e so cieties’ d yn a m ic rea lities, a n d a lso b eca u se th ere a re co u n tries wh o se ep i-d em iologica l p rofiles i-d em on stra te th a t th is is n ot a u n iversal ru le.
Ch esn a is, in h is b roa d socio-d em ogra p h ic stu d y of m ortality from extern al cau ses in two cen tu ries o f Eu ro p ea n h isto ry, a n a lyzin g d a ta o n vio len ce d a ta fro m 1780 to 1981, o b ser ved th a t “at th e base of both h om icid e an d su icid e on e fin d s th e sam e aggressive im p u lses of in d i-vid u als”(Ch esn a is, 1981:191). Co rro b o ra tin g th e a u th o r’s th in kin g, so m e em p irica l stu d ies con trad ict th e n otion of an op p osition b etween th ese two p h en om en a. Exam p les of th eir con -vergen ce a re fo u n d in th e h isto rica l series o n violen t d eath s in th e Un ited States, wh ere su i-cid e an d h om ii-cid e rates follow p arallel cu rves, with th e sa m e p ea ks a n d va lleys, with b o th rates h igh in th e years 1929-1930, exactly in th e con text of th e in fam ou s Great Dep ression (Mer-cy et a l., 1993). An o th er recen t ca se is th a t o f
Colom b ia (Agu d elo, 1999), wh ere b oth su icid e an d h om icid e rates are h igh . Th e op p osite situ -a tio n -a lso o ccu rs, -a s in En gl-a n d , wh ere b o th p h en om en a are rare. Ap p aren tly (an d th e cu r-ren t stu d y ca n o n ly ra ise th is a s a h yp o th esis) wh a t is h a p p en in g in th e Bra zilia n ca se is th e b egin n in g of a con vergen ce b etween h om icid e a n d su icid e ra tes a m o n g yo u n g p eo p le, a l-th ou gh l-th e la tter p h en om en on is still sta tisti-cally in sign ifican t.
In its so cia l co n figu ra tio n so m e clu es a re p rovid ed b y d o m estic a n d in tern a tio n a l ep i-d em iological an alyses: th e m ajority of su icii-d es am on g you n g p eop le occu r at h om e; p oor rela-tion s with th e m oth er figu re are on e of th e risk fa cto rs; th e in stru m en ts u sed in self-d estru c-tion d ep en d on given loca l u ses a n d cu stom s, as well as d ifferen t h istorical con texts; th ere is a sign ifican t relation sh ip b etween rep eated at-tem p ts an d actu al p erp etration of th e act; th ere is evid en ce th a t yo u n g p eo p le with self-d estru ctive id eas ten d to give sign s of a d eath im -p u lse b efore th ey con su m m ate it, es-p ecially by m ea n s o f sym p to m s o f d ep ressio n a n d iso la -tio n ; su icid e ra tes a re u su a lly h igh er a m o n g you n g m ales an d sin gle in d ivid u als; an d a m a-jo r p o rtio n a re n eith er en ro lled in sch o o l o r workin g wh en th ey com m it su icid e.
In th e d a ta p resen ted a b ove, we n o te th a t suicides are distributed heterogen eously am on g th e Brazilian State cap itals, in d icatin g Salvad or a n d Rio d e Ja n eiro a s th o se with th e lowest ra tes. Fo r th e ep id em io lo gica l level a t wh ich th e d ata were an alyzed (an d for th e d ata qu ali-ty) it was im p ossib le to estab lish a cau sal rela-tion sh ip. Still, it wou ld b e p ossib le to raise th e h yp oth esis id en tified by Ch esn ais (1981) – an d b a cked by Du rkh eim (1982) – wh en a n a lyzin g th e d ata on th ese even ts in Eu rop e. Th e id ea is th at th e greater or lesser op p ression of th e socio cu ltu ra l m ed iu m o n yo u n g p eo p le in flu -en ces su icide rates. Tradition ally, Rio de Jan eiro a n d Sa lva d o r a re two co sm o p o lita n a n d even “festive” cities, wh ere th e p lu ra lity o f cu ltu ra l o p tio n s is m u ch m o re evid en t th a n in o th er p la ces o f Bra zil. Certa in ly, o th er h yp o th eses su ch as Eu rop ean in flu en ces in sou th ern Brazil (sin ce su icid e is m u ch m ore frequ en t in all age b ra ckets in Eu ro p e th a n in Bra zil) co u ld b e raised, in addition to differen ces in data record-in g an d q u ality. However, at b est, th e d ata d iscu ssed in th is article call for research of a com -p reh en sive n atu re on th e -p h en om en on , wh ich can n ot b e red u ced to its qu an tification .
e-cia l stu d ies o n th e p roxim ity a n d in flu en ce o f in d igen o u s cu ltu re, sin ce in d igen o u s p eo p les h a ve b een id en tified a s h a vin g h igh su icid e ra tes a m o n g th eir yo u th (Erth a l, 1998; Terra , 1994).
In five of th e n in e cities stu d ied (Fortaleza, Sa lva d o r, Belo Ho rizo n te, Rio d e Ja n eiro, a n d São Pau lo) th ere were sign ifican t gen d er d iffer-en ces, sin ce m ore m iffer-en th an wom iffer-en com m itted su icid e. Co n sid erin g a ge b ra ckets, Sã o Pa u lo was th e on ly city wh ere 20-24-year-old s h ad a h igh er an d statistically m ore sign ifican t risk of com m ittin g su icid e th an 15-19-year-old s.
On e sh o u ld th u s b e a lert to gen d er d iffer-en ces in su icid al b eh avior. It is well-kn own th at m o re m en th a n wo m en a ctu a lly co m m it su i-cid e, wh ile wo m en m a ke m o re su ii-cid e a t-tem p ts (esp ecially you n g an d eld erly wom en ). Th e stu d y sh owed a 3:1 m a le-to -fem a le ra tio am on g su icid e victim s. Note th at th e in crease in d eath s from extern al cau ses h as h ad a n ega-tive im p act on th e m ean life exp ectan cy of m en a s co m p a red to wo m en , with th e la tter livin g som e 6 years lon ger th an th eir p artn ers, on av-erage.
Th u s, gen d er issu es a n d a ge stru ctu re a re im p orta n t to h elp u n d ersta n d th e typ e of vio-len ce in a given a rea . Acco rd in g to Co rrêa (1996), a ge stru ctu re fa cto rs sh ow th a t th e el-d erly p o p u la tio n ru n s a h igh er risk o f el-d yin g from su icid e as com p ared to you n g p eop le. In ad d ition , m arital statu s is also a u n iversal d if-feren tia tin g fa cto r fo r su icid e. Wo rld wid e, a m ajor p ortion of su icid e victim s are sin gle, d i-vorced , or wid owed . Based on th e d ata p resen t-ed in th is article, from th is an gle th e Brazilian cities con firm th e tren d : m ore th an 80% of th e yo u n g su icid e victim s were sin gle. Of co u rse th is by itself is n ot h igh ly sign ifican t, given th e age b racket stu d ied . Wh at calls on e’s atten tion is th e p resen ce of wid owed an d sep arated in d i-vid u a ls in su ch a yo u n g gro u p. No te th a t fa c-to rs su ch a s lo n elin ess a n d la ck o f em o tio n a l ties (con d ition s m ore com m on am on g th e sin -gle, wid owed , an d sep arated ) are id en tified as exp lan atory factors for com m ittin g su icid e.
As for th e m ea n s u sed by you n g Bra zilia n s to ta ke th eir own lives, h a n gin g a n d firea rm s were th e m ost com m on . Th is p referen ce is n ot a co in cid en ce. Th e p eo p le’s d esire to p ro tect th em selves fro m u rb a n vio len ce, a lo n g with th e ease in ob tain in g firearm s, m ean th at in d i-vid u a ls to ta lly u n p rep a red a n d u n tra in ed to h a n d le su ch wea p o n s b eco m e verita b le tim e b om b s. Th ey ru n th e con stan t risk of h u rtin g or killin g others or them selves. In a study on Am er-ican society, Mercy et al. (1993) n oted th at p
ossession of a firearm in creases 43fold th e p rob -a b ility o f -a crim e o ccu rrin g in th e h o u seh o ld , wh eth er a ga in st th e in d ivid u a ls th em selves, th eir fa m ily, o r o th er fa m ilia r o r u n fa m ilia r th ird p arties.
Conclusion
Th is stu d y h igh ligh ts th e n eed to co n d u ct in -d ep th resea rch a im e-d a t a n u n -d ersta n -d in g o f th e im p a ct o f in d ivid u a l, so cio -cu ltu ra l, a n d gen etic factors (all widely referred to in the liter-atu re) on su icid e am on g you n g Brazilian s, h ow su ch factors act, an d th e ways th eir in teract.
Th e greatest con trib u tion of ep id em iologi-ca l stu d ies on su icid e is th eir iologi-ca p a city to m a p risks in areas an d grou p s, exp an d in g th e an aly-sis of social an d cu ltu ral factors related to th is p h en o m en o n . In th e cu rren t stu d y, grea ter risks were ob served in certain Brazilian cities, am on g m en , an d in th e 20-24-year age b racket. However, stu d ies like th is a re n o t ca p a b le o f id en tifyin g th e m od e of in flu en ce of m an y fac-tors cited in th e Brazilian an d in tern ation al lit-erature, thus requirin g sp ecific further research . Variou s stu d ies in d icate a sp ecific in crease in h o m icid es a m o n g in crea sin gly yo u n ger m ales. However, self-in flicted violen ce, alth ou gh n ot on th e sam e p rop ortion , h as also ten d ed to o ccu p y a n im p o rta n t p la ce in th e set o f fa ta l even ts am on g you th . Alth ou gh th e in cid en ce of su icid e in th is a ge b ra cket h a s still n o t ca lled th e atten tion of h ealth p rofession als an d p oli-cy-m a kers, in ligh t o f th e u n m ista ka b le rele-va n ce o f h o m icid e ra tes, o n e ca n n o t tu rn a d eaf ear on th e in crease in th is p h en om en on as p art of th e overall socio-p sych o-en viron m en tal “m a la ise” exp erien ced in key u rb a n a rea s o f Brazil.
References
AGUDELO, S. F., 1999. El Qu in to: N o M atar.Bo go tá : TM Ed itores.
BAECHLER, J., 1975. Les Su icides.Paris: Ed itorial Cal-m an -Lévy.
BORLAND INTERNATIONAL, 1986. D-Base III. Scotts Valley: Borlan d In tern ation al.
BRENT, D. A.; MORITZ, G.; BRIDGE, J.; PERPER, J. & CANOBBIO, R., 1996. Lon g-term im p act of exp o-su re to o-su icid e: A th ree year con trolled follow-u p. Jou rn al of th e Am erican Acad em y of Ch ild an d Adolescen t Psych iatry,35:646-653.
BRIDGE, J. A.; BRENT, D. A.; JOH NSON, B. A. & CONOLLY, J., 1997. Fa m ilia l a ggrega tio n o f p sy-ch iatric d isord ers in a com m u n ity sam p le of ad o-lescen ts. Jou rn al of th e Am erican Acad em y of Ch ild an d Adolescen t Psych iatry,36:628-636. CASSORLA, R. M. S., 1984. Joven s qu e ten tam su icídio:
An teced en tes m órb id os e d e con d u tas au to-d es-tru tivas. Jorn al Brasileiro de Psiqu iatria, 33:93-98. CASSORLA, R. M. S., 1987. Com p ortam en tos su icid as n a in fân cia e n a ad olescên cia. Jorn al Brasileiro de Psiqu iatria, 36:137-150.
CASSORLA, R. M. S. & SMEKE, E. L. M., 1994. Au to -d estru ição h u m an a. Cad ern os d e Saú d e Pú blica, 10(Su p. 1):61-73.
CDC (Cen ters fo r Disea se Co n tro l a n d Preven tio n )/ WHO (World Health Organ ization ), 1996. Epi In fo 6, Version 6.04. A Word Processin g, Database, an d Statistics Program for Pu blic Health. Atla n ta : CDC/ Gen eva: WHO.
CHESNAIS, J. C., 1981. Histoire de Violen ce.Paris: Éd i-torial Plu riel.
COGGAN, C.; PATTERSON, P. & FILL, J., 1997. Qu ali-ta tive d a ali-ta fro m fo cu s gro u p in ter views with you th . Jou rn al of Pu blic Health, 45:1563-1570. CORRÊA, A. C. O., 1996. Dep ressão e su icíd io n o id
o-so: Um a qu estão cru cial em p sicogeriatria. Jorn al Brasileiro de Psiqu iatria, 45:149-157.
DATASUS (Dep a rta m en to d e In fo rm á tica d o SUS), 1998. Sistem a d e In form ações sobre Mortalid ad e, 1979-1997: Dad os d a Declaração d e Óbito. CD-ROM. Brasília: Min istério d a Saú d e.
DURKH EIM, E., 1982. O Su icíd io. Lisb o a : Ed ito ria l Presen ça.
ERTHAL, R. M. C., 1998. O Su icíd io Ticu n a n a Região d o Alto Solim ões.Tese d e Do u to ra d o, Rio d e Ja n eiro : Esco la Na cio n a l d e Sa ú d e Pú b lica , Fu n -d ação Oswal-d o Cru z.
ÉSQUIROL, J. E., 1827. Su r la Mon om an ie Su icid e. Paris: Ed itorial Calm an -Lévy.
FELDMANN, M. & WILSON, A., 1997. Ad olescen t su i-cid a lity in u rb a n m in o rities a n d its rela tio n sh ip to con d u ct d isord ers, d ep ression an d sep aration an xiety. Jou rn al of Ch ild an d Adolescen t Psych ia-try,36:75-84.
FREUD, S., 1917. Deu il et M élan colie.Paris: Éd ition s Gallim ard .
GOLDSTON, D. B.; DANIEL, S.; REBOUSSIN, D. M.; KELLEY, A.; IEVERS, C. & BRUNSTETTER, R., 1996. First-tim e a ttem p ters, rep ea t a ttem p ters, an d p reviou s attem p ters on an ad olescen t in p a-tien t p sych ia tr y u n it. Jou rn al of th e Am erican
Acad em y of Ch ild an d Ad olescen t Psych iatry,
35:631-639.
GOULD, M. S.; FISHER, P.; PARIDES, M.; FLORY, M. & SHAFFER, D., 1996. Psych ologica l risk fa ctors of ch ild an d ad olescen t com p leted su icid e. Arch ives
of Gen eral Psych iatry,53:1155-1162.
JUCH EM, E., 1998. Revisão Literária sobre Su icíd io. Porto Alegre: Un iversid ad e Fed eral d o Rio Gran d e d o Su l. (m im eo.)
H ARTER, S.; MAROLD, D. B. & WH ITESELL, N. R., 1992. Mod el of p sych osocia l risk fa ctors lea d in g to su icid a l id ea tio n in yo u n g a d o lescen ts.
Psy-ch opath ology, 4:167-188.
HOBERMAN, H. M. & GARFINKEL, B. D., 1988. Com -p leted su icid e in ch ild ren an d ad olescen ts. Jou r-n al of th e Am ericar-n Academ y of Ch ild ar-n d
Adoles-cen t Psych iatry, 27:689-695.
HOVEY, J. D. & KING, C. A., 1996. Accu ltu rative stress, d ep ressio n , a n d su icid a l id ea tio n a m o n g im m i-gran t an d secon d -gen eration Latin o ad olescen ts.
Jou rn al of th e Am erican Acad em y of Ch ild an d
Adolescen t Psych iatry, 35:1183-1192.
IBGE (Fu n d a çã o In stitu to Bra sileiro d e Geo gra fia e Esta tística ), 1980. Cen so Dem ográfico 1980.Rio d e Jan eiro: IBGE.
IBGE (Fu n d a çã o In stitu to Bra sileiro d e Geo gra fia e Estatística), 1991.Cen so Dem ográfico 1991: Resu l-tad os d o Un iverso Relativos às Características d a
Popu lação e do Dom icílio.Rio d e Jan eiro: IBGE.
KAPLAN, H . I.; SADOCK, B. I. & GREBB, J. A., 1997.
Com p ên d io d e Psiqu iatria: Ciên cias d o Com p
or-tam en to e Psiqu iatria Clín ica. Porto Alegre: Artes
Méd icas.
KASHANI, J. H.; REID, J. & ROSENBERG, T., 1989. Lev-els of h op elessn ess in ch ild ren an d ad olescen ts: A d evelop m en tal p ersp ective. Jou rn al of Con su
lt-in g an d Cllt-in ical Psych ology, 57: 496-499.
LEVIN, J., 1985. Estatística Ap licad a a Ciên cias Hu -m an as. 2aEd . Sã o Pa u lo : Ed ito ra Ha rp er & Row d o Brasil.
MANN, J. J., 1998. Th e n eu ro b io lo gy o f su icid e. N
a-tu re Medicin e,4:25-30.
MELLO-JORGE, M. H . P., 1988. In vestigação Sobre a Mortalid ad e p or Acid en tes e Violên cia n a In fân -cia.Tese d e Livre Docên cia, São Pau lo: Facu ld ad e d e Saú d e Pú b lica, Un iversid ad e d e São Pau lo. MELLO-JORGE, M. H. P.; GAWRYSZEWSKI, V. P. &
LA-TORRE, M. R. D. O., 1997. An á lise d o s d a d o s d e m ortalid ad e. Revista de Saú de Pú blica, 31(Su p. 4): 5-25.
MELLO-JORGE, M. H. P. & GOTLIEB, B. L. D., 2000. As
Con dições de Saú de n o Brasil. Rio d e Jan eiro: Ed
i-tora Fiocru z.
MENNINGER, K., 1938. M an Again st Him self. Ne w York: Harcou rt Brace.
MERCY, J. A.; ROSENBERG, M. L.; POWELL, K. E.; BROOME, C. V. & ROPER, W. L., 1993. Pu b lic h ealth p olicy for p reven tin g violen ce. Health Af-fairs, 12:7-29.
OMS (Organ ização Mu n d ial d a Saú d e), 1985. Man u al d a Classificação Estatística In tern acion al d e Doen ças, Lesões e Cau sas de Óbitos – Non a Con ferên -cia d e Revisão. Sã o Pa u lo : Cen tro Bra sileiro d e Classificação d e Doen ças em Portu gu ês. OMS (Organ ização Mu n d ial d a Saú d e), 1996. CID–10.
QUÉTELET, A., 1835. Su r l’Hom m e et le Develop m en t de ses Facu ltés, ou Éssai de Ph ysiqu e Sociale. Paris: Éd itorial Bach elier.
ROBBINS, D. R. & ALESSI, N. E., 1985. Dep ressive sym p tom s an d su icid al b eh avior. Am erican Jou r-n al of Psych iatry,142:588-592.
RODRIGUES, J. C., 1983. Tabu da Morte. Rio d e Jan ei-ro: Ed itora Ach iam é.
SAMPAIO, D., 1991. N in gu ém Morre Sozin h o: O Ad o-lescen te e o Su icíd io.11aEd . Lisb o a : Ed ito ria l Cam in h o.
SONENREICH, C. & FRIEDRICH, S., 1984. Su icíd ios: Asp ectos p siqu iátricos. Tem as,26:49-61. SOUZA, E. R., 1991. Violên cia Velada e Revelada: Estu
-do Epidem iológico da Mortalidade por Cau sas Ex-tern as em Du qu e d e Cax ias – RJ. Disserta çã o d e Mestra d o, Rio d e Ja n eiro : Esco la Na cio n a l d e Saú d e Pú b lica, Fu n d ação Oswald o Cru z. SOUZA, E. R., 1995. Hom icíd ios: Metáfora d e u m a
Nação Au tofágica. Tese d e Dou torad o, Rio d e Jan eiro : Esco la Na cio Jan a l d e Sa ú d e Pú b lica , Fu Jan -d ação Oswal-d o Cru z.
SOUZA, E. R. & MINAYO, M. C. S., 1995. O im p acto d a violên cia social n a saú d e p ú b lica d o Brasil: Déca-d a Déca-d e 80. In : Os Mu itos Brasis: Saú de e Pop u lação n a Décad a d e 80 (M. C. S. Min a yo, o rg.), p p. 87-116, Sã o Pa u lo : Ed ito ra Hu citec/ Rio d e Ja n eiro : ABRASCO.
TERRA, A. R., 1994. O Su icíd io d e Joven s In d ígen as Kayow as de Dou rados: Um a Explicação Psicológi-ca.Dissertação d e Mestrad o, Cam p in as: Un iver-sid ad e Estad u al d e Cam p in as.
TOOLAN, J. M., 1975. Su icid e in ch ild ren an d ad oles-cen ts. Am erican Jou rn al of Psych oth erapy, 29:339-344.
TURECKI, G.; BRIERE, R.; DEWAR, K.; ANTONETTI, T.; LESAGE, A. D.; SEGUIN, M.; CH AWKY, N.; VANIER, C.; ALDA, M.; JOOBER, R.; BENKELFAT, C. & ROULEAU, G. A., 1999. Pred iction of level of sero to n in 2A recep to r b in d in g b y sero to n in re-cep tor 2A gen etic variation in p ostm ortem b rain sa m p les fro m su b jects wh o d id o r d id n o t co m -m it su icid e. Am erican Jou rn al of Psych iatry, 156:1456-1458.
VANSAN, G. A., 1987. Asp ectos esp ecíficos d os m eios u tilizad os p elos su icid as n o Mu n icíp io d e Rib ei-rão Preto. Neu robiologia,50:281-288.
VANSAN, G. A., 1988. Sep a ra çã o p a ren ta l e su icíd io. Neu robiologia,51:57-66.
VERMELHO, L. L., 1994.Mortalid ad e d e Joven s: An á-lise d o Períod o d e 1930 a 1991 – A Tran sição Ep i-dem iológica para a Violên cia.Tese d e Dou torad o, São Pau lo: Facu ld ad e d e Saú d e Pú b lica, Un iversi-d aiversi-d e iversi-d e São Pau lo.
WILSON, G. L., 1991. Su icid al b eh avior: Clin ical con -sid eration s an d risk factors. Jou rn al of Con su ltin g an d Clin ical Psych ology, 59:869-873.
Su b m itted on 8 May 2001
