Suicidal Behavior in Metropolitan France: Results of the 2014 Health Barometer

© Frédéric Mercier - Vincent Galtier

This 36th issue of the "Évolutions" series analyzes data from Santé publique France’s 2014 Health Barometer regarding suicide. The results confirm the significance of the suicide phenomenon in the general population and the need for targeted and effective prevention measures. In France, suicide mortality and suicide attempts resulting in hospitalization are studied using medical-administrative surveillance data. Barometer surveys are an indispensable complement to this information, as they provide prevalence data on suicidal thoughts and suicide attempts that are representative of the situation in the general population. They also help identify certain vulnerability profiles regarding these behaviors. The 2014 survey shows, for example, that among respondents aged 15–75, 4.9% reported having had suicidal thoughts during the past year and 7.1% had attempted suicide (SUI) at some point in their lives. Another finding: more women than men report suicidal thoughts and suicide attempts over the course of their lives, and the most disadvantaged individuals (the unemployed or economically inactive, those with low levels of education or financial difficulties, and isolated individuals) are overrepresented. Furthermore, suicide attempts are more common among young people and decrease with age. Suicidal thoughts, on the other hand, are more common among those aged 45–64. The survey also notes an increase in these phenomena between 2010 and 2014, with prevalence rising from 4.0% to 4.9% for suicidal thoughts and from 0.5% to 0.8% for suicide attempts. Finally, only 53.0% of people who had suicidal thoughts during the year spoke to someone about them, and 42.0% of men who attempted suicide during the year did not go to the hospital and were not treated by a professional.

Suicide attempts among sexual minorities

Since the 1990s, several studies conducted primarily in the United States have shown that the prevalence of suicide attempts was very high among sexual minorities compared to the heterosexual population. In France, the Gay Press Surveys conducted by Santé publique France via the press and identity-based websites were the first to include specific questions on suicidal behavior. In the 2011 Gay and Lesbian Press Survey, 10,100 men and 2,963 women residing in France answered questions about suicide attempts. Among the respondents, 16% of men and 18% of women reported having made at least one suicide attempt in their lifetime, and 1.6% of men and 1.9% of women in the past year. Factors associated with an increased risk of suicide attempts in the past year among men and women included being unemployed, having been a victim of forced sexual intercourse at some point in their lives, having ended a stable relationship in the past year, having consumed alcohol excessively, and reporting depression. Furthermore, among men, living in a small town, having experienced physical and/or verbal assaults due to their sexual orientation, and having used anxiolytics in the past year increased the likelihood of attempting suicide within the year. Thus, combating homophobia must be a key element in preventing suicidal behavior among sexual minorities, as homophobic assaults represent a risk factor for suicide attempts among gay and bisexual men.

Suicide Attempts in the Health Barometer for the Deaf and Hard of Hearing

In line with the Health Barometers, the Deaf and Hard-of-Hearing Health Barometer (BSSM), conducted in 2011–2012, specifically targeted people living with reduced hearing acuity or hearing disorders (tinnitus and hyperacusis). Compared with data from the 2010 Health Barometer, the BSSM data showed that deaf and hard-of-hearing individuals reported having suicidal thoughts 5 times more often in the past 12 months, made suicide attempts 2.5 times more often in their lifetime, and made suicide attempts 3.6 times more often in the past 12 months than the general population.The higher prevalence of suicidal thoughts in the past 12 months among deaf and hard-of-hearing individuals was associated with both hearing-related factors (communication fatigue and the presence of highly disruptive hearing impairments) and psychological and physical violence experienced.

PMSI and OSCOUR®: Hospitalizations for Suicide Attempts

The Program for the Medicalization of Information Systems (PMSI) was used by the InVS to analyze hospitalizations for suicide attempts (SA). In mainland France, between 2004 and 2011, a total of 765,616 hospital stays for SU were recorded in medical and surgical departments, corresponding to 556,708 patients, or approximately 90,000 hospitalizations for 70,000 patients per year. Over the eight years studied, 80% of patients were hospitalized once and 20% were hospitalized multiple times for suicide attempts. In every year, female hospitalizations accounted for 65% of all hospitalizations for suicide attempts. Drug ingestion was by far the most common method of suicide attempt, accounting for 82% of hospitalized suicide attempts, or between 70,000 and 85,000 hospital stays per year. The rate of hospitalizations for suicide attempts was 17.7 per 10,000 population (13.4 per 10,000 men and 21.6 per 10,000 women). Hospital stays for suicide attempts among adolescents aged 15 to 19 had the highest rates, at around 43 per 10,000. The Northern and Western regions, with the exception of Île-de-France and Pays de la Loire, had standardized rates higher than the national rate among both men and women. The rate of rehospitalization for suicide attempts increased from 12.8% at 12 months to 26.6% at 8 years, with no difference by sex; it was higher among those aged 30–49 and among patients with a psychiatric diagnosis.Between 2007 and 2011, the Oscour® network (Organization for Coordinated Emergency Surveillance) estimated that 63% of individuals who visited the emergency department for suicide attempts were hospitalized. Among these, 9% were admitted directly to psychiatric units and 54% to medical or surgical units. Based on data from the PMSI-MCO and Oscour®, the number of emergency department visits for suicide attempts in mainland France is estimated at between 176,000 and 200,000 per year (between 66,000 and 78,000 among men and between 108,000 and 120,000 among women).

Sentinelles Network

General practitioners (GPs) play a major role in suicide prevention through the identification, prevention, and care of suicidal patients. Studies among GPs in the Sentinelles network highlight the difficulties GPs face in identifying patients at risk of suicide and providing them with care. An initial study conducted between 2009 and 2011 revealed that young adults (18–39 years old, n=106) consulted their GPs less frequently than older adults (40 years and older, n=164) in the month preceding a suicide attempt (40.9% vs. 64.6%, p=.01) and reported suicidal ideation less frequently during their last visit (11.3% vs. 21.9%, p=.03). In the three months preceding the SUI, GPs’ care for young adults was less active in terms of psychological support, referrals to mental health professionals, and prescriptions for antidepressants and other psychotropic medications. A second study aimed to compare GP care for patients who died by suicide (n=141) with those who attempted suicide (n=498) between 2009 and 2013. Patients who died by suicide were more often male, older, had fewer prior suicide attempts, and were less frequently followed by GPs. However, in terms of care provided by GPs, there was no difference between the two groups, although patients who died by suicide had more often expressed suicidal ideation during their last visit. These two studies show that training programs on identifying and managing suicide risk in patients seeking care in general practice would be useful in supporting GPs in their practice.

Suicide mortality

Suicide mortality is described using data from the CépiDc. A collective review by the French National Institute of Health and Medical Research (Inserm) of international studies utilizing psychological autopsy highlights the prevalence and significance of mental disorders in suicidal behavior: a mental disorder was found in 90% of suicide cases. All types of mental disorders were represented, with major depression being the most common. According to an analysis conducted by the InVS, the description of mental disorders contributing to suicide, as indicated on death certificates, does not allow for the identification of such a significant role of mental disorders in the occurrence of suicides. In fact, over the 2000–2010 period, an annual average of 10,700 suicide deaths was recorded across France, 73% of whom were men. A mental disorder associated with the death was indicated in only 40% of these cases: 49.2% among women versus 37.2% among men. The mental disorders associated with suicides were overwhelmingly mood disorders (32.7%) and, to a lesser extent: addictive behaviors—primarily alcoholism—(5.4%), anxiety disorders (2.9%), and psychotic disorders (2.4%). In comparison, mental disorders were reported in 9.6% of deaths other than by suicide. After adjusting for sex and age, the risk that at least one mental disorder would be cited as a diagnosis associated with the death was four times higher in cases of suicide (RR = 4.0). This relative risk was 3.5 for psychotic disorders, rose to over 20 for anxiety disorders, and reached 38 for mood disorders.