摘要：US suicide rates have declined in recent years, reversing earlier trends. We examined suicide rates among 4 age groups from 1970 to 2002 and the factors that may have contributed to the decline. We paid particular attention to newer anti-depressants because of recent concerns and controversy about a possible association with suicidal behaviors. These trends warrant more extensive analysis of suicide rates among specific subgroups, including consideration of additional variables that may influence rates differentially. The relative contributions of depression diagnosis and treatment, postsuicide attempt care, and other contextual factors (e.g., overall economic conditions) also deserve attention. If the decline is associated with contextual factors, clarifying these associations will better inform public policy decisions and contribute to more effective interventions for preventing suicide. Suicide was among the 10 leading causes of death until 1998, when it was number 8 overall. Since that time, it has been surpassed by deaths due to Alzheimer disease and septicemia. Preliminary data for 2003 placed suicide at number 11 overall, with a provisional age-adjusted rate of 10.5 per 100000, a 3.7% decline from the 2002 age-adjusted rate. 1 However, it remains one of the 10 leading causes of death among individuals aged 10 to 64 years, and it ranks between second and fourth among those aged 10 to 45 years. 2 Rates varied by region in the United States, with the highest rates being in the West (14.7 suicides per 100000 people), which was followed closely by the South (13.1 per 100000) the Midwest (10.9 per 100000) and the Northeast (8.6 per 100000). 3 This regional variation remained after control for age, race/ethnicity, and gender. The proportion of suicides by firearms also varied regionally, with the South having the highest proportion (68.9%), followed by the West (58.3%), the Midwest (57.8%), and the Northeast (44.9%). 3 The presence of firearms in the home has been associated with a higher risk for suicide. 4 , 5 Other risk factors for suicide include previous diagnosis of major depression, bipolar disorder, substance abuse, conduct disorder, and previous suicide attempts, suicidal ideation, and homicidal ideation. 6 – 8 Previous suicidality, including previous attempts, is a major risk factor for completed suicide 6 , 7 , 9 – 12 ; therefore, it is reasonable to expect that factors influencing attempts have similar effects on completions. Considerable attention has been given to past increases in suicide rates, especially among adolescents and the elderly. During the early 1990s, a number of articles and editorials called attention to increasing rates of suicide among adolescents and older adults. 13 – 16 The perception has persisted that suicide rates continue to increase overall, specifically among these 2 groups. 17 With a few exceptions, 18 – 22 there has been less recognition of recent declines in suicide rates among these age groups, and there has been little investigation of factors that may have contributed to these declines. Several recent studies have investigated the association between suicide rates and the increase in use of selective serotonin reuptake inhibitor (SSRI) antidepressants. 20 , 23 – 36 This research is particularly important because of the recent controversy about whether SSRIs increase suicide-related behavior among children and adolescents. The US Food and Drug Administration (FDA) has recently issued a black-box warning for all antidepressant use among children and adolescents, because data from clinical trials of antidepressants showed a 1.5- to 2-fold increase in suicide-related behavior among children who were given SSRIs compared with children who were given a placebo. 37 Understanding whether these treatments for depression contribute to increased risk or to the observed decline in rates—or to both in some complex way—is important. We examined recent trends in US suicide death rates among 4 age groups from 1970 to 2002, paying close attention to the recent controversy about possible increased risk for suicidal behaviors associated with certain antidepressants. Recent trends call into question frequently held assumptions about increasing rates of suicide. Although the risk factor profiles differ somewhat for nonfatal attempts and completed suicides, it is obvious that every completed suicide is a successful attempt. Our intent is to stimulate further discussion and research into the seeming paradox of a significant decline in completed suicides that is coinciding with the introduction of new antidepressants and the recent warnings that these same medications increase suicidality. We also want to stimulate a broader discussion about these trends and encourage a more extensive investigation of larger social, contextual, and policy issues and the evidence associated with antidepressants that may be contributing to the decline in one of the major causes of preventable death.
