Sociodemographic characteristics of persons committing suicide in Durban, South Africa: 2006–2007

Abstract Background Suicidal behaviour is a leading contributor to the burden of disease worldwide and varies widely between countries. South African figures are amongst the highest in the world, with recent trends indicating a disturbing rise, especially amongst the younger age groups, across all races. Aim This study analysed sociodemographic characteristics and trends relating to suicides committed in Durban, South Africa during the period of 2006–2007. Method A retrospective analysis of suicidal deaths (during 2006–2007), extracted from autopsy registers at all three government-run mortuaries in Durban, was conducted. Results The total number of suicides in Durban increased by 6.68% from 2006 to 2007. Suicide accounted for an average of 8.8% of all non-natural deaths per year of the study. The overall suicide rates of 14.53 (2006) and 15.53 (2007) per 100 000 population are comparable with national and global figures. The majority of suicides occurred in single unemployed persons, men and younger age groups. The largest number of suicides per year was recorded in black people, followed by Indian, white and mixed-race people. Hanging was the preferred method in the majority of victims, followed by self-poisoning, shooting and jumping. Conclusions The findings indicate a disturbingly high suicide rate amongst the various population and age groups in Durban. The dominant methods used may be influenced by ease of access. The reported trends may worsen unless there is a swift and decisive public health response and cohesive community-based programmes which include a supportive multidisciplinary network.


Introduction
Suicidal behaviour (comprising suicidal ideation, planning, attempts and completed or fatal episodes) has increased globally over the last decade and has been identified as being one of the major contributors to the high disease and healthcare burden in many low-to middle-income countries. 1 According to the World Health Organization (WHO), approximately 1.53 million people will die annually from suicide by 2020, compared with the 0.88 million suicides that occurred in 2002. 2 Suicide rates are higher amongst men (with male to female ratios up to 3:1) throughout the world except in China, where female rates are consistently higher than those for men, particularly in rural areas. 3,4 Globally, the majority of suicides occur in people aged 35-44 years in both sexes and the ratio of suicide attempts to suicide varies from 20-40:1. 2 In South Africa, it was reported in 2008 that approximately 6500 suicides and 130 000 suicide attempts occurred annually. 5 It is widely believed that these figures have since increased. 1 Non-fatal suicidal behaviour in South Africa outnumbers suicides, with the ratio varying between 8:1 and 20:1, depending on the geographical area and the racial group of the study sample. 6 The average age for suicide nationally is 34 years and the highest number of suicides occur in the [15][16][17][18][19] year age group, followed by the 10-14 year group. 7 Suicide rates have been increasing steadily in all population groups in the country over the last decade, although the prevalence varies considerably across age and race groups. Suicide has been labelled as the third major cause of death in Indian, black and mixed-race people after homicide and natural deaths and it is the second major cause of deaths in white people. 8,9,10 A wide range of methods is used by persons committing suicide. 1 These depend on a number of factors such as the mental state of the suicidal person; intention to die (high or low); intensity of the trigger factor or stressor and the ensuing crisis; threshold or tolerance to trigger factors; personal or popular choices in terms of knowledge of prior effectiveness of the method; access to the agent or instrument to be used; and the environment where the act is planned to take place. At a global level, shooting, hanging and self-poisoning have remained the leading agents of choice. 4,6,11,12 Figures released for South Africa in the last decade have shown that hanging and shooting were the most preferred methods, followed by other methods such as self-poisoning with agents such as pesticides and poisons, drug overdoses, self-gassing and selfimmolation. 13,14,15,16,17 An analysis of the autopsy register in the Eastern Cape Province in South Africa (previously called Transkei) for the period 1993-2003 showed an increasing trend of hangings from 5.2 per 100 000 in 1993 to 16.2 per 100 000 in 2003, particularly in the younger (20-29 year) age group. 13 This is consistent with other studies on choice of method in South Africa. 6 Homicide-suicide and extended suicide, especially involving adult men, intimate partners, and/or family members, have increased notably in South Africa, attracting much publicity, mainly because of their associated physical trauma and psychosocial impact. Several case study reports have been published highlighting characteristics of the perpetrator (usually male and often employed in the security or police services, or unemployed); the victim (usually female); the location of the event (usually the home); and the method generally used (firearms). 6,18,19,20 Durban is the third-largest city in South Africa and the largest in KwaZulu-Natal Province. It accounts for 1.4% of the geographical area of the KwaZulu-Natal Province but, according to the 2001 national population census, was home to 3.2 million (34%) of the province's population. 21 Sixty percent of the province's economic activity takes place in this port city, with 68% of its inhabitants being of a working age (15- This study was part of a larger study carried out by the lead researcher during the period 2007-2011, 1 and was intended to analyse the existing suicide trends amongst the different population groups in Durban, South Africa, as well as sociodemographic characteristics of persons who committed suicide in Durban during the period 2006-2007.

Research method and design
Medico-legal autopsies of all unnatural deaths occurring in the Durban municipality are routinely carried out in three state mortuaries (Phoenix, Gale Street and Pinetown). Final cause of death is entered into the autopsy record following the routine inquest procedure. This process, including finalisation of the inquest docket prepared for each case and authentication of the exact cause of death, can sometimes take as long as two years.
This epidemiological study was conducted in 2010-2011. A retrospective analysis of the autopsy registers at the three government-run mortuaries in the Durban Municipality was conducted for the period 2006-2007. All suicidal deaths were further extracted from these registers and analysed. The rationale for choosing the above study period was to ensure that only authentic suicide cases finalised via the inquest methodology employed in South Africa were included for analysis in the study. Cases that were classified as 'deaths due to other causes' or those that could not be finalised via the inquest process were excluded from this study.

Ethical considerations
Ethical approval to conduct the study was granted by the University of KwaZulu-Natal's Biomedical Research Ethics Committee (Reference number HSS/0181/06D) and the KwaZulu-Natal Provincial Department of Health.

Data analysis
All data were captured and analysed using the Statistical Software Package for Social Sciences ® (SPSS) version 19 (IBM Corp, Armonk, NY, 2010) and SAS/STAT software version 8.2 (Cary, NC, SAS Institute, 2010).

Prevalence of suicide in Durban
During

Suicide victim characteristics
Male suicides outnumbered female suicides (Table 2)  In both years, the largest number of suicides was recorded in black people, followed by Indian, white and mixed-race people ( Table 2).

Monthly frequencies for all groups
The  (Table 3). The suicide rate per 100 000 had increased from 2006 to 2007 for all race groups except for white people (Table 3).
In terms of race and gender (Table 4 and Figure 2), the majority of suicides in both years were in black men and women, with a rise in the number of black men and a shift reduction in the number of black women between 2006 and 2007. There was a small increase in both mixed-race and Indian men and women, a decrease in white men and a small increase in white women.
The aggregated data indicates that most of the suicides occurred in people between the ages of 15 and 44 years (    The overall mean age (95% CI) at which people committed suicide was 34.14 years (95% CI 32.

Breakdown of preferred methods of suicide
Overall, of the nine main methods used to commit suicide (Figure 4), hanging accounted for nearly two-thirds in both 2006 (61%) and 2007 (62%).This was followed by guns, jumping from heights and overdose. These four methods accounted for 88% of all suicides in 2006 and 94% of all suicides in 2007.
Hanging was the preferred method of suicide for all age groups except for those over 65 years in 2007, where jumping from high-rise buildings was the preferred method ( Figure 5). In both the 15-24 and 25-34 year age groups, gun usage was the next most common method used, whilst in the 35-44 and 45-55 year age groups, overdose was the method of choice, followed by hanging and gun usage.

Discussion
This study was part of a larger study undertaken by the researcher during the period 2006-2011, some of the findings of which have been used in partial fulfilment of a doctoral degree. 1 The salient findings of this study in particular support and complement those found by Donson and others in 2007. 22 The total number of suicides confirmed in this study (n = 495) for Durban during 2007 was greater than that shown in the Donson study (n = 398). 22 The difference may be explained by the differing methodologies used in each study. There are no other recent relevant studies.
This study showed a gradient of increase in suicides over the two-year period studied, which is consistent with the reported gradual increase in suicide rates for the country as a whole from around 8% in 1999 to 11% currently. 6,23 Compared with suicide rates for the other major South African cities, the rates per 100 000 population in this study shows that Durban has a high suicide rate, which is also comparable with the average global rate. 22 Although the results of the present study indicate that suicides occur throughout the year in Durban, there were discernible peaks at particular times, namely, early and   toward the end of the year, which is consistent with other findings for the country. 6,23 It has been postulated that this finding may be linked to high degrees of stress toward the year end, which have been precipitated by socio-economic difficulties and academic expectations, particularly amongst our youth. 6 This study also demonstrated that the actual number of suicides per year of study varied considerably between racial groupings in Durban -it was twice as high for black people as for Indian people, the former constituting the largest racial or population group in the metropolitan area. Figures for mixed-race people and white people were much lower. These findings are in sharp contrast with earlier studies on suicide rates for the different race groups in South Africa, which showed that white South Africans consistently outnumbered black, Indian and mixed-race South Africans. 8,9,24 The suicide gradient amongst the different race groups per year showed an increase from 2006 to 2007 in all groups except for white South Africans.
The fact that the majority of suicides in both years were committed by men is consistent with those found in other studies. 9,15,25,26,27,28 At least two-thirds of the suicide victims in our research were unmarried, widowed or divorced. Similar findings have been reported in other studies with some reporting that separated men were at higher risk of committing suicide compared with separated women. 29,30 In terms of age groupings, the majority of suicides in our study took place amongst 25-34 year olds, followed by 15-24 year olds and 35-44 year olds. Other local studies have reported comparable findings, 25,31 which is similar to the global trend of a shift to younger people committing suicide. 2 However, a study in Dar es Salaam, Tanzania, showed that the 45-59 year group had the highest suicide rate, 27 although varying figures are reported for Africa. 32 The high number of suicides committed by young students in the present study is a source of great concern and is consistent with previous South African research findings. Research findings have linked this trend to a variety of pre-disposing and risk factors. These include child abuse and neglect, interpersonal problems, peer pressure, substance abuse, family dysfunction and unrealistic academic expectations. 6,33,34,35    The majority of suicide victims in our study were unemployed or casual workers. It is possible that socioeconomic issues played a role in influencing a fatal suicidal outcome in these victims. This is supported by other studies which have shown an inverse relationship between income and psychological distress. 36 Also, a number of researchers have offered various related explanations regarding the deteriorating trend in suicides in South Africa. These include the inability to cope with new roles since the abolition of apartheid and the introduction of a democracy since 1994; acculturation and western lifestyle influences and moving away from protective traditional lifestyles; socio-economic pressures, with resulting interpersonal and family problems; inappropriate family and peer expectations; increasing urbanisation; increasing competitiveness; and rising unemployment in a changing South African society since democracy. 6,37,38 The methods used in committing suicide depend on availability, knowledge of lethality and access to the method by the victim. In our study, hanging emerged as the dominant method in at least two-thirds of suicide victims, all racial groups, both genders and all ages, except in the over-65 year age group in 2007 where jumping was the chosen method. This was followed by other methods such as guns, jumping from heights and over-dosing of medicines. In general, hanging was the preferred method amongst unemployed victims (65.5%) compared with those who were employed at the time (56.6%). Interestingly, in the Eastern Cape Province of South Africa, hanging was reported to be the preferred method in uneducated (70%) and unemployed (64%) victims, whilst the more highly educated (17%) used firearms to commit suicide. 39 The prominence of suicide by hanging has also been documented in a number of other studies 13,40 and differs from those in a recent study conducted in Malawi where self-poisoning emerged as the being the most common method used by both men and women. 41

Limitations
The data recorded in this study may not be truly representative for several reasons. Only data relating to confirmed suicides were extracted from mortuary registers and analysed in this study. It is possible that these registers may have contained administrative errors, omissions and inaccurate recordings, meaning that the number of suicides analysed may thus have been underestimated. The study also relied on the accuracy of the data entries recorded in mortuary registers in Durban. Some of the data may have been obtained from contacts other than next-of-kin and may not have been accurate. Missing data were noted in particular categories studied, such as marital status, occupation and method of suicide.
All suicides committed in Durban during the study period were analysed. This may have included persons not normally resident in Durban, therefore the figures presented in this study may not be truly representative of the residents domiciled in Durban.
The study design unfortunately precluded an exploration of precipitating factors and causes. Relatives and family members could not be interviewed. In instances where suicide notes were left by victims, details within these notes were filed in inquest files and not made part of the mortuary registers.

Conclusion
The actual rates of suicide per racial group showed a gradient increase from 2006 to 2007 for all groups except for white people. Health and education policy makers, counsellors and community leaders should respond to the disturbingly-high suicide figures recorded amongst certain categories of Durban residents such as black and Indian people, the unemployed and the youth, including scholars. This study endorses the call made by many researchers and policy makers for the enactment of a national policy framework in South Africa that would embrace a comprehensive multidisciplinary primary care approach to the current burden of suicidal behaviour in the country. Hanging emerged as the dominant method used by the majority of those committing suicide mainly because of its simplicity, proven effectiveness and easy access to structures within or adjacent to homes. There is therefore an urgent need for innovative employment strategies to help the unemployed, as well as greater awareness and education campaigns (amongst public health policy makers, low-cost housing developments and families) designed to restrict such easy access to any potential method by vulnerable individuals.
A larger and more extensive study over a longer period is recommended in order to confirm the reported trends.