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An Exploratory Analysis of Fifteen Years Suicide Trends Using Population-Level Data From Croatian Committed Suicides Registry

Objectives: The provide a descriptive analysis of the available population-level aggregated data on committed suicides in the Republic of Croatia, in the 2004–2018 period, showing emerging trends in suicide incidence focusing on sex/age/geographical distribution of suicides and the primary and secondary causes of suicide mortality, as well as making comparisons with similar neighboring neighboring countries. Methods: The aggregated suicide data were obtained from the Croatian Committed Suicides Registry, a national registry maintained by the public health authority. The raw data extract was organized into tables according to several variables (age, sex, place of birth, place of residence, and cause of death). Simple descriptive statistics were performed on the structured data. Results: Despite being among the highest in the world and EU, the number of committed suicides in Croatia is in decline since 2004. A higher number of suicides by males was observed when compared to females. Most of the suicides occur during spring and summer. The wealthier, northern continental region of the country had the highest average rate of committed suicides per 1, 00, 000 population, contrary to some of the findings in the published literature associating economic instability with suicide. The most common way to commit suicide for both sexes in all age groups is self-harm by hanging, strangulation and suffocation. Suicide by firearm and explosive devices discharge remains higher than the global average. Conclusions: Despite its steadily declining incidence rates in the past 20 years, suicides remain a major public health challenge in Croatia. Results may bolster the Ugro-Finnish suicide hypothesis, linking higher suicide rates to regions with populations of Hungarian descent. Introduction Suicides are one of the leading causes of death from injuries in the Republic of Croatia. As a major public health issue, suicide remains a growing national concern with the suicide rates in Croatia being among the highest in the world. In 2016, Croatia was the 16th highest ranking country globally and 8th in the EU when it came to suicide with an average overall (both male and female) suicide rate of 16 per 1, 00, 000 population (1, 2). Moreover, when compared to other causes of death in Croatia, death by suicide is ranked among the top 10 most frequent causes of death (2). Suicide remains an extremely complex phenomenon that includes the interactions of factors at different levels of analysis: the systemic level (access to suicide means such as post-war firearms and ammunition), societal level (socio-economic determinants of mental health), community level (support from the community, family, and peer group) and individual level (sex, age, medical and biological determinants). Despite this, little comprehensive epidemiological research has been made regarding the population-wide study of suicide in Croatia in the 21st century that would account for these different factors. Some noteworthy examples do exist, mostly focusing on specific demographics. Notably, a number of studies have addressed the 1990's post-war suicide as a direct result of the trauma experienced by many people during the Croatian War of Independence in the early 1990s (3–10). Also, several studies have explored the epidemiological characteristics of suicide in specific Croatian regions (11–15) or were otherwise focusing on a specific demographic group characterized by age (16– 20) and the relevant diagnosis (21) and therapy (22). Additionally, several papers analyzing epidemiological data on suicide in Croatia do exist (23–25), however, there seems to be lack of research focusing on the entirety of the Croatian population in the last 20 years. This seems surprising considering that Croatia has one of the highest suicide rates globally and within the EU, only being comparable to other countries in the same geographical region, such as Slovenia and Hungary. The reason of such high suicide rates in the region are not fully understood, however several attempts were made to indicate a link between genetics and suicide ideation in Ugro-Finnish populations from Finland and the Baltic countries, including Russia, Belarus, and Ukraine all the way to eastern Central Europe and the Western Balkans – including Croatia (26–28). The aim of the research is to describe some of the key factors contributing to the incidence of suicides in all the territory of the Republic of Croatia, based on the aggregated data obtained from the Croatian Institute of Public Health, and focusing on the period from 2004 to 2018. Root causes of suicide and suicide ideation are out of scope in this research, however Croatia is compared to other neighboring countries with similar geographical position, economic status, as well as age and sex distribution, adding to the body of research on suicides in the broader region, hopefully bolstering the main assumptions regarding the Ugro-Finnish suicide hypothesis. Our population of interest were the persons who committed suicide on the territory of Croatia, between 2004 and 2018 (including the years 2004 and 2018), which were registered in the Croatian Committed Suicides Registry. Methods The source of data in the Croatian Committed Suicide Registry is the Death Certificate. The Death Certificate is an official medical document issued by a doctor or any other person authorized by law to determine death, or a health care institution if the person died in such an institution. The method of data collection is determined by the Annual Implementation Plan of Statistical Activities of the Republic of Croatia under the heading of Statistics on Psychosis with the Register for Psychosis and the Register of Suicides (29). This registry collects data on suicide completions and therefore suicide attempts were left out of scope. The suicide data from the Croatian Committed Suicide Registry was retrieved as a Microsoft Excel sheet export from the Croatian Institute of Public Health's database which included the raw cumulative number of suicides cases on the territory of the Republic of Croatia, during the 15- year period between 1st January 2004 and 31st December 2018, aggregated monthly (January-December) for each year separately, according to: a) The county of birth (Croatia), b) The county of residence (Croatia), c) Age (expressed in age groups 0–19, 20– 39, 40– 59, 60–79, 80–99), (*ages above 99 were omitted due to an extremely low number of reported cases) d) Sex (Male and Female, respectively), and e) The proximal and external cause of death (expressed as WHO ICD-10 codes: S00–T98 for Injury, poisoning and certain other consequences of external causes ; and X60–X84 for Intentional self-harm), (the ICD-10 codes for Event of undetermined intent (Y10– Y34) and especially Y34 for External cause of death of unknown intent were excluded from this analysis due to a low number of reported cases related to a rigorous process of data clean-up during the suicide registration process).

Death Certificate ; committed suicide ; incidence ; regional distribution ; suicide rate

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