Introduction

Suicidal behavior is a worldwide phenomenon, and has been acknowledged as a major public health problem. World Health Organization estimates almost 1 million people dying by suicide every year, contributing more than 2 % to the global burden of disease by the year 2020 [1]. Suicide reflects one of the leading causes of death in many nations and particular among youths, where it constitutes the second leading cause of death in the age-group 15–19 years [2]. Numbers of suicide exceed the number of deaths in traffic accidents in many countries [3], and this is also the case in Austria [4]. Completed suicides can be understood as the tip of the iceberg, beside other forms of suicidal behavior, ranging from suicidal ideation to plans, threats, and suicidal attempts. Each individual engaged in some sort of suicidal behavior reflects an enormous amount of pain, suffering, and despair. It deserves attention, as “suicide is largely preventable” [1]. Furthermore, suicide creates great pain for the victims’ relatives and for other survivors, World Health Organization estimates six persons closely afflicted in each suicide [5].

Austria is well known as a country with a high suicide rate compared with other European countries. Already in the Austro-Hungarian Empire, rates were higher than in other parts of the Empire [6]. Also, in the past decades, Austria ranked high in Europe [7]. Since 1960, an increase had been observed [8], resulting in a peak in 1986 [9], with a decrease since then until the year 2000 [10].

Investigations of more recent suicide data in Austria are missing but needed as important prerequisite for preventive strategies. In several countries, national suicide prevention programs already have been established [11]. In Austria, efforts to establish such a national program have been initiated more than 10 years ago [4] and recently acknowledged by policy makers. In 2012, the Austrian Ministry of Health started an implementation of a national suicide prevention program called Suicide Prevention Austria—SUPRA [12]. To plan and focus on preventive initiatives, data are needed to closely study developments in different age-groups, to identify specific risk groups, and in regard of methods eligible for specific preventive strategies that already have been proven to be successful [13]. The aim of this study was to examine Austrian suicide mortality in the past decade, as a continuation of analyses of the two previous decades [9, 10]. We focus on time trends, age-group risks, and the utilization of suicide methods as well as on the societal burden in terms of potential years of life lost due to premature deaths by suicide.

Material and methods

The data analyzed here represent all suicides in Austria during the period 2000–2010. Data on the suicide victims’ sex, age, and method used (registered as external cause-of-death ICD-9 codes E950–E959 and ICD-10 codes X60–X84), together with sex- and age-stratified general population figures, were obtained from Statistics Austria. Suicide rates were calculated and reported as the annual number of suicides per 100,000 inhabitants of the reference population.

The reliability and validity of the Austrian suicide statistics is rather high in comparison with other countries, especially due to the infrequent use of the “unknown” and “undetermined” cause of death categories, relatively high autopsy rates, and further investigations by coding officials of Statistics Austria in uncertain cases [14–16].

In Austria, for all deaths, a certificate has to be completed by a physician authorized by the local health authority, coding the cause of death. In cases where the mode of death remains unclear (accident, murder or suicide) during a death examination, a police commission has to be involved and a forensic autopsy might be requested. In other cases, a sanitary autopsy is requested, and in hospital related deaths, clinical autopsies are performed [16]. The autopsy rate in Austria has traditionally been high by international standards, at 34 % of all deaths in Austria (data for 1983), with a local maximum of 51–53 % in the capital Vienna (data for 1983–1987) [17]. However, following the international trend of decreasing autopsy rates [18], also in Austria, the autopsy rate has declined (31.2 % in 1988–1997 to 23.3 % in 1998–2007, representing a decline of 8 % points or a reduction to about three-fourth of the earlier value [14]).

The crude potential years of life lost (PYLLc) analyses were first based on the difference between the age at the time of suicide and life expectancy of the cohort at birth in the year 2000, which was 76 years for men and 81 for women according to Statistics Austria [19]. Furthermore, to control for the age structure of the population, we calculated age standardized PYLLs per 100,000 persons based on the old European standard population [20]. We assumed that persons not dying due to suicide would otherwise have lived until the age of 70 years according to The Organisation for Economic Co-operation and Develpoment (OECD) (2008) recommendations [21]. Where possible, analyses were performed for each gender. For time trend analysis, we used Spearman tests for trend using the year of observation as the independent variable. For comparisons of decades, we used nonparametric two-sample Wilcoxon–Mann–Whitney test.

Results

For the whole period 2000–2010, the mean suicide rate for the overall Austrian population was 16.9 per 100,000 persons, 26.1 for men and 8.2 for woman, resulting in a male to female ratio of 3.2.

The suicide rate decreased for both sexes during the examined period. Among men, the decrease was from 29.3 in 2000 to 23.7 (− 20.6 %, ρ = − 0.96, p < 0.001) in 2010. Among women, the highest suicide rate was observed in 2000 (10.4) and the lowest 2010 (6.8; − 34.8 %, ρ = − .92, p < 0.001). For the Austrian population as total, the suicide rate significantly decreased from 19.8 per 100,000 persons in 2000 to 15.0 in 2010 corresponding to an overall decrease by 24.2 % during this period (ρ = − 0.98, p < 0.001).

The mean suicide rate for the period has decreased compared with the previous decade 1990–2000 (W = 2.5, p < 0.001). The change of the mean suicide rate in the period 2000–2010, compared with the period 1990–2000, has been higher for woman than men, with a reduction by 26.3 % (from 11.1 in 1990–2000 to 8.2 in 2000–2010; W = 3.5, p < 0.001) versus 20.0 % (from 32.7 in 1990–2000 to 26.1 in 2000–2010; W = 5.5, p < 0.001; also see Table 1, last row).

Table 1 Change of the suicide rates by method in Austria for the period 2000–2010 compared with 1990–2000 [10]
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In all age-groups among both men and women, a decrease of suicide rates was observable (Fig. 1). Among both men and women, suicide rates still increase with age. Especially in men, there was an exponential increase of suicide rates with age-groups, especially over 65 years, as has been shown also in previous decades (1980–1990 and 1990–2000). The highest median suicide rate was found in the age-group of 85+ years in men (131.8 per 100,000) as well as in women (24.0). These rates reflect fivefold, respectively 2.9-fold higher rates, than the median of the corresponding population.

Fig. 1
figure 1

Median suicide rates in Austria per age-group (years) of the period 2000–2010 compared with1990–2000 [10]

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Regarding suicide methods, hanging is still the most common method for suicide in Austria (45.6 % in total, 49.1 % for men and 35.0 % for women). For men, hanging is followed by shooting (21.0 %), jumping (8.4 %), poisoning (7.4 %), and drowning (3.0 %), while other heterogeneous methods account for 11.0 % of all cases in the examined period 2000–2010. For women, hanging is followed by jumping (18.7 %), poisoning (18.2 %), drowning (10.4 %), and shooting (3.2 %), while other methods account for 14.5 % of cases in the period (Table 1).

During the past decades, suicides decreased for each method, except that for men, the suicides by drowning have slightly increased (+ 2.3 %, from 0.77 mean suicide rate in 1990–2000 to 0.79 mean suicide rate in 2000–2010), although from an originally low level (Table 1).

PYLLc analyses of the 2000–2010 decade showed a general decrease from 40,702 years in 2000 to 29,883 in 2010 (ρ = − 0.95, p < 0.001), with an average of 33,868 ± 4,180 person years of life lost per year (25,274 ± 2,890 in men and 8596 ± 1,465 in woman). This resulted in a total PYLLc of 372,551 person-years lost in this period in Austria due to suicide, 277,998 (74.6 %) among men and 94,553 (25.4 %) among women. Every person who committed suicide lost, on an average, 29 years of life expectancy (29.2 years lost in men and 29.3 years lost in women).

Age-standardized PYLLs among men showed a steady decrease from 531 years per 100,000 population in 2000 to 388 per 100,000 in 2010 (ρ = − 0.95, p < 0.001). Among females, PYLLs decreased similarly from 161 in 2000 to 96 in 2006 and remained nearly constant afterward with a slight increase to 114 per 100,000 in 2010 (ρ = − 0.83, p < 0.003).

Discussion

General decrease

In the past decade, a further decrease of suicide rates can be observed in Austria (Fig. 2). The decrease can consistently be found in all age-groups in both sexes, thus reflecting a general decrease rather than to age/gender specific changes. However, the change of the median suicide rate in the period 2000–2010, compared with the period 1990–2000, has been larger for woman, with a reduction by 26.3 %, than for men, where a reduction by 20.0 % was observed. This continuation of the decreasing trend, which began in 1987 [10], has been discussed to coincide with important social and other changes in Austria. For example, the density of psychotherapists increased by + 86 % and the prescription of antidepressants increased by more than + 415 % alone during the period 1991–2005 [22]. Besides substantial increases in psychologists, general practitioners, and psychiatrists, an increased inpatient treatment of depressive disorders accompanied the decrease of suicide rates after 1986 in Austria [23].

Fig. 2
figure 2

Suicide rates in Austria, 1970–2010

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A recent comprehensive study has shown for 29 European countries that suicide rates decreased when antidepressant prescriptions increased [24]. The authors further discuss that the increasing antidepressant prescriptions in many countries are associated with increased funding for mental health systems and a growing need for treatment and support in Europe. As reported, we believe that the increases of antidepressant prescriptions in Austria reflect major changes in the psychosocial system and a higher utilization of mental health professionals and hospitals during the past 2 decades [22]. Of course, other important aspects may account for this decrease of suicide mortality as well, such as the implementation of media recommendations for suicide reporting in 1987 [25], introduction of mandatory catalytic converters in 1986, the effects of which in Austria have not been examined yet but are well known from other countries [13], or changes in the availability of potentially lethal prescription drugs [26].

Method changes

The decrease of suicides in comparison with the period 1990–2000 is reflected by a decrease of suicides by all methods, with the exception of suicides by drowning for men, which has slightly increased (+ 2.3 %), although from a low level. The proportion of methods underlies a large variation in different regions of the world, hanging being the predominant method in most countries [27].

Hanging also traditionally represents the most common method of suicide in Austria since many years, and with 49.1 % among men and 35.0 % among women in the past decade, reflects a method that is not easily preventable by selective or restrictive prevention programs, reducing the availability of this suicide mean [28, 29]. Hanging suicides can rather be addressed by universal prevention strategies such as media coverage regulation or the treatment of psychiatric disorders [13].

Firearm suicides have been shown to decrease continuously since the strengthening of firearm laws in 1997 [30] still constituted 21 % of all suicides by men during the last examined period. It might be considered by policy makers whether further regulations of firearm acquisition and possession, such as longer cool-off periods after sales, stricter gun-storage regulations, or continuous relicensing procedures, can be adopted to save further lives.

Besides hangings and shootings, suicides by poisoning contributed most to the general decrease of the suicide rate. With a reduction of more than 30 %, poisonings became a very uncommon suicide method in Austria. Previous studies have shown that restriction of the availability of toxic medications and the introduction of catalytic converters reduces suicide rates by these means [13]. A fact that might have contributed also to the decrease in Austria, as some preliminary results suggest that poisonings by some hypnotics as well as by carbon monoxide from car exhaust gases have substantially declined. A national suicide prevention program, therefore, would need to take these results into account and should develop interventions to address these specific characteristics of suicide mortality in Austria.

Old men

The highest suicide rates still are found in old men, with a fivefold higher rate than the general male population in the age-group 85 years and older. The increase of suicide risk with age is also observable in women of the same age-group, albeit with only a 2.9-fold higher rate in comparison with the average female population. An increase of suicide rates with age in both sexes has also been found in previous decades [10], and reflects the so-called “Hungarian pattern,” which can be found in many European countries, in contrast to the “Camel pattern” in some other countries. Comparing the periods 1980–1990 and 2000–2010, all age-groups of men (with the exception of those aged 85+ years) have a lower median suicide rate in the past decade. The male age-group of 85+ years still has a median rate in 2000–2010 of 131.8, which is higher than 128.0 in 1980–1990, but lower than the peak of 148.9 in 1990–2000. This reflects the fact that old men still constitute the group with the highest suicide risk and need to remain in the focus of suicide prevention [10]. In this regard, the fivefold risk in old male individuals reaches a ratio, which is comparable with some of the most important risk factors for suicide such as alcoholism or personality disorders [31].

Person years of life lost (PYLL)

The usual calculations of suicide rates represent a traditional count measure of suicide, where each death is weighted equal. It has been discussed that PYLL analyses, in contrast to suicide rates, allow weighting each death according to age, and thus allow to account for the assumption that suicides by younger persons represent a larger burden to society than suicides of old persons [32, 33]. Of course, the individual and subjective burden of suicide to survivors cannot be accounted for in this way. PYLL analyses enable, for example, to calculate the loss of earnings by lost labor force, which is typically calculated as lost years up to the age of 65 or 70 years in studies. However, such an age limit based on labor participation in PYLL analyses of suicide has been described to be discriminating the elderly population [34].

We used, therefore, both age limits to account for lost labor force and the average life expectancy to calculate the years of potential life lost. We have found that, on an average, 29 years of life are lost due to a suicide, which accumulates to a tremendous average of 33,868 potential years of life lost every year. Our standardized PYLLs analyses showed that 388 productive years were lost per 100,000 persons per year among men and 114 among women in 2010, which is comparable with results from Australia [32] and UK [34].

Similar results were also found in Switzerland for 2006, with 448 PYLLs per 100,000 persons for men and 187 in women, thus demonstrating that suicide mortality was the leading cause of premature death quantified by PYLLs analyses [35]. Although PYLLs allow to estimate the socioeconomic costs incurred by each death to society, there is much debate about the appropriateness of such measures [33]. However, some studies have estimated that the loss of productivity and costs to society may sum up to 1 million € per suicide [36, 37]. While such calculated costs represent raw approximations, even a small fraction of the costs of suicides in Austria would be well allocated in the national suicide prevention program.

Conclusion

Austrian suicide rates are on the decline since 1986, but Austria still belongs to European countries with average rates in comparison [7, 14]. Current rates and potential years of life lost thus still urge for the need to implement the Austrian suicide prevention program in a sustainable way. Due to numerous available effective suicide prevention strategies, and clear targets for prevention, a laissez-faire approach to suicide is ethically not appropriate [33].

Conflict of interest

The authors declare that there are no actual or potential conflicts of interest in relation to this article.