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Suicide rates among Estonians, Russians in Estonia, and Russians: overemphasis of recent trend differences
- Martin Voracek (12 January 2005)
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Re: Suicide rates among Estonians, Russians in Estonia, and Russians: overemphasis of recent trend differences
- Aasa H Reidak (13 January 2005)
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e-mail addresses
- Dr. Herbert H. Nehrlichd (15 January 2005)
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Suicide rates among immigrants
- Oliver Razum, Ulrich Ronellenfitsch (25 January 2005)
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Martin Voracek, research resident School of Psychology, University of Vienna, A-1010 Vienna, Austria
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EDITOR––Värnik and colleagues[1] aimed to demonstrate that large- scale sociopolitical changes impact differently on suicide rates of differently affected populations. The authors compared age adjusted suicide rates in Estonia and Russia before and after 1991, when Estonia regained independence and the Soviet Union collapsed. During the late Soviet period, suicide rates among the formerly privileged Russian minority in Estonia were somewhat lower than for native Estonians and for Russians in Russia (mean suicide rates, 1983-90, in above order: 27.8, 29.2, and 29.0), whereas rates were statistically significantly higher afterwards, when Russians in Estonia became a non-privileged minority (mean rates, 1991-98: 38.7, 34.2, and 36.5, respectively). I think the authors overemphasised this difference in change patterns. Estonia is a small country (1.3 million inhabitants). Hence, calculating yearly suicide rates involves rather small and fluctuating numerators (400-600 cases per year), which all the more applies for the Russian minority (30%) in Estonia. Further, paired samples t tests for the evaluation of trend differences in yearly suicide rates were used, when statistical methods for standardised rates[2] would have been more appropriate. In the light of these caveats, caution in interpreting the trend difference is advisable. An alternative interpretation, consistent with these data, is that suicide mortality in all three populations increased after the sociopolitical changes. Compared with international reference values, the extent of suicide mortality in Estonia and Russia is known to be worrying.[3] In fact, all of the above suicide rates rank among the highest ones presently observed around the world[4], and, importantly so, for all three populations, 1980s to 1990s changes in suicide rates were uniform: they increased noticeably. In relation to the already high level of suicide mortality in these populations and its further increase, the trend difference between native Estonians versus Russians in Estonia, albeit statistically significant, is comparatively small and therefore of little practical relevance for antisuicide strategies. [1] Värnik A, Kõlves K, Wasserman D. Suicide among Russians in Estonia: database study before and after independence. BMJ, doi:10.1136/bmj.38328.454294.55 (published 15 December 2004) [2] Altman DG, Machin G, Bryant TN, Gardner, MJ, eds. Statistics with confidence: confidence intervals and statistical guidelines, 2nd ed. London: BMJ Books, 2000:70-1. [3] Sartorius N. Recent changes in suicide rates in selected eastern European and other European countries. Int Psychogeriatr 1995;7:301-8. [4] Voracek M. National intelligence and suicide rate: an ecological study of 85 countries. Pers Individ Dif 2004;37:543-53. Competing interests: None declared |
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Aasa H Reidak, elementary teacher Toronto, Ontario M5B 2H9
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Despite the current article about suicide rates about various groups in Estonia, some of us may have a different perspective about this state of affairs. Many of us, of Estonian descent have lost many, many relatives thanks to the annexation of Estonia to Russia. While a current BMJ article makes some extent to explain why some Estonians may be killing themselves, I am sure many more Estonians, especially of Estonian background, may have been wiped off the map quite literally, around the time of the WWII, without anyone else giving much of a care about their demise. Why isn't anyone interested in doing a study about the effects of WWII on certain groups who lost plenty of relatives during that war? I am sure that they would find much to deal with. Competing interests: My parents are Estonian and many of our relatives died thanks to the Russian takeover of Estonia cerca WWII |
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Dr. Herbert H. Nehrlichd, Private Practice Bribie Island, Australia 4507
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May I respectfully suggest that the listing of individuals' e-mail addresses be left to the individuals. They could be provided under the name, location of the person commenting UNLESS the person chooses not to be listed by electing, ticking a box like the one for the competing interests. If this is not feasible would someone from the BMJ kindly explain WHY NOT. Thank you. drhhnehrlich@westnet.com.au Competing interests: None declared |
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Oliver Razum, Professor in Epidemiology & International Public Health School of Public Health, P. O. Box 10 01 31, 33501 Bielefeld, Germany, Ulrich Ronellenfitsch
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EDITOR – Värnik et al [1] claim that “migration is an important risk factor for suicide”, and that “immigrants have a higher risk of suicide than (…) the native population of their new country”. We agree that socio- cultural stress linked to migration can increase suicide risk. We doubt, however, that suicide rates among immigrants are unvaryingly higher than among natives of the host country. Suicide mortality rates in migrant populations tend to closely correlate with rates in their countries of origin for some time, presumably because social and cultural particularities are maintained.[2] Since suicide rates differ greatly between countries,[3] the difference in suicide rates between immigrants and the host population primarily depends on the rates in the country of origin and the host country. The effect of migration-related stressors can be small in comparison. This also applies to the protective “healthy migrant effect”, a self-selection of particularly healthy individuals into migration. Two hypothetical examples illustrate this: In Greece and Germany, age-standardised suicide rates are 3.6 and 13.5 per 100,000, respectively.[3] Immigrants from Greece to Germany would thus maintain a substantially lower suicide mortality than native Germans, even if their risk doubled due to migration stress. In contrast, immigrants from Lithuania, where the suicide rate is 44.7,[3] would experience a considerably higher suicide rate than Germans, even if their risk decreased by 50% due to selection effects associated with migration. Empirical evidence supports our point. In Turkey, the suicide rate is approximately 3.3 per 100,000.[4] Turkish immigrants in Germany, who are a minority and socio-economically disadvantaged, maintain a significantly lower suicide mortality than German nationals (age-adjusted rate ratio 0.3).[5] We believe that the introductory statement by Värnik et al, which is given further prominence in the “What this paper adds” box, is an over- generalisation. Ulrich Ronellenfitsch, PhD student, Department of Tropical Hygiene and Public Health, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany Oliver Razum, chair, Department of Epidemiology & International Public Health, School of Public Health P. O. Box 10 01 31, 33501 Bielefeld, Germany oliver.razum@uni-bielefeld.de 1 Värnik A, Kõlves K, Wasserman D. Suicide among Russians in Estonia: database study before and after independence. BMJ 2005;330:176-7. 2 Burvill PW. Migrant suicide rates in Australia and in country of birth. Psychol Med 1998;28:201-8 3 WHO suicide prevention page. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/ (accessed Jan 22, 2005) 4 Sayil I. Review of suicide studies in Turkey. Soc Sci Med 1998;47:1677-86. 5 Razum O, Zeeb H. [Suicide mortality among Turks in Germany]. Nervenarzt 2004;75:1092-8. Competing interests: None declared |
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