SUMMARY

INTRODUCTION

Recent decades have seen an uptick in suicide attempts and completed suicides among adolescents and young adults worldwide. In the Americas, including Cuba, suicide is the third leading cause of death in adolescents (ages 10–19 years).

OBJECTIVE

Characterize the epidemiology of attempted and completed suicide in Cuban adolescents from 2011 through 2014.

METHODS

A descriptive epidemiological study was carried out. The information was gathered from morbidity records for suicide attempts and mortality records for suicide deaths in adolescents, taken from the Cuban Ministry of Public Health’s Medical Records and Health Statistics Division database for January 1, 2011 through December 31, 2014. Variables were sex, age, occupation or employment status, and suicide method. Suicide attempt incidence rates and suicide mortality rates by age group per 100,000 population (crude, adjusted and age/sex specific), mortality sex ratio and attempt/suicide ratio were calculated. Relative change was calculated as a percentage, as were frequencies by variable for attempted suicide and suicide, and by age and sex for method used.

RESULTS

A total of 19,541 suicide attempts and 149 suicides were reported. Average annual numbers were 4,885.2 suicide attempts and 37.2 suicides (131:1 ratio). There were 3,966 suicide attempts among boys, for a sex ratio of 0.25:1. Age-adjusted suicide attempt rates decreased from 391.8 per 100,000 population to 304.5 (22.3% reduction over the study period). Boys accounted for 107 of 149 suicide deaths, for a sex ratio of 2.5:1. Age-adjusted suicide mortality rates decreased from 2.8 to 2.3 per 100,000 population (17.9% reduction). The group aged 15–19 years had the highest age-adjusted suicide rate (3.9 per 100,000 population) and contributed the most deaths (114/149, 76.5%), although it did experience a 31.8% reduction over the study period. The group aged 10–14 years recorded a relative increase of 60% over the study period. Hanging was the most common suicide method (116/149, 77.9%). The suicide rate in Cuban adolescents (2.6 per 100,000 population, 3.7 in boys and 1.5 in girls) is less than that reported by the Region of the Americas between 2005 and 2009, 3.7 per 100,000 population (5/100,000 in boys and 2.3/100,000 in girls).

CONCLUSIONS

Suicide rates in Cuban adolescents are lower than reported elsewhere in the Americas. Suicide attempts and suicide rates decreased modestly between 2011 and 2014. Hanging is the most commonly used method. The highest rates occur in the group aged 15–19 years, but those aged 10–14 years showed a relative increase over the study period. These results update the epidemiology of suicide in Cuban adolescents and demonstrate the extent of the problem. Suicides and suicide attempts show opposite patterns in boys and girls; suicides are more frequent among boys while suicide attempts are more frequent among girls.

CONTRIBUTION OF THIS RESEARCH

These results update the epidemiology of suicide in Cuban adolescents and reveal the extent of the problem for one of the main preventable causes of death in this age group.

Suicide; suicide, attempted; mortality rate; adolescents; Cuba

INTRODUCTION

Suicide is one of the most urgent problems that health professionals face today. Worldwide, suicide attempts and deaths increase each year, and so do their negative psychological and social effects on victims, their family members and their healthcare team. It is a multifactorial issue stemming from a complex mix of biological, genetic, psychological, social and environmental factors. Its impact in terms years of life lost and pain experienced by loved ones justifies the utmost attention.[¹1 World Health Organization. Prevención de la Conducta Suicida [Internet]. Washington, D.C.: World Health Organization; Pan American Health Organization; 2016 [cited 2017 Oct 2]. Available from: http://iris.paho.org/xmlui/bitstream/handle/123456789/31167/9789275319192-spa.pdf?sequence=1&isAllowed=y. Spanish.
http://iris.paho.org/xmlui/bitstream/han... –³3 Gore FM, Bloem PJ, Patton GC, Ferguson J, Joseph V, Coffey C, et al. Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet [Internet]. 2011 Jun 18 [cited 2017 Mar 20];377(9783):2093–102. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140-6736(11)60512-6
https://linkinghub.elsevier.com/retrieve... ]

Suicide’s impact is especially severe in adolescence, the portion of the life cycle between childhood and adulthood, and characterized by biological, psychological and sociological changes, many of which create crises, conflicts and contradictions. It includes two stages: early adolescence, 10–14 years and late adolescence, 15–19 years.[³3 Gore FM, Bloem PJ, Patton GC, Ferguson J, Joseph V, Coffey C, et al. Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet [Internet]. 2011 Jun 18 [cited 2017 Mar 20];377(9783):2093–102. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140-6736(11)60512-6
https://linkinghub.elsevier.com/retrieve... ]

Suicide in adolescents has been a growing problem for decades.[¹1 World Health Organization. Prevención de la Conducta Suicida [Internet]. Washington, D.C.: World Health Organization; Pan American Health Organization; 2016 [cited 2017 Oct 2]. Available from: http://iris.paho.org/xmlui/bitstream/handle/123456789/31167/9789275319192-spa.pdf?sequence=1&isAllowed=y. Spanish.
http://iris.paho.org/xmlui/bitstream/han... ] Suicide attempts are more frequent in adolescence than in adulthood and are more frequent than completed suicides. It is estimated that by 2020, some 15–30 million adolescents worldwide will deliberately hurt themselves. Suicide is one of the main causes of death in adolescents and, together with suicide attempts, represents 3% of adolescent burden of disease, higher than asthma, tuberculosis and AIDS, and comparable to drug abuse and violence.[²2 Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS, et al. Grand challenges in global mental health. Nature [Internet]. 2011 Jul 6 [cited 2017 Mar 20];475(7354):27–3. Available from: http://www.nature.com/nature/journal/v475/n7354/full/475027a.html
http://www.nature.com/nature/journal/v47... ,³3 Gore FM, Bloem PJ, Patton GC, Ferguson J, Joseph V, Coffey C, et al. Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet [Internet]. 2011 Jun 18 [cited 2017 Mar 20];377(9783):2093–102. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140-6736(11)60512-6
https://linkinghub.elsevier.com/retrieve... ]

During the 2013 World Health Assembly, WHO’s first mental health action plan proposed a goal of a 10% reduction of global suicide rates by 2020.[⁴4 World Health Organization. 53 Plan de Acción para la Salud Mental. Consejo directivo 66a Sesión del comité regional de la OMS para las Américas [Internet]. Washington, D.C.: World Health Organization; Pan American Health Organization; 2014 [cited 2017 Jan 2]. Available from: http://www.paho.org/HQ/index.php?option=com_content&view=article&id=9774%3A2014-53rd-directing-council&catid=7003%3A53rd-directing-council-29-sep-3-oct&Itemid=41062&lang=es. Spanish.
http://www.paho.org/HQ/index.php?option=... ] PAHO declared suicide an important public health problem and resolved that its indicators should be evaluated and monitored in the Americas.[⁵5 Pan American Health Organization. Marco de Referencia para la Implantación de la Estrategia Regional de Salud Mental. Washington, D.C.: Pan American Health Organization; 2011. p. 142–7. Spanish.] In many countries, suicidal behavior among adolescents is a mental health issue that must be addressed.[⁶6 Medina MR, Vazquez de Anda GF, Valdespino Salinas E. Revisión de la conducta suicida en el sur del Estado de México. Med Int Mex [Internet]. 2013 May–Jun [cited 2017 Mar 20];29(3):257–64. Available from: www.medigraphic.com/pdfs/medintmex/mim-2013/mim133f.pdf. Spanish.
www.medigraphic.com/pdfs/medintmex/mim-2... 7 Piedrahital LE, Garcia MA, Mesa JS, Stivalis Rosero I. Identificación de los factores relacionados con el intento de suicidio en niños y adolescentes a partir de la aplicación del Proceso de Atención de Enfermeria. Colomb Med [Internet]. 2011 Jul–Sep [cited 2017 Mar 14];42(3):334–41. Available from: http://www.scielo.org.co/pdf/cm/v42n3/v42n3a10.pdf. Spanish.
http://www.scielo.org.co/pdf/cm/v42n3/v4... 8 Cendales R, Vanegas C, Fierro M, Córdoba R, Loiret A. Tendencias del suicidio en Colombia, 1985–2002. Rev Panam Salud Püblica [Internet]. 2007 [cited 2017 Apr 9];22(4):231–8. Available from: http://www.scielosp.org/pdf/rpsp/v22n4/02.pdf. Spanish.
http://www.scielosp.org/pdf/rpsp/v22n4/0... 9 Paniagua RE, Gonzalez CM, Rueda SM. Orientación al suicidio en adolescentes en una zona de Medellin, Colombia. Rev Fac Nac Salud Püblica [Internet]. 2014 Sep–Dec [cited 2017 Mar 14];32(3):314–21. Available from: http://www.redalyc.org/pdf/120/12031816008.pdf. Spanish.
http://www.redalyc.org/pdf/120/120318160... 10 Albores-Gallo L, Méndez-Santos JL, Xochitil-Garcia Luna A, Delgadillo-Gonzalez L, Chavez-Flores CI, Martinez OL. Nonsuicidal Self-Injury in a Community Sample of Older Children and Adolescents of México City. Actas Esp Psiquiatr[Internet]. 2014 Jul–Aug [cited 2017 Mar 20];42(4):159–68. Available from: http://www.actaspsiquiatria.es/repositorio//16/90/ENG/16-90-ENG-159-168-700617.pdf. Spanish.
http://www.actaspsiquiatria.es/repositor... –¹¹11 Trigylidas TE, Reynolds EM, Teshome G, Dykstra HK, Lichenstein R. Paediatric suicide in the USA: analysis of the National Child Death Case Reporting System. Inj Prev [Internet]. 2015 [cited 2016 Jun 7]. Epub ahead of print. Available from: http://injuryprevention.bmj.com/content/early/2016/01/18/injuryprev-2015-041796abstract
http://injuryprevention.bmj.com/content/... ]

In Cuba, suicide is the third leading cause of death among adolescents.[¹²12 National Health Statistics and Medical Records Division (CU). Anuario Estadistico de Salud 2015 [Internet]. Havana: Ministry of Public Health (CU); 2016 [cited 2017 May 11]. 206 p. Available from: http://files.sld.cu/dne/files/2016/04/Anuario_2015_electronico-1.pdf. Spanish.
http://files.sld.cu/dne/files/2016/04/An... ] The National Program for Prevention of Suicidal Behavior (created in the 1980s and upgraded several times since)[¹³13 Riera Betancourt C, Alonso Betancourt O, Masid Oramas E. La Conducta Suicida y su Prevención. Havana: Hygiene and Epidemiology National Center (CU); 1990. Spanish.] aims to decrease suicide mortality and morbidity from suicide attempts. It focuses on searching for risk factors, patient followup and assessment by multidisciplinary teams.[¹⁴14 Lomba Acevedo P, Alfonso Carrillo E, Fernandez Coto L. Prevención del suicidio en la comunidad. In: Medio Residencial y Salud. Havana: World Health Organization; Pan American Health Organization; 2013. p. 207–14. Spanish.] This study’s objective was to characterize the epidemiology of suicide attempts and completed suicides in Cuban adolescents in 2011–2014.

METHODS

Study type and data sources

A descriptive epidemiological study was carried out to characterize suicide attempt morbidity and suicide mortality in people aged 10–19 years in Cuba in 2011–2014. Data sources included morbidity records for suicide attempts from notifiable disease cards and suicide death certificates in the mortality database of the Cuban Ministry of Public Health’s (MINSAP) National Medical Records and Health Statistics Division from January 1, 2011 through December 31, 2014.[¹²12 National Health Statistics and Medical Records Division (CU). Anuario Estadistico de Salud 2015 [Internet]. Havana: Ministry of Public Health (CU); 2016 [cited 2017 May 11]. 206 p. Available from: http://files.sld.cu/dne/files/2016/04/Anuario_2015_electronico-1.pdf. Spanish.
http://files.sld.cu/dne/files/2016/04/An... ]

Variables

For suicide attempts variables were sex (male, female) and age group (10–14 and 15–19 years). Variables for suicide were the same as for suicide attempts, plus occupation or employment status: student, unemployed, homemaker, with an incapacitating disability, and other (includes armed forces, skilled and unskilled workers, middle-level professional or technician, office workers and unknown) and methods used for suicide (hanging, poisoning, firearms, self-immolation, jumping from high places and intentional motor vehicle collision).

Data collection, processing and analysis

Authorization was requested from MINSAP’s Medical Records and Health Statistics Division to collect information. Notifiable disease cards and death certificates were the primary sources. To classify cause of death (intentionally self-inflicted injury), we used ICD 10 codes X60–X84.[¹⁵15 Pan American Health Organization. Clasificación internacional de enfermedades CIE-10. Causas externas de morbilidad y mortalidad. Lesiones auto infligidas intencionalmente. Capitulo 20 (X60-X84) [Internet]. Washington, D.C.: Pan American Health Organization; 2001 [cited 2017 Mar 2]. Available from: http://ais.paho.org/classifications/Chapters/. Spanish.
http://ais.paho.org/classifications/Chap... ]

The following were calculated: suicide attempt and suicide mortality rates per 100,000 population by age group (crude, age adjusted and sex specific); sex ratio (male:female); and attempt:suicide ratio. Rates were directly standardized by age group and sex to Cuba’s 2012 population. Relative change in rates was calculated and percentages were used to show distribution of variables (sex, age, occupation or employment status, and suicide methods) to indicate respective burden.

Medical Records and Health Statistics Division code books were used for the abovementioned variables. An Excel database was created to store and manage data and to generate tables and graphs.

Ethics

Only morbidity and mortality records were used. Anonymity of patients and the deceased was preserved, and data were used exclusively for this research, which was approved by the National Hygiene, Epidemiology and Microbiology Institute Ethics Committee.

RESULTS

Suicide attempts

There were 19,541 suicide attempts reported (4885.2 per year on average), a crude rate of 336.8 per 100,000 population for the period. The age-adjusted rate in 2011 was 391.8 per 100,000 population (hereinafter, rates reported are age adjusted, unless otherwise specified). In 2014, the rate dropped to 304.5 (Table 1), a 22.3% reduction.

At the beginning of the period, the rate for suicide attempts in boys was 139.2 per 100,000, and decreased to 127.5 in 2014 (relative decrease of 8.4%). In girls, the rate was 658.7 per 100,000 population in 2011 and decreased to 491.6 in 2014 (relative decrease of 25.4%).

There were 6484 suicide attempts reported in the group aged 10–14 years, a rate of 232.7 per 100,000 population. The 2011 rate of 253.4 per 100,000 fell to 209.1 per 100,000 population in 2014, a 17.5% reduction. In the group aged 15–19 years, there were 13,057 attempts, for a rate of 452.4 per 100,000 population. In 2011, the rate was 522.5, decreasing to 394.8 per 100,000 population in 2014, a 24.4% reduction. Sex ratio for attempted suicide was 0.25:1. The attempt:suicide ratio for the period was 131:1. Girls made 371 attempts per successful suicide and boys made 37 (Table 1).

Suicides

Between 2011 and 2014, 149 suicides were reported (37.2 per year on average), for a rate of 2.6 per 100,000 population (Table 1). The rate was 2.8 per 100,000 population in 2011 and 2.3 in 2014, a 17.9% reduction.

There were 107 suicide deaths among boys, for a rate of 3.7 per 100,000 population (Table 1). The rate in 2011 was 3.9 per 100,000 population, decreasing to 3.5 in 2014, a 10.3% reduction.

Girls accounted for 42 suicides, for a rate of 1.5 per 100,000 population (Table 1). The 2011 rate was 1.6 per 100,000 population, dropping to 1 per 100,000 population in 2014, a 37.5% reduction. The overall sex ratio for 2011–2014 was 2.5:1 (107/42).

There were 35 suicides in the group aged 10–14 years, for a rate of 1.2 per 100,000 population (Table 1). In 2011, the rate in this group was 1 per 100,000 population, increasing to 1.6 in 2014, an increase of 60%.

The group aged 15–19 years had the highest mortality, with 114 deaths and a rate of 3.9 per 100,000 (Table 1). The 2011 rate of 4.4 per 100,000 decreased to 3 per 100,000 population in 2014, a 31.8% reduction. This group comprised 66.8% of the population but 76.5% of suicide deaths during the period (Table 2).

Students accounted for 54.4% of all suicide deaths (Table 2). Hanging was the most commonly used suicide method (77.9%), in all age groups (Figure 1) and in both sexes (Table 2).

DISCUSSION

There is considerable recent literature on risk factors for suicide. Depression, desperation, impulsiveness, violence, alcohol and drug use, school failure, low cultural and economic levels, chronic diseases, immigration, bullying (psychological, moral and/or physical harassment at school, where one student exerts power over another systematically with intent to cause harm) are the most commonly invoked factors. [¹⁶16 Estévez Garcia K, Velazquez Reinaldo R. Conductas de riesgo en adolescentes y jóvenes. Videojuegos: ¿ parmas letales? ES [Internet]. 2014 Oct [cited 2017 Mar 14];11:43–96. Available from: http://209.177.156.169/libreria_cm/archivos/pdf_1062.pdf. Spanish.
http://209.177.156.169/libreria_cm/archi... –²¹21 Greydanus DE, Apple RW. The relationship between deliberate self-harm behavior, body dissatisfaction, and suicide in adolescents: current concepts. J Multidiscip Health [Internet]. 2011 [cited 2017 Mar 14];4:183–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141836/
https://www.ncbi.nlm.nih.gov/pmc/article... ]

Poor family communication, frequent quarrels, lack of affection and cohesion among family members and overall lack of support, are main factors that contribute to suicidal behavior in children and adolescents.[²²22 Ruiz R. Familia, género y violencia doméstica. Diversas experiencias de investigación social. ES [Internet]. 2014 Oct [cited 2017 Mar 14];11:27:45. Available from: http://209.177.156.169/libreria_cm/archivos/pdf_1062.pdf. Spanish.
http://209.177.156.169/libreria_cm/archi... ] Home and school are the contexts in which most risk factors for suicidal behavior can develop, but at the same time can offer many opportunities to detect factors and stigmas that can lead to suicidal ideation.

Some researchers argue that the global economic crisis, globalization and advanced technologies contribute to increased suicidal behavior during adolescence, arguing that stress associated with a faster pace of life, conflicts and competition leads to desperation and tension during a critical period in life in which psychological, sociological and biological changes make adolescents especially vulnerable.[²³23 Córdova Moreno MA, Cubillas Rodriguez MJ, Roman Pérez R. ¿Es posible prevenir el suicidio? Evaluación de un programa de prevención en estudiantes de bachillerato. Pensamiento Psicol [Internet]. 2011 [cited 2017 Mar 13];9(17):21–32. Available from: http://revistas.javerianacali.edu.co/index.php/pensamientopsicologico/article/download/153/455. Spanish.
http://revistas.javerianacali.edu.co/ind... ] Despite its socially inclusive system and the special protection afforded vulnerable groups, these problems also affect Cuban adolescents.

In Cuba, young people are increasingly exposed to modern technologies and audiovisual products. A study of Cuban adolescents reported notable increases in video gaming and Internet addiction.[¹⁶16 Estévez Garcia K, Velazquez Reinaldo R. Conductas de riesgo en adolescentes y jóvenes. Videojuegos: ¿ parmas letales? ES [Internet]. 2014 Oct [cited 2017 Mar 14];11:43–96. Available from: http://209.177.156.169/libreria_cm/archivos/pdf_1062.pdf. Spanish.
http://209.177.156.169/libreria_cm/archi... ] Such addictions are known to accentuate loneliness, reduce psychological wellbeing and affect socialization and psychomotor development in adolescents.[¹⁶16 Estévez Garcia K, Velazquez Reinaldo R. Conductas de riesgo en adolescentes y jóvenes. Videojuegos: ¿ parmas letales? ES [Internet]. 2014 Oct [cited 2017 Mar 14];11:43–96. Available from: http://209.177.156.169/libreria_cm/archivos/pdf_1062.pdf. Spanish.
http://209.177.156.169/libreria_cm/archi... ] In addition, young people’s increasing access to the Internet exposes them to images and other visual information about selfdestructive behavior, or other apocalyptic content, all of which can have quite harmful effects.[¹⁷17 Durkee T, Hadlaczky G, Westerlund M, Carli V. Internet pathways in suicidality: a review of the evidence. Int J Environ Res Public Health. 2011 Oct;8(10):3938–52.,¹⁸18 McCarthy MJ. Internet monitoring of suicide risk in the population. J Affect Disord. 2010 May;122(3):277–9. 19 Canón Buitrago SC. Factores de riesgo asociados a la conducta suicida en ninos y adolescentes. Arch Med [Internet]. 2011 Jan–Jun [cited 2016 Mar 14];11(1):62–7. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=lth&AN=82584789&lang=es&site=ehost-live. Spanish.
http://search.ebscohost.com/login.aspx?d... 20 Acosta-Hernandez M, Mancilla-Percino T, Correa-Basurto J, Saavedra-Vélez M, Ramos-Morales FR, Cruz-Sanchez JS, et al. Depresión en la infancia y adolescencia: enfermedad de nuestro tiempo. Arch Neurocien (Mex) [Internet]. 2011 Jul–Sep [cited 2016 Mar 14];16(3):156–61. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=lth&AN=88924012&lang=es&site=ehost-live. Spanish.
http://search.ebscohost.com/login.aspx?d... ]

The 60% increase over the study period in suicide rates in the group aged 10–14 years is consistent with international studies reporting that suicide is increasingly frequent in early adolescence. This may be due not only to traditional risk factors, but also to technological development in recent years. Modern technologies have changed our relationships. We no longer rely on face-to-face interactions. A child alone in their bedroom can be in touch with dozens of people, but this tends to foster weak connections, superficiality, short-term relationships and ultimately, social isolation.[²⁴24 Picazo-Zappino J. El suicidio infanto-juvenil: una revisión. Actas Espanolas Psi [Internet]. 2014 May [cited 2017 Mar 14];42(3):125–32. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=lth&AN=96033542&lang=es&site=ehost-live. Spanish.
http://search.ebscohost.com/login.aspx?d... ] Overreliance on technology, if combined with lack of parental supervision or a dysfunctional family environment, can have negative effects on adolescent behavior and might help explain why suicidal behavior and thoughts historically attributable to adults, are occurring among youth in our societies.[²⁴24 Picazo-Zappino J. El suicidio infanto-juvenil: una revisión. Actas Espanolas Psi [Internet]. 2014 May [cited 2017 Mar 14];42(3):125–32. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=lth&AN=96033542&lang=es&site=ehost-live. Spanish.
http://search.ebscohost.com/login.aspx?d... ]

Attempted suicide is considered a psychiatric emergency.[¹³13 Riera Betancourt C, Alonso Betancourt O, Masid Oramas E. La Conducta Suicida y su Prevención. Havana: Hygiene and Epidemiology National Center (CU); 1990. Spanish.,¹⁴14 Lomba Acevedo P, Alfonso Carrillo E, Fernandez Coto L. Prevención del suicidio en la comunidad. In: Medio Residencial y Salud. Havana: World Health Organization; Pan American Health Organization; 2013. p. 207–14. Spanish.] Cuba’s National Program for Prevention of Suicidal Behavior has established a protocol for all such attempts. A mandatory note is entered on the notifiable disease card of those who attempt suicide, for followup by the patient’s basic primary care team (family doctor, nurse, pediatrician, clinician, OB/GYN, psychologist) and mental health team (psychiatrist, psychologist, nurse, social worker) in their municipality. This aimed at timely treatment and monitoring by psychiatric specialists after initial assessment. Reports on assessment and evaluation of the Program in selected municipalities have revealed both strengths and weaknesses. One Program evaluation study reported that 72.9% of cases had been monitored satisfactorily in clinics and on-site visits, as stipulated, and that in the remainder of cases, monitoring was not possible due to incorrect addresses or family refusal.[²⁵25 Aguilar Hernandez I, Louro Bernal I, Perera Milian SL. Ejecución del Programa de Prevención y Control de la Conducta Suicida en Nueva Paz. Rev Cubana Salud Püblica [Internet]. 2012 Jan–Mar [cited 2014 Apr 6];38(1). Available from: http://scielo.sld.cu/scielo.php?pid=S0864-34662012000100008&script=sci. Spanish.
http://scielo.sld.cu/scielo.php?pid=S086... ] Another report detected lack of compliance with the Program.[²⁶26 Toro Kondeff M, Hernandez Gonzalez Y, David Huerta B. Caracterización de la conducta suicida en adolescentes del municipio Cerro, 2009–2010. Rev Hosp Psiquiatrico de la Habana [Internet]. 2012 [cited 2015 Dec 14];9(2). Available from: http://www.revistahph.sld.cu/Revista%202-2012/hph03212.html. Spanish.
http://www.revistahph.sld.cu/Revista%202... ] However, these results are not representative of Cuba as a whole. When the Program functions properly, it is a valuable resource for suicidal behavior prevention.

Previous studies in Cuba have reported increases in suicide attempts in Cuban adolescents in 2011 and 2012, but none of them had national coverage.[²⁷27 Acosta Gonzalez A, Milian Martinez M, Vina Pérez H. Factores de riesgo del intento suicida en adolescentes con esta conducta. Rev Hosp Psiquiatrico de la Habana [Internet]. 2012 [cited 2014 Apr 9];9(1). Available from: http://new.medigraphic.com/cgi-bin/resumen.cgi?IDARTICULO=34791. Spanish.
http://new.medigraphic.com/cgi-bin/resum... 28 Moreno Campa C, Diaz Cantün CL, Soler Santana R, Brossard Cisnero M, Carbonell Garcia IC. Caracterización epidemiológica de la conducta suicida en la provincia de Santiago de Cuba. MEDISAN [Internet]. 2012 [cited 2017 May 10];16(2):204–10. Available from: http://bvs.sld.cu/revistas/san/vol_16_2_12/san08212.pdf. Spanish.
http://bvs.sld.cu/revistas/san/vol_16_2_... –²⁹29 Cruz Rodriguez E, Moreira Rios I, Orraca Castillo O, Pérez Moreno N, Hernandez Gonzalez P. Factores de riesgo del intento suicida en adolescentes, Pinar del Rio. Rev Ciencias Médicas [Internet]. 2011 Oct–Dec [cited 2017 May 11 ]; 15(4):52–61. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1561-31942011000400007. Spanish.
http://scielo.sld.cu/scielo.php?script=s... ] No such increase was apparent in our national study. On the contrary, there was some decline in suicide and suicide attempts in Cuba over the study period, less in boys than in girls, although boys had lower initial rates. Attempts declined more than completed suicides.

The suicide rate in Cuban adolescents (2.6 per 100,000 population) is less than that reported by the Region of the Americas between 2005 and 2009, 3.7 per 100,000 population (5 in boys and 2.3 in girls). Rates of 4.4 and 3.5 per 100,000 population were reported in North America, and Central America and the Spanish Caribbean, respectively.[³⁰30 Pan American Health Organization. Mortalidad por Suicidio en las Américas: Informe Regional [Internet]. Washington, D.C.: Pan American Health Organization; World Health Organization; 2014 [cited 2017 May 10]. p. 6–49. Available from: http://www.bvsde.paho.org/documentosdigitales/bvsde/texcom/PAHOMortalidad-suicidio.pdf. Spanish.
http://www.bvsde.paho.org/documentosdigi... ] In contrast, suicide rates in Spain are lower than those we found: in 2010, 0.1 per 100,000 population for the group aged 10–14 years, and 1.2 per 100,000 population for the group aged 15–19 years.[²⁴24 Picazo-Zappino J. El suicidio infanto-juvenil: una revisión. Actas Espanolas Psi [Internet]. 2014 May [cited 2017 Mar 14];42(3):125–32. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=lth&AN=96033542&lang=es&site=ehost-live. Spanish.
http://search.ebscohost.com/login.aspx?d... ]

In Colombia, suicide attempts have been reported as early as age seven years, although with rates gradually increasing with age, and more frequent in girls.[³¹31 Jiménez Quenguan M, Hidalgo Bravo J, Camargo Santacruz C, Dulce Rosero B. El intento de suicidio en la población pediatrica, una alarmante realidad. Rev Cienc Salud [Internet]. 2014 [cited 2017 May 11];12(1):63–87. Available from: http://www.scielo.org.co/pdf/recis/v12n1/v12n1a06.pdf. Spanish.
http://www.scielo.org.co/pdf/recis/v12n1... ,³²32 Garavito Egea G. Autopsia psicológica en ninos y adolescentes con conductas suicidas. Rev Cultura, Educación y Sociedad [Internet]. 2017 [cited 2017 Nov 27];2(1). Available from: http://revistascientificas.cuc.edu.co/index.php/culturaeducacionysociedad/article/view/933. Spanish.
http://revistascientificas.cuc.edu.co/in... ] The higher frequency of suicide attempts among girls is consistent with our findings.

Although children aged less than 10 years are not included in our study and will be the subject of another paper, there is considerable literature sounding an alert about suicidal behavior in children.[³³33 Pfeffer CR. Suicidal behavior in children: from the 1980s to the new millennium. In: Maris RW, Canetto SS, McIntosh JM, Silverman MM, editors. Review of Suicidology. New York: Guilford; 2000. p. 159–69. 34 Matter DE, Matter RM. Suicide among elementary school children: a serious concern for counselors. Elem School Guidance Counseling. 1984;18:260–7. 35 Pompili M, Mancinelli I, Girardi P, Ruberto A, Tartarelli R. Childhood suicide: a major issue in pediatric health care. Issues Compr Pediatr Nurs. 2005;28:63–8.–³⁶36 Trad PV. Self-destructive preschool children. In: O’Brien JD, Pilowski DJ, Lewis OW, editors. Psychotherapies with children and adolescents. Adapting the psychodynamic process. Northvale: Jason Aronson Inc.; 2000. p. 27–51.]

As seen elsewhere, the number of suicide attempts far exceeded completed suicides; the attempt:suicide ratio was within the range of a Spanish study that found ratios of 100–200 attempts per suicide.[³⁷37 Giner Jiménez L. Diferencias en la conducta suicida: estudio comparativo entre los intentos de suicidio y suicidio consumado [thesis] [Internet]. [Madrid]: Universidad Autónoma de Madrid; 2010 [cited 2017 May 17]. 243 p. Available from: https://repositorio.uam.es/bitstream/handle/10486/5657/35431_giner_jimenez_lucas.pdf?sequence=1. Spanish.
https://repositorio.uam.es/bitstream/han... ]

The relation between suicide attempts and suicide is clearly sex-related, with girls more likely to attempt and boys more likely to complete. Our finding that boys were more affected by suicide coincides with PAHO’s technical report, which states that in the Americas Region, boys have higher suicide rates across all age groups.[³⁸38 Pan American Health Organization. Mortalidad por Suicidio en las Américas: Informe Regional [Internet]. Washington, D.C.: Pan American Health Organization; World Health Organization; 2014 [cited 2017 May 10]. p. 6–49. Available from: http://www.bvsde.paho.org/documentosdigitales/bvsde/texcom/PAHOMortalidad-suicidio.pdf. Spanish.
http://www.bvsde.paho.org/documentosdigi... ] In other regions, it has been reported that completed suicide is two to five times more frequent in boys, consistent with our findings.[³⁹39 Freuchen A, Kjelsberg E, Groholt B. Suicide or accident? A psychological autopsy study of suicide in youths under the age of 16 compared to deaths labeled as accidents. Child Adolesc Psychiatry Mental Health [Internet]. 2012 [cited 2016 Dec 2];30(6):[about 6 p.]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3526543/
https://www.ncbi.nlm.nih.gov/pmc/article... ] In Cuba, the suicide sex ratio has been increasing among adolescents.[⁴⁰40 Corona Miranda B, Alfonso Sagué K, Hernandez Sanchez M, Lomba Acevedo P. Epidemiology of suicide in Cuba 1987–2014. MEDICC Rev [Internet]. 2016 Jul [cited 2017 Mar 20];18(3):15–20. Available from: http://www.scielosp.org/pdf/medicc/v18n3/1555-7960-medicc-18-03-0015.pdf
http://www.scielosp.org/pdf/medicc/v18n3... ] A study carried out in Mexico reported that 68.4% of suicides occurred in boys,[⁴¹41 Sanchez-Cervantes FS, Serrano-Gonzalez RE, Marquez-Caraveo ME. Suicidios en menores de 20 anos. México 1998–2011. Salud Ment. 2015 Sep–Oct;38(5):379–89. Spanish.] which is lower than in our study. A 2.2 sex ratio in this age group was reported for the Americas, while for Central America, Spanish Caribbean and Mexico, it was 1.7,[³⁸38 Pan American Health Organization. Mortalidad por Suicidio en las Américas: Informe Regional [Internet]. Washington, D.C.: Pan American Health Organization; World Health Organization; 2014 [cited 2017 May 10]. p. 6–49. Available from: http://www.bvsde.paho.org/documentosdigitales/bvsde/texcom/PAHOMortalidad-suicidio.pdf. Spanish.
http://www.bvsde.paho.org/documentosdigi... ] lower than ours. China and India are the only countries in which suicide rates in women are higher than in men.[⁴²42 World Health Organization. Preventing suicide: A global imperative [Internet]. Luxembourg: World Health Organization; 2014 [cited 2015 Dec 2]. 92 p. Available from: http://www.who.int/mental_health/suicide-prevention/world_report_2014/
http://www.who.int/mental_health/suicide... ]

The highest number of attempted and completed suicides occurred in the group aged 15–19 years, consistent with other studies reflecting that risk is higher in late than in early adolescence.[²⁴24 Picazo-Zappino J. El suicidio infanto-juvenil: una revisión. Actas Espanolas Psi [Internet]. 2014 May [cited 2017 Mar 14];42(3):125–32. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=lth&AN=96033542&lang=es&site=ehost-live. Spanish.
http://search.ebscohost.com/login.aspx?d... ] In Mexico, this age group also presented the highest percentage of suicide cases (78.2%), even higher than in our study.[⁴¹41 Sanchez-Cervantes FS, Serrano-Gonzalez RE, Marquez-Caraveo ME. Suicidios en menores de 20 anos. México 1998–2011. Salud Ment. 2015 Sep–Oct;38(5):379–89. Spanish.]

Most suicides occurred among students. This might simply reflect the fact that the vast majority of youngsters in Cuba are students.[⁴³43 Rojas Ochoa F. Situación, sistema y recursos humanos en salud para el desarrollo en Cuba. Rev Cubana Salud Püblica [Internet]. 2003 Apr–Jun [cited 13 Mar 2017];29(2): [about 6 p.]. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0864-34662003000200011. Spanish.
http://scielo.sld.cu/scielo.php?script=s... ] Cuba offers free education for all, and school attendance is compulsory up to age 14 years; in 2015, 91% of secondary-school-aged youth were enrolled.[⁴⁴44 National Statistics Bureau (CU). Anuario Estadistico de Cuba 2016. Educación [Internet]. Havana: National Statistics Bureau (CU); 2017 [cited 2018 Jan 15]. p. 28. Available from: http://www.one.cu/aec2016/18%20Educacion.pdf. Spanish.
http://www.one.cu/aec2016/18%20Educacion... ] A Spanish study found that suicide risk was five-fold higher among youngsters who abandon school and eight-fold higher in those without postsecondary education.[⁴⁵45 Pérez Camarero S. El suicidio adolescente y juvenil en Espana. Rev Estudios de Juventud. 2009 Mar;84(2):126–42. Spanish.]

Suicide methods depend on availability and access. Our finding that the most commonly used suicide method in this study was hanging is in accord with other research reporting that hanging is most common in ages 10–19 years, as it is inexpensive, easy and does not require laborious planning.[³²32 Garavito Egea G. Autopsia psicológica en ninos y adolescentes con conductas suicidas. Rev Cultura, Educación y Sociedad [Internet]. 2017 [cited 2017 Nov 27];2(1). Available from: http://revistascientificas.cuc.edu.co/index.php/culturaeducacionysociedad/article/view/933. Spanish.
http://revistascientificas.cuc.edu.co/in... ,⁴¹41 Sanchez-Cervantes FS, Serrano-Gonzalez RE, Marquez-Caraveo ME. Suicidios en menores de 20 anos. México 1998–2011. Salud Ment. 2015 Sep–Oct;38(5):379–89. Spanish.] Hanging is also the most frequent suicide method in Central America, the Spanish Caribbean and Mexico (65.2%), as well as South America (59%), although by smaller margins than in Cuba.[³⁸38 Pan American Health Organization. Mortalidad por Suicidio en las Américas: Informe Regional [Internet]. Washington, D.C.: Pan American Health Organization; World Health Organization; 2014 [cited 2017 May 10]. p. 6–49. Available from: http://www.bvsde.paho.org/documentosdigitales/bvsde/texcom/PAHOMortalidad-suicidio.pdf. Spanish.
http://www.bvsde.paho.org/documentosdigi... ]

Poisoning ranked second in our study, as it did in PAHO’s Report on Suicide Mortality in the Americas, which placed poisoning at 23.5%, more than double the percentage in Cuba. Poisoning is the most common method in the non-Spanish Caribbean, at 47.4%.[³⁸38 Pan American Health Organization. Mortalidad por Suicidio en las Américas: Informe Regional [Internet]. Washington, D.C.: Pan American Health Organization; World Health Organization; 2014 [cited 2017 May 10]. p. 6–49. Available from: http://www.bvsde.paho.org/documentosdigitales/bvsde/texcom/PAHOMortalidad-suicidio.pdf. Spanish.
http://www.bvsde.paho.org/documentosdigi... ] In some high-income countries, different methods are more frequently used. In North America, predominantly in the United States, firearms were the number one suicide method among boys and young men.[³⁸38 Pan American Health Organization. Mortalidad por Suicidio en las Américas: Informe Regional [Internet]. Washington, D.C.: Pan American Health Organization; World Health Organization; 2014 [cited 2017 May 10]. p. 6–49. Available from: http://www.bvsde.paho.org/documentosdigitales/bvsde/texcom/PAHOMortalidad-suicidio.pdf. Spanish.
http://www.bvsde.paho.org/documentosdigi... ]

The study’s main limitation was its inability to obtain reliable information from secondary sources on other geodemographic stratification criteria that could have helped create broader, more complete epidemiological insights into socially related causes of suicide or suicide attempts.

Despite this limitation, the study provides important baseline information on the characteristics of attempted and completed suicide among young people. It gives visibility to attempted suicide, a problem for which Cuba is one of the few countries reporting data to PAHO/WHO, although it is not included in MINSAP’s annual statistical yearbook.[¹²12 National Health Statistics and Medical Records Division (CU). Anuario Estadistico de Salud 2015 [Internet]. Havana: Ministry of Public Health (CU); 2016 [cited 2017 May 11]. 206 p. Available from: http://files.sld.cu/dne/files/2016/04/Anuario_2015_electronico-1.pdf. Spanish.
http://files.sld.cu/dne/files/2016/04/An... ] While current trends do not point to a marked decline in completed suicides, there have been substantial decreases in attempted suicide.

There are very few Cuban publications on suicide, especially among adolescents. The information obtained here provides an essential basis for other, more specific family or individual studies regarding causes of suicide and suicide attempts. Such studies will help Cuba design and implement more effective prevention strategies to address identified causes of preventable morbidity and death. As a collateral benefit for future research and surveillance, a complete database is now available for researchers to contact families and monitor adolescents at risk. Although our study does not and cannot purport to establish causal associations, it provides the epidemiological basis for further studies seeking causal factors.

CONCLUSIONS

Suicide rates in Cuba are lower than those reported elsewhere in the Americas and overall suicide attempt and suicide rates decreased somewhat between 2011 and 2014. However, there is no room for complacency. The highest suicide rates occur in the group aged 15–19 years, but rates in those aged 10–14 years are increasing. Hanging is the most commonly used method. Boys are more likely to commit suicide, but girls more likely to attempt it. These results update the epidemiology of suicide in Cuba in the group aged 10–19 years and demonstrate the extent of the problem for one of the main preventable causes of death in Cuban adolescents. Thus, these findings alert us to the need to take action to further reduce rates of suicide and suicide attempts in Cuban young people.

ACKNOWLEDGMENTS

Our thanks to Silvia Serrá Larín and María del Carmen Hinojosa Álvarez for assistance with the literature review.

REFERENCES

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