Suicides in Finland Are Decreasing
My childhood friend committed a suicide not so long ago. I still remember the last day when I met him and my other childhood friend. I arranged a gathering and we drank beer and reminisced the good old times. I did not see anything suicidal in his behavior or in the way he talked. He had changed for sure, but everybody changes in ten to fifteen years. And so when I heard the news, I was without words.
He inspired me to understand more about suicide. The following essay is an assignment that I wrote for the course Humanism and Peace Work.
As is the norm for scientific articles, I define suicide and describe contributing risk and protective factors.
Then I explain the positive decline in suicides evidenced by data. Suicides have most likely decreased as a result of framing suicide as a mental health problem, treating depression, limiting access to lethal means of suicide like firearms, reducing alcohol consumption, and urbanisation.
Lastly, I discuss suicide from Western and Eastern humanist perspective.
Finns met one of the deepest economic recessions of all western Europeans in the mid-1990s. Unemployment climbed up to 20%, and as a consequence the government cut down funding from health services (Lehtinen & Taipale, 2001). Despite the hardship, suicides peaked in 1990 and declined significantly thereafter, and halved in 2015 (figure 1) (OSF, 2021).
This positive trend emerged after the implementation of the National Suicide Prevention Project from 1986 to 1996 (Vorma et al., 2020). Majority of people then who committed suicide (88%) suffered from illnesses, notably depression, serious physical illness, and substance abuse.
figure 1. suicides per 100 000 inhabitants, 1971 to 2019 (OSF, 2021)
Suicide
Suicidal behavior refers to suicidal ideation, suicide attempt, and committed suicide─the act of intentionally causing one's own death (THL, 2021a). Thus, suicidal behavior exists on a spectrum of severity where it progresses from less severe ideation to a more severe form, committed suicide (Turecki & Brent, 2016).
Suicidal ideation is not rare among Finnish people (THL, 2021a). At least one in six people in their lives have thought about committing a suicide. Luckily suicidal ideations are momentary for many people. Suicide ideation is much more common for women, whereas committed suicide is more common for men, worldwide (Ritchie, Roser & Ortiz-Ospina, 2015). Still, among the people who do not seek help, suicide attempts happen to 1/100 people per year (THL, 2021a).
Notwithstanding the importance of explicating between and within different suicidal behaviors like ideation, attempts, and completions, the following data and literature in this essay concerns committed suicides (hereafter suicides).
Globally, there are 800,000 people who commit suicide every year, which is twice the amount of homicides (Ritchie, Roser & Ortiz-Ospina, 2015). Suicide accounts for 1.4% of the global deaths in 2017, which coincides with Finland in 2019 when 1.4% commited suicide. Indeed, suicide is among the top ten causes of death in Finland (OSF, 2019).
In Finland, the three most common suicide methods were by hanging, firearm, or by an overdose of psychotropic medicine (e.g., antidepressant), all three of which are characterized by sex differences (OSF, 2021). Men die by hanging or by firearm much more than women, whereas both women and men die by psychotropic drug overdose to an equal extent.
Risk factors to suicide include mental illness, alcohol abuse, somatic disease, alienation from society, life crises surrounded by negative emotions, male gender, firearms availability, history of suicides and mental illnesses in family, and prior suicide attempts (Baxter et al., 2011; Darvishi et al., 2015; Ferrari et al., 2010; Grinshteyn & Hemenway, 2019; Haukka et al., 2008; Suokas et al., 2001; THL, 2021a). Regarding age as a risk factor, young Finns aged 10 to 14 tend to have very low suicide rates until age 15 to 19 when suicide rate sharply increase five-fold, and then doubles after the age of 20 and beyond (OSF, 2021).
Protective factors include support and access to therapy, familial and extrafamilial supportive relationships, physical health, positive mental health, problem-solving and coping skills, cognitive flexibility, good self-esteem, and feelings of togetherness and hope (THL, 2021a). Studies also show that online-only friendships may offer protective benefits for youth, especially those who experience suicidal ideation (Massing-Schaffer et al., 2020).
Given that suicide is often associated with a mental health illness, there is then a way to treat it with therapeutic and pharmacological means. Moreover, evidence suggests that limiting access to lethal means of suicide like firearms, reducing alcohol consumption, and urbanisation may reduce suicides.
Possible causes
There are five possible causes as to why suicides may have decreased in Finland: framing suicide as a mental health problem, treating depression, limiting access to lethal means of suicide like firearms, reduction in consumption of alcohol, and urbanisation.
Framing suicide as a mental health problem and raising awareness of suicide in general has spurred improvement in access to mental health services (Abrams et al., 2020). After the constant increase in suicides from 1921 onward (figure 2), Finns became aware of the growing problem and started the National Suicide Prevention Project in 1986 (Lönnqvist, 2003, 2007).
In addition, the mental health service system was revamped from the ground up in the 1990s (Lehtinen & Taipale, 2001), which was reflected by the explosive increase in mental and behavioral illness diagnoses from 1995 onwards (figure 5). In the end, these two changes together helped ensure that people at the risk of suicide received treatment (Vorma et al., 2020).
figure 2. absolute number of suicides per year, 1921–2019. (OSF, 2021)
Given that depression and suicide go hand in hand (figure 3), treating depression with therapy and/or pharmaceuticals may prevent suicides.
Laukkala et al. (2002) and Vilhelmsson (2013) report that there was a fourfold surge in the use of antidepressants after 1990. The available data suggests that reimbursements for depression medicines between 1994 to 2020 tripled (figure 4), which is associated with an exponential amount of behavioral and mental illness diagnoses between 1995 and 2019 (figure 5). People finally received the help they needed.
Korkeila et al. (2007) and Salokangas et al. (2012) say that increased antidepressant use is associated with decline in suicides when controlling for other variables and their interactions. Thus, treating mental and behavioral illnesses, and especially depression, has most likely prevented majority of potential suicides.
figure 3. suicide rates vs. prevalence of depression, 1990–2017 (Ritchie, Roser,& Ortiz-Ospina, 2015)
figure 4. reimbursements for depression medicines, recipients aged 18-64 per 1000 persons of the same age, 1994–2020 (THL, 2021b)
figure 5. rehabilitation clients in certain main disease categories, 1995–2019 (KELA, 2021)
Limiting lethal means of suicide like firearms may reduce suicides (Abrams et al., 2020). It is easier to commit suicide if there are means to do it. In Finland, firearms (i.e., handguns, rifles, and shotguns) have over the years been the third most commonly used method in suicide (figure 6).
Privately owned licit and illicit firearms (figure 7) have decreased between the years 2005 and 2019 (Alpers, Michael & Dylan, 2021; MOI, 2021). Thus, there may be a positive association in the decline of firearms and suicides. Overdose of psychotropic drugs or hanging is harder if not impossible to counteract given there are no sensible restrictions that can be implemented.
figure 6. suicides by method, 1998–2017 (OSF, 2021)
figure 7. number of privately owned licit and illicit firearms, 2005–2019 (Alpers, Michael, & Dylan, 2021; MOI, 2021)
In Finland, documented alcohol consumption increased from 1960, peaked in 2007, and decreased thereafter (figure 8).
In their meta-analysis, Darvishi et al. (2015) found a significant positive association between alcohol use and suicide. However, suicides declined after 1990, but alcohol consumption continued to increase around until 2007, so there is no clear-cut positive association during that time period. In any case, alcohol does not cause suicide per se, but it heightens the risk of suicide.
figure 8. recorded consumption of alcoholic beverages, 100% alcohol, 1933–2019 (THL, 2020)
figure 9. sale of alcoholic beverages by type of beverage and by region, per capita aged 15 and over, 100% alcohol, 2019 (THL, 2020)
Sha, Yip and Law (2017) found that suicides declined in China between 1990 to 2010, which was strongly associated with urbanisation. More urbanisation, less suicides. Generally urban areas provide greater cultural and economical benefits compared to rural areas.
In Finland, suicides per region between 2016 to 2020 (figure 9) show that suicides crudely lie in rural regions compared to urban regions (my understanding is that East- and North-Finland are more rural compared to West- and South-Finland.
Pesonen et al. (2001) studied urban-rural differences in male suicides between 1988 to 1997 and found that male suicide mortality may be regionally diverging in Finland. However, there are no studies that focus on the effect of urbanisation in Finland, countrywide, on suicides, as of yet.
figure 10. suicides per 100 000 inhabitants per region, 2016–2020. Darker blue means to more suicides compared to lighter blue (THL, 2021c)
Discussion
There is always hope for a better life in the future, a life that may be sufficiently rich and strange, creative and beautiful, peaceful and vibrant to have made the wait worthwhile. (Hecht, 2013)
Suicide’s meaning changed across historical and geographical contexts. Ancient philosophers were largely against suicide, although some suicides were considered as philosophically sound, heroic, respected, pragmatic, and justified (Hecht, 2013). Then major religions, namely Judaism, Christianity, and Islam heavily condemned suicide because God forbade it. Suicide was an offensive act toward God for life is sacred.
After the Age of Enlightenment in the 18th century Europe, suicide’s meaning changed, and became medicalized, secularized, and decremininalized. Medical education flourished in the beginning of 20th century, and suicide was soon framed as a mental health problem.
But despite the positive development over the decades and centuries, Hecht states that we still have no coherent argument against suicide, apart from what God says. Somehow the Western culture tolerates suicide, namely that death is fiercely challenged in other domains but not when death is caused by oneself. An argument found from humanism may pave path against suicide.
In the Western perspective of humanism, Pinker (2018) states that its goal is maximizing human flourishing. This means that life, health, happiness, freedom, knowledge, love, and richness of experience are at the core of humanism.
In the the Eastern perspective of humanism, Patel and Prasad (2020) argue that humanism is defined as relational and virtue-based rather than absolute and authority-based; there was a flexible set of ethical standards; a notion of the ideal person (e.g., Junzi, Buddha); a concept of universal justice and a rejection of supreme authority or sovereignty; and a focus on education.
In the Western sense of humanism, there has been undeniable humanistic progress made toward understanding and preventing suicides in the world, especially in Finland (Vorma et al., 2020).
Less suicides is a win for life. But at what cost? What I will write next is controversial so heads up: I am not sure if eating depression medication to prevent suicides is “human flourishing” to the individual, especially in the long term. Maybe for the society as a whole, because then we avoid suicides that would create suffering to the people close to the person who killed him or herself.
I have never suffered from a mental illness and I am not sure what depression and its medication does to you. The people that I have had the pleasure to get to know in the past four years, I have experienced doubt regarding medication.
I do not think that people under medication live their lives to their fullest. I do not think they experience all emotions one can feel. It is as though they have numbed some emotional aspects of their lives. At the same time, they may have more control of their thoughts and in that way process their emotions without falling into emotional rollercoaster.
Then again, people who do not take their medication do not necessarily live their life to the fullest anyway given the pain the have to endure. So there is no right answer. Still, science currently states that medication alone or psychotherapy alone are not as effective compared to the combination of the two for long-term healing.
In the Eastern humanistic sense, a person who commits suicide is far from an ideal person. And while no authority can reject suicide, there is no virtue in taking one’s own life.
As Hecht (2013) argues, we not only owe it to society and especially our personal communities to stay alive, but also to our future self. Suicide rules out the future self that may not have wanted suicide.
Conclusion
Taken as a whole, there is a complex interplay of factors impacting suicide including psychological, sociodemographic, cultural, religious, economical, regional factors, risk and protective factors.
And while there has been a 21-year positive downward trend in suicides in Finland, it cannot be expected to continue without research and continuous preventive measures.
The strong associations of suicide may be possible causes, although correlation does not imply causation. Even if the aforementioned possible causes were not actual causes, but mere associations, they all individually contribute to human flourishing nevertheless.
Namely, framing suicide as a mental health problem, treating depression, limiting access to lethal means of suicide like firearms, reducing alcohol consumption, and urbanisation are all humanistic endeavours by themselves. If suicides decreased as a result of these strong associations, then all the better.