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|4C Suicide Mortality
Description | Specific Indicators | Ontario Public Health Standards | Corresponding Indicators from Statistics Canada and CIHI | Corresponding Indicators from Other Sources | Data Sources | Alternative Data Sources | ICD Codes | Analysis Check List | Method of Calculation | Basic Categories | Indicator Comments | Definitions | Cross-References to Other Indicators | Cited References | Other References | Changes Made | Acknowledgements
- Crude mortality rate - the total number of deaths from suicide relative to the total population during a given year (fiscal or calendar) (usually expressed per 100,000).
- Age-specific mortality rates - the annual number of deaths in a given age group from suicide per the population in that age group during a given year (fiscal or calendar) (usually expressed per 100,000).
- Age-standardized mortality rates (SRATEs) - the number of deaths from suicide per 100,000 population that would occur if the population had the same age distribution as the 1991 Canadian population.
- Standardized mortality ratios (SMRs) - the ratio of observed deaths from suicide to the number expected if the population had the same age-specific death rates as Ontario.
|Specific Indicators |
- Crude suicide death rate
- Age-specific suicide mortality rates
- Age-standardized suicide mortality rate
- SMR for suicide
|Ontario Public Health Standards|
The Ontario Public Health Standards (OPHS) establish requirements for the fundamental public health programs and services carried out by boards of health, which include assessment and surveillance, health promotion and policy development, disease and injury prevention, and health protection. The OPHS consist of one Foundational Standard and 13 Program Standards that articulate broad societal goals that result from the activities undertaken by boards of health and many others, including community partners, non-governmental organizations, and governmental bodies. These results have been expressed in terms of two levels of outcomes: societal outcomes and board of health outcomes. Societal outcomes entail changes in health status, organizations, systems, norms, policies, environments, and practices and result from the work of many sectors of society, including boards of health, for the improvement of the overall health of the population. Board of health outcomes are the results of endeavours by boards of health and often focus on changes in awareness, knowledge, attitudes, skills, practices, environments, and policies. Boards of health are accountable for these outcomes. The standards also outline the requirements that boards of health must implement to achieve the stated results.
|Outcomes Related to this Indicator|
- Board of Health Outcome (Prevention of Injury and Substance Misuse): The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services for the prevention of injury and substance misuse.
- Board of Health Outcome (Foundational Standard): The public, community partners and health care providers are aware of relevant and current population health information.
|Assessment and Surveillance Requirements Related to this Indicator |
- The board of health shall conduct epidemiological analysis of surveillance data....in the areas of injury and substance misuse outcomes, including violence and suicide prevention.
|Corresponding Health Indicators from Statistics Canada and CIHI|
- Suicide deaths
- Suicide deaths Potential Years of Life Lost (PYLL)
Statistics Canada, Health Indicators http://www.statcan.gc.ca/pub/82-221-x/82-221-x2011002-eng.htm
|Corresponding Indicators from Other Sources|
- Pan American Health Organization (PAHO) - Regional Office of the World Health Organization (WHO)
- Estimated Mortality Rate from Suicide and Purposely Self-Inflicted Injuries (per 100,000 population)
Under "Basic Indicator Browser - Indicators by Countries and Years" http://ais.paho.org/phip/viz/indicatorsbycountryandyears.asp
Select "Mortality" as the indicator domain and "Estimated Mortality Rate from Suicide and Purposely Self-Inflicted Injuries (per 100,000 pop.)" as the indicator.
Indicator definition and technical notes available from: http://www.paho.org/English/SHA/glossary.htm
|Data Source(s) (see Resources: Data Sources)|
Numerator: Vital Statistics Mortality Data
Original source: Vital Statistics, Ontario Office of Registrar General (ORG), Service Ontario
Distributed by: Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH ONTARIO
Suggested citation (see Data Citation Notes): Ontario Mortality Data [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].
Denominator: Population Estimates
Original source: Statistics Canada
Distributed by: Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH ONTARIO
Suggested citation (see Data Citation Notes): Population Estimates [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].
|Alternative Data Source(s) |
- ICD-10-CA: Intentional self-harm - X60-X84, Y87.0
- ICD-9: Suicide and self-inflicted injury - E950.0 to E959.9
|Analysis Check List |
- Aggregation (e.g. combining years, age groups, categories) should also be considered when small numbers result in unstable rates.
- IntelliHEALTH Ontario is developing a complete set of pre-defined reports for injury-related Core Indicators, (i.e., templates that permit standardized queries by local public health agencies). Registered IntelliHEALTH users can find a predefined report called 'Mortality - Injury External Causes - indicator data list' in the APHEO Public Health Indicator folder in the Standard Reports section. This report will provide all injury-related deaths, to get only suicide deaths, please filter on ‘ICD10 Code (3 char) Primary Cause'= is between values (inclusive) X60 to X59 and use ICD10 Code Primary Cause (or Primary_cause_ICD10_code as in the predefined report) to filter for Y87.0.
- For IntelliHEALTH:
- Use Deaths data source from the Vital Statistics folder in IntelliHEALTH, select # Dths (ON res) measure (number of deaths for Ontario residents who died in Ontario). Note: deaths for Ontario residents who died outside the province are not captured in Vital Statistics.
- Select appropriate geography from Deceased Information folder (public health unit or LHIN). Include other items, depending on your requirements (ICD-10-CA Chapter, Lead Cause Group, age group, sex, etc.).
- For population estimates, use the Population Estimates County PHU Municipality or the Population Estimates and Projections LHIN data source in the Populations folder in IntelliHEALTH; select the # people measure and the appropriate geography (PHU or LHIN), age group(s), and sex.
- In the mortality data set, External Cause of Injury Codes (ICD-10 V-Y; ICD9 E-Codes), and not Injury & Poisoning Codes (ICD-10 S-T codes; ICD9 800-999 codes) are used in assigning primary cause of death. However for the years 1986-1999, the Injury and Poisoning ICD9 codes are also available and can be accessed from the "Nature of Injury" folder. The Injury and Poisoning ICD-10-CA codes (S-T) are not available for the years that ICD-10-CA codes are used (beginning in 2000).
- Prior to age ten, a death cannot be classified as a suicide (1).
- HELPS Data: Historically, PHUs obtained data for deaths from the Ministry of Health through HELPS (the HEalthPlanning System). Although these data are no longer commonly used, some PHUs may still be accessing these data files. Information about the data can be found in the HELPS Data Source resource.
- Please note that the Mortality dataset uses ICD-10 codes which can have a maximum length of 4 digits, instead of ICD-10-CA codes which can be up to 5 digits long.
- 'Place of occurrence' may also be used for codes W00-Y34 to identify place of external cause. Please note that there may be a large number of cases where place of occurrence is missing or not specfied.
|Method of Calculation|
total number of deaths from suicide by ICD code
| x 100,000|
Age-specific mortality rate
total number of deaths from suicide in an age group ICD code
| x 100,000|
total population in that age group
SRATE (See Resources: Standardization of Rates)
sum of (rate of death from suicide in the population in a given age group x 1991 Canadian population in that age group)
| x 100,000|
sum of 1991 Canadian population
SMR (See Resources: Standardization of Rates)
sum of deaths from suicide in the population
| x 100|
sum of (Ontario age-specific rate x population in that age group)
|Basic Categories |
- Age groups: 10-14, 15-19, 20-24, (or 10-24, 15-24), 25-44, 45-64, 65-74, 75+
- Please note: Prior to age ten, a death cannot be classified as a suicide (1).
- Given the small number of suicide deaths, it may be necessary to aggregate data based on age groups and/or years to produce stable rates. (Refer to Document: Methods for Calculating Moving Averages)
- Sex: male, female and total
- Geographic areas of residence: Ontario, public health unit, municipality, and smaller areas of geography based on aggregated postal code
|Indicator Comments |
- Suicide is considered to be an action rather than an illness. Suicidal behaviour is associated with mental/psychological and physical disorders, including schizophrenia, personality disorder, eating disorders, substance abuse and dependence, and terminal illness (2). Most mental health professionals consider suicidal behaviour to be a result of irrational mental states (distorted perceptions, impaired judgment, extreme moods, feelings of hopelessness, loss of interest or pleasure) brought on by mental illness (2, 3).
- Diagnoses of psychiatric conditions precede close to 90% of suicides (4). Depression is the principal psychiatric condition associated with suicide (2).
- Regardless of the strong association between mental illness and suicide, mental illness is not a sufficient cause for suicide given the large number of individuals who suffer from mental illness in the population who do not engage in suicidal behavior (3).
- Risk of suicide is not the same for all parts of the population (5). Risk factors include presence of mental/psychiatric conditions, substance abuse, genetic and family background, sociological and biological factors and stressful life events (3). Suicides are more likely to occur during periods of socioeconomic, family and individual stress (2).
- In Canada, in 2007, 15,064 people died of injury-related causes (6% of all fatalities) (2). Of these deaths, 24% were suicides (7).
- In Canada, suicide is the leading cause of death in men aged 25-44 and the third-ranking cause of potential years of life lost. High suicide rates are observed among young adults, people living alone, and people of low socioeconomic status (5). Mortality rates from suicide are typically four times higher among males than females (5, 8).
- Among the elderly population, studies indicate that increased risk of suicide is associated with social factors, particularly poverty (2). It is anticipated that suicidal behaviour will increase among elderly individuals as the number and proportion of older people in the population continues to increase (9).
- The Central West Health Planning Information Network report, "Profile of Suicide and Suicide Attempts in Adolescents and Young Adults in Ontario", describes many of the data quality issues that can make interpreting local data on suicide problematic, including changes in definitions and procedures over time (1).
- The Office of the Registrar General obtains information about mortality from death certificates which are completed by physicians. When cause of death is uncertain, a coroner may initially code the death as "undetermined". Following further investigation, the coroner may reclassify the death to a more specific cause.
- There is an underestimation of suicide rates. The actual number of deaths from suicide may be greater because information regarding the nature of the death may only become available after the original death certificate is complete. In some situations, assessing whether the death was intentional may be difficult (5). A death can only be certified as a suicide when the victim's intent is clear (10).
- ICD-10-CA has a greater level of specificity and different code titles than ICD-9. CIHI does not endorse forward conversions because of differences in the classification systems. Refer to Resources: ICD-10 for more information.
- Comparability ratios for Intentional self-harm (suicide) between ICD-9 and ICD-10-CA have been found to be very close to 1.0, which suggest that the revision does not substantially affect mortality patterns for suicide (11).
- Variation in data collection procedures over time and/or geography may reduce the validity of time-and/or place-specific comparisons.
- In making comparisons over time, consideration should be given to the influence of changes in one or another of the following factors: social attitudes regarding suicide, attitude of the coroner, development of forensic medicine methods, and the way suicides and attempted suicides are coded. Some suicides may be classified as traffic collisions.
- Potential years of life lost (PYLL) due to suicide (but not suicide mortality) is a Health Canada Comparable Health Indicator. http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2008-fed-comp-indicat/index-eng.php. PYLL due to suicide is also a health outcome indicator included in the Ontario Ministry of Long Term Care's "Ontario Health System's Performance Report" http://www.health.gov.on.ca/english/public/pub/ministry_reports/pirc_02/pirc_tech.pdf.
- To best understand mortality or disease trends in a population, it is important to determine crude rates, age-specific rates and age-standardized rates (SRATES) or ratios (SMRs, SIRs). The crude death (or disease) rate is the number of deaths (or disease cases) divided by the number of people in the population. This rate depicts the "true" picture of death /disease in a community although it is greatly influenced by the age structure of the population. An older population would likely have a higher crude death rate whereas a younger population may have a higher crude birth rate. Age-specific rates can best describe the "true" death /disease pattern of a community and allow comparison of populations that have different age structures.
- To best understand mortality or disease trends in a population, it is important to determine crude rates, age-specific rates and age-standardized rates (SRATES) and/or ratios (SMRs, SIRs). Although the crude death (or disease) rate depicts the "true" picture of death /disease in a community, it is greatly influenced by the age structure of the population: an older population would likely have a higher crude death rate. Age-specific rates can best describe the "true" death/disease pattern within particular age groups of a community, and allow for comparison of age groups across populations that have different age structures.
- Since many age-specific rates are cumbersome to present, age standardized rates have the advantage of providing a single summary number that allows different populations to be compared; however, they present an "artificial" picture of the death/disease pattern in a community. For more information about standardization, refer to the Resources section: Direct Standardization (SRATES) and Indirect Standardization (SMRs, SIRs). For more information about standardization, refer to the Resources section: Standardization of Rates.
- Suicide - death resulting from intentional self-harm (ICD10 codes X60-X84)
|Cross-References to Other Indicators|
|Cited References |
- Cutcliffe JR. Research endeavours into suicide: a need to shift the emphasis. Br J Nurs. 2003;12(2):92-99.
- Health Canada. Suicide in Canada: Update of the report of the task force on suicide in Canada. Ottawa, ON: Her Majesty the Queen in Right of Canada; 1994 [cited 2012 May 22]. Available from: http://www.phac-aspc.gc.ca/mh-sm/pdf/suicid_e.pdf.
- Conner KR, Duberstein PR, Conwell Y, Seidlitz L, Caine ED. Psychological vulnerability to completed suicide: a review of empirical studies. Suicide and Life-Threatening Behaviour. 2001 [cited 2012 May 22];31(4):367-375. Available from: http://onlinelibrary.wiley.com/doi/10.1521/suli.31.4.367.22048/pdf.
- Health Canada. A report on mental illnesses in Canada. Ottawa, ON: Health Canada Editorial Board Mental Illnesses in Canada; c2002 [cited 2012 May 22]. Available from: http://www.cpa.ca/cpasite/userfiles/Documents/Practice_Page/reports_mental_illness_e.pdf.
- Brass BM, Holton T, Paul K, Simpson C. Tait C. Suicide among Aboriginal people in Canada. Ottawa: Aboriginal Healing Foundation, 2007. Available from: www.ahf.ca/downloads/suicide.pdf.
- Billette JM, Janz T. Injuries in Canada: Insights from the Canadian Community Health Survey. Health At a Glance Statistics Canada Catalogue no. 82-624-X. Ottawa, ON: Her Majesty the Queen in right of Canada; 2011 [cited 2012 May 22]. Available from: http://www.statcan.gc.ca/pub/82-624-x/2011001/article/11506-eng.htm.
- Sakinofsky I. Suicide: the persisting challenge. Can J Psychiatry 2003;48(5):289-291.
- Beautrais AL. A case control study of suicide and attempted suicide in older adults. Suicide and Life-Threatening Behaviour. 2002;32(1):1-9.
- Langlois S., Morrison, P. Suicide deaths and suicide attempts. Health Reports. 2002 [cited 2012 May 22];13(2):9-22. Available from: http://www.statcan.gc.ca/pub/82-003-x/2001002/article/6060-eng.pdf.
- Anderson RN, Miniño AM, Hoyert DL, Rosenberg HM. Comparability of cause of death between ICD-9 and ICD-10: Preliminary Estimates. National Vital Statistics Reports. 2001 [cited 2012 May 22];49(2). Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_02.pdf.
- Bethel J, and Rhodes AE. Identifying deliberate self-harm in emergency department data. Health Reports Statistics Canada Catalogue no. 82-003-XPE. Ottawa, ON: Her Majesty the Queen in Right of Canada; 2009 [cited 2012 May 22]. Available from: http://www.statcan.gc.ca/pub/82-003-x/2009002/article/10836-eng.pdf.
- Statistics Canada [homepage on the Internet]. Ottawa: Statistics Canada; 2008 [cited 2012 May22]. Leading causes of death in Canada, 2008. Available from: http://www.statcan.gc.ca/pub/84-215-x/84-215-x2011001-eng.htm.
- SmartRisk. Suicide and Self-Inflicted Injury. Ontario Injury Compass;2(2):Special Edition March/April 2005. Available at: http://smartrisk.ca/ContentDirector.aspx?tp=2600.
- Ward M. Mental health in Northern Ontario. Short Report #5. Sudbury, ON: Northern Health Information Partnership; 2005 [cited 2012 May 22]. Available from: http://www.apheo.ca/resources/indicators/MentalHealthinNorthernOntario.pdf.
- Statistics Canada. Suicide in Canada's immigrant population. Health Reports. 2004;15(2):9-17.
- Canadian Association for Suicide Prevention. CASP Blueprint for a Canadian national suicide prevention strategy. Winnipeg, MB: Canadian Association for Suicide Prevention; 2004 [2012 May 22]. Available at: http://www.suicideprevention.ca/.
- Region of Peel Health Department. State of the Region's health 2004: focus on suicide. Brampton, ON: Region of Peel Health Department; 2004 [cited 2012 May 22]. Available from: http://www.region.peel.on.ca/health/health-status-report/focusonsuicide/index.htm.
- Rhodes AE, Fung K. Self-reported use of mental health services vs. administrative records: care to recall? Int J Methods Psychiatr Res. 2004 13(3):165-175.
- Rhodes AE, Agha M, Creatore M. Glazier R. Monitoring mental health reform in a Canadian inner city. Health and Place 2004;10(2):163-168.
- Rhodes, AE, Links PS, Streiner DS, Cass D, Janes S. Do E-codes consistently capture hospital admissions for suicidal behaviour? Chronic Dis Can. 2002;23(4):139-145.
- Rhodes AE, Lin E, Mustard CA. Self-reported use of mental health services vs. administrative records: should we care? Int J Methods Psychiatr Res. 2002. 11(3);125-133.
- Canadian Institute for Health Information (December 2002). Ontario Trauma Registry 2002 report injury deaths in Ontario. [Online]. Available from: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_04dec2002_e.
- McEwan K, Goldner EM. Accountability and performance indicators for mental health services and supports: a resource kit. Ottawa, ON: Her Majesty the Queen in Right of Canada, represented by the Minister of Public Works and Government Services Canada; 2001 [cited 2012 May 22]. Available from: http://www.phac-aspc.gc.ca/mh-sm/pdf/apimhss.pdf.
- Weir E, Wallington T. Suicide: the hidden epidemic. CMAJ. 2001 [cited 2012 May 22];165(5): 634-36. Available from: http://www.canadianmedicaljournal.ca/content/165/5/634.full.pdf+html.
|Changes Made |
Type of Review (Formal Review or Ad Hoc?)
Changes made by
June 4, 2012
Injury and substance misuse prevention sub-group
- Replaced Mandatory Health Programs section with updated Ontario Public Health Standards outcomes.
- Updated age categories.
- Updated indicator comments and references.
- Lee-Ann Nalezyty, Northwestern Health Unit
- Suzanne Fegan, KFL&A Public Health (Subgroup Lead)
- Injury and Substance Misuse Prevention Subgroup
- Christina Bradley, Niagara Region Public Health
- Badal Dhar, Public Health Ontario
- Jeremy Herring, Public Health Ontario
- Natalie Greenidge, Public Health Ontario
- Sean Marshall, Public Health Ontario
- Jayne Morrish, Parachute
- Michelle Policarpio, Public Health Ontario
- Narhari Timilshina, Toronto General Hospital
- Jessica Deming, Waterloo Region Public Health