Suicide in Hungary-epidemiological and clinical perspectives
© Rihmer et al.; licensee BioMed Central Ltd. 2013
Received: 11 April 2013
Accepted: 17 June 2013
Published: 26 June 2013
Annual suicide rates of Hungary were unexpectedly high in the previous century. In our narrative review, we try to depict, with presentation of the raw data, the main descriptive epidemiological features of the Hungarian suicide scene of the past decades. Accordingly, we present the annual suicide rates of the period mentioned and also data on how they varied by gender, age, urban vs. rural living, seasons, marital status, etc. Furthermore, the overview of trends of other factors that may have influenced suicidal behavior (e.g., alcohol and tobacco consumption, antidepressant prescription, unemployment rate) in the past decades is appended as well. Based on raw data and also on results of the relevant papers of Hungarian suicidology we tried to explain the observable trends of the Hungarian suicide rate. Eventually, we discuss the results, the possibilities, and the future tasks of suicide prevention in Hungary.
Suicidal behavior is a major public health problem worldwide, and its prediction and prevention receives increasing attention. Approximately 1 million people die by suicide in the world every year, and it is estimated that 1.5 million will die from suicide in 2020. The global suicide rate of the world is 14 suicides per 100,000 inhabitants: more specifically, 18 suicides per 100,000 males and 11 suicides per 100,000 females [1, 2]. In spite of the fact that suicide rates of different countries and continents differ substantially, the rate of completed suicide, in general, is much higher among males, among older people, and among Caucasians.
Although suicide is a very complex, multi-causal behavior, involving several medical-biologic and psycho-social components, history of untreated major psychiatric (particularly depressive and alcohol-related) disorders constitute the most important risk factors. However, lifetime and current psycho-social and personality factors (stressful life events, financial problems, unemployment, impulsivity) and other forms of addictive behaviors than drinking (e.g., cigarette smoking) have been also found to be in a statistically significant positive relationship with suicide mortality [3–8].
The highest annual suicide rates are reported from Eastern Europe (13–42 suicides per 100,000 persons) followed by Western/Nordic European countries (8–21 suicides per 100,000 persons) and North America and Australia (11–13 suicides per 100,000 persons). Latin America, as well as ‘Latin Europe’ (Greece, Spain, Italy), and Central Asian countries report annual suicide rates less than 10 [1, 9, 10]. Reasons for these great differences between national/regional suicide rates have not been fully explained. Geographic, climatic, socio-cultural, dietary, religious, and economic differences can be taken into account, but differences in the psychiatric morbidity as well as the accuracy of the registration of suicide, the stigma associated with suicide possibly influencing reporting rates, the availability of lethal methods, and the availability of the social/health care system should also be considered [4, 11].
The primary aim of our narrative review, based on both raw data retrieved from the databases of the Hungarian Central Statistical Office and papers published in international journals (identified by Pubmed searches using keyword combinations ‘suicide + Hungary’, ‘suicidal + Hungary’; ‘suicide + Hungarian’; ‘suicidal + Hungarian’) and also on papers/books in Hungarian (identified by Google), is to present the main characteristic features of the Hungarian suicide scene of the last 50 years and also to append some possible explanations of the trends observed.
Suicide in Hungary-an introduction
Suicide rates are high in large parts of Northern and Eastern Europe, and some of the highest figures have been reported in Hungary [1, 10]. In addition to psycho-social factors, several lines of evidence indicate genetic and biological contributions to unexpectedly high Hungarian suicide rate . Within Europe, the countries with the highest suicide rate constitute a contiguous J-shaped belt from Finland through the Baltic countries, Russia, Belarus, and Ukraine to central Europe (Hungary, Slovenia, Austria) . Genetic similarities observed between populations of these countries led to the Finno-Ugrian suicide hypothesis which states that high suicide rates of these countries are the consequence of a shared genetic susceptibility . Genetic background of this phenomenon is very probable because other (e.g., cultural/socio-political/economic) features of these countries are quite different. Consonant with the theory about the genetic background of the high suicide rate of Hungary, Hungarian immigrants in the USA have the highest suicide rates of all immigrant groups . In addition, the existence of an unfortunate genetic/cultural susceptibility of Hungarians to suicidal behavior is further bolstered by the fact that suicide rates of those Romanian counties where the proportions of Hungarian people are high (e.g., Harghita, Covasna, Mures) were much higher than of those counties where the population percentages of Hungarians are low .
Between 1960 and 2000 in the vast majority of years, the suicide rate of Hungary was the highest in the world. The reason of this very high suicide mortality of Hungary is not fully understood. It is one possibility is that the medical examiners in Hungary certify those deaths as suicide which would otherwise be labeled as undetermined death or as death related to other causes. However, the highest suicide rate of Hungarian immigrants in the USA  and the similarly high suicide rate of ethnic Hungarians living in Romania  contradict this possibility. Political or economic causes are also very unlikely, as between 1960 and 1990 the suicide rates of Poland, Bulgaria, Romania, and former Yugoslavia (countries with similar political and economic systems) were around one third of the Hungarian figure, and during the mentioned period, in the majority of the years, the suicide mortality of Denmark, Finland, Austria, and Sweden (with much more advantageous political and economic situations) have been among the top ten in the world. As mentioned above, the most established risk factor(s) of suicide are different forms of (untreated) major affective disorders. Although direct comparison of national epidemiological data on prevalences of affective disorders is not fortunate due to some methodological issues (e.g., different studies have frequently used different diagnostic instruments), it can be said that lifetime prevalence of ‘any’ bipolar disorder, which carries the highest risk of suicide [14–16], is unusually high in Hungary (5.1%) [17, 18]. Albeit, lifetime prevalence of major depressive disorder according to the DSM-IV criteria in the Hungarian population (15.1%) is similar to the corresponding data from other European countries and the USA, a recent study, assessing depressive symptoms using CES-D in the general population of 23 European countries, reported the highest mean scores in Hungary among all investigated countries [19, 20]. In summary, these results raise the possibility that high prevalence of affective (especially bipolar) disorders (and possibly also subthreshold manifestations of bipolarity and bipolar spectrum disorders) in the Hungarian population may be one of the most important contributors to the markedly high suicide rate of Hungary.
Looking at European countries with the highest suicide rates 25 years ago (between 20 and 46 per 100,000 per year), the 26%–54% decline in the national suicide rates of Hungary, Denmark, Germany, Austria, Estonia, Switzerland, Sweden, and Finland in the last 2 decades is quite impressive [3, 10, 21–23]. However, given the recent economic crisis, suicide rates are stabilized or show a slight increase in many European countries [24, 25].
Suicide mortality of Hungary between 1961 and 2010
Time trends, gender distribution, and method of suicide
Suicide rates ( n /100,000/year) for Hungarian total, male, and female populations between 1961 and 2011
Total suicide rate
Male suicide rate
Female suicide rate
In Hungary, similar to the great majority of developed countries, males consistently show much higher suicide rates than females [2, 27]. However, the female suicide rate decreased more markedly between 1983 and 2010 (females, 61% decline; males, 39% decline) and while the male-to-female suicide ratio was 2.53 in 1983, the same figure was 3.93 in 2010.
Distribution (%) of violent and nonviolent suicides in Hungarian populations in 1980, 1995, and 2010
Method of suicide
In line with data from the majority of other countries, suicide attempts are more prevalent among females than among males in Hungary as it was suggested by results of studies conducted in consecutive series of suicide attempters in different areas of the country (Budapest, Pécs, Győr) and also in a sample representative of the Hungarian population (n = 2.953; number of suicide attempters = 94) [15, 30–32]. According to the unpublished data of the Hungarian National Ambulance Emergency Service, the number of ‘suicide events’ (which mainly mirrors suicide attempts) decreased in a monotonic and relevant manner from 1986 to 2006 (from 23,729 to 8,025). After 2007 (till 2011), the values were between 8,256 and 8,795 (Göbl and Andics, personal communication). Accordingly, trends in suicide attempts roughly followed the trends in completed suicide (a decrease from the mid 1980s to 2006 and a stabilization period from 2007 till now). Previously, we have already provided some supposed explanations (and later we will provide others) for the decreasing part of the curve of suicide rate (observable from the mid 1980s to 2006). However, there are no exact explications to the disappearance of the declining trend from the suicide rate from 2007 till now, it is probable that increasing unemployment and restrictions/destructions with which Hungarian psychiatry had to be faced in the last few years may contribute to this unfavorable turn [25, 33].
Alcohol consumption, antidepressant prescription, unemployment, and cigarette smoking
Alcohol and tobacco consumption, antidepressant use, unemployment rates and total suicide rates in Hungary
Pure (absolute) alcohol consumption (in liters per capita)
Antidepressant use (DDD/1,000 inhabitants/day)
Unemployment rate (total)
Unemployment rate (male)
Unemployment rate (female)
Tobacco consumption (in kilogram per capita)
Total suicide rate (per 100,000/year)
Age distribution, marital status
Distribution of suicide rates ( n /100,000/year) by age in populations in Hungary in 1980 and 2010
Age group (years)
90 and above
Hungarian suicide rates ( n /100,000/year) in groups with different marital status in 1980 and 2010
60 and above
60 and above
60 and above
60 and above
60 and above
60 and above
60 and above
60 and above
Regional distribution, urban–rural differences
Suicide rates ( n /100,000/year) in different kinds of Hungarian settlements in 1970, 1980, and 2010
Type of settlement
Capital city (Budapest)
Towns with county’s rights (a.k.a. urban counties)
Seasonal and other temporal components of suicidal behavior
The proportions (%) of suicide cases by seasons in the Hungarian total population
The proportions (%) of suicide cases by seasons in Hungarian males
The proportions (%) of suicide cases by seasons in Hungarian females
Another highly confirmed and noteworthy result regarding temporal variations of suicide is that more subjects commit suicide in the first days of the week than in the weekend [58, 59]. In Hungary, between 1970 and 2002, the average number of suicides peaked on Monday for both sexes and was lowest on Saturday (for males) and Sunday (for females) .
Decreasing suicide mortality in Hungary: what is beyond the figures?
Although the traditionally high suicide rate of Hungary is the second highest in the European community and the fifth to sixth highest in Europe, characteristics of suicidal behavior (gender, age, and urban–rural distribution, method of suicide, marital status, seasonality, rate of psychiatric morbidity) are very similar to those reported from other countries.
In spite of the fact that unemployment and alcohol consumption are well-accepted suicide risk factors [6, 7, 24, 60], these two indices do not show a strong positive correlation with suicide rate in Hungary between 1992 and 2010. However, a significant positive correlation has been found between tobacco consumption and national suicide rate between 1985 and 2008 , which may reflect that, as demonstrated also by our studies in Hungary, patients with mood disorders smoke much more frequently than members of the general population  and smoking is a suicide risk factor [6, 62]. Moreover, smokers are significantly more impulsive than nonsmokers [63, 64], and it is well demonstrated that impulsive-aggressive personality features are powerful predictors of suicidal behavior [65, 66].
Looking at the problem of suicide from the side of a given individual, there is no doubt that suicidal behavior is the result of the complex interplay between macro-social and personal suicide risk factors, the most powerful of them is current major depression [3–5]. In agreement with international findings, several studies demonstrated the important role of depression in suicidal behavior in Hungary, as we will discuss below. This is particularly important from a practical point of view, as depression is one of most easily amendable suicide risk factor.
Investigating the regional distribution of recognized and treated depressions and suicide rates in 20 regions of Hungary in 1985, 1986, and 1987, the suicide rate showed a significant negative correlation with the rate of treated depressions in each of the 3 years: the higher was the rate of treated depressions and the lower was the suicide rate in the given region. It is also important to note that no such relationship was found regarding treated schizophrenic cases .
In a psychological autopsy study conducted more than 25 years ago in Budapest, we have found that 63% of 200 consecutive suicide victims had current depressive disorders (almost half of them had bipolar depression), 9% schizophrenia, and 8% alcoholism [14, 67]. More than half of the depressed suicide victims had medical contact during their last depressive episode, but less than 20% of them received antidepressants and/or mood stabilizers . In a most recent case, control psychological autopsy study in 194 suicide victims and 194 controls in Budapest  we also found that 60% of victims (and 11% of controls) had current affective disorder, 26% of victims (and 38% of controls) had medical contact and 18% of suicides (and 8% of controls) took antidepressants in the last 4 weeks before the suicide or before the interview. This study also identified a number of societal factors that may be important determinants of the suicide risk in individuals. It has been found that lifetime history of psychiatric illness, such as separated/divorced/widowed marital status, lower educational level, unemployment, or long-term sick/disabled status, adverse life events within the previous 3 months, alcoholism, and current cigarette smoking, was significantly more common among suicide victims, while being responsible for a child less than 18 years of age and practicing a religion was significantly less frequent among the victims than among the controls .
Two independent studies on nonviolent suicide attempters (drug overdose or poisoning) in Budapest showed that 69%–87% of the attempters had a current major depressive episode (in many cases with comorbid anxiety and/or substance-use disorders), and unemployment, living alone, and economically inactive status were overrepresented among them [30, 68]. The strong relationship between suicide attempts and agitated/mixed depression has been also found both in population-based epidemiological  and clinical samples .
the appropriate acute and long-term treatment of patients with major depressive and bipolar disorders markedly reduces the suicide mortality even in this high-risk patient-population [5, 76, 77] and initially suicidal depressives become nonsuicidal with antidepressant treatment [5, 78]; and
It is logical to assume that more widespread treatment of depression is one of the main causes of declining suicide rates in countries where antidepressant utilization recently increased markedly. On the other hand, however, as national suicide rates are affected by many known (unemployment, divorce rate, alcohol consumption, living standard, etc.) and unknown factors [80, 81], the isolation of the result of better treatment of depression in declining suicide rates is not easy.
The increase in antidepressant utilization, as reflected in antidepressant prescriptions, is only a proxy marker of greater access of patients to appropriate care, and higher population density of doctors in general [82, 83] and psychiatrists and psychotherapists in particular [21, 22, 83] are negatively associated with national and regional suicide rates. It is likely that many patients receiving antidepressants also receive a prescription of lithium and other mood stabilizers as well as they receive more frequently supportive or specific psychotherapy for depression. Between 1982 and 2000, the number of psychiatrists in Hungary increased from 550 to 850, as well as the number of outpatient psychiatric departments (from 95 to 139), and the number of S.O.S. telephone services (from 5 to 28) . It should be also noted that between 1990 and 2010, the number of telephones (the best mean for rapid communication even in the case of suicidal crisis) increased by fivefold in Hungary, and recently, the number of ordinary and mobile phones is over 11 million while the population of the country is 10 million. Although it is not possible to measure, it is very likely that the new democratic political system since 1990 (including freedom of religion and several newly founded civil organizations) plays also important role in this favorable process. Therefore, the decrease of suicide rates could reflect a general improvement in mental health care rather than being caused by increasing antidepressant sales alone. The robust increase of antidepressant prescription in Hungary remains the only consistent correlate of declining national suicide rate of Hungary in the last 25–30 years [8, 21, 23, 34, 70], indicating that better recognition and treatment of depression is one, but not the only, important contributor to this favorable change. On the other hand, however, recently, we have suggested that increasing unemployment rate after 2005 might be one of the contributing factors that accounted for the disappearance of the strong decreasing trend from the Hungarian suicide rate that stabilized around 24/100,000 between 2006 and 2011 . The exact causes, the role of possible contributory factors as well as the relationship between them remain to be elucidated, yet it seems increasingly obvious that patterns and trends in suicide rates in Hungary are determined by a delicate interplay between various genetic, psychiatric, cultural, economic, political, social, and treatment-related factors specific for Hungary.
In spite of the great decline in the suicide rates of Hungary in recent decades most likely resulting from advancements in Hungarian healthcare well indicating the possibilities for suicide prevention, there is, unfortunately, no centrally directed, government-organized suicide prevention program in Hungary. However, in the last 20–25 years the importance of psychiatric disorders (particularly depression) in suicide and suicide prevention receives more and more attention in the training of medical students, residents, psychiatrists, and general practitioners. These regular trainings are organized by the four medical universities (Budapest, Pécs, Szeged, Debrecen), the Hungarian Psychiatric Association, the Association of Hungarian Neuropsychopharmacologists, and also by pharmaceutical companies. In spite of the fact that the decline of national suicide mortality in Hungary in the last 25 years (46%) is among the greatest decreases in the world, the suicide rate of Hungary is still very high (in 2011, 24.3/100,000), so much remains to be done.
In agreement with the findings of the Swedish Gotland Study , our community-intervention suicide preventive project in the Kiskunhalas region of Hungary (68,000 inhabitants) between 2000 and 2005 showed that education of doctors, other healthcare professionals, and gatekeepers, as well as the public, is an effective method of reducing suicide mortality . The Hungarian Depression Recognition and Suicide Prevention Program in Szolnok between 2004 and 2006 (as a part of the European Alliance Against Depression program) directed by Maria Kopp also supported the key role of general practitioners and other gatekeepers (psychiatrists, psychologists, telephone help service providers, pharmacists, teachers, pastors, police officers, family nurses, geriatric care providers, etc.) in suicide prevention .
Screening and also medical care for those at increased risk of suicide should be extended from psychiatric practices to all specialities of healthcare, especially to primary care, and primary care providers should not only be qualified to screen for depression and suicide risk, but should also provide subsequent care for previous suicide attempters since previous attempts are among the major risk factors for suicide. Also, in primary care practices, family suicide events, another important risk factor, should also be screened for . General practitioners are in the best position to detect if multiple important risk factors of the suicide constellation are present in case of their patients and could provide referral to mental health care or counselling services.
As psychosocial and community factors also play an important role in suicidal behavior, it is not only health care workers who are responsible for its prevention. Improving well-being and quality of life of people in general (including decreasing unemployment and providing more support for health and social services), restricting lethal suicide methods (e.g., reducing domestic and car exhaust gas toxicity and introducing stricter laws on gun control), and initiating more restricitve alcohol and smoking policies, which may also reduce suicide mortality [4, 9, 88, 89], exceed the limits and jurisdiction of health and social care and are rather the leaders’ competence and responsibility at any level of the society. Individual programs developed and implemented in each level of the society, however, need to be coordinated by a unified, government-level central suicide prevention plan. A central prevention plan should appoint possible targets of prediction, prevention, and intervention, at multiple levels and building on multiple groups within the society. The suicide prevention plan should include guidelines for data collection concerning suicide and its risk factors; outline of necessary changes in medical training; training for workers in the social field; and also training for church associated persons as well as teachers and policemen; enhancing scientific research in related fields, tackling ethical, moral, and legal issues related to suicide; and changing legislation if necessary, designing and launching public campaigns, planning enlightenment campaigns, and creating possibilities for interventions in schools. Coordinators at all levels should also be appointed. However, for such a plan to be realized, first awareness concerning the burning issue of suicide in Hungary should be raised not only for the population but also for politicians, legislators, and health/social care decision makers.
In our review, we tried to collect the current knowledge and data on the main topics of the Hungarian suicide scene and also on the pilot projects which were conducted in order to better prevention of suicide cases. Our primary aim with this review was to draw attention to the severity of suicide scene in Hungary, a problem which has however shown an improving trend in the last decades but still poses a serious burden to the society.
We also hope that these raw data, and our inferences and proposals based on them, will be taken into account by the political and academic decision makers when they will consider the necessity of the launching of a nationwide prevention program and the concommitant scientific research on the background mechanisms as well.
We are, of course, unable to prevent all suicides. Nevertheless, the already existing theoretical knowledge and the available treatment and preventive strategies are sufficient to prevent many, probably the majority, of them.
Peter Dome and Xenia Gonda are recipients of the Bolyai János Postdoctoral Fellowship of the Hungarian Academy of Sciences.
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