Suicide methods The suicide method of choice has been found by a number of studies, to be influenced by seasonality [2+] [26+]

[40+]. The general view is that seasonality is found in violent suicides opposed to non violent suicides. Non violent suicides are defined as poisonings, where as violent suicides are all other methods, such as, hanging, jumping from a height and stabbings [2+]. Massing and Angermeyer, 1985, were the first authors to report seasonality in suicides by hanging, but not in poisoning [2+]. They suggested that the reason for this may be because when an individual hangs themselves there is less time for medical intervention, and hence death is less likely to be prevented [19+]. These findings have been replicated in Taiwan [40+], Italy [26+], Finland [11+] [38+], Australia [16+], Sweden [15+] [44], Germany [5+], and Switzerland [39+]. An Italian study, 1998, examining suicides in Italy from the period of 1984-1995 reported that only suicides committed by violent methods show clear evidence of seasonality, with a defined spring peak in both sexes [26+]. Male and females both showed seasonal patterns in hanging and submersion [26+]. Males however, showed greater seasonal differences when considering the suicide method of jumping from a height where as in females they showed a greater seasonal difference when considering poisoning [26+]. A study by Erazo et al, 2004, that analysed railway suicides in Germany from the period of 1997-2002, observed a distinctive suicide peak in April and September, but interestingly, this seasonality was only found in males and not females [5+]. Again not all studies agree with the notion that violent suicides show strong seasonality. In a study by Page et al, they found that no seasonality was observed for violent suicides in England and Wales during the period 1993-2001 [29+]. Interestingly, it has been suggested that the decline in overall seasonality during 20th century could be due to the decline in the use of methods with previously strong seasonal effects e.g. hanging and drowning [2+]. In support of this, Adjacic-Gross et al, conducted a study in which they analysed data from the WHO mortality database and found that pesticide and firearm suicide had replaced traditional suicide methods in many countries [41+]. Other authors have suggested that recent technological advances have led to a decrease in seasonal social contact, and social activities and thus this has also contributed to a decrease in the number of violent suicides (in keeping with Durkheim theory, as previously mentioned) [40+]. Differentiating between violent and non violent methods of suicide is difficult when assessing seasonality as some violent methods such as stabbing and firearm suicides, do not show seasonality whereas suicide via specific poisons described as non violent suicides do, for example, a study by Rasanen et al, 2002, demonstrated a summer peak in suicides by gaseous substances where as they found no seasonality in suicide by shooting [38+]. Similarly a Korean study, showed distinct seasonality in poisoning

suicides, as during the summer months, poisons such as herbicides and pesticides are more accessible [35+]. One conclusion that many researchers appear to develop in regards to the association between violent methods of suicide and seasonality is that often, it is not the violence of the method used that is important but the seasonal context determining when and how the methods are used [2+]. For instance, pills are available in Western countries throughout the year and hence, poisoning suicides show little seasonality where as pesticide suicides occur more often when pesticides are available in agriculture, which is generally crop growing season [2+]. Deaths from drowning and jumping from a height occur mostly in months when outdoor activities common [38+], thus it could be interpreted from this data that the availability of the means to commit suicide is what is important not the violence of the method [2+]. This is supported by one study that analyses the distribution of suicide methods across different countries, and shows that for example, pesticide suicides are more common in Asian countries than in European ones [41+]. Unfortunately the classification of suicides into non violent and violent methods is simplistic and arbitrary, perhaps in future research, it would be more useful to look at the influence of specific suicide methods and seasonality, opposed to these two classifications [40+]. The biological and physiological contribution to suicide and seasonality A number of authors have suggested theories as to why there is such a defined association between seasonality and violent suicides [40+]. These include seasonal variations in physiological conditions such as plasma serotonin levels [40+]. This factor has also been associated with the diurnal distribution of suicides throughout the day [25+] [26+]. It has been suggested that there is a 24-hour oscillation in biological processes which are timed by an endogenous clock which is specifically sensitive to the activity of serotonergic neurons [25+]. Lower serotonergic function has been associated with suicide risk and interestingly serotonergic functions show a clear circadian and seasonal pattern [25+]. Low levels of serotonin are also often associated with impulsive and aggressive behaviour which may account for the seasonality often shown amongst suicides by violent methods [25+] [40+]. Hence this biological system may have an influence in the seasonality of suicide [26+]. Other physiological conditions which have been considered the concentration of 3methoxy-4-hydroxyphenylglycol in cerebrospinal fluid, plasma melatonin concentrations and serum cholesterol level [40+].

Ferri and Morselli suggested that suicides peak in warm months due to a heat related excitability of the nervous system Dixon and shulman 1983, kevan 1980 Weather variables and neuroendocrine cycles de vriese, christrophe and Maes 2004 desienhammer et al 2003, preti 1998 Plasma melatonin souetre, salvati and darcout 1987 Cholesterol maes et al 1996

Pollen data postolache et al 2005

Urban vs. Rural Suicide seasonality has been associated with rural rather than urban communities. This notion is supported by Swiss data, 2003, that showed seasonality to be absent in Geneva and Basle City which are both urban cantons [39+]. Similarly, in a comprehensive analysis, Chew and McCleary, 1995, examined monthly suicide data from 28 nations, covering the 1960s to 1980s, and revealed that agricultural populations portrayed relatively large spring peaks when compared with industrial populations, which had relatively small ones [36+]. A study by and found that seasonality was more pronounced for black South Africans, consistent with the expectation that less urbanised sectors of the population would display greater seasonal variation in suicide.

It has been put forward that the reason for a decline in seasonality over more recent years, as discussed previously, may be due to the modernisation and urbanisation of rural communities and hence suicide seasonality is expected to further decrease in future years. Durkheim 2002/1897 Other studies chew McCleary, granberg and Westerberg 199, micciolo Williams..1991 Contrast micciolo zimmer,amm tansella Italian study, higher association seasonality and suicide in urban areas of Italy Male farmers are considered an occupational group which portrays a high risk for suicide [15+]. This is because the farming year is subject to cyclical workload, with spring and summer being busy times for people in this profession [15+]. In addition, a lot of farming work is performed outdoors which means that farmers may be more vulnerable to climatic influences than someone who works, for example, in an office job. Thus, it would be expected that suicides in farmers should show a seasonal pattern. This was investigated in British study; however, no evidence of major differences in seasonal distribution of suicides was detected [15+]. Suicide seasonality and a concomitant disorder A previous history of a mood disorder is considered to be a prominent risk factor for suicide. Coincidentally this risk factor also shows a spring peak in exacerbation [39]. This has led to the hypothesis that the spring peak in suicide is driven by a seasonal inability of an individual with a mood disorder to maintain normal psychological defences during this period [39]. A study by Postolache et al, 2010, analysing data from the entire national population in Denmark over a 32-year period supported this theory in that they found that there was an increased relative risk of suicide in spring among those with history of hospitalisation for mood disorders when compared to those without such a history [13+]. This supports a similar study by Reutfors et al, 2009, in which they examined suicide in patients with previous admission into

hospital for a psychiatric disorder, and found distinct seasonal variation (spring/summer peaks) [44]. Depression has been reported as one of the most common diagnosis among patients who commit suicide [24+]. Depression has been found in many cases to show a seasonal pattern [13+], and thus the association between depression and the seasonality of suicide has been considered by a number of studies [24+]. One Swedish study, 2002, reported a monthly distribution in the number of suicides in patients who had been diagnosed previously with severe depression [24+]. There was found to be a significant peak in October/November for men, with predominance for suicides on Sundays for both sexes [24+]. The association between depression and suicide seasonality has led researchers to theorise that the reason seasonality in suicide is decreasing is due to the advances in antidepressant medication, this highlights the, influence this psychiatric disorder has on this phenomenon [15+]. Alcoholism is thought to also govern the seasonality of suicide. In a study by Bradvik and Berglund, 2002, it was observed that alcoholics were found to commit suicide more frequently during the second quarter of the year coinciding with the spring peak often reported in literature [43]. Evidence not strong Rocchi, Sisti Miotto et al, yip, yang and qin2006 Evidence of a psychiatric illness is not the only predisposing factor towards suicide; in fact, atopy and allergic disease have also been indicated. In a study by Timmonen et al, 2004, it was reported that in Northern Finland, atopic patients who committed suicide showed greater suicide seasonality than those who did not have any atopic disorders [45]. Other disorders finish data linkage e study = suicides in patients hospitalised with atopic disorders in previous months or years such as asthma, allergic rhinitis, atopic dermatitis occur predominantly in the first half of the year opposed to no difference in other patients. Lester and frank 1988, yip et al, 2000, meares mendelsohn and milgrom-friedman 1981 micciolo 1989 Micciolo et al 1989 suggested explanation, social activities of women in autumn trigger more frequent suicides Explanation Durkheim seasonality with suicide characteristic of the intensity of social life seasonal peaks with level of social activity high in spring and summer Gabennesch broken promise theory unmet expectations more suicide at the beginning of a cycle coincides with return to school/work does not explain differences in suicide method/sex Corcoran et al 2004, Granberg and Westerberg 1999, Jessen and Jensen 1999

Chew McCleary opportunity structure concept need suicidal motivation - but also, opportunity, suicide cannot occur without opportunity. explains specific seasonal patterns, also suicidal methods, such as drowning, jumping from height. Conclusion The link between suicide and seasonality remains an elusive subject and there are clearly many factors which contribute to this phenomenon. This essay only examines the tip of the iceberg and is by no means conclusive. Unfortunately, this is an area of research in which the methodology is inherently flawed as the underestimation of suicide is a world-wide phenomenon, especially in children, certain professions and specific religious groups that condemn suicide [25+]. This means that [1+] Altamura C, VanGastel A, Pioli R, Mannu P, Maes M. Seasonal and circadian rhythms in suicide in Cagliari, Italy. Journal of Affective disorders 1999; 53: 77-85 [2+]Adjacic-Gross V, Bopp M, Ring M, Gutzwiller F, Rossler W. Seasonality in suicide- A review and search of new concepts for explaining the heterogeneous phenomena. Social Science & Medicine 2010; 71: 657-666 [19+] Massing W, Angermeyer MC. The monthly and weekly distribution of suicide. Soc. Sci. Med 1985; 21 (4): 433-441 [25+] Preti A, Miotto P. Diurnal variations in suicide by age and gender in Italy. Journal of Affective Disorders 2001; 65: 253-261 [24+] Bradvik L. The occurrence of suicide in severe depression related to the months of the year and the days of the week. Eur Arch Psychiatry Clin Neurosci 2002; 253: 28-32 [20+] McCleary R, Chew KSY, Hellstern JJ, Flynn-Bransford M. Age-and sexspecific cycles in United States suicides, 1973 to 1985. Am J Public Heath 1991; 81: 1494-1497 [26+] Preti A, Miotto P. Seasonality in suicides: the influence of suicide method, gender and age on suicide distribution in Italy. Psychiatry research 1998; 81: 219-231 [40+] Lin HC, Chen CS, Xirasagar S, Lee HS. Seasonality and climatic associations with violent and non violent suicide: a population-based study. Neuropsychobiology 2008; 57: 32-37 [14+] Rocchi MBL, Sisti D, Cascio MT, Preti A. Seasonality and suicide in Italy: Amplitude is positively related to suicide rates. Journal of Affective Disorders 2007; 100: 129-136 [41+] Adjacic-Gross V, Weiss MG, Ring M, Hepp U, Bopp M, Gutzwiller F, Rossler W. Methods of suicide: international suicide patterns derived from the WHO mortality database. Bulletin of the World Heath Organisation 2008; 86: 726-732

[38+] Rasanen P, Hakko H, Jokelainen J, Tiihonen J. Seasonal variation in specific methods of suicide: a national register study of 20 234 Finnish people. Journal of Affective Disorders 2002; 71: 51-59 [16+] Rock D, Greenberg DM, Hallmayer JF. Increasing seasonality of suicide In Australia. Psychiatry Research 2003; 120: 43-51 [33+] Nejar KA, Bensenor IM, Lotufo PA. Sunshine and suicide at the tropic of Capricorn, Sao Paulo, Brazil, 1996-2004. Rev Saude Publica 2007 [27+] Preti A. The influence of climate on suicidal behaviour in Italy. Psychiatry Research 1998; 78: 9-19 [28+] Partonen T, Haukka J, Viilo K, Hakko H, Pirokola S, Isometsa E, Lonnqvist J, Sarkioja T, Vaisanen E, Rasanen P. Cyclic time patterns of death from suicide in northern Finland. Journal of Affective Disorders 2004; 78: 11-19 [21+] Lee HC, Lin HC, Rsai SY, Li CY, Chen CC, Huang CC. Suicide rates and the association with climate: a population-based study. Journal of Affective Disorders 2006; 92: 221-226 [15+] Rihmer Z, Rutz W, Pihlgren H, Pestality P. Decreasing tendency of seasonality in suicide may indicate lowering rate of depressive suicides in the population. Psychiatry Research 1998; 81: 233-240 [4+] Simkin S, Hawton K, Yip PSF, Yam CHK. Seasonality in suicide: a study of farming suicides in England and Wales. Crisis 2003; 24 (3): 93-97 [5+] Erazo N, Baumert J, Ladwig KH. Sex-specific time patterns of suicidal acts on the German railway system. An analysis of 4003 cases. Journal of Affective Disorders 2004; 83: 1-9 [22+] Preti A. The influence of season change on suicidal behaviour in Italy. Journal of Affective Disorders 1997; 44: 123-130 [35+] Shin SDS, Suh GJ, Rhee JE, Sung J, Kim J. Epidemiologic characteristics of death by poisoning in 1991-2001 in Korea. J Korean Med Sci 2004; 19: 186-194 [29+] Page L, Hajat S, Kovats RS. Relationship between daily suicide counts and temperature in England and Wales. British Journal of Psychiatry 2007; 191: 106-112. [17+] Retamal P, Humphreys D. Occurrence of suicide and seasonal variation. Rev. Saude Publica 1998; 32 (5): 408-12 [24] Preti A. Seasonal variation and meteotropism in suicide. Current opinion in psychiatry 2000; 13: 655-660 [25] Patonen T, Haukka J, Nevanlinna H, Lonnqvist J. Analysis of the seasonal pattern in suicide. Journal of Affective disorders 2004; 81: 133-139

[6+] Oravecz R, Sisti D, Rocchi MBL, Preti A. Changes in the seasonality of suicides over time in Slovenia 1971-2002; Amplitude is only positively related to suicide rates among females. Journal of Affective Disorders 2007; 104: 211-215 [12+] Oravecz R, Sisti D, Rocchi MBL, Zorko M, Marusic A, Preti A. Changes in the seasonality of suicides over time in Slovenia 1971 to 2002. Journal of Affective Disorders 2006; 95: 135-140 [18+] Bridges SF, Yip PSF, Yang KCT. Seasonal changes in suicide in the United States, 1971 to 2000. Perceptual and motor skills 2005; 100: 920-924. [23+] Tsai JF, Cho W. Re-examination of the seasonality of suicide in Taiwan during 1991-2008: A population-based study. Psychiatry research 2011; 186: 147-149 [39+] Adjacic-Gross V, Bopp M, Sansossio R, Lauber C, Gostynski M, Eich D, Gutzwiller F, Rossler W. Diversity and change in suicide seasonality over 125 years. J epidemio Community Health 2005; 59: 967-972 [36+] Chew KSY, McCleary RM. The spring peak in suicides: a cross-national analysis. Soc. Sci. Med 1995; 40 (2) 223-230 [7+] Yip PSF, Chao A. A re-examination of seasonal variation in suicides in Australia and New Zealand. Journal of Affective Disorders 1998; 47: 141-150. [34+] Bando DH, Scrivani H, Morettin PA, Tung Teng C. Seasonality of suicide in the city of Sao Paulo, Brazil 1979-2003. Rev Bras Psiquiatr 2009; 31 (2): 101-5. [8+] Voracek M, Yip SF, Fisher ML, Zonda T. Seasonality of suicide in Eastern Europe: A rejoinder to Lester and Mokonsony. Perceptual and Motor Skills 2004; 99: 17-18 [9+] Yip PSF, Chao A, Chiu CWF. Seasonal variation in suicides: diminished or vanished. British journal of psychiatry 2000; 177: 366-369. [10+] Yip PSF, Yang KCT. A comparison of seasonal variation between suicide deaths and attempts in Hong Kong SAR. Journal of Affective Disorders 2004; 81: 251-257 [37+] Chao HTP, Yip P. Seasonal variation I suicides re-examined: no sex difference in Hong Kong and Taiwan. Acta Psychiatr Scand 1997; 95: 26-31 [30+] Flisher AJ, Parry CDH, Bradshaw D, Juritz JM. Seasonal variation of suicide in South Africa. Psychiatry Research 1997; 66: 13-22 [39] Postolache TT, Mortensen PB, Tonelli LH, Jiao X, Frangakis C, Soriano JJ, Qin P. Seasonal spring peaks of suicide in victims with and without prior history of mood disorders. Journal of Affective Disorders. 2010; 121 (1-2): 88-93

[13+] Morken G, Lilleeng S, Linaker OM. Seasonal variation in suicides and in admissions to hospital for mania and depression. Journal of Affective Disorders 2002; 69: 39-45 [11+] Hakko H, Rasanen P, Tiihonen J. Secular trends in the rates and seasonality of violent and non-violent suicide occurrences in Finland during 1980-95. Journal of Affective Disorders 1998; 50: 49-54 [31+] Bjorksten KS, Bjerregaard P, Kripke DF. Suicides in the midnight sun a study of seasonality in suicides In West Greenland. Psychiatry research 2005; 133: 205-213 [43] Bradvik L, Berglund M. Seasonal distribution of suicide in alcoholism. Act Psychiatr Scand 2002; 106: 299-302 [44] Reutfors J, Osby U, Ekborn A, Nordstrom P, Jokinen J, Papadopoulos FC. Seasonality of suicide in Sweden: relationship with psychiatric disorder. Journal of Affective Disorders 2009; 119: 59-65 [45] Timmonen M, Viilo K, Hakko H, Sarkioja T, Meyer-Rochow VB, Valsanen E, Rasanen P. Is seasonality of suicides stronger in victims with hospital treated atopic disorders? Psychiatry Research 2004; 126: 167-175