The tragedy of becoming tired of living: Youth and young adults’ suicide in Greenland and Denmark

Abstract

Background:

Suicide is a tremendous public health issue and worldwide the second leading cause of death among young people. In 2015, Greenland had the highest burden of disease due to self-harm with loss of 2,952.97 disability-adjusted life years per 100,000 inhabitants, more than six times as many as Denmark.

Aims:

What are possible reasons for Greenland’s higher youth suicide rate compared to Denmark, despite being one kingdom of Denmark?

Method:

Mixed methods in the form of qualitative, semi-structured interviews, the analysis of available data for 2003–2016 and a literature review were conducted with the aim to answer this question.

Results:

Several exposures cause this difference, most significantly adverse effects of the colonial past, such as social issues and experienced traumas in Greenland compared to its former coloniser Denmark.

Conclusion:

The ongoing burden of youth suicide in Greenland requires enhanced actions of all stakeholders involved in suicide prevention, intervention and postvention.

Keywords

Youth suicide adolescent suicide suicidal behaviour Denmark Greenland

Introduction

Each year, 11.4 per 100,000 people die by suicide worldwide (World Health Organization (WHO), 2014). Young people between 15 and 29 years of age are a high-risk group, since suicide is the second leading cause of death, after road traffic injuries (WHO, 2016), among that age group.

In 2015, Greenland had the highest estimated disability-adjusted life years (DALYs) loss due to self-harm worldwide with 2,952.97 DALYs per 100,000 inhabitants (IHME, 2015). This is more than double the burden of disease due to self-harm and suicide as in Sweden, Norway, and Denmark combined! Within the period of 2003–2013, the suicide rate of all ages was substantially higher in Greenland than in Denmark among both sexes (L. Pedersen & Vestergaard, 2017). The prevalence in Denmark was rather stable over the years with peaks of 0.018% among men and 0.007% among women (D. Larsen, 2017). In Greenland, the prevalence was fluctuating over the years with peaks of 0.143% among men and 0.082% among women (L. Pedersen & Vestergaard, 2017). Although there is a decreasing trend of DALYs lost due to self-harm and suicide in both countries (and worldwide) from 1990 until 2015, while Denmark is slightly under the worldwide rate, the prevalence in Greenland is still extremely high. Furthermore, despite this being an on-going public health challenge, there is a clear lack of knowledge about causes for suicides and suicide attempts in Greenland (Lynge, 2013).

Overview of Greenland’s history

Norse immigrants from Island settled in the late 10th century along the south-west coast of Greenland, regions which were not populated until then. Around the 1200s, the Thule people, who are the ancestors of today’s Greenlandic Inuit, arrived and spread from northern Greenland to the eastern, southern and western coastal areas (Grydehøj, 2016). The long-declining settlements of the Norse in Greenland disappeared entirely in the 1400s (Gulløv, 2008). What began as a protestant religious mission turned out as the beginning of the Danish-Norwegian colonial project in 1721. The preservation of the Greenlandic nomadic hunting society became gradually the focus of the mission (Brock, 2008).

In the late 18th and 19th centuries, the Greenlanders were discouraged to adopt the ‘civilised’ lifestyle, since the Danes wanted to assure that they remained the only traders of seal products (Rud, 2014). Unlike other relationships between the coloniser and the colonised region, Denmark neither gained large profits from Greenland nor exposed Greenland to violence of slavery. By the early 1900s, the growth to a fishing economy, with a focus on export, started. This new market economy required increasing acquisition of imported materials, which led to economic dependence of Greenland on Denmark (Grydehøj, 2016).

Greenland was a colony of Denmark from 1721 until 1953, while colonisation started later along the east coast and in northern Greenland, compared to the west coast (Bjerregaard & Larsen, 2015).

The urbanisation process from a former nomadic society (Grydehøj, 2016) began in the early 20th century, increasing rapidly since the 1950s. In 1951, 68% of the population were living in villages with less than 500 residents with a decreasing trend to 15% until 2010. Greenland had home rule since 1979 and the self-governance status since 2009 (Bjerregaard & Larsen, 2015).

Referring to the latest statistics, Greenland has a population of 55,860 people (L. Pedersen, 2017). A total of 90% of the population are ethnic Greenlandic Inuit. Genetically, Greenlandic people have a mixture of European, mostly Scandinavian genes (Moltke et al., 2015). Culturally and genetically, Greenlandic Inuit are closely related to the Inuit in the United States and Canada. Until today, the most remote places are the communities which have been colonised the latest, impacted by lower income and less opportunities for employment (Bjerregaard & Larsen, 2015).

Greenland is politically and administratively part of the kingdom of Denmark. Therefore, it is justified to ask the question ‘what are possible reasons for Greenland’s higher youth and young adults’ suicide rate?’. The presented paper aims to bring answers to this question and provide explanations.

Methods

Study population

The population of interest includes 15- to 29-year-old men and women, with residence in Denmark or Greenland, irrespective of their place of birth. For a more detailed analysis of the statistics and their comparability, three common age groups were used: 15–19, 20–24, and 25–29 years. For this paper, the terms ‘young person’ and ‘young people’ include males and females within the age of 15–29 years. Included are data of young people who died by suicide or who previously survived a suicide attempt or several attempts.

Sources of data

Qualitative interviews

Six qualitative interviews with 10 experts of youth and young adults’ suicide in Greenland were conducted in the period of February and March 2017. The interviewees were contacted via email and the interview guide, developed by the first author of this manuscript, was provided to them a few workdays in advance of the interview.

All interviews were conducted by the first author of this manuscript; four of them in person in Nuuk, Greenland, while the other two interviews were organised via video conference call on Skype since the interviewees were in Ilulissat, Greenland, or Saskatoon, Canada. Three interviews were individual, while the other three were organised as focus groups, giving a greater opportunity for discussion.

The interview guide was pretested via discussion with two non-experts in the field of youth and young adults’ suicide.

All interviewees gave permission beforehand to record the interview as audio data on a mobile phone and to take written notes on the laptop. All interviewees signed a written agreement to participate in this study. The interviews lasted between 55 minutes and 2 hours 10 minutes, including the introduction part and acknowledgements at the end of the interview.

Analysis of data

Quantitative data were downloaded from databases of Statistics Denmark, Statistics Greenland, and reports of the Greenlandic national police.

The period of interest for most of the used statistics has been set for the years 2003–2013, since 2013 was the most recent data published. Furthermore, this period of several years allowed observations of time trends and possibilities to compare to other sources. Calculations for the suicide attempts and the monthly distribution of suicides are based on data provided by the Greenlandic national police. The police reports are more recent, meaning from the years 2014–2016 (no data available about suicide attempts in 2013), respectively, 2013–2016.

Since the phenomenon of suicide is not a long-term disease and happens within a short period, the period prevalence has been preferred to the point prevalence.

Results

Epidemiology of youth and young adults’ suicide in Denmark and Greenland

The suicide prevalence is visibly lower in Denmark compared to Greenland. In both countries, a higher suicide prevalence was measured among young men than among young women. Furthermore, the suicide prevalence in Denmark stayed rather stable over time in all age groups for both sexes, compared to clear peaks in suicide rates among young men and young women in Greenland.

The time trend of the suicide prevalence in Denmark and Greenland is presented in Figures 1 and 2.

Figure 1.

Suicide prevalence, Denmark and Greenland, male, three age groups, 2003–2013.

Figure 2.

Suicide prevalence, Denmark and Greenland, female, three age groups, 2003–2013.

Among Danish men, the highest average suicide prevalence was found among 25- to 29-year-olds with 0.012%, followed by 20- to 24-year-olds with 0.011%, and 15- to 19-year-olds with 0.005%. Among Greenlandic men, 20- to 24-year-olds were at greatest risk, followed by 15- to 19-year-olds and 25- to 29-year-olds.

Among Danish women, the highest average suicide prevalence occurred among 20- to 24-year-olds and 25- to 29-year-olds with 0.003%, followed by 15- to 19-year-olds with 0.001%. Among Greenlandic women, 15- to 19-year-olds were at greatest risk, followed by 20- to 24-year-olds and 25- to 29-year-olds. In both countries, there is no clear time trend of an increasing or decreasing suicide prevalence indicated.

Figure 3 shows a time trend of DALYs per 100,000 inhabitants due to self-harm from 1990 until 2015 in Denmark and Greenland, for both sexes for the age groups of 15–19, 20–24 and 25–29 years.

Figure 3.

DALYs per 100,000 inhabitants due to self-harm, Denmark and Greenland, both sexes, 1990–2015.

Although there is a decrease over time of DALYs in both countries in all age groups, Greenland loses a substantially higher amount of DALYs as Denmark.

Suicide methods differ substantially among the population of Greenland and Denmark. In Greenland, hanging is the most frequently used method to commit suicide (67%–86% of cases depending on age and sex) followed by the use of a firearm, whereas in Denmark, it is clearly self-poisoning (about 75%) followed by use of sharp objects and hanging (C. P. Larsen & Thrue Mikkelsen, 2016).

What are possible reasons for Greenland’s higher youth and young adults’ suicide rate compared to Denmark, despite being one kingdom of Denmark?

According to the information gathered via the interview process, there could be several reasons for Greenland’s higher youth and young adults’ suicide rate compared to Denmark. In Figure 4, the 10 most significant exposures are illustrated, without a ranking of significance, since a suicide is not caused by a single exposure and the exposures for a suicide are individual for each victim. The exposures are not independent from each other and the exposures shown in green seem especially significant for the differences in youth and young adults’ suicide exposures between Denmark and Greenland and are therefore connected to the colonial past.

Figure 4.

Ten most significant exposures for youth suicide in Greenland.

Discussion

Several influences lead to the high youth and young adults’ suicide rate in Greenland, which can be summarised in 10 exposures. Four of the above exposures, illustrated in green, can be connected to the Danish influence on Greenland during the colonial past, while the colonial past itself is not a youth and young adults’ suicide exposure.

The alcohol consumption became an issue during the modernisation process due to increased import of alcoholic beverages, as learned from interviewee 6. Alcohol abuse can lead to loss of restraints and therefore an increased risk for violent behaviour to cope with frustration and anger. Furthermore, sexual abuse can be interpreted as a reaction to identity loss, especially loss of power and prestige of the Greenlandic men, since the Danes showed little respect for the Greenlandic lifestyle, as explained by interviewee 6. The combination of the influence of alcohol problems in the family and sexual abuse during childhood comes out as the independent predictive aspects of the highest importance concerning suicide risk. A study has shown that only 10% of the participants who have experienced neither alcohol problems nor sexual abuse reported to have suicidal thoughts, whereas 82% of the ones who experiences both mentioned suicidal thoughts (Bjerregaard & Young, 1998, p. 155). Interviewee 5 confirmed the severity of the combination of alcohol abuse and sexual abuse as a leading cause for youth and young adults’ suicide. Therefore, alcohol abuse, sexual abuse and identity loss are causing intergenerational traumas, leading to high youth and young adults’ suicide rate.

Although the geographical location itself is not the exposure, the disadvantages that certain regions bring along can increase the suicide risk. The regions with the highest suicide rates were colonised last (Bjerregaard & Larsen, 2015) and are experiencing the on-going influences from the colonial past as well as less opportunities for young people and hindered overall living conditions, especially concerning the healthcare system, as mentioned by interviewee 6.

In addition to those four exposures connected to the colonial past, six further exposures, illustrated in grey, are essential to gain a better understanding of youth and young adults’ suicide in Greenland.

The suicide of a close person increases the risk tremendously for the individual. Furthermore, it can trigger a suicide cluster or a ‘copycat’ suicide, as described in youth and young adults’ suicide theories (Stillion, McDowell, & May, 1989, p. 90). As research with a global focus shows, such a ‘copycat’ suicide can be provoked by unsuitable media reporting of suicides to create a sensation (WHO, 2014) and is a major risk factor among young people, presumably in Greenland as well.

Loneliness and the feeling of having no one to talk to is a further important aspect. Due to those psychological challenges, young people may feel lost and misunderstood, while suicide arises as a comforting solution. Connected to such feelings is the experience of burdensomeness (Van Orden et al., 2010), as explained in recent suicide theories. As experienced by interviewee 5, young people mentioned anxiety of becoming a burden for their family as a key exposure for their suicide attempt, phrasing it as the better way for everyone if oneself is not around anymore.

Conflicts within any kind of relationship are an additional factor influencing youth and young adults’ suicide, independently of their place of origin. Occurring at home, in school or among other contacts, the disputes have an adverse effect on the young persons’ self-esteem and may lead to mistrust and further painful experiences, which decreases the overall mental stability and can increase suicidal behaviour.

Referring to a study by Slama, there are two major age groups attempting suicide. One group are adults around the age of 38 years, where the major exposure for a suicide attempt is depression. The other group are young people around the age of 19 years, where several major exposures were found, such as substance abuse, comorbid anxiety disorders and a personal history of emotional and sexual abuse. This leads to impulsive behaviour of young people, putting them at risk to commit suicide (Slama et al., 2009). Those results were confirmed for Greenland, where most suicide attempts seem to be triggered by a personal or social crisis, rather than by a mental illness (Lynge, 2013). Interviewee 5 agreed that not a mental illness, but difficult social circumstances are often the leading suicide exposures. A study of 2004–2005 suggests the same tendency based on their results. Among males, loneliness is the leading cause, followed by suicide of the girlfriend or another close friend, and symptoms of depression. Among females, experiences of sexual abuse is the main cause, followed by suicide of the boyfriend or another close friend, loneliness and symptoms of depression (C. P. Pedersen, Dahl-Petersen, & Bjerregaard, 2006).

Although depression is not the leading cause for youth and young adults’ suicide in Greenland, symptoms of depression need to be handled carefully. Especially, since a depression is often a consequence of all other exposures, mental health issues need to be taken seriously. A suicide attempt is often described as a ‘cry for help’, as explained in youth and young adults’ suicide theories (Topol & Reznikoff, 1982). Nevertheless, any kind of suicidal behaviour deserves careful and appropriate attention from professional healthcare workers.

The long darkness in winter, the cold and lack of exposure to sunlight as a major determinant of suicide in Greenland stays a myth without statistical strength. Although suicide rates are higher in the northern than in the southern part of Greenland, this difference lacks statistical power. As discussed, the geographical location has an influence on the suicidal risk in the form of regional differences, which can be explained rather due to the health system and overall life conditions than due to natural environmental conditions.

A previous suicide attempt or several attempts often lead to the choice of a more aggressive and lethal method, for instance, from an attempt of drowning to the use of a firearm. This is particularly observable in Greenland, where using an aggressive method such as hanging and the use of a firearm accounts for the majority of completed suicides. In Denmark, the common methods of self poisoning and the use of sharp objects are underlining a less aggressive suicidal behaviour compared to Greenland.

To advance prevention, intervention and postvention further, suicide theories need to be considered. To improve suicide prevention, the knowledge and further research about risk factors is essential, yet to achieve a decrease of suicides and suicide attempts, protective factors need to be investigated and included in any kind of prevention programme. Concerning the postvention, the mental health support for the family and friends of a suicide victim needs to be strengthened and expanded to the family and friends of survivors of suicide attempts.

Limitations and proposal for further research

Most severe limitations of the study are related to uncertainties of primary data. The illustrated decreasing trend in DALYs may lead to an underestimation of the still urgent suicide challenge in Greenland. The mortality statistics of Greenland is based on the national registration similarly as in Denmark, but there is little knowledge upon mental illness in Greenland making the years lived with disability element of DALY sensitive for misclassification. Since depression was rarely mentioned as an exposure of youth and young adults’ suicide in Greenland, there might be a lack of diagnosed depressions, which would lead to a critical shortage of necessary treatment. Due to limited time and financial resources, the personal interviews had to be limited to Nuuk. Furthermore, one interview with a person of interest located in Tasiilaq could not be conducted due to limited Internet capacity.

Further research should focus on application of participatory approach involving all relevant stakeholders, including young people and families. More focus on intervention research is needed to speed up prevention work and save lives.

Along with Denmark and Greenland, the Faroe Islands are part of the kingdom of Denmark. Interviews with experts of youth and young adults’ suicide in Denmark and the Faroe Islands and according to the literature review would improve the comparison to Greenland. A direct Faroe Islands–Greenland comparison could shed more light on causes of suicide in Greenland.

Another approach could be to focus on Greenlandic Inuit population in different countries in the circumpolar region (and the Inuit in the United States, Canada, etc.).

Conclusion

Greenland has a significantly higher suicide prevalence compared to Denmark, among the whole population as well as specifically between 15- and 29-year-olds. Influenced by the colonial past, social issues and experienced traumas are the leading youth and young adults’ suicide exposures in Greenland, which could explain the higher prevalence compared to its former coloniser Denmark. The geographical location in the arctic circle and associated weather conditions do not seem to be a strong determinant of youth and young adults’ suicide in Greenland. Hanging and the use of a firearm are the most common suicide methods among young people in Greenland, differently to Denmark where self-poisoning is the leading method. A stronger focus on young people and their protective factors against suicide is required and increased financial support and human resources in prevention, intervention, postvention, as well as in research are inevitable.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

References

Bjerregaard

Larsen

C. V.

(2015). Time trend by region of suicides and suicidal thoughts among Greenland Inuit. International Journal of Circumpolar Health, 74, Article 26053. doi:10.3402/ijch.v74.26053

Bjerregaard

Young

T. K.

(1998). The circumpolar Inuit – Health of a population in transition. Viborg, Denmark: Special-Trykkeriet Viborg AS.

Brock

D. M.

(2008). The arctic promise: Legal and political autonomy of Greenland and Nunavut. Canadian Journal of Political Science, 41, 228–229. doi:10.1017/S0008423908080244

Grydehøj

(2016). Navigating the binaries of island independence and dependence in Greenland: Decolonisation, political culture, and strategic services. Political Geography, 55, 102–112. doi:10.1016/j.polgeo.2016.09.001

Gulløv

H. C.

(2008). The nature of contact between native Greenlanders and Norse. Journal of the North Atlantic, 1, 16–24. doi:10.3721/070425

IHME. (2015). GBD compare / Data visualization – Self-harm. Retrieved from https://vizhub.healthdata.org/gbd-compare/

Larsen

C. P.

Thrue Mikkelsen

A. K.

(2016). The register for suicide attempts – Methods and rates in relation to age and gender in two regions of Denmark. Retrieved from http://selvmordsforskning.dk/wp-content/uploads/sites/2/2016/09/CRPE-2016.pdf

Larsen

(2017). Statistics Denmark – Suicide and population. Retrieved from http://www.statbank.dk/statbank5a/default.asp?w=1536

Lynge

(2013). National strategy for suicide prevention in Greenland 2013–2019. Nuuk, Greenland: Ministry of Health, Government of Greenland.

10.

Moltke

Fumagalli

Korneliussen

T. S.

Crawford

J. E.

Bjerregaard

Jorgensen

M. E.

… Albrechtsen

(2015). Uncovering the genetic history of the present-day Greenlandic population. American Journal of Human Genetics, 96, 54–69. doi:10.1016/j.ajhg.2014.11.012

11.

Pedersen

C. P.

Dahl-Petersen

Bjerregaard

(2006). Memorandum on suicidal ideations and suicide attempts among youth and young adults in Greenland. Nuuk, Greenland: Documentation Centre on Children and Youth and young adults, National Institute for Public Health, Office of Health and Preventive Measures.

12.

Pedersen

(2017). Statistics Greenland – Same population estimate as last year. Retrieved from http://www.stat.gl/dialog/main.asp?lang=en&version=201701&sc=BE&subthemecode=O1&colcode=O

13.

Pedersen

Vestergaard

(2017). Statistics Greenland – Suicide and population. Available from http://bank.stat.gl/pxweb/en/Greenland/

14.

Rud

(2014). Governance and tradition in nineteenth-century Greenland. Interventions, 16, 551–571. doi:10.1080/1369801X.2013.851827

15.

Slama

Courtet

Golmard

J. L.

Mathieu

Guillaume

Yon

… Bellivier

(2009). Admixture analysis of age at first suicide attempt. Journal of Psychiatric Research, 43, 895–900. doi:10.1016/j.jpsychires.2009.01.007

16.

Stillion

J. M.

McDowell

E. E.

May

J. H.

(1989). Suicide across the life span – Premature exits. New York, NY: Hemisphere Publishing.

17.

Topol

Reznikoff

(1982). Perceived peer and family relationships, hopelessness and locus of control as factors in adolescent suicide attempts. Suicide and Life-threatening Behavior, 12, 141–150.

18.

Van Orden

K. A.

Witte

T. K.

Cukrowicz

K. C.

Braithwaite

Selby

E. A.

Joiner

T. E.

(2010). The Interpersonal Theory of Suicide. Psychological Review, 117, 575–600. doi:10.1037/a0018697

19.

World Health Organization. (2014). Preventing suicide – A global imperative. Retrieved from http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1

20.

World Health Organization. (2016). World health statistics 2016 – Monitoring health for the SDGs (Sustainable Development Goals). Retrieved from http://www.who.int/gho/publications/world_health_statistics/2016/en/