Time trends and geographical clusters in suicide among Greenland Inuit

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The aim of this study is to investigate suicide rates in Greenland according to age, birth cohort, period, sex, place of residence and suicide method from 1970 until 2018. Methods Suicide rates were examined using register and census data from 1970-2018 among Greenland Inuit. Rates were calculated by Poisson regression in Stata and by use of Excel. In analyses of the period trends, rates were standardized according to the World Standard Population 2000-2025. Results The suicide rate has been declining since a peak at 120 suicides per 100,000 person-years in the 1980s but remained high at a rate of 81.3 suicides per 100,000 person-years from 2015-2018. Descriptive analyses point to the decrease in male suicides as the primary factor for the overall decreasing rates while the rate among women has been increasing. Simultaneously, the proportion of women who used a violent suicide method increased from 60% in 1970-1979 to 90% in 2010-2018. The highest rates are seen among young people, especially young men aged 20-24 years and youth suicide rates increased with later birth cohorts. When the rates started to increase in the 1908s both the capital Nuuk and East Greenland had the highest rates. Since then, the rate in Nuuk has declined while the rate in East Greenland was three times the national rate from 2015-2018. Conclusions Across a 50-year period the suicide rate has increased drastically in Greenland mirroring a rapid societal transition in the post-colonial period. The rate has slowly declined from the peak in the 1980s but remains at a very high level. Young people in general are at risk, but the steady increase in the rate among women is worrying. Research points to the importance of adverse childhood experiences in relation to suicide risk and the high prevalences of these adversities among women may contribute to the explanation of the decreasing gender gap, however there is a need to investigate this further. Suicide Time trends Inuit Greenland Register Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Greenland is the least densely populated country in the world with 56,000 people living scattered along the coast of the 2 million km 2 island. The majority of the population are Inuit. Inuit in Greenland are related to Inuit populations living across the Arctic sharing similar cultural heritages, language, but also challenges. Indigenous populations across the Arctic experience very high suicide rates compared to non-indigenous populations. These high rates are linked to colonization, rapid sociocultural and economic transformations leading to significant changes in lifestyles and livelihoods across a historically short span of 50 years. This has been linked to the onset of events causing social problems, intergenerational traumas, high prevalence of adverse childhood experiences, and loss of cultural affiliation especially impacting youth mental health (1-3). With one of the highest suicide rates in the world it is of great public health and societal value to continuously monitor suicide rates in regard of specific trends and risk factors. Today Greenland experience between 60-40 suicides every year. A century of monitoring suicide in Greenland The World Health Organization has stated that registration and ongoing monitoring of suicides are essential for national prevention strategies (4). Registrations of suicides from 1901-1960 reported that suicide was a rare event in Greenland mainly related to psychiatric disease with rates varying from 0-3.5 suicides per 100.000 person-years (5-7). After the initiation of an intensive modernization plan for Greenland in the 1950s the suicide rate increased dramatically from the 1960s and stabilized at a high level from 1980 and onwards with an average rate of 96 suicides per 100.000 person-years. From 1968 until 2018, suicide has accounted for 10% of all deaths in Greenland contributing to a significantly lower life expectancy when comparing with Western countries and in the period of 2005-2009 suicide was the third leading single cause of death in Greenland (1, 8). Methods of suicide are categorized as either violent or non-violent. Distinguishing the method of suicide is important because violent methods (e.g., hanging, shooting, or drowning) are associated with a higher lethality than non-violent methods. There are several ways of defining which methods are violent or non-violent but a simple approach is to define non-violent methods as poisoning and all other methods as violent (9). The type of method is associated with sex and the general pattern is that men use violent methods and thereby die more often than women who primarily use poisoning as method (9). In Greenland research has found the same association between method and sex which may in turn explain some of the sex-related differences in suicide rates (10, 11). Sex, age, birth cohort and geography Most suicides in Greenland are youth suicides with the highest rates among young men, while suicide attempts are more prevalent among young women (7). Regional differences have shifted across time and more recent research has found the highest rates in East and North Greenland as opposed to the capital Nuuk where rates have decreased from more than 150 suicides per 100.000 person-years in the 1980s to around 60 since the 2000s. An inspection of birth cohorts show a pattern of higher rates of youth suicides in younger birth cohorts where the youngest birth cohorts include the age group 10-14 years (7). Period, birth cohort and childhood adversities are key indicators/variables to include when analyzing temporal trends in suicide rates because they reflect both historical context and the rapid sociocultural developments of the postcolonial period in Greenland dating from 1953 and forward (1, 2, 7, 12). Objective The study objective was to investigate suicide rates in Greenland according to age, birth cohort, period, sex, and place of residence from 1970 until 2018. To get a more detailed understanding of the main objective potential patterns in suicide methods during the study period were investigated. Results may offer important knowledge for future strategies and interventions to prevent suicides in Greenland. Methods The population of interest are Greenland Inuit here defined as both being born and living in Greenland. The exclusion of other ethnicities is based on the fact that the majority of non-Greenlanders are non-Inuit Danes who have come to Greenland to work and who often stay for a limited time. These are assumed to have a significantly different risk profile for suicide, given that the suicide rate in Denmark is around seven time less than in the rate Greenland based on rates from 2007 until 2018 (13). Data sources We examined suicide rates using register and census data for Greenland Inuit. The Central Population Register covers all Greenlandic citizens each assigned with a unique personal identification number allowing for register-linkage. Information on suicide was obtained from the nationwide Greenland register of causes of death dating back to 1968. The register is updated regularly, and deaths are validated against the Central Population Register. From 1970 until 2018 1,952 suicides were registered among 19,766 deaths using the International Classification of Diseases ICD-8 and ICD-10 codes developed by the World Health Organization. The Greenland causes of death register has been validated and compared to police records with good agreement, while a more recent study evaluated the usability of the register to be of medium quality based on The Vital Statistics Performance Index for Quality (7, 14-16). Population size was based on information from the Central Population Register and obtained from the statistical databank of Statistics Greenland for 1977-2018 and combined with census data for 1970 and 1976 (17-19). The data included 2,265,676 person-years from 1970 until 2018. Method of suicide Based on the ICD-8 and ICD-10 codes method of suicide was categorized into four categories: poisoning ; hanging , strangulation or suffocation ; firearms or use of explosives and other . The category other includes drowning, cutting or piecing instruments, jumping from high places, other and unspecified means, and late effects of self-inflicted injury . Covariates To investigate geographical differences Greenland was divided into five regions based on socioeconomic conditions and remoteness from the capital. Nuuk, the capital, is the largest and wealthiest community with the greatest variety of jobs, shops, and cultural institutions. In 2021 Nuuk had 18,800 inhabitants. The largest communities on the west coast, Maniitsoq and Sisimiut (8,108 inhabitants), are centrally located and in many ways intermediate between Nuuk and the more remote communities on the west coast (20,156 inhabitants), the latter offering fewer jobs, shops, and cultural institutions. The 50 smaller communities (often referred to as villages) on the west coast of Greenland offer few jobs, often only a single shop and rarely any cultural institutions (6,179 inhabitants). The east coast is remote and suffers from a high unemployment rate and many social problems. In East Greenland there are 3,110 inhabitants living in two larger and five smaller communities. Smaller communities are generally defined as having less than 500 inhabitants (17). Statistical analyses Analyses were performed using the statistical software Stata version 17. Rates were calculated by Poisson regression in Stata and by use of Excel. In analyses of the period trends, rates were standardized according to the World Standard Population 2000-2025 (20). In the analyses of suicide rate according to sex and period rates were age adjusted according to the age distribution of the Greenland population in period 2015-2018. Results Table 1 shows the development of the suicide rate from 1970–2018. From 1970–1974 the rate was 29 per 100,000 person-years. Over a 15-year period the rate more than quadrupled peaking at 121 per 100,000 person-years in 1985–1989. The rate started declining from 1990 and in 2015–2018 the rate was 81 per 100,000 person-years. Among the 1,952 suicides registered from 1970–2018, 41 suicides were registered in children aged 11–14 years. Table 1 Suicide and suicide rates from 1970 to 2018. Period Suicides Suicides/year Suicide rate per 100000 person-years Standardized suicide rates per 100000 person-years a 1970–1974 56 11.2 28.7 33.3 1975–1979 95 19.0 46.9 47.8 1980–1984 210 42.0 100.0 88.8 1985–1989 268 53.6 120.5 99.7 1990–1994 240 48.0 101.6 96.9 1995–1999 251 50.2 102.4 106.1 2000–2004 236 47.2 94.7 101.9 2005–2009 211 42.2 83.7 84.6 2010–2014 222 44.4 88.2 86.7 2015–2018 163 32.6 81.3 80.4 Total 1952 40.7 86.2 86.2 a Standardized according to World Standard Population 2000–2025. The highest rate was seen in young men aged 20–24 years with 387 suicides per 100,000 person-years followed by a decline with increasing age. Among women young women aged 15–19 years had the highest rate of 96 suicides per 100.000 person years (Fig. 1 ). The rates for both men and women increased until 1985–1989 whereafter the male rates declined while the female rates increased slowly until 2018 thus decreasing the gender gap (Fig. 2 ). Figure 3 shows that birth cohorts born after 1960 had the highest suicide rates in the youngest age groups and that youth suicide rates continued to increase with later birth cohorts. The pattern was similar in the youngest birth cohort born in 1990–1999 but at a lower level compared to previous cohorts born between 1960 and 1989. Regional temporal trends are shown in Fig. 4 . East Greenland showed the highest rate of around 300 suicides per 100,000 person-years in 1995–1999. In the capital Nuuk, the rate was at its highest in the 80s followed by a large decrease further increasing the differences in rates in West and East Greenland. Figure 5 show that men mainly used violent methods for suicide with shooting or use of explosives as the most common methods in 1970–1979 (70%). Across time, suicide by hanging has become the most prevalent method in both sexes accounting for 73% of suicides in men and 76% in women from 2010–2018. Women had a high proportion of non-violent suicides (poisoning) at the beginning of the study period whereas the more violent methods, predominantly hanging, strangulation or suffocation became more prevalent during the study period increasing by 30%. Discussion The suicide rate in Greenland from 1970 until 2018 differed markedly according to age, birth cohort, period, sex, and place of residence. The suicide rate has been declining since a peak in the 1980s but remains extremely high today. Descriptive analyses point to the decrease in male suicides as the primary factor for the overall decreasing rates but the tendency of increasing rates in women is worrying. Simultaneously, the proportion of women who used a violent suicide method increased from 60% in 1970–1979 to 90% in 2010–2018 which in part explains the increase in the suicide rate among women. This is the first study to identify a reducing gender gap in suicide rates among Greenlandic Inuit. As is the case across many Arctic Indigenous peoples the young men have had and continue to have the highest rates, however the authors have no clear indication explaining why rates are decreasing in men and increasing in women ( 7 , 21 , 22 ). Adverse Childhood Experiences among Arctic Indigenous Peoples Research has pointed to the association of adverse childhood experiences (ACEs) and suicidality in Arctic Regions ( 23 ). ACEs are stressful and traumatic events such as sexual abuse, domestic violence, and other forms of domestic dysfunction, with potentially serious negative consequences for well-being ( 24 – 26 ). In Western non-indigenous populations ACEs have been associated with a lifetime prevalence for depression of 23% and a population attributable risk fraction of 67% in lifetime risk of suicide attempts ( 24 , 25 ). Having experienced just one ACE increases the lifetime risk of suicide attempt with 80%, while having experienced four or more ACEs is associated with a 12-fold increase ( 26 ). In Nunavut Canada, where the population is 84% Inuit, a follow-back study indicated that people who died by suicide were more likely to have experienced ACEs ( 22 ). In Greenland ACEs have been linked to both suicides and suicidal thoughts ( 1 , 2 , 7 , 27 , 28 ). It is well-documented in Greenland that alcohol problems in the childhood home is associated with being a victim of child sexual abuse. Experiencing alcohol problems often in childhood home and sexual abuse was associated with up to four times higher odds of past year suicidal thoughts according to data from the population health surveys in Greenland ( 1 , 12 ). The latest survey data among youth aged 15–34 years reported that 41% of the young women were victims of sexual abuse before the age of 18, whereas the corresponding proportion was 12% in young men. The same survey found a cumulative effect between the number of experienced ACEs and prevalence of suicidal thoughts and attempts ( 29 ). The high prevalence and the type of ACEs in Greenland may contribute to the pathogenesis of suicides: The high proportion of young women exposed to sexual abuse could be a contributing factor of the detected increase in female suicide rates. However, the population health surveys have shown a decrease in ACEs in the youngest birth cohorts compared to birth cohorts born in 1970–1989 where ACEs were the proportion who experienced ACEs were high ( 12 ). The latter grew up during the period where the alcohol consumption was at its highest, which is paralleled in the high suicide rates of the birth cohorts from Fig. 3 . According to the figure, youth suicide began to increase in the generations born during the 1950s and more than quadrupled in the following 10-year birth cohorts after which youth suicide became the most prevalent across all age groups. Based on these observations there is a potential link between alcohol consumption, ACEs, and youth suicide. Intergenerational trauma The trends in suicide rates of birth cohorts are also seen in other Arctic Indigenous peoples and has been interpreted as a sign of cultural cohort effects caused by cultural discontinuities related to colonialization and rapid societal changes ( 23 , 30 ). Problems with alcohol and ACEs does not only severely affect the individuals exposed to them but may have long lasting consequences across generations. Often these are referred to as intergenerational trauma. In the case of many Indigenous Peoples’, colonization of Indigenous land and lives, and rapid societal developments caused the onset of trauma and consequently intergenerational trauma ( 1 – 3 ). Intergenerational traumas are mirrored in the prevalence of both alcohol-related problems and ACEs. The prevalence has shifted across time and so has the impact on the generations exposed. Connection to culture has been identified as an important factor fostering resilience and improved mental health among those affected by intergenerational trauma ( 31 – 34 ). The association between culture and resilience differs across generations: Older generations feel more connected to their cultural heritage enhancing the protective effect, whereas younger generations experience a more distorted cultural connection making them more vulnerable to the ongoing rapid societal transitions compared to the older generations ( 31 ). Geographical clustering of suicide Whereas the rate in Nuuk started to decrease during the 1980s the rate in East Greenland continued to increase and stabilized at a very high level of three times the national rate. Similar trends have been seen among young Indigenous men in the Arctic and reflect that a transition towards an urban lifestyle induces an increase in suicide rates: Young men positioned between an urban life and a more traditional way of life are at increased risk indicating that modern living conditions and social determinants might be associated with this tendency ( 30 ). East Greenland is the most remote populated area of Greenland with less access to education, social- and health services, welfare, employment, and cultural institutions. The high suicide rate in East Greenland is further related to the high prevalence of social problems and ACEs. Growing up in either a smaller community in West Greenland or in East Greenland is associated with a smaller likelihood of obtaining longer education which in turn affects the individuals’ capacity to fit into a urbanized society build on western ideals ( 30 , 35 ). Living in smaller communities in West, East or North Greenland is further associated with lower income compared to the income of people living in the capital. In 2014 East Greenland has the highest prevalence of sexual abuse (46%), while violence and problems with alcohol consumption was most prevalent in Nuuk and other larger communities ( 35 ). The Greenland Police releases a yearly report every year with statistics on ‘sexual relations with children under the age of 15’, and here East Greenland and larger peripheral communities have the highest numbers ( 36 ). Survey data from 2018 among the Greenlandic youth aged 15–34 years support this clear geographical clustering of ACEs in the Eastern, Northern, and Southern municipalities. Nuuk (Sermersooq West) have the lowest prevalence but overall prevalence of alcohol in childhood home, violence in childhood home, and experience of sexual abuse before the age of 18 are high ( 29 ). The geographical clustering of high suicide rates and related risk factors point to the need for different approaches in the preventive effort of suicide. Implications for prevention and health promotion Temporal trends in the suicide rates are paralleled by trends in ACEs and can be linked to rapid societal developments in the post-colonial area ( 1 , 2 ). Hence the prevention of ACEs would be an important factor in the preventive effort to reduce the number of suicides in Greenland. The regional differences in the suicide rate and prevalence of ACEs should be taken into consideration in the preventive efforts. The findings of this paper underline the need to focus on suicide prevention among youth. Research have shown that there is a particular need to include a broad focus of not only the individual but also their surrounding community and relations ( 34 ). Culture and relations have been found to prevent youth suicide by providing knowledge and connection to the culture, intergenerational relationships, and role models ( 32 , 33 ). Arctic research is developing a more holistic strength-based approach to suicide prevention focusing on community strengths and protective factors fostering thriving communities ( 32 , 33 , 37 – 39 ). Prevention should be culturally relevant, community-based, and include individual, family, social, historical, cultural, and environmental factors that constitute the base of the ‘iceberg’ of which suicide would figure as part of the visible tip above water ( 40 ). In Greenland, land-based and intergenerational interventions for mental health among youth are being conducted and monitored. The Greenlandic Government is currently working on a new suicide prevention strategy expected to launch in the fall of 2022. This strategy is based on input from experts and local knowledge and includes perspectives from youth. Conclusion Across a 50-year period the suicide rate has increased drastically in Greenland mirroring a rapid societal transition in the post-colonial period. The rate has slowly declined from the peak in the 1980s but remains at a very high level. Young people, and especially young men, are at risk but the steady increase in the rate in women is worrying. This can in part be explained by the fact that there has been an increase in the proportion of violent suicide methods among women increasing the lethality. Research points to the importance of ACEs in relation to suicide risk and the high prevalences of ACEs among women may contribute to the explanation of the decreasing gender gap but there is a need to investigate this further. Youth suicide increased with later birth cohorts born after 1949. The youngest birth cohort still exhibited the pattern of high youth suicide rates but at a lower level compared to older generations. These findings coincide with a decrease in ACEs and urbanization which authors believe is reflected in the rates overall and the development of geographical clustering of the highest rates. These factors must be taken into consideration in the preventive work along with a strong focus on the community and protective factors that increases intergenerational bonds and cultural connectedness. Such important factors may heal intergenerational trauma and enhance a feeling of cultural identity creating a strong foundation for youth and foster thriving communities. Abbreviations ACEs: Adverse childhood experiences ICD: International Classification of Diseases Declarations Ethics approval and consent to participate All research methods were carried out in accordance with guidelines and regulations of the Helsinki declaration. Data are personal data and was anonymized and handled according to the General Data Protection Regulation. In Denmark and Greenland register data are available for research without the need to collect any form of consent from participants according to the Danish Data Protection Act §10 and the General Data Protection Regulation art. 6(1)(e) (Voigt and Von dem Bussche, 2017). The study is part of a Ph.D. project and was approved by two institutional boards in Greenland and in Denmark. In Greenland, the project has been approved by the Committee of Research Ethics in Greenland (KVUG 2018-16). In Denmark, the study is approved by the legal services of the University of Southern Denmark, notification number 11.266. Consent for publication Not applicable. Availability of data and materials Data on population size are available from Statistics Greenlands homepage, https://bank.stat.gl/pxweb/en/Greenland/. The Greenland register of causes of death is not publicly available. Researchers can apply for access to anonymized data via The Chief Medical Office: www.nun.gl. Competing interests The authors declare that they have no competing interests. Funding The study was financed as a part of a PhD project by Ministry of Education and Research - Danish State Funds for Arctic Research and a faculty scholarship by the University of Southern Denmark. The funding bodies played no role in the study design, data collection, analyses, interpretation or writing of the manuscript. Authors’ contributions IKS developed the study design together with CLL, PB and JST. JST and PB created datasets and IKS did the analyses. IKS wrote the manuscript and CLL, PB, JST and AC commented and added to the manuscript. Acknowledgements Authors would like to thank The Chief Medical Officer of Greenland and Statistics Greenland for their support with the registers. Authors’ information The main author, Ivalu Katajavaara Seidler, is of Greenland Inuit heritage and has been working with Greenlandic health research since 2018. More specifically her research topics include youth, mental health and alcohol consumption. Ivalu has a master’s degree in Public Health Science and is part of the Centre for Public Health in Greenland. The study in question is the first part of her Ph.D. project entitled ‘Patterns for suicides in Greenland – Risk and protective factors with a particular focus on Adverse Childhood Experiences’. Janne Tolstrup is a professor of epidemiology and is working in the field of public health especially focusing on the significance of alcohol intake and alcohol problems for somatic and psychiatric diseases. The preferred choice of methodology is to use a combination of data from large population-based studies and national registers. She is also running several intervention studies and is the author of more than 140 scientific papers. Peter Bjerregaard is a Professor of Arctic Health and has authored of more than 330 articles in peer reviewed journals, monographs, books, book chapters and research reports, predominantly on circumpolar epidemiology and community health. He is part of the of the Centre for Public Health in Greenland. Dr. Allisson Crawford is a psychiatrist and Associate Professor in the Department of Psychiatry, University of Toronto, where she is the Medical Director of the Northern Psychiatric Outreach Program and Telepsychiatry at the Centre for Addiction and Mental Health. Allison has worked as a psychiatrist in Nunavut for over 10 years and coordinates psychiatric services for the Government of Nunavut. Professor Christina Larsen is a sociologist by training (University of Copenhagen, 2006) and completed her PhD in Public Health (University of Southern Denmark, 2014). 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Cueva K, Rink E, Lavoie JG, Healey Akearok G, Guistini S, Kanayurak N, et al. From Resilient to Thriving: Policy Recommendations to Support Health and Well-being in the Arctic. Arctic. 2022;74(4):550–8. Pollock NJ, Healey GK, Jong M, Valcour JE, Mulay S. Tracking progress in suicide prevention in Indigenous communities: a challenge for public health surveillance in Canada. BMC Public Health. 2018;18(1):1–17. Finlay S, Wenitong M. Aboriginal Community Controlled Health Organisations are taking a leading role in COVID-19 health communication. Aust N Z J Public Health. 2020;44(4):251–2. Cueva K, Rink E, Lavoie JG, Stoor JPA, Healey Akearok G, Gladun E, et al. Diving below the surface: A framework for arctic health research to support thriving communities. Scand J Public Health. 2021:1–10. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Mar, 2023 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Major revision 27 Jan, 2023 Reviews received at journal 12 Dec, 2022 Reviewers agreed at journal 04 Dec, 2022 Reviewers agreed at journal 01 Dec, 2022 Reviewers invited by journal 01 Dec, 2022 Editor assigned by journal 01 Dec, 2022 Editor invited by journal 07 Nov, 2022 Submission checks completed at journal 07 Nov, 2022 First submitted to journal 07 Oct, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2141882","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":150233502,"identity":"33a6ee76-b2e5-442d-ae16-a4e28575195d","order_by":0,"name":"Ivalu Katajavaara Seidler","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAnklEQVRIiWNgGAWjYBACNgYGxgMMFQyMDQwMxkRrYTjAcIYULSBwgLGNFC18EskPDvPOq5PdcIB5swFxDpNIMzjMu+2w8YYDbMUJxGnhOQDSciBxwwEe4wNEajn+4TDvnDpStLD3AG1pYAZrIdJh7D0FB+ccO2w88zBbMXHel29m3/jgTU2dbN/x5s0SRGlBAGYS1Y+CUTAKRsEowAMAQ9Mvpxr/M3YAAAAASUVORK5CYII=","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ivalu","middleName":"Katajavaara","lastName":"Seidler","suffix":""},{"id":150233503,"identity":"bb342113-ff43-4dd5-900f-3d16c7f1bfc0","order_by":1,"name":"Janne Schurmann Tolstrup","email":"","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Janne","middleName":"Schurmann","lastName":"Tolstrup","suffix":""},{"id":150233504,"identity":"a0df0d7f-732a-44c3-8936-384df089ad3c","order_by":2,"name":"Peter Bjerregaard","email":"","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Bjerregaard","suffix":""},{"id":150233505,"identity":"48bf1478-be7f-4f4f-bfc2-8cf8bd93a907","order_by":3,"name":"Allison Crawford","email":"","orcid":"","institution":"Centre for Addiction and Mental Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Allison","middleName":"","lastName":"Crawford","suffix":""},{"id":150233506,"identity":"9a85cd32-54eb-4caf-ac4a-16671cf8db4c","order_by":4,"name":"Christina Viskum Lytken Larsen","email":"","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Christina","middleName":"Viskum Lytken","lastName":"Larsen","suffix":""}],"badges":[],"createdAt":"2022-10-07 11:14:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2141882/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2141882/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-023-04675-2","type":"published","date":"2023-03-21T20:08:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":28873056,"identity":"74c0ba13-496f-401e-98e6-7911d574a8e6","added_by":"auto","created_at":"2022-11-09 20:46:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29697,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAge specific suicide rates by sex.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"FIgure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2141882/v1/ac21ca5214599dbec6a6d58c.png"},{"id":28873059,"identity":"cedd6b6d-93a5-4bc0-9f51-75d143336bb2","added_by":"auto","created_at":"2022-11-09 20:46:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35378,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePeriod specific crude and age adjusted suicide rates by sex. Age adjusted rates were standardized according to the age distribution of 2015-2018\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"FIgure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2141882/v1/ae737a951316115c1495664c.png"},{"id":28873057,"identity":"f35ac1dc-dbc4-42c3-ac6c-141d7bbcf751","added_by":"auto","created_at":"2022-11-09 20:46:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":37959,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAge specific suicide rates by 10-year birth cohorts.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"FIgure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2141882/v1/be29d21c9a83d01346459000.png"},{"id":28873060,"identity":"21d1fcc2-8e5b-4073-894c-72a4f3b38363","added_by":"auto","created_at":"2022-11-09 20:46:41","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":39728,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePeriod specific suicide rates by community size and geographical location.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"FIgure4.png","url":"https://assets-eu.researchsquare.com/files/rs-2141882/v1/a67500fe131f95617883a514.png"},{"id":28873058,"identity":"2efc1ee3-cc73-4b36-bea7-0d74ecc61ab7","added_by":"auto","created_at":"2022-11-09 20:46:41","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":33678,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMethod of suicide according to year in men and women. The category other includes drowning, cutting or piecing instruments, jumping from high places, other and unspecified means, and late effects of self-inflicted injury.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"FIgure5.png","url":"https://assets-eu.researchsquare.com/files/rs-2141882/v1/030723e295956889f96bd822.png"},{"id":44723587,"identity":"d35b46ac-612b-43bc-a0b0-ca1d0697cbbc","added_by":"auto","created_at":"2023-10-16 20:16:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":580867,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2141882/v1/d91ff53a-731b-4803-aab9-1efe8547748c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTime trends and geographical clusters in suicide among Greenland Inuit\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGreenland is the least densely populated country in the world with 56,000 people living scattered along the coast of the 2 million km\u003csup\u003e2\u003c/sup\u003e island. The majority of the population are Inuit. Inuit in Greenland are related to Inuit populations living across the Arctic sharing similar cultural heritages, language, but also challenges. Indigenous populations across the Arctic experience very high suicide rates compared to non-indigenous populations. These high rates are linked to colonization, rapid sociocultural and economic transformations leading to significant changes in lifestyles and livelihoods across a historically short span of 50 years. This has been linked to the onset of events causing social problems, intergenerational traumas, high prevalence of adverse childhood experiences, and loss of cultural affiliation especially impacting youth mental health\u0026nbsp;(1-3). With one of the highest suicide rates in the world it is of great public health and societal value to continuously monitor suicide rates in regard of specific trends and risk factors. Today Greenland experience between 60-40 suicides every year.\u003c/p\u003e\n\u003ch3\u003eA century of monitoring suicide in Greenland\u003c/h3\u003e\n\u003cp\u003eThe World Health Organization has stated that registration and ongoing monitoring of suicides are essential for national prevention strategies\u0026nbsp;(4). Registrations of suicides from 1901-1960 reported that suicide was a rare event in Greenland mainly related to psychiatric disease with rates varying from 0-3.5 suicides per 100.000 person-years\u0026nbsp;(5-7). After the initiation of an intensive modernization plan for Greenland in the 1950s the suicide rate increased dramatically from the 1960s and stabilized at a high level from 1980 and onwards with an average rate of 96 suicides per 100.000 person-years. From 1968 until 2018, suicide has accounted for 10% of all deaths in Greenland contributing to a significantly lower life expectancy when comparing with Western countries \u0026nbsp;and in the period of 2005-2009 suicide was the third leading single cause of death in Greenland\u0026nbsp;(1, 8). Methods of suicide are categorized as either violent or non-violent. Distinguishing the method of suicide is important because violent methods (e.g., hanging, shooting, or drowning) are associated with a higher lethality than non-violent methods. There are several ways of defining which methods are violent or non-violent but a simple approach is to define non-violent methods as poisoning and all other methods as violent\u0026nbsp;(9). The type of method is associated with sex and the general pattern is that men use violent methods and thereby die more often than women who primarily use poisoning as method\u0026nbsp;(9). In Greenland research has found the same association between method and sex which may in turn explain some of the sex-related differences in suicide rates\u0026nbsp;(10, 11).\u003c/p\u003e\n\u003ch3\u003eSex, age, birth cohort and geography\u003c/h3\u003e\n\u003cp\u003eMost suicides in Greenland are youth suicides with the highest rates among young men, while suicide attempts are more prevalent among young women\u0026nbsp;(7). Regional differences have shifted across time and more recent research has found the highest rates in East and North Greenland as opposed to the capital Nuuk where rates have decreased from more than 150 suicides per 100.000 person-years in the 1980s to around 60 since the 2000s. An inspection of birth cohorts show a pattern of higher rates of youth suicides in younger birth cohorts where the youngest birth cohorts include the age group 10-14 years\u0026nbsp;(7). Period, birth cohort and childhood adversities are key indicators/variables to include when analyzing temporal trends in suicide rates because they reflect both historical context and the rapid sociocultural developments of the postcolonial period in Greenland dating from 1953 and forward\u0026nbsp;(1, 2, 7, 12). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eObjective\u003c/h3\u003e\n\u003cp\u003eThe study objective was to investigate suicide rates in Greenland according to age, birth cohort, period, sex, and place of residence from 1970 until 2018. To get a more detailed understanding of the main objective potential patterns in suicide methods during the study period were investigated. Results may offer important knowledge for future strategies and interventions to prevent suicides in Greenland.\u003c/p\u003e\n"},{"header":"Methods","content":"\u003cp\u003eThe population of interest are Greenland Inuit here defined as both being born and living in Greenland. The exclusion of other ethnicities is based on the fact that the majority of non-Greenlanders are non-Inuit Danes who have come to Greenland to work and who often stay for a limited time. These are assumed to have a significantly different risk profile for suicide, given that the suicide rate in Denmark is around seven time less than in the rate Greenland based on rates from 2007 until 2018\u0026nbsp;(13).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData sources\u003c/h3\u003e\n\u003cp\u003eWe examined suicide rates using register and census data for Greenland Inuit. The Central Population Register covers all Greenlandic citizens each assigned with a unique personal identification number allowing for register-linkage. Information on suicide was obtained from the nationwide Greenland register of causes of death dating back to 1968. The register is updated regularly, and deaths are validated against the Central Population Register. From 1970 until 2018 1,952 suicides were registered among 19,766 deaths using the International Classification of Diseases ICD-8 and ICD-10 codes developed by the World Health Organization. The Greenland causes of death register has been validated and compared to police records with good agreement, while a more recent study evaluated the usability of the register to be of medium quality based on The Vital Statistics Performance Index for Quality\u0026nbsp;(7, 14-16). Population size was based on information from the Central Population Register and obtained from the statistical databank of Statistics Greenland for 1977-2018 and combined with census data for 1970 and 1976\u0026nbsp;(17-19). The data included 2,265,676 person-years from 1970 until 2018.\u003c/p\u003e\n\u003ch3\u003eMethod of suicide\u003c/h3\u003e\n\u003cp\u003eBased on the ICD-8 and ICD-10 codes method of suicide was categorized into four categories: \u003cem\u003epoisoning\u003c/em\u003e; \u003cem\u003ehanging\u003c/em\u003e, \u003cem\u003estrangulation or suffocation\u003c/em\u003e; \u003cem\u003efirearms or use of explosives\u0026nbsp;\u003c/em\u003eand \u003cem\u003eother\u003c/em\u003e. The category \u003cem\u003eother\u003c/em\u003e includes \u003cem\u003edrowning, cutting or piecing instruments, jumping from high places, other and unspecified means, and late effects of self-inflicted injury\u003c/em\u003e.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eCovariates\u003c/h3\u003e\n\u003cp\u003eTo investigate geographical differences Greenland was divided into five regions based on socioeconomic conditions and remoteness from the capital. Nuuk, the capital, is the largest and wealthiest community with the greatest variety of jobs, shops, and cultural institutions. In 2021 Nuuk had 18,800 inhabitants. The largest communities on the west coast, Maniitsoq and Sisimiut (8,108 inhabitants), are centrally located and in many ways intermediate between Nuuk and the more remote communities on the west coast (20,156 inhabitants), the latter offering fewer jobs, shops, and cultural institutions. The 50 smaller communities (often referred to as villages) on the west coast of Greenland offer few jobs, often only a single shop and rarely any cultural institutions (6,179 inhabitants). The east coast is remote and suffers from a high unemployment rate and many social problems. In East Greenland there are 3,110 inhabitants living in two larger and five smaller communities. Smaller communities are generally defined as having less than 500 inhabitants\u0026nbsp;(17).\u003c/p\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eAnalyses were performed using the statistical software Stata version 17. Rates were calculated by Poisson regression in Stata and by use of Excel. In analyses of the period trends, rates were standardized according to the World Standard Population 2000-2025 (20). In the analyses of suicide rate according to sex and period rates were age adjusted according to the age distribution of the Greenland population in period 2015-2018. \u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the development of the suicide rate from 1970\u0026ndash;2018. From 1970\u0026ndash;1974 the rate was 29 per 100,000 person-years. Over a 15-year period the rate more than quadrupled peaking at 121 per 100,000 person-years in 1985\u0026ndash;1989. The rate started declining from 1990 and in 2015\u0026ndash;2018 the rate was 81 per 100,000 person-years. Among the 1,952 suicides registered from 1970\u0026ndash;2018, 41 suicides were registered in children aged 11\u0026ndash;14 years.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSuicide and suicide rates from 1970 to 2018.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePeriod\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSuicides\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSuicides/year\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSuicide rate per 100000 person-years\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStandardized suicide rates per 100000 person-years \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1970\u0026ndash;1974\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1975\u0026ndash;1979\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e47.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1980\u0026ndash;1984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1985\u0026ndash;1989\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e120.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e99.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1990\u0026ndash;1994\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e101.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e96.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1995\u0026ndash;1999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e102.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e106.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2000\u0026ndash;2004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e47.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e94.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e101.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2005\u0026ndash;2009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e211\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e83.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e84.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2010\u0026ndash;2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e86.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2015\u0026ndash;2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e81.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e80.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1952\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e86.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e86.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e Standardized according to World Standard Population 2000\u0026ndash;2025.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe highest rate was seen in young men aged 20\u0026ndash;24 years with 387 suicides per 100,000 person-years followed by a decline with increasing age. Among women young women aged 15\u0026ndash;19 years had the highest rate of 96 suicides per 100.000 person years (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe rates for both men and women increased until 1985\u0026ndash;1989 whereafter the male rates declined while the female rates increased slowly until 2018 thus decreasing the gender gap (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Figure \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e shows that birth cohorts born after 1960 had the highest suicide rates in the youngest age groups and that youth suicide rates continued to increase with later birth cohorts. The pattern was similar in the youngest birth cohort born in 1990\u0026ndash;1999 but at a lower level compared to previous cohorts born between 1960 and 1989. Regional temporal trends are shown in Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. East Greenland showed the highest rate of around 300 suicides per 100,000 person-years in 1995\u0026ndash;1999. In the capital Nuuk, the rate was at its highest in the 80s followed by a large decrease further increasing the differences in rates in West and East Greenland.\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e show that men mainly used violent methods for suicide with shooting or use of explosives as the most common methods in 1970\u0026ndash;1979 (70%). Across time, suicide by hanging has become the most prevalent method in both sexes accounting for 73% of suicides in men and 76% in women from 2010\u0026ndash;2018. Women had a high proportion of non-violent suicides (poisoning) at the beginning of the study period whereas the more violent methods, predominantly hanging, strangulation or suffocation became more prevalent during the study period increasing by 30%.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe suicide rate in Greenland from 1970 until 2018 differed markedly according to age, birth cohort, period, sex, and place of residence. The suicide rate has been declining since a peak in the 1980s but remains extremely high today. Descriptive analyses point to the decrease in male suicides as the primary factor for the overall decreasing rates but the tendency of increasing rates in women is worrying. Simultaneously, the proportion of women who used a violent suicide method increased from 60% in 1970\u0026ndash;1979 to 90% in 2010\u0026ndash;2018 which in part explains the increase in the suicide rate among women. This is the first study to identify a reducing gender gap in suicide rates among Greenlandic Inuit. As is the case across many Arctic Indigenous peoples the young men have had and continue to have the highest rates, however the authors have no clear indication explaining why rates are decreasing in men and increasing in women (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdverse Childhood Experiences among Arctic Indigenous Peoples\u003c/p\u003e \u003cp\u003eResearch has pointed to the association of adverse childhood experiences (ACEs) and suicidality in Arctic Regions (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). ACEs are stressful and traumatic events such as sexual abuse, domestic violence, and other forms of domestic dysfunction, with potentially serious negative consequences for well-being (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In Western non-indigenous populations ACEs have been associated with a lifetime prevalence for depression of 23% and a population attributable risk fraction of 67% in lifetime risk of suicide attempts (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Having experienced just one ACE increases the lifetime risk of suicide attempt with 80%, while having experienced four or more ACEs is associated with a 12-fold increase (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In Nunavut Canada, where the population is 84% Inuit, a follow-back study indicated that people who died by suicide were more likely to have experienced ACEs (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In Greenland ACEs have been linked to both suicides and suicidal thoughts (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). It is well-documented in Greenland that alcohol problems in the childhood home is associated with being a victim of child sexual abuse. Experiencing alcohol problems often in childhood home and sexual abuse was associated with up to four times higher odds of past year suicidal thoughts according to data from the population health surveys in Greenland (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The latest survey data among youth aged 15\u0026ndash;34 years reported that 41% of the young women were victims of sexual abuse before the age of 18, whereas the corresponding proportion was 12% in young men. The same survey found a cumulative effect between the number of experienced ACEs and prevalence of suicidal thoughts and attempts (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The high prevalence and the type of ACEs in Greenland may contribute to the pathogenesis of suicides: The high proportion of young women exposed to sexual abuse could be a contributing factor of the detected increase in female suicide rates. However, the population health surveys have shown a decrease in ACEs in the youngest birth cohorts compared to birth cohorts born in 1970\u0026ndash;1989 where ACEs were the proportion who experienced ACEs were high (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The latter grew up during the period where the alcohol consumption was at its highest, which is paralleled in the high suicide rates of the birth cohorts from Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. According to the figure, youth suicide began to increase in the generations born during the 1950s and more than quadrupled in the following 10-year birth cohorts after which youth suicide became the most prevalent across all age groups. Based on these observations there is a potential link between alcohol consumption, ACEs, and youth suicide.\u003c/p\u003e \u003cp\u003eIntergenerational trauma\u003c/p\u003e \u003cp\u003eThe trends in suicide rates of birth cohorts are also seen in other Arctic Indigenous peoples and has been interpreted as a sign of cultural cohort effects caused by cultural discontinuities related to colonialization and rapid societal changes (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Problems with alcohol and ACEs does not only severely affect the individuals exposed to them but may have long lasting consequences across generations. Often these are referred to as intergenerational trauma. In the case of many Indigenous Peoples\u0026rsquo;, colonization of Indigenous land and lives, and rapid societal developments caused the onset of trauma and consequently intergenerational trauma (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Intergenerational traumas are mirrored in the prevalence of both alcohol-related problems and ACEs. The prevalence has shifted across time and so has the impact on the generations exposed. Connection to culture has been identified as an important factor fostering resilience and improved mental health among those affected by intergenerational trauma (\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The association between culture and resilience differs across generations: Older generations feel more connected to their cultural heritage enhancing the protective effect, whereas younger generations experience a more distorted cultural connection making them more vulnerable to the ongoing rapid societal transitions compared to the older generations (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGeographical clustering of suicide\u003c/p\u003e \u003cp\u003eWhereas the rate in Nuuk started to decrease during the 1980s the rate in East Greenland continued to increase and stabilized at a very high level of three times the national rate. Similar trends have been seen among young Indigenous men in the Arctic and reflect that a transition towards an urban lifestyle induces an increase in suicide rates: Young men positioned between an urban life and a more traditional way of life are at increased risk indicating that modern living conditions and social determinants might be associated with this tendency (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). East Greenland is the most remote populated area of Greenland with less access to education, social- and health services, welfare, employment, and cultural institutions. The high suicide rate in East Greenland is further related to the high prevalence of social problems and ACEs. Growing up in either a smaller community in West Greenland or in East Greenland is associated with a smaller likelihood of obtaining longer education which in turn affects the individuals\u0026rsquo; capacity to fit into a urbanized society build on western ideals (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Living in smaller communities in West, East or North Greenland is further associated with lower income compared to the income of people living in the capital. In 2014 East Greenland has the highest prevalence of sexual abuse (46%), while violence and problems with alcohol consumption was most prevalent in Nuuk and other larger communities (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The Greenland Police releases a yearly report every year with statistics on \u0026lsquo;sexual relations with children under the age of 15\u0026rsquo;, and here East Greenland and larger peripheral communities have the highest numbers (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Survey data from 2018 among the Greenlandic youth aged 15\u0026ndash;34 years support this clear geographical clustering of ACEs in the Eastern, Northern, and Southern municipalities. Nuuk (Sermersooq West) have the lowest prevalence but overall prevalence of alcohol in childhood home, violence in childhood home, and experience of sexual abuse before the age of 18 are high (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The geographical clustering of high suicide rates and related risk factors point to the need for different approaches in the preventive effort of suicide.\u003c/p\u003e \u003cp\u003eImplications for prevention and health promotion\u003c/p\u003e \u003cp\u003eTemporal trends in the suicide rates are paralleled by trends in ACEs and can be linked to rapid societal developments in the post-colonial area (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Hence the prevention of ACEs would be an important factor in the preventive effort to reduce the number of suicides in Greenland. The regional differences in the suicide rate and prevalence of ACEs should be taken into consideration in the preventive efforts. The findings of this paper underline the need to focus on suicide prevention among youth. Research have shown that there is a particular need to include a broad focus of not only the individual but also their surrounding community and relations (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Culture and relations have been found to prevent youth suicide by providing knowledge and connection to the culture, intergenerational relationships, and role models (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Arctic research is developing a more holistic strength-based approach to suicide prevention focusing on community strengths and protective factors fostering thriving communities (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Prevention should be culturally relevant, community-based, and include individual, family, social, historical, cultural, and environmental factors that constitute the base of the \u0026lsquo;iceberg\u0026rsquo; of which suicide would figure as part of the visible tip above water (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). In Greenland, land-based and intergenerational interventions for mental health among youth are being conducted and monitored. The Greenlandic Government is currently working on a new suicide prevention strategy expected to launch in the fall of 2022. This strategy is based on input from experts and local knowledge and includes perspectives from youth.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAcross a 50-year period the suicide rate has increased drastically in Greenland mirroring a rapid societal transition in the post-colonial period. The rate has slowly declined from the peak in the 1980s but remains at a very high level. Young people, and especially young men, are at risk but the steady increase in the rate in women is worrying. This can in part be explained by the fact that there has been an increase in the proportion of violent suicide methods among women increasing the lethality. Research points to the importance of ACEs in relation to suicide risk and the high prevalences of ACEs among women may contribute to the explanation of the decreasing gender gap but there is a need to investigate this further. Youth suicide increased with later birth cohorts born after 1949. The youngest birth cohort still exhibited the pattern of high youth suicide rates but at a lower level compared to older generations. These findings coincide with a decrease in ACEs and urbanization which authors believe is reflected in the rates overall and the development of geographical clustering of the highest rates. These factors must be taken into consideration in the preventive work along with a strong focus on the community and protective factors that increases intergenerational bonds and cultural connectedness. Such important factors may heal intergenerational trauma and enhance a feeling of cultural identity creating a strong foundation for youth and foster thriving communities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACEs: Adverse childhood experiences\u003c/p\u003e\n\u003cp\u003eICD: International Classification of Diseases\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eAll research methods were carried out in accordance with guidelines and regulations of the Helsinki declaration. Data are personal data and was anonymized and handled according to the General Data Protection Regulation. In Denmark and Greenland register data are available for research without the need to collect any form of consent from participants according to the Danish Data Protection Act §10 and the General Data Protection Regulation art. 6(1)(e) (Voigt and Von dem Bussche, 2017). The study is part of a Ph.D. project and was approved by two institutional boards in Greenland and in Denmark. In Greenland, the project has been approved by the Committee of Research Ethics in Greenland (KVUG 2018-16). In Denmark, the study is approved by the legal services of the University of Southern Denmark, notification number 11.266.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eData on population size are available from Statistics Greenlands homepage, https://bank.stat.gl/pxweb/en/Greenland/.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Greenland register of causes of death is not publicly available. Researchers can apply for access to anonymized data via The Chief Medical Office: www.nun.gl.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThe study was financed as a part of a PhD project by Ministry of Education and Research - Danish State Funds for Arctic Research and a faculty scholarship by the University of Southern Denmark. The funding bodies played no role in the study design, data collection, analyses, interpretation or writing of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAuthors’ contributions\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eIKS developed the study design together with CLL, PB and JST. JST and PB created datasets and IKS did the analyses. IKS wrote the manuscript and CLL, PB, JST and AC commented and added to the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eAuthors would like to thank The Chief Medical Officer of Greenland and Statistics Greenland for their support with the registers.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAuthors’ information\u003c/h3\u003e\n\u003cp\u003eThe main author, Ivalu Katajavaara Seidler, is of Greenland Inuit heritage and has been working with Greenlandic health research since 2018. More specifically her research topics include youth, mental health and alcohol consumption. Ivalu has a master’s degree in Public Health Science and is part of the Centre for Public Health in Greenland. The study in question is the first part of her Ph.D. project entitled ‘Patterns for suicides in Greenland – Risk and protective factors with a particular focus on Adverse Childhood Experiences’.\u003c/p\u003e\n\u003cp\u003eJanne Tolstrup is a professor of epidemiology and is working in the field of public health especially focusing on the significance of alcohol intake and alcohol problems for somatic and psychiatric diseases. The preferred choice of methodology is to use a combination of data from large population-based studies and national registers. She is also running several intervention studies and is the author of more than 140 scientific papers.\u003c/p\u003e\n\u003cp\u003ePeter Bjerregaard is a Professor of Arctic Health and has authored of more than 330 articles in peer reviewed journals, monographs, books, book chapters and research reports, predominantly on circumpolar epidemiology and community health. He is part of the of the Centre for Public Health in Greenland.\u003c/p\u003e\n\u003cp\u003eDr. Allisson Crawford is a psychiatrist and Associate Professor in the Department of Psychiatry, University of Toronto, where she is the Medical Director of the Northern Psychiatric Outreach Program and Telepsychiatry at the Centre for Addiction and Mental Health. Allison has worked as a psychiatrist in Nunavut for over 10 years and coordinates psychiatric services for the Government of Nunavut.\u003c/p\u003e\n\u003cp\u003eProfessor Christina Larsen is a sociologist by training (University of Copenhagen, 2006) and completed her PhD in Public Health (University of Southern Denmark, 2014). She is the research director of the Centre for Public Health in Greenland (based in Copenhagen) and responsible for the research-based consultancy for the Greenland Ministry of Health (Government of Greenland). In 2020-2022 Christina is part of the Lancet Commission on Arctic Health.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBjerregaard P, Larsen CVL. Health Aspects of Colonization and the Post-Colonial Period in Greenland 1721 to 2014. J North Stud. 2016;10(2):85\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBjerregaard P, Larsen CVL. Three lifestyle-related issues of major significance for public health among the Inuit in contemporary Greenland: a review of adverse childhood conditions, obesity, and smoking in a period of social transition. Public Health Rev. 2018;39:5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePollock NJ, Apok C, Concepcion T, Delgado RA Jr, Rasmus S, Chatwood S, et al. Global goals and suicide prevention in the Circumpolar North. Indian J Psychiatry. 2020;62(1):7\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Preventing Suicide: A Global Imperative. Luxembourg: World Health Organization; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBertelsen A. Gr\u0026oslash;nlandsk medicinsk Statistik og Nosografi. I. Gr\u0026oslash;nlands Befolkningsstatistik 1901-30 (Greenland medical statistics and nosography. I. Population statistics 1901-30). [In Danish]. 1935.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChief Medical Officer. Annual report. Nuuk Chief Medical Officer; 1951\u0026ndash;1970.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBjerregaard P, Larsen CVL. Time trend by region of suicides and suicidal thoughts among Greenland Inuit. 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Accessed 11 May 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWexler L, Silveira ML, Bertone-Johnson E. Factors associated with Alaska Native fatal and nonfatal suicidal behaviors 2001\u0026ndash;2009: trends and implications for prevention. Arch Suicide Res. 2012;16(4):273\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChachamovich E, Kirmayer LJ, Haggarty JM, Cargo M, McCormick R, Turecki G. Suicide among Inuit: Results from a Large, Epidemiologically Representative Follow-Back Study in Nunavut. Can J Psychiatry. 2015;60(6):268\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrawford A, Hicks J. Early childhood adversity as a key mechanism by which colonialism is mediated into suicidal behaviour. North Public Aff. 2018(March):18\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord. 2004;82(2):217\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA. 2001;286(24):3089\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFelitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindholm J, Pleisner JJ. 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Copenhagen: National Institute of Public Health, University of Southern Denmark; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHicks J. The social determinants of elevated rates of suicide among Inuit youth. Indigenous Affairs. 2007;4(2007):30 \u0026ndash; 7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWexler L. Looking across three generations of Alaska Natives to explore how culture fosters indigenous resilience. Transcult Psychiatry. 2013;51(1):73\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRedvers J, Bjerregaard P, Eriksen H, Fanian S, Healey G, Hiratsuka V, et al. A scoping review of Indigenous suicide prevention in circumpolar regions. Int J Circumpolar Health. 2015;74(1):27509.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacDonald JP, Ford JD, Willox AC, Ross NA. A review of protective factors and causal mechanisms that enhance the mental health of Indigenous Circumpolar youth. Int J Circumpolar Health. 2013;72:21775.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIngemann C, Larsen CVL. Well-being among indigenous children and youth in the Arctic\u0026ndash;with a focus on Sami and Greenland Inuit: A scoping review. Copenhagen: Nordic Council of Ministers, Nordic Council of Ministers Secretariat; 2018. p.\u0026nbsp;9289353856. Report No..\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahl-Petersen I, Larsen C, Nielsen N, J\u0026oslash;rgensen M, Bjerregaard P. Befolkningsunders\u0026oslash;gelsen i Gr\u0026oslash;nland 2014. Levevilk\u0026aring;r, livsstil og helbred. (Population Health Survey in Greenland 2014. Living conditions, lifestyle, and health.) [In Danish and Greenlandic]. Copenhagen: National Institute of Public Health; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGr\u0026oslash;nlands Politi. \u0026Aring;rsstatistik (Yearly statistics.) [In Danish]. Nuuk. Greenland: Gr\u0026oslash;nlands Politi; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCueva K, Rink E, Lavoie JG, Healey Akearok G, Guistini S, Kanayurak N, et al. From Resilient to Thriving: Policy Recommendations to Support Health and Well-being in the Arctic. Arctic. 2022;74(4):550\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePollock NJ, Healey GK, Jong M, Valcour JE, Mulay S. Tracking progress in suicide prevention in Indigenous communities: a challenge for public health surveillance in Canada. BMC Public Health. 2018;18(1):1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinlay S, Wenitong M. Aboriginal Community Controlled Health Organisations are taking a leading role in COVID-19 health communication. Aust N Z J Public Health. 2020;44(4):251\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCueva K, Rink E, Lavoie JG, Stoor JPA, Healey Akearok G, Gladun E, et al. Diving below the surface: A framework for arctic health research to support thriving communities. Scand J Public Health. 2021:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Suicide, Time trends, Inuit, Greenland, Register","lastPublishedDoi":"10.21203/rs.3.rs-2141882/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2141882/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch3\u003eBackground\u003c/h3\u003e\n\u003cp\u003eBetween 1980 and 2018 Greenland has had one of the highest suicide rates in the world with an average rate of 96 suicides per 100.000 person-years. The aim of this study is to investigate suicide rates in Greenland according to age, birth cohort, period, sex, place of residence and suicide method from 1970 until 2018.\u003c/p\u003e\n\u003ch3\u003eMethods\u003c/h3\u003e\n\u003cp\u003eSuicide rates were examined using register and census data from 1970-2018 among Greenland Inuit. Rates were calculated by Poisson regression in Stata and by use of Excel. In analyses of the period trends, rates were standardized according to the World Standard Population 2000-2025.\u003c/p\u003e\n\u003ch3\u003eResults\u003c/h3\u003e\n\u003cp\u003eThe suicide rate has been declining since a peak at 120 suicides per 100,000 person-years in the 1980s but remained high at a rate of 81.3 suicides per 100,000 person-years from 2015-2018. Descriptive analyses point to the decrease in male suicides as the primary factor for the overall decreasing rates while the rate among women has been increasing. Simultaneously, the proportion of women who used a violent suicide method increased from 60% in 1970-1979 to 90% in 2010-2018. The highest rates are seen among young people, especially young men aged 20-24 years and youth suicide rates increased with later birth cohorts. When the rates started to increase in the 1908s both the capital Nuuk and East Greenland had the highest rates. Since then, the rate in Nuuk has declined while the rate in East Greenland was three times the national rate from 2015-2018.\u003c/p\u003e\n\u003ch3\u003eConclusions\u003c/h3\u003e\n\u003cp\u003eAcross a 50-year period the suicide rate has increased drastically in Greenland mirroring a rapid societal transition in the post-colonial period. The rate has slowly declined from the peak in the 1980s but remains at a very high level. Young people in general are at risk, but the steady increase in the rate among women is worrying. Research points to the importance of adverse childhood experiences in relation to suicide risk and the high prevalences of these adversities among women may contribute to the explanation of the decreasing gender gap, however there is a need to investigate this further.\u003c/p\u003e","manuscriptTitle":"Time trends and geographical clusters in suicide among Greenland Inuit","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-09 20:46:36","doi":"10.21203/rs.3.rs-2141882/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-01-27T09:10:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-12-12T23:32:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b93157f3-ca7d-4c75-85d5-e31ca5a504d5","date":"2022-12-04T19:11:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"844fd47a-a962-4498-96ad-c671b6254190","date":"2022-12-01T22:30:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-12-01T06:00:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-12-01T05:50:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-11-07T20:19:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-11-07T19:52:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2022-10-07T11:05:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f7e7e92f-068a-4cb7-aec8-5b63905b5c3e","owner":[],"postedDate":"November 9th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:15:17+00:00","versionOfRecord":{"articleIdentity":"rs-2141882","link":"https://doi.org/10.1186/s12888-023-04675-2","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2023-03-21 20:08:14","publishedOnDateReadable":"March 21st, 2023"},"versionCreatedAt":"2022-11-09 20:46:36","video":"","vorDoi":"10.1186/s12888-023-04675-2","vorDoiUrl":"https://doi.org/10.1186/s12888-023-04675-2","workflowStages":[]},"version":"v1","identity":"rs-2141882","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2141882","identity":"rs-2141882","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}