Meda Nicola, Angelozzi Ludovica, Poletto Matteo, Patane' Angelo, Zammarrelli Josephine, Slongo Irene, Sambataro Fabio, De Leo Diego
Department of Neuroscience, University of Padova, Padova, Italy.
De Leo Fund, Padova, Italy.
Front Psychiatry. 2025 Aug 12;16:1609580. doi: 10.3389/fpsyt.2025.1609580. eCollection 2025.
Suicide underreporting undermines accurate public health assessments and resource allocation for suicide prevention. This study aims at synthesizing evidence on suicide underreporting and to estimate a global underreporting rate.
We conducted a PRISMA-compliant systematic review on suicide underreporting, following a pre-registered protocol. A meta-analytical synthesis was also conducted. Quantitative data from individual studies was extracted to provide an overall global estimate of suicide underreporting (42 studies covering 71 countries out of the initial 770 unique studies, spanning 1900-2021). Most studies used retrospective institutional datasets to estimate underreporting through reclassification of undetermined deaths or comparisons across databases. Demographic and geographic disparities were also examined.
The 42 studies selected provided some quantitative data on suicide underreporting for general or specific populations. 14 of these studies provided data to be meta-analyzed. The global suicide underreporting rate was estimated to be 17.9% (95% CI: 10.9-28.1%) with large differences between countries with high and low/very low data quality. In this scenario, the last WHO estimates of suicide deaths - corrected for underreporting - would be more than one million (1,000,638; 95% CI: 859,511-1,293,006) and not 727,000 suicides per year. Underreporting was higher in low- and middle-income countries (LMICs) with incomplete death registration systems, such as India and China (34.9%; 95% CI 20.3-53%), while high-income countries exhibited lower rates (11.5%; 95% CI 6.6-19.3%). Contributing factors included stigma, religiosity, limited forensic resources, and inconsistent use of International Classification of Diseases (ICD) codes. Gender and age disparities were notable; Female suicides and those among younger or older individuals were more likely to be misclassified.
Addressing suicide underreporting requires improving death registration systems globally, particularly in LMICs. Standardizing ICD usage, improving forensic capacity, and reducing stigma are critical steps to ensure accurate data. Heterogeneity, geographical disparities, temporal biases, and invariance of suicide underreporting for countries with low-quality data demand further corroboration of these findings.
自杀报告不足会影响对公共卫生的准确评估以及自杀预防资源的分配。本研究旨在综合关于自杀报告不足的证据，并估算全球报告不足率。
我们按照预先注册的方案，对自杀报告不足情况进行了一项符合PRISMA标准的系统评价。还进行了荟萃分析。从各项研究中提取定量数据，以提供全球自杀报告不足情况的总体估算（最初的770项独立研究中有42项研究涵盖71个国家，时间跨度为1900 - 2021年）。大多数研究使用回顾性机构数据集，通过对未确定死亡进行重新分类或跨数据库比较来估算报告不足情况。还研究了人口统计学和地理差异。
所选的42项研究提供了一些关于一般人群或特定人群自杀报告不足的定量数据。其中14项研究提供了可进行荟萃分析的数据。全球自杀报告不足率估计为17.9%（95%置信区间：10.9 - 28.1%），数据质量高和低/极低的国家之间存在很大差异。在这种情况下，世界卫生组织对自杀死亡人数的最新估计——校正报告不足情况后——将超过100万（1,000,638；95%置信区间：859,511 - 1,293,006），而不是每年72.7万例自杀。在死亡登记系统不完整的低收入和中等收入国家（如印度和中国），报告不足情况更高（34.9%；95%置信区间20.3 - 53%），而高收入国家的报告不足率较低（11.5%；95%置信区间6.6 - 19.3%）。促成因素包括耻辱感、宗教信仰、法医资源有限以及国际疾病分类（ICD）编码使用不一致。性别和年龄差异显著；女性自杀以及年轻或年长个体的自杀更有可能被错误分类。
解决自杀报告不足问题需要改善全球的死亡登记系统，特别是在低收入和中等收入国家。标准化ICD的使用、提高法医能力以及减少耻辱感是确保数据准确的关键步骤。异质性、地理差异、时间偏差以及低质量数据国家自杀报告不足情况的不变性需要进一步证实这些发现。
