Table 2.

Important findings and information regarding suicide in the Pacific Islands.

Author(s), year	Suicide rates	Risk groups/ risk factors	Suicide methods	Other important information	Limitations	Quality
Booth, 1999a [3]	Rates per 100,000: Fiji (ASR P: 19 M: 22 F: 15; CR P: 17 M: 19 F: 14), Vanuatu (CR: P: 3 M: 3 F: 3), 'Micronesia(1960-87)' (ASR T: 20 M: 36 F: 3; CR T: 18 M: 33 F: 3), Federated States of Micronesia (CR P: 31), Marshall Islands (1988-1992 CR T: 26; 1992-1993 CR T: 16 M: 29 F: 2), Tonga (CR T: 1 M: 2 F: <1), Western Samoa (ASR T: 34 M: 49 F: 18; CR T: 31 M: 41 F: 21), American Samoa (CR T: 18 M: 34 F: 0), New Caledonia (CR P:10, M: 17, F: 2), Papua New Guinea (1990: CR: <1, unreliable data), French Polynesia (1988-1992, ASR T: 9, M: 12, F: 5, CR T: 9 M: 12, F: 5), Guam (1988-1992 ASR P: 15, M: 24, F: 4, CR P:16, M:27, F: 4); Northern Marianna Islands 1990-1992 CR P: 13, M: 22, F: 3; Palau 1988-92 C P: 29.	Male youth in all countries, female youth in Indian-Fijians and Western Samoa.	The predominant method was hanging (60% and 73% in Indian-Fijians, >80% in Micronesia, 79% in French Polynesia), except for Western Samoa where paraquat (pesticide) predominates (74-82%)	For Fiji, Tonga and Western Samoa suicide attempt information were available, however, data was used only to calculate the fatality rate.	Pacific data on suicide vary in completeness and quality (see further details/reasons p 434), ASRs only for selected countries.	13 (Medium)
Booth, 1999b [55]	Female youth suicide rate: 70 per 100,000 in 1981. Indian-Fijians: 60 per 100,000. For males, youth rates of 64 among Western Samoans and 57 among Indian-Fijians.	Higher in females in these two populations. Female youth account for a greater number of suicides than male youth in both populations.	Predominant method hanging (60% % 73%) for Indian-Fijians. Predominant method paraquat (pesiticide) (82% and 73%) for Western Samoans.	Crude rates reported in graph: Indian-Fijians and Western Samoans, female age pattern peaks at younger age than males. For Western Samoans, the female rate exceeds the male rate at age 20-24. For Indian-Fijians, the female suicide rate was slightly higher than the male rate at 15-24.	Relative suicide rates used for internal comparison. The sum of male and female rates is 100 and are not comparable between populations. Data from drowning were omitted due to uncertainty of intent. The data for 1989-1990 are unpublished and also omit some months are thus incomplete. Data from 1988-1991 cover only deaths in hospital (including dead on arrival) and are also incomplete. The incomplete data are only used for internal comparison.	8 (Low)
Booth, 2010 [6]	Suicide rates increased rapidly in 1990s. ASR: Males - 1978-1982: 35; 1988-1992 - 75; 1998-2002 - 100; 2002-2006: 70; Females: 1978-1982: 32; 1988-1992 - 58; 1998-2002 - 100; 2002-2006: 62.	Youth - 19% of male suicides aged <20 (mode) and 59% aged <30. In females, 25% of suicides occurring in aged <20 (mode) and 54% aged <30.	NR	Several potential factors increasing suicide were hypothesised, including militarisation, loss of land, threats to loss of language and culture, migration, urbanisation, rapid economic growth, tourism and suicide contagion.	Different ICD classification used over years. Population data for rates were available for limited years.	14 (Medium)
Bridges, 2008 [4]	ASRs per 100,000: Cook Islands 4.6, Federated States of Micronesia 5.0, Fiji Islands 4.1, Marshall Islands 7.4, Nauru 4.1, Niue 4.4, Palau 5.6, Papua New Guinea 12.4, Western Samoa 5.4, Solomon Islands 4.7, Tonga 4.6, Tuvalu 7.9, Vanuatu 5.1.	NR	NR	A positive correlation between suicide rates and population growth was reported. No association between suicide rates and population size or population density.	WHO data with varying quality	11 (Low)
De Leo et al., 2013 [24]	NR as differing years.	Males (e.g., 19:1 in Tonga and 8:1 in Guam) and youth (e.g., a median age of 22 in Tonga, 27 in Guam).	The predominant method is hanging (over 70% in males and females, except females in Guam and Tongan - 57.1% and 50%)	Several other areas could contribute data only for either fatal or NFSB, rather than both.	Very small numbers for Vanuatu (n=2), likely to underreport.	16 (Medium)
Goodfellow et al., 2020 [49]	NA	Indigenous Kanak were over-represented in suicide deaths, suicide ratio by gender was 1.7 men to women, 62% had at least one mental disorder (major depression and alcohol/other substance use disorders being the most common), and serious relationship difficulties were common preceding death.	NR	Recall bias, emotional and interviewer bias.	Small sample	18 (High)
Haynes, 1984 [37]	Annual rates per 100,000 in Fiji (total): Indian-Fijian males - n = 78, rate = 45.2; Fijian males - n = 14, rate= 9.2; Indian-Fijian females - n = 57, rate = 33.1; Fijian females n = 14, rate = 9.3. In Macuata, 1979-1982: Indian-Fijian males n = 29, rate = 61.0; Fijian males n = 2, rate= 11.6; Indian-Fijian females n = 34, 71.9; Fijian females - 0.	Indian-Fijian women under 30 (vs Indian-Fijian men under 30); Indian-Fijian men over 30 (vs women over 30). Higher rates among Indian-Fijians in Macuata vs. Indian-Fijians in Fiji. Indian-Fijians account for 90% of all suicides - 100% of females and 91% of males. Suicides rarely recorded in Bua and Cakaudrove populations. 69% of cases in Fiji aged < 30. Hindus (vs. Muslims): ratios of 14:1 in males and 8:1 in females.	Predominant method hanging - 60% of male cases and 77% of female cases.	NA	Small area analysis mainly, police data	16 (High)
Herman et al., 2016 [46]	Fatal self-harm was present in 35 cases of hospitalisation (55.6% of all cases in the year), of which 6 were Indigenous Fijians, and 26 were Indian-Fijians	Men and women of Indian ethnicity	NR	NA	Unclear what methods were used for self-harm, specifically	15 (Medium)
Lowe, 2019 [7]	The Ten-year average suicide rate was 18.8 per 100,000 - 32.8 in urban municipalities, 23.2 in near urban, and 13.2 in outer atolls (these differences were significant).	Urbanisation, disintegration, and incongruity between modern economic resources and achieved modern material lifestyle were linked to increase the risk of suicide in the community level.	NR	NA	Ecological study - subject to ecological fallacy. Overall models only accounted for a small amount of the variance, and models did not include other important variables (e.g., mental health).	17 (High)
Peiris-John et al., 2013 [39]	The annual crude rate of fatal intentional poisonings was 2.3 per 100,000.	Indian ethnicity and those aged 15-29.	Out of 1/3 of documented substances, 41.2% were chemicals (e.g., kerosene), 35.3% drugs and 23.5% pesticides	Out of all poisoning fatalities, 76% were of Indian ethnicity, 53% were male, and 70% were aged 15-29 years old	Only poisoning cases over one year, substances involved recorded only in 1/3 of cases, of the 17 fatalities, one was deemed unintentional, and rates should be interpreted accordingly.	17 (High)
Price & Karim, 1975 [40]	An annual crude rate of 8.4 per 100,000 (M: 8.7 F: 8.2) (90 suicides over the study period).	Of the 90 cases reported, 82 (91.1%) occurred in Indian-Fijians. Indian-Fijian females were slightly higher than Indian-Fijian males. Rural residence and Hinduism faith.	Predominant method hanging (100% in females, 91.6% in males)	Only 7.8% (n=7) received psychiatric treatment, with the next of kin information revealing that 40% had a diagnosed or suspected mental illness. Suicide rates for the Indian-Fijian subpopulation are higher for females in younger age groups (15-44) and males in older age groups (45 and over).	The crude rate for two years. It is likely an underestimate as it includes only those in which the ascertainment of suicide seemed to be in no doubt (e.g., excluding drowning).	9 (Low)
Pridmore, 1997 [52]	An annual crude suicide rate of 3.9 per 100,000 in a population of 75,000 (13 suicides over the study period).	Females accounted for 62% of suicides.	Chloroquine (n=9), M: 33%, F: 67% Hanging (n=4), M: 50%, F: 50%	The Central Hospital serves the 75,000 people living in Honiara and to the east and west, along the northern coast.	Possibility of missing cases (those not hospitalised), particularly in more isolated areas; crude rate.	12 (Low)
Pridmore et al., 1996 [41]	An annual crude rate 8.87 per 100,000 (304 autopsies over the study period).	Indian Fijians - 19.5 per 100,000 compared to 1.53 per 100,000 for Indigenous Fijians. The Difference rate of autopsies between regions and sexes not significant.	The predominant method was hanging (6.09 autopsies per 100,000), followed by poisoning (2.78 per 100,000).	NA	Coverage of 2 out of 3 pathology departments in Fiji (exact population of their coverage not provided). Crude rates only. It did not include burning, drowning and motor vehicle accidents. The Eastern Division is the most traditional; it has a small population (46 652) and no pathology department and cannot be examined separately.	12 (Low)
Pridmore et al., 1995 [42]	An annual crude rate 1.5 (1.3- 1.7); the suicide rate rose from 0.2 (0.1-0.4) in 1969-1979 to 2.6 (2.2-2.9) in 1980-1989. The two epoch ratio (%) was 1100 (630-1800): a 1000% increase, which was statistically significant.	Indian Fijians (> 6 times the rate of Indigenous Fijians); females (1.7 times the rate of males).	NA	Subgroup data by ethnicity and sex provided for violence by self (AKA suicide and self-inflicted injury - includes fatal and non-fatal).	Crude rate - no data by age groups. Authors assumed that sex distribution in the population was 50:50.	12 (Low)
Ree, 1971 [43]	An annual crude rate 25.8 per 100,000 (73 recorded suicides over the study period), the majority were hanging (70, 95.9%); two shootings and one drowning. The Indian-Fijian suicide rate was 33.4, and the Fijian suicide rate was 5.7.	Indian-Fijians (vs Fijians), and rates higher overall in Indian-Fijian females than males, particularly in young Indian-Fijian females.	The predominant method was hanging (70 of 73, 95.9%).	No deaths in the urban area of Macuata.	Crude rate over eight years.	9 (Low)
Rubinstein, 1983 [51]	Suicide rates were calculated in 4 year sequences (the population figure from the midpoint of the sequence was used). Annual suicide rates per 100,000 for males had 8-fold rise: 1960-63 - 6.4 (n=9); 1964-1967 - 10.25 (n=16); 1968-1971 - 22.2 (n=39); 1972-1975 - 42.4 (n=84); 1976-1979 - 49.5 (n=110); for females: 1960-63 - 0; 1964-1967 - 1.2 (n=2); 1968-1971 - 1.2 (n=2); 1972-1975 - 2.0 (n=4); 1976-1979 - 4.5 (n=10).	Adolescent males aged 15-24 years old (altogether accounting for >50%). Overall, male: female ratio is 16:1.	NA	Independence after the study: the Republic of Palau in 1981; The Federated States of Micronesia in 1986; the Marshall Islands formal in 1990. Includes extra information from about 250 semi-structured interviews modelled on the ‘psychological autopsy’ protocol conducted with friends and relatives of suicide victims throughout Micronesia. Indication to contagion.	Annual rates, over 20 years, age-specific rates over five years. Likely to have severe recall bias as going back over 20 years with psychological autopsy.	16 (Medium)
Tavite & Tavite, 2009 [53]	Six suicides in a small population of 1,500 from 1980-2004 (as per official records).	Youths (14-25 years old), accounted for 83% of fatalities. No gender difference (1:1). Most (67%) fatal cases occurred in Fakaofo and none in Nukunonu.	The predominant method was hanging (83%).	NA	Very little information available from hospital records and only accounted for suicidal cases that needed medical attention. Members of the public were aware of several other cases that were not recorded.	12 (Low)
Wainiqolo et al., 2012 [45]	An annual crude rate 12.0 per 100,000 (95% CI = 9.3-14.6) (78 cases over the study period, 32% of all admissions).	The indian-Fijians self-inflicted injury death rate was almost ten times higher than Indigenous Fijians.	NR	The study does focus more widely on injuries, not specific to suicidal behaviour.	The crude rate for one year based on small numbers.	15 (Medium)

Note: ASR = age standardised rate; CR = crude rate; NA = not applicable; NR = not reported; WHO = World Health Organization; 95%CI = 95% confidence interval; F = female; M = male