Artigos

Introduction
The political approach to suicide has gained increasing importance worldwide, given that it represents a fatal outcome of mental health conditions (1), considering the increasing global burden of morbidity associated with mental disorders (2).
The relationship between mental disorders and specific causes of mortality is complex, as most individuals with mental disorders do not die directly from their psychiatric condition. Instead, they often die from infections, cardiovascular disease, other chronic illnesses such as cancer, and, notably, from suicide (3).
The close association between suicide risk and the presence of mental disorders has been well documented in the scientific literature (3,4). Studies have shown that the risk is particularly high in conditions associated with affective disorders and schizophrenia (5,6). In high-income countries, up to 80% of suicide cases are associated with mental disorder or substance use, whereas in low-income countries, this association is observed in approximately 70% of cases (7).
At the international level (1990–2016), Europe reported the highest suicide mortality rate (27,5 per 100.000 inhabitants), whereas the Central Latin America region (which includes Colombia) recorded rates below 6.4 per 100.000. Within this region, Guyana, Suriname, Nicaragua, El Salvador, Chile, and Ecuador reported the highest suicide mortality rates among young people(8). Regarding sex (9,10), the Age-Standardized Mortality Rate (ASMR) has been higher in men (15,6 per 100.000 inhabitants) compared to women (7,0 per 100.000 inhabitants), a trend that mirrors findings observed in most countries across other regions of the world (10,11).
As a result, interest in suicide prevention has grown since the early 21st century due to the significant number of lives it claims each year (9). It has been declared a priority public health issue and included as an indicator in the Sustainable Development Goals (under Goal 3), with a target of reducing suicide mortality by one third (12). Using 2015 as a reference, the rate was 7,7 suicides per 100,000 inhabitants (13). Additionally, the World Health Organization (WHO) prioritizes suicide prevention within global health goals, as part of the Comprehensive Mental Health Action Plan (2013–2030). Since 2012, member countries have been encouraged to reduce global suicide mortality by 10% (14).
Traditionally, the risk of suicide has been directly associated with individual factors such as interpersonal stress and mental disorders, primarily depression(10). In a similar way, studies have suggested that the prevalence of mental disorders varies by geographic area (15). This variation is influenced by factors specific to each region, such as socioeconomic characteristics, the availability of mental health services, physical and social isolation, and access to highly lethal means, such as firearms and pesticides (15,16). These factors may contribute to the differences in mortality rates between urban and rural areas.
Demographic indicators from the 2021 Census data shows that Colombia exhibits significant regional demographic diversity, with crude birth rates ranging from 11,73 per 1.000 inhabitants in Quindío to 32,22 in Vaupés, and fertility rates from 1,46 in Bogotá to 4,78 in Vaupés (17). These differences reflect deep contrasts in social and health dynamics. Income inequality also varies notably across departments. A study by the Universidad Nacional de Colombia, using Theil and Gini indices, demonstrated marked disparities in income distribution, shaped by regional economic characteristics (18). In addition, research from the Universidad de Antioquia highlighted that Córdoba and Bolívar exhibited lower levels of social wellbeing during the COVID-19 pandemic, while Bogotá, Antioquia, and Caldas showed higher resilience (19).
Determining the causes associated with suicidal behavior is challenging, as it is a multifactorial phenomenon(9,20). It involves, on one hand, structural determinants such as gender, socioeconomic status, area of residence, and public policies, and on the other hand, intermediary determinants such as biological, psychosocial, and environmental factors, as well as the healthcare system(21,22).
The above description aligns with the perspective of the Social Determinants of Mental Health (SDMH), which posits that this phenomenon involves individual, biological, and contextual factors (21) Thus, suicide is framed as a fatal and multidimensional outcome in mental health (23), reinforcing the trend toward epidemiological analysis of geographic variations in suicide mortality. However, the findings are not universal, and contradictory conclusions have emerged (16,24). On one hand, some studies have observed significantly higher suicide rates in urban areas compared to rural ones; on the other hand, other studies have reported the opposite, while some have found no, differences at all (25).
Given the international focus on suicide prevention, it is essential to assess the levels and geographic trends of suicide mortality, considering variations across areas and regions within each country, as well as by age and sex. This study aims to quantitatively describe sociodemographic patterns in suicide mortality by age group, sex, department, and area of residence in an upper-middle-income country.

Material and Methods
Geographical context: Colombia is an upper-middle-income country located in South America. The country's population increased by 21,59% during the study period (1990–2019), going from 38.088.000 to 46.314.000 inhabitants(26).
Colombia is divided into 32 departments and one capital district, organized into six natural regions: Andean, Caribbean, Pacific, Orinoquia, Amazon, and Insular. Although this constitutes the official geographic division, the territorial context is considerably more complex (27).
In regions such as the Amazon (Amazonas, Vaupés, and Guainía) and the Orinoquia (Vichada, Arauca, Meta), population density is very low, and state presence is limited. Much of these territories is occupied by Indigenous reserves, which possess autonomy and self-government(28).
In contrast, the Pacific region (Chocó, Cauca, and Nariño) has also been heavily affected by the armed conflict, characterized by a convergence of state neglect, illegal economies, and significant ethnic diversity(28).
Thus, Colombia’s political-administrative division coexists with a reality shaped by territorial inequality, multiculturalism, and conflict, posing major challenges for peace and development.
Study population (deaths): A total of 23.895 deaths (1990–2019) were included, considering the tenth revision of the International Classification of Diseases (ICD 10) and selecting intentional self-inflicted injuries (suicides) and sequelae (codes X60 to X84 and Y87.0).
The data used come from national mortality registries, obtained from the official mortality registries (National Administrative Department of Statistics or DANE). The data was downloaded in August 2022 (29).
Variables: For the descriptive analysis, data from four sociodemographic variables (sex, age group, department, and area of residence) were considered.
Age was grouped into four categories: adolescent (15–24 years old), young adult (25–44 years old), middle-aged adult (45–64 years old), and older adult (65 years old and older). The lower age limit was considered, taking the worldwide scientific literature (9, 30,31).
Data analysis:
Frequencies were calculated by sex, age group, area of residence, and departments, according to the classification of the National Planning Department of Colombia (DNP).
We employed the WHO direct method (32) to calculate and analyze the Age-Standardized Mortality Rate (ASMR). This metric adjusts crude mortality rates to account for variations in age distribution across different populations, thereby facilitating valid comparisons. The ASMR represents the mortality rate that would have been observed in a study population if it had the same age structure as a standard reference population.
To calculate the rate ratios (RR), a Poisson regression model was developed, where the dependent variable was constructed from the modeling of the mortality rate by age group and area of occurrence (as the numerator), and the exposure (denominators) was the population of Colombia according to the groupings above. The covariates were age group and area of residence for each of the models.
Finally, georeferencing was carried out to describe the behavior and possible differences in mortality rates according to their geographical distribution(33). ASMR were plotted by department (identification and coordinates by municipality), sex, and area of residence, and the map of Colombia with its political-administrative division was used through the DANE geoportal (29)ASMR intervals were calculated using the box plot method, which consists of the distribution of the variable attribute in six intervals defined as follows: [min, p25 – 1,5*iqr], (p25 – 1,5*iqr, p25], (p25, p50], (p50, p75], (p75, p75 + 1,5*iqr] and (p75 + 1,5*iqr), max.], where iqr = interquartile range.
All calculations and statistical analysis were performed in Stata version 14, with a statistical significance level of p < 0,01.
Limitations: The limitations of this study are primarily related to potential underreporting, hypothetically associated with the social stigma surrounding suicide in a country like Colombia. This may lead to challenges in case detection and reporting. Nevertheless, the use of mortality data recorded by DANE ensures that the analysis is based on reliable information, as this institution is the sole body responsible for consolidating cases with an officially confirmed cause of death.
Finally, the absence of data corresponding to the denominators of key variables for the analysis (such as educational level, marital status, and health insurance affiliation) necessitated the omission of certain calculations.

Results
Table 1, describes the period evaluated (1990–2019), in which 57,161 deaths by suicide were reported in people over 15 years of age. Eighty percent were men (n = 45.803), and the remaining 20% corresponded to women (n = 11.358).
Regarding age behavior, the distribution of males presented higher proportions for young adults (25–44 years) with 40% (n = 18.226), followed by adolescents (15–24 years) with 30% (n = 13.620), while in women, a higher proportion is observed in adolescents with 49% (n = 5.521). Table 1 also describes the behavior of the area of residence, showing that suicides occurred more frequently in urban areas, representing 72% (n = 32.824) of deaths in men and 77% (n = 7.556) in women, respectively.
Mortality by suicide in Colombia (Table 1) is described through the behavior of Age-Standardized Mortality Rates (ASMR) by sex and age group. Even though statistically significant differences exist between the groups in the male population, these are not particularly large; adolescents have the highest mortality (12,18/100.000), followed by older adults (12,05/100.000), young adults (10,48/100.000), and middle-aged adults (9,41/100.000).
Concerning women (Table 1), the behavior of ASMR per 100.000 inhabitants did show considerable differences between age groups, with a predominance of the group of adolescents with higher mortality rates (ASMR = 4,91), followed by young adults (ASMR = 2,05), middle-aged adults (ASMR = 1,40), and adults over 65 years of age (ASMR = 1,00). This phenomenon is replicated in all the territorial units of the country where the highest ASMR are most strongly concentrated in the population of adolescent women. At the same time, mortality in men varies according to the department analyzed, with the adolescent population being the most representative in most departments, except Cesar, Huila, La Guajira, Meta, Norte de Santander, Sucre, and Arauca, where the highest rates were concentrated in older adults (Table 2).
The behavior of men's RR (table 1) also showed slight trends between age groups, with adolescent mortality being the highest with an RR = 1,29 (95% CI: 1,26–1,32), followed by the group of adults over 65 years of age (RR = 1,28; 95% CI: 1,24–1,33), and finally young adults (RR = 1,12; 95% CI: 1,09–1,15). In contrast to women, whose RR showed greater differences, the highest mortality was observed in adolescents (RR = 3,51; 95% CI: 3,31-3.71), followed by young adults (RR = 1,49; 95% CI: 1,40–1.58) and older adults with an RR = 0.70 (95% CI: 0,63-0,78).
According to the area of residence (table 1), statistically significant differences in age-standardized mortality rates (per 100.000 inhabitants) are evidenced in men in rural areas (ASMR = 11,37) versus urban areas (ASMR = 10,63), as well as in the female population, with the highest AMSRs in rural areas (ASMR = 3,69) versus urban areas (ASMR = 2,17).
However, the risk of mortality reflected a behavior similar to that of age (table 1); in men, it is possible to observe a slight difference: the rural area had a relative risk of 1,07 (95% CI: 1,05–1,09) concerning the urban area, while in women the difference was greater, with the RR in rural areas being 1,70 (CI: 1,63–1,77).
Figure 1 shows that Colombia’s capital, Bogotá, has the highest age-standardized rural suicide rates for both sexes, with male mortality significantly higher (ASMR = 106,97; 30,35–106,97) compared to females (ASMR = 34,18; 10,89–34,80). The department of Vaupés follows, exhibiting the highest urban suicide mortality rates for both sexes (urban male ASMR = 42,63; 36,97–48,29; urban female ASMR = 16,32; 12,48–20,16), and the second-highest rates in rural areas (rural male ASMR = 26,44; 20,58–32,30; rural female ASMR = 13,43; 8,66–18,20).
Continuing with the description of age-standardized suicide mortality rates (per 100.000 inhabitants) in Colombia, higher trends are observed among the male population living in rural areas. Following Bogotá, the departments with the highest rural male suicide mortality rates are Quindío (ASMR = 24,38; 15,48–30,35), Huila (ASMR = 19,46; 15,48–30,35), Guaviare (ASMR = 19,19; 15,48–30,35), and Tolima (ASMR = 17,29; 15,48–30.35). In urban areas, the departments of Guainía (ASMR = 18,21; 14,50–20,68), Amazonas (ASMR = 18,15; 14,50–20,68), Arauca (ASMR = 16,53; 14,50–20,68), and Vichada (ASMR = 16,22; 14,50–20,68) presented the highest suicide mortality rates.
Regarding older adults, although absolute suicide mortality rates were lower compared to younger groups, a significant burden was still observed among men aged 65 years and older, particularly in departments such as Meta, Cesar, and Norte de Santander. Among Indigenous populations, higher suicide rates were concentrated in departments with larger Indigenous communities, such as Vaupés, Guainía, and Amazonas, where social exclusion and limited access to health services are prominent issues.

Discussion
This study examines 29 years of suicide mortality trends in Colombia, revealing higher overall rates and mortality risks among men—findings that are consistent with global scientific literature. Regarding differences by area of residence, general Age-Standardized Mortality Rates (ASMR) were higher in rural areas, with a greater mortality risk compared to urban areas. It is worth noting, however, that these disparities were not strong, which led to a department-level analysis. This analysis did not reveal a consistent pattern in ASMR behavior. Of the 32 territorial units analyzed, 16 showed higher suicide mortality rates among rural men, while among women, 20 territorial units had higher ASMR in rural areas.
In the case of Bogotá, it presents notable particularities, showing significantly higher Age-Standardized Mortality Rates in rural areas. On the other hand, departments such as Vaupés, Quindío, Huila, Guaviare, Arauca, and Tolima are regions where high mortality rates are concentrated. These departments are characterized by a high concentration of Indigenous territories and low population density.
Comparison with other countries and other studies
Colombia is not among the countries with the highest suicide mortality rates (34). Other worldwide studies (1990–2016) estimate a higher average age-standardized mortality rate for men (15,6 per 100.000 inhabitants; 95% CI: 13,7 to 17,2) versus women (7,0/100.000 population; 95% CI: 6,5 to 7,4) (35, 36, 37) . In Colombia’s case, mortality behavior was lower than the global average but similar to the regional average (ASMR men = 10,83; 95% CI: 10,73–10,93 versus ASMR women = 2,52; 95% CI: 2,47–2,56). ASMR in the Central Latin American region was 11,00; 95% CI: 8,5–13,4 for men and 2,1 for women; 95% CI: 1,9–2,3 (38).
The results of our study show a higher mortality in men, a behavior observed in all countries of the world (except Liberia), with a relative risk of dying of 4,25 times greater than women. Globally, RR for men were 2,2 (between 1990 and 2016), a frequent trend in most regions of the world except South Asia and East Asia, where mortality among men versus women is very close to parity (35, 39,40,41).
The general behavior of suicide in Colombia suggests differences in mortality risks, finding higher RRs for men living in rural areas (RR = 1,07) and women living in this same area, where the risk increased (RR = 1,70). This is also the case in the United States (RR rural women 1,3; RR rural men = 1,4), Korea (RR rural women = 1,28; RR rural men = 1,18), Japan (RR rural women = 1,08; RRrural men = 1,33), and countries in the region such as Mexico (RR rural = 1,18) and Peru (RR rural = 1,63) (42, 43 ,44 ,45). Decades of research on suicide mortality in urban and rural areas have produced numerous important findings (46), revealing that urban–rural disparities in suicide have emerged worldwide, regardless of a country's income level. Higher suicide mortality risks have consistently been found among rural populations (25).
Regarding the results by age group, our study found higher male mortality rates among adolescents and older adults. This aligns with national statistics, where suicide ranks among the top five leading causes of death exclusively in adolescent and young adult men (ages 15 to 49) between 1990 and 2019 (30,47). A similar pattern is observed globally, where the highest mortality rates are concentrated in these same age groups for both sexes(35,48,49).
Colombian women did not show higher rates in the older adult population, in contrast to international statistics (9,35). It is possible that the results of this study align with the scientific concept known as the "gender paradox," which explains the differences in suicide behavior rates between men and women (50). Studies conducted in numerous countries around the world show that women are at higher risk of suicide attempts, while men are at higher risk of suicide death (51,52), a pattern also reflected in the Colombian case (across all departments).
In addition to the factors previously described, from this perspective, suicides among the female population occur mainly during adolescence and young adulthood, whereas among men, they occur more frequently in both adolescence/young adulthood and late adulthood/old age (53) This stance is fully consistent with the findings of our study as well as other research conducted during similar time periods (54).
By area of residence, several departments stand out nationally (after Bogotá and Vaupés) in rural areas, such as Guaviare and Huila, while Amazonas stands out in urban areas in terms of ASMR.
Possible explanations
Suicide mortality rates in Colombia are below the global average. According to the results of the Global Burden of Disease studies, the leading cause of mortality in Colombia was interpersonal violence (homicide) (55), particularly among adolescent and young adult men (30,56), with a risk of 1,2 compared to men in other countries around the world. This pattern is similar to that observed in regional countries such as Brazil, El Salvador, Guatemala, Honduras, and Venezuela (56). Therefore, it is possible that Colombia contributes more significantly to the Global Burden of Disease through homicide, thereby pushing the burden of suicide into the background for these population groups (57).
Our results suggest a pattern for overall suicide mortality, characterized by a slightly higher mortality risk for rural areas. These results contradict a study conducted between 1974 and 2014, where ASMR urban = 4,2 versus ASMR rural = 3,7, and a relative risk of death in urban areas of 1,2 compared to rural areas was found (58). A possible explanation (by way of hypothesis) is that DANE mortality registries may present high percentages of missing data (more than 60% of total cases) when linking variables such as the method of suicide execution (included in the study). On the other hand, there is scientific evidence that supports the idea that it is not possible to make universal and deterministic associations between the area of residence and suicide (25, 58, 59), which is why it is essential to analyze the geographical variations within a country.
Higher ASMR are observed in the rural areas of the capital (Bogotá). This phenomenon in Bogotá’s population may be linked to the fact that the city is estimated to be the main recipient of migrant populations in the country (18,60). This situation has led to a concentration of populations displaced by the internal armed conflict (among other causes) in the peripheral areas of Bogotá’s localities (61,62).
Thus, in Colombia, it is not possible to identify a general pattern of behavior regarding mortality by area of residence. In rural areas, higher ASMR are observed (after Bogotá) in Vaupés, Huila, Arauca, Quindío, and Guaviare, while urban ASMR in Amazonas also stand out. The behavior of these regions can be explained, first, by the fact that they are territories with a higher percentage of the population living in rural areas (with the exception of Bogotá and Quindío), as observed in the population counts used for our analyses (results not shown)(18). Second, these are low population density areas, a factor strongly associated with high suicide rates (63,64), as these regions have limited access to mental health services (64,65). It is important to note that suicide is a fatal outcome linked to this category of individual care and public health programs (14,66–70). Third, these regions—where suicide mortality rates are considerably higher—are some of the areas most affected by the internal armed conflict (57).
Finally, departments with high mortality rates are identified—such as Vaupés (both sexes) and men in Amazonas—which have a high percentage of Indigenous communities (18). Since 2000, Indigenous populations have historically represented the third highest ethnic group at risk of suicide mortality compared to other vulnerable groups (49). Additionally, the Indigenous population in Colombia accounts for 30% of the country's poor population and consists of communities exposed to violence that leads to displacement. They represent 18% of the total displaced population—figures higher than those observed in other population groups in Colombia (71).

Conclusions
The disparities in suicide observed between urban and rural areas in the general population are possibly related to the availability and quality of mental health care services (e.g., general practitioners, psychiatrists). People living in rural areas may be less likely to seek help due to the greater travel distances to healthcare centers.
When specifically analyzing the behavior of mortality rates among men, a potential gap becomes evident in the promotion and prevention programs targeted at the male population. This suggests the presence of cultural barriers that hinder men's access to mental health services, particularly those residing in rural areas.
Suicide mortality patterns at the departmental level differ from those of other violent causes of death, such as homicide. Departments with the highest suicide ASMR do not have a significant representation in overall homicide mortality. This points to suicide being more strongly linked to barriers in access to health services, poverty, social exclusion, and other social and cultural determinants.
Therefore, it is necessary to develop differentiated health policies based on a comprehensive and accessible health system, grounded in intercultural dialogue. Such policies should include approaches and methodologies tailored to the specific needs of affected communities, such as Indigenous populations and territories with low population density.?
Statements:

Author contribution statement: LVE: Analyzed and interpreted the data; Wrote the paper. IA: Analyzed and interpreted the data; Wrote the paper.: LVA

Ethical statement: In accordance with resolution 8430 of 1993 issued by the Colombian Ministry of Health, this study is considered of “No risk.”

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References
1. Vijayakumar L, Pathare S, Jain N, Nardodkar R, Pandit D, Krishnamoorthy S, et al. Implementation of a comprehensive surveillance system for recording suicides and attempted suicides in rural India. BMJ Open. 2020 Nov 9;10(11).
2. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3(2):1–14.
3. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. The Lancet. 2013 Nov;382(9904):1575–86.
4. Ferrari AJ, Norman RE, Freedman G, Baxter AJ, Pirkis JE, Harris MG, et al. The Burden Attributable to Mental and Substance Use Disorders as Risk Factors for Suicide: Findings from the Global Burden of Disease Study 2010. PLoS One. 2014 Apr 2;9(4):e91936.
5. Walker ER, McGee RE, Druss BG. Mortality in Mental Disorders and Global Disease Burden Implications. JAMA Psychiatry. 2015 Apr 1;72(4):334.
6. Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. British Journal of Psychiatry [Internet]. 1997 [cited 2018 Sep 20];170:205–28. Available from: http://bjp.rcpsych.org/content/170/3/205#BIBL
7. Moitra M, Santomauro D, Degenhardt L, Collins PY, Whiteford H, Vos T, et al. Estimating the risk of suicide associated with mental disorders: A systematic review and meta-regression analysis. J Psychiatr Res. 2021 May;137:242–9.
8. Quinlan-Davidson M, Sanhueza A, Espinosa I, Escamilla-Cejudo JA, Maddaleno M. Suicide among young people in the Americas. Journal of Adolescent Health. 2014 Mar;54(3):262–8.
9. OMS, OPS. Prevención del suicidio: un imperativo global [Internet]. Organización Mundial de la salud y Organización Panamericana de la Salud. 2014. Available from: http://www.who.int/iris/handle/10665/136083
10. Turecki G, Brent DA. Suicide and suicidal behaviour. The Lancet. 2016 Mar 19;387(10024):1227–39.
11. OMS, OPS. Mortalidad por suicidio en las Américas [Internet]. Organización Mundial de la Salud y Organización Panamericana de la Salud. 2014. p. 1–14. Available from: http://www.bvsde.paho.org/documentosdigitales/bvsde/texcom/PAHOMortalidad-suicidio.pdf
12. OMS, OPS. Agenda de Salud Sostenible para las Américas 2018-2030. 2018.
13. Instituto Nacional de Estadística. Indicadores de la Agenda 2030 para el Desarrollo Sostenible. 2023.
14. OMS, OPS. Plan de acción sobre Salud Mental [Internet]. Washington, DC; 2022 [cited 2021 May 4]. Available from: www.paho.org
15. Hagedoorn P, Groenewegen PP, Roberts H, Helbich M. Is suicide mortality associated with neighbourhood social fragmentation and deprivation? A Dutch register-based case-control study using individualised neighbourhoods. J Epidemiol Community Health (1978). 2020 Feb;74(2):197–202.
16. Fontanella CA, Hiance-Steelesmith DL, Phillips GS, Bridge JA, Lester N, Sweeney HA, et al. Widening Rural-Urban Disparities in Youth Suicides, United States, 1996-2010. JAMA Pediatr. 2015 May 1;169(5):466.
17. Urdinola BP. Demografía colombiana: en preparación para la era del envejecimiento. En Fedesarrollo. In: Descifrar el futuro La economía colombiana en los próximos diez años. Bogotá : Penguinlibros; 2021. p. 111–75.
18. Dirección de Epidemiología y Demografía. Ministerio de Salud y protección Social. Análisis de Situación de Salud Colombia 2022. 2023.
19. Restrepo Gil AI. Publicación: Medición del bienestar social e impacto Covid-19 en los principales departamentos de Colombia mediante análisis multivariado no lineal. [Medellín ]: Universidad de Antioquia ; 2022.
20. Sánchez Loyo LM, Camacho Gutiérrez E, Vega Michel C, Castellanos Martín HD. Factores biológicos, psicológicos y sociales asociados a las conductas suicidas. In: Teresita Morfín López AMIL, editor. Fenómeno suicida Un acercamiento transdiciplinar. Jalisco: Manual Morderno; 2015. p. 55–62.
21. Carod-Artal FJ. Social determinants of mental health. Global Mental Health: Prevention and Promotion. 2017;33–46.
22. Martinez-Parra AG, Abadía-Barrero CE, Murata C, Méndez Ramírez I, Méndez Gómez-Humaran I. Social Class for Collective Health Research: A Conceptual and Empirical Challenge. Glob Public Health [Internet]. 2019 Jul 3 [cited 2019 May 21];14(6–7):977–95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/30407893
23. Díaz-Oliván I, Porras-Segovia A, Barrigón ML, Jiménez-Muñoz L, Baca-García E. Theoretical models of suicidal behaviour: A systematic review and narrative synthesis. Eur J Psychiatry. 2021 Jul;35(3):181–92.
24. Helbich M, Blüml V, de Jong T, Plener PL, Kwan MP, Kapusta ND. Urban–rural inequalities in suicide mortality: a comparison of urbanicity indicators. Int J Health Geogr. 2017 Dec 30;16(1):39.
25. Casant J, Helbich M. Inequalities of Suicide Mortality across Urban and Rural Areas: A Literature Review. Int J Environ Res Public Health. 2022 Feb 25;19(5):2669.
26. Departamento Administrativo Nacional de Estadística - DANE. Proyecciones de población por sexo y edades simples hasta 80 años y más, a nivel nacional y departamental. 2005-2020.
27. Fundación Universitaria del Área Andina. Geografía física de Colombia. 2017.
28. Bulla P, Guarín S. Rural security in Colombia: An opportunity for state consolidation. Stability. 2015;4(1).
29. Departamento Administrativo Nacional Estadística. Geoportal. 2023.
30. Healthdata.org. GBD Compare | IHME Viz Hub [Internet]. [cited 2020 Aug 22]. Available from: https://vizhub.healthdata.org/gbd-compare/
31. Campisi SC, Carducci B, Akseer N, Zasowski C, Szatmari P, Bhutta ZA. Suicidal behaviours among adolescents from 90 countries: a pooled analysis of the global school-based student health survey. BMC Public Health. 2020 Dec 10;20(1):1102.
32. Ahmad OB, Boschi-Pinto C, Lopez Christopher AD, Murray JL, Lozano R, Inoue M. Age Standardization Of Rates: A New Who Standard. World Health Organization. 2001.
33. Kassem AM, Carter KK, Johnson CJ, Hahn CG. Spatial clustering of suicide and associated community characteristics, Idaho, 2010-2014. Prev Chronic Dis. 2019 Mar 1;16(3).
34. Ilic M, Ilic I. Worldwide suicide mortality trends (2000-2019): A joinpoint regression analysis. World J Psychiatry. 2022 Aug 19;12(8):1044–60.
35. Naghavi M. Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016. BMJ. 2019 Feb 6;364:l94.
36. Sinyor M, Tse R, Pirkis J. Global trends in suicide epidemiology. Curr Opin Psychiatry. 2017;30(1):1–6.
37. Uddin R, Burton NW, Maple M, Khan SR, Khan A. Suicidal ideation , suicide planning , and suicide attempts among adolescents in 59 low-income and middle-income countries?: a population-based study. Lancet Child Adolesc Health [Internet]. 2016;3(4):223–33. Available from: http://dx.doi.org/10.1016/S2352-4642(18)30403-6
38. WHO. Suicide worldwide in 2019 Global Health Estimates. 2021.
39. Londoño Pérez C, González Rodríguez M. Prevalencia de depresión y factores asociados en hombres. Acta.colomb.psicol [Internet]. 2016 [cited 2019 Feb 20];19(2):315–29. Available from: http://www.dx.
40. Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, et al. Prevalence and Correlates of Bipolar Spectrum Disorder in the World Mental Health Survey Initiative. Arch Gen Psychiatry. 2011 Mar 7;68(3):241.
41. Petersen A, Lupton. D. The “healthy” citizen. In: The New Public Health?: Discourses, Knowledges, Strategies. SAGE Publications,; 1996.
42. Pettron K, Curtin S. Urban–rural Differences in Suicide Rates, by Sex and Three Leading Methods: United States, 2000–2018. NCHS Data Brief. 2020;373:1–8.
43. Yoshioka E, Hanley SJB, Sato Y, Saijo Y. Geography of suicide in Japan: spatial patterning and rural–urban differences. Soc Psychiatry Psychiatr Epidemiol. 2021 May 7;56(5):731–46.
44. Cheong KS, Choi MH, Cho BM, Yoon TH, Kim CH, Kim YM, et al. Suicide Rate Differences by Sex, Age, and Urbanicity, and Related Regional Factors in Korea. Journal of Preventive Medicine & Public Health. 2012 Mar 31;45(2):70–7.
45. Ferri CP, Acosta D, Guerra M, Huang Y, Llibre-Rodriguez JJ, Salas A, et al. Socioeconomic Factors and All Cause and Cause-Specific Mortality among Older People in Latin America, India, and China: A Population-Based Cohort Study. PLoS Med. 2012 Feb 28;9(2):e1001179.
46. Varia SG, Ebin J, Stout ER. Suicide prevention in rural communities: Perspectives from a Community of Practice. Journal of Rural Mental Health. 2014 Oct;38(2):109–15.
47. James SL, Castle CD, Dingels Z V., Fox JT, Hamilton EB, Liu Z, et al. Global injury morbidity and mortality from 1990 to 2017: Results from the global burden of disease study 2017. Injury Prevention [Internet]. 2020 Oct 1 [cited 2021 Jan 14];26(1):I96–114. Available from: http://dx.doi.org/10.1136/injuryprev-2019-043494
48. Ordóñez-Monak* I, Arroyave-Zuluaga I, Segura-Cardona A, Cardona-Arango. D. Trends in inequalities in suicide mortality by educational level in colombia, 1998–2015. injury prevention. 2018;24(2).
49. INMLCF. Forensis datos para la vida [Internet]. Instituto Nacional de Medicina Legal y Ciencias Forenses Grupo Centro de Referencia Nacional sobre Violencia. 2021. p. 1–249. Available from: http://www.medicinalegal.gov.co/documents/20143/49526/Forensis+2016.+Datos+para+la+vida.pdf
50. Canetto S, Sakinofsky I. The gender paradox in suicide. Spring. 1993;28(1):1–23.
51. Canetto SS. Women and suicidal behavior: A cultural analysis. American Journal of Orthopsychiatry. 2008;78(2):259–66.
52. Miranda-Mendizabal A, Castellví P, Paré S-Badell O, Alayo • Itxaso, Almenara J, Alonso I, et al. Gender differences in suicidal behavior in adolescents and young adults: systematic review and meta-analysis of longitudinal studies. Int J Public Health [Internet]. 2018 [cited 2019 Mar 22];64(2):265–83. Available from: https://doi.org/10.1007/s00038-018-1196-1
53. Schrijvers DL, Bollen J, Sabbe BGC. The gender paradox in suicidal behavior and its impact on the suicidal process. Vol. 138, Journal of Affective Disorders. Elsevier; 2012. p. 19–26.
54. Vasquez L, Toloza Pérez Y, Lagos L, Ibáñez E, Téllez-Avila EM, Malagón Rojas JN. Intento de suicidio en Colombia: un estudio de los factores asociados a la intoxicación intencionada. 2007-2017. Salud Uninorte. 2022 Sep 1;38(02):543–59.
55. Naghavi M, Abajobir AA, Abbafati C, Abbas KM, Abd-Allah F, Abera SF, et al. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet [Internet]. 2017 Sep 16 [cited 2018 Sep 16];390(10100):1151–210. Available from: http://eds.b.ebscohost.com/eds/detail/detail?vid=3&sid=e3d9f70c-930f-4015-8142-f5e0d951f331%40sessionmgr101&bdata=Jmxhbmc9ZXMmc2l0ZT1lZHMtbGl2ZQ%3D%3D#AN=125306547&db=pbh
56. Vos T, Abajobir AA, Abbafati C, Abbas KM, Abate KH, Abd-Allah F, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. The Lancet [Internet]. 2017 Sep;390(10100):1211–59. Available from: http://www.narcis.nl/publication/RecordID/oai:pure.rug.nl:publications%2Fa3b2b01d-033e-432d-9838-7688e9ba2329
57. Vallejo K, Tapias J, Arroyave I. Trends of Rural/Urban Homicide in Colombia, 1992-2015: Internal Armed Conflict and Hints for Postconflict. Biomed Res Int. 2018 Oct 1;2018:1–11.
58. Chaparro-Narváez P, Díaz-Jiménez D, Castañeda-Orjuela C. Tendencia de la mortalidad por suicidio en las áreas urbanas y rurales de Colombia, 1979-2014. Biomédica. 2019 Jun 15;39(2):339–53.
59. Carriere DE, Marshall MI, Binkley JK. Response to Economic Shock: The Impact of Recession on Rural–Urban Suicides in the United States. The Journal of Rural Health. 2019 Mar 14;35(2):253–61.
60. Piñeros-Ortíz SE, Urrego-Mendoza ZC, Garzón-Orjuela N, Eslava-Schmalbach J. Social determinants, symptoms and mental problems in adults internally displaced by armed conflict. Soacha, Colombia, 2019. Revista Colombiana de Psiquiatría (English ed). 2024 Jan;53(1):8–16.
61. Carvajal Sánchez NI. Nuevas dinámicas urbano-rurales en Bogotá y Soacha. Eutopía: Revista de Desarrollo Económico Territorial. 2012;(6):51–66.
62. Centro Nacional de Memoria Histórica. Una nación desplazada: Informe nacional del desplazamiento forzado en Colombia. Bogotá; 2015.
63. Helbich M, Leitner M, Kapusta ND. Lithium in drinking water and suicide mortality: Interplay with lithium prescriptions. British Journal of Psychiatry. 2015 Jul 2;207(1):64–71.
64. Behere PB, Mansharamani H, Behere AP, Yadav R. Suicide and Self-Harms in Rural Setting. In: Mental Health and Illness in the Rural World. SpringerLink; 2020. p. 151–67.
65. Ardón-Centeno N, Cubillos-Novella A, Javeriana el Fondo Distrital de Salud U, ArdóN-CeNteNo N, ANdrés Cubillos-NovellA B. La salud mental: una mirada desde su evolución en la normatividad colombiana. 1960-2012. Revista Gerencia y Políticas de Salud. 2012 Jul;11(23):12–38.
66. Minsalud. Plan Decenal de Salud Pública 2012-2021 Antecedentes y análisis de situación [Internet]. 2012. Available from: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/ED/PSP/antecedentes PDSP.pdf
67. República de Colombia. Congreso Nacional. Ley 1616 de 2013 “Por medio de la cual se expide la Ley de Salud Mental y se dictan otras disposiciones.” Diario Oficial No. 48.680 Colombia; Jan 21, 2013.
68. MinSalud. Plan Decenal de Salud Pública 2012-2021. 2012.
69. Organización Mundial de la Salud. mhGAP Programa de acción para superar las brechas en salud mental. Mejora y ampliación de la atención de los trastornos mentales , neurológicos y por abuso de sustancias. [Internet]. mhGAP Programa de acción para superar las brechas en salud mental. 2008. p. 48. Available from: http://www2.paho.org/hq/dmdocuments/2009/mhgap final spanish.pdf
70. Vasquez-Escobar L, Arroyave I, Alejandro Gómez L. Conducta suicida en Colombia, una revisión documental a partir de la agenda política en Salud Mental [Internet]. 2024. Available from: https://orcid.org/0000-0003-4054-9527
71. Gómez-Restrepo C, Rincón CJ, Urrego-Mendoza Z. Salud mental, sufrimiento emocional, problemas y trastornos mentales de indígenas colombianos. Datos de la Encuesta Nacional de Salud Mental 2015. Rev Colomb Psiquiatr. 2016 Dec;45:119–26.