National Real-Time Surveillance System for Suicide Attempts in Uruguay: Results from the First Year of Implementation

Abstract

Suicide is a major public health concern, and Uruguay has one of the highest suicide mortality rates in the Americas. In 2022, the Ministry of Public Health implemented a real-time digital surveillance system for suicide attempts as part of the National Suicide Prevention Strategy. This study presents findings from its first year, analysing 4723 emergency department presentations nationwide. The age-standardised suicide attempt rate was 140.44 per 100,000 inhabitants, with women accounting for 71.6% of cases. Self-poisoning was the most common method, followed by hanging and suffocation for men and self-cutting for women. Nearly half of all attempts involved individuals aged 15–29, highlighting the need for youth-focused and gender-sensitive interventions. This study demonstrates the value of real-time surveillance systems in identifying at-risk groups, informing prevention efforts, and supporting timely interventions. While some challenges in system implementation remain, future efforts should focus on strengthening data integration, leveraging artificial intelligence for risk assessment, and improving follow-up care to reduce repeated attempts and overall suicide mortality.

1. Introduction

Suicide is a significant public health issue worldwide, with more than 700,000 people dying by this cause annually [1] and an age-standardised rate of 9.0 per 100,000 inhabitants in 2019 [2]. Suicide and suicide attempts lead to enduring emotional, mental, and physical health consequences, as well as significant economic costs [3]. Their impact reaches beyond the individual, affecting families and communities, and can span multiple generations [4].

While the global suicide rate has decreased by 36% since 2000, the Americas remain the only World Health Organisation (WHO) region where suicide mortality has increased, with a 17% rise between 2000 and 2019 [1]. However, within this region, suicide mortality rates vary considerably across countries, influenced by sociocultural, economic, and structural determinants. Despite these variations, research focusing on the impact of context-specific factors on suicide mortality in the Americas remains limited [5].

Uruguay is among the countries in the Americas with the highest suicide mortality rates. In 2023, the age-standardised mortality rate was 19.4 per 100,000 inhabitants (n = 763) [6]. In the region, it is preceded by Guyana (40.8 per 100,000 inhabitants) and Suriname (25.9 per 100,000 inhabitants) and followed by the United States of America (14.5 per 100,000 inhabitants), Haiti (11.2 per 100,000 inhabitants), and Canada (10.3 per 100,000 inhabitants) [2].

Suicide mortality rates in the country have historically remained high [7], prompting efforts from both the public and private sectors to implement suicide prevention initiatives over the past decades [8]. However, these efforts were largely isolated and fragmented. In 2011, the National Honorary Commission on Suicide Prevention, under the leadership of the Ministry of Public Health, designed and implemented the first national suicide prevention strategy. This interministerial body, composed of four ministries, works alongside a technical advisory task force to develop intersectoral actions aimed at reducing suicide rates. The current National Suicide Prevention Strategy (2021–2025) defines key policy directions and interventions at the national level [9].

In line with these efforts, the country has established a national implementation plan to provide psychological treatments in healthcare institutions nationwide, prioritising individuals with suicide attempts [10]. Additionally, specific clinical guidelines have been developed to standardise the management and follow-up of individuals who have attempted suicide, ensuring timely care and improving post-attempt support [11,12]. Also, the Ministry of Public Health has recently approved a new regulation that mandates a reduction in costs for commonly used antidepressants (Sertraline, Escitalopram, and Fluoxetine). Furthermore, a nationwide 24 h suicide prevention helpline, staffed by trained psychologists, has been operational for over a decade, offering immediate crisis intervention and support.

A prior history of suicide attempts is considered one of the strongest predictors of future suicide, with research indicating that individuals who attempt suicide are at a substantially elevated risk of subsequent attempts and completed suicide [13,14,15]. International evidence suggests that for every suicide, there are approximately 20 suicide attempts [13]. As a result, promptly monitoring suicide attempts offers essential information for detecting emerging patterns and high-risk populations that require intervention [16].

Improving suicide attempt surveillance systems is a key recommendation from the WHO on suicide prevention [17]. Real-time monitoring systems enable policy-makers to identify new trends, such as at-risk locations or populations [18]. An increasing number of countries have established regional or national systems for recording self-harm and suicide attempts [19]. Some had developed surveillance systems for hospital-presenting self-harm, principally high-income countries [16]. These principal countries are Ireland, England, New Zealand, and Australia. Hospital-presenting self-harm registries are also emerging from low and middle-income countries (LMIC), including Sri Lanka, Pakistan, India, and Jamaica [20].

In Uruguay, the registration of suicide attempts has been mandatory since 2013. However, this requirement was only partially fulfilled, partly because the records were kept in paper format [21].

In 2022, a digital registry system was launched by the Ministry of Public Health as part of the National Suicide Prevention Strategy [9]. The system is mandatory for all healthcare providers nationwide and has been implemented in all emergency departments (ED) across the country [6]. It provides real-time access to information on suicide attempts, with registration required within 24 h following the event. Developed by the National Mental Health Department, the purpose of the national registry is to determine and monitor the incidence and repetition of suicide attempts, identify high-incidence groups, and inform healthcare services and practitioners involved with the prevention and attention of suicidal behaviour.

This article aims to present the initial findings from the first year of systematic data collection and analysis of data recorded by the national real-time surveillance system for suicide attempts in Uruguay.

2. Materials and Methods

2.1. Context and Background

Uruguay is a small country located in South America with a population of 3,499,451. As of 2023, it has a demographic composition of 48.4% men and 51.6% women [22]. About 37% of the population resides in Montevideo, the capital and largest urban area [22]. In 2024, life expectancy at birth is projected to be 75 years for men and 81.5 years for women [23]. The literacy rate has risen to 99% of the population [24]. Since 2021, the number of deaths has surpassed births, signalling an acceleration of population decline [22].

Health coverage stands at 98.5% [25]. The National Integrated Health System (SNIS—its acronym in Spanish), established in 2007, restructured the healthcare system by integrating public and private providers to ensure universal coverage with guaranteed access. Currently, 59% of the population is covered by private healthcare institutions, while 41% relies on the public sector. The SNIS is based on the principles of universality, accessibility, sustainability, and healthcare quality, with a strong emphasis on health promotion and preventive care, guided by a Primary Health Care strategy. The Ministry of Public Health oversees leadership and governance of the system. The funding of the SNIS comes from the National Health Fund using a mixed mechanism of capitation and payment by results and from the national income.

Regarding mental health, Uruguay has a comprehensive regulatory framework established through the Mental Health Law (2017) and the National Mental Health Plan (2020–2027) [26,27].

2.2. Definition of Suicide Attempt

The following definition of a suicide attempt is used by the registry: “any act whose main purpose is to try to end one’s own existence, whether this act is clearly manifested by the person and/or is the result of a health professional diagnosis” [11] p. 1. This includes different levels of suicide attempts and underlying motives. It was developed by a national task force group of experts who convened when suicide attempts started being recorded in paper format.

2.3. Data Items and Collection

All 97 EDs across the country contribute data to the registry. Data from the system are obtained in real time (within 24 h of the event). This study includes data recorded between 1 January and 31 December 2023.

Access to the system is restricted and limited to healthcare workers who have been authorised by the Ministry of Public Health to register suicide attempts. During the system’s implementation, all authorised healthcare workers received a short training on the use of the registration system.

Inclusion and exclusion criteria for the registry and surveillance of case presentations were established according to recommendations by the Pan American Health Organisation (PAHO) [19].

Inclusion criteria:

• All ED presentations for suicide attempts;
• Diagnostic confirmation by a mental health professional;
• All methods of self-harm with suicidal intent.

Exclusion criteria:

• Self-harm without confirmed suicidal intent;
• Suicidal ideation without attempt;
• Accidental injuries;
• Fatal cases (suicides).

The core datasets included in the national system are ID number (random number created to anonymise and protect the identity of people), country of origin, sex, date of birth, methods used in the suicide attempt, suicide attempt date, previous suicide attempts, mental health treatment, referral to mental health care, health care institution, ED where the suicide attempt was recorded, and date of registration.

The method of suicide attempt is recorded according to the consensus of a task force group of experts and includes hanging or suffocation, handgun discharge, self-poisoning by drugs/medicines, intentional self-harm by sharp object, and other. Only the main method is recorded, prioritising the most lethal.

2.4. Quality Control

To ensure the accuracy and consistency of recorded information, a comprehensive quality assurance protocol has been established. A central team at the Health Surveillance Department of the Ministry of Public Health conducts daily reviews of the records, verifying the completeness and internal consistency of the data. Records that do not meet the inclusion criteria of a suicide attempt are excluded.

2.5. Data Analysis

Categorical variables are summarised as frequency counts and percentages. Also, age-standardised rates are presented. Continuous variables were summarised using the mean and standard deviation or median and interquartile range according to their distribution. The comparison between groups for categorical variables was performed using the chi-square test.

2.6. Ethical Considerations and Data Protection

The national surveillance system operates under stringent data protection and privacy protocols aligned with international standards for health surveillance systems [28].

Each record is anonymised through an automatically generated unique identifier, following the recommendations by the WHO for suicide surveillance data [17]. Access is restricted to authorised healthcare workers, with all system access being logged and audited.

The system complies with national personal data protection regulations [29]. Furthermore, data management processes are conducted following the WHO’s established protocols for handling sensitive health information within surveillance systems [28]. These measures ensure the confidentiality, integrity, and security of the data collected.

3. Results

3.1. Suicide Attempts

For the period from 1 January to 31 December 2023, the registry recorded 4723 suicide attempt presentations to ED that were made by 4274 individuals. The age-standardised rate of individuals who attempted suicide in 2023 was 140.44 per 100,000 inhabitants. Of these individuals, 99.8% were Uruguayans, with 0.2% registered as foreign nationals.

Regarding healthcare providers, 61.1% (n = 2888) of the suicide attempts corresponded to individuals with a private health care provider, while 38,8% (n = 1835) had a public health care provider.

3.2. Gender and Age

Of the recorded presentations, 28.4% were made by men, and 71.6% were made by women. The annual rates for males and females were 77 (95% CI: 73–82) and 184 (95% CI: 178–190) per 100,000 inhabitants respectively. The female-to-male rate ratio was 2.38 (95% CI: 2.23–2.54).

The average age was 32 (sd = 16.5) in a range of 5 to 93 years. Presentations were higher among younger age groups, with over half (54.8%) involving people under 30 years of age, and 47.3% of all presentations involving those between 15 and 29 years.

In most age groups, rates of suicide attempts among women exceeded those of men (Figure 1). This disparity was most pronounced in the 10–14 age group, where there were over seven attempts by women for every man, and in the 75–79 age group, where the ratio was 6 to 1. The exception was in the 85–89 and 90–94 age groups, where the rate of presentations by men exceeded those by women.

3.3. Method of Suicide Attempt

Self-poisoning by drugs or medicines accounted for 71.6% of all recorded suicide attempts, making it the most common method for both sexes (78% in men and 56.5% in women) (Figure 2).

Hanging and suffocation was the second most frequent method for men (18.4%), while self-cutting was the second most frequent method for women (8.5%). Across both sexes, the “Other” category was the second most reported method overall, representing 9.8% of all cases.

Firearm discharge was the least common method for men and women, representing 1% and 0.1%, respectively. Among men, firearm use was predominantly observed in the 45–69 age group. Although firearm use was infrequent among women overall, it represented 11.1% of attempts within the 85–89 age group.

3.4. Variation by Day, Week, and Month

The average monthly number of suicide attempt presentations to hospitals in 2023 was 393.6 (SD = 43.7). October (spring) recorded the highest number of suicide attempts.

On average, 12.9 suicide attempts occurred per day. The number of attempts was slightly higher on Mondays (n = 796) and Sundays (n = 734), while Fridays registered the lowest count (n = 583). The single day with the highest number of suicide attempts was October 11, accounting for 0.6% of all attempts.

A slight decrease in suicide attempts was observed between weeks 25 and 29 (Figure 3). This period corresponds to the onset of winter in Uruguay and the school holiday season.

3.5. Repeated Suicide Attempts

In 50.6% of the records of suicide attempts, it was reported that the individual had made previous attempts. Of these, 74.25% were female and 25.75% were male, and the difference was statistically significant (p < 0.05). Among females, 61.90% reported prior suicide attempts, while 38.10% did not. Among males, 55.35% reported previous suicide attempts, while 44.65% did not.

Of the 4274 individuals who attempted suicide in 2023, 348 (8.17%) repeated a suicide attempt within the same year. Of these, 280 individuals (6.55%) recorded two suicide attempts, and 68 individuals (1.59%) recorded more than two suicide attempts in 2023. The median time to the first re-presentation was 54 days, with an interquartile range of 16 to 127 days.

Of the 348 individuals who repeated a suicide attempt in 2023, 250 (71.84%) were female and 98 (28.16%) were male; the mean age was 31.95 years, with a standard deviation of 16.15. No differences were found between the sex distribution and mean age of this group compared to the total number of people with suicide attempts.

3.6. Mental Health Care

The national registry system collects data on the mental health care received by individuals at the time of their suicide attempts. In 2023, most individuals (69%, n = 2939) were undergoing mental health treatment, with 67.1% receiving care within the SNIS.

3.7. Suicide Attempt Follow-Up

The Ministry of Public Health continuously monitors adherence to the national mandatory guidelines for the management and follow-up of individuals with suicide attempts within the SNIS [11,12]. This ongoing surveillance is essential for evaluating compliance, identifying gaps in care, and informing timely interventions.

In 2023, all individuals who attempted suicide (n = 4274) were systematically followed up by a dedicated technical team from the Health Surveillance Department. Daily monitoring ensured that healthcare providers adhered to established protocols, promoting continuity of care and early intervention.

To further strengthen these efforts, in 2024, the Ministry introduced a pay-for-performance action plan aimed at improving the quality of follow-up care and reducing waiting times for individuals recently discharged after a suicide attempt. Specific measures were implemented to enhance post-discharge monitoring, including structured follow-up phone calls at 2 days and 30 days post-attempt, ensuring timely reassessment and support.

4. Discussion

The aim of this article was to present the initial findings from the first year of systematic data collection and analysis of the national real-time surveillance system for suicide attempts in Uruguay.

During this period, the national attempted suicide registration in Uruguay was 4723, with 763 deaths by suicide, revealing a national attempted suicide-to-suicide ratio of 6.4:1. The WHO estimation indicates a ratio of 20:1 [13]. Ireland, a pioneer in developing a national-specific registry system, reported a ratio of 21.9:1 [30]. However, evidence indicates that although individuals who have attempted suicide, or their families, often seek help at hospital EDs, a significant number do not access healthcare services, and some may never enter the healthcare system [19,20]. This discrepancy highlights the potential underreporting of suicide attempts in national data, making it challenging to fully understand the scale of the problem, as many cases go unreported unless medical treatment is necessary [31]. The lack of clear consensus on the definition of a suicide attempt and standardisation for case coding in most systems could be a disadvantage when attempting to make comparisons or draw conclusions in relation to other countries [32].

In Uruguay, the findings highlight young people, particularly women aged 15 to 19, as a high-risk group for attempted suicide. This underscores the need to develop targeted strategies addressing adolescent and youth mental health with a gender-sensitive approach.

In 2023, the most common method of suicide attempt for both men and women involved self-poisoning by drugs or medicines, mirroring global patterns [30]. Similarly, men have a higher rate of suicide attempts by hanging or suffocation than women [30].

International literature attributes the rise in overdose cases to an increase in the prescription of therapeutic drugs, particularly opioids [33]. Among suicide attempts involving intoxication, over 75% involve benzodiazepine receptor agonists and antidepressants [34]. National research indicates that consumption levels are similar to those in high-income countries, with alprazolam being the most widely used substance, followed by sertraline, diazepam, clonazepam, and quetiapine [35]. However, a current limitation of the system is its inability to distinguish the specific drug types most frequently involved in suicide attempts. Several high-income countries have faced this challenge by imposing restrictions on the prescription of such medications, including limiting tablet pack sizes, removing certain drugs from the market, restricting prescriptions to specific indications, and providing training for healthcare professionals [2,36,37].

Seasonality effects in suicide attempts have been documented, suggesting a higher incidence during the warmer months of the year, particularly in spring and early summer [38,39,40,41]. Similarly, our findings indicate an increase in suicide attempts during spring and a decrease during winter. Regarding the day of the week, this study observed a slightly higher frequency of suicide attempts on Mondays and Sundays, with the lowest frequency on Fridays. A multi-country time-series study across 26 countries (1971–2019) found that most countries recorded the highest proportion of suicides on Mondays [42]. Freichel and O’Shea [43] reported an association between negative mood, desire to die, and desire to self-injure with Mondays in a study on suicidality and mood. While suicide risk in South American countries was generally higher on weekends, the opposite trend was observed in most North American, European, and Asian countries, where suicide risk was lowest during weekends [42]. A hospital-based study in India also found the highest proportion of suicide attempts on Sundays [38], a pattern similarly observed in a Danish population study [44]. In the region, Alves et al. [40], reported that suicide attempts in Brazil were most prevalent on Sundays and Saturdays. In many countries, suicide risk has been found to decrease on national holidays [42]. In our study, a decrease in suicide attempts was observed during the school holiday period in winter. However, as this study is based on a single year of data, a more robust seasonality analysis will require multiple years of observation to confirm cyclical patterns in Uruguay. Understanding these patterns is crucial for the planning and allocation of mental health care resources.

Individuals who make repeated suicide attempts are at heightened risk, particularly those who have used more severe methods [45]. This risk is most pronounced within the first week and up to 12 months following discharge [46]. In this study, among the 348 individuals who repeated a suicide attempt in 2023, no significant differences were found in sex distribution or mean age compared to the overall population of attempters. These findings highlight the importance of identifying risk factors associated with repetition to inform more effective intervention strategies. A systematic review and meta-analysis of 110 studies, encompassing 248,829 individuals who attempted suicide, found that one in five individuals who attempt suicide will make a subsequent attempt [47]. The study identified the female sex, the use of highly lethal methods, and psychiatric disorders as key risk factors for repetition. Importantly, the findings also suggest that psychotherapy interventions and structured prevention programmes can significantly reduce the likelihood of reattempts. Given that the months following an initial attempt are a critical period for recurrence, timely and targeted interventions are essential. Among the most effective strategies, scheduling a follow-up appointment at the time of discharge from emergency or inpatient care has shown a strong protective effect, substantially lowering the risk of subsequent suicide attempts and related mortality [11,48,49].

The analysis of the data shows the value of the real-time system for understanding the current situation of suicide attempts and identifying the at-risk population with the objective of design-tailored interventions.

Monitoring the evolution of the collected variables over the coming years is necessary to identify trends and fully leverage its benefits. One challenge is the real-time dissemination of data, which is crucial for the development of local and early responses [32].

A comprehensive public health approach is required to address suicide as a complex and multifactorial phenomenon, integrating evidence-based policies, intersectoral collaboration, equitable access to mental health care, and considering the social determinants of health [50].

4.1. Limitations

Some limitations were identified. Despite the implementation of guidelines to ensure data quality, this study presents findings from the first year of data collection, warranting caution in their interpretation. Methodological challenges include potential selection bias due to underreporting in some healthcare providers.

Another limitation related to the data obtained is that although the system is implemented across the country and provides information on the ED where the suicide attempt was recorded, the city or department where the person lives is not recorded. The absence of this data is a limitation for identifying regional variations and planning specific interventions.

To prioritise feasibility during implementation, only the most frequently used methods of suicide attempts were included in the registry. The options available for the “method of self-harm” variable do not cover all methods included in ICD-10 [51], making it difficult to achieve international comparability regarding the most common methods across different populations.

4.2. Future Directions

As Uruguay’s National Real-Time Surveillance System for Suicide Attempts continues to evolve, several key challenges and research opportunities arise. Ensuring data quality remains fundamental for developing evidence-based strategies while leveraging advanced analytical tools, including artificial intelligence, could enhance risk assessment and support real-time decision-making.

Integrating surveillance data with other relevant sources—such as mortality records, medical histories, and sociodemographic databases—could provide a more comprehensive understanding of suicide behaviour and its determinants. Moreover, the application of AI-driven models to identify high-risk profiles may not only facilitate targeted interventions but also contribute to the development of predictive frameworks for suicidal behaviour.

Further efforts should also focus on refining data collection related to suicide methods, particularly the substances involved in overdose attempts, given recent regulatory changes that have increased access to certain antidepressants. Finally, the continuous evaluation of follow-up interventions will be essential to ensure their effectiveness in reducing repeated attempts and improving long-term outcomes.

5. Conclusions

The first year of Uruguay’s National Real-Time Surveillance System for Suicide Attempts has provided critical insights into the prevalence, patterns, and risk factors associated with suicidal behaviour. While the attempted suicide-to-suicide ratio suggests potential underreporting, the system offers valuable data for identifying high-risk populations and informing targeted interventions. The findings underscore the need for comprehensive public health strategies that integrate mental health care, intersectoral collaboration, and data-driven approaches.