For personal use. Only reproduce with permission from The Lancet publishing Group. RESEARCH LETTERS Acknowledgments These studies were supported by public health service grant AI41977 from the US National Institute of Allergy and Infectious Disease (CDP). We thank Opendra Sharma for his long-standing support of this research and Joan Hanson for technical assistance. The sponsors had no role in study design, data collection, data analysis, data interpretation, or writing of the report. 1 Pantaleo G, Cohen OJ, Schacker T, et al. Evolutionary pattern of human immunodeficiency virus (HIV) replication and distribution in lymph nodes following primary infection: implications for antiviral therapy. Nat Med 1998; 4: 341-45. 2 Scharko AM, Perlman SB, Hinds PW II, Hanson JM, Uno H, Pauza CD. Whole body positron emission tomography imaging of simian immunodeficiency virus-infected rhesus macaques. Proc Natl Acad Sci USA 1996; 93: 6425–30. 3 Wallace M, Pyzalski R, Horejsh D, et al. Whole body positron emission tomography imaging of activated lymphoid tissues during acute SHIV89.6PD infection in rhesus macaques. Virology 2000; 274: 255–61. 4 Garcia CF, Lifson JD, Engleman EG, Schmidt DM, Warnke RA, Wood GS. The immunohistology of the persistent generalized lymphadenopathy syndrome (PGL). Am J Clin Path 1986; 86: 706–15. 5 Pantaleo G, Graziosi C, Demarest JF, et al. Role of lymphoid organs in the pathogenesis of human immunodeficiency virus (HIV) infection. Immunol Rev 1994; 140: 105–30. Department of Pathology (A M Scharko MD, Prof C D Pauza PhD), Nuclear Medicine (S B Perlman MD, R W Pyzalski MD), and Medicine (Prof F M Graziano PhD, J Sosman MD), University of Wisconsin, Madison, WI, USA; and Institute of Human Virology, University of Maryland Biotechnology Institute, MD, USA (C D Pauza) Correspondence to: Dr C David Pauza, Institute of Human Virology, University of Maryland Biotechnology Institute, 725 W Lombard St, Baltimore, MD 21201,USA (e-mail: pauza@umbi.umd.edu) National suicide rates as an indicator of the effect of suicide on premature mortality David Gunnell, Nicos Middleton The health strategies of many nations include targets to reduce suicide rates. In several countries, because suicide rates are rising in young men but falling or unchanging in most other groups, achievement of target reductions might mask rises in potential years of life lost (PYLL). Analysis of routine mortality and census data for England and Wales, UK, shows that although age-standardised suicide rates fell by 18% (95% CI 15–21) between 1981 and 1998, the PYLL before age 65 years increased by 5% (4–6). National suicide reduction targets should focus on PYLL and overall suicide rates. Lancet 2003; 362: 961–62 Suicide is one of the main causes of premature mortality in industrialised countries. For this reason, and because trends in suicide are thought to reflect changing patterns of population mental health, the health improvement strategies of many nations now include suicide reduction targets. 1 Targets are generally based on reduction of age-standardised overall (all-age, male and female) population suicide rates. 2 An important limitation of such targets is that during the past 50 years, reductions in suicide rates in many countries have been driven by substantial decreases in suicide rates of men older than 50 years and women of all ages. These favourable trends have masked a concurrent rise in young male, and in some countries young female, suicide. 3 Measures of potential years of life lost (PYLL) provide a better approach to quantify the effect of premature mortality for health outcomes with high prevalence in young people. We have investigated the implications of using these two alternative approaches to monitoring suicide trends in England and Wales of the past two decades. THE LANCET • Vol 362 • September 20, 2003 • www.thelancet.com 961 We used population and mortality data for England and Wales, UK, produced by the Office of National Statistics to calculate suicide rates, standardised by age (5-year age bands) and sex, between 1981 and 1998 for people aged 15 years and older using the European standard population. We defined suicide as deaths coded E950–E959 and E980–E989, excluding E988.8 (accelerated registrations, most of which are homicides), using the International Classification of Diseases, ninth revision. We calculated PYLL before age 65 years using the exact age at death of all suicides occurring between 1981 and 1998. This method assumes 400 350 300 150 200 250 50 100 0 Potential years of life lost 1982 1981 1983 Year 1993 1995 1998 1992 1991 1990 1989 1988 1987 1986 1985 1984 1994 1997 1996 20 18 16 8 10 12 14 4 2 6 0 R ate (p e r 1 0 0 0 0 0 pe op le ) s ta n da rd is e d b y a ge a nd s e x Suicides and undetermined mortality Potential years of life lost Figure 1: Potential years of life lost and rates of suicide and undetermined mortality, 1981–98 Data are potential years of life lost per 100 000 people before age 65 years and suicide and undetermined mortality rates per 100 000 people aged 15 years or older. 25 Men 20 15 5 10 0 Suicide rates per 100 000 Age 15–44 years Age 45 years Women 1981 Year 1983 1985 1987 1989 1991 1993 1995 1997 25 20 15 5 10 0 Age 15–44 years Age 45 years Figure 2: Trends in age-standardised suicide rates, 1981–98