Highs, lows, and fault lines: The geography of suicide clusters in Ecuador

Suicide is a major public health problem in Ecuador, which until a few years ago had one of the highest rates of suicide among children and adolescents in the world. We employ the Poisson-based retrospective space-time scan statistic in SaTScan™ to identify spatiotemporal suicide clusters in Ecuador from 2012 to 2022, covering traumatic events such as the 2016 Manabí earthquake and the COVID-19 pandemic. Six statistically significant spatio-temporal suicide clusters were identified, most located in moderate and high-altitude areas, as shown by the GIS mapping. After adjusting for altitude and rurality as covariates, three clusters disappeared, and the other three remained with minor changes. This strengthens the possibility of a relationship between altitude and suicide, consistent with international studies suggesting altitude-induced hypobaric hypoxia as a suicide risk factor. A cluster persisted after adjusting for covariates and was detected two years after the Manabí 2016 earthquake in some of the hardest-hit areas. This result is in line with literature suggesting higher levels of psychological distress among adolescents after the earthquake. Conversely, only one cluster was detected during the COVID-19 pandemic in 2020, suggesting no nationwide increase in suicides for this event and consistent with existing literature. We also show that restricting the maximum reported cluster size (MCRS) to a smaller distance-based value, even while using the default MSWS value for inference, results in more realistically distributed clusters that are smaller and have higher relative risks. This study underscores the importance of spatial analysis in public health and provides insights into the spatial and temporal patterns of suicide in Ecuador.