Suicide surveillance in the U.S. Military--reporting and classification biases in rate calculations

The military has a well-defined population with suicide prevention programs that have been recognized as possible models for civilian suicide prevention efforts. Monitoring prevention programs requires accurate reporting. In civilian settings, several studies have confirmed problems in the reporting and classification of suicides. This analysis evaluated whether suicides were underreported or misclassified under accident or undetermined manner of death in the military system. We reviewed all 1998 and 1999 military deaths using official death reports and compared these data with additional sources, most importantly the DoD Medical Mortality Registry. We assessed for evidence of expressed suicidal intent and past psychiatric history among deaths classified as undetermined and accidents due to gunshot, overdose, drowning, falls, or asphyxia. Using sources other than official records, we found 17% more suicides than were reported, and an additional 4% of deaths that were suspicious for suicide. This study suggests that reporting and classification errors may account for 21% additional suicides in the military. These findings are comparable to rates seen in civilian studies and add to the literature regarding the problems inherent in using administrative death classification data for medical surveillance purposes.     

A consideration of the validity and reliability of suicide mortality data

The question of the validity and reliability of suicide statistics may be considered at three levels: (1) Are suicide deaths misidentified or differentially identified across jurisdictions or over time? (2) To what degree are suicide deaths misidentified? and (3) Is the degree to which suicides are misidentified sufficient to threaten the validity of research based on suicide statistics? There is general agreement that suicides are likely to be undercounted, both for structural reasons (the burden-of-proof issue, the requirement that the coroner or medical examiner suspect the possibility of suicide) and for sociocultural reasons. There is also substantial anecdotal and empirical evidence suggesting that the mode of death for some true suicides is in fact certified as other than suicide. Overall, it does not seem that very many true nonsuicides are incorrectly certified as suicides. There is not, however, much agreement as to the degree to which true suicides are undercounted. At least some of the inconsistencies in the findings of different investigators arise because the validity of suicide certification seems to vary from place to place. But the source of apparent conflicts in many of the findings is undoubtedly the lack of a "gold standard" against which the verdicts of any given death certification process can be measured. At best, we can estimate that the sensitivity with which coroners and medical examiners certify true suicides varies from approximately 55% to 99%. A central question in estimating the sensitivity of suicide certification is this: What proportion of true suicides are either equivocal or likely to go unsuspected by the coroner or medical examiner? Very little has been done to investigate this issue. Yet the sensitivity of suicide certification clearly varies for equivocal versus unequivocal suicides. As shown in Table 1.2, specificity is also at issue when it comes to certifying equivocal cases. The final question--whether the degree of undercounting of suicide deaths is so great that it threatens the validity of research based on official statistics--is at the crux of the general concern about suicide certification. There are examples of studies in which conclusions based on crude comparisons of reported suicide statistics appear to be invalid. For the most part, these are comparisons among nations with substantially differing death certification procedures. When official statistics are interpreted with a degree of caution and an understanding of the source and direction of biases likely to affect the published rates, however, it seems unlikely that major conclusions based on these statistics will be in error.(ABSTRACT TRUNCATED AT 400 WORDS)     

An Examination of Potential Misclassification of Army Suicides: Results from the Army Study to Assess Risk and Resilience in Servicemembers

Debate continues about the accuracy of military suicide reporting due to concerns that some suicides may be classified as accidents to minimize stigma and ensure survivor benefits. We systematically reviewed records for 998 active duty Army deaths (510 suicides; 488 accident, homicide, and undetermined deaths; 2005‐2009) and, using research criteria, reclassified 8.2% of the nonsuicide cases to definite suicide (1), suicide probable (4), or suicide possible (35). The reclassification rate to definite suicide was only 0.2% (1/488). This low rate suggests that flagrant misclassification of Army deaths is uncommon and surveillance reports likely reflect the “true” population of Army suicides.     

Apparent higher brain weight in suicide victims: possible reasons

In 2000 we tested previously reported findings by Salib and Tadros that brain weight of fatal self-harm victims is higher than of those who died of natural causes. Our results were based on data from 15 suicides and 15 deaths of other causes. Data included matching variables of age, sex, time between death and postmortem examination, and temperature of the surrounding environment. The exploratory variables were brain weight and method of death. No significant difference was found between the brain weights of suicides and others. On the other hand, some differences were obtained for different suicide methods, which also differed in the temperature of the environment, this being lower for the group of suicides that occurred outdoors (around or below 0 degrees C). Once we excluded all the outdoor cases and controls, a significantly higher brain weight was obtained for suicide cases. These and previous results are intriguing and require explanation. Respirator brain syndrome as described by Moseley, Molinari, and Walker in 1976 may provide only a partial explanation. Another possible suggestion is that higher brain weight in suicide victims may be related to previously demonstrated increased amygdala blood flow and subsequent amygdala enlargement due to the increased processing of emotional information.     

A Century of Suicide in Italy: A Comparison between the Old and the Young

This study analyzes suicide rates from 1887 to 1993 in the Italian population between the ages of 15 and 24 years old and over 65 years of age, based on official data published in the Health Statistics Year Book. The rates of death by suicide (per 100,000) subjects) are calculated for each year and for 10-year periods, as are the mortality rates relative to each method of suicide, standardized by gender. The latter analysis was possible starting from 1951 only, when it became customary to record method. The findings indicate an increase in the suicide phenomenon in the elderly population in Italy over the test period. Rates are at least 3 times higher for men than for women. The highest rates are reported for elderly men, but there appears to have been a greater proportional increase in the number of suicides committed by elderly women. The rise was statistically significant in both males and females. By contrast, a rather constant decrease in suicide rates in young people emerges from the beginning of the century through to the present date. This decrease is more marked in females, although suicide rates are lower for females than for males. Over the study period, substantial changes have come about in the suicide methods used by both young and old people. There was an increase in poisoning by care exhaust fumes, jumping from heights, hanging, and firearms.     

9 Suicide in San Francisco,CA: A Comparison of Caucasian and Asian Groups, 1987–1994

Completed suicides in the city of San Francisco, California, were examined across all ages in the racial groups of Caucasians (n = 798) and Asians (n = 124) from 1987 to 1994. A comparison of Caucasians and Asians showed that there were differences between them in their rates across all age groups. The major findings are: (1) Caucasians predominately used gunshot to complete suicide whereas Asians predominately used hanging to complete suicide, (2) Asian women over the age of 85 have the highest rates across both groups and genders, (3) Asians, as compared to Caucasians, used fewer drugs and alcohol at time of death. Theoretical connections between differences in suicide and definition of the self, as influenced by culture, are discussed.     

Suicide survivors: psychotherapeutic implications of egocide.

Interviews with seven of ten known survivors of jumps from the Golden Gate Bridge and San Francisco-Oakland Bay Bridge revealed that all of them experienced transcendence and spiritual rebirth phenomena. The psychotherapeutic implications of these findings lie in helping depressed and suicidal individuals confront death in a symbolic and meaningful way. The issue is one of "egocide" (symbolic suicide) and aiding individuals in the rebirth process. In this way actual suicides can be prevented. When individuals experience partial "deaths" (like loss, failure, rejection, depression, suicidal states, or negative parts of their egos), there is opportunity for "rebirth" (positive transformation, creative change, growth, and significant spiritual reawakening). The therapeutic task is to help individuals differentiate between "ego death" and total death and to discover through the creative process of psychotherapy that overt suicide need not be a solution.     

The Scandinavian Suicide Phenomenon—Myth or Reality?

ABSTRACT: This paper reexamines the “Scandinavian Suicide Phenomenon,” the observation that reported suicides are typically high in Denmark and Sweden and typically low in Norway even though these three countries seem otherwise similar. It has been suggested that in Norway more suicides are reported as accidental death or as death due to unknown causes. This paper explores this possibility by means of a detailed examination of causes of death. Nine other countries are included in the comparisons to facilitate interpretation of the findings. It was found that there were significantly higher rates of accidental and unclassified deaths in Norway than in Denmark or Sweden; if it is assumed that many of these are suicide, this could account for the reported differences in suicide rates.     

Disentangling the Person and the Place as Explanations for Regional Differences in Suicide

Identifying whether suicides in a region are due to characteristics of the residents living there or to some enduring feature of the region is difficult when using cross‐sectional studies. To distinguish these factors, we compared the suicides of a region's residents with people who were temporarily visiting the region. Using U.S. death records from 1973–2004, we focused on states with the highest and lowest suicide rates over this period. The high suicide region consisted of Arizona, Colorado, Montana, New Mexico, Nevada, Oregon, and Wyoming; the low suicide region consisted of Connecticut, Illinois, Massachusetts, New Jersey, and New York. For each region, we considered three groups of decedents: residents who died inside the region, residents who died outside the region, and visitors to the region. Proportionate mortality ratios were calculated for all suicides and separately for firearm suicides. In the high suicide region, visitors to and residents away from the region both had elevated suicide levels, to about the same extent as residents dying inside the region. Therefore, short‐term exposure to the region and being a resident of the region each predicted suicide. In the low suicide region, the suicides of residents at home were reduced, but their suicides rose dramatically once they left the area. There was no decrease in suicides among visitors to the region. Firearm use was related to the suicide levels of each region. Overall, the results suggest that both the available means to commit suicide and the contextual features of the regions contributed to their extreme suicides. We discuss how an examination of visitors can help researchers generate novel inferences about the causes of suicide.     

Schizophrenia--a high-risk factor for suicide: clues to risk reduction.

Suicide is the chief cause of premature death among schizophrenic persons. The lifetime incidence of suicide for patients with schizophrenia is 10% to 13% compared to a general population estimate of about 1%, and is quite close to that observed among those with major affective disorder. The magnitude of increased risk for suicide among schizophrenics peaks before middle age and declines thereafter, although schizophrenic persons tend to be at increased risk throughout the life span. Among psychiatric patients, schizophrenics are overrepresented among suicides, and often schizophrenics constitute the majority of inpatient suicides. It is important in evaluating suicide risk among schizophrenic persons to assess depression and suicidal ideation especially during index admission and during acute phases of the illness. It is noteworthy that schizophrenic persons often commit suicide as the overall level of psychopathology decreases during a nonpsychotic phase. Research has yielded salient risk factors for suicide in schizophrenic persons and "types" of especially vulnerable patients, even though statistical prediction of individual suicides has not proven effective.     

Elevated suicide rates at high altitude: sociodemographic and health issues may be to blame

Suicide rates are higher at high altitudes; some hypothesize that hypoxia is the cause. We examined 8,871 suicides recorded in 2006 in 15 states by the National Violent Death Reporting System, with the victim's home county altitude determined from the National Elevation Dataset through FIPS code matching. We grouped cases by altitude (low<1000m; middle=1000-1999m; high≥2000m). Of reported suicides, 5% were at high and 83% at low altitude, but unadjusted suicide rates per 100,000 population were higher at high (17.7) than at low (5.7) altitude. High and low altitude victims differed with respect to race, ethnicity, rural residence, intoxication, depressed mood preceding the suicide, firearm use and recent financial, job, legal, or interpersonal problems. Even after multivariate adjustment, there were significant differences in personal, mental health, and suicide characteristics among altitude groups. Compared to low altitude victims, high altitude victims had higher odds of having family or friends report of a depressed mood preceding the suicide (OR 1.78; 95%CI:1.46-2.17) and having a crisis within 2weeks before death (OR 2.00; 95%CI:1.63-1.46). Suicide victims at high and low altitudes differ significantly by multiple demographic, psychiatric, and suicide characteristics; these factors, rather than hypoxia or altitude itself, may explain increased suicide rates at high altitude.     

Blue Monday Is Real for Suicide: A Case–Control Study of 188,601 Suicides

Many studies have reported that suicides tend to occur on Mondays. However, owing to a lack of controls, conclusive findings on the potential effects of a day of the week on suicides have been lacking. We analyzed public data for causes of death from 1997 to 2015 in the Republic of Korea. Accidental death was used as a control group. The probability of suicide on each day of the week according to age group was calculated. A total of 377,204 deaths (188,601 suicides and 188,603 accidental deaths) were used. The frequency of suicide was highest on Monday and decreased throughout the week until Saturday. Accidental death was highest on Saturday and showed no variations according to weekday. For people in their teens and 20s, the probabilities of suicide on Monday were 9% and 10% higher, respectively, than those on Sunday. As age increased, the differences in suicide probability according to the day of the week were attenuated. The so‐called Blue Monday effect is real, particularly for people in their teens and 20s. Suicide prevention strategies that aim to attenuate the burden and stress of Mondays should be planned.     

Mortality and Causes of Death in a 10-Year Follow-Up of Patients Treated for Self-Poisonings in Oslo

The present 10-year follow-up study includes all patients (N = 926; 50% females) treated in the medical departments in Oslo for self-poisonings during one year (1980). Seventeen percent were considered suicidal attempts upon admission, 25% among the non-substance abusers and 8% among the abusers. At follow-up, 207 patients (22%) were dead (62% males). The mortality rate was highest among the abusers. The most common causes of death were suicide (21%), heart disease (17%), opiate abuse (15%), and accidents/wounds (13%). Forty-one percent of the suicides occurred during the first two years of the follow-up period. The suicides were by poisoning (57%), hanging (20%), and other methods (23%). The female mortality rate decreased in the second half of the follow-up period whereas the male rate did not change. The risk of death within 10 years after discharge increased with age and was higher in men and in abusers, whereas social group and motive for suicide were not predictive factors. The females had an excess suicide rate of 182 (36–327, 95% CI) in the first year after the self-poisoning and 61 (36–87, 95% CI) in the total period. The corresponding figures for males were 70 (19–122) and 21 (12–30). The only factor associated with an increased suicide rate was a suicidal motive upon the admission for self-poisoning with a 3.1 (1.7–5.8, 95% CI) times increased risk of suicide in the 10-year follow-up period.     

The Kurt Cobain Suicide Crisis: Perspectives from Research,Public Health,and the News Media

The suicide of rock star Kurt Cobain in 1994 raised immediate concerns among suicidologists and the public at large about the potential for his death to spark copycat suicides, especially among vulnerable youth. The Seattle community, where Cobain lived and died, was especially affected by his sudden death. An overview of Cobain's life and death is presented and various crisis center and community-based interventions that occurred are discussed. Preliminary data collected from the Seattle Medical Examiner's Office and from the Seattle Crisis Center to assess the potential impact of Cobain's death on completed suicides and the incidence of suicide crisis calls are presented. The data obtained from the Seattle King County area suggest that the expected “Werther effect” apparently did not occur, but there was a significant increase in suicide crisis calls following his death. It is hypothesized that the lack of an apparent copycat effect in Seattle may be due to various aspects of the media coverage, the method used in Cobain's suicide, and the crisis center and community outreach interventions that occurred. The Cobain suicide and the role of media influence on copycat suicides are further discussed in commentaries from public health and news media perspectives.     

Suicide without explicit precursors: a state of secret despair?

Although it is usually assumed that all those who commit suicide give some prior indication of their intention to take their own life, there is growing evidence that a small but significant proportion of suicides occur without any clear, explicit indicators. It is proposed that these suicides share similar pathways to other suicides but that the despair involved is not expressed so clearly, often being kept secret. In order to identify such suicides and potential suicides it is helpful to have an indicator of the dominant sub‐sets of constituents that are precursors to suicide. A 14‐item Suicide Precursors Scale (SPS) was therefore developed. This was applied to 128 cases of suicide that occurred between January 1997 and December 2000 in Stockport (South Manchester, UK). A very high alpha coefficient of 0.98 supported the reliability and homogeneity of the SPS. A Multi‐Dimensional Scaling (MDS) analysis of the SPS revealed three prototypical sub‐sets of expressions of suicidal actions—illness, life circumstances, and depressive history. These are offered as coherent themes in the life of potential suicides, which may be of assistance both in determining whether an equivocal death is suicide or not, and in alerting caring agencies to the potential for suicide even when the despair is kept secret. Copyright © 2004 John Wiley & Sons, Ltd.     

The Change in Suicide Rates between 2002 and 2011 in China

Chinese suicide rates have been reported in various studies in the past two decades, but few of them were based on national data. The most recent mortality data (2002–2011) provided by the China Ministry of Health and the detailed census data provided by the National Population Census were used in this study. We calculated the age‐, gender‐, and region‐specific suicide rates and their trends in the past 10 years between 2002 and 2011. The overall suicide rates in China decreased during the study period. The rural/urban ratio of the suicide rates has been significantly reduced from the ratio in the 1990s, and male suicide rates have exceeded those of females. Age was positively associated with suicide rates without the two peaks found in the suicide rates over 20 years ago. The Chinese suicide rates have significantly declined in the past decade, with withering of the unique suicide rate patterns previously found in Chinese suicides about 20 years ago.     

Suicide of Japanese Youth

ABSTRACT: The uniquely intense stress due to the Examination Hell (shiken jigoku) not only generates a basic drive for Japan's economic success but also contributes to a high rate of young people's suicide. This paper discusses the major factors in the intensity of Japanese stress on both institutional and psychological levels. The social structural factors which convert stress to suicide are analyzed in terms of weak ego; restraint on aggression; a lack of social resources; and views of life, death and suicide. Japanese views of life, death and suicide are treated in terms of Absolute phenomenalism, the original form of Shintoism, to which Buddhism and Confucianism have been adjusted in Japan. Japanese phenomenalism affects suicide through its three aspects: animism, present-time oriented small groupism, and the absolute acceptance of the established social order. Confusion and conflict since World War II have increased anomic suicides; however, elements of fatalistic suicide (due to excessive formal or informal social regulations) and altruistic suicide (due to strong social integration) are evident. Suicide is still a highly institutionalized adjustment mechanism in Japan.     

Suicide in the army national guard: an empirical inquiry

Since 2004, suicides in the U.S. military have risen, most notably in the Army National Guard (ARNG). Data used in this study were obtained for suicides occurring from 2007 to 2010 and for a random sample of nonsuicides from the general ARNG population. Of the military-related variables considered, a few showed relationships to suicide. Rather, the primary variables associated with suicide were soldier background characteristics, including age (17-24 years), race (White), and gender (male). Cluster analysis revealed two distinct suicide groups: "careerists" (about one third of all suicides) and "first-termers" (about two thirds of all suicides), each group exhibiting different concurrent behavioral problems.     

Epilepsy and suicide

Although statistics dealing with the causes of death are often difficult to compare, in some cases they indicate that suicide rates are high among people suffering from seizures. The author considers this critically. At present the number of attempted suicides among this group is at least five times higher than among the average population. The author reports on his own findings, on factors indicating potential suicide victims, and on the possible prevention of suicide, particularly in connection with pharmaceutical treatment.