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)     

The Growing Use of Firearms by Suicidal Older Women, 1979–1992: A Research Note

Suicide among older women (65 +) has received very little attention despite increasing numbers of suicides in this population. An examination of national mortality data from the National Center for Health Statistics for the years 1979 through 1992 shows an increasing trend in rates of suicide among older women and a declining trend among women under 65. Over the 14-year period, firearms replaced poisoning as the most prevalent method of suicide by women 65 and over. The results seem consistent with the assertion that the availability, familiarity, and cultural acceptability of firearms may play a role in the choice of suicide method among older women. Although violent death and the use of firearms are generally associated with males in our society, the trends reported here indicate that greater attention to firearm suicides among older women is warranted.     

Firearm legislation and statewide suicide rates: The moderating role of household firearm ownership levels

Firearm legislation is associated with statewide suicide rates; however, prior research has often relied upon older data and categorical legislative grades while also failing to consider the nuanced role of firearm ownership. Therefore, the robust literature base on legislation and suicide has not directly examined regarding the extent to which the value of legislation hinges upon the rate of firearm ownership in a given state. The current study examined 2015 US statewide firearm legislation strength scores from Giffords Law Center to Prevent Gun Violence and 2016 statewide suicide rates from the Centers for Disease Control and Prevention. Firearm legislation strength was inversely associated with statewide overall and firearm suicide rates, but not with non‐firearm suicide rates. Firearm ownership rates moderated the association between firearm legislation strength and statewide overall suicide rates. Specifically, firearm legislation strength was inversely associated with statewide overall suicide rates at mean and high levels of firearm ownership. Findings support the potential utility of firearm legislation as part of a national effort to decrease US suicide deaths, particularly in areas with higher firearm ownership rates.     

Firearm Storage Practices and Risk Perceptions Among a Nationally Representative Sample of U.S. Veterans With and Without Self‐Harm Risk Factors

Despite the disproportionate use of firearms in Veteran suicides and the well‐established link between firearm access and suicide, little is known about how Veterans store their firearms or what they think about the relationship between firearm access and suicide risk. Using data from 2015 nationally representative online survey (response rate 60.9%), we compare characteristics of Veteran firearm owners with and without self‐harm risk factors with respect to how they store their firearms and their beliefs about suicide risk related to firearms. Overall, one in three U.S. Veteran firearm owners store household firearms loaded and unlocked, one in twenty believe that a firearm increases household suicide risk, and one in four consider their loaded and unlocked firearm to be inaccessible to suicidal household members. Storage practices and risk perceptions are similar among those with and without self‐reported suicide risk factors. Affecting risk perceptions may be a critical aspect of interventions addressing lethal means safety among U.S. Veterans.     

Suicide and Firearm Prevalence: Are Youth Disproportionately Affected?

The effect of firearm availability on suicide may differ among age groups. We used regression analysis to examine the relationship between suicide rates and household firearm ownership for four age groups in the nine census regions from 1979 to 1994, adjusting for regional divorce rates, education, unemployment, and urbanicity. Results showed that firearm ownership levels are correlated with suicide rates among 15- to 24-year-olds and 65- to 84-year-olds, but not among 25-to 64-year-olds. The findings suggest that if the relationship is causal, a 10% fall in regional firearm ownership levels would lead to a 3.0% decrease in suicide rates.     

Suicide among adolescents and young adults: a cross-national comparison of 34 countries

Few cross-national reports have examined suicide rates among adolescents and young adults. A survey of suicides among 15-24-year-olds in 34 of the wealthiest nations demonstrated that 15,555 youths killed themselves in a 1-year study period. Thirty-four percent of these suicides were firearm-related. Finland led the participating nations in total and firearm-related suicide rates. An association was found between divorce rates and youth suicide rates, firearm-related suicide among youths, and suicide rates among young males. For a smaller sample of countries, an association was found between firearm availability and firearm-related suicide rates among youths and suicide rates among young males.     

Rural‐Urban Differences in Suicide Rates for Current Patients of a Public Mental Health Service in Australia

Rural versus urban rates of suicide in current patients of a large area mental health service in Australia were compared. Suicide deaths were identified from compulsory root cause analyses of deaths, 2003–2007. Age‐standardized rates of suicide were calculated for rural versus urban mental health service and compared using variance of age‐standardized rates with 95% confidence intervals. There were 44 suicides and the majority (62%) were rural. Only urban patients used jumping from heights as a method of suicide (4/17; p = 0.02). Rural patients had 2.7 times higher rates of suicide, similar to findings for rural versus urban community suicides and may reflect the underlying community rates, differences in mental health service delivery, or socioeconomic disadvantage.     

Firearm possession and violent death: A critical review

This article critically reviews the empirical research on the association of firearm possession with suicide and homicide. Both suicide and homicide reflect intentional behavior with the goal of killing oneself or another person. Firearms provide merely a means of reaching this goal. The possession of a firearm can, therefore, not be a primary cause of either suicide or homicide. However, since a defining characteristic of both suicide and homicide is the success of killing, and since guns are more effective means for reaching this goal than poison or other weapons, the rate of firearm possession can be expected to be positively related to overall rates of suicide and homicide. This prediction has been tested with individual-level as well as macro-level studies. Individual-level studies, which typically use case–control designs, allow a better control than macro-level studies of the cultural, demographic, and economic determinants of suicide and homicide. In macro-level studies, the potential impact of gun possession on overall rates is likely to be confounded by the factors that motivate people to commit suicide or homicide. Despite these methodological limitations, the research reviewed in this article supports the assumption that easy access to firearms increases the risk of dying from violent causes. With very few exception, studies found gun ownership positively related to gun-related suicides and homicides. Furthermore, there is evidence that guns do not merely serve as substitutes for other means of killing, but increase the overall rates of suicide and homicide.     

Youth suicide: insights from 5 years of Arizona Child Fatality Review Team data

Data on 153 youth suicides in Arizona (1994-1999) were used to explore demographic, behavioral, and experiential factors that distinguish between firearm suicide and suicide by other means. In bivariate analyses, White youths were more likely than non-White youths to use a firearm to commit suicide as were youths who had not experienced a life crisis or expressed suicidal thoughts in the past, relationships that hold in multivariate analyses at the p < 0.2 level. Targeted suicide prevention activities should supplement interventions focused on restricting access to highly lethal means of suicide such as firearms.     

Teen suicide and changing cause-of-death certification, 1953-1987.

This study examines whether the purported tripling in teenage suicides since the 1950s represents a real increase or is simply an artifact of the increased skill of medical examiners in distinguishing youth suicides from fatal accidents. This study examines firearms and poisoning deaths, which together account for 75% of all certified youth suicides, from 1953 through 1987, and concludes: (a) a past undercount of youth suicides is likely, (b) the increase in youth suicide that has occurred is less dramatic than reported and resembles increases in adult suicide, and (c) the suicide increase indicated among youths and adults occurred from 1964 to 1971 and has since stabilized.     

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.     

A Suicide Prevention Campaign for Firearm Dealers in New Hampshire

A spate of suicides involving a just‐purchased firearm led a statewide coalition of firearm dealers, firearm rights advocates, and suicide prevention professionals to discuss the role of gun shops in preventing suicide. The group developed and mailed materials for (1) firearm retailers on avoiding sales to suicidal customers and (2) their customers on suicide and firearm safety. All storefront retailers were identified (n = 65), visited unannounced 6 months after receiving materials, and asked to complete a survey. Nearly half (48%) had at least one campaign product on display. Belief that reducing a suicidal person's access to firearms might save a life was associated with displaying materials (69% vs. 41%, p = .06). Public health and gun groups can successfully collaborate on suicide prevention activities.     

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.     

Suicide mortality among Kentucky farmers, 1979-1985

Farmers may be at high risk for suicide because of their social environment and because of chemical exposure resulting in neurotoxic effects in the workplace. Age-specific suicide rates are compared for Kentucky white farmers, Kentucky white males, and U.S. white males. Data for suicides occurring in Kentucky represent the 7-year period between 1979 and 1985; data for the United States suicides represent the period 1980. Overall, suicide rates were highest for Kentucky farmers, followed by Kentucky males and then by U.S. males. All males were most likely to use firearms as the mode of suicide, but the farmers used firearms significantly more often than the U.S. males, as did the other Kentucky males. These findings and other evidence support the need to assess suicide rates in this occupational group in other states, to begin suicide prevention programs for Kentucky, and to work to identify risk factors contributing to the Kentucky farm suicides.     

Gun availability and use of guns for suicide, homicide, and murder in Canada

A reliability check of Lester's (2000b) 1970-1995 time series that examined associations between the availability of firearms and their use for homicide and suicide in Canada. For the period 1974 to 1999, the relative availability of firearms as measured by the rate of accidental death from firearms and the average of the percentages of suicides + homicides using firearms was positively associated with the rate of homicide by firearms but not negatively associated with the rate of homicide by all other methods, and positively associated with the rate of suicide by firearms and negatively associated with the rate of suicide by all other methods. Correlations for the homicide versus murder rates, homicide rate using guns versus murder rate using guns, and homicide rate by all other methods versus murder rate by all other methods were very similar. There was a decrease over time of total suicide and homicide rates and firearm suicide and homicide rates, and with a slight indication of substitution of other methods for suicide.     

Musical creativity and suicide

The different abilities involved in artistic creativity may be mirrored by differences among mental disorders prevalent in each artistic profession, taking poets, painters, and composers as examples. Using suicide rates as a proxy for the prevalence of mental disorders in groups of artists, we investigated the percentage of deaths by suicide in a sample of 4,564 eminent artists who died in the 19th and 20th centuries. Of the sample, 2,259 were primarily involved in activities of a linguistic nature, e.g., poets and writers; 834 were primarily visual artists, such as painters and sculptors; and 1,471 were musicians (composers and instrumentalists). There were 63 suicides in the sample (1.3% of total deaths). Musicians as a group had lower suicide rates than literary and visual artists. Beyond socioeconomic reasons, which might favour interpretations based on effects of health selection, the lower rate of suicides among musicians may reflect some protective effect arising from music.     

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.     

Who are the Owners of Firearms Used in Adolescent Suicides?

In this brief report, the source of firearms used in adolescent suicides was examined using data from the National Violent Injury Statistics System, the pilot to the CDC's National Violent Death Reporting System, a uniform reporting system for violent and firearm-related deaths. Data represent the 63 firearm suicides among youth (<18 yrs) that occurred in 2001 or 2002 in one of four states (CT, ME, UT, WI) or two metropolitan counties (San Francisco, CA; Allegheny County, PA). Four-fifths of the suicides took place in the decedents' homes, and--when the firearm owner was known--most of the firearms were owned by parents. Findings replicate results from previous research and highlight the importance of limiting youth access to firearms.     

Gender and Suicide Risk: The Role of Wound Site

That males have higher suicide rates than females is one of the most empirically documented social facts in suicidology, but the reasons for this continue to be debated. For the present paper, we tested a neglected contributing factor to the gender suicide ratio: wound site or the area of the body that is wounded in firearm suicides. Males may have a higher suicide rate, in part, due to their greater likelihood than women for shooting themselves in the head as opposed to the body. This has been related to gender differences in fear of facial disfigurement and suicide intent. Data from the Wayne County Medical examiner's office regarding 807 suicides committed with firearms was analyzed. The dependent variable was dichotomous and referred to the location of the site of the wound: gunshot to the head vs. gunshot to the body. Controls for demographic covariates of suicide included age and race of the suicide victim. The results of the multivariate logistic regression analysis determined that women were 47% less apt than men to shoot themselves in the head. Further analysis determined that women were less apt than men to use shotguns and rifles in their suicides (weapons that make head shooting more awkward). The findings are consistent with the notion that women are more concerned than men with facial disfigurement, and that women have a lower desire to die than men.