Suicide patterns in children and adolescents: a review from a pediatric institution in England

Suicide is a catastrophic event to both families and communities yet it is potentially preventable. This study aims to determine incidence and patterns of suicide in children and young adolescents in our region, raise awareness of this entity as a potentially preventable cause of death in this age group, and identify its possible associated risk factors. We retrospectively reviewed suicide cases presenting as sudden unexpected death in children and adolescents that underwent coronial post-mortems at our institution. This is the largest pathological review of completed suicide in children and young adolescents within a single institution in the United Kingdom. We identified 23 suicide cases during a 12 year period from 2003 to 2015, in which 18 cases (78%) were male and 5 cases (22%) were female. The age range was from 8 to 16 years (mean age 12.82 +/- 2.52 SD). With the exception of one case, all of the victims were Caucasian. The majority, 19 cases (81%), were found dead inside their place of residence, 15 of whom were discovered in their own bedrooms. Twenty-one cases (91%) died from neck compression due to hanging; 6 cases (26%) had used the cord of a dressing gown and 5 (22%) opted to use a belt as the ligature. Two cases (9%) that died from multiple-drug toxicity were female. In 7 cases (30.5%) there was evidence of self-harm and in 3 cases (13%) there was a history of previous suicide attempts. Petechial hemorrhages were found at autopsy in more than half of hanging victims and only three cases (14%) displayed dual distribution of post-mortem hypostasis (back and legs). Seven victims (30.5%) left some form of suicide message to family members and friends, 2 of which wrote the message on their arm. Parental separation, conflict with parents, and depression, were common amongst decedents prior to committing suicide. Substance abuse was uncommon in suicide within our cases. Valuable information is available from thorough review of suicide data in children and young adolescents from a single institution. Pathologists and clinicians can play crucial roles in identifying potential risk factors that may contribute to prevent future deaths.

Epidemiology of Injury-Related Death in Children under 5 Years of Age in Hunan Province, China, 2009-2014

BACKGROUND

Injury is an important cause of childhood mortality in China. We described the epidemiology and trends of injury-related deaths of children <5 years of age in Hunan province, and discussed several policy implications.

METHODS

Injury-related deaths of children <5 years of age in 2009-2014 were identified from surveillance data. All specific injury mortality and mortality rates in urban and rural area were calculated from census data; Cochran-armitage trend test was used to assess the time trends.

RESULTS

Injury was the leading cause of death in children <5 years of age. Overall injury mortality was 48.96 per 100,000 persons, gradually declined with the year (Z = -18.75, P<0.001), and accounted for 27.14% of all deaths. Injury mortality in rural areas was 64.66 per 100,000 persons, which was more than 3.73 times higher than the rate in urban areas. The three leading causes of injury-related death were drowning (43.63%), suffocation (27.57%), and traffic accidents (14.34%). Suffocation was the leading cause in children <1 year of age (79.49%). Suffocation has high incidence in the winter and spring, and drowning has high incidence in the summer season. Drowning was the leading cause in children 1-4 years of age (62.80%). Drowning and suffocation accounted for 67.74% and 65.11%, of injury-related deaths that occurred at home; while the traffic injury deaths (54.12%) occurred mainly in transit.

CONCLUSIONS

Injury-related fatalities in children <5 years of age followed time trends that were different in rural and urban areas. Effective childhood injury prevention may require different prevention policies combination depending on epidemiological characteristics such as development of injury surveillance and public education on injury knowledge. There is a need for evidence-based surveillance of risk factors for development of effective injury prevention programs.

Thirty years of American cave diving fatalities

INTRODUCTION

Cave divers enter an inherently dangerous environment that often includes little visibility, maze-like passageways and a ceiling of rock that prevents a direct ascent to the surface in the event of a problem.

METHODS

Reports of cave diving fatality cases occurring between 01 July 1985 and 30 June 2015 collected by Divers Alert Network were reviewed. Training status, safety rules violated, relevancy of the violations, and root causes leading to death were determined.

RESULTS

A total of 161 divers who died were identified, 67 trained cave divers and 87 untrained. While the annual number of cave diving fatalities has steadily fallen over the last three decades, from eight to less than three, the proportion of trained divers among those fatalities has doubled. Data regarding trained cave divers were divided into two equal 15-year time periods. Trained cave divers who died in the most recent time period were older but little else differed. The most common cause of death was asphyxia due to drowning, preceded by running out of breathing gas, usually after getting lost owing to a loss of visibility caused by suspended silt. An overwhelming majority of the fatalities occurred in the state of Florida where many flooded caves are located.

CONCLUSION

Even with improvements in technology, the greatest hazards faced by cave divers remain unchanged. Efforts to develop preventative interventions to address these hazards should continue.

[Specific features of suicides committed in a state of alcoholic intoxication]

The objective of the present work was to study the specific features of suicides committed in a state of alcoholic intoxication in 1985, 1995, and 2010 based on the materials collected by the Central Bureau of Forensic Medical Expertise, Ministry of Health of Republic Uzbekistan. It was shown that the blood alcohol content in the subjects committing suicide tended to decrease during the aforementioned periods which does not confirm the opinion that limitations on alcohol consumption reduces the frequency of suicide attempts. Most cases of completed suicide among the residents of Tashkent were recorded in a group of men of the medium and advanced age in the state of alcoholic intoxication. The immediate cause of death in the majority of such cases was mechanical asphyxia due to hanging.

Methods of committing suicide among 2,347 people in Ohio

The present study explored gender differences in suicidal methods, aiming to identify ways to improve our identification of individuals at risk for suicide. Preferred suicide methods vary by demographics; however, method-specific risk factors have not been consistently identified. All suicidal deaths (N=2,347) in a large urban county were identified over a 15-year period (1994-2008). The majority of men used shooting and hanging. In contrast, women relied on a variety of methods, including self-poisoning, shooting, hanging, and carbon monoxide poisoning. Significant demographic differences are evident among individuals who die by shooting and self-poisoning.

Acute influence of alcohol, THC or central stimulants on violent suicide: A Swedish population study

Alcohol and substance abuse in general is a risk factor for suicide, but very little is known about the acute effect in relation to suicide method. Based on information from 18,894 medico-legal death investigations, including toxicological findings and manner of death, did the present study investigate whether acute influence of alcohol, tetrahydrocannabinol (THC), or central stimulants (amphetamine and cocaine) was related to the use of a violent suicide method, in comparison with the nonviolent method self-poisoning and alcohol-/illicit drug-negative suicide decedents. Multivariate analysis was conducted, and the results revealed that acute influence of THC was related to using the violent suicide method–– jumping from a height (RR 1.62; 95% CI 1.01–2.41). Alcohol intoxication was not related to any violent method, while the central stimulant-positive suicide decedent had a higher, albeit not significant, risk of several violent methods. The study contributes with elucidating suicide methods in relation to acute intoxication.

Burden of traumatic injuries in Saudi Arabia: lessons from a major trauma registry in Riyadh, Saudi Arabia

BACKGROUND AND OBJECTIVES

In Saudi Arabia (SA), injuries are the second leading cause of death; however, little is known about their frequencies and outcomes. Trauma registries play a major role in measuring the burden on population health. This study aims to describe the population of the only hospital-based trauma registry in the country and highlight challenges and potential opportunities to improve trauma data collection and research in SA.

DESIGN AND SETTINGS

Using data between 2001 and 2010, this retrospective study included patients from a large trauma center in Riyadh, SA.

PATIENTS AND METHODS

A staff nurse utilized a structured checklist to gather information on patients' demographic, physiologic, anatomic, and outcome variables. Basic descriptive statistics by age group ( 14 years) were calculated, and differences were assessed using student t and chi-square tests. In addition, the mechanism of injury and the frequency of missing data were evaluated.

RESULTS

10 847 patients from the trauma registry were included. Over 9% of all patients died either before or after being treated at the hospital. Patients who were older than 14 years of age (more likely to be male) sustained traffic-related injuries and died in the hospital as compared to patients who were younger than or equal to years of age. Deceased patients were severely injured as measured by injury severity score and Glasgow Coma Scale (P < .001). Overall, the most frequent type of injury was related to traffic (52.0%), followed by falls (23.4%). Missing values were mostly prevalent in traffic-related variables, such as seatbelt use (70.2%).

CONCLUSION

This registry is a key step toward addressing the burden of injuries in SA. Improved injury classification using the International Classification of Disease-external cause codes may improve the quality of the registry and allow comparison with other populations. Most importantly, injury prevention in SA requires further investment in data collection and research to improve outcomes.

[Epidemiological study on the trend of accidental deaths among children under five in Beijing, during 2003-2012]

OBJECTIVE

To study the trend of accidental death among children under 5 years of age in Beijing.

METHODS

Cases of death in children under 5 years old in Beijing, during 2003-2012 were collected, to analyze the strength and trends of accidental death, main causes of accident and its epidemiological features.

RESULTS

The overall accidental death was 8.47% of all death among children under 5 years old in Beijing during 2003-2012. During these 10 years, data showed a downward trend on the mortality rates on injuries (P < 0.05), especially on drowning, in 1-4 year old and rural children under five years of age. In 2012, the accidental death rate of children under five was 6.37/105. The 5 main causes of accidental deaths were suffocation, traffic accident, falling, poisoning and drowning, in order of size. The main causes of death were suffocation in the 0-1 year group, suffocation and traffic accident in the 1-2 year group and traffic accident in the 3-4 year group. The proportion of deaths due to traffic accident increased gradually with age. Area distribution showed that accidental deaths mainly happened in rural area (52.19%), with two main types as traffic accident and suffocation.

CONCLUSION

The reduction of accidental death rate among children under 5 years old in Beijing mainly was caused by the decline of accident mortality in 1-4 year old and children in the rural areas. Our data suggested that the focus in reducing the accidental death rate among children under 5 years old in Beijing should target on the prevention of infant suffocation and traffic accidents among the 1-4 year old, with rural areas in particular.

Autopsy practice in forensic pathology - evidence-based or experience-based? a review of autopsies performed on victims of traumatic asphyxia in a mass disaster

Current autopsy practice in forensic pathology is to a large extent based on experience and individual customary practices as opposed to evidence and consensus based practices. As a result there is the potential for substantial variation in how knowledge is applied in each case. In the present case series, we describe the variation observed in autopsy reports by five different pathologists of eight victims who died simultaneously from traumatic asphyxia due to compression during a human stampede. We observed that there was no mention of the availability of medical charts in five of the reports, of potentially confounding resuscitation efforts in three reports, of cardinal signs in seven reports and of associated injuries to a various degree in all reports. Further, there was mention of supplemental histological examination in two reports and of pre-autopsy radiograph in six reports. We inferred that reliance on experience and individual customary practices led to disparities between the autopsy reports as well as omissions of important information such as cardinal signs, and conclude that such reliance increases the potential for error in autopsy practice. We suggest that pre-autopsy data-gathering and the use of check lists specific to certain injury causes are likely to result in less deviation from evidence-based practices in forensic pathology. Pre-autopsy data-gathering and check lists will help ensure a higher degree of standardization in autopsy reports thus enhancing the quality and accuracy of the report as a legal document as well as rendering it more useful for data-gathering efforts.

Blood alcohol concentration of suicide victims by partial hanging

During the investigated period, 2000-2007, 4249 suicides were reported in Slovenia, and 1061 autopsies of suicide deaths from the central, northwestern, and southwestern parts of Slovenia were conducted at the Institute of Forensic Medicine in Ljubljana. To identify a possible role of alcohol use in the selection of suicide method blood samples were collected during medicolegal autopsies of suicide victims in order to establish their blood alcohol concentration (BAC) level at the time of death. The study group consisted of 844 suicide victims that used violent suicide methods and 174 suicide victims that used non-violent suicide methods. Out of the group with violent suicide methods 184 (21.8%) suicide victims by partial hanging and 112 (13.3%) suicide victims by complete hanging were identified. The average age was higher in the group of suicide victims by partial hanging than in the group of suicide victims by complete hanging (p < 0.001; T = 3653; df = 294). The mean BAC was higher (T = 1.604; df = 278; p < 0.05) in the group of suicide victims by partial hanging (0.57 g/kg; SD ± 0.92) than in the group of suicide victims by complete hanging (0.40 g/kg; SD ± 0.82). The proportion of BAC positive suicide victims with blood alcohol concentration above 0.1 g/kg at the time of death was higher in the group of suicide victims who used non-violent suicide methods in comparison to the group of suicide victims who used violent suicide methods (p < 0.001; χ(2) = 14.988, df = 1). Partial hanging was almost twice as common as complete hanging. Higher BAC in the group of suicide victims by partial hanging and more BAC positive suicide victims in the group who died by non-violent suicide methods could give indications about the role of alcohol in the selection of suicide method.

Forensic investigation of suicide cases in major Greek correctional facilities

INTRODUCTION

According to Greek legislation the medico-legal investigation of deaths occurring in prisons is mandatory. Furthermore, in cases of suicide or of suspected suicide the contribution of medico-legal investigation is of grave importance. The current paper addresses the medico-legal investigation of suicide cases in Greek correctional facilities and aims to describe the current situation.

MATERIALS & METHODS

Our study consists of the meticulous research in the data records of major Greek correctional facilities, for the time period 1999-2010. Official permission was obtained by the Hellenic Ministry of Justice, which provided us the access to the records. Data was also collected from the Piraeus Forensic Service, from the Department of Pathological Anatomy of the University of Athens and finally from our own records. Measures were taken to respect the anonymity of the cases. Data was collected for the social, penal, medical history as well as for the medico-legal investigation.

RESULTS-CONCLUSIONS

It appears that 85.7% of suicide cases were transferred to the Prisoner's Hospital (p < 0.0001), the forensic pathologist who conducted the PME did not perform scene investigation in none of the 70 suicide cases. In a total of 70 cases, histopathological examination, was requested only in 30 cases (42.9%). Hanging was the preferred method for those who committed suicide, followed by the poisoning due to psychoactive substances. Understanding the mistakes made during the forensic investigation of suicide cases inside correctional facilities is necessary, in order to prevent them from occurring again in the future, by implementing appropriate new policies and guidelines.

An analysis of the murder of women in a 10-year period in Eskişehir Province located in western Anatolia in Turkey

Murder of women generally occurs as a result of violence by their husbands and relatives. We evaluated the female victims of murder in Eskişehir, located in western Anatolia, where the education level is high in this study. Our aim was to assess and discuss data related to the victims and murderers. A total of 141 women's murder cases were analysed in the study. After a legal process and the results of the autopsies during 2002-2011 in Eskişehir, 715 subjects found to have died as a result of murder were chosen. Cases were evaluated in terms of their age, marital status, education level, relationship to the murderer, reasons for violence, type of action and reasons for death. It was determined that 48.2% (n = 68) of the victims had been killed by the husband and 7.8% (n = 11) by the ex-husband. Murderers generally stated that the reason of murder was the woman's request for divorce or breaking up (n = 40, 28.4%). In compliance with the literature, the women were most commonly killed by their husbands in our study. Enhancing women's status and preventing violence against women will decrease such murders.

[Forensic analysis of 24 dismembered homicide cases in Shanghai]

OBJECTIVE

To explore the characteristics of the dismembered homicide cases in Shanghai and to provide the valuable guidance for forensic pathological practices.

METHODS

Twenty-four cases of dismembered homicides were selected from 2005 to 2012 in Institute of Forensic Science, Shanghai Public Security Bureau. The general information of the victims and suspects, cause of death, criminal motive, postmortem body parts, tools and information of discarding body parts were retrospectively analyzed.

RESULTS

Among the 24 dismembered homicide cases, victims were female in 16 cases, and suspects were male in 23 cases and were acquaintances in 22 cases. The main causes of death were mechanical asphyxia and traumatic brain injury. Most of the criminal motives were emotional disputes. The number of postmortem body parts was commonly from 20 to 30. The tools were mainly sharp instruments, including kitchen knives used in 20 cases. The postmortem body parts were discarded to different transregional areas, mainly using vehicles.

CONCLUSION

The dismembered homicide cases in Shanghai show the following characteristics: the number of postmortem body parts is in large quantity; the methods of dismembered corpse are complex and different; the job characteristics of suspects are difficult to determine; the distance from homicide scene is far and the vehicles are commonly used.

Anatomopathological findings in hangings: a retrospective autopsy study

BACKGROUND

In this retrospective autopsy study, we aimed to review the anatomopathological findings observed in cases of hanging death for a five year period and to evaluate the role of contributing factors such as age, sex, type of hanging and localization of the ligature knot.

METHODS

Autopsy reports of 102 hanging cases performed by the Department of Forensic Medicine, Faculty of Medicine of Pamukkale University, between January 2007 and September 2011, were retrospectively reviewed.

RESULTS

In the 102 hanging cases 73 of the victims were males (71.6%) and 29 (28.4%) were females, with a mean age of 40.97 ± 17.41 years. All cases were suicidal hanging. Fifty four cases (52.9%) were typical hanging, with the ligature knot located posteriorly. There were petechial hemorrhage on the face and eye lids in 46 (45.1%), ecchymoses of the cervicale muscles in 43 (42.2%), and fractures of the neck structure(s) in 69 cases (67.6%).

CONCLUSIONS

The incidence of neck structure fractures increased with age. In addition, there was no correlation between the incidence of neck structure fractures and sex or type of hanging.

Provisional report on diving-related fatalities in Australian waters 2008

INTRODUCTION

An individual case review of diving-related deaths, reported as occurring in Australia in 2008, was conducted as part of the DAN Asia-Pacific dive fatality reporting project.

METHOD

The case studies were compiled using reports from witnesses, the police and coroners. In each case, the particular circumstances of the accident and details from the post-mortem examination, where available, are provided.

RESULTS

In total, there were 19 reported fatalities (the same as for 2007), 17 involving males. Twelve deaths occurred while snorkelling and/or breath-hold diving,and six while scuba diving. One diver died while using surface-supply breathing apparatus. Two breath-hold divers appear to have died as a result of apnoeic hypoxia, at least one case likely associated with hyperventilation. Two deaths resulted from trauma: one from impact with a boat and the other from an encounter with a great white shark. Cardiac-related issues were thought to have contributed to the deaths of five snorkellers and at least two, possibly three, scuba divers.

CONCLUSIONS

Trauma from a marine creature, snorkelling or diving alone, apnoeic hypoxia and pre-existing medical conditions were once again features in several deaths in this series.

[Retrospective forensic analysis of 483 solved homicide cases in Suzhou city]

OBJECTIVE

To summarize the solved homicide cases taking place in Suzhou city and to find out the characteristics and commonness of them in order to analyze the key points of investigation at the scene.

METHODS

The data of 483 solved homicide cases occurring from January 2006 to March 2010 in the city were analyzed.

RESULTS

Most cases involved 1 victim and 1 suspect, with young male adults dominated. Most of them were non-local residents. The majority of suspects were intentional by passion due to quarrel and dispute. The most common weapons were sharp instruments generally carried by the suspects. Mechanical asphyxia and mechanical injury were the two most common causes of death in these cases.

CONCLUSION

The social characteristics of suspects, criminal motivation, injury instruments, distribution of injuries, cause of death, and manner of death in Suzhou showed similar general characteristics as the experience for detecting homicide cases in the future.

An analysis of the causes of compressed-gas diving fatalities in Australia from 1972-2005

In order to investigate causative factors, root cause analysis (RCA) was applied to 351 Australian compressed-gas diving fatalities from 1972-2005. Each case was described by four sequential events (trigger, disabling agent, disabling injury, cause of death) that were assessed for frequency, trends, and dive and diver characteristics. The average age increased by 16 years, with women three years younger than men annually. For the entire 34-year period, the principal disabling injuries were asphyxia (49%), cerebral arterial gas embolism (CAGE; 25%), and cardiac (19%). There was evidence of a long-term decline in the rate of asphyxia and a long-term increase in CAGE and cardiac disabling injuries. Asphyxia was associated with rough water, buoyancy trouble, equipment trouble, and gas supply trouble. CAGE was associated with gas supply trouble and ascent trouble, while cardiac cases were associated with exertion, cardiovascular disease, and greater age. Exertion was more common in younger cardiac deaths than in older deaths. Asphyxia became less common with increasing age. Equipment-related problems were most common during the late 1980s and less so in 2005. Buoyancy-related deaths usually involved loss of buoyancy on the surface but decreased when buoyancy control devices were used. Countermeasures to reduce fatalities based on these observations will require validation by active surveillance.

[Epidemiological study on the trend of accidental deaths among children under five in Guangzhou, 2001 - 2010]

OBJECTIVE

To study the trend of accidental death among children under 5 years of age.

METHODS

A survey on accidental death among children was performed in Guangzhou to compare the data from the national monitoring program on the deaths under five in the same period during 2001 - 2010. Data on mortality and causes of injures were adjusted by missing reports.

RESULTS

Mortality rates on injuries were decreasing annually from 2001 to 2010. Comparing with 2001, the magnitude of the drop in mortality among the 0, 1 - 4 and under 5 year groups were 72.02%, 77.17% and 74.66% respectively, with statistically significant differences (P = 0.000). During the 10 years of observation, data showed a dropping trend (P = 0.000) of the mortalities on drowning, traffic accident, suffocation and falling, especially on drowning and suffocation. The main causes of death were suffocation in the 0 year group, drowning in the 1-2-year group, traffic accident and poisoning in the 3-year group, traffic accident and falling in the 4-year group. The accidental deaths happened in 'C area' which including Huadu, Conghua, Zengcheng, Panyu and Nansha, with the total proportion of accidental death in Guangzhou as 75.69%.

CONCLUSION

The mortality of accidental deaths among children under 5 years of age in Guangzhou had been decreasing during 2001 - 2010, mainly owing to the practice of intervention programs on drowning and suffocation, suggesting the necessity of integrating the health education programs on accidental injury with the healthcare management system in children in the country, focusing on the suburban and county levels where economy was relatively undeveloped or with more floating population.

Suffocation deaths associated with use of infant sleep positioners--United States, 1997-2011

Unintentional suffocation is the leading cause of injury death among children aged <1 year in the United States, accounting for nearly 1,000 infant deaths annually. Since 1984, an estimated fourfold increase has been observed in accidental suffocation and strangulation in bed, with many of these deaths linked to unsafe sleep environments. Infant sleep positioners (ISPs) are devices intended to keep an infant in a specific position while sleeping, yet ISPs have been reported to have been present in the sleep environment in some cases of unintentional infant suffocation. Some specific ISPs have been cleared by the Food and Drug Administration (FDA) for the management of gastroesophageal reflux or plagiocephaly (asymmetry of the skull). However, many unapproved ISPs have been marketed to the general public with claims of preventing sudden infant death syndrome (SIDS), improving health, and enhancing sleep comfort. To characterize infant deaths associated with ISPs, FDA, the U.S. Consumer Product Safety Commission (CPSC), and CDC examined information reported to CPSC about 13 infant deaths in the past 13 years associated with the use of ISPs. In this case series, all infants but one were aged ≤3 months, and most were placed on their sides to sleep. Many were found prone (i.e., lying on their abdomens). Accompanying medical issues included prematurity and intercurrent respiratory illnesses. When providing guidance for parents of newborns, health-care providers need to emphasize the importance of placing infants to sleep on their backs in a safe sleep environment. This includes reminders about the American Academy of Pediatrics (AAP) recommendations against side sleep position, ISPs and pillows, comforters, and other soft bedding.

[Lethal course following overlooked foreign body in the airway]

A 52-year-old previously healthy woman suffered death from choking. Asphyxia after aspiration of a foreign body is a well-known, but frequently overlooked cause of sudden death. We describe a case in which a foreign body in the airway was initially overlooked. Early recognition and treatment might have altered the outcome.

[Sudden deaths by hobble restraint of severely hyperactive persons]

Cardiac arrest may occur while persons are being kept in hobble restraint. It has been suggested that asphyxia caused by the restraint position, so-called restraint asphyxia, is the cause, but experimental evidence has not confirmed this theory. Some of the sudden deaths are associated with excited delirium syndrome (EDS), an acute condition characterized by a hyperactive, combative behaviour in individuals, who are influenced by psychoactive drugs or suffer from psychiatric illness. Autopsy findings fail to explain this type of deaths. The pathophysiology of EDS is complex and poorly understood. Sensibilisation of the heart by a hyperadrenergic autonomous dysfunction, metabolic acidosis and hyperthermia offer possible mechanisms.

Declines in the lethality of suicide attempts explain the decline in suicide deaths in Australia

Background

To investigate the epidemiology of a steep decrease in the incidence of suicide deaths in Australia.

Methods

National data on suicide deaths and deliberate self-harm for the period 1994–2007 were obtained from the Australian Institute of Health and Welfare. We calculated attempt and death rates for five major methods and the lethality of these methods. Negative binomial regression was used to estimate the size and significance of method-specific time-trends in attempts and lethality.

Results

Hanging, motor vehicle exhaust and firearms were the most lethal methods, and together accounted for 72% of all deaths. The lethality of motor vehicle exhaust attempts decreased sharply (RR = 0.94 per year, 95% CI 0.93–0.95) while the motor vehicle exhaust attempt rate changed little; this combination of motor vehicle exhaust trends explained nearly half of the overall decline in suicide deaths. Hanging lethality also decreased sharply (RR = 0.96 per year, 95% CI 0.956–0.965) but large increases in hanging attempts negated the effect on death rates. Firearm lethality changed little while attempts decreased.

Conclusion

Declines in the lethality of suicide attempts–especially attempts by motor vehicle exhaust and hanging–explain the remarkable decline in deaths by suicide in Australia since 1997.