Methods of suicide: international suicide patterns derived from the WHO mortality database

The effectiveness of structural interventions at suicide hotspots: a meta-analysis

BACKGROUND

Certain sites have gained notoriety as 'hotspots' for suicide by jumping. Structural interventions (e.g. barriers and safety nets) have been installed at some of these sites. Individual studies examining the effectiveness of these interventions have been underpowered.

METHOD

We conducted a meta-analysis, pooling data from nine studies.

RESULTS

Following the interventions, there was an 86% reduction in jumping suicides per year at the sites in question (95% CI 79% to 91%). There was a 44% increase in jumping suicides per year at nearby sites (95% CI 15% to 81%), but the net gain was a 28% reduction in all jumping suicides per year in the study cities (95% CI 13% to 40%).

CONCLUSIONS

Structural interventions at 'hotspots' avert suicide at these sites. Some increases in suicide are evident at neighbouring sites, but there is an overall gain in terms of a reduction in all suicides by jumping.

Suicide, guns, and public policy

Suicide is a serious public health concern that is responsible for almost 1 million deaths each year worldwide. It is commonly an impulsive act by a vulnerable individual. The impulsivity of suicide provides opportunities to reduce the risk of suicide by restricting access to lethal means. In the United States, firearms, particularly handguns, are the most common means of suicide. Despite strong empirical evidence that restriction of access to firearms reduces suicides, access to firearms in the United States is generally subject to few restrictions. Implementation and evaluation of measures such as waiting periods and permit requirements that restrict access to handguns should be a top priority for reducing deaths from impulsive suicide in the United States.

Most common methods of suicide in Eastern Mediterranean Region of WHO: a systematic review and meta-analysis

The aim of this study is to determine the frequency of various methods of suicide in Eastern Mediterranean Region by a systematic review and meta-analysis. All published articles in international database were systematically searched before September 2011. In order to analyze the data we used STATA, ver.10 software. We reported proportions with standard errors (SE) for single studies and pooled estimates for proportions of different suicidal methods based on random model meta-analysis. We included 19 articles in the final analysis. The pooled proportion of hanging, self-immolation, and poisoning were 39.7% (95% CI: 26.8%-52.7%), 17.4% (95% CI: 10%-24.8%), and 20.3% (95% CI: 14%-26.5%) respectively. Self-immolation and poisoning were gender dependent and hanging was country dependent in the meta-regression method. We found out that the 3 most common methods of suicide in EMR are hanging, poisoning, and self-immolation. These methods are estimated to account for 77.4% of all methods of suicide in EMR.

Suicide or accident? A psychological autopsy study of suicide in youths under the age of 16 compared to deaths labeled as accidents

OBJECTIVE

In the present paper, we describe suicide in youths under 16 years of age and compare their risk factors for suicide to those of older adolescents as described in the literature. Furthermore, we evaluate the possible mislabeling of suicides as accidents, and vice versa.

METHOD

We used the data from a nationwide psychological autopsy of youths 15 years and younger who had committed suicide or died in accidents in Norway from 1993 to 2004 (n = 84). We additionally constructed a suicide index to distinguish between the two causes of death.

RESULTS

The young suicide victims presented, with little gender difference, fewer obvious risk factors and less suicide intent than commonly described for older adolescents. The suicide index distinguished quite well between suicides and accidents, with few cases indicating a possible mislabeling, although some suicide cases could have been labeled as uncertain.

CONCLUSION

In line with previous research, suicides in 11-15-year-olds have many similarities to suicides in older adolescents in terms of external circumstances, but they present less apparent warning signs. In our total sample of 84 deaths, there were few indications of incorrect labeling.

Do-Not-Resuscitate Orders in Fatal Toxic Exposures: A Poison Center's Review

INTRODUCTION

Self-exposure is a leading method for suicide both in the United States and worldwide and thus is a major preventable public health issue. Surrogate decision makers are tasked with making medical decisions for the patient while keeping the patient's wishes in mind. Decisions related to code status become more complicated when the patient's situation is the result of a suicidal act. The objectives were to 1) determine how frequently Do Not Resuscitate orders (DNR orders) are placed for the intentionally self-exposed (ISE) patient using the Regional Poison Control Center (RPCC) data, and 2) identify if DNR orders in intentionally self-exposed patients were placed before or after development of poor prognostic signs.

METHODS

We analyzed all exposure-related deaths reported to the RPCC from January 1, 2000 to December 31, 2010. We reviewed data for the following: exposure intent, exposure substance, outcome, age, code status, date of DNR/withdrawal of care order, previous suicide attempts, and poor prognostic signs.

RESULTS

Of the 476 total deaths, nearly half were the result of an intentional self-exposure (n= 235; 49.4%). Most deaths, when code status was reported, had advanced cardiac life support, or "full codes" (n=131; 55.6%). Of the total deaths with a DNR or withdrawal of care order (n=104), over half were from an ISE (n=55; 52.9%). A higher percentage of the ISEs had a DNR order/withdrawal of care order; however, it was not a statistically significant difference OR 1.23 (95% CI 0.64, 2.37). of intent, patients treated as full codes were on average 19.5 years younger than the DNR orders group. Only 2 DNR orders were placed prior to development of poor prognostic signs. Unintentional self-exposures consumed a mean of 1.4 substances (range 1 to 4). ISEs consumed a mean of 2.3 substances (range 1 to 19).

CONCLUSION

People are often asked to make life-and-death decisions for a loved one. The nature of the exposure can complicate the issue if the exposure has an antidote or is known to have a limited effect. Further study is needed to assess the extent of these cases and to identify optimal management guidelines or policy to aid both the medical teams caring for these patients and the surrogate decision makers.

Means restriction for suicide prevention

Limitation of access to lethal methods used for suicide--so-called means restriction--is an important population strategy for suicide prevention. Many empirical studies have shown that such means restriction is effective. Although some individuals might seek other methods, many do not; when they do, the means chosen are less lethal and are associated with fewer deaths than when more dangerous ones are available. We examine how the spread of information about suicide methods through formal and informal media potentially affects the choices that people make when attempting to kill themselves. We also discuss the challenges associated with implementation of means restriction and whether numbers of deaths by suicide are reduced.

Complex contribution of combat-related post-traumatic stress disorder to veteran suicide: facing an increasing challenge

PURPOSE

The purpose of this case study is to present the complex contribution of combat-related post-traumatic stress disorder (PTSD) to suicide and international standards of treatment among veterans deployed to the Middle East.

CONCLUSIONS

PTSD carries increased physical and psychological health risk in combat soldiers. Internationally, guidelines for PTSD promote cognitive behavior therapies, specifically exposure therapy, as first line treatment; however, implementation varies among countries.

PRACTICE IMPLICATIONS

Evidence supports the benefit of exposure-based psychotherapy for combat-related PTSD. Commonly prescribed antidepressants and other psychotherapy treatments may not be as beneficial.

Suicide methods in Asia: implications in suicide prevention

As the largest continent in the World, Asia accounts for about 60% of World suicides. Preventing suicide by restricting access to suicide methods is one of the few evidence-based suicide prevention strategies. However, there has been a lack of systematic exploration of suicide methods in Asian countries. To amend this shortage, the current review examines the leading suicide methods in different Asian countries, their trend, their age- and sex- specific characteristics, and their implications for suicide prevention. In total, 42 articles with leading suicide methods data in 17 Asian countries/regions were retrieved. The epidemiologic characteristics and recent trends of common suicide methods reflect specific socio-cultural, economic, and religious situations in the region. Common suicide methods shift with the introduction of technologies and constructions, and have specific age- or sex-characteristics that may render the restriction of suicide methods not equally effective for all sex and age sub-groups. Charcoal burning, pesticide poisoning, native plant poisoning, self-immolation, and jumping are all prominent examples. In the information society, suicide prevention that focuses on suicide methods must monitor and control the innovation and spread of knowledge and practices of suicide "technologies". It may be more cost-effective to design safety into technologies as a way of suicide prevention while there is no rash of suicides yet by the new technologies. Further research on suicide methods is important for public health approaches to suicide prevention with sensitivity to socio-cultural, economic, and religious factors in different countries.

Stoicism and Sensation Seeking: Male Vulnerabilities for the Acquired Capability for Suicide

Our aim was to investigate two personality traits (i.e., stoicism and sensation seeking) that may account for well-established gender differences in suicide, within the framework of the interpersonal theory of suicide. This theory proposes that acquired capability for suicide, a construct comprised of pain insensitivity and fearlessness about death, explains gender differences in suicide. Across two samples of undergraduates (N = 185 and N = 363), men demonstrated significantly greater levels of both facets of acquired capability than women. Further, we found that stoicism accounted for the relationship between gender and pain insensitivity, and sensation seeking accounted for the relationship between gender and fearlessness about death. Thus, personality may be one psychological mechanism accounting for gender differences in suicidal behavior.

Hostility, physical aggression and trait anger as predictors for suicidal behavior in Chinese adolescents: a school-based study

Purpose

This study explored the extent to which trait aggression is associated with suicidal behavior in a nationwide school-based sample of adolescents.

Methods

A nationwide sample of 14,537 high school students in urban areas of China was recruited. Information concerning suicide ideation, plans, attempts, trait aggression and other risk factors was collected by a self-reported questionnaire. Multivariate regression analyses were employed to predict suicidal behavior.

Results

Approximately 18.5% of students reported suicide ideation, 8.7% reported suicide plans, and 4.1% reported attempts during the past one year. Hostility and trait anger had a significant positive association with suicidal ideation. Hostility and physical aggression were positively related to suicide plans. Hostility had a positive correlation with suicide attempts, while trait anger was inversely associated with suicide attempts.

Conclusions

This study suggests that hostility, physical aggression and trait anger may be able to be used to predict suicidal behavior among adolescents. Suicide prevention programs should target at attenuating the severity of hostility, anger and physical aggression. But teachers and parents should also give close attention to students with low trait anger.

Suicide by multiple blunt head traumatisation using a stone

Apart from collisions with road or rail vehicles and falls from height, self inflicted blunt force is a rare suicide method and mainly seen in psychiatric patients. The paper presents a rare case of suicide by active blunt force. A 68-year-old man committed suicide by repeatedly hitting his head with a stone. He sustained a craniocerebral trauma and finally died from hypothermia due to the low outdoor temperature. According to the relatives, the man was not diagnosed with a mental disorder or suicidal tendencies. Uncommon manners of self-harm are challenging for those involved in the investigation, and a differentiation between suicide, accident and homicide can only be made in synopsis of all findings.

From pesticides to medicinal drugs: time series analyses of methods of self-harm in Sri Lanka

OBJECTIVE

To explore if recent changes in methods of self-harm in Sri Lanka could explain the decline in the incidence of suicide.

METHODS

Time series analyses of suicide rates and hospitalization due to different types of poisoning were carried out.

FINDINGS

Between 1996 and 2008 the annual incidence of hospital admission resulting from poisoning by medicinal or biological substances increased exponentially, from 48.2 to 115.4 admissions per 100,000 population. Over the same period, annual admissions resulting from poisoning with pesticides decreased from 105.1 to 88.9 per 100,000. The annual incidence of suicide decreased exponentially, from a peak of 47.0 per 100,000 in 1995 to 19.6 per 100,000 in 2009. Poisoning accounted for 37.4 suicides per 100,000 population in 1995 but only 11.2 suicides per 100,000 in 2009. The case fatality rate for pesticide poisoning decreased linearly, from 11.0 deaths per 100 cases admitted to hospital in 1997 to 5.1 per 100 in 2008.

CONCLUSION

Since the mid 1990s, a trend away from the misuse of pesticides (despite no reduction in pesticide availability) and towards increased use of medicinal and other substances has been seen in Sri Lanka among those seeking self-harm. These trends and a reduction in mortality among those suffering pesticide poisoning have resulted in an overall reduction in the national incidence of accomplished suicide.

Controlling access to suicide means

Background: Restricting access to common means of suicide, such as firearms, toxic gas, pesticides and other, has been shown to be effective in reducing rates of death in suicide. In the present review we aimed to summarize the empirical and clinical literature on controlling the access to means of suicide. Methods: This review made use of both MEDLINE, ISI Web of Science and the Cochrane library databases, identifying all English articles with the keywords “suicide means”, “suicide method”, “suicide prediction” or “suicide prevention” and other relevant keywords. Results: A number of factors may influence an individual’s decision regarding method in a suicide act, but there is substantial support that easy access influences the choice of method. In many countries, restrictions of access to common means of suicide has lead to lower overall suicide rates, particularly regarding suicide by firearms in USA, detoxification of domestic and motor vehicle gas in England and other countries, toxic pesticides in rural areas, barriers at jumping sites and hanging, by introducing “safe rooms” in prisons and hospitals. Moreover, decline in prescription of barbiturates and tricyclic antidepressants (TCAs), as well as limitation of drugs pack size for paracetamol and salicylate has reduced suicides by overdose, while increased prescription of SSRIs seems to have lowered suicidal rates. Conclusions: Restriction to means of suicide may be particularly effective in contexts where the method is popular, highly lethal, widely available, and/or not easily substituted by other similar methods. However, since there is some risk of means substitution, restriction of access should be implemented in conjunction with other suicide prevention strategies.

Suicide methods in singapore (2000-2004): types and associations

The choice of suicide methods varies between countries. Common methods used in Singapore between 2000 and 2004 were jumping (72.4%), hanging (16.6%), and poisoning (5.9%). Those who jumped were more likely to be young, single, female, and to have had a major mental illness. By comparison, those who hung themselves were more likely to be older (OR 2.68), Indian (OR 2.32), and to leave a suicide note (OR 1.53). Those who used poison were more likely to be married (OR 2.33), to be on antidepressants (OR 2.40), to have previously attempted suicide (OR 2.13), and to leave a letter (OR 2.30). The choice was determined by accessibility, acceptability, generational, gender, and racial factors.

The effect of national suicide prevention programs on suicide rates in 21 OECD nations

Suicide has become a serious and growing public health problem in many countries. To address the problem of suicide, some countries have developed comprehensive suicide prevention programs as a collective political effort. However, no prior research has offered a systematic test of their effectiveness using cross-national data. This paper evaluates whether the national suicide prevention programs in twenty-one OECD nations had the anticipated effect of reducing suicide rates. By analyzing data between 1980 and 2004 with a fixed-effect estimator, we test whether there is a statistically meaningful difference in the suicide rates before and after the implementation of national suicide prevention programs. Our panel data analysis shows that the overall suicide rates decreased after nationwide suicide prevention programs were introduced. These government-led suicide prevention programs are most effective in preventing suicides among the elderly and young populations. By contrast, the suicide rates of working-age groups, regardless of gender, do not seem to respond to the introduction of national prevention programs. Our findings suggest that the presence of a national strategy can be effective in reducing suicide rates.

Suicide in Indigenous people in Queensland, Australia: trends and methods, 1994-2007

OBJECTIVE

Suicide among Indigenous Australians is a well-recognized public health issue. Due to scarcity of epidemiological investigations in this area the exact size of this problem and its main characteristics remain uncertain. In this paper we present trends and methods of Indigenous suicides based on the Queensland Suicide Register for the period 1994-2007.

METHODS

Trends of age-standardized suicide rates were calculated for Indigenous and non-Indigenous populations. Suicide methods were compared between the two groups, with particular focus on hanging. Discriminant analysis was used to ascertain the size of under-estimation of suicide rates due to a considerable number of cases with unknown ethnicity in the Queensland Suicide Register.

RESULTS

Between 1994 and 2007, Indigenous populations had suicide rates 2.2 times higher than non-Indigenous Australians. Age-specific suicide rates for Indigenous men were highest in the 25-34 age group, while in women they were highest among 15-24 year olds. In children younger than 15 years, Indigenous suicide rate was almost ten times higher than of non-Indigenous counterparts. More than 90% of Indigenous suicides occurred by hanging. It was estimated that lack of information about ethnicity for 7% of suicide cases might have caused an under-estimation of Indigenous suicide mortality for 15.4% in men and 9.1% in women in the period 1994-2007.

CONCLUSIONS

Suicide mortality of Indigenous Australians has reached alarming levels, particularly among youths. The unique profile of Indigenous suicides indicates the need for specifically tailored preventative programmes.

Suicide by firearms on the island of Crete: a 9-year record

BACKGROUND

Whereas firearm suicide mortality has been a longstanding public concern worldwide, in Greece no systematic analysis has been reported so far despite the recent evidence of a rising rate of gun ownership.

AIMS

To estimate the proportion of firearm suicides on the island of Crete, Southern Greece, well-known for its widespread gun ownership; to describe the victims' sociodemographic profile and firearm-related suicide variables; and to assess the severity of suicidal intention in the group.

METHODS

Records of suicides between 1999 and 2007 were reviewed and information was extracted into a computerized database. A rating of the circumstances section of the Beck's Suicide Intent Scale (SIS) for each case was also performed.

RESULTS

The firearm suicide rate was 1.3 per 100,000, with males constituting the vast majority. These men were more likely to be less than 55 years of age, to have lived in the western part of the island, to have some degree of planning prior to the suicidal act, and to have used a shotgun, but less likely to have left a note.

CONCLUSIONS

As an important first step toward implementing preventive initiatives the authors stress the need for a thorough look at the sociocultural factors associated with firearms in the region.

Firearm suicides and availability of firearms: the Swiss experience

This study aimed to examine the association between the availability of firearms at home, and the proportion of firearm suicides in Switzerland in an ecological analysis. The data series were analysed by canton and yielded a fairly high correlation (Spearman's rho=0.60). Thus, the association holds also at a sub-national level.

Characteristics of young suicides by violent methods in rural China

Suicide is one of the most common public health problems in the world. Information on 392 completed suicides aged 15-34 years were consecutively collected from 16 counties in three provinces of China. Information on each suicide was obtained from two informants. The results showed ingesting pesticides or other poisons (73.5%) and hanging (10.5%) were the two most common methods of suicide. Suicides happened more in autumn (30.10%) or summer (27.29%), nighttime (68.3%), and at home (73.6%). However, suicides with violent methods were more common in winter and spring and outside of home. Season (autumn or summer), place (at home), and pesticide stored in home were negatively while depression was positively associated with violent methods of suicide. Characteristics of the suicides by violent methods are different from those by nonviolent methods. Investigations into the methods of rural young suicides are necessary for suicide prevention in China.

Drug suicide: a sex-equal cause of death in 16 European countries

Background

There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex- and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84).

Methods

Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated.

Results

No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (X61) ranked second. The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low X64 and high X61 figures, Scotland had high levels of X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk.

Conclusions

Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level.

Jumping, lying, wandering: analysis of suicidal behaviour patterns in 1,004 suicidal acts on the German railway net

Current knowledge on behavioural patterns and personal characteristics of subjects who choose the railway as means of suicide is sparse. The aim of this study was to determine the frequency of three distinct behaviour patterns (jumping, lying, wandering) in railway suicides and to explore associated variables. Cases were derived from the National Central Registry of person accidents on the German railway net covering the period from 2002 to 2006. A retrospective analysis of registry protocols of all 4127 suicidal acts allowed classification of behaviour patterns in 1004 cases. Types of suicidal behaviour occurred with nearly equal frequencies; jumping in 32.2%, lying in 32.6% and wandering in 34.2% of cases. Age and sex were not associated with type of suicidal behaviour. The proportion of jumping was highest during 9:01 am to 6:00 pm while at night, lying was used most frequently. Jumping predominated in the station area, while lying and wandering on the open track. Fatality was highest in liers and lowest in jumpers. The frequency of jumping decreased during the study period by 12.6% (p < .05). These findings may help to elucidate differential risk features of this highly lethal suicide method.

Suicide and mental illness: a clinical review of 15 years findings from the UK National Confidential Inquiry into Suicide

INTRODUCTION

Suicide risk is most commonly associated with mental illness. In particular, suicide in people under mental health care presents distinct patterns of risk and opportunities for prevention due to their close proximity to specialist care.

SOURCES OF DATA

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (Inquiry) is a unique UK-wide national database of all suicide cases in contact with mental health services in the 12 months preceding suicide. This review presents Inquiry findings from the beginning of the Inquiry in 1996 up to the present (2011) (15 years).

AREAS OF AGREEMENT

Suicide varies substantially by socio-demographic (age, gender) and clinical features (e.g. diagnosis; care variables). Effective suicide prevention initiatives should incorporate research findings to inform clinical practice and policy.

AREAS OF CONTROVERSY

Risk assessment remains one of the most difficult areas of clinical practice and management although all areas of clinical practice, research and policy development would benefit from continued high-quality studies.

GROWING POINTS

The Inquiry work has positively influenced mental health practice and policy in the UK. These changes include: falling suicide rates in mental health patients, informing suicide prevention strategies and developing safety checklists for mental health services.

AREAS TIMELY FOR DEVELOPING RESEARCH

Investigating suicide in non-mental health settings, investigating suicide following different treatment services and investigating models of service delivery could usefully inform future directions for improving patient safety.

Self-poisoning suicide deaths in England: could improved medical management contribute to suicide prevention?

BACKGROUND

Suicide by self-poisoning is a major cause of death worldwide. Few studies have investigated the medical management of fatal self-poisoning.

AIM

To describe the characteristics and management of a national sample of individuals who died by intentional self-poisoning in hospital and assess the quality of care that they received.

DESIGN

National population-based descriptive study and confidential inquiry.

METHODS

Adults (aged ≥ 16 years) who had died by self-poisoning in English hospitals in 2005 and received a coroner's verdict of suicide or undetermined death at inquest were included. Socio-demographic and clinical data were collected through detailed questionnaires sent to clinicians at the treating hospitals. A panel of three expert assessors rated each case with respect to quality of care and likely contribution to the fatal outcome.

RESULTS

We obtained information on 121 cases (response rate for questionnaires 77%). Expert assessors rated 41/104 cases [39% (95% CI 30-49%)] as having received inadequate care; in the majority (38/41-93%) of these, this poor care was felt to have potentially contributed to the patient's death. The most common reason for a rating of inadequate care was poor airway management (recorded in over half of inadequate care cases). In three cases, the receipt of inadequate care was associated with the presence of some form of advance directive.

CONCLUSION

In as many as 39% of in-hospital self-poisoning fatalities, the care received may be in some way sub-optimal. The challenge for clinical services is to ensure that optimal management strategies are implemented in practice.

Comparison of patients with and without mental disorders treated for suicide attempts in the emergency departments of four general hospitals in Shenyang, China

OBJECTIVE

Compare the sociodemographic and psychological characteristics of suicide attempters admitted to emergency departments of general hospitals in China that do and do not meet diagnostic criteria for mental disorders.

METHODS

The Structured Clinical Interview for DSM-IV, the Suicide Ideation Scale, the Hamilton Depression Rating Scale and a quality of life measure were administered to 239 consecutive suicide attempters who were treated in the emergency departments of four randomly selected general hospitals in Shenyang.

RESULTS

Among the enrolled subjects, 166 (69.5%) met diagnostic criteria for a current mental disorder. Among these 166 subjects, 62.7% had mood disorders, 14.5% had anxiety disorders, 10.8% had psychotic disorders and 3.6% had substance use disorders. The 73 suicide attempters without a mental disorder were younger, had higher levels of impulsiveness and were more likely to have ideas about being rescued. Multivariate logistic regression analysis identified the following independent predictors of having a current psychiatric disorder in the suicide attempters: female gender (OR=3.67, 95% CI=1.23-10.91), more than 6 years of formal education (OR=1.19, 95% CI=1.04-1.36), a higher score on the suicide ideation scale (OR=1.01, 95% CI=1.00-1.03), a higher score on Hamilton depression rating scale (OR=1.26, 95% CI=1.16-1.37) and a lower score on the quality of life scale (OR=0.75, 95% CI=0.63-0.90).

CONCLUSION

The prevalence of psychiatric disorders in suicide attempters in emergency departments of urban China is lower than that reported in most western countries. Suicide attempters with and without mental illnesses are distinct on a number of important dimensions. Mental health assessment and appropriate discharge planning for patients treated in emergency departments for suicide attempts are crucial components of comprehensive suicide prevention efforts.

The leading methods of suicide in Taiwan, 2002-2008

Background

Diverse socioeconomic and cultural developments between geographic regions and cities/counties have resulted in different physical availability and socio-cultural acceptability of certain methods of suicide. This study examined the changes in distribution of the leading methods of suicide across cities/counties in Taiwan between 2002-04 and 2006-08.

Methods

Mortality data for all deaths classified as suicide or as of undetermined intent from 2002 through 2008 were extracted for analysis. The number of deaths and proportion of completed suicides by four main methods were calculated in order to identify the leading lethal methods in each city/county.

Results

Hanging was the leading method of suicide in 18 out of 22 cities/counties in 2002-04 but decreased to 10 out of 22 in 2006-08. On the other hand, charcoal burning was not the leading method in any city/county in 2002-04 but increased to 10 out of 22 in 2006-08. The younger the age of the deceased, the more likely the leading method of suicide changed from 2002-04 to 2006-08. Charcoal burning was the most often used method in most cities/counties among those aged 15-44; however, hanging was most frequent for those aged 45 or above. Pesticides were the leading method for the elderly in five counties with a high percentage of agricultural population in 2006-08.

Conclusion

The leading method of suicide varied by age group and changed from 2002-04 to 2006-08 in Taiwan. This was due primarily to changes in socio-cultural acceptability of the use of charcoal burning as a method for suicide by younger age groups.

Seasonality in suicide--a review and search of new concepts for explaining the heterogeneous phenomena

Seasonality is one of the oldest and most resistant-to-elucidation issues in suicide research. However, in recent years epidemiological research has yielded new results, which provide new perspectives on the matter. This qualitative review summarizes research published since the 1990 s. In particular, the focus is on studies dealing with the historical change of seasonality, cross-sectional comparisons including method-specific diversity, and the association with weather variables and other putative covariates. Recent research has shown that in Western countries the seasonality of suicide is tending to diminish and may, eventually, disappear. It can no longer be considered a universal and homogeneous phenomenon. In addition, different major seasonal cycles have now been determined which mainly depend on different suicide methods. Just as in the epidemiology of suicide methods, the (seasonal) availability and perceived adequacy of methods emerge as the major driving force beyond the seasonal phenomena in suicide.

Epidemiology of paediatric out-of-hospital cardiac arrest in Melbourne, Australia

BACKGROUND

Previous studies of paediatric cardiac arrest have reported a low survival rate but there is limited data from Australia. We sought to determine the characteristics and outcomes of paediatric out-of-hospital cardiac arrest in Melbourne, Australia.

METHODS

Between October 1999 and June 2007, all cases of out-of-hospital cardiac arrest attended by emergency medical services in Melbourne, Australia were entered into a database (the Victorian Ambulance Cardiac Arrest Registry). Data on patients aged less than 16 years in cardiac arrest on arrival of ambulance paramedics was analysed.

RESULTS

There were 209 children in cardiac arrest on arrival of paramedics during the study period. Of these, resuscitation was not attempted in 16 children due to signs of definite death. Of the 193 children who had attempted resuscitation, 143 (74%) had an initial cardiac rhythm of asystole, 36 (18%) were in pulseless electrical activity and 14 (7%) were in ventricular fibrillation. There were 49 patients (25%) with return of spontaneous circulation at arrival to hospital of whom 14 (7%) survived to hospital discharge. Of 138 patients without return of a circulation, 120 were transported to hospital with continuing resuscitation and one survived (0.9%). Survival was higher in patients with an initial cardiac rhythm of ventricular fibrillation (5/14; 35%) compared with other rhythms (10/179; 4%), OR 9.38, 95% CI 2.64-33.2.

CONCLUSIONS

Overall, 7.7% of paediatric patients with out-of-hospital cardiac arrest survive to leave hospital. Increased survival was seen if the initial cardiac rhythm was ventricular fibrillation. Survival was very rare (<1%) unless there was return of spontaneous circulation prior to hospital arrival.

Characteristics of pesticide-related hospitalizations, Louisiana, 1998-2007

OBJECTIVE

Pesticides are widely used on agricultural crops and in homes, workplaces, and public spaces. Exposure to pesticides can cause acute and chronic health effects. We analyzed data from the Louisiana Hospital Inpatient Discharge Database from 1998 through 2007 to characterize hospitalizations involving pesticides.

METHODS

Data for the study period consisted of 384 pesticide-related hospitalizations. We used demographic information and diagnosis codes for analysis.

RESULTS

Males consistently had higher hospitalization rates than females (p=0.0073). Children aged 0-4 years had the highest pesticide-related hospitalization rate of all age groups (2.69 hospitalizations per 100,000); children aged 5-9 years had the lowest rate (0.36 hospitalizations per 100,000). Compared with adults, children had a higher rate of disinfectant exposure (15% vs. 5%; odds ratio [OR] = 3.41, 95% confidence interval [CI] 1.61, 7.21; p=0.0008) and rodenticide exposure (14% vs. 2%; OR=8.55, 95% CI 3.07, 23.78; p<0.0001). Rural parishes (counties) were more likely than urban parishes to have higher pesticide hospitalization rates (OR=4.72, 95% CI 2.34, 9.54; p<0.0001). Intentional poisonings accounted for 27% of cases. Only eight cases were coded as work-related.

CONCLUSIONS

Analyzing pesticide-related hospitalization data provides important information about some of the most severe pesticide poisoning cases. Significant findings include the elevated rate of hospitalizations among young children and men, and the large proportion of self-inflicted poisonings. Health departments and health-care providers may use these findings to target outreach and prevention activities.

Impact of Traumatic Suicide Methods on a Level I Trauma Center

Suicide is a major, preventable public health issue. Although firearm-related mechanisms commonly result in death, nonfirearm methods cause significant morbidity and healthcare expenditures. The goal of this study is to compare risk factors and outcomes of firearm and nonfirearm traumatic suicide methods. This retrospective cohort study identified 146 patients who attempted traumatic suicide between 2002 and 2007 at a Level I trauma center. Overall, mean age was 40.2 years, 83 per cent were male, 74 per cent were white, and mean Injury Severity Score (ISS) was 12.7. Most individuals (53%) attempted suicide by firearms and 25 per cent died (84% firearm, 16% nonfirearm techniques). Subjects were more likely to die if they were older than 60 years-old, presented with an ISS greater than 16, or used a firearm. On average, patients using a firearm were older and had a higher ISS and mortality rate compared with those using nonfirearm methods. There was no statistical difference between cohorts with regard to gender, ethnicity, positive drug and alcohol screens, requirement for operation, intensive care unit admission, and hospital length of stay. Nonfirearm traumatic suicide prevention strategies aimed at select individuals may decrease overall attempts, reduce mechanism-related mortality, and potentially impact healthcare expenditures.

The evolution of the epidemic of charcoal-burning suicide in Taiwan: a spatial and temporal analysis

BACKGROUND

An epidemic of carbon monoxide poisoning suicide by burning barbecue charcoal has occurred in East Asia in the last decade. We investigated the spatial and temporal evolution of the epidemic to assess its impact on the epidemiology of suicide in Taiwan.

METHODS AND FINDINGS

Age-standardised rates of suicide and undetermined death by charcoal burning were mapped across townships (median population aged 15 y or over = 27,000) in Taiwan for the periods 1999-2001, 2002-2004, and 2005-2007. Smoothed standardised mortality ratios of charcoal-burning and non-charcoal-burning suicide and undetermined death across townships were estimated using Bayesian hierarchical models. Trends in overall and method-specific rates were compared between urban and rural areas for the period 1991-2007. The epidemic of charcoal-burning suicide in Taiwan emerged more prominently in urban than rural areas, without a single point of origin, and rates of charcoal-burning suicide remained highest in the metropolitan regions throughout the epidemic. The rural excess in overall suicide rates prior to 1998 diminished as rates of charcoal-burning suicide increased to a greater extent in urban than rural areas.

CONCLUSIONS

The charcoal-burning epidemic has altered the geography of suicide in Taiwan. The observed pattern and its changes in the past decade suggest that widespread media coverage of this suicide method and easy access to barbecue charcoal may have contributed to the epidemic. Prevention strategies targeted at these factors, such as introducing and enforcing guidelines on media reporting and restricting access to charcoal, may help tackle the increase of charcoal-burning suicides. Please see later in the article for the Editors' Summary.

Lethal means reduction: what have we learned?

PURPOSE OF REVIEW

Suicide is an important global public health problem. Across nations, suicide rates are linked to the availability of lethal means. Three methods dominate country-specific suicide rates: firearms, pesticides, and hanging. There is increasing international support for reducing the availability of lethal means to prevent suicide. This article reviews evidence regarding lethal means reduction as a suicide-prevention strategy.

RECENT FINDINGS

Most evidence in support of means reduction comes from ecological studies examining the association between population-level decreases in the availability of a given lethal means of suicide and method-specific suicide rates. Substantial declines in method-specific suicide rates were shown following reductions in availability of lethal means through initiatives such as the passage of firearm control laws, detoxification of domestic gas, modification of drug packaging and toxicity, and installation of barriers at jump sites. The vast majority of the evidence for the effectiveness of lethal means reduction relates to reducing the availability of firearms and pesticides.

SUMMARY

Implementing means reduction at both the population and individual levels poses many challenges, particularly when political issues arise during regulation of firearms or pesticides. Nevertheless, evidence strongly suggests that means reduction is effective and should be an important part of a suicide-prevention strategy.