A truly national National Violent Death Reporting System

The impact of suicide registers and other monitoring systems on suicide prevention: A scoping review

BACKGROUND

Decreasing suicide mortality has become an overarching goal for societies worldwide. Suicide registers and other monitoring systems are a valuable source of information that can be used for addressing the suicide phenomenon and evaluating preventative interventions.

AIMS

This scoping review provides an overview of literature published in the last decade that has focussed on the operations (functioning) and characteristics of suicide registers and other suicide monitoring systems.

METHODS

Four electronic databases were searched in 2020 for identifying published material from January 2010 to October 2020. The searches were updated in October 2023 to include material from 2020 to date. Grey literature through Google searches and mental health commissions websites and the reference lists of selected documents were also searched.

RESULTS

Twenty-five articles were included in this review. Nearly half the articles were from the United States, followed by Australia. Nine countries were identified as having used suicide registers or suicide-specific monitoring systems to inform suicide prevention. Monitoring mechanisms varied across the countries examined. No article provided evidence that definitively linked suicide registers or other monitoring systems for suicide with the prevention of suicide or reduction in suicide rates. However, a variety of benefits of suicide monitoring for preventative and public health interventions were identified.

CONCLUSIONS

The number of nations with surveillance systems for suicide prevention is low. Further, there is a lack of consistency in the systematic collection, analysis and interpretation of suicide-related information across the countries examined. Efforts to establish high-quality suicide surveillance systems that can be accessed in a timely and easy manner are needed to inform tailored strategies for suicide prevention.

Firearm Possession Rates in Home Countries and Firearm Suicide Rates Among US- and Foreign-Born Suicide Decedents in the United States: Analysis of Combined Data from the National Violent Death Reporting System and the Small Arms Survey

BACKGROUND

Suicide by firearms is a serious public health issue in the United States. However, little research has been conducted on the relationship between cultural backgrounds and suicide by firearms, specifically in those born and raised in the United States compared to those who have immigrated to the United States.

OBJECTIVE

To better understand the relationship between cultural backgrounds and suicide, this study aimed to examine firearm suicide rates among US- and foreign-born suicide decedents based on the firearm possession rate in the decedent's home country.

METHODS

Multivariate logistic regression was performed to analyze data of 28,895 suicide decedents from 37 states obtained from the 2017 National Violent Death Reporting System data set. The firearm possession rate in the home countries of foreign-born suicide decedents was obtained from the 2017 Small Arms Survey.

RESULTS

The firearm suicide rate was about twice as high among US-born suicide decedents compared to their foreign-born counterparts. Meanwhile, suicide by hanging was about 75% higher among foreign-born compared to US-born suicide decedents. Those from countries with a low-to-medium firearm possession rate were significantly less likely to use firearms compared to US-born suicide decedents (adjusted odds ratio [AOR]=0.45, 95% CI 0.31-0.65, and AOR=0.46, 95% CI 0.39-0.53, respectively). Meanwhile, firearm suicide rates were not different between US- and foreign-born suicide decedents from countries with a similarly high firearm possession rate.

CONCLUSIONS

The results suggest that there is an association between using firearms as a means of suicide and the firearm possession rate in the decedent's home country. Suicide by firearms in the United States needs to be understood in the sociocultural context related to firearm possession.

Research utility and limitations of textual data in the National Violent Death Reporting System: a scoping review and recommendations

BACKGROUND

Many studies of injury deaths rely on mortality data that contain limited contextual information about decedents. The National Violent Death Reporting System (NVDRS) is unique among such data systems in that each observation includes both quantitative variables and qualitative texts (called "narratives") abstracted from original source documents. These narratives provide rich data regarding salient circumstances that can be used to inform prevention efforts. This review provides a comprehensive summary of peer-reviewed research using NVDRS narratives over the past 20 years, including the limitations of these texts and provides recommendations on utilizing and improving narrative quality for researchers and practitioners.

MAIN BODY

Studies that used narratives to examine deaths related to suicide, homicide, undetermined intent, accidental firearm, or legal intervention were identified by a title/abstract screening, followed by a full-text review. The search was conducted on English-language, peer-reviewed literature and government reports published from 2002 to 2022 in PubMed, PsycInfo, Scopus, and Google Scholar. Abstracted elements focused on the methodologies used to analyze the narratives, including approaches to explore potential biases in these texts. Articles were abstracted independently by two reviewers, with disagreements resolved through consensus discussion. During the 20-year period, 111 articles used narratives. Two-thirds studied suicide (n = 48, 43%) and homicides (n = 25, 23%). Most studies analyzed the narratives using manual review (n = 81, 73%) and keyword searches (n = 9, 8%), with only 6 (5%) using machine learning tools. Narratives were mainly used for case finding (n = 49, 44%) and characterization of circumstances around deaths (n = 38, 34%). Common challenges included variability in the narratives and lack of relevant circumstantial details for case characterization.

CONCLUSION

Although the use of narratives has increased over time, these efforts would be enhanced by detailed abstraction of circumstances with greater salience to injury research and prevention. Moreover, researchers and practitioners would benefit from guidance on integrating narratives with quantitative variables and standardized approaches to address variability in the completeness and length of narratives. Such efforts will increase the reliability of findings and set the stage for more widespread applications of data science methods to these texts.

Comparing fatal child abuse involving biological and surrogate parents

BACKGROUND

Nearly half of pediatric homicides younger than 5 years are attributable to child abuse. Parents are most commonly the perpetrators, but less is known about incidents involving biological versus surrogate parents. We sought to evaluate the characteristics of fatal child abuse involving biological and surrogate parents using the Georgia National Violent Death Reporting System, which we believe may differ in demographics and incident characteristics.

METHODS

This database was used to examine all homicides of children younger than 18 years from 2011 to 2017. Demographics and incident characteristics were analyzed using the existing National Violent Death Reporting System variables and incident narratives. Nonparametric and χ2 tests were used to compare fatal child abuse incidents involving biological and surrogate parents (e.g., adoptive, foster, step-parents, intimate partners of biological parent).

RESULTS

There were 452 pediatric homicides and 219 cases of fatal child abuse. Of all cases of fatal child abuse, 60% involved biological and 29% involved surrogate parents. Compared with children killed by biological parents, children killed by surrogate parents were older (4 vs. 3 years), more often male (71% vs. 51%), more likely to survive the initial injury and present to the emergency department before death (96% vs. 69%), and less likely to have a medical comorbidity (2% vs. 11%; all p < 0.05). Surrogate parents were more likely to be male (90% vs. 48%) and use a firearm (20% vs. 13%) to inflict the injury, both p < 0.05. The race/ethnicity of the child was not associated with the parent's relationship.

CONCLUSION

Child abuse accounts for half of all pediatric homicides. Parents are the most common perpetrators of fatal child abuse, but surrogate parent perpetrators are almost exclusively male and more likely to use firearms. Most children have a history of abuse, leaving an opportunity to intervene on potentially preventable deaths if abuse is identified in a timely fashion.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level III.

Characteristics and patterns of older adult homicides in the United States

Background

Nearly 1800 homicides were reported in 2018 among individuals aged 60 years or older in the US. The characteristics and circumstances of these homicides are understudied. We investigated the trends of homicides over time and compared victim, perpetrator, and incident characteristics by mechanism (firearm vs. non-firearm) among adults aged 60 years or older.

Methods

We examined cross-sectional restricted-access data from the National Violent Death Reporting System from 2003 to 2017. Fatal Injury Data by CDC provided age-adjusted homicide rates. We quantitatively summarized victim, perpetrator, and incident characteristics for firearm and non-firearm homicides. We also reviewed 150 qualitative narratives to better understand the context of older adult homicides perpetrated by firearms. All data were analyzed in February 2020.

Results

Overall and firearm-specific older adult homicide rates increased between 2014 and 2017. Of the 6188 victims, 62% were male. The majority of victims (68%) were killed at home. Firearms (44%), sharp (19%) and blunt weapons (15%) were common mechanisms used in older adult homicides. The perpetrator was an intimate partner in 39% of firearm homicides and 12% of non-firearm homicides (prevalence difference = 27%; 95% CI: 25, 30%). Similarly, homicide-suicides (prevalence difference = 21%; 95% CI: 19, 22%) and multiple-victim incidents (prevalence difference = 7%; 95% CI: 5, 8%) were more common in firearm (23 and 13%, respectively) than in non-firearm (2 and 6%, respectively) homicides. Common contexts of firearm homicides were familial/intimate partner problems, robbery/burglary, argument, and illness.

Conclusions

A substantial number of older adults were killed with firearms and by their intimate partners. Further research to identify violence victimization prevention strategies in this group, especially those that limit access to firearms by potential perpetrators, is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00299-w.

Unintentional firearm deaths in the United States 2005-2015

Background

Unintentional gun death occurs four times more often in the United States than other high-income countries. Research on these deaths typically has a narrow scope. We believe this is the first study describing the circumstances of these deaths in the United States that covers more than a single state or municipality.

Methods

We use data on all unintentional firearm fatalities in the sixteen states reporting to the National Violent Death Reporting System (NVDRS) for all years 2005–2015. Our final count of unintentional firearm deaths in these states and years is 1260. The detailed nature of the data allows us to categorize and compare the circumstances of the incident.

Results

We estimate 430 unintentional firearm fatalities in the United States per year. The rate is highest for older children to young adults, ages 10 to 29, and the vast majority of the victims are male. Common circumstances include playing with the gun (28.3% of incidents), thinking the gun was unloaded (17.2%), and hunting (13.8%). The victim is suspected to have consumed alcohol in nearly a quarter of the deaths and in 46.8% of deaths among those aged 20–29.

Conclusions

Certain circumstances, such as consuming alcohol, playing with the gun, and hunting, are common settings for unintentional firearm deaths. Firearm safety instructors, firearm manufacturers, and firearm owners can all contribute to preventing these deaths.

Surveillance for Violent Deaths - National Violent Death Reporting System, 32 States, 2016

PROBLEM/CONDITION

In 2016, approximately 65,000 persons died in the United States as a result of violence-related injuries. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) regarding violent deaths from 32 U.S. states for 2016. Results are reported by sex, age group, race/ethnicity, type of location where injured, method of injury, circumstances of injury, and other selected characteristics.

PERIOD COVERED

2016.

DESCRIPTION OF SYSTEM

NVDRS collects data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, law enforcement reports, and secondary sources (e.g., child fatality review team data, Supplementary Homicide Reports, hospital data, and crime laboratory data). This report includes data collected from 32 states for 2016 (Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Utah, Vermont, Virginia, Washington, and Wisconsin). NVDRS collates information for each death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident.

RESULTS

For 2016, NVDRS captured 40,374 fatal incidents involving 41,466 deaths in the 32 states included in this report. The majority (62.3%) of deaths were suicides, followed by homicides (24.9%), deaths of undetermined intent (10.8%), legal intervention deaths (1.2%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). (The term legal intervention is a classification incorporated into the International Classification of Diseases, Tenth Revision [ICD-10] and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Demographic patterns varied by manner of death. Suicide rates were highest among males, non-Hispanic American Indians/Alaska Natives, non-Hispanic whites, adults aged 45-64 years, and men aged ≥75 years. The most common method of injury was a firearm among males and poisoning among females. Suicides were most often preceded by a mental health, intimate partner, substance abuse, or physical health problem or a recent or impending crisis during the previous or upcoming 2 weeks. Homicide rates were highest among males and persons aged <1 year and 15-44 years. Among males, non-Hispanic blacks accounted for most homicides and had the highest rate of any racial/ethnic group. The most common method of injury was a firearm. Homicides were most often precipitated by an argument or conflict, occurred in conjunction with another crime, or for females, were related to intimate partner violence. When the relationship between a homicide victim and a suspected perpetrator was known, the suspect was most frequently an acquaintance/friend among males and a current or former intimate partner among females. Legal intervention death rates were highest among men aged 20-44 years, and the rate among non-Hispanic black males was three times the rate among non-Hispanic white males. Precipitating circumstances for legal intervention deaths most frequently were an alleged criminal activity in progress, reported use of a weapon by the victim in the incident, a mental health or substance abuse problem (other than alcohol abuse), an argument or conflict, or a recent or impending crisis. Unintentional firearm deaths were more frequent among males, non-Hispanic whites, and persons aged 15-24 years. These deaths most often occurred while the shooter was playing with a firearm and most often were precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. Rates of deaths of undetermined intent were highest among males, particularly non-Hispanic black and American Indian/Alaska Native males, and adults aged 25-64 years. Substance abuse, mental health problems, physical health problems, and a recent or impending crisis were the most common circumstances preceding deaths of undetermined intent. In 2016, a total of 3,655 youths aged 10-24 years died by suicide. The majority of these decedents were male, non-Hispanic white, and aged 18-24 years. Most decedents aged 10-17 years died by hanging/strangulation/suffocation (49.3%), followed by a firearm (40.4%), and suicides among this age group were most often precipitated by mental health, family relationship, and school problems. Most suicides among decedents aged 18-24 years were by a firearm (46.2%), followed by hanging/strangulation/suffocation (37.4%), and were precipitated by mental health, substance abuse, intimate partner, and family problems. A recent crisis, an argument or conflict, or both were common precipitating circumstances among all youth suicide decedents.

INTERPRETATION

This report provides a detailed summary of data from NVDRS for 2016. Suicides rates were highest among non-Hispanic American Indian/Alaska Native and white males, whereas homicide rates were highest among non-Hispanic black males. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary precipitating events for multiple types of violent deaths, including suicides among youths aged 10-24 years.

PUBLIC HEALTH ACTION

NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths. For example, Utah VDRS data were used to help identify suicide risk factors among youths aged 10-17 years, Rhode Island VDRS suicide data were analyzed to identify precipitating circumstances of youth suicides over a 10-year period, and Kansas VDRS data were used by the Kansas Youth Suicide Prevention Task Force. In 2019, NVDRS expanded data collection to include all 50 states, Puerto Rico, and the District of Columbia. This expansion is essential to public health efforts to reduce violent deaths.

Research utility of the National Violent Death Reporting System: a scoping review

Background

To better understand and prevent suicide and homicide, the National Center for Injury Prevention and Control of the US Centers for Disease Control and Prevention launched the National Violent Death Reporting System (NVDRS) in six states in 2002. As of 2018, the NVDRS has been expanded to include all 50 states, the District of Columbia and Puerto Rico. The purpose of this review was to assess the research utility of the NVDRS based on studies indexed in major bibliographical databases.

Methods

We performed a scoping review of published studies that were based on data from the NVDRS, identified by searching six electronic databases: PubMed, EMBASE, Google Scholar, OVID, Scopus, and Web of Science. We examined the time trend of annual NVDRS-based research output, generated a word cloud using the keywords listed in the publications, and mapped the knowledge domains covered by NVDRS-based studies.

Results

Our review included a total of 150 studies published between 2005 and 2018. There was a marked increase in the annual number of NVDRS-based publications, with 120 (80.0%) of the 150 studies published between 2011 and 2018. Overall, 104 (69.3%) studies focused on suicide and 39 (26.0%) on homicide. Of the included studies, 100 (66.7%) were descriptive epidemiology, 31 (20.7%) were risk factor analyses, 9 (6.0%) were evaluations, 7 (4.7%) were trend analyses, and 4 (2.7%) were data quality assessments. Knowledge domain mapping identified two major clusters of studies, one on suicide and the other on homicide. The cluster on suicide was commonly linked to “circumstance,” “alcohol” and “substance abuse” and the cluster on homicide was commonly linked to “firearm,” “injury,” and “gang.” The two clusters were interlinked to overlapping networks of keywords, such as “firearm” and “mental health problem.”

Conclusions

Research utility of the NVDRS has increased considerably in recent years. Studies based on data from the NVDRS are clustered in two knowledge domains – suicide and homicide. The vast potential of the NVDRS for violence research and prevention remains to be fully exploited.

Validating the National Violent Death Reporting System as a Source of Data on Fatal Shootings of Civilians by Law Enforcement Officers

OBJECTIVES

To evaluate the National Violent Death Reporting System (NVDRS) as a surveillance system for fatal shootings of civilians by law enforcement in the United States.

METHODS

We cross-linked individual-level mortality data from the 2015 NVDRS and 5 open-source data sets ( FatalEncounters.org , Mapping Police Violence, the Guardian's "The Counted," Gun Violence Archive, and The Washington Post's "Fatal Force Database"). Using the comprehensive cross-linked data set, we assessed the proportion of study-identified fatal police shootings that were captured by NVDRS, overall and by state, and by each open-source data set.

RESULTS

There were 404 unique study-identified fatal shootings by law enforcement in the 27 states for which data were available from NVDRS, 393 (97%) of which were captured in NVDRS. The proportion of shootings captured by NVDRS varied only slightly by state.

CONCLUSIONS

The NVDRS provides a comprehensive count of fatal police shootings. Public Health Implications. Expanding NVDRS to all 50 states would provide comprehensive counts of fatal police shootings and detailed circumstantial information about these deaths at the national level. Open-source data can continue to provide real-time data collection as well as more complete information about nonfirearm officer-involved deaths.

Honor-Related Suicide in the United States: A Study of National Violent Death Reporting System Data

Personal honor is associated with culturally defined honor-norms and its loss may predicate suicide. This exploratory study aimed to identify honor-related suicides within a public health dataset and to compare them to other suicides. Honor-related suicides (n = 163) were identified from case narratives within the National Violent Death Reporting System dataset. The distribution of factors associated with honor-related suicide were compared with all other suicides (n = 54,333). Honor-related suicides were more likely associated with leaving a suicide note; discussing suicidal intent; criminal-legal, job and relationship problems; and suffering depression while being less likely to seek help for distress. They were not associated with gender or suicide method. Honor suicides were identified and appear to be most associated with public challenges to personal reputation. Implications for suicide prevention are discussed.

The epidemiology of homicide perpetration by children

Background

The United States has by far the highest rates of homicide perpetration among high-income countries. The perpetration of homicide by children is often newsworthy, but little is known about the incidence or the circumstances of child homicide perpetration.

Methods

We use data from the sixteen states reporting to the National Violent Death Reporting System (NVDRS) for all years 2005–2012. We read every violent death report that was classified a homicide with a child suspect (aged 0–14). To help ensure that we did not miss any homicide cases we also read those classified as an other-inflicted unintentional firearm injury death with a child shooter, to determine if they were actually homicides.

Results

There were 154 child suspects, which corresponds to an average annual rate of 1.2 child perpetrators per million child population. We estimate for the United States as a whole, 74 children per year were homicide perpetrators. Nearly 90% were boys, 79% were aged 13–14, and another 13% were aged 11–12. We created five categories, which accounted for over 70% of events with sufficient information to determine what happened: (1) The caretaker, a juvenile, typically an older brother, is given the responsibility to care for an infant. The homicide usually occurs in a residence, and blunt force is used (no guns); (2) Killing an adult family member, typically a parent or grandparent. These cases usually occur in a residence, and the child uses either a gun or a knife; (3) Impulsive shooting during play, the child typically shoots a sibling or friend. Except for some notion of momentary anger, these cases look much like unintentional firearm fatalities; (4) Robbery, a group of youth are trying to steal money, usually from an adult; and (5) Group Assault, a group of youth are fighting, usually other youth.

Conclusions

Child homicide perpetrators are typically boys who use guns, and the events can be classified into a small number of relevant categories. Such a categorization of events is useful for understanding the problem and determining solutions.

Homicides by Police: Comparing Counts From the National Violent Death Reporting System, Vital Statistics, and Supplementary Homicide Reports

OBJECTIVE

To evaluate the National Violent Death Reporting System (NVDRS) as a surveillance system for homicides by law enforcement officers.

METHODS

We assessed sensitivity and positive predictive value of the NVDRS "type of death" variable against our study count of homicides by police, which we derived from NVDRS coded and narrative data for states participating in NVDRS 2005 to 2012. We compared state counts of police homicides from NVDRS, Vital Statistics, and Federal Bureau of Investigation Supplementary Homicide Reports.

RESULTS

We identified 1552 police homicides in the 16 states. Positive predictive value and sensitivity of the NVDRS "type of death" variable for police homicides were high (98% and 90%, respectively). Counts from Vital Statistics and Supplementary Homicide Reports were 58% and 48%, respectively, of our study total; gaps varied widely by state. The annual rate of police homicide (0.24/100,000) varied 5-fold by state and 8-fold by race/ethnicity.

CONCLUSIONS

NVDRS provides more complete data on police homicides than do existing systems.

POLICY IMPLICATIONS

Expanding NVDRS to all 50 states and making 2 improvements we identify will be an efficient way to provide the nation with more accurate, detailed data on homicides by law enforcement.

Children and unintentional firearm death

Background

Children in the United States are at far greater risk of unintentional gun death than children in other developed countries. The relative figures may even be worse since the estimates for US child unintentional gun deaths are derived from the Vital Statistics which have been shown to be underestimates. No study has used a national data system to investigate the circumstances of fatal child gun accidents.

Methods

We use data from the National Violent Death Reporting System for 16 states from 2005 to 2012. We examine the cases of unintentional gun death involving children in five age groups, 0–1, 2–4, 5–10, 11–12, and 13–14, where the child was either the victim or shooter.

Results

We estimate that there were 110 unintentional firearm deaths to children 0–14 annually in the U.S. during this 8 year time period, 80 % higher than reported by the Vital Statistics. The victims were predominantly male (81 %). Approximately two thirds of the shootings were other-inflicted, and in 97 % of those cases the shooter was a male. The typical shooter in other-inflicted shootings is a brother or friend. Indeed, children aged 11–14 are often shot in the home of friends. The large majority of children are shot by other children or by themselves. It is rare for a child accidentally to be shot by or accidentally to shoot an adult who is not a family member.

Conclusions

Our study highlights the fact that unintentional firearm death to children is a problem of children shooting children and thus the importance of keeping guns away from children, their siblings, and their friends.

Reducing a suicidal person's access to lethal means of suicide: a research agenda

Reducing the availability of highly lethal and commonly used suicide methods has been associated with declines in suicide rates of as much as 30%-50% in other countries. The theory and evidence underlying means restriction is outlined. Most evidence of its efficacy comes from population-level interventions and natural experiments. In the U.S., where 51% of suicides are completed with firearms and household firearm ownership is common and likely to remain so, reducing a suicidal person's access to firearms will usually be accomplished not by fiat or other legislative initiative but rather by appealing to individual decision, for example, by counseling at-risk people and their families to temporarily store household firearms away from home or otherwise making household firearms inaccessible to the at-risk person until they have recovered. Providers, gatekeepers, and gun owner groups are important partners in this work. Research is needed in a number of areas: communications research to identify effective messages and messengers for "lethal means counseling," clinical trials to identify effective interventions, translational research to ensure broad uptake of these interventions across clinical and community settings, and foundational research to better understand method choice and substitution. Approaches to suicide methods other than firearms are discussed. Means restriction is one of the few empirically based strategies to substantially reduce the number of suicide deaths.