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

Case report: Electrocardiographic (ECG) recording during the hanging process

A 48-year-old woman was found hanged in the bathroom. She was wearing a Holter monitor, which was later analysed by a cardiologist. During autopsy, findings congruent with atypical hanging were collected. The ECG showed a 20 s asystole and four minutes later bradycardia, which progressed to a second-degree AV-block Mobitz I, then Mobitz II, then to a third-degree AV-block. Finally, only P waves could be observed, before heart action ceased. This is one of few cases reporting ECG-changes during hanging and might give further insight into the complex pathophysiology of this type of death.

Risk of suicide and suicidal behavior in refugees. A meta-review of current systematic reviews and meta-analyses

BACKGROUND

Despite the exposure to a wide combination of risk factors, evidence concerning risk of suicide among refugees is mixed.

AIMS

We aimed to establish more precise estimates of suicide and suicidal behavior in refugees and asylum seekers, investigate the role of somatic and psychiatric comorbidities, and the effectiveness of preventative interventions.

METHODS

We searched PubMed/Medline, EMBASE, CINAHL, and PsycInfo without time limitations from inception until June 5, 2024. Studies were included if systematic reviews or meta-analyses reporting data on suicide or suicidal behavior in refugees or asylum seekers, or detailing the results of preventive interventions. Quality was assessed using the National Institutes of Health Quality Assessment Tool for Systematic Reviews and Meta-Analyses.

RESULTS

Out of 49 papers, 10 systematic reviews and meta-analyses were included. Refugees showed significantly higher suicide death rates and suicidal ideation, suicide plan and suicide attempt prevalence compared to people living in the host countries. Refugees who arrived in low-income and lower-middle-income countries displayed lower suicidal ideation, but higher suicide death rates and suicide attempt prevalence compared to refugees who arrived in high-income and upper-middle-income countries. However, no review provided data regarding somatic comorbidity, psychiatric comorbidity, or the effectiveness of treatments, and evidence on specific categories of refugees is scarce.

CONCLUSION

Refugees have been proven to be at risk for suicide and suicidal behavior. More research is required to identify the targets and procedures of intervention.

Fatal Intoxications with Zopiclone-A Cause for Concern?

INTRODUCTION

Zopiclone, a controlled substance prescribed for insomnia, has become a common toxicological finding in forensic autopsy cases. This study investigated the role and extent of zopiclone use in fatal intoxications in Sweden.

METHODS

All forensic autopsy cases positive for zopiclone in femoral blood during 2012-2020 were selected. Among these cases, fatalities caused by intoxication according to the cause of death certificates issued by the forensic pathologist were identified. Intoxications where zopiclone contributed to the cause of death were included in the study. The Swedish Prescribed Drug Register was utilized to examine whether the included cases were prescribed zopiclone or not.

RESULTS

In total 7320 fatal intoxications underwent a forensic autopsy during the study period, 573 of them were caused by zopiclone. Among the zopiclone fatalities, 87% (n = 494) had a prescription for zopiclone, and 8% (n = 43) were monointoxications. Most fatalities, 62% (n = 354) were suicides, and zopiclone was involved in about 17% (n = 354) of all intoxication suicides in Sweden. Women were significantly (p < 0.01) overrepresented in suicides with zopiclone, comprising 56% (n = 291) of fatalities. The median age was 55 years among zopiclone intoxications compared with 44 years amongst all fatal intoxications.

CONCLUSION

This study demonstrates that the toxicity of zopiclone can be lethal both in combination with other substances and on its own. Most individuals dying in fatal zopiclone intoxications were prescribed zopiclone, which potentially indicates that a more restrictive prescribing rate could prevent future intoxication deaths, especially when caring for patients with an increased suicide risk.

The Profile of Self-Harm and Suicide in Iran Considering Gender Differences: A Multicenter Study Affiliated with the National Trauma Registry of Iran

Objective: The main objective of this study was to determine various characteristics and outcomes of self-harm and suicide in men and women with data obtained from the National Trauma Registry of Iran (NTRI). Method : This retrospective multicenter study using data from the NTRI included all patients who went to the emergency department (ED) due to self-harm and suicide, considering the NTRI's specific inclusion criteria, from September 2016 to January 2023. We evaluated patients regarding demographics and clinical characteristics, various outcomes, and factors influencing in-hospital death. Statistical analyses were conducted using the STATA software version 15.0. The chi-square test was used to compare the distribution of variables between men and women. Also, the logistic regression models were applied to assess the predictors of in-hospital death. Results: Self-harm and suicide cases were gathered from eleven geographically diverse hospitals across the country, and our study included 511 men and 347 women out of 50,661 registered trauma cases. Among them, 443 men (86.7%) and 267 women (76.9%) were between 18 and 49 years old (P < 0.001). Single women constituted 130 (37.3%) of the female cases, while single men were 313 (61.6%) of the male cases (P < 0.001). The three most common methods among our patients were poisoning with 234 (45.8%) of men and 245 (70.6%) of women cases, stab/cut with 208 (40.7%) of men and 54 (15.6%) of women cases, and fall with 16 (3.1%) of men and 26 (7.5%) of women cases (P < 0.001). The risk of death in patients with a Glasgow Coma Scale (GCS) score of 3 to 8 was 46.22 (95% CI = 18.66 to 114.45) times more than patients with a GCS score of 13 to 15. Conclusion: Data on self-harm and suicide traumatology were gathered from eleven hospitals in Iran. Our findings indicated differences in the distribution of age and marital status between genders. Moreover, both genders used similar methods for self-harm and suicide, and gender did not affect the outcome.

Autopsy-Based Study of Non-accidental Violent Neck Asphyxia in Jordan: A Retrospective Study

Background There is a global increase in the number of deaths caused by violent neck asphyxia, which includes both suicides and homicides. This research presents autopsy-based findings and analytical demographic data that are pertinent to significant medicolegal cases. Methods A retrospective examination of 113 autopsy reports of non-accidental violent neck asphyxia reported to the forensic pathology department of Al-Balqa Governorate in Jordan within the period from January 2010 to March 2023. Age, gender, and autopsy results were documented, along with medicolegal records that included toxicology reports. Conversely, information on the manner of death was derived from police inquest records. For the purpose of this research, all the cases of throttling and ligature strangulation have been determined to be homicidal, and all cases of hanging were classified as suicide. Results Males were predominant in hanging (72%), while females were predominant in ligature strangulation (82%). The mean age group in hanging was 21-35 years (51%), while the range for throttling was 36-50 years, and that in strangulation was 2-20 years. Most hanging and throttling cases showed typical external neck findings. Seventy-two percent of hanging cases (n = 68) did not exhibit any internal neck findings, while all throttling cases yielded positive results. Both hanging and strangulation by ligature cases exhibited an absence of thyroid cartilage fracture (83%). Eighty-nine cases (95%) of hanging did not exhibit any injuries to the rest of the body. However, all cases of throttling and ligature strangulation had an almost positive external body injury. In all cases of throttling and ligature strangulation, ocular petechial hemorrhage was present, whereas one-third of the hanging cases had it. Conclusion The forensic doctor must observe the pattern of ligature marks and other signs of physical assault found on the neck, meticulously examine the rest of the body, rule out other causes of death, and cooperate with the legal authorities regarding the collection of the history and death scene findings to accurately determine the manner and mechanism of death in cases of violent neck asphyxia.

Self-harm behaviors and their intentions: a cross-cultural analysis

BACKGROUND

Self-harm behaviors (performed with either lethal and non-lethal intentions) are common, especially among individuals suffering from mood disorders, and the reasons individuals self-harm vary both by person and by the type of behavior. Understanding these variations may help clinicians determine levels of risk more accurately.

AIMS

To understand whether culture and gender are associated with the likelihood of engaging in specific self-harm behaviors and whether the intention (lethal, ambivalent, non-lethal) of these behaviors vary with culture and gender.

METHODS

2826 individuals took part in an international multilingual online depression/suicidality screening study and reported at least one instance of self-harm in the past year. Participants were grouped into six broad cultural categories (Latin America, South Asia, Russian, Western English, Chinese, Arab).

RESULTS

3-way (culture x gender x intent) interactions were observed for several self-harm behaviors (overdosing, self-burning, asphyxiating, poisoning, and jumping from heights), suggesting that individuals engage in each of these behaviors with different intentions depending on gender and culture. Cultures and genders likewise differed in the likelihood of engaging in several self-harm behaviors.

CONCLUSIONS

Clinicians should consider culture and gender when assessing for suicide risk, as similar self-harming behaviors may reflect different intentions depending on an individual's culture and gender.

Alcohol use disorder and risk of specific methods of suicide death in a national cohort

INTRODUCTION

Alcohol use disorder (AUD) is among the strongest correlates of suicide death, but it is unclear whether AUD status is differentially associated with risk of suicide by particular methods.

METHODS

The authors used competing risks models to evaluate the association between AUD status and risk of suicide by poisoning, suffocation, drowning, firearm, instruments, jumping, or other means in a large Swedish cohort born 1932-1995 (total N = 6,581,827; 48.8% female). Data were derived from Swedish national registers, including the Cause of Death Register and a range of medical registers.

RESULTS

After adjusting for sociodemographic factors and familial liability to suicidal behavior, AUD was positively associated with risk of suicide for each method evaluated (cumulative incidence differences: 0.006-1.040 for females, 0.046-0.680 for males), except the association with firearm suicide in females. AUD was most strongly associated with risk of suicide by poisoning. Sex differences in the effects of AUD and family liability were observed for some, but not all, methods. Furthermore, high familial liability for suicidal behavior exacerbated AUD's impact on risk for suicide by poisoning (both sexes) and suffocation and jumping (males only), while the inverse interaction was observed for firearm suicide (males only).

CONCLUSIONS

AUD increases risk of suicide by all methods examined and is particularly potent with respect to risk of suicide by poisoning. Differences in risk related to sex and familial liability to suicidal behavior underscore AUD's nuanced role in suicide risk. Future research should investigate targeted means restriction effectiveness among persons with AUD.

Reflections on the trends of suicide in Sri Lanka, 1997-2022: The need for continued vigilance

Despite reductions in suicide rates in Sri Lanka during the past decades, largely by introduction of national bans on highly hazardous pesticides, the country continues to record a higher than global average rate of suicide. With the changing availability of methods of suicide over time, we aimed to examine the age-standardized suicide rates in Sri Lanka by sex, age, and method between 1997 to 2022 using national police suicide data to identify trends. The rate of suicide in Sri Lanka in 2022 was 27/100,000 and 5/100,000, in males and females respectively, with an overall suicide rate of 15/100,000 population. When considering the previous decades, the overall rate of suicide has declined from 1997 until about 2015, in both sexes, driven by a drop in the numbers of suicides due to pesticide ingestion. In females the overall rates of suicide plateaued around 2015, but in males there has been an upward trend in overall suicide that started in 2016, mostly due to an increase in rates of hanging. Since 2016 rates of suicide by hanging have increased among older males, and young females (17-25 years). Whilst the current suicide rate in Sri Lanka is substantially lower than it was during the 1990s, the upward trend in hanging seen in the last few years, particularly among older men and young women, is of concern. Ongoing monitoring of suicide rates should be a priority during the next few years, to detect and respond to changes as soon as possible. There is an urgent need to address current risk factors for suicide in Sri Lanka, such as significant financial insecurity, unemployment, depression, alcohol misuse, and domestic violence, and to minimize media glamourization of hanging by suicide.

Self-harm, suicide and brain death: the role of the radiologist

Suicide is a leading cause of death worldwide and takes many forms, which include hanging, jumping from a height, sharp force trauma, ingestion/poisoning, drowning, and firearm injuries. Self-harm and suicide are associated with particular injuries and patterns of injury. Many of these patterns are apparent on imaging. Self-harm or suicidal intent may be overlooked initially in such cases, particularly when the patient is unconscious or uncooperative. Correct identification of these findings by the radiologist will allow a patient's management to be tailored accordingly and may prevent future suicide attempts. The initial role of the radiologists in these cases is to identify life-threatening injuries that require urgent medical attention. The radiologist can add value by drawing attention to associated injuries, which may have been missed on initial clinical assessment. In many cases of self-harm and suicide, imaging is more reliable than clinical assessment. The radiologist may be able to provide important prognostic information that allows clinicians to manage expectations and plan appropriately. Furthermore, some imaging studies will provide essential forensic information. Unfortunately, many cases of attempted suicide will end in brain death. The radiologist may have a role in these cases in identifying evidence of hypoxic-ischaemic brain injury, confirming a diagnosis of brain death through judicious use of ancillary tests and, finally, in donor screening for organ transplantation. A review is presented to illustrate the imaging features of self-harm, suicide, and brain death, and to highlight the important role of the radiologist in these cases.

The rising trends of self-harm in Brazil: an ecological analysis of notifications, hospitalisations, and mortality between 2011 and 2022

Background

Self-harm is considered an important public health issue and is comprised by a wide range of definitions and behaviours. It is estimated that suicide affects more than 700,000 individuals every year, although, globally, there is a lack of evidence on other self-harm behaviour, such as attempted suicide. The objective of this study is to report and examine temporal trends of notifications, hospitalisations related to self-harm and suicide rates in Brazil between 2011 and 2022, as well as investigating differences in sociodemographic characteristics, methods, and region.

Methods

This ecological study used secondary, Brazilian Health Information System data between 2011 and 2022. Self-harm notifications were collected from the Notifiable Diseases Information System (SINAN); self-harm hospitalisations from the Hospital Information System (SIH), and suicide data from the Mortality Information System (SIM). We calculated self-harm notifications, hospitalisations, and suicide rates by sex, age, race, region, and overall. We assessed time-related trends using Joinpoint regression analyses.

Findings

From 2011 to 2022, 720,480 self-harm notifications, 104,458 self-harm hospitalisations, and 147,698 suicides were recorded in Brazil. In this period, self-harm notifications (AAPC: 21.13 (CI: 17.50, 25.33)) and suicide (AAPC: 3.70 (CI: 3.05, 4.38)) have increased in the country. Male adults (25-59 years old) and the elderly (>60 years old) continue to be the groups most affected by suicide, with respective rates of 9.59 and 8.60/100,000 in 2022. However, the largest percentage increases have been seen in young people (AAPC: 6.14 (CI: 4.57, 7.88)). The Indigenous population had the highest self-harm notification (103.72, 10,000) and suicide (16.58/100,000) rates, but the lowest hospitalisation rates (1.14/100,000) in 2022), compared to the overall population (70.06, 7.27, and 4.69/100,000, respectively, in 2022).

Interpretation

The observed trend of increased self-harm notifications and suicide rates suggests the need for a greater allocation of resources to strategies to prevent self-harm and suicide. The Indigenous population seems to be the group with less access to healthcare.

Funding

Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award number R01MH128911-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The characteristics of suicide attempters in Chinese patients: Comparison of adolescents, youths, middle-aged and elderly

BACKGROUND

Potential risk factors for suicide differ by age group. Therefore, this study aims to investigate the characteristics of patients with suicide attempts according to age group and any the relevant risk factors.

METHODS

This study retrospectively reviewed the medical records of attempted suicide patients who were admitted to the emergency departments (ED) of the First Affiliated Hospital of Wenzhou Medical University between January 1, 2017, and December 31, 2021. Demographic information and clinical characteristics were collected. The participants were divided into four age groups and the characteristics of each group were compared.

RESULTS

A total of 834 participants were included in this study. Suicide attempts were more prevalent in females, and the gender difference decreased with age. Having religious belief and less educated suicide attempts were concentrated in the elderly groups. Adolescents suicide attempts were more likely to occur in the spring, autumn and during non-office hours. Mental disorders were the major motivation for suicide among adolescents, and interpersonal and social problems were more prevalent among youths. Psychiatric medication was the leading suicidal substances among adolescents, while pesticides and herbicides were more prevalent in adults. The history of psychiatric diagnosis was more common in adolescents, while the history of somatic disorder was more prevalent in the elderly.

CONCLUSION

This study confirmed differences in the demographic and clinical characteristics of patients in different age groups. Therefore, it is necessary to construct individualized intervention strategies for each age group based on the characteristics of the patients in order to reduce suicide.

Analysis of Forensic Death Statistics From 2013 to 2022 and Autopsy Practices in Türkiye

Background

Autopsy rates are significantly lower that what they should be worldwide. Additionally, autopsy practices vary between countries.

Aims

To examine the autopsy rates, the distribution and temporal changes of forensic autopsy cases, so as to identify the areas in the death investigation system that require improvement in Türkiye.

Study Design

Cross-sectional study.

Methods

“Forensic Death Examination Statistics” of the Council of Forensic Medicine (CFM) and “Death Statistics” of the Turkish Statistical Institute were compared and analyzed for the years 2013-2022 in Türkiye.

Results

The number of forensic death cases sent to the CFM has increased over time. For all causes of deaths, the autopsy rate is approximately 3.6-4.8%. The cause-specific mortality rates for deaths due to sharp instrument trauma, blunt trauma, occupational accident, undetermined, and poisoning have increased over the years. “The percentage of “undetermined” deaths, which are important to demonstrate negative autopsies, was 14.2% in 2021.

Conclusion

Although the autopsy rates have slightly increased in a volatile trend over time in Türkiye, they are still not at the desired level. Thus, it is essential to further raise awareness among all professionals involved in death investigations about the importance of autopsies.

Suicide Attempt by Hanging - A Study on Patients Admitted in Tertiary Care Hospital in Eastern India

Background

Suicide is defined as a fatal self-injurious act with some evidence of intent to die. Despite the evolution of sophisticated methods to commit suicide, hanging remains one of the commonest methods to commit suicide across the world. To evaluate the individuals using hanging as a method of suicide and identify the contributing factors for this behaviour.

Material and Methods

The study was carried out in a tertiary care hospital, over a period of 1 year on the suicide attempters using the method of hanging. Semi-structured in-depth interviews were conducted with all the 46 attempters. The questions focused on the precipitating events present before the attempt. After the in interview the risk factors of the conversations were identified, tabulated and categorized using descriptive analysis.

Results

Findings from descriptive analysis reveals that significant age group using this method was below 19 years followed by 20-29 age group, female attempters were more compared to male. Psychiatric diagnosis was present in 8 attempters and 4 attempters had alcohol/substance dependence. The most common personality component in attempters was impulsivity. The most common immediate stressor found were financial stress, conflict with family, spouse, humiliation, substance abuse, exam stress and domestic violence.

Conclusion

This study demonstrates that the reasons for suicide attempt by hanging is multifactorial. which includes, psychiatric diagnosis, personality factors, immediate stressors, ease of use, and accessibility, Overall, our study adds to understanding the intricates of this method and will help in developing effective suicide prevention strategies.

Cardiac Manifestations after Ingestion of a Commercial Desiccant: A Case Report

Background and Objectives: The rise in suicidal attempts has led to an increase in unusual intoxication cases. The ingestion of anhydrous calcium chloride (CaCl2) causes direct injury to the gastrointestinal wall via a thermal burn. Therefore, previous reports on CaCl2 ingestion primarily considered the gastrointestinal injury. Severe CaCl2 intoxication can induce a hypercalcemic crisis, presenting with arrhythmia, acute pancreatitis, and acute kidney injury. This case report details a patient with hematemesis and hypercalcemia following the ingestion of a commercial desiccant. We aimed to report the progression of the case, with a focus on the electrocardiographic manifestations. Case Presentation: A 39-year-old female presented at a regional emergency center with blood in her vomit after the ingestion of a commercial desiccant. Bloody emesis was the initial symptom, and various electrolyte imbalances developed during admission. Electrocardiogram (ECG) changes occurred early after hospitalization and disappeared before the electrolyte levels normalized. The patient was maintained in an NPO (Nil Per Os) state throughout her hospital stay. The bloody emesis and abdominal pain resolved quite early, despite her minimal mention of symptoms, possibly due to her suspected negative psychiatric symptoms. Conclusions: In this case, we observed dynamic and prolonged multiple electrolyte imbalances along with the early-phase ECG changes, all of which responded well to supportive care. This report adds to the understanding of the diverse manifestations and management of CaCl2 intoxication.

Characteristics of deaths by suicide in postmortem studies in Brazil: A systematic review and meta-analysis

INTRODUCTION

Suicide is one of the leading causes of death, with a trend for its increase in Brazil in past decades. This study aimed to review the characteristics of suicides in Brazilian postmortem studies.

METHODS

Studies investigating suicide deaths in Brazil, and based on autopsy or psychological autopsy were included. Proportions were pooled across studies with the use of random and fixed effects models.

RESULTS

6777 references were retrieved from six databases (searches up to January, 2023), and 45 studies included. In autopsy studies (k = 37, n = 16,231), substance use at toxicological analysis was found in 36.42% of cases (95% CI: 30.05-43.32), previous suicide attempts in 23.92% (95% CI: 6.73-57.78). In psychological autopsy studies (k = 8, n = 139), previous suicide attempts were reported in 28.09% (95% CI: 19.74-38.28), psychiatric conditions/symptoms in 90.67% (95% CI: 67.79-97.82), family history of suicidality in 21.33% (95% CI: 13.5-32.03). Most suicide deaths were reported in males and took place at the victim's home, hanging was the most frequent suicide method. Included studies presented significant limitations in quality assessment.

CONCLUSION

Future studies should present more robust methodology, including bigger samples, the use of controls, and validated methodology.

Suicide attempts and the factors that lead to suicidal ideation: A 3-year analysis

OBJECTIVE

We explored the epidemiological characteristics of suicide attempts and identified suicide trends and associated factors.

METHODS

This retrospective, cross-sectional, observational, and single-center study included consecutive 412 patients who were admitted to Emergency Department for follow-up and treatment after a suicide attempt between June 2019 and June 2022. We assessed patient demographics, suicidal behavior, previous suicide attempts, psychiatric disorders, drug use, visits to the psychiatry clinic within the past 6 months, the persistence of suicidal ideation, and clinical outcomes.

RESULTS

The study population consisted of 259 females (62.86%) and 153 males (37.14%), with a mean age of 29.50±11.51 (range: 13-72) years. Females attempted suicide more often than males, but suicide completion was more common in males. Overall, 79.37% (n=327) of the suicide attempters were aged <40 years and most were 20-29 years old (n=147, 35.68%). Non-fatal suicide attempts were more common in single, unemployed, and poorly educated individuals, but this was not the case for suicide completers. However, there was no significant difference in marital status, education, and occupation among suicide completers. Drug poisoning was the major form of suicide attempt (n=345, 83.74%). Mental disorders, family or relationship conflicts, and separation from a partner were common causes of suicidal ideation. Patient numbers were particularly high in the autumn (i.e., September), and at night.

CONCLUSION

Females, young adults, singletons, the unemployed, and individuals with psychiatric disorders and low education levels are more likely to attempt suicide, particularly during hours when they are likely to be alone.

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.

Suicide rates in the Slovak Republic in 2011-2020

PURPOSE

Suicide is a serious public health problem leading to premature mortality. The aim of the present study is to describe and analyze the trends of suicide rates in the Slovak Republic in 2011-2020.

METHODS

Trends of age-standardized suicide rates were described and incidence rate ratios of suicide were analyzed by negative binomial regression. The age-standardized rates of death by the undetermined intent and its ratio to suicide rate were calculated.

RESULTS

The overall suicide rate for the Slovak population was 7.58 per 100,000. Age-standardized suicide rate had a declining trend in the reported period, from 10.24 in 2011 to 6.65 per 100,000 in 2020. The highest suicide rate was in the oldest age groups. The male to female ratio was 6.09. The most common method of suicide in the Slovak population was hanging. The age-standardized rate of deaths by undetermined intent increased from 15.72 in 2011 to 18.46 per 100,000 in 2020.

CONCLUSION

We observed the overall declining annual suicide mortality trends in the Slovak Republic in 2011-2020. Further investigation is necessary to understand the exceptionally high undetermined intent mortality.

SMARThealth PRegnancy And Mental Health study: protocol for a situational analysis of perinatal mental health in women living in rural India

Introduction

The situation for women experiencing mental health problems during pregnancy and postpartum in rural India is critical: a high burden of disease, a high estimated number of women are undiagnosed and untreated with mental health problems, a substantial gap in research on women's perinatal health, and severe stigma and discrimination. The SMARThealth Pregnancy study is a cluster randomised trial using a digital intervention to identify and manage anaemia, hypertension, and diabetes in the first year after birth in rural India. Within this study, the SMARThealth Pregnancy and Mental Health (PRAMH) study is a situational analysis to understand mental health problems during pregnancy and in the first year following birth in this population.

Methods/design

This situational analysis aims to analyse and to assess the context of perinatal mental health, health services, barriers, facilitators, and gaps in Siddipet district of Telangana state in India, to develop an implementation framework for a future intervention. A tested, standardised situational analysis tool will be adapted and applied to perinatal mental health in rural India. A desktop and policy review will be conducted to identify and analyse relevant mental health and pregnancy care policies at the national and state levels. We will conduct in-depth interviews with policymakers, planners, mental health professionals and other experts in perinatal mental health (n = 10-15). We will also conduct focus group discussions with key stakeholders, including women with perinatal mental health problems, their families and carers, and community health workers (n = 24-40). A theory of change workshop with key stakeholders will be conducted which will also serve as a priority setting exercise, and will clarify challenges and opportunities, priorities, and objectives for a pilot intervention study. The analysis of qualitive data will be done using thematic analysis. Based on the data analysis and synthesis of the findings, an implementation framework will be developed to guide development, testing and scale up of a contextually relevant intervention for perinatal mental health.

Discussion

The situational analysis will help to establish relationships with all relevant stakeholders, clarify the context and hypotheses for the pilot intervention and implementation.

Suicide Trends in Jordan in Correlation With the COVID-19 Pandemic: A Forensic Medicine Perspective

Background This study aimed to examine the suicide trends among Jordanians who died by suicide before and during the coronavirus disease 2019 (COVID-19) pandemic and assess their correlation with demographic data, including gender, age, marital status, and the method used for suicide, from a forensic medicine perspective. Methodology This was a retrospective, observational, autopsy-based study. Of the 731 medicolegal autopsies performed at the Al-Hussein New Hospital at Al Salt City between 2017 and 2022, 41 confirmed cases of suicide were identified. Results The study indicated that 75% of the subjects committed suicide during the COVID-19 pandemic period, of whom 13% were children. The average age of those who died by suicide was 32.1 (SD = 12.2) years. Overall, 58.5% were single, 61.0% unemployed, and 53.7% had a mental illness. Males were four times more likely to commit suicide than females. Hanging represented 60.61% of all male suicides, followed by firearms (27.27%); however, females used poisoning. Around 60% and 25% of the study subjects were in the age group of 21-40 years and 41 and more, respectively. The study also identified a statistically significant association between gender, age, and the time of suicide (during COVID-19). The findings of this study could not confirm any association between suicide and mental illness, marital status, and employment status. Conclusions The suicide rate in Jordan increased during the COVID-19 pandemic, and it is alarming that most of those who committed suicide were at a young age and in their productive years.

A comparative study of the injury pattern between suicidal and accidental falls from height in Northern Tunisia

BACKGROUND

Falls from height are a common cause of marbidity and mortality. The aim of this study is to examine the characteristics of the victims, the circumstances of the fall and distribution of the injuries of accidental and suicidal falls from height.

MATERIALS AND METHODS

It was a retrospective cross-sectional study, based on autopsies performed over 16 years (January 2005 to December 2020). The recorded variables included demographic data of the victim, height of fall, death scene findings, length of hospital stay, autopsy findings, and toxicological results.

RESULTS

Of the 753 victims of fall from height, 607 were fallers and 146 were jumpers. We found that male victims were predominant in the accidental group (86.8% vs. 69.2%). The mean age at death was 43.6 ± 17.9 years. Suicidal falls occurred in a private house in the majority of cases (70.5%), while accidental falls occurred most frequently at workplace (43.8%). Suicidal falls were higher than accidental falls (10.4 ± 7.3 m vs. 7.1 ± 5.7 m). Injuries in the thorax, abdomen, pelvis, upper and lower extremities were more frequentl in the suicidal falls group. Pelvic fractures were 2.1 times more likely to occur in the suicidal falls. Head injuries were more frequent in the accidental falls group. The survival delay was shorter in the suicidal falls group.

CONCLUSIONS

our study highlights the differences in the profile of the victims and in the pattern of injuries caused by falls from height, depending on the victim's intention to fall.

Perspectives on reasons for suicidal behaviour and recommendations for suicide prevention in Kenya: qualitative study

BACKGROUND

Little is known about the reasons for suicidal behaviour in Africa, and communities' perception of suicide prevention. A contextualised understanding of these reasons is important in guiding the implementation of potential suicide prevention interventions in specific settings.

AIMS

To understand ideas, experiences and opinions on reasons contributing to suicidal behaviour in the Coast region of Kenya, and provide recommendations for suicide prevention.

METHOD

We conducted a qualitative study with various groups of key informants residing in the Coast region of Kenya, using in-depth interviews. Audio-recorded interviews were transcribed and translated from the local language before thematic inductive content analysis.

RESULTS

From the 25 in-depth interviews, we identified four key themes as reasons given for suicidal behaviour: interpersonal and relationship problems, financial and economic difficulties, mental health conditions and religious and cultural influences. These reasons were observed to be interrelated with each other and well-aligned to the suggested recommendations for suicide prevention. We found six key recommendations from our thematic content analysis: (a) increasing access to counselling and social support, (b) improving mental health awareness and skills training, (c) restriction of suicide means, (d) decriminalisation of suicide, (e) economic and education empowerment and (f) encouraging religion and spirituality.

CONCLUSIONS

The reasons for suicidal behaviour are comparable with high-income countries, but suggested prevention strategies are more contextualised to our setting. A multifaceted approach in preventing suicide in (coastal) Kenya is warranted based on the varied reasons suggested. Community-based interventions will likely improve and increase access to suicide prevention in this study area.

Transplantation of Organs From DCD and DBD Donors Who Died After Ligature Asphyxiation

BACKGROUND

The United Kingdom transplant registry data demonstrated similar transplant outcomes for recipients of kidneys from donors who died following ligature asphyxiation and those who received organs from donors dying from other causes. The impact that this donor cause of death has on the outcomes of other solid organ transplant recipients remains uncertain.

METHODS

The United Kingdom transplant registry analysis was undertaken to determine transplant outcomes in recipients of lungs, hearts, livers' and pancreases from donors who died following ligature asphyxiation.

RESULTS

Between January 01, 2003, and December 31, 2016, 2.7% (n = 521) of all potential United Kingdom donors died following ligature asphyxiation (mostly suicide by hanging). Of these, 416 (79.9%; 197 donation after brain stem death and 219 donation after circulatory death [DCD]) donated an organ for transplantation. These donors provided organs for 574 transplants (66 lung transplants, 75 heart transplants, 279 liver transplants, and 154 pancreas transplants). Patient and graft survival were similar for recipients of both donation after brain stem death and DCD hearts, livers, and pancreases from donors who died following ligature asphyxiation. Unadjusted graft and patient survival were significantly worse for recipients of lungs from DCD donors who died following ligature asphyxiation. This detrimental effect persisted after propensity score matching.

CONCLUSIONS

Livers, hearts, and pancreases from donors who die following ligature asphyxiation suffer an additional warm ischemic insult, but this does not negatively impact transplant outcomes. Outcomes for recipients of DCD lungs appear to be significantly worse.

Postmortem reference concentrations of 68 elements in blood and urine

INTRODUCTION

Fatal intoxications, both accidental and intentional, are a global issue. In the Western world, intoxications with pharmaceuticals dominate, but in other parts of the world, other substances are more common. In a forensic setting, elemental intoxications are of great importance when investigating both accidental, suicidal, and homicidal deaths. The current study presents normal postmortem reference concentrations of 68 elements in femoral blood and urine. In addition, possible sources of error such as contamination from sample tubes, preservative potassium fluoride (KF) solution, and storage time are evaluated.

METHODS

Paired femoral blood and urine samples from 120 cases of death by suicidal hanging in Sweden were collected. Additionally, multiple batches of sample tubes and multiple batches of KF solution were also analyzed. Concentrations of elements were determined by double focusing sector field ICP-MS.

RESULTS

Key descriptive statistics for 68 elements are provided in blood and urine. Contamination from sample tubes was minor compared to the overall mean elemental concentrations in both blood and urine. KF solution contained a large assortment of elements, but the overall contribution is relatively minor for most elements given the small amounts of solution added to samples. There were significant differences for 22 elements in blood and 17 elements in urine between samples with short and long storage time.

CONCLUSION

The present study provides an important tool when evaluating postmortem elemental concentrations. It fills a needed gap between large antemortem population studies and postmortem case reports or small case series of elemental intoxications.

The Impact of the COVID-19 Pandemic and Lockdowns on Self-Poisoning and Suicide in Sri Lanka: An Interrupted Time Series Analysis

Evidence from high-income countries suggests that the impact of COVID-19 on suicide and self-harm has been limited, but evidence from low- and middle-income countries is lacking. Using data from a hospital-based self-poisoning register (January 2019-December 2021) and data from national records (2016-2021) of suicide in Sri Lanka, we aimed to assess the impact of the pandemic on both self-poisoning and suicide. We examined changes in admissions for self-poisoning and suicide using interrupted time series (ITS) analysis. For the self-poisoning hospital admission ITS models, we defined the lockdown periods as follows: (i) pre-lockdown: 01/01/2019-19/03/2020; (ii) first lockdown: 20/03/2020-27/06/2020; (iii) post-first lockdown: 28/06/2020-11/05/2021; (iv) second lockdown: 12/05/2021-21/06/2021; and (v) post-second lockdown: 22/06/2021-31/12/2021. For suicide, we defined the intervention according to the pandemic period. We found that during lockdown periods, there was a reduction in hospital admissions for self-poisoning, with evidence that admission following self-poisoning remained lower during the pandemic than would be expected based on pre-pandemic trends. In contrast, there was no evidence that the rate of suicide in the pandemic period differed from that which would be expected. As the long-term socioeconomic impacts of the pandemic are realised, it will be important to track rates of self-harm and suicide in LMICs to inform prevention.

Evaluation of psychometric properties of the Persian version of the predicaments questionnaire, exploring social attitudes to suicide

Background

Due to the growing prevalence of suicide, assessing people's attitudes toward suicide is necessary. Therefore, this study aimed to examine the psychometric properties of the Persian version of the Predicaments Questionnaire (PQ), measuring social attitudes toward suicide.

Methods

This psychometrics study evaluated face validity, content validity, temporal stability, internal consistency, and construct validity. First, the questionnaire was translated into Persian by the translate-back-translate method. The Persian version was provided to 10 experts in psychiatry for further revision. Two indicators, CVR and CVI, were calculated to evaluate the content validity. To check the face validity, we prepared a form and gave it to 10 people outside the campus to submit their opinions. Temporal stability was investigated by the test-retest method, reporting Intraclass correlation (ICC). Internal consistency was assessed by reporting Cronbach's alpha and McDonald's Omega coefficients. Construct validity was assessed using the confirmatory factor analysis to determine the number of dimensions of the questionnaire.

Results

A total of 151 students were enrolled with a mean age of 25 (SD = 0.32). The Persian PQ was valid in terms of content validity and face validity. Furthermore, it was reliable as Cronbach's alpha, McDonald's Omega, and the ICC were 0.94, 0.943, and 0.998, respectively. In addition, the confirmatory factor analysis yielded one dimension. Finally, after reviewing the experts' comments, the final amendments were made, and only question 29 was removed from the final version.

Conclusion

Consequently, the Persian version of the PQ is acceptable in terms of content validity, face validity, temporal stability, and internal consistency.

Polygenic Contributions to Suicidal Thoughts and Behaviors in a Sample Ascertained for Alcohol Use Disorders

Introduction

Suicidal thoughts and behaviors have partially distinct genetic etiologies.

Methods

We used PRS-CS to create polygenic risk scores (PRSs) from GWAS of non-suicidal self-injury, broad-sense self-harm ideation, nonfatal suicide attempt, death by suicide, and depression. Using mixed-effect models, we estimated whether these PRSs were associated with a range of suicidal thoughts and behaviors in the Collaborative Study on the Genetics of Alcoholism (N = 7,526).

Results

All PRSs were significantly associated with suicidal ideation and suicide attempt (betas = 0.08-0.44, false discovery rate [FDR] <0.023). All PRSs except non-suicidal self-injury PRS were associated with active suicidal ideation (betas = 0.14-0.22, FDR <0.003). Several associations remained significant in models where all significant PRSs were included as simultaneous predictors, and when all PRSs predicted suicide attempt, the PRS together explained 6.2% of the variance in suicide attempt. Significant associations were also observed between some PRSs and persistent suicidal ideation, non-suicidal self-injury, compounded suicide attempt, and desire to die.

Conclusion

Our findings suggest that PRS for depression does not explain the entirety of the variance in suicidal thoughts and behaviors, with PRS specifically for suicidal thoughts and behaviors making additional and sometimes unique contributions.

Association Between Loneliness and Suicidal Behaviour: A Scoping Review

OBJECTIVE

Suicide is a public health issue, and there are several factors leading to suicide, like mental illness and psychosocial stressors. Actual loneliness (living alone) and subjective loneliness (feeling of being alone) and different suicidal behaviors have been reported to have some link. This scoping review aimed to assess the association between loneliness and suicidal behaviour by exploring the existing literature.

METHODS

A scoping review was conducted implementing the appropriate framework and in accord with the PRISMA-ScR extension. A PubMed database search was made using a combination of terms to find publications in English from 2011 to 2021. Studies were included if they reported quantitative outcomes of the association between loneliness and suicidal experiences, including suicidal thoughts, plans, and/or attempts. Screening and data charting of the published literature was conducted by a panel of authors. The accuracy and clarity of extracted data was checked by three reviewers.

RESULTS

Among 421 articles found, 31 full texts were evaluated based on exclusion and inclusion criteria, out of which, 18 papers that reported quantitative outcomes of the association between loneliness and suicidal experiences were included. We found that association between loneliness and suicidal behaviour is determined by individual, social and cultural factors. Co-existing mental illness, substance use disorder and economic hardship play an important role for the completion of suicide.

CONCLUSION

Loneliness is correlated with suicide, and the knowledge about this association could assist in the identification of suicidal individuals or those at elevated risk of suicidal behaviour. Future studies should focus on loneliness and its relation to suicidal ideation in individuals with different mental health disorders and personalities.

Suicide rates in Ecuador: A nationwide study from 2011 until 2020

Suicide, suicide ideations, and psychiatric disorder rates tend to increase after natural disasters such as earthquake. In 2016 Ecuador experienced a 7.8Mw earthquake and, more recently, the Covid-19 confinement. Both events may have negatively affected the mental health of the Ecuadorian population. Therefore, the present study aimed to evaluate the suicide rates and choice of suicide method in the Ecuadorian population between January 2011 and December 2020. The dataset used is publicly available on the Ecuadorian National Institute of Statistics and Censuses. Multivariate logistic regression models were used to calculate adjusted odds ratios (OR) for potential sociodemographic factors associated with each suicide method compared to other reported suicide methods. There were 10,380 registered cases of suicide in Ecuador between 2011 and 2020. Significant suicide rates per provinces were seen in Napo with 12.63 and Azuay with 12.52, followed by Bolívar with 12.30, and Orellana with 11.36 suicides/100,000 habitants. Hanging accounted for 7082 cases (68.2 %). The mestizos (82 %) were the most prevalent ethnicity of all suicide cases. School-age children with 6-12 years (OR 8.83, 95 % CI 5.34-14.59) and adolescents with 13-19 years (OR 1.46, 95 % CI 1.29-1.66) were more likely to use hanging as method of suicide. In conclusion, we observed an increase of suicide rates from 8.15 per 100,000 in 2011 to 8.81 in 2020. The confinement of COVID-19 pandemic in the period evaluated did not significantly affect the suicide rates. An increased suicide rate was observed in the province hardest hit by the 2016 earthquake.

The epidemiology of non-suicidal self-injury: lifetime prevalence, sociodemographic and clinical correlates, and treatment use in a nationally representative sample of adults in England

BACKGROUND

Although the clinical importance of non-suicidal self-injury (NSSI) has received increasing recognition, relatively little is known about its epidemiology. The objective of this study was to estimate the lifetime prevalence of NSSI in adults and its association with sociodemographic characteristics, psychiatric disorders, and lifetime treatment for NSSI.

METHODS

A nationally representative face-to-face survey was conducted with 7192 adults aged ≥18 years in England. Respondents were interviewed about engagement in NSSI, psychiatric illness, suicidal thoughts and behavior, and treatment history for this behavior.

RESULTS

The estimated lifetime prevalence rate of NSSI was 4.86%. Younger age, growing up without biological parents in the household, being unmarried, and impoverished backgrounds were associated with NSSI. The majority of respondents with lifetime NSSI (63.82%) had at least one current psychiatric disorder. Most psychiatric conditions were associated with greater odds of lifetime NSSI in multivariate models. NSSI was strongly associated with suicidal ideation and suicide attempts, respectively, even after accounting for psychiatric disorders and sociodemographic covariates. A substantial proportion of respondents with NSSI history (30.92%) have engaged in medically severe self-harm, as indexed by requiring medical attention for this behavior. The majority of respondents with NSSI (56.20%) had not received psychiatric care for this behavior.

CONCLUSIONS

NSSI is prevalent in the general population and associated with considerable psychiatric comorbidity. A high rate of unmet treatment needs is evident among those with this behavior. Those at the greatest lifetime risk for NSSI may also be particularly limited in their resources to cope with this behavior.

Epidemiology of suicide in the Tri-City metropolitan area in Poland in 2010-2019

The paper, which is a continuation of our previous epidemiological studies on the phenomenon of suicide in the Tri-City metropolitan area, presents the results of statistical analyses of suicides in the autopsy material of the Department of Forensic Medicine of the Medical University of Gdańsk in the years 2010-2019. The purpose of the study was to analyse in detail demographic data of suicides (age, sex, place of death), as well as to assess suicide methods and the impact of alcohol on suicides in the study area. During the 10-year study period, 8495 autopsies were performed, of which 1261 were suicides (14.8%). Statistical analyses were conducted using the statistical data analysis software system STATISTICA, version 13 (StatSoft, Tulsa, Oklahoma, USA). The results of the study indicate a continuing downward trend in the number of suicides since the beginning of the 21th century, with the number of suicides in rural areas increasing over the same period. In the analysed cohort, suicides were committed in particular by middle-aged men and the number of suicides among older people (65 +) increased at the same time. The increase in suicide occurred in late autumn and early spring. The most common method of suicide was hanging. There was a high percentage of inebriated victims (45%), and a comparison of the present studies with previous ones indicates the increasing impact of alcohol on suicide.

Trends in suicide methods in Switzerland from 1969 to 2018: an observational study

BACKGROUND

Suicide is a serious societal and health problem. We examined changes in rates of completed suicides in Switzerland between 1969-2018 with particular regard to different methods of suicide used in different subgroups of the resident population.

METHODS

We used data of the Swiss cause of death statistics and Poisson regression models to analyse annual incidence rates and calendar time trends of specific suicide methods used in population subgroups by sex (men vs women), age (10-29, 30-64, >64 years), and nationality (Swiss vs other citizenship).

RESULTS

There were 64,996 registered suicides between 1969 and 2018. Across these 5 decades, the overall suicide rate was higher in men than in women (incidence rate ratio [IRR] 2.62, 95% confidence interval [CI] 2.58-2.67), in Swiss citizens than in foreigners (IRR 2.02; 95% CI 1.97-2.07), and in older residents (>64 years) than in the age groups 30-64 years (IRR 1.35, 95% CI 1.32-1.37) and 10-29 years (IRR 2.37, 95% CI 2.32-2.43). After peaking in the 1980s, the overall suicide rate had declined in all of these population subgroups, with flattening trends over most recent years. The most common specific methods of suicide were hanging (accounting for 26.7% of all suicides) and firearms (23.6%). The rates of the specific suicide methods were usually higher in men, in Swiss citizens and in older residents, and they had typically declined over most recent decades in the population subgroups examined. However, some methods diverged from this general pattern, at least in some population subgroups. For instance, railway suicides most recently increased in younger and in male residents whereas suicides by gas and by drowning were only at a low level after rapid declines in the last millennium.

CONCLUSIONS

Restricting access to lethal means (e.g., detoxification of domestic gas), improvements in health care and media guidelines for responsible reporting of suicides are possible explanations for the generally declining suicide rates in Switzerland. Whereas some methods (e.g., poisoning by gases or drowning) had become rare, others continue to account for many suicides every year, at least in some population subgroups (e.g., firearms in older Swiss men or railway suicides in younger and in male residents). As different methods of suicide are chosen by different people or subgroups of the population, preventive efforts should include differentiated strategies and targeted measures to further reduce suicides in Switzerland and elsewhere.

A comparative autopsy study of the injury distribution and severity between suicidal and accidental high falls

Falls are the second cause of accidental deaths worldwide. Falls from height are also a common method of suicide. The aim of this study is to compare the characteristics of the victims, the circumstances of the fall and the severity and distribution of the injuries reported in an autopsy case series of falls from height. This study is a retrospective analysis of consecutive autopsy cases of suicidal and accidental falls from height which were investigated in the Department of Forensic Medicine and Toxicology of the National and Kapodistrian University of Athens during the period 2011-2019. The recorded variables included demographic data of the victim, height of fall, length of hospital stay, toxicological results, the existence and location of injuries and Injury Severity Score (ISS). Victims of suicidal falls were younger (55.53 vs. 62.98, p = 0.001), they fell from higher heights (12.35 vs. 5.18 m, p < 0.001), and they sustained more severe injuries compared with victims of accidental falls (ISS 51.01 vs. 40.88, p < 0.001). Injuries in the thorax, abdomen, pelvis, upper and lower extremities were more frequently observed after a suicidal fall (93.6% vs. 67.3%, 72.1% vs. 21.4%, 72.1% vs. 27.6%, 42.9% vs. 15.3%, 45.7% vs. 13.3%, respectively-p < 0.001), probably due to the higher height of fall. Our study outlines the differences in the profile of the victims and in the severity of injuries caused by falls from height depending on the intention of the victim to fall. However, a distinctive injury pattern in victims of suicidal falls was not demonstrated.

Toxicological Findings of Self-Poisoning Suicidal Deaths: A Systematic Review by Countries

The use of illicit and non-illicit substances is widespread in suicides. The toxicological data may help in understanding the mechanism of death. This systematic review aimed to analyze autopsies related to suicides by consuming poison, focusing on the correlation between substance use and the country of origin to create an alarm bell to indicate that suicide maybe attempted and prevent it. The systematic review was conducted according to the PRISMA guidelines, with the primary objective of identifying autopsies conducted in cases of suicide by consuming poison in specific geographic areas. Significant differences in substances were observed between low-income and Western countries that confirm previous literature data. In rural areas and Asian countries, most suicides by consuming poison involve the use of pesticides, such as organophosphates and carbamates. In Western countries, illicit drugs and medically prescribed drugs are the leading cause of suicide by self-poisoning. Future research should shed light on the correlation between social, medical, and demographic characteristics and the autopsy findings in suicides by self-poisoning to highlight the risk factors and implement tailored prevention programs worldwide. Performing a complete autopsy on a suspected suicide by self-poisoning could be essential in supporting worldwide public health measures and policy makers. Therefore, complete autopsies in such cases must be vigorously promoted.

Linking suicide and social determinants of health in South Korea: An investigation of structural determinants

Introduction

Studies have shown that suicide is closely related to various social factors. However, due to the restriction in the data scale, our understanding of these social factors is still limited. We propose a conceptual framework for understanding social determinants of suicide at the national level and investigate the relationships between structural determinants (i.e., gender, employment statuses, and occupation) and suicide outcomes (i.e., types of suicide, places of suicide, suicide methods, and warning signs) in South Korea.

Methods

We linked a national-level suicide registry from the Korea Psychological Autopsy Center with the Social Determinants of Health framework proposed by the World Health Organization's Commission on Social Determinants of Health.

Results

First, male and female suicide victims have clear differences in their typical suicide methods (fire vs. drug overdose), primary warning signs (verbal vs. mood), and places of death (suburb vs. home). Second, employees accounted for the largest proportion of murder-suicides (>30%). The proportion of students was much higher for joint suicides than for individual suicides and murder-suicides. Third, among individuals choosing pesticides as their suicide method, over 50% were primary workers. In terms of drug overdoses, professionals and laborers accounted for the largest percentage; the former also constituted the largest proportion in the method of jumping from heights.

Conclusion

A clear connection exists between the investigated structural factors and various suicide outcomes, with gender, social class, and occupation all impacting suicide.

Is Lethality Different between Males and Females? Clinical and Gender Differences in Inpatient Suicide Attempters

According to the gender paradox in suicidology, an important sex difference has been reported with a preponderance of females in nonfatal suicidal behavior and a preponderance of males in completed suicide. Furthermore, females and males present different risk factors for suicide. The present study explored possible clinical differences between male and female psychiatric inpatients who had recently attempted suicide. The study included 177 adult inpatients hospitalized following a suicide attempt at the University Psychiatric Clinic, Sant'Andrea Hospital, Sapienza University of Rome. Clinical features assessed included psychiatric diagnosis, method and lethality of suicide attempts using the Risk/Rescue Rating Scale, the history of suicide attempts, age at onset of psychiatric illness, the presence of substance or alcohol use, and the length of stay. The results found that males and females differed in the method used for the suicide attempt, the scores for risk and rescue, and the length of hospitalization post-suicide attempt. In conclusion, identifying gender characteristics of patients at higher risk of suicide is important for implementing specific suicide prevention strategies and reducing the risk of future suicidal behavior in psychiatric inpatients.

Worldwide suicide mortality trends (2000-2019): A joinpoint regression analysis

BACKGROUND

Studies exploring suicide mortality on a global scale are sparse, and most evaluations were limited to certain populations.

AIM

To assess global, regional and national trends of suicide mortality.

METHODS

Suicide mortality data for the period 2000-2019 were obtained from the mortality database of the World Health Organization and the Global Burden of Disease Study. Age-standardized rates (ASRs; expressed per 100000) were presented. To assess trends of suicide mortality, joinpoint regression analysis was used: The average annual percent change (AAPC) with the corresponding 95% confidence interval (95%CI) was calculated.

RESULTS

A total of 759028 (523883 male and 235145 female) suicide deaths were reported worldwide in 2019. The global ASR of mortality of suicide was 9.0/100000 population in both sexes (12.6 in males vs 5.4 in females). In both sexes, the highest rates were found in the region of Africa (ASR = 11.2), while the lowest rates were reported in Eastern Mediterranean (ASR = 6.4). Globally, from 2000 to 2019, ASRs of mortality of suicide had a decreasing tendency in both sexes together [AAPC = -2.4% per year; 95%CI: (-2.6)-(-2.3)]. The region of the Americas experienced a significant increase in suicide mortality over 2000-2019 unlike other regions that had a declining trend. Out of all 133 countries with a decline in suicide mortality, Barbados (AAPC = -10.0%), Grenada (AAPC = -8.5%), Serbia (AAPC = -7.6%), and Venezuela (AAPC = -6.2%) showed the most marked reduction in mortality rates. Out of all 26 countries with a rise in suicide mortality, Lesotho (AAPC = +6.0%), Cyprus (AAPC = +5.1%), Paraguay (AAPC = +3.0%), Saudi Arabia (AAPC = +2.8%), Brunei (AAPC = +2.6%), Greece (AAPC = +2.6%), Georgia (AAPC = +2.1%), and Mexico (AAPC = +2.0%), are among those with the highest increase in mortality.

CONCLUSION

Decreasing trends in suicide mortality were observed in most countries across the world. Unfortunately, the mortality of suicide showed an increasing trend in a number of populations. Further research should explore the reasons for these unfavorable trends, in order to consider and recommend more efforts for suicide prevention in these countries.

The impact of daylight on suicide rates

Since Durkheim and Morselli found a spring peak in suicides in the late 19th century, researchers have presented possible explanations, including daylight variation, for this seasonal pattern. Our identification strategy exploits the idiosyncratic variation in daylight within Norwegian regions, arising from the country's substantial latitudinal range. We use full population data for a period of 45 years in a pre-registered research design. We find a small and non-significant relationship: One extra hour of daylight increases the suicide rate by merely 0.75 % (95 % CI: -0.4 % to 1.9 %).

The association between food insecurity and gun violence in a major metropolitan city

BACKGROUND

Food insecurity (FI) is an important social determinant of health that is associated with many forms of violence. We hypothesized that FI would be associated with gun violence.

METHODS

Firearm injury data was collected from 2016 to 2020 (n = 3115) at a single institution that serves as the only Level I trauma center in a major southern US city. The data were linked with Map the Meal Gap data, a publicly available data set, which estimates rates of county-level FI based on state-level FI and social determinants, including unemployment, poverty, disability, and other factors. Regression analysis was utilized to examine the relationship between FI with rates of overall gun trauma and odds of gun-related violence. Food insecurity by county of patient residence was categorized by rates less than the national average of 11.5% (low), between the national and state average (16.5%) (moderate), and greater than the state average (high). Out of state residents were excluded from the analyses.

RESULTS

Of the 3,115 patients with firearm injuries identified, 138 (4.4%) resided in counties with low FI rates, 1048 (33.6%) in moderate FI, and 1929 (62.0%) in counties with high FI. Patients in regions of high FI were more likely to be a Level I trauma activation, a victim of assault, and have Medicaid or be self-pay. There was no significant difference in mortality by levels of FI. Food insecurity was significantly associated with firearm injury, with each percent increase in FI being related to approximately 56 additional gun-related injuries per 100,000 people (95% confidence interval, 54-59) and increased odds of the injury classified as assault (odds ratio, 1.13; 95% confidence interval, 1.07-1.19).

CONCLUSION

Violence prevention initiatives targeting food insecure communities may help alleviate the US gun violence epidemic. Further, trauma center screening for household FI and in-hospital interventions addressing FI may help reduce gun violence recidivism.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

Exploring characteristics of increased suicide during the COVID-19 pandemic in Japan using provisional governmental data

Background

The Japanese age-standardised death rate of suicide (SDR) had decreased during 2009-2019, but increased in 2020-2021, during the COVID-19 pandemic.

Methods

This study aimed to explain the trend change in the SDR during the pandemic, disaggregated by prefecture, gender, suicide method and household, as compared to predicted SDR derived from pre-pandemic data, using linear mixed-effect and hierarchical linear regression models with robust standard error analyses.

Findings

The SDR was lower during March-June 2020 (during the first wave of the pandemic), but higher during July-December 2020 than the predicted SDR. In 2021, males' SDR was nearly equal to the predicted SDR, whereas females' SDR in the metropolitan-region (17.5%: 95% confidence interval: 13.9-21.2%) and non-metropolitan-region (24.7%: 95% confidence interval: 22.8-26.7%) continued to be higher than the predicted SDR. These gender- and region-dependent temporal fluctuations of SDR were synchronised with those of SDRs caused by hanging, at home and single-person-households. Additionally, the rising number of infected patients with the SARS-CoV-2 and polymerase chain reaction (PCR) diagnostic examinations were positively (β = 0.024) and negatively (β =-0.002) related to the SDR during the pandemic, respectively.

Interpretation

Japanese suicide statistics have previously established that the predominant method and place of suicide were by hanging and at the individual's home, respectively. The present findings suggest that transformed lifestyles during the pandemic, increasing time spent at home, enhanced the suicide risk of Japanese people by hanging and at home.

Funding

Regional Suicide Countermeasures Emergency Enhancement Fund of Mie Prefecture (2021-40).

Validation of Diagnostic Codes to Identify Carbon Monoxide Poisoning in Taiwan’s Claims Data

Purpose: Previous studies identified the study cohort or outcome of carbon monoxide poisoning (COP) by using the relevant disease diagnosis codes in secondary databases, but the validity of diagnosis codes of COP is unclear in such secondary databases. This study aimed to evaluate the accuracy of case definitions for COP using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes in Taiwan’s health insurance claims data.

Methods: We selected a 10% simple random sample from an original cohort of patients newly undergoing carboxyhemoglobin (COHb) testing under any clinical diagnosis at four Chang Gung Memorial Hospitals in Taiwan during 2011–2020. Two clinical doctors independently ascertained the COP diagnosis by reviewing the medical records as the reference standard. We estimated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of various case definitions (e.g., ICD-9-CM code, ICD-10-CM code and the uses of hyperbaric oxygen therapy) in the claims data.

Results: We randomly selected 557 cases from the original cohort of 5,571 cases newly receiving COHb test in the study hospitals. We found 90, 35, and 9 cases were true-positive, false-positive, and false-negative episodes of COP, respectively, among 278 cases with an ICD-9-CM code of 986. A further 111, 34, and 6 cases were true-positive, false-positive, and false-negative episodes of COP, respectively, among 279 cases with an ICD-10-CM code of T58. Using ICD-9-CM codes, the sensitivity, specificity, PPV and NPV for COP were 90.9, 80.4, 72, and 94.1%, respectively. Using ICD-10-CM codes they were 94.9, 79, 76.6, and 95.5%, respectively. PPV typically increased when COP was the primary diagnosis and could reach 100% if patients with ICD-CM code 986 or T58 also received hyperbaric oxygen therapy during hospitalization.

Conclusion: The COP-related ICD-CM codes alone did not accurately identify COP patients, but accuracy improved after including oxygen therapy data with the ICD-CM codes in Taiwan’s claims data.

Associations Between Firearm and Suicide Rates: A Replication of Kleck (2021)

OBJECTIVE

Using data from n = 194 nation-states, Kleck found that firearm availability was only associated with firearm suicide rates, but not total or non-firearm suicides. He thus concluded that while firearm availability influences how people commit suicide, it does not affect total numbers. However, the study contains numerous logical and methodological issues and is at odds with the evidence base. Therefore, I attempt to reproduce the original results.

METHOD

I reproduce the original study's methods: ordinary least squares regression, weighted by the square root of the population, with log-transformed suicide rates and three separate firearm availability measures: global estimates from the Small Arms Survey, proportion of suicides committed with firearms, and a European Union survey of firearm ownership. I also test several methodological variations and include U.S. suicide data.

RESULTS

In contrast to Kleck, global analyses with Small Arms Survey data found a significant and positive association between firearm availability and total suicides, as did U.S. analyses. Analyses with other firearm availability measures comported with the original study, finding no association.

CONCLUSION

The main result in Kleck failed to reproduce, finding instead a significant association between firearm availability and suicide rates, as did U.S. analyses. While reproductions of Kleck's other analyses continued to show no association, they were based on unreliable methods. I therefore reject Kleck's conclusion that that firearm availability does not influence suicide rates. HighlightsUsing data global data, I find firearm availability is positively associated with suicide rates.I identify serious flaws in the logic and methods of Kleck and an earlier review.For transparency, data and code have been archived on a public repository.

Worldwide suicide mortality trends by firearm (1990–2019): A joinpoint regression analysis

Introduction

Suicide by firearm is a major public health problem in many countries. But, studies that investigated the mortality of suicide by firearm on a global scale are still limited. The aim of this study was to assess the global, regional and national trends in mortality of suicide by firearm from 1990 to 2019.

Method

Mortality data of suicide by firearm was presented using the age-standardized rates (ASRs, expressed per 100,000). Joinpoint regression analysis was used to assess trends of mortality of suicide by firearm: the average annual percent change (AAPC) with the corresponding 95% confidence interval (95%CI) was calculated.

Results

A total of 52,694 (45,110 male and 7584 female) deaths of suicide by firearm were reported worldwide in 2019. The global ASR of suicide by firearm was six-fold higher in males than in females (1.15 per 100,000 and 0.19 per 100,000, respectively), and varied greatly across countries: the highest rates were in Greenland (24.52 per 100,000 and 2.69 per 100,000, respectively) and the United States of America (10.13 per 100,000 and 1.66 per 100,000, respectively), while the lowest rates (0.05 per 100,000 or less) were observed in China, Japan and Singapore. Globally, the mortality of suicide by firearm had a decreasing tendency from 1990 to 2019 in both sexes together (AAPC = -2.0% per year; 95%CI = -2.1 to -1.9).

Conclusion

Decreasing trends in mortality of suicide by firearm were observed in majority of countries across the world, but not in all. Future research should determine more effective ways to further reduce mortality of suicide by firearm.

Sociocultural perspectives on suicidal behaviour at the Coast Region of Kenya: an exploratory qualitative study

OBJECTIVES

To explore perceived sociocultural factors that may influence suicidality from key informants residing in coastal Kenya.

DESIGN

We used an exploratory qualitative study design.

SETTING

Mombasa and Kilifi Counties of Coastal Kenya.

PARTICIPANTS

25 key informants including community leaders, professionals and community members directly and indirectly affected by suicidality.

METHODS

We conducted in-depth interviews with purposively selected key informants to collect data on sociocultural perspectives of suicide. Thematic analysis was used to identify key themes using both inductive and deductive processes.

RESULTS

Four key themes were identified from the inductive content analysis of 25 in-depth interviews as being important for understanding cultural perspectives related to suicidality: (1) the stigma of suicidal behaviour, with suicidal victims perceived as weak or crazy, and suicidal act as evil and illegal; (2) the attribution of supernatural causality to suicide, for example, due to sorcery or inherited curses; (3) the convoluted pathway to care, specifically, delayed access to biomedical care and preference for informal healers; and (4) gender and age differences influencing suicide motivation, method of suicide and care seeking behaviour for suicidality.

CONCLUSIONS

This study provides an in depth understanding of cultural factors attributed to suicide in this rural community that may engender stigma, discrimination and poor access to mental healthcare in this community. We recommend multipronged and multilevel suicide prevention interventions targeted at changing stigmatising attitudes, beliefs and behaviours, and improving access to mental healthcare in the community.

Sexual Orientation Differences in Lethal Methods Used in Suicide: Findings From the National Violent Death Reporting System

We examined sexual orientation and sex differences in seven methods of suicide among adult suicides reported in the United States National Violent Death Reporting System (2012-2015; N = 59,075). Overall, most sexual minorities (i.e., lesbians, gay men, bisexuals) identified in the dataset used hanging (38%) followed by firearm (30%) and drug or poison ingestion (20%). Sexual minorities were more likely than heterosexuals to be younger, female, and Black/African American. Multivariate sex-stratified analyses in the overall sample showed that strong sexual orientation differences in lethal methods existed among men but not among women. However, when we compared sex differences in lethal methods among sexual minorities only, we found that lesbian/bisexual women, as compared to gay/bisexual men, were more likely to use a firearm or drug or poison ingestion than hanging. Findings suggest that the higher rate of suicide mortality among sexual minorities is likely driven by hanging, a method of suicide that is not particularly amenable to lethal method restricted-access prevention approaches. Future research directions, clinical training recommendations, and intervention opportunities are discussed.

Trends in suicide by hanging, strangulation, and suffocation in Serbia, 1991-2020: A joinpoint regression and age-period-cohort analysis

BACKGROUND

Hanging is one of the most commonly used methods for suicide in both sexes worldwide. In a number of countries, hanging mortality has increased over the last decades. Nevertheless, there is a scarcity of studies that have explored the patterns and trends for mortality of suicide by hanging on global, regional and national levels, as most evaluations are limited to certain populations.

AIM

To assess the trends of suicide mortality by hanging, strangulation, and suffocation in Serbia, from 1991 to 2020.

METHODS

This nationwide study, with epidemiological descriptive study design, was carried out based on official data. The age-standardized rates (ASRs, expressed per 100000 persons) were calculated by direct standardization, using the World Standard Population. Mortality trends from suicide by hanging were assessed using the joinpoint regression analysis: The average annual percent change (AAPC) with the corresponding 95% confidence interval (95%CI) was calculated. Age-period-cohort analysis was performed to address the possible underlying reasons for the observed suicide trends.

RESULTS

Over the 30-year period studied, there were 24340 deaths by hanging (17750 males and 6590 females) in Serbia. In 2020, the ASR of deaths by hanging was 4.5 per 100000 persons in both sexes together (7.6 in males vs 1.7 in females). The trends of suicide mortality by hanging decreased significantly between 1991 and 2020 in both males (AAPC = -1.7% per year; 95%CI: -2.0 to -1.4) and females (AAPC = - 3.5% per year; 95%CI: -3.9 to -3.1). Mortality rates of suicide by hanging had a continuously decreasing tendency in both sexes together in all age groups: The only exception was among males in 40-49 age group, with an increasing trend of suicide by hanging from 1991 to 2011 (by +0.3% per year).

CONCLUSION

The trends in suicide mortality by hanging have been decreasing in Serbia in the last three decades in both sexes, but this was more pronounced in women than in men. Despite the decreasing trends observed in mortality of suicide by hanging, further research is needed for better clarification of trends and help in suicide prevention in the future.

Association Between Medical Diagnoses and Suicide in a Medicaid Beneficiary Population, North Carolina 2014-2017

BACKGROUND

Firearms are used in about half of U.S. suicides. This study investigated how various medical diagnoses are associated with firearm and nonfirearm suicide.

METHODS

We used a case-control design including n = 691 North Carolina Medicaid beneficiaries who died from suicide between 1 January 2014 and 31 December 2017 as cases. We selected a total of n = 68,682 controls (~1:100 case-control ratio from North Carolina Medicaid member files using incidence density sampling methods). We linked Medicaid claims to the North Carolina Violent Death Reporting System to ascertain suicide and means (firearm or nonfirearm). We matched cases and controls on number of months covered by Medicaid over the past 36 months. Analyses adjusted for sex, race, age, Supplemental Security Income status, the Charlson Comorbidity Index, and frequency of health care encounters.

RESULTS

The case-control odds ratios for any mental health disorder were 4.2 (95% confidence interval [CI]: 3.3, 5.2) for nonfirearm suicide and 2.2 (95% CI: 1.7, 2.9) for firearm suicide. There was effect measure modification by sex and race. Behavioral health diagnoses were more strongly associated with nonfirearm suicides than firearm suicide in men but did not differ substantially in women. The association of mental health and substance use diagnoses with suicides appeared to be weaker in Blacks (vs. non-Blacks), but the estimates were imprecise.

CONCLUSION

Behavioral health diagnoses are important indicators of risk of suicide. However, these associations differ by means of suicide and sex, and associations for firearm-related suicide are weaker in men than women.

Suicide and Psychosis: Results From a Population-Based Cohort of Suicide Death (N = 4380)

Approximately 5% of individuals with schizophrenia die from suicide. However, suicide in psychosis is still poorly characterized, partly due to a lack of adequate population-based clinical or genetic data on suicide death. The Utah Suicide Genetics Research Study (USGRS) provides a large population-based cohort of suicide deaths with medical record and genome-wide data (N = 4380). Examination of this cohort identified medical and genetic risks associated with type of suicide death and investigated the relative contributions of psychotic and affective symptoms to method of suicide. Key differences in method of suicide (common vs. atypical methods) were tested in relation to lifetime psychosis and genome-wide genetic risk for schizophrenia, major depressive disorder, and neuroticism. Consistent with previous studies, psychosis-spectrum disorders were observed to be common in suicide (15% of the cohort). Individuals with psychosis more frequently died from atypical methods, with rates of atypical suicide increasing across the schizophrenia spectrum. Genetic risk for schizophrenia was also associated with atypical suicide, regardless of clinical diagnosis, though this association weakened when filtering individuals with schizophrenia from the analysis. Follow-up examination indicated that high rates of atypical suicide observed in schizophrenia are not likely accounted for by restricted access to firearms. Overall, better accounting for the increased risk of atypical suicide methods in psychosis could lead to improved prevention strategies in a large portion of the suicide risk population.

Fatal drowning statistics from the Netherlands - an example of an aggregated demographic profile

Introduction

Incompleteness of fatal drowning statistics is a familiar problem impeding public health measures. Part of the problem may be that only data on accidental drowning are used and not the full potential of accessible data.

Methods

This study combines cause-of-death certificates and public prosecutor’s court documents between 1998 and 2017 to obtain an aggregated profile. Data are also used as a basis for a trend analysis.

Results

The dataset includes 5571 drowned persons (1.69 per 100,000). The highest risk group are persons above the age of 50. Demographic differences are observed between suicide by drowning, accidental drowning, and drowning due to transportation (0.72, 0.64, 0.28 per 100.000) and between native Dutch, and Dutch with western and non-western background (1.46, 1.43, 1.76 per 100.000). Non-residents account for another 12.2%. When comparing the periods 1998–2007 with 2008–2017, the Standard Mortality declines for suicide drowning and accidental drowning among persons with a native Dutch and non-western background. Single regression analysis confirms a decrease of drowning over the full period, breakpoint analysis shows an increase in the incidence of the total number of drowning, suicide by drowning and accidental drowning starting in 2007, 2008 resp. 2012.

Discussion

Compared to the formal number of fatal accidental drowning in the Netherlands (n = 1718; incidence 0.52 per 100,000), the study identifies 350% more drowning. Differences in demographic data and the recent increase needs to be explored for public health interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12620-3.