Dyadic deaths involving Huntington's disease: a case report

Investigation of Deaths of Chronically Disabled Persons and Institutionalized Persons

The investigation of deaths involving chronically disabled and/or institutionalized persons represents an important challenge to the medicolegal death investigation community. For the purposes of this review, the chronically disabled and/or institutionalized are considered to include three non-mutually exclusive subcategories: the disabled elderly, the severely disabled, and psychiatric patients. Because deaths within certain of these populations tend to be common and expected, a very important goal when such deaths occur is the appropriate referral of cases to the medical examiner/coroner. Although each subcategory has distinct issues of importance regarding death investigation, there is also a reasonable amount of overlap between the three groups. This review provides an overview of the three subcategories, the reasons such persons may be at risk for premature, unexpected, or unnatural death, the many important issues of concern when investigating deaths within these vulnerable populations, and important preventative strategies within each group.

Women who kill their mates

Spousal homicide perpetrators are much more likely to be men than women. Accordingly, little research has focused on delineating characteristics of women who have committed spousal homicide. A retrospective clinical review of coroners' files containing all cases of spousal homicide occurring in Quebec over a 20-year period was carried out. A total of 276 spousal homicides occurred between 1991 and 2010, with 42 homicides by female spouses and 234 homicides by male spouses. Differences between homicides committed by female offenders and male offenders are discussed, and findings on spousal homicide committed by women are compared with those of previous studies. Findings regarding offenses perpetrated by females in the context of mental illness, domestic violence, and homicide-suicide are explored. The finding that only 28% of the female offenders in the Quebec sample had previously been subjected to violence by their victim is in contrast to the popular belief and reports that indicate that most female-perpetrated spousal homicide occurs in self-defense or in reaction to long-term abuse. In fact, women rarely gave a warning before killing their mates. Most did not suffer from a mental illness, although one-fifth were acutely intoxicated at the time of the killing. In the vast majority of cases of women who killed their mates, there were very few indicators that might have signaled the risk and helped predict the violent lethal behavior.

Predictors of suicide in patients with dementia

BACKGROUND

Assessing predictors of suicide and means of completion in patients with dementia may aid the development of interventions to reduce risk of suicide among the growing population of individuals with dementia.

METHODS

This national, retrospective, cohort study used data from the Department of Veterans Affairs (fiscal years 2001-2005). The sample included patients ≥60 years old diagnosed with dementia (N = 294,952), of which 241 committed suicide. Potential predictors of suicide were identified using logistic regression. Suicide methods are also reported.

RESULTS

Increased risk of suicide was associated with white race (OR: 2.4, 95% CI: 1.2, 4.8), depression (OR: 2.0, 95% CI: 1.5, 2.9), a history of inpatient psychiatric hospitalizations (OR: 2.3, 95% CI: 1.5, 3.5), and prescription fills of antidepressants (OR: 2.1, 95% CI: 1.6, 2.8) or anxiolytics (OR: 2.0, 95% CI: 1.5, 2.7). Nursing home admission was associated with lower suicide risk (OR: 0.3, 95% CI: 0.1, 0.8). Severity of medical comorbidity did not affect risk of suicide. Sensitivity analysis indicated that the majority of suicides occurred in those who were newly diagnosed with dementia. Firearms were the most common method of suicide (73%) used.

CONCLUSIONS

Given the higher rate of suicide in those receiving treatment for psychiatric symptoms and the high proportion that died using firearms, closer monitoring and assessment of gun access may be an important part of initial treatment planning for older male patients with dementia, particularly those with symptoms of depression or anxiety.

Dyads of father and son suicide separated by time and circumstances

We encountered 2 dyadic suicides among fathers and sons. In the first dyad, the father was a 64-year-old man with complications of heart surgery. He committed suicide with a shotgun. The decedent's son was a 38-year-old man. Five years after his father's death, the son had an argument with his wife. That morning, he drove to the house where his father had lived and inflicted a handgun wound to his head. In the second dyad, the son was a 22-year-old man whose girlfriend left him. He inflicted a shotgun injury to the head. His blood alcohol level was 294 mg/dL. The father of this decedent was a 43-year-old man who 1 year later was despondent after a fight with his girlfriend. He was found dead at home with a single handgun wound to the chest. His blood alcohol level was 173 mg/dL. All 4 suicides appear to have been premeditated and all 4 men used guns. Suicide in a family tends to cause depression and complicate bereavement in survivors more than other types of death. Copycat suicide is well-documented in high-profile cases. The effect of father-son relationships is likely closer and more influential than celebrity suicides.

A demographic study of homicide-suicide in the Pretoria region over a 5 year period

A study was undertaken to research the occurrence of homicide-suicide events in the Pretoria region from January 1997 until October 2001. It is important to attempt understanding this tragic phenomenon from psychiatric and forensic perspectives. This uncommon phenomenon has attracted widespread and sensational media coverage, but little is known about the causal factors and demographic profile of perpetrators and victims, and possible sites of intervention. Case files of the Pretoria Medico-Legal Laboratory (where all cases of unnatural death in Pretoria are investigated) were reviewed and information collected from relevant investigating officers of the South African Police Services. The average annual incidence of homicide-suicide in Pretoria over the period studied was found to be 1 per 100,000 of the population. Two profiles of typical perpetrators seem to emerge: a younger, single, black male shooting his girlfriend and himself at home; and an older, married, Caucasian male shooting his wife and himself at home. Employment in peace forces and unemployment are shown to play significant roles, suggesting need for the availability of psychological support systems to members of peace forces and for intervention regarding unemployment.

Hospital-diagnosed dementia and suicide: a longitudinal study using prospective, nationwide register data

OBJECTIVE

The current study aims to examine the risk of suicide in persons diagnosed with dementia during a hospitalization and its relationship to mood disorders.

DESIGN

Event-history analysis using time-varying covariates.

SETTING

Population-based record linkage.

PARTICIPANTS

All individuals aged 50+ living in Denmark (N=2,474,767) during January 1, 1990 through December 31, 2000.

MEASUREMENTS

Outcome of interest is suicide. Relative risks are calculated based on person-days spent in each stratum.

RESULTS

A total of 18,648,875 person-years were observed during the 11-year study period. During this period, 136 persons who previously had been diagnosed with dementia died by suicide. Men and women aged 50-69 years with hospital presentations of dementia have a relative suicide risk of 8.5 (95% confidence interval: 6.3-11.3) and 10.8 (95% confidence interval: 7.4-15.7), respectively. Those who are aged 70 or older with dementia have a threefold higher risk than persons with no dementia. The time shortly after diagnosis is associated with an elevated suicide risk. The risk among persons with dementia remains significant when controlling for mood disorders. As many as 26% of the men and 14% of the women who died by suicide died within the first 3 months after being diagnosed whereas 38% of the men and 41% of the women died more than 3 years after initial dementia diagnosis.

CONCLUSIONS

Dementia, determined during hospitalization, was associated with an elevated risk of suicide for older adults. Preventive measures should focus on suicidal ideation after initial diagnosis but also acknowledge that suicides can occur well after a dementia diagnosis has been established.

Epidemiology of Homicide-Suicide Events

In Oklahoma, all nonnatural deaths must be reported to the Office of the Chief Medical Examiner (ME), whose trained investigators report cause of death using a centralized, statewide, standardized reporting system. The purpose of this study was to determine temporal trends of Oklahoma homicide-suicide events and characterize the epidemiology of these events. By reviewing all ME reports of homicides and suicides from 1994 through 2001, we identified 73 homicide-suicide events resulting in 73 suicides and 89 homicides. Suicidal perpetrators of homicide-suicide events were most often white men aged >or=30 years who killed a current or ex-spouse or intimate partner. Homicide victims tended to be younger women the same race as their killer. Firearms were the predominant method of death in both homicides and suicides, with handguns used most frequently. Divorce/estrangement was the main contributing factor to these events, and the most common relationship type was possessive. The existence of a statewide, centralized, and computerized ME system and the ability to access the detailed information in the ME narratives were critical to identifying homicide-suicide events and obtaining the type of detailed information necessary to fully investigate these events.

A newspaper surveillance study of homicide-suicide in the United States

The objective of this study was to identify the number and subtypes of homicide-suicides in the United States by age group and state over a 3-year period from 1997 through 1999. A total of 673 homicide-suicides, including 674 perpetrators and 779 victims, were identified from Internet searches of 191 national newspapers, and they were classified according to a modified Hanzlick-Koponen typology. One quarter of the homicide-suicides were perpetrated by persons 55 years or older, and 77% were spousal/consortial, higher than the 57% observed in the younger age group; 11% of the older homicide-suicides were familial, compared with 16% in the younger age group. Whereas only 3% of older homicide-suicides were infanticide/pedicide, 16% of the younger homicide-suicides involved parents killing their children. Forty-five states, including the District of Columbia, reported a homicide-suicide during the 3-year period, and they occurred most frequently in Florida (163), California (98), Texas (36), and New York (35). Newspaper surveillance is useful to identify where homicide-suicides are occurring most frequently, but they are underestimates of the true prevalence. However, the number of incidents detected is large enough that the cases detected may be a fairly representative sample.