Autopsy rates and the misclassification of suicide and accident deaths

Mortality statistics are critical to determine the burden of disease. Certain causes of death are prone to being misclassified on cause of death certificates. This poses a serious risk for public health and safety, as accurate death certificates form the basis for mortality statistics, which in turn are crucial for research, funding allocation and health interventions. This study uses generalised estimating equations and regression modelling to investigate for which cause of death categories suicide and accident deaths are misclassified as. National mortality statistics and autopsy rates from North America and Europe covering the past forty years were analysed to determine the associations between the different causes of death in cross-sectional and longitudinal models. We find that suicides and deaths by accidents are frequently mutually misclassified. We also find that suicides are frequently misclassified as drug use disorder deaths, in contrast to accident deaths, which are not misclassified as drug use disorder deaths. Furthermore, suicides do not seem to be misclassified as undetermined deaths or ill-defined deaths. The frequency of misclassification shows that the quality of death certificates should be improved, and autopsies may be used systematically to control the quality of death certificates.

Understanding the Fluctuations in Korea's Suicide Rates: A Change-Point Analysis and Interrupted Time Series Analysis

BACKGROUND

Korea has witnessed significant fluctuations in its suicide rates in recent decades, which may be related to modifications in its death registration system. This study aimed to explore the structural shifts in suicide trends, as well as accidental and ill-defined deaths in Korea, and to analyze the patterns of these changes.

METHODS

We analyzed age-adjusted death rates for suicides, deaths due to transport accidents, falls, drowning, fire-related incidents, poisonings, other external causes, and ill-defined deaths in Korea from 1997 to 2021. We identified change-points using the 'breakpoints' function from the 'strucchange' package and conducted interrupted time series analyses to assess trends before and after these change-points.

RESULTS

Korea's suicide rates had three change-points in February 2003, September 2008, and June 2012, characterized by stair-step changes, with level jumps at the 2003 and 2008 change-points and a sharp decline at the 2012 change-point. Notably, the 2003 and 2008 spikes roughly coincided with modifications to the death ascertainment process. The trend in suicide rates showed a downward slope within the 2003-2008 and 2008-2012 periods. Furthermore, ill-defined deaths and most accidental deaths decreased rapidly through several change-points in the early and mid-2000s.

CONCLUSION

The marked fluctuations in Korea's suicide rate during the 2000s may be largely attributed to improvements in suicide classification, with potential implications beyond socio-economic factors. These findings suggest that the actual prevalence of suicides in Korea in the 2000s might have been considerably higher than officially reported.

Patterns of follow-up mental health care after hospitalization for suicide-related behaviors among older adults in South Korea

OBJECTIVE

This study aimed to investigate the sociodemographic and clinical factors associated with receiving follow-up mental healthcare within 7 days and 30 days after hospitalization for suicide-related behaviors (SRB) among older adults in South Korea.

METHODS

Data from the Korean National Health Information Database were used, including information on sociodemographic variables and healthcare utilization. The study cohort consisted of individuals born in 1950 or before with a prior hospitalization record for suicide attempts or probable suicide attempts. Logistic regression analysis was conducted to predict the odds of receiving follow-up care within 7 days and 30 days, adjusting for covariates.

RESULTS

Among the 37,595 older adults discharged from hospitalization for SRB, 29.13 % and 37.86 % received follow-up care within 7 days and 30 days, respectively. Follow-up care was more common among younger individuals, women, those with higher socio-economic status (SES), urban residents, and individuals with comorbidities.

CONCLUSION

The provision of mental health follow-up care for older adults after hospitalization for suicide attempts is inadequate in South Korea. Increasing access to follow-up care among those with lower income, residing in rural areas, and older age is crucial. Public awareness campaigns, stigma reduction training for healthcare providers, and system-level changes, such as telemedicine and integrated care pathways, can help bridge the healthcare gap and reduce suicide mortality among older adults.

Suicidal behaviour and ideation among adolescents during the COVID-19 pandemic

Adolescence is a period of elevated risk for suicide, and mental health professionals expressed concerns that suicidal behaviours and suicide rates may increase among this age group during the COVID-19 pandemic. Adolescent suicide rates, attempts, and ideation during the pandemic varied depending on the country, data collection methodology, and population (e.g., general population vs. emergency department). Many pre-pandemic risk factors for suicidal behaviour or ideation were identified as risk factors during the pandemic; however, there was also some evidence that certain groups were disproportionately at risk, such as girls, and adolescents identifying as Black, Asian, American Indian/Alaska Native, or Asian/Pacific Islander. Given the trend of increased adolescent suicide in many countries over the past two decades, there is an ongoing need to direct resources toward prevention programs, screening, and evidence-based interventions for suicide risk.

Predictors of suicide ideation among South Korean adolescents: A machine learning approach

BACKGROUND

The current study developed a predictive model for suicide ideation among South Korean (Korean) adolescents using a comprehensive set of factors across demographic, physical and mental health, academic, social, and behavioral domains. The aim of this study was to address the pressing public health concerns of adolescent suicide in Korea and the methodological limitations of suicidal research.

METHODS

This study used machine learning methods (decision tree, logistic regression, naive Bayes classifier) to improve the accuracy of predicting suicidal ideation and related factors among a nationally representative sample of Korean middle school students (N = 6666).

RESULTS

Factors within all domains, including demographic characteristics, physical and mental health, and academic, social, and behavioral, were important in predicting suicidal thoughts among Korean adolescents, with mental health being the most important factor.

LIMITATIONS

The predictive model of the current research does not infer causality, and there may have been some loss of information due to measurement issues.

CONCLUSIONS

Study results provide insights for taking a multidimensional approach when identifying adolescents at risk of suicide, which may be used to further address their needs through intervention programs within the school setting. Considering the cultural stigma attached to disclosing suicidal ideation and behavior, the current study proposes the need for a preventive screening process based on the observation and assessment of adolescents' general characteristics and experiences in everyday life.

Perception of the criminality of attempted suicide in Nepal and its impact on suicide reporting

In 2018-2019, according to the official statistics, 5754 people died as a result of suicide in Nepal. This is a high number for a country with a population of 29 million people. Experts believe that the actual rate is considerably higher and that many suicides are not reported. This underreporting of suicide is frequently blamed on the stigma and the criminality of attempted suicide. Yet, there has never been a criminal liability for attempted suicide in Nepal. This article discusses the reasons for the perception of the criminality of attempted suicide in the country, its consequences, and the ways of addressing them. We found that the involvement of the police at the initial stages of suicide investigation confirms public perceptions that attempted suicide is a punishable offense and this may reinforce the stigma of suicide. Recent criminalization of the abetment of suicide has contributed to this perception as the public may not be clear about the distinction between abetment of suicide and attempted suicide. Criminalization of suicide not in the laws but in minds discourages reporting and help-seeking behaviour and victimizes people who need support and services. We argue that decriminalization is more than removing the outdated legal clauses from the legal statutes, but also public awareness raising about the reasons for police investigation of suspicious deaths, sensitivity training, and education of government officials, policymakers, and police about suicide and its prevention. These are needed to dispel the myth of criminalization of attempted suicide in Nepal. Our findings could be of wider interest to scholars working on reducing the stigma of suicide and decriminalization of suicide attempts.

Estimates of suicide mortality in women residents in northeast brazilian states from 1996 to 2018

The objective of this study was to analyze the temporal trend of suicide mortality in women in the states of Northeastern Brazil. This is an ecological study of a time series stratified by states in Northeast Brazil from 1996 to 2018, with data extracted from the Mortality Information System (SIM). The temporal trend was evaluated by negative binomial regression (p values≤0.05). There was a higher proportion of deaths in black and brown women (73.9%), single (57.3%), with the place of death occurring in the home (53.4%). Hanging and strangulation stood out as the perpetration means (47.6%). Most states showed an upward temporal trend, except for Pernambuco, Rio Grande do Norte, Sergipe and Maranhão, which showed a steady trend (p>0.05). An upward temporal trend was identified in the analysis of deaths by suicide in women in five states in northeastern Brazil between 1996 and 2018. The information presented can support planning and decision-making for the prevention of suicide among women in northeastern Brazil.

Self-Stigma and Its Relationship With Rates of Depression Diagnosis

Background: Self-stigma about suicide might impede people seeking help from mental health professionals. There is little research about self-stigma expressed by suicide decedents. Aims: We aimed to explore (a) self-stigma about suicide through examination of suicide notes; and (b) whether the expression of self-stigma was associated with the formal diagnoses of depression. Method: Data were extracted from notes left by people who died by suicide in two major Chinese cities (Shanghai, 2004-2017; Wuhan, 2005-2019). Note content was examined and self-stigma items were coded. Demographics associated with self-stigma were reported. Rates of depression were compared between note-leavers who expressed self-stigma, and those who did not. Results: Notes were left by 567 suicide decedents (representing about 19% all suicides). Approximately 25% notes contained at least one self-stigma item. Older people made fewer self-stigma references, as did people from Wuhan. Depression was not associated with self-stigma. Limitations: Not all people dying from suicide leave notes, and suicide notes variably report self-stigma, thus self-stigma about suicide may be underestimated. Conclusion: Self-stigma items varied across regions and age groups, but not with depression. Therefore, self-stigma expressed by suicide decedents may not reflect help-seeking behaviours from professional mental health services.

Prediction of suicide among 372,813 individuals under medical check-up

BACKGROUND

Suicide is a serious social and public health problem. Social stigma and prejudice reduce the accessibility of mental health care services for high-risk groups, resulting in them not receiving interventions and committing suicide. A suicide prediction model is necessary to identify high-risk groups in the general population.

METHODS

We used national medical check-up data from 2009 to 2015 in Korea. The latest medical check-up data for each subject was set as an index point. Analysis was undertaken for an overall follow-up period (index point to the final tracking period) as well as for a one-year follow-up period. The training set was cross-validated fivefold. The predictive model was trained using a random forest algorithm, and its performance was measured using a separate test set not included in the training.

RESULTS

The analysis covered 372,813 individuals, with an average (SD) overall follow-up duration of 1.52 (1.52) years. When we predicted suicide during the overall follow-up period, the area under the receiver operating characteristic curve (AUC) was 0.849, sensitivity was 0.817, and specificity was 0.754. The performance of the predicted suicide risk model for one year from the index point was AUC 0.818, sensitivity 0.788, and specificity 0.657.

CONCLUSIONS

This is probably the first suicide predictive model using machine learning based on medical check-up data from the general population. It could be used to screen high-risk suicidal groups from the population through routine medical check-ups. Future studies may test preventive interventions such as exercise and alcohol in these high-risk groups.