Jumping from the Westgate Bridge, Melbourne

Health and Economic Burden of Injurious Falls Into Irrigation Canals in Japan: A Retrospective Cohort Study

BACKGROUND

Falls into small water bodies can cause drowning and trauma. Such falls, especially into irrigation canals, and the subsequent trauma are common in Japan. However, few studies have investigated their characteristics, costs, and prognosis.

OBJECTIVE

Our aim was to clarify the characteristics, prognosis, and economic burden of trauma due to falls into irrigation canals in Kurashiki City, Japan.

METHODS

This 4-year, single-center, retrospective cohort study was conducted at a Japanese tertiary care hospital between January 1, 2013 and December 31, 2016. We enrolled patients who had fallen into irrigation canals constructed more than 300 years ago, and transported to our hospital by ambulance. The study outcomes included the characteristics, prognosis, and health care costs of such trauma.

RESULTS

We enrolled 266 patients with a median age of 66 years (range 19-64 years). Most patients fell into irrigation canals while walking (49.3%), riding a bicycle (35.0%), or driving or riding in a car (7.1%). Extremities were the most frequently affected body parts, and the head and chest were less frequently affected. Four patients (1.5%) died in the emergency department (ED), and 121 (45.5%) were hospitalized (109 in our hospital and 12 transferred to other hospitals). The total costs of ED and hospital stays were 777,625 US dollars (266 patients) and 712,059 US dollars (109 patients hospitalized in our hospital), respectively.

CONCLUSIONS

Trauma due to falls into irrigation canals can be severe and even fatal, and the related costs are high. Our study highlights the importance of implementing appropriate measures to prevent falls into irrigation canals and of promoting awareness among citizens.

Means restriction for the prevention of suicide by jumping

BACKGROUND

Jumping from a height is an uncommon but lethal means of suicide. Restricting access to means is an important universal or population-based approach to suicide prevention with clear evidence of its effectiveness. However, the evidence with respect to means restriction for the prevention of suicide by jumping is not well established.

OBJECTIVES

To evaluate the effectiveness of interventions to restrict the availability of, or access to, means of suicide by jumping. These include the use of physical barriers, fencing or safety nets at frequently-used jumping sites, or restriction of access to these sites, such as by way of road closures.

SEARCH METHODS

We searched the Cochrane Library, Embase, MEDLINE, PsycINFO, and Web of Science to May 2019. We conducted additional searches of the international trial registries including the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov, to identify relevant unpublished and ongoing studies. We searched the reference lists of all included studies and relevant systematic reviews to identify additional studies and contacted authors and subject experts for information on unpublished or ongoing studies. We applied no restrictions on date, language or publication status to the searches. Two review authors independently assessed all citations from the searches and identified relevant titles and abstracts. Our main outcomes of interest were suicide, attempted suicide or self-harm, and cost-effectiveness of interventions.

SELECTION CRITERIA

Eligible studies were randomised or quasi-randomised controlled trials, controlled intervention studies without randomisation, before-and-after studies, or studies using interrupted time series designs, which evaluated interventions to restrict the availability of, or access to, means of suicide by jumping.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion and three review authors extracted study data. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary. We summarised the quality of the evidence included in this review using the GRADE approach.

MAIN RESULTS

We included 14 studies in this review. Thirteen were before-and-after studies and one was a cost-effectiveness analysis. Three studies each took place in Switzerland and the USA, while two studies each were from the UK, Canada, New Zealand, and Australia respectively. The majority of studies (10/14) assessed jumping means restriction interventions delivered in isolation, half of which were at bridges. Due to the observational nature of included studies, none compared comparator interventions or control conditions. During the pre- and postintervention period among the 13 before-and-after studies, a total of 742.3 suicides (5.5 suicides per year) occurred during the pre-intervention period (134.5 study years), while 70.6 suicides (0.8 suicides per year) occurred during the postintervention period (92.4 study years) - a 91% reduction in suicides. A meta-analysis of all studies assessing jumping means restriction interventions (delivered in isolation or in combination with other interventions) showed a directionality of effect in favour of the interventions, as evidenced by a reduction in the number of suicides at intervention sites (12 studies; incidence rate ratio (IRR) = 0.09, 95% confidence interval (CI) 0.03 to 0.27; P < 0.001; I2 = 88.40%). Similar findings were demonstrated for studies assessing jumping means restriction interventions delivered in isolation (9 studies; IRR = 0.05, 95% CI 0.01 to 0.16; P < 0.001; I2 = 73.67%), studies assessing jumping means restriction interventions delivered in combination with other interventions (3 studies; IRR = 0.54, 95% CI 0.31 to 0.93; P = 0.03; I2 = 40.8%), studies assessing the effectiveness of physical barriers (7 studies; IRR = 0.07, 95% CI 0.02 to 0.24; P < 0.001; I2 = 84.07%), and studies assessing the effectiveness of safety nets (2 studies; IRR = 0.09, 95% CI 0.01 to 1.30; P = 0.07; I2 = 29.3%). Data on suicide attempts were limited and none of the studies used self-harm as an outcome. There was considerable heterogeneity between studies for the primary outcome (suicide) in the majority of the analyses except those relating to jumping means restriction delivered in combination with other interventions, and safety nets. Nevertheless, every study included in the forest plots showed the same directional effects in favour of jumping means restriction. Due to methodological limitations of the included studies, we rated the quality of the evidence from these studies as low. A cost-effectiveness analysis suggested that the construction of a physical barrier on a bridge would be a highly cost-effective project in the long term as a result of overall reduced suicide mortality.

AUTHORS' CONCLUSIONS

The findings from this review suggest that jumping means restriction interventions are capable of reducing the frequency of suicides by jumping. However, due to methodological limitations of included studies, this finding is based on low-quality evidence. Therefore, further well-designed high-quality studies are required to further evaluate the effectiveness of these interventions, as well as other measures at jumping sites. In addition, further research is required to investigate the potential for suicide method substitution and displacement effects in populations exposed to interventions to prevent suicide by jumping.

Suicides by Jumping Off Istanbul Bridges Linking Asia and Europe

AIM

The aim of this study was to determine the injury spectrum and characteristics of people who committed suicide by jumping into water from the July 15th Martyrs Bridge and Fatih Sultan Mehmet Bridges in Istanbul, Turkey.

METHODS

This study included all of the jumpers from the July 15th Martyrs Bridge and Fatih Sultan Mehmet Bridge who were autopsied by the Council of Forensic Medicine, Istanbul Morgue Department, between 2000 and 2013. All of the data were collected from archived case files. Trauma scores were calculated from the traumatic findings of the autopsy reports using the New Injury Severity Score (NISS).

RESULTS

A total of 80 jumping suicides were identified. The male-to-female ratio was 9:1, and the mean age was 34.06 ± 9.6 years. Most suicides occurred in 2009. The suicide rates were higher in the winter, particularly in December. The most frequent injuries were skin lesions, rib fractures, and lung lacerations. In 12% of the cases, the trauma was minor (NISS range, 0-14; mean, 7 ± 5.67), and in 88% of the cases, it was major (NISS range, 17-66; mean NISS, 44.5 ± 12.46).

CONCLUSION

The sociodemographic features of the jumpers who committed suicide were quite similar to those reported in previous studies. Preventative measures (installation of barriers or banning pedestrian access to bridges) reduced the suicide rate but were not completely effective. Establishing early warning systems and rescue strategies could save the lives of jumpers who have minor trauma.

Epidemiology of low-level bridge jumping in Pittsburgh: a 10-year study

BACKGROUND

Outcomes of patients who fall from bridges lower than 160 feet above water have been poorly characterized. Pittsburgh offers a unique setting in which to study these patients as the city has 41 major bridges, only four of which are above 70 feet.

OBJECTIVE

This study examined patients who fell or jumped from Pittsburgh bridges over a 10-year period for their characteristics, injury patterns, and the effects of prehospital care on outcomes.

METHODS

We conducted a retrospective cohort study of patients who jumped or fell from bridges in Pittsburgh, Pennsylvania, over a 10-year period. Subjects were identified through manual searches of three data repositories: City of Pittsburgh Bureau of Emergency Medical Services (EMS), Pittsburgh River Rescue, and Allegheny County Medical Examiner records. Data abstracted included patient name, age, gender, date of birth, and address; incident date, time, location, and river conditions; prehospital interventions; emergency department intervention; hospital disposition; evidence of prior or subsequent psychiatric admission; toxicology results or evidence of substance involvement; and causes of death.

RESULTS

Seventy-four subjects were identified. Most were male (80%) young adults (mean age 34.3 years) who lived near the bridges from which they jumped or fell. Mortality from bridges less than 50 feet high was 18%; mortality from bridges 180 feet high was 75%. All patients who required prehospital interventions beyond warming or intravenous (IV) fluids died. Injury patterns were similar to those described for high-bridge patients, concentrated in the trunk or skull, but low-bridge injuries were milder and less common. Cause of death was predominantly drowning (84%). More than a third (47.3%) of the patients had previous psychiatric histories, but evidence of a previous attempt to jump was uncommon (5.4%).

CONCLUSIONS

People who jump from low- to medium-rise bridges may suffer injuries, but most often die from drowning. EMS interventions beyond water rescue are typically not helpful, emphasizing the importance of prevention and a water rescue plan.

Suicides by jumping from iconic bridges in Hong Kong

BACKGROUND

Three bridges in Hong Kong have become iconic sites for suicide since their openings 11 years ago.

AIMS

This retrospective record-based study aimed to examine suicides by jumping from a group of three iconic bridges in Hong Kong, and to explore potential preventive strategies on these bridges to prevent future suicide.

METHODS

We examined the Coroner's files of 12 people who killed themselves by jumping from the bridges between 1997 and 2007. We also examined the Coroner's files of other suicides in 2003, and compared them with the bridge suicides.

RESULTS

The majority of the suicides were male, middle-age (40-59 years), married or cohabiting, not living alone, employed or self-employed, and in financial difficulty. None of these cases had a reported psychiatric diagnosis or psychiatric care history, and only one case had a history of suicidal attempt. Compared with other suicides in Hong Kong, the bridge jumpers were more likely to be younger, holding a job, indebted, free from a psychiatric and attempt history, and to leave a suicide note (p < .05). The bridge suicide cases in Hong Kong also appeared to be different from the profiles of bridge jumpers in other countries.

CONCLUSIONS

Erection of an effective safety barrier has been found to prevent bridge suicides in many countries. Given the different characteristics of bridge jumpers in Hong Kong and the technical difficulties, more innovative ways may be needed to prevent suicides by such means. Potential prevention measures are discussed and, hopefully, will better inform the future design and development of bridges of significance.

Effect of restricting access to a suicide jumping site

OBJECTIVE

The road to a headland that had become a suicide jumping hotspot was temporarily closed because of construction work. This created an opportunity to assess whether loss of vehicular access would lead to a reduction in suicides and emergency police callouts for threatened suicide at the site.

METHOD

Deaths at the headland were ascertained for a 10 year period before road closure and for 2 years following closure using records from the local police inquest officer, the coroner's pathologist and Marine Search and Rescue. Police provided a list of police callouts for threatened suicide at the site for a 4 year period before closure and for 2 years following closure. Simple rates were compared and incident rate ratios were calculated where possible.

RESULTS

There were 13 deaths at the headland involving suicide or open verdicts in the 10 years before access was restricted, and none in the 2 years following road closure. This difference was statistically significant (incident rate difference = 1.3 deaths per year, 95% confidence interval (CI) = 0.6-2.0). No jumping suicides occurred elsewhere in the police district following the road closure. Police callouts for threatened suicide also fell significantly, from 19.3 per year in the 4 years prior to road closure to 9.5 per year for the following 2 years (incident rate ratio = 2.0, 95% CI = 1.2-3.5).

CONCLUSIONS

Preventing vehicular access to a suicide jumping hotspot was an effective means of suicide prevention at the site. There was no evidence of substitution to other jumping sites.

Removing bridge barriers stimulates suicides: an unfortunate natural experiment

OBJECTIVES

Safety barriers to prevent suicide by jumping were removed from Grafton Bridge in Auckland, New Zealand, in 1996 after having been in place for 60 years. This study compared the number of suicides due to jumping from the bridge after the reinstallation of safety barriers in 2003.

METHODS

National mortality data for suicide deaths were compared for three time periods: 1991-1995 (old barrier in place); 1997-2002 (no barriers in place); 2003-2006 (after barriers were reinstated).

RESULTS

Removal of barriers was followed by a fivefold increase in the number and rate of suicides from the bridge. These increases led to a decision to reinstall safety barriers. Since the reinstallation of barriers, of an improved design, in 2003, there have been no suicides from the bridge.

CONCLUSIONS

This natural experiment, using a powerful a-b-a (reversal) design, shows that safety barriers are effective in preventing suicide: their removal increases suicides; their reinstatement prevents suicides.

Pelvic fractures due to falls from a height in people with mental disorders

BACKGROUND

Pelvic fracture resulting from a fall, is a serious condition with morbidity and mortality that are higher among people with mental disorders.

METHODS

A retrospective study of fall pelvic fractures 1999-2006, comparing clinical features of cases with and without mental disorders.

RESULTS

Of 248 participants, 69 had comorbid mental disorder, sustained worse injuries requiring more treatment, and displayed injury recidivism.

CONCLUSION

A strategy of injury prevention is vital in the subsequent management of these patients.

Preventing suicide by jumping: the effect of a bridge safety fence

OBJECTIVE

To evaluate the effect of a bridge safety fence in preventing suicide.

METHODS

We examined suicides from jumping off the Memorial Bridge in Augusta, Maine, from 1 April 1960 to 31 July 2005. The safety fence was installed during 1983, the mid-point of the study period.

RESULTS

14 suicides from the bridge were identified; all occurred before installation of the safety fence. The number of suicides by jumping from other structures remained unchanged after installation of the fence.

CONCLUSION

The safety fence was effective in preventing suicides from the bridge. There was no evidence that suicidal individuals sought alternative sites for jumping.

Suicide by Jumping

Abstract. Research on suicide by jumping is summarized. The incidence of suicide by this method varies but tends to be higher in cities, city states, or countries that have extensive high-rise housing. Most suicides by jumping occur from high-rise residential housing units. However, our knowledge about suicide by jumping tends to be limited to a small number of reports from sites, often bridges, which become well-known as places from which to take one's life. Media reports of newsworthy suicides from these sites appear to encourage imitative behavior. Prevention strategies have focused upon limiting suicides from iconic sites by surveillance, barriers, muted media reporting, and signage offering help and telephone hotlines. A small number of studies provides evidence that installing barriers at popular jumping sites reduces suicides from those sites. There are few reports of efforts to reduce suicides from high-rise residential buildings.

Suicidal behavior in schizophrenia

There is a high prevalence of suicidal behavior in individuals suffering from schizophrenia and recent investigations substantially elucidate this problem and provide useful insights about clinical risk factors, neurobiologic underpinnings and the impact of various treatments on reducing such behavior. The risk of suicide is greatest early in the course of schizophrenic illness but continues throughout life; risk factors for suicidal behavior include psychosis, depression and substance abuse. Effectively treating positive symptoms and depression, reducing substance abuse, avoiding akathisia, addressing demoralization and instilling hope are important elements in this treatment approach. The newer generation of atypical antipsychotics (particularly clozapine) and new psychologic approaches (particularly cognitive behavioral therapy) appear to be useful in reducing suicidality in schizophrenia. The significant advances in defining the neurobiologic basis of suicidality may enable the development of more effective treatments. The renewed emphasis on resilience and recovery as desired outcomes in schizophrenia and the accompanying sense of hope encourage optimism about effectively reducing suicidality in schizophrenia. Over the past 10 years, much has been learnt and hopefully this momentum will be translated into increasingly better outcomes.

Securing a suicide hot spot: effects of a safety net at the Bern Muenster Terrace

The city of Bern has a high percentage of suicides by jumping (28.6%). Related to other local hotspots, the highest number of deaths (mean 2.5 per year) is found at the Muenster Terrace in the old city. In 1998, after a series of suicides, a safety net was built to prevent people from leaping from the terrace and to avoid further traumatization of people living in the street below. We analyzed the numbers of suicides by jumping before and after the installation of the net. We also assessed the number of media reports referring to this suicide method. After the installation of the net no suicides occurred from the terrace. The number of people jumping from all high places in Bern was significantly lower compared to the years before, indicating that no immediate shift to other nearby jumping sites took place. Furthermore, we found a moderate correlation between the number of media reports and the number of persons resident outside Bern committing suicide by jumping from high places in the city.

Suicide prevention through means restriction: assessing the risk of substitution. A critical review and synthesis

The effectiveness of restricting access to certain means of committing suicide has been demonstrated, at least as regards toxic domestic gas, firearms, drugs and bridges. At the individual level, studies tend to indicate that many persons have a preference for a given means, which would limit the possibility of substitution or displacement towards another method. Similarly, the fact that suicidal crisis are very often short-lived (and, what is more, influenced by ambivalence or impulsiveness) suggests that an individual with restricted access to a given means would not put off his plans to later or turn to alternative methods. This has been more difficult to demonstrate scientifically in population studies. Nevertheless, it appears that, should such a shift occur towards other means, it would be put into effect only in part and over a longer term.

Pathologic Features of Fatal Falls From Height

Deaths due to falls from height are common in urban settings. At the time the body is found, it is often unclear whether the mode of death is accident, suicide, or homicide. To assess the injury pattern in fatal falls from height with special regard to criteria that might be helpful in discrimination between accident, suicide, and homicide, respectively, we reviewed 68 medicolegal autopsy cases (22 females, 46 males, age range 13-89 years) of fatal falls from height regarding demographic data, findings at the death scene, results of the postmortem examination, psychiatric history, and toxicologic findings. Among the 68 cases, there were 34 suicides, 23 accidents, and 11 unclarified cases, in 3 of which homicide was suspected. In general, suicides were from greater heights than accidents (mean height 22.7 m for suicides and 10.8 m for accidents, respectively; 79% of suicides from more than 16 m). Strikingly, severe head injuries predominantly occurred in falls from heights below 10 m (84%) and above 25 m (90%), whereas in the group of falls from 10 to 25 m, these lesions were seen less frequently (28%). Neck injuries like muscle bleeds and fractures of the hyoid bone were found in 33% of falls from more than 10 m and did not occur from less than 10 m. Our data stress that the evaluation of pathologic features alone is not sufficient to assess the mode of death in fatal falls from height. Instead, postmortem findings have to be considered within the framework of the subject's social, medical, and psychiatric history in conjunction with findings at the death scene and toxicology results to obtain the clearest possible picture of the circumstances of death.

Are suicides by jumping off bridges preventable? An analysis of 50 cases from Sweden

This is a community-based sequential case series of 50 individuals who committed suicide by jumping from bridges in two regions of Sweden. Of the 50 subjects, 32 were men and 18 women, with a median age of 35 years. At least 40 had psychiatric problems. The frequency of suicide was highest during the summer months and during the weekends. A total of 27 bridges were used, with a total length of just under 9 km. Three bridges accounted for almost half of all suicides. Limiting the availability of one method of committing suicide is reported to reduce the overall suicide rate; why suicide and injury suicide preventive measures might be considered. Since this study demonstrates that few bridges attract suicide candidates, this injury mechanism needs to be acknowledged by the road system owners and included in the safety work.

Effectiveness of barriers at suicide jumping sites: a case study

OBJECTIVES

Suicide safety barriers were removed from a central city bridge in an Australasian metropolitan area in 1996 after having been in place for 60 years. The bridge is a known suicide site and is located adjacent to the region's largest hospital, which includes an acute inpatient psychiatric unit. This paper examines the impact of the removal of these barriers on suicide rates.

METHOD

Data for suicide deaths by jumping from the bridge in question, from 1992 to 2000, were obtained from the regional City Police Inquest Office. Data for suicide deaths by jumping from other sites in the metropolitan area in question, from 1992 to 1998, were obtained from the national health statistics database. Case history data about each suicide death by jumping in the metropolitan area in question, from 1994 to 1998, were abstracted from coronial files held by a national database.

RESULTS

Removal of safety barriers led to an immediate and substantial increase in both the numbers and rate of suicide by jumping from the bridge in question. In the 4 years following the removal of the barriers (compared with the previous 4 years) the number of suicides increased substantially, from three to 15 (chi2 = 8, df = 1, p < 0.01); the rate of such deaths increased also (chi2 = 6.6, df = 1, p < 0.01). The majority of those who died by jumping from the bridge following the removal of the safety barriers were young male psychiatric patients, with psychotic illnesses. Following the removal of the barriers from the bridge the rate of suicide by jumping in the metropolitan area in question did not change but the pattern of suicides by jumping in the city changed significantly with more suicides from the bridge in question and fewer at other sites.

CONCLUSIONS

Removal of safety barriers from a known suicide site led to a substantial increase in the numbers of suicide deaths by jumping from that site. These findings appear to strengthen the case for installation of safety barriers at suicide sites in efforts to prevent suicide deaths, and also suggest the need for extreme caution about the removal of barriers from known jumping sites.