Under-reporting of suicide in an Irish county

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.

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.

Accidents and undetermined deaths: re-evaluation of nationwide samples from the Scandinavian countries

Background

National mortality statistics should be comparable between countries that use the World Health Organization’s International Classification of Diseases. Distinguishing between manners of death, especially suicides and accidents, is a challenge. Knowledge about accidents is important in prevention of both accidents and suicides. The aim of the present study was to assess the reliability of classifying deaths as accidents and undetermined manner of deaths in the three Scandinavian countries and to compare cross-national differences.

Methods

The cause of death registers in Norway, Sweden and Denmark provided data from 2008 for samples of 600 deaths from each country, of which 200 were registered as suicides, 200 as accidents or undetermined manner of deaths and 200 as natural deaths. The information given to the eight experts was identical to the information used by the Cause of Death Register. This included death certificates, and if available external post-mortem examinations, forensic autopsy reports and police reports.

Results

In total, 69 % (Sweden and Norway) and 78 % (Denmark) of deaths registered in the official mortality statistics as accidents were confirmed by the experts. In the majority of the cases where disagreement was seen, the experts reclassified accidents to undetermined manner of death, in 26, 25 and 19 % of cases, respectively. Few cases were reclassified as suicides or natural deaths. Among the extracted accidents, the experts agreed least with the official mortality statistics concerning drowning and poisoning accidents. They also reported most uncertainty in these categories of accidents. In a second re-evaluation, where more information was made available, the Norwegian psychiatrist and forensic pathologist increased their agreement with the official mortality statistics from 76 to 87 %, and from 85 to 88 %, respectively, regarding the Norwegian and Swedish datasets. Among the extracted undetermined deaths in the Swedish dataset, the two experts reclassified 22 and 51 %, respectively, to accidents.

Conclusion

There was moderate agreement in reclassification of accidents between the official mortality statistics and the experts. In the majority of cases where there was disagreement, accidents were reclassified as undetermined manner of death, and only a small proportion as suicides.

Are suicide deaths under-reported? Nationwide re-evaluations of 1800 deaths in Scandinavia

OBJECTIVE

Valid mortality statistics are important for healthcare planning and research. Suicides and accidents often present a challenge in the classification of the manner of death. The aim of this study was to analyse the reliability of the national suicide statistics by comparing the classification of suicide in the Scandinavian cause of death registers with a reclassification by 8 persons with different medical expertise (psychiatry, forensic pathology and public health) from each of the 3 Scandinavian countries.

METHODS

The cause of death registers in Norway, Sweden and Denmark retrieved available information on a sample of 600 deaths in 2008 from each country. 200 were classified in the registers as suicides, 200 as accidents or undetermined and 200 as natural deaths. The reclassification comprised an assessment of the manner and cause of death as well as the level of certainty.

RESULTS

In total, 81%, 88% and 90% of deaths registered as suicide in the official mortality statistics were confirmed by experts using the Swedish, Norwegian and Danish data sets, respectively. About 3% of deaths classified as accidents or natural deaths in the cause of death registers were reclassified as suicides. However, after a second reclassification based on additional information, 9% of the natural deaths and accidents were reclassified as suicides in the Norwegian data set, and 21% of the undetermined deaths were reclassified as suicides in the Swedish data set. In total, the levels of certainty of the experts were 87% of suicides in the Norwegian data set, 77% in the Swedish data set and 92% in Danish data set; the uncertainty was highest in poisoning suicides.

CONCLUSIONS

A high percentage of reported suicides were confirmed as being suicides. Few accidents and natural deaths were reclassified as suicides. Hence, reclassification did not increase the overall official suicide statistics of the 3 Scandinavian countries.

Suicide rates in Irish counties: 10 years later

Objectives: This exploratory study was designed to explore the social correlates of suicides rates of Irish counties.

Method: Suicide rates were calculated for Irish counties and subdivisions for the period 1988-1994 and correlated with social data for these regions obtained from the 1991 Census.

Results: The suicide rates showed a low level of reliability for the periods 1978-1984 and 1988-1994, and the social correlates of suicide rates changed between the two periods. Whereas age structure was associated with suicide rates in 1978-1984, urbanisation was associated with suicide rates in 1988-1994.

Conclusions: It is important to check the reliability of results of ecological studies of Irish suicide rates. Furthermore, the impact on suicide rates of the changing role of women in Ireland needs to be explored in time-series studies of the Irish suicide rate.

Suicide or undetermined intent? A register-based study of signs of misclassification

Background

Several studies have concluded that some deaths classified as undetermined intent are in fact suicides, and it is common in suicide research in Europe to include these deaths. Our aim was to investigate if information on background variables would be helpful in assessing if deaths classified as undetermined intent should be included in the analyses of suicides.

Methods

We performed a register study of 31,883 deaths classified as suicides and 9,196 deaths classified as undetermined intent in Sweden from 1987 to 2011. We compared suicide deaths with deaths classified as undetermined intent with regard to different background variables such as sex, age, country of birth, marital status, prior inpatient care for self-inflicted harm, alcohol and drug abuse, psychiatric inpatient care, and use of psychotropics. We also performed a multivariate analysis with logistic regression.

Results

Our results showed differences in most studied background factors. Higher education was more common in suicides; hospitalization for self-inflicted harm was more common among female suicides as was prior psychiatric inpatient care. Deaths in foreign-born men were classified as undetermined intent in a higher degree and hospitalization for substance abuse was more common in undetermined intents of both sexes. Roughly 50% of both suicide and deaths classified as undetermined intent had a filled prescription of psychotropics during their last six months. Our multivariate analysis showed male deaths to more likely be classified as suicide than female: OR: 1.13 (1.07-1.18). The probability of a death being classified as suicide was also increased for individuals aged 15–24, being born in Sweden, individuals who were married, and for deaths after 1987–1992.

Conclusion

By analyzing Sweden’s unique high-validity population-based register data, we found several differences in background variables between deaths classified as suicide and deaths classified as undetermined intent. However, we were not able to clearly distinguish these two death manners. For future research we suggest, separate analyses of the two different manners of death.

National registration system of suicide behaviors in Iran: barriers and challenges

The present article describes the process of developing a national suicide registry in Iran and evaluates the obstacles in this respect. We established a systematic and uniform portal data collection system in the country and evaluated it from March 2009 for a year. The quality of database and data registration challenges were assessed from different aspects. A total number of 41,109 suicide attempts and 1,338 completed suicides were reported from an area that covered 83.6% of Iran's population in 2009. The rate of suicide attempt was 65.8 per 100,000 people. This study revealed some of the obstacles and challenges of implementing a national registration system. Nationwide suicide registry can serve as a solid foundation for conceptual work, data collection, and preventive interventions. A concerted effort between various organizations is required to efficiently collect data on suicide behaviors.

The reliability of suicide statistics: a systematic review

BACKGROUND

Reliable suicide statistics are a prerequisite for suicide monitoring and prevention. The aim of this study was to assess the reliability of suicide statistics through a systematic review of the international literature.

METHODS

We searched for relevant publications in EMBASE, Ovid Medline, PubMed, PsycINFO and the Cochrane Library up to October 2010. In addition, we screened related studies and reference lists of identified studies. We included studies published in English, German, French, Spanish, Norwegian, Swedish and Danish that assessed the reliability of suicide statistics. We excluded case reports, editorials, letters, comments, abstracts and statistical analyses. All three authors independently screened the abstracts, and then the relevant full-text articles. Disagreements were resolved through consensus.

RESULTS

The primary search yielded 127 potential studies, of which 31 studies met the inclusion criteria and were included in the final review. The included studies were published between 1963 and 2009. Twenty were from Europe, seven from North America, two from Asia and two from Oceania. The manner of death had been re-evaluated in 23 studies (40-3,993 cases), and there were six registry studies (195-17,412 cases) and two combined registry and re-evaluation studies. The study conclusions varied, from findings of fairly reliable to poor suicide statistics. Thirteen studies reported fairly reliable suicide statistics or under-reporting of 0-10%. Of the 31 studies during the 46-year period, 52% found more than 10% under-reporting, and 39% found more than 30% under-reporting or poor suicide statistics. Eleven studies reassessed a nationwide representative sample, although these samples were limited to suicide within subgroups. Only two studies compared data from two countries.

CONCLUSIONS

The main finding was that there is a lack of systematic assessment of the reliability of suicide statistics. Few studies have been done, and few countries have been covered. The findings support the general under-reporting of suicide. In particular, nationwide studies and comparisons between countries are lacking.

The reliability of suicide rates: an analysis of railway suicides from two sources in fifteen European countries

BACKGROUND

National suicide data are an underestimation of the actual number of suicides but are often assumed to be reliable and useful for scientific research. The aim of this study is to contribute to the discussion of the reliability of suicide mortality data by comparing railway suicides from two data sources.

METHODS

Data for the railway suicides and the concurrent causes of death of fifteen European countries were collected from the European Detailed Mortality Database and the European Railway Agency (ERA). Suicide rates, odds ratios and confidence intervals were calculated.

RESULTS

The suicide data from the ERA were significantly higher than the national data for six out of fifteen countries. In three countries, the ERA registered significantly more railway suicides compared to the sum of the national suicides and undetermined deaths. In Italy and France, the ERA statistics recorded significantly more railway related fatalities than the national statistical offices. In total the ERA statistics registered 34% more suicides and 9% more railway fatalities compared with the national statistics.

LIMITATIONS

The findings of this study concern railway suicides and they cannot be extrapolated to all types of suicides. Further, the national suicide statistics and the ERA data are not perfectly comparable, due to the different categorisations of the causes of death.

CONCLUSIONS

Based on the data for railway suicides, it seems that the underestimation of suicide rates is significant for some countries, and that the degree of underestimation differs substantially among countries. Caution is needed when comparing national suicide rates. There is a need for standardisation of national death registration procedures at the European level.

Suicide in Ireland: a cross-national view

Recent epidemiological trends in Irish suicide rates were examined and found to be consistent with worldwide trends. However, the time-series Irish suicide rate was not consistent with predictions made from Durkheim's classic theory of suicide. Finally, current theories of the etiology of suicide were used to derive a linear regression equation to predict the Irish suicide rate which turned out to be quite inaccurate. The task addressed in this article is a review of the epidemiology of suicide in Ireland and, in doing so, the suicide rate in Ireland will be compared with the suicide rates of other nations of the world. Table 1 reports the suicide rate in Ireland from 1901 to 1949, Table 2 for the period 1950-2001, overall and for men and women (and parallel data for Northern Ireland are shown in Table 3). These data were compiled from Lester and Yang and from World Health Organisation publications and online (www.who.int). It should be noted that suicide was decriminalised in Ireland in 1993.

A Study of the Irish System of Recording Suicide Deaths

Background: Many studies have examined the reliability of national suicide statistics. Aims: To examine the Irish system of certifying suicide deaths and data collected by it. Methods: Data were recorded from a police form (Form 104) completed and sent to the Irish Central Statistics Office (CSO) after all inquested deaths that occurred in Ireland in 2002. Results: Of the approximately 1,800 inquested deaths, 6% (and 4% of suicides) were not included in routine mortality statistics because of late registration. Of the 495 deaths thought by the police to be suicide, 485 (98%) were so recorded by the CSO. Information relating to medical history and contributory factors was provided in just 54% and 34% of suicides, respectively. Suicide deaths showed significant variation by weekday (excess on Mondays) and calendar month (summer peak). The peak suicide rate (35 per 100,000) was among men aged 25–34 years. Persons separated, living alone, and unemployed had significantly elevated suicide rates. Conclusions: There is a need for a better understanding of national suicide recording systems, as this study has provided for Ireland. Such systems may routinely provide data relating to sociodemographic factors but not relating to medical and psychosocial factors.

'Hidden' suicides amongst deaths certified as undetermined intent, accident by pesticide poisoning and accident by suffocation in Taiwan

OBJECTIVE

To identify cause-of-death categories in which suicides might be misclassified in Taiwan.

METHODS

We plotted secular trends (1971-2007) in sex- and method-specific rates of deaths classified as suicide, undetermined intent and accident for the Taiwanese population aged 15+ and compared the sex, age and marital status profiles of deaths in these three categories by method of death.

RESULTS

The demographic profiles of registered suicides generally resembled those for deaths of undetermined intent and accidents by pesticide poisoning/suffocation but differed from those for accidents from non-pesticide poisoning/drowning/falling/poisoning by non-domestic gas. For the period 1990-2007, suicide rates based on suicides alone (14.8 per 100,000) would increase by 23, 7 and 1%, respectively, when including deaths of undetermined intent, accidental pesticide poisonings and accidental suffocations.

CONCLUSIONS

Suicide rates may be underestimated by more than 30% in Taiwan because some suicides are 'hidden' amongst deaths certified as due to other causes.

Deaths due to suicide: the effects of certification and coding practices in Australia

OBJECTIVE

To highlight issues relating to suicide coding that have an impact on the final reported mortality data by the Australian Bureau of Statistics.

METHOD

This paper presents an outline of the way in which the official Australian suicide data is captured and coded and highlights issues relating to the classification used, coronial processes, documentation requirements and data sources that have an impact on the final reported data, especially deaths associated with coronial investigations.

RESULTS

Issues related to the coding of Australian suicide data are: *Disparity between jurisdictions due to differences in documentation about accidental or undetermined causes of death. *Lack of standardisation in the way that coronial deaths are reported across Australia. *Lack of a standard form for police reports. *Administrative processes that cause delays in reporting the results of coronial investigations. *Reluctance on the part of some coroners to report deaths as suicides.

CONCLUSIONS

Researchers and policy makers need to be aware of the constraints under which suicide can be reported as such in the official data before interpreting time trends.

A study of suicides in Kildare, 1995–2002

This paper focuses on 109 cases of suicide that occurred in Kildare from 1995 to 2002. These statistics were obtained by examining the records of the Kildare County Coroner. There is no central national location for the records of the 48 coroner jurisdictions in Ireland and all coroners are required by law to retain the files on each inquest indefinitely. However, the actual record of verdict given at inquest is not the one used for determining the suicide rate in the country. This is achieved by the Central Statistics Office (CSO) Form 104, which asks for the investigating police officer to give his or her opinion as to the cause of death. This results in discrepancies between what the coroner records and what the official suicide rate is presumed to be. These figures are further influenced by some coroners choosing to return a verdict "death in accordance with the medical evidence" as opposed to a verdict of suicide. The files were also examined to find the high-risk groups or those groups which have a tendency towards suicide. Over 84% of suicides were male and 32 men were between the ages of 20 and 30. It is suggested that the standardisation of recording verdicts of suicide be implemented as soon as possible as the current situation leads to variances between coroner's records and those kept by the CSO.

Estimation of reporting delay and suicide incidence in Hong Kong

This paper uses a semi-parametric method to examine the reporting delay distribution in suicides in Hong Kong reporting system. The data arise from a rightly truncated situation in which only suicide cases registered before a specific time are known to have occurred; otherwise they are not recorded in the known death files even if they have occurred. It is shown that the poisoning-related suicide deaths have a longer reporting delay than other suicide methods. By modelling the reporting delay function, a Horvitz-Thompson-type estimator is suggested to adjust for reporting delay and to provide a more timely estimate of the suicide incidences for monitoring the suicide problem in Hong Kong. Based on these analyses, we recommended a suitable cut-off date to collect suicide cases occurring in the previous year and reported before this date in Hong Kong.

Coding of pediatric behavioral and mental disorders

BACKGROUND

In response to changing reimbursement and other pressures in the health care environment, many physicians have reported the use of alternate coding to substitute for certain clinical diagnoses. However, very little information is available on how physicians who care for children approach diagnosis and coding dilemmas for behavioral and mental disorders, which often present unique additional challenges.

OBJECTIVE

Our study sought to describe the frequency of alternate coding, different approaches to coding, and attitudes toward diagnosis and coding practices by physician specialty.

METHODS

We conducted a mail survey of 1492 physicians--497 developmental/behavioral pediatricians (DBP), 500 pediatricians (PED), and 495 child and adolescent psychiatrists (PSY). The main outcomes were survey items on frequency of alternate coding (never, rarely, monthly, weekly, daily), use of different coding strategies (use of somatic symptoms, modifiers, and substitution with other terms), and attitudes on coding practices (Likert scales of agreement). We analyzed outcomes by physician specialty and demographics using Pearson's chi2 and multivariate logistic regression.

RESULTS

Overall response rate was 62% (787 of 1269 eligible physicians). The majority of physicians had used an alternate code (DBP 83%, PED 68%, PSY 58%), and many respondents reported monthly-daily alternate coding (DBP 60%, PED 36%, PSY 27%). Physicians used multiple approaches to diagnosis and a variety of coding options, which varied by physician specialty. Financial issues were commonly cited reasons for alternate coding--both to obtain patient services and to receive physician reimbursement. However, challenges of diagnostic classification and coding subthreshold symptoms were cited as frequently as reimbursement issues. Stigmatization, confidentiality, and parental acceptance were mentioned, but reported less frequently. Very few practices and providers have organized administrative methods of alternate coding (26%) or receive feedback on denied claims (46%). Most physicians believe that alternate coding is justified in the present system; however, some physicians expressed concerns that these practices may contribute to stigmatization or lead to improper management decisions.

CONCLUSIONS

Alternate coding is commonly reported; however, approaches to diagnostic coding vary by provider specialty. Reimbursement issues are important, but other challenges in diagnosis and classification hold special relevance to children with behavioral and mental disorders. There seems to be a great need to reconsider the separate goals and uses of clinical diagnosis and administrative coding. Additional study is needed to assess how reported coding practices may affect administrative data, patient care, and health care economics.

Non-registration of deaths as a source of error in mortality data in the Irish Republic

Objectives: To ascertain whether or not there had been any improvement in the registration of deaths in Co. Mayo, Ireland, since 1970. At the time is was shown that 7.5% of deaths, in a sample of parishes in the west of Ireland had not been registered.

Method: A list of all those who died and were buried in Co. Mayo in 1992, was obtained and compared with a list of deaths registered in that and subsequent years.

Results: One hundred and twenty eight deaths (11.5%) occurring in the county in 1992 had not been registered by the time of this study in 1997.

Conclusions: Non-registration of deaths continues to pose serious problems for research and for the planning of health services. It is suggested that the government introduce legislation to address the issue. Registration of deaths should be standardised throughout the EU.