Insight to the psychosocial factors of survivors of suicidal hanging

Introduction

The incidence of hanging has increased over the last ten years and is the most common method of suicide. Because of its multifactorial causation, the reason behind hanging remains unfolded unless the victims leave a suicidal note. In the present study, the psychodynamic factors of hanging were assessed among the survivors of suicidal hanging.

Materials and Methods

The cross-sectional study was conducted at S.C.B Medical College and Hospital, Cuttack, India, over a period of three years. Eighty-two individuals admitted in medicine ward of this tertiary care hospital to receive treatment for the complications as a sequel of hanging and willing to participate in study were included after obtaining informed consent. The information was recorded in a pre-designed pro forma.

Results

Subjects from rural areas (87.8%) and low socio-economic backgrounds (67.1%) attempted suicide more often. Most of the victims were in the age group of 21-30 years, followed by less than 20 years. The most common cause of attempted suicide by hanging was family-related issues, and mainly by immediately available materials like dupattas, saree, lungi, and other fabrics. Females in rural areas and males from urban areas attempted suicide by hanging in significantly higher proportions (P = 0.041).

Conclusion

Most people commit suicide at a younger age due to failure to cope with the different stressful situations. The most common reason for attempted suicide by hanging was family-related issues. Early intervention in family disputes in developing countries, especially in younger individuals, may help to curb suicide.

Needs for help and received help for those bereaved by a drug-related death: a cross-sectional study

Background and aims: Individuals bereaved after sudden and unexpected deaths can benefit from professional help to cope after the loss, and the bereaved call for proactive, early and flexible help from professional services. Most drug-related deaths (DRDs) happen suddenly and unexpectedly. DRDs are a significant public health issue, yet few studies have examined DRD-bereaved people's needs and experiences with professional help. This article investigates the needs for help and received help reported by DRD-bereaved family members and friends, and suggests improvements in services based on the findings. Data and method: A heterogeneous convenience sample of DRD-bereaved family members and close friends (n = 255) were recruited for a survey from February to December 2018. Descriptive analyses were conducted for experiences with professional help, chi-square analyses to find predictors for help needs and received help, and logistic regression analysis to find predictors for satisfaction with the help provided. Results: Most DRD-bereaved individuals reported a need for professional help after the death regardless of family relation to the deceased, and about half of the participants received help. Nearly half of them were satisfied with the help. Our results indicated higher satisfaction with help among older bereaved, and the participants who received help from a crisis team or psychotherapist. The latter was particularly stated for younger participants. Few participants with children in the family reported that the children had received help, and less than one-third were satisfied with this help. Conclusion: The study shows that younger age groups and children need particular recognition, and a family perspective from services is essential. When assessing the help needs of the DRD-bereaved, relations of both psychological and biological closeness should be recognised. Help efforts should be tailored according to established knowledge of the provided help that bereaved populations deem effective.

Estimation of Time Since Death From Potassium Levels in Vitreous Humor in Cases of Unnatural Death: A Facility-Based Cross-Sectional Study

Background Estimation of time since death/postmortem interval (PMI) forms a crucial component for all autopsy surgeons. With the subjectivity that is prevalent with conventional morphological and physical signs of death, newer-age modalities such as chemical analysis provide better precision. The easy accessibility and the resistance to putrefaction make vitreous humor the best choice for such chemical analysis. Thus, the present study's aim is to estimate the time since death in cases of unnatural death by investigating the potassium level changes in the vitreous humor. Methodology This is a facility-based cross-sectional study conducted in the mortuary under the Department of Forensic Medicine in a public tertiary healthcare teaching hospital in South India between August and September 2022. Deceased individuals fulfilling the inclusion and exclusion criteria were recruited in the study. Vitreous samples were collected from a single eye and analyzed using an autoanalyzer for potassium values. After due derivations, postmortem intervals were calculated from potassium values, then they were compared with the PMIs estimated using physical signs and those determined using official police records. Data were entered using MS Excel 20 (Microsoft Corporation, Redmond, Washington) and analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 20 (IBM Corp., Armonk, NY). Results Of the 100 deceased individuals included in the study, 68% were men, and the majority (24%) belonged to the age group of 53-62 years. A linear relationship is said to exist between vitreous potassium concentration and postmortem interval. No correlation was seen between the ambient temperature and the potassium levels of the vitreous humor. PMI confirmed by the potassium levels seconded the PMI given by the police records and physical signs (Rigor mortis) (Spearman's rho was statistically significant at the two-tailed level or at the 0.01 level with a kappa value of 0.88). Conclusion Potassium measurements in the vitreous humor to estimate the PMI are associated with improved accuracy and precision in determining the time since death. They are not affected by external factors, making them a reliable marker for the same.

First-time offenders for recreational ketamine use under a new penalty system in Taiwan: incidence, recidivism and mortality in national cohorts from 2009 to 2017

BACKGROUND AND AIMS

Ketamine has become a new recreational drug of choice among young people in parts of Asia. Using national databases in Taiwan, this study aimed to (1) examine the yearly trend in the ketamine offence rate over time; (2) estimate the 3-year risk of drug-related re-offence and its correlates among the first-time offenders; and (3) estimate the 3-year standardized mortality ratio (SMR) among the first-time offenders.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort studies of offenders for recreational ketamine use in a penalty system initiated in 2009. Offenders for recreational ketamine use were identified from the Administrative Penalty System for Schedule III/IV Substances database from 2009 to 2017, and the re-offence rate and mortality among first-time offenders were assessed via record-linkage within the database as well as with both the criminal drug offence database and the national mortality database. The cohort from 2009 to 2016 (n = 39 178) was used for the recidivism analysis and the cohort from 2009 to 2013 (n = 25 357) was used for the 3-year SMR analysis.

MEASUREMENTS

Recidivism was estimated using survival analysis of the event as re-arrest for using ketamine, more serious illicit drugs (Schedules I/II), or any illicit drugs (ketamine or Schedules I/II). SMRs were estimated for overall and cause-specific death within 3 years after the first offence for ketamine use.

FINDINGS

The age-standardized rates for both prevalent (1.38 per 1000) and first-time offenders (0.65 per 1000) peaked in 2013 and then decreased steadily. The 3-year risk of re-offence was 33.85% [95% confidence interval (CI) = 33.23-34.47%) for ketamine use and 39.52% (95% CI = 39.00-40.04%) for any illicit drug use. These first-time offenders had an SMR of 4.9 (95% CI = 4.3-5.4) for overall mortality, 2.1 (95% CI = 1.6-2.7) for natural deaths and 7.6 (95% CI = 6.7-8.6) for unnatural deaths.

CONCLUSIONS

Recreational ketamine use in Taiwan appears to lead not only to high risk for drug-related re-offence but also to excess mortality.

Potential significance of swastika tattoos in a medico-legal setting

Although the increasing popularity of tattoos has challenged the previous associations with criminality and psychiatric illness, particular subsets of tattooed individuals may still have an association with unnatural deaths in a forensic context. A retrospective review of the autopsy database at Forensic Science South Australia was undertaken over a 23-year period from 1997 to 2019 for cases with swastika tattoos. Twenty-six cases (23 males and 3 females) were identified, ranging in age from 19 to 67 years (M_age = 36 years). The cases comprised seven (27%) suicides, seven (27%) accidents (including five vehicle crashes), five (19%) drug-related deaths (toxicity/overdose), four (15.4%) natural deaths and three (11.5%) homicides. There were significantly more unnatural deaths in the group with swastika tattoos compared to tattooed controls (p < 0.01). Multiple swastikas, expletives and white supremacist sentiments were also present in a number of cases. However, in one Asian male, the presence of a sacred Buddhist tattoo suggested that the swastika tattoo instead had religious rather than antisocial/racist significance. This study shows that in the population of individuals undergoing forensic autopsies, subgroups may be identified by their tattoos who have a predisposition to violent and unnatural death. Evaluation of this risk has to be tempered by considering the cultural/religious background of a decedent, as the symbol may have completely different connotations for certain religious groups such as Jains, Hindus and Buddhists.

Exploration of morbidity, suicide and all-cause mortality in a Scottish forensic cohort over 20 years

BACKGROUND

Premature mortality among patients experiencing forensic care is high. This paper examines the morbidity and mortality of all Scottish high secure patients in 1992/1993 and followed up 20 years later through the context of recovery.

AIMS

To explore morbidity and delineate which patients are at greatest risk of premature mortality. To assess the extent of suicide and unnatural deaths. To establish which factors, if any, appear protective.

METHOD

Health and mortality data were extracted from national data-sets and death categorised as premature or post-expected age. Standardised mortality ratios were calculated to explore natural, unnatural and suicide deaths with Cox regression conducted to explore baseline demographics and premature death.

RESULTS

During a mean follow-up of 21.1 years, 36.9% (n = 89) died, at an average age of 55.6 years. Of these, 70.8% (n = 63) died prematurely. Men lost on average 14.9 years and women 24.1 years of potential life. Five lives (5.6%) were lost by suicide and three (3.4%) by unnatural means.

CONCLUSIONS

In contrast to other mainstream and forensic cohorts, high rates of suicide and accidental deaths were not apparent. Risk of premature mortality is high. A greater focus upon physical health by community and in-patient services is essential.

Solitary Deaths in the Tokyo Metropolis and Labor Force Status: Characteristics of Unnatural Deaths at Home among Persons Living Alone

OBJECTIVE

To identify associations of solitary death with social determinants of health, namely, labor force status and welfare status, in Tokyo in 2015.

METHODS

We obtained data on solitary deaths in 2015 in the 23 special wards of Tokyo and calculated the incidence rate and postmortem interval of solitary death in relation to sex, age, and labor force status.

RESULTS

Data for 3,972 solitary deaths (2,785 males, 1,187 females) were analyzed. The non-employed rate was 79.3% among males and 89.5% among females. The incidence rate was significantly higher among non-employed persons than among employed persons in both sexes. Moreover, with the exception of women 65 years or older, the postmortem interval was significantly longer among non-employed persons than among employed persons in both sexes.

CONCLUSIONS

The incidence rates of solitary death were significantly higher among non-employed persons than among employed persons in both sexes, and the postmortem interval was significantly longer for non-employed persons.

Characteristics of unnatural deaths in Tierra del Fuego, Argentina: A 10-year study (2008-2017)

A retrospective review was undertaken of 287 unnatural deaths undergoing medicolegal investigation over a 10-year period from January 2008 to December 2017 in Rio Grande, Tierra del Fuego, Argentina. There were 219 males and 68 females, age range 7 months to 88 years (average 38.4 years). The 135 accidental deaths (47%) were due mainly to vehicle crashes ( N = 62) and carbon monoxide toxicity from fires ( N = 31). The 115 cases of suicides (40.1%) were predominantly due to hanging ( N = 75) and gunshot wounds ( N = 20). The 37 cases of homicide (12.9%) were mainly due to stabbing/sharp force injury ( N = 20) and blunt force trauma ( N = 9). Carbon monoxide toxicity from faulty heating accounted for a substantial percentage (8.1%) of the accidental deaths. Firearm homicides and suicides related to drug toxicity and carbon monoxide inhalation were relatively uncommon medicolegal cases in this centre.

Unnatural Death among Treatment Seeking Substance Users in Singapore: A Retrospective Study

Substance use carries a higher risk of unnatural death. A retrospective analysis of 42 treatment seekers between 2011-2015 was conducted through medical record review to understand the profile and circumstances leading to premature deaths. Ninety percent of the subjects were males. The mean age at death was 44.9 (SD ± 13.1). Opioids (52.4%), benzodiazepines (45.2%) and alcohol (35.7%) were the main substances used by the group. Suicide was the most common cause of death (n = 27, 64.3%) followed by accidents (n = 15; 35.7%). Among the suicide cases, alcohol was the main substance used (33.3%) followed by opioids (25.9%). A total of 58.5% (n = 24) deaths occurred within a year of their last visit while 41.5% (n = 17) were dead more than a year after their last visit. Of the total cases (n = 41), 63% had a history of mental illness with depressive disorder (53.8%) being the most common. History of suicide attempts were reported in 34.1% (n = 14) of cases and 50% of the subjects (n = 21) had a history of suicidal ideation. Drug related offences were reported in 57.1% of the subjects, of which 60% (n = 18) committed suicide. The findings support the need for appropriate treatment resources to reduce the untimely deaths among substance users.

New insights into odontological exploration of drowning using rat model - A pilot study

Dental forensics for the resolution of unnatural death remains an underdeveloped field. Accordingly, an experimental study was conducted with six to seven months old Wistar rats that were drowned in order to identify key postmortem features and pattern of dental decomposition. The visual, structural and elemental changes were assessed periodically. Based on mode of death, they were designated as SB (euthanized and soil buried), FWD (fresh water drowned) and SWD (sea water drowned). Postmortem features as well as the structural and elemental patterns of decomposition of teeth were analyzed with Field Emission Scanning Electron Microscopy (FE-SEM) and Energy Dispersive Spectroscopy (EDAX) periodically for two months. The periodic observation of elemental changes in the teeth of SB, FWD and SWD rats allowed us to derive an equation using linear regression analysis to relate the degree of dental decomposition with the time since death. The difference in pattern of surface deterioration was also observed. The present findings could provide a better knowledge in resolving unnatural deaths and supporting evidence for legal prosecution.

Independent predictors of mortality in adolescents ascertained for conduct disorder and substance use problems, their siblings and community controls

BACKGROUND AND AIMS

Adolescents with conduct and substance use problems are at increased risk for premature mortality, but the extent to which these risk factors reflect family- or individual-level differences and account for shared or unique variance is unknown. This study examined common and independent contributions to mortality hazard in adolescents ascertained for conduct disorder (CD) and substance use disorder (SUD), their siblings and community controls, hypothesizing that individual differences in CD and SUD severity would explain unique variation in mortality risk beyond that due to clinical/control status and demographic factors.

DESIGN

Mortality analysis in a prospective study (Genetics of Antisocial Drug Dependence Study) that began in 1993.

SETTING

Multi-site sample recruited in San Diego, California and Denver, Colorado, USA.

PARTICIPANTS

A total of 1463 clinical probands were recruited through the juvenile correctional system, court-mandated substance abuse treatment programs and correctional schools, along with 1399 of their siblings, and 904 controls.

MEASUREMENTS

Mortality and cause-of-death were assessed via National Death Index search (released October, 2017).

FINDINGS

There were 104 deaths documented among 3766 (1168 female) adolescents and young adults (average age 16.79 years at assessment, 32.69 years at death/censoring). Mortality hazard for clinical probands and their siblings was 4.99 times greater than that of controls (95% confidence interval = 2.40-10.40; P < 0.001). After accounting for demographic characteristics, site, clinical status, familial dependence and shared contributions of CD and SUD, CD independently predicted mortality hazard, whereas SUD severity did not.

CONCLUSIONS

In the United States, youth with conduct and substance use disorders and their siblings face far greater risk of premature death than demographically similar community controls. In contrast to substance use disorder severity, conduct disorder is a robust predictor of unique variance in all-cause mortality hazard beyond other risk factors.

Death by Suicide in Graves' Disease and Graves' Orbitopathy: A Nationwide Danish Register Study

BACKGROUND

Graves' disease (GD) is associated with excess morbidity and mortality, but little is known about unnatural manners of death and the potential relation with Graves' orbitopathy (GO). This study investigated the risk of unnatural death in Graves' patients with and without orbitopathy compared to matched control populations.

METHODS

This was a cohort study covering all adult Danes (≥18 years) diagnosed with GD or GO during 1995-2012. Median follow-up time was 7.9 years (range 0-17.5 years). Utilizing the Danish Register of Causes of Death and the Danish National Patient Registry, 28,461 subjects with GD and 3965 with GO were identified and matched for age and sex with four subjects from the background population. The manner of death was identified, and hazard ratios (HR) for mortality due to unnatural deaths (accident, suicide, violence/homicide, and unknown) were calculated using Cox regression analyses, adjusted for pre-existing somatic and psychiatric morbidity.

RESULTS

In Graves' disease overall (GD + GO), there was an increased risk of death from unknown unnatural manners (HR = 2.01 [confidence interval (CI) 1.17-3.45], p = 0.012) and of suicide, although the latter difference was not with certainty statistically significant (HR = 1.43 [CI 1.00-2.04], p = 0.053). There was no significant difference in risk of death from suicide in GD subjects compared to their controls (HR = 1.27 [CI 0.85-1.89], p = 0.253). However, GO patients had a significantly higher risk of death from suicide (HR = 2.71 [CI 1.16-6.32], p = 0.022).

CONCLUSIONS

Mortality by suicide was increased in Graves' disease overall, most significantly in patients with GO, also after adjustment for pre-existing somatic and psychiatric disease. These findings indicate that GD and GO may have a significant role in the pathophysiological mechanisms of suicidal behavior. Beyond independent confirmation, reasons for this need to be explored in order to introduce preventive measures.

Psychopathy and Mortality

It is not known how mortality differs between psychopathic and nonpsychopathic individuals. We linked data from subjects having been in forensic mental examinations at Niuvanniemi Hospital during 1984-1993 to the data from the National Death Registry to estimate the association between psychopathy and mortality. One hundred psychopathic individuals scoring 25 or higher in the PCL-R scale were followed up for 20-30 years. Two control groups were used as follows: 178 offenders scoring less than 25 on the PCL-R, and sample of general population drawn from the Finnish National Statistics database. Results reveal that psychopaths die younger than the general population, and the causes of death are more violent than in the nonpsychopath control group. There was a significant positive correlation between PCL-R score and mortality, and the mortality among psychopaths was about fivefold when compared with general population.

Unnatural and Violent Death in Cases with High Blood Alcohol Concentration- Autopsy Study

The use of alcohol increases the risk of dying from unnatural or violent causes. The presented study explored the distribution of age, gender, cause, and circumstances of death in persons who died in an unnatural and violent manner, with a blood alcohol concentration (BAC) higher than 0.3 g/dL, and where the cause of death was not alcohol intoxication. We defined the control (0 < BAC < 0.3 g/dL) and study (BAC ≥ 0.3 g/dL) groups, as in subjects with these concentrations, there is a significant risk of gross intoxication, stupor, and death. The subjects from the study group were older, with no difference in gender distribution. Traffic accidents were the most common fatal event in both groups, followed by suicides. Other accidents (choking on food and exposure to fire) were more frequent in the study group. Compared to the control group, subjects from the study group were older persons whose deaths were mainly accidental.

Signs of Fungal Infection in Dead Mimic the Chronic Torture

The cases of battered woman syndrome (BWS) are very common in India. The majority of the women suffer battering by their family members especially in-laws. The injuries occurring each time indicate their being battered, but on being questioned about these happenings, a mismatched history being given by them is the major indication of BWS. In many of the cases, the injuries present over the body either in healing stages or in association with skin diseases may mislead the forensic pathologists and investigating agencies. One such rare autopsy was conducted where the healing lesions of the chronic fungal infections were mistaken as the injuries of chronic torture. The case is presented here to remind to the forensic pathologist about the possibility of the signs of chronic fungal infections in dead, which can mimic the torture, and to discuss its medicolegal implications.

Latent prostate cancer in Japanese men who die unnatural deaths: A forensic autopsy study

BACKGROUND

An accurate natural history of prostate cancer (PC) can be obtained from forensic autopsies of individuals who had performed their normal daily activities immediately before death and had not undergone long-term medical interventions. A retrospective analysis of such individuals was performed to understand the features of latent PC in Japan.

METHODS

The findings of forensic autopsies performed at Dokkyo Medical University from August 2002 to July 2005 on men without severely destroyed or severely decomposed tissues were collected. Two cross sections, at the base and apex of the prostate, were examined histopathologically. Data collected included basic history, cause of death, location of PC, and Gleason score.

RESULTS

Of 196 forensically autopsied males aged 0-90 years, 24 (12.7%) had latent PC. When analyzed by age group, PC was most prevalent among individuals in their eighties (33.3%). The prevalence of PC was similar in males who died of disease and of external causes. Most PCs were located at the base of the prostate, but were present on both the anterior and posterior sides. Nine of the 24 autopsied individuals also had other diseases, with three having cancers other than PC.

CONCLUSIONS

This is the first report of the features of latent PC in Asian men who died of unnatural causes. Forensic autopsies can clarify the natural history of PC and may help fill knowledge gaps regarding latent PC.

Suicide mortality in comparison to traffic accidents and homicides as causes of unnatural death. An analysis of 14,441 cases in Germany in the year 2010

AIM

To assess suicide mortality in comparison to traffic accidents and homicide deaths in Germany in the year 2010 and to compare years of life lost (YLL) due to these unnatural deaths.

METHODS

Mortality data were provided by the Federal Statistical Office giving death rates (related to 100,000 inhabitants) and proportions (related to 100 deaths of individuals) for suicide, traffic accidents and homicide as well as YLL data.

RESULTS

A total of 14,441 unnatural deaths (suicide, traffic accidents, homicide) were reported in 2010 in Germany. Of those, 10,021 subjects (69.4%) committed suicide, 3,942 (27.3%) died in traffic accidents, 478 (3.3%) were murdered. Suicide death rates were by far the highest, with rates for men (18.6) three times higher than for women (6.1). For both sexes, suicide rates increased with age, whereas suicide as a proportion of all causes of death was higher in younger age groups. In both sexes, suicide was the leading cause of YLL (men: 314 YLL, women: 90 YLL).

CONCLUSIONS

Suicide is the leading cause of unnatural death and YLL. The sex- and age- specific patterns in suicide mortality call for different action plans to target high risk groups.

Does informed consent exempt Japanese doctors from reporting therapeutic deaths?

The Japanese Medical Act section 21 states that doctors must report unnatural deaths to the police, even though the term "unnatural death" is not defined by law. However, many doctors are reluctant to report potential therapeutic deaths (PTDs). The Japanese Society of Legal Medicine has submitted guidelines for unnatural death, including PTD. These define a PTD as an unexpected death, the cause of which is unknown, but which is potentially related to medical practice. Such deaths are "reportable" to the coroner in the UK. In this study, we addressed the question of whether physicians would report each of eight hypothetical PTDs. Although the clinical societies (the Japan Society of Internal Medicine and the Japan Surgical Society) declare that doctors must report deaths due to gross negligence, 60% of the participants said that they would not report gross negligence involving an overdose in cases where they had obtained informed consent or had provided an explanation after the death occurred. This can be accounted for by the mistaken belief on the part of the participants that obtaining informed consent exempts Japanese physicians from the duty of reporting PTDs. The attitude of Japanese physicians is caused by the death investigation system, which is designed to discover whether a crime has been committed rather than focusing on the cause of death. Accordingly, the Japanese Government has decided to commission a pilot study from an independent organisation in which medical specialists will investigate PTDs in order to prevent deaths occurring as a result of gross negligence.