Trends in suicide by carbon monoxide inhalation in King County, Washington: 1996-2009

Carbon monoxide (CO) inhalation is one of the leading methods of suicide in the United States. A sharp increase in suicide by inhaling the CO produced from burning charcoal has been reported in parts of Asia; however, the incidence of this method has not been determined in a U.S. population. Thus, we determined trends of CO suicide in the ethnically diverse population of King County, Washington, U.S.A. During the period 1996-2009, we identified 158 cases of suicide by CO poisoning, with 125 because of automotive exhaust, 26 because of charcoal burning, and seven from other CO sources. While historical U.S. data indicate >99% of CO suicides in the United States occurring by automobile exhaust inhalation, in the most recent years analyzed, c. 40% of CO-related suicides in King County, Washington, were because of charcoal burning, indicating a possible shift in suicide trends that warrants further scrutiny in additional populations.     

Homicide–Suicide in Cuyahoga County,Ohio, 1991–2016

Research on homicides followed by suicides has relied heavily on small samples and relatively short time spans of data. This study helps to fill this gap by examining 26 years of homicide–suicide data from Cuyahoga County, Ohio, between 1991 and 2016. The main data source for the study is medical examiner files. Analyses of the data indicate the rate of homicide–suicide in Cuyahoga County is consistent with other studies but fluctuates considerably across years studied. The majority of victims are female while perpetrators are overwhelmingly male. Black people are overrepresented as victims and offenders. Use of drugs and/or alcohol leading up to the incident is common among perpetrators. Both the homicides and suicides were overwhelming committed with firearms. When comparing our results to the typology of murder–suicides developed by Marzuk, Tardiff, and Hirsch (JAMA 1992;267:3179), we find amorous jealousy is a significant motivating factor in a many cases, including those involving nonintimate partners. Our findings underscore the importance of widespread use of lethality assessment instruments.     

Schizophrenia and suicide: a 10-year review of Kentucky medical examiner cases

The risk of suicide is significantly increased in schizophrenics; it is estimated that 10-13% of individuals suffering from schizophrenia commit suicide. Schizophrenia is marked by psychotic exacerbations and remissions, with persistent deterioration in baseline functioning with each relapse. We present a 10-year (1993-2002) retrospective review of Medical Examiners' cases of suicide of schizophrenic victims. Twenty-nine cases were between the ages of 20 and 75 (mean age of 41.6 years). The majority of victims were male (62.1%) and Caucasian (86.2%). The leading method of suicide for both males and females was firearm injury (48.3%) mostly of the head, followed by overdose (20.7%), and hanging (13.8%). A comprehensive investigation of the biopsychosocial factors is warranted in cases of schizophrenics who commit suicide. This study offers an insightful analysis pertaining to the determination of intent in formulating the manner of death in this unique population.     

Psychosocial Complications of Crohn's Disease and Cause of Death

Patients who suffer from Crohn's disease are prone not only to the complications of a relapsing, unpredictable disease, but also to feelings of stigmatization; depression; and increased risk of suicidal ideation, suicide, or drug and alcohol abuse. Cases performed at the Jackson County Medical Examiner's Office from 2008 to 2010 were reviewed. Autopsy findings, investigator reports, toxicology results, medical records, and interviews with survivors were analyzed. Twelve cases of Crohn's disease were recovered. In 10 of these cases, inflammatory bowel disease was not the cause of death. Instead, psychosocial consequences of the disease had significant implications in the deaths. The mean age of decedents was 45 years, with a female predominance. In eight cases, the decedents lived alone. Five patients had issues of acute or chronic drug or alcohol use. Five patients committed suicide. These cases underscore the role of psychosocial factors that can contribute significantly to the cause of death in patients with Crohn's disease.     

A Ten‐year Study of Suicides from a Rural/Suburban County

This study will discuss trends in suicide data compiled over 10 years in Dutchess County, NY, from 2004 to 2013. These data were based on reporting and examination standards recommended by the National Association of Medical Examiners and Department of Justice death investigation standards. Almost 300 cases were analyzed in terms of the deceased's gender, age, race, method of suicide, and weapon used. Results from this study agree with other reports showing significant differences for method of death both in terms of age and gender, with men more likely to choose firearms and women more likely to choose overdose. Furthermore, older persons were more likely to commit suicide by firearms, and the younger persons were more likely to commit suicide by overdose. However, other areas, such as method of suicide, differ from national statistics.     

Suicide Pacts: Six Cases and Literature Review

A suicide pact is the decision of two or more people to die together. This event is rare. The majority of suicide pacts victims are married, socially isolated, with a serious physical illness in one or both partners. We performed a retrospective study of all cases of suicide pacts leading to death between January 1, 2003 and December 31, 2010 referred to the Forensic Medicine Department of Tours (France). Six cases were recorded as suicide pacts. Firearms were the preferred means of death. Five suicide notes were discovered. For some cases, it was difficult to establish whether death was the result of a suicide pact or of a homicide–suicide without the consent of the victim. An objective element, such as a suicide note and motive, is required to prove that a suicide pact is involved. The prevalence of mental disorders is hard to assess. In France, psychological autopsies are not performed in such cases, as the investigation is usually very sparse after the death of both individuals.     

Medical examiner response to the drug overdose epidemic in King County Washington: “Real-time” surveillance,data science,and applied forensic epidemiology

As the overdose epidemic overwhelmed medicolegal death investigation offices and toxicology laboratories, the King County Medical Examiner's Office responded with “real-time” fatal overdose surveillance to expedite death certification and information dissemination through assembling a team including a dedicated medicolegal death investigator, an information coordinator, and student interns. In-house testing of blood, urine, and drug evidence from scenes was performed using equipment and supplies purchased for surveillance. Collaboration with state laboratories allowed validation. Applied forensic epidemiology accelerated data dissemination. From 2010 to 2022, the epidemic claimed 5815 lives in King County; the last 4 years accounted for 47% of those deaths. After initiating the surveillance project, in-house testing was performed on blood from 2836 decedents, urine from 2807, and 4238 drug evidence items from 1775 death scenes. Time to complete death certificates decreased from weeks to months to hours to days. Overdose-specific information was distributed weekly to a network of law enforcement and public health agencies. As the surveillance project tracked the epidemic, fentanyl and methamphetamine became dominant and were associated with other indicators of social deterioration. In 2022, fentanyl was involved in 68% of 1021 overdose deaths. Homeless deaths increased sixfold; in 2022, 67% of 311 homeless deaths were due to overdose; fentanyl was involved in 49% and methamphetamine in 44%. Homicides increased 250%; in 2021, methamphetamine was positive in 35% of 149 homicides. The results are relevant to the value of rapid surveillance, its impact on standard operations, selection of cases requiring autopsy, and collaboration with other agencies in overdose prevention.     

Teenage suicide in King County, Washington. I. Rates of suicide for 26 years

The population-adjusted rate of teenage suicide in King County, Washington, was reviewed for the 26 years from 1959 to 1984. For the entire period, the rate did not change significantly. An abrupt change did occur during the middle of this period, but, for reasons discussed in the text, this may well represent a change in procedures and philosophy of death certification rather than a real change in rate. Reasons for the apparent discrepancy with national statistics are discussed.     

Fatal Firearm Injuries in Tennessee: A Comparison Study of Tennessee's Two Most Populous Counties 2009–2012

Firearm injuries are a leading cause of violent death in Tennessee. This study was designed to compare the demographic and epidemiologic features of fatal firearm injuries in Shelby County and Davidson County, Tennessee between 2009 and 2012. We identified 1081 gunshot fatalities for the study period in these two counties. Shelby County had a higher overall, age‐adjusted gunshot mortality rate, a higher male age‐adjusted gunshot mortality rate, and a higher age‐adjusted gunshot homicide rate than Davidson. Age groups 25–34 years and 35–44 years had higher crude mortality rates for gunshot deaths in Shelby County than Davidson County. Both counties had higher age‐adjusted gunshot mortality rates for black males than white males, higher homicide rate for black race than white, and higher suicide rate for white race than black. Homicide was the most common manner of death, and handguns were the most common type of firearm used in both counties.     

A study of drug detection in a postmortem pediatric population

At The Office of the Cuyahoga County Coroner (CCCO), Cleveland, Ohio, it is customary to perform an autopsy and conduct toxicological testing on decedents less than 19 years of age. This study provides a retrospective evaluation of drugs detected in a pediatric postmortem population between the years 1998 and 2002 (n = 730). Demographic information, cause and manner of death, and toxicological results were examined. Blacks comprised 54% of cases, males 59%, and 48% were less than one year of age or stillborn. Forty-two percent of deaths were ruled natural, 27% accident, 13% undetermined, 5% suicide, and 2% homicide. Of the 640 cases subjected to comprehensive testing, 38% of the cases were positive for at least one compound. Resuscitative/treatment drugs were detected most frequently (56% of positive results), followed by illicit drugs (26%), ethanol (11%), carbon monoxide (8%), and antihistamines (6%). Eighty-seven cases contained more than one drug. The deaths of 47 individuals were drug related (6%). In this population, it is recommended that illicit drugs and ethanol are targeted for testing, especially when limited specimens are available for analysis.     

The Suicide Mortality Rates between 1997–1998 and 2000–2001 in Nantou County of Taiwan Following the Earthquake of September 21 in 1999

Abstract:  The paper aims to show the different suicide mortality rate between 1997–1998 and 2000–2001 in Nantou County of Taiwan with earthquake on September 21 (often referred to as the "9-21 earthquake") in 1999. In additional, it also identifies the preventive strategies for the high-risk suicide population. The age-standardized mortality rates for suicide in Nantou County were calculated for the years 1997–1998 and 2000–2001. The suicide standardized mortality ratio (SMR for townships in Nantou were calculated by "type of township" as the standard rate). There is a statistically significant difference in male suicide rates for the years prior to the earthquake (1997–1998) when pooled and compared to the suicide rates for the years after the earthquake (2000–2001). The rate for four age groups (under 25, 25–44, 45–64, 65 and above) all increased, yet all but one (the group of age 45–64) was not statistically significant. The male SMR has slightly increased after the 9-21 earthquake. Yet there are no statistical significances in most townships, except in Kaohsiung and Puli after the 9-21 earthquake. The Kaohsiung SMRs were 1.36 (95% CI: 0.54–2.80) before the earthquake (1997–1998) and 2.01 (95% CI: 1.04–3.52) after the earthquake (2000–2001). The SMRs before and after the earthquake in the Puli Township were 1.51 (95% CI: 0.95–2.29) to 1.56 (95% CI: 1.03–2.27). This study suggests that monitoring high-risk population, especially males or 45–64 years of age who experienced the highest statistically significant suicide rate in this study. The study provides support for providing both the psychological restoration program and, to the extent feasible, financial support for the unemployed as useful public health strategies for suicide prevention in Taiwan.     

Manners of Death in Drug‐Related Fatalities in Florida

To understand the mortality patterns among drug users and potential risk factors, we evaluated drug‐related deaths reported to the Florida Medical Examiners Commission from 2001 to 2013, by substances, demographics, and manner of death. The annual drug‐related fatalities increased by 57% from 2001 to 2013 (total n = 100,882); 51.8% were accidental, 7.9% homicide, 18.6% natural, and 19.6% suicide. The different manners of death exhibited distinct demographic profiles and drug composition. The gender gap was more prominent in homicide. Age ≥55 years was more closely associated with natural death and suicide. Age <35 years and central nervous system (CNS) stimulants including amphetamines and cocaine showed higher relative risks for accidental death and homicide, whereas CNS depressants including benzodiazepines, carisoprodol, opioids, and zolpidem were more strongly associated with accidental death and/or suicide. The findings aid in identifying populations more vulnerable to drug‐related deaths, developing targeted interventions and thereby improving efficiency of preventive efforts.     

Evolution of the Psychological Autopsy: Fifty Years of Experience at the Los Angeles County Chief Medical Examiner‐Coroner's Office

The origin of the psychological autopsy was in the late 1950s and the result of a collaboration between the Los Angeles County Chief Medical Examiner‐Coroner's Office and the Los Angeles Suicide Prevention Center. It was conceptualized as a thorough retrospective analysis of the decedent's state of mind and intention at the time of death. It was used initially in “equivocal” deaths where the manner of death was possibly either suicide or accident. Later, it was used in cases where a party (primarily family members) protested the Medical Examiner‐Coroner's suicide determination. Over the past 25 years, the University of Southern California Institute of Psychiatry, Law, and Behavioral Science has served as the psychiatric/psychological consultants to the Coroner's Department. Research findings, the use of this approach in high‐profile cases, and the most recent manner in which the psychological autopsy is conducted are discussed.     

John and Jane Doe: the epidemiology of unidentified decedents

Abstract:  The number of people who cannot be identified at the time of death, sometimes referred to as John or Jane Does, is unknown, and little is known about them as a group. The study's objectives were to estimate the number of annual unidentified deaths, to identify demographic characteristics associated with dying unidentified, to determine whether the rates of such deaths vary geographically or over time, and to better characterize the causes of death. This was a population-based surveillance study of data collected from death certificates from 1979 to 2004 in the U.S. Subjects were selected by the absence of name, date of birth, and Social Security Number on their certificates. Main outcome measures were distributions by age, sex, and underlying cause of death and rates by sex, race, year, and state of death. An average of 413 unidentified persons died each year. The peak year was 1987 with 691 deaths, a rate of 28.5 per 10 million people. The rate declined to 9.7 per 10 million in 2004. Most unidentified decedents were male (80.6%). Unidentified death rates were highest among black people and in the Southwest. Among deaths for which the cause was known, 82.7% were due to injuries. Among injury deaths, 31.8% were homicides. Improvement in identification technology may have reduced rates of unidentified death since the 1980s. In addition, variations in rates of unidentified decedents may reflect changes in risk factors such as homelessness and substance abuse.     

FORENSIC Autopsy of People Having Committed Suicide in 2002 and in 2012: Comparison of Epidemiological and Sociological Data

This work compares epidemiological and sociological data on persons having committed suicide in 2002 and in 2012 through a retrospective study of every suicide case having led to an autopsy at the Institute for Forensic Medicine of Lyon in 2002 and in 2012. The study included sociodemographic data, medical data, and toxicological data. A total of 486 cases were included (242 cases in 2002 and 244 cases in 2012). People committing suicide were on average older in 2012 than in 2002 with a larger proportion of over 55. There was also an increase in the proportion of psychiatric antecedents (p < 0.001). Whatever the date of death by suicide, the most affected age range is the 45–54. The results highlight the necessity of bolstering the prevention plans, in particular for people over 45.     

Teenage suicide in King County, Washington. II. Comparison with adult suicides

The 25 teenage suicides that occurred in King County, Washington, during 1983 and 1984 were compared with the 158 adult suicides that occurred during 1984. The comparison included the following features: sex, race, declaration of intent, motive, method, isolation, alcohol or drug intoxication at the time of death, prior suicide threats and attempts, counseling history and diagnosis, and family history of suicide. For the teens, we also queried school or employment status, anxiety-producing experiences, symptoms of depression, marital history of the parents, and number and order of siblings.     

Subway Train‐Related Fatalities in New York City: Accident versus Suicide*

Abstract: We examined the characteristics of subway train‐related fatalities in New York City between Jan. 1, 2003 and May 31, 2007 in order to determine which factors are useful in differentiating accident from suicide. Subway train‐related deaths with homicide and undetermined manners also are included. During this period, there were 211 subway train‐related fatalities. The manners of death were: suicide (n = 111), accident (n = 76), undetermined (n = 20), and homicide (n = 4). The causes of death were blunt trauma (n = 206) and electrocution (n = 5). Torso transection and extremity amputation were more frequent in suicides. Antidepressant medications were more frequently detected in suicides, whereas cocaine and ethanol were more frequent in accidents. However, autopsy findings should be weighed in the context of the entire evaluation along with other circumstantial and investigative findings. In unwitnessed deaths where additional information is unavailable or discrepant, the most appropriate manner of death usually is undetermined.     

Changes in the Frequency and Clinical Features of Suicide Attempts in the Midwestern Area of Kanagawa after the Great East Japan Earthquake

The aim of this study was to investigate the relationship between the clinical features of suicide attempts and the Great East Japan earthquake in Kanagawa. We enrolled 592 patients who attempted suicide and were hospitalized for inpatient treatment. Clinical features were compared between before the earthquake (A) and after the earthquake (B) groups. The number of suicide attempts increased from 286 to 306. The rate of increase in suicide attempts in men was the highest in the age group of 40–59 years. The frequency of joblessness, family psychiatric histories, precipitating event, and alcohol intake at suicide attempt was significantly higher in the B group than in the A group. The number of patients in serious condition in the B group was significantly higher than that in the A group. Other clinical features related to suicide in people who were indirectly affected by the earthquake disaster should be investigated to develop targeted prevention strategies.     

Suicide and Psychiatrist's Liability in Italian Law Cases

The aim of the study is to analyze the factors that are most frequently associated with a verdict of guilty delivered to the psychiatrist in cases of a patient's suicide in Italian law. Twenty‐six sentences (1975–2009) were analyzed according to the claim of malpractice, patient characteristics, circumstances of the suicide, and reasons for the court's judgment. The court held the psychiatrist guilty in 12 cases, considering that the act of suicide was predictable and could have been avoided. Predictability was mainly related to errors in surveillance (7 cases), therapy (1 case), or both (2 cases). An error in diagnosis was considered to be related to the patient's death in two cases. Analysis of medical behavior considered to be erroneous and associated with a verdict of guilty provides an opportunity to discuss the topics relevant not only to practicing psychiatrists but also to experts assessing medical liability in cases of patient suicide.