Characteristic Features of Pediatric Firearm Fatalities—Comparisons Between Australia and the United States

Abstract:  Gunshot deaths in children less than 17 years of age from Adelaide, SA, Australia (1969–2005) and from San Diego County, CA, United States (1988–2005) were compared. Forty-two pediatric gunshot fatalities occurred in South Australia (1.1 cases/year; M:F = 30:12). There were 6 accidents (14%), 14 suicides (33%), and 22 homicides (52%). In San Diego there were 185 cases ( c. 10 cases/year; M:F = 148:37). There were 6 accidents (3%), 42 suicides (23%), 130 homicides (70%), and 7 undetermined cases (4%). The incidence of homicide was significantly higher in San Diego County compared to Adelaide ( p  < 0.001), with a higher proportion of murder–suicides occurring in Adelaide. There were markedly more accidents and suicides involving males in Adelaide and a far higher number of male homicide victims in San Diego County compared to females. Rifles of 0.22-caliber were preferred weapons in South Australia, compared to handguns in San Diego County.     

Recent trends in suicides utilizing helium

Retrospective review of cases of suicide involving helium inhalation was undertaken at Forensic Science South Australia over a 25-year period from 1985 to 2009. No cases of helium-related suicides were identified in the first 15 years of the study, with one case between 2000 and 2004 and eight cases between 2005 and 2009. Australian data were also reviewed from 2001 to 2009 that showed 30 cases between January 2001 and June 2005, compared to 79 cases between July 2005 and December 2009, an increase of 163%. A review of Swedish data between 2001 and 2009 showed no cases between January 2001 and June 2005, compared to seven cases between July 2005 and December 2009. Thus, all three areas showed recent and striking increases in cases of suicide involving helium inhalation. Given the availability of helium and the recent promotion of this method of suicide, it is quite possible that this may represent a newly emerging trend in suicide deaths.     

Contributory and Incidental Blood Concentrations in Deaths Involving Citalopram

All cases presenting to the New South Wales Department of Forensic Medicine between January 1, 2001 and December 31, 2010 in which citalopram was detected were retrieved. A total of 348 cases were identified. Citalopram contributed to death in 21.0%, and was incidental in 79.0%. Cases in which citalopram was contributory to death had significantly higher blood citalopram concentrations than incidental cases (0.50 mg/L vs. 0.30 mg/L). Citalopram concentrations varied significantly by contributory status: sole citalopram toxicity (median = 1.30 mg/L), citalopram/other drug toxicity (0.50 mg/L), and incidental cases (0.30 mg/L). Citalopram concentrations also varied by suicide status, with the highest concentration found in suicides where citalopram contributed to death (0.70 mg/L) compared with 0.50 mg/L for nonsuicide cases where citalopram contributed to death. In almost all contributory cases (69/73), other psychoactive substances were also detected, most commonly benzodiazepines (47.9%), alcohol (45.2%), and opioids (40.1%).     

Presence of alcohol in suicide victims

A number of studies have established a strong connection between acute inebriation, alcohol addiction and suicides, as the last act of alcoholism or an act of desperation in an alcoholic's family, an act of escape from restraints in state of depression or as a way of self-destruction.In recent years in average 600 people per year committed suicide. Slovenia is a country with extremely high and variable suicide tendencies and harmful alcohol use levels, as well as a high level of alcohol-related troubles.The aim of our research was to ascertain some typical features, especially those connected to the inebriation of suicide victims from a wider Ljubljana region. Autopsies were carried out on the victims in the period between 1995 and 1999.There were 508 (31.2%) suicides among all the analyzed violent deaths; 73.2% of them were men. The average age of the victims was 46.5 years. Most suicides were committed at home (50.0%). 25.4% were completely sober in the moment of the act, while in all other cases inebriation was established, the average value being 9.57 g/kg. Men were drunk in 87.1% of cases, women only in 12.9% and the given alcohol levels were substantially higher with men (0.65:0.26 g/kg). The share of inebriated persons decreases with age—reaching its peak in the 35–54 age group. Regarding the method, the predominant ones are intoxication and the use of firearms, which is a typical way of committing suicide among men, while women rather choose jumping from great heights and drowning.Alcohol was present in as many as 55.7% of suicides with intoxication and in 68.8% of all suicides committed by using firearms, while the highest alcohol levels were found in those who died from cutting their veins (2.01 g/kg).Based on this and on other research, more effort should be focused on alcohol abuse prevention, making all people aware of the consequences of alcohol abuse, the possibilities of treatment and their availability as well as possible co-morbid depressions. Simultaneously, due to an established link, the national alcohol policy and strategy for prevention of suicides should be professionally harmonized.     

Fatal Falls from Height in Taiwan

This study conducts an investigation of fatal falls from height, examines gender differences, and compares our findings with those of Western countries. We review deaths in Taiwan caused by falls from height that underwent forensic autopsy from 1994 to 2010. Among the examined cases, 182 were suicide, 156 were accidents, and 18 were homicides. Men who fell from greater heights had a lower probability of fatal head trauma (p = 0.045), and women exhibited a lower fatal head trauma rate when falling from heights of between 10 and 25 m in accident group (p = 0.003). There was no significant difference between cases of falling from greater and lower heights within the suicide group (p = 0.834). Psychiatric illness was only reported in 20.3% and 28.8% cases in suicide and accident groups. Only in male cases was the use of psychotropic substances higher in the suicide groups than in the accident groups (p = 0.047).     

Suicide in children and adolescents at a province in Turkey

Despite the well-documented increases in the rate of completed suicide among children, accurate knowledge of the characteristics of these suicides is limited. We examined all suicides by children and adolescents in Diyarbakir during 1999 and 2001. All of the cases were analyzed regarding the age, sex, method and location of suicide, time of year, and predictive factors. There were 56 children aged 11 through 19 years. Adolescents between 15 and 19 years of age constituted the overwhelming number (87%) of all the childhood suicides. Female children and adolescents predominated among the suicide victims (71%). The most frequent means of suicide were firearms (43%), hanging (28%), and jumping (16%), respectively. The majority of suicides occurred at the decedent's home (88%). Reasons identified were mainly psychiatric disorders, followed by troubles within the family. A prior suicide attempt or a note that was left by the decedent and elucidated the reason for the suicide was rare. There was no seasonal difference in rates of suicides.     

Deprivation, importation, and prison suicide: Combined effects of institutional conditions and inmate composition

Previous research on suicide in United States prisons focused on the characteristics of inmates who commit suicide while largely ignoring the prison context surrounding these suicides. The following analyses used national data on 1,082 state prisons in the United States to examine how prison conditions (deprivation) and inmate composition (importation) predict prison suicide. Results of a negative binomial regression model showed that the number of suicides was significantly increased in supermaximum and maximum security prisons (relative to minimum), under conditions of overcrowding and violence, and in prisons where a greater proportion of inmates received mental health services. Although deprivation variables were overwhelmingly predictive of suicide, the results pointed to the combined effects of institutional conditions and inmate composition on prison suicide.     

The Gender Paradox in Prison Suicide Rates

Few studies of prison suicide have focused on suicide among female inmates, and even fewer studies have provided comparisons of rates by gender. Using national data on U.S. prisons and suicide, this study examined the “gender paradox” in prison suicide rates by comparing suicide rates of female and male inmates and U.S. residents and then examined characteristics of prisons that reported suicides. Findings indicated that rates of suicide in prison were similar for female and male inmates, but rates were higher for female inmates and lower for male inmates compared to the respective rates for female and male U.S. residents. Prisons that reported female suicides evidenced significant differences in prison conditions, including higher assault rates and mental health service utilization, compared to prisons for males and female prisons without suicide. Implications of the findings for understanding the gender paradox and for prison suicide prevention are discussed.     

Suicide behind bars: trends, inconsistencies, and practical implications

The results of two comprehensive approaches are compared: the nationwide surveys of suicides in U.S. jails by Hayes and the international meta-analyses of suicides in jails and prisons by Fazel et al. Factors are classified as demographic, situational, clinical, and methodical. More than 50% of U.S. jail suicide victims were men, white, unmarried, under 28 years of age, charged with minor or drug-related offenses, and intoxicated with drugs or alcohol. Suicides significantly occurred in isolation. Suicide victims in the international study were significantly (p < 0.001) men, white, married, pretrial, and charged with or convicted of violent offenses. Psychiatric diagnosis, alcohol abuse, taking psychotropic medication, and suicidal ideation were also positively correlated in the international study, but suicide victims were distributed more evenly over age-groups. Results of other studies illustrate the near universality of some findings. Three theories of suicide are briefly discussed.     

Why Do People Hang Themselves on Trees? An Evaluation of Suicidal Hangings on Trees in Konya,Turkey, between 2001 and 2008

Hanging is the most common method of suicide in the world, and many public places offer a means or opportunity to carry out the activity. Of 4,452 death examinations and autopsies, there were 378 (8.5%) suicides and suicide method was hanging in 185 (48.9%) cases. In 20 of these (10.8%), the suspension point was the branch of a tree. The incident location was the garden of the victim's house in nine cases, the woodlands in seven cases. The suicides were attributed to psychiatric disorders in nine cases, economic problems in six cases, and family problems in five cases. It is concluded that hanging on a tree as a suicide method is often committed by males and the underlying motive may be different in suicidal hangings on trees occurring at daytime and night. For preventional purposes, the reporting of such suicides in public places by the media may be restricted by local authorities.     

Clinicopathologic features of fatal self-inflicted incised and stab wounds: a 20-year study

The files of the Forensic Science Center in Adelaide, South Australia, were examined for all cases listed as suicide in which death had been caused by the use of a sharp instrument during the 20-year period from January 1981 to December 2000. Fifty-one cases were identified, consisting of 35 men and 16 women. The age range was 23 to 83 years (mean 49 years) representing 1.6% of total suicides (513182). Fatal injuries included incised wounds to the arms in 51.4% of men (n = 1835) compared with 87.5% of women (n = 1416), incised and stab wounds to the neck in 40% of men (n = 1435) and 25% of women (n = 416), and stab wounds to the chest or abdomen in 28.6% of men (n = 1035) and 12.5% of women (n = 216). In 8 cases, multiple sites were involved. The use of sharp instruments in suicide was favored by older, rather than younger, individuals, with a tendency for women to incise their wrists. Hesitation marks were present in 23 cases (54%) and scarring of the wrists from previous suicide attempts in 5 cases. Although this study demonstrated a higher number of men than women committing suicide by using sharp objects, this method of suicide remains uncommon.     

Suicide by Medication Overdose in Prison: A Study of Three Cases

Suicide is one of the principal causes of mortality in a prison environment. Although suicide by medication overdose is less frequent than suicide by hanging, self‐strangulation, or vein cutting, it raises questions as to how the medications are obtained, particularly in view of the specific organization of the medication circuit in prisons. We present three cases of suicide by medication overdose involving different therapeutic classes with different distribution circuits and review the regulatory requirements and the measures that could be taken to prevent such suicides.     

Self-immolation Suicide in Greece: A Forensic Psychiatric Autopsy Study between 2011 and 2019

Self-immolation is a rare suicide method in the developed countries of the western world (0.06–1%); however, it has relatively higher prevalence rates in the developing countries of Asia and Africa (6–57%). The present study aims to examine self-immolation suicides within the Greek mainland (Attiki, Thrace, and Peloponnese) over a period of 9 years (2011–2019) in order to investigate the phenomenon in the Greek population forensically, identify the characteristics and motivations of suicide victims, explore its associations to socio-cultural or psychiatric factors, and describe a fatal case of suicide by self-immolation that was partially recorded on camera. The medical files (autopsy reports) of cases performed at the Departments of Forensic Medicine of the National and Kapodistrian University of Athens, Democritus University of Thrace, and the Forensic Service of Messinia—Peloponnese were retrospectively examined yielding 19 cases of suicides by self-immolation. A 3.7% prevalence of suicide by self-immolation among suicide fatalities within the Greek population was estimated. A distinctive feature of the Greek population regarding self-immolation was disclosed that it is being practiced predominantly by the elderly (mean age 2–3.5 decades higher than other countries). The phenomenon correlated strongly with poorly controlled mental disorders (mostly affective and adjustment disorders). Unlike other countries, there was no significant association with domestic or sexual violence, social or political protest, or religious issues. Therefore, the suicide victims preferred secluded or private outdoor locations (not public). Findings deriving from the examined variables localize Greek population culturally between the Western European and Asian African countries, but with its own idiosyncrasies.     

Characteristic features of suicidal drownings: a 20-year study

A retrospective study of cases of drowning suicide was undertaken at the Forensic Science Centre in Adelaide, South Australia for the period April 1980 to March 2000. A total of 123 cases were found, with 76 males (age, 16-88 years; average, 50.5 years; standard deviation [SD], 20.1 years) and 47 females (age, 34-88 years; average, 60.6 years; SD, 13.9 years). There were 66 fresh water drownings and 57 saltwater drownings. Female victims were significantly older than male victims for both fresh water and saltwater drownings (P < .05 and P < .01, respectively). Deaths in young women were rare. No temporal trend in drowning suicides could be shown, with annual numbers varying from 0 to 12 cases (average, 6.15; median, 7). Women preferentially chose the ocean or bath to drown themselves in, whereas males chose rivers, ditches, and lakes. Swimming pools were rarely used for suicide in this population; alcohol use was not usual; and there was often a significant history of mental illness.     

Factors related to suicide in New York state prisons

OBJECTIVE: Examine factors related to prison suicides to aid prevention. METHOD: Review the mental health records of all 76 suicides that occurred between 1993 and 2001 in New York State Department of Correctional Services (NYSDOCS) prisons that had some contact with mental health services during their incarceration. (This represented 84% of all NYSDOCS suicides.) Extract data from the psychological autopsies for a sample of 40 of these suicides. RESULTS: Of the suicide victims with some mental health contact, 95% had a substance abuse history, 70% displayed agitation or anxiety prior to the suicide, and 48% had a behavioral change. Common stressors preceding the suicide were inmate-to-inmate conflict (50%), recent disciplinary action (42%), fear (40%), physical illness (42%), and adverse information (65%) such as loss of good time or disruption of family/friendship relationships in the community. Forty-one percent had received a mental health service within 3 days of the suicide. Compared to the about 7200 inmates actively receiving mental health services in state prison, African-Americans and patients with a Major Mood (Bi-polar or Major Depression) were under-represented. Adjustment Disorder, Schizophrenia, and Personality Disorder diagnoses were over-represented. Suicide victims were more likely to have been incarcerated for a violent crime. CONCLUSION: Mental illness, anxiety/agitation, behavior change, stressors, history of substance abuse, and non-African-American were important risk factors.     

Suicidal drowning in south Florida.

Autopsy protocols at the office of the Chief Medical Examiner were reviewed with respect to suicidal drowning. Between July 1, 1994 and June 30, 1998, there were 267 drownings and 873 people committed suicide in Broward County, Florida. Of those, 25 were suicidal drownings, representing 2.86% of all suicides, and overall the 8th leading cause of suicidal death. When considering suicide in the age group of 65 years and older, (n = 239), which accounts for 19.8% of the population and 27.4%, of all suicides, drowning represents 6.7% of all suicidal deaths, and within females in this group represents the third most common form of suicidal death (13.8%). The presence of alcohol or other drugs is less usual in elderly suicide victims than younger victims. Of the 25 drowning suicides, there was a preference for swimming pools, canals, and lakes as the locations of choice. Additional drowning and suicide related criteria were evaluated including marital status, mental health, clothing worn, previous attempts or threats, suicide notes, and personal effects at the scene; with the intention of establishing a profile for drowning by suicide. Given the relative abundance of water, the suicidal drowning rate appears to be lower than what might otherwise be anticipated.     

Female suicides in Diyarbakir, Turkey

The aim of this study was to investigate the methods used and demographic data of women suicides by examining postmortem investigation and autopsy reports from the Branch of the Council of Forensic Medicine in Diyarbakir Province, Turkey, between 1996 and 2001. Fifty-eight percent (174/302) of suicides were females and 42% (128/302) were males. The suicide rates were similarly higher for females than for males (2.6 and 1.8 per 10,000 population, respectively). Over half of female suicides (56.3%) occurred in those under 20 years of age. The most common suicide method for women was hanging (32.2%), and for men was firearms (51.7%), but for women younger than 20 years the most frequent method was firearms. Among the female suicides, five (2.8%) were known to have attempted suicide at least once in the past. Twenty-nine women (16.7%) were documented to have any psychiatric illness. None of the women had a history of drug or alcohol abuse. A suicide note was found in only six cases (3.4%). The predominant suicide motive was family problems (in 32% or 56/174). The higher rate of suicide in females than in males, and the absolute female predominance in suicides in Diyarbakir, Turkey, are in contrast to most of the medical literature and statistical information about suicide rates by country, in which suicide rates are usually higher among males.     

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.     

The problem of determining the manner of death as suicide or accident in borderline cases

The purpose of this study was to check the reliability of the classification of death in cases regarded primarily as accidents or undetermined. The material used for the analysis consisted of the documents of autopsies performed at our department in 1981. There were altogether 283 cases of suicides, accidents or undetermined deaths, accounting for 8.4% of total mortality, and of these 180 cases were of the two last categories. In 125 cases primarily regarded as non-suicides (accidents or undetermined) there were some features of suicide leading to reclassification as probable suicide in 24 cases. Fifteen of these were primarily poisoning "accidents", mainly alcohol intoxications. The result indicates that the suicide rate would be 3.7% instead of 3.0% of the total mortality. It may thus be concluded that the official figure for suicides could be as much as 18.9% smaller than the "actual" figure.