The descriptive epidemiology of unnatural deaths in Oregon's state institutions: a 25-year (1963-1987) study. I. A preliminary analysis of recent incidence rates of suicide in mental and correctional facilities

This paper presents for the first time the annual suicide incidence rates of residents from four Oregon state institutions for a 5-year (1983-1987) period of time. The suicide rate for inmate-patients of the Forensic Psychiatric Program (for the care and treatment of individuals who have been found guilty of serious crime and to be mentally ill) is 820/100,000. This represents a suicide rate 51 times higher than the rate for Marion County or the state of Oregon. This is also one of the highest annual suicide rates ever reported. The suicide rate for patients of the Oregon State Hospital is 289/100,000, which is similar to other reported suicide rates in hospitalized mentally ill populations. This rate is approximately 18 times higher than the rate for Marion County or the state of Oregon. The suicide rate for inmates of Oregon's four correctional institutions is approximately 29/100,000, which is similar to other reported rates for prisoners. This rate is approximately 1.8 times higher than the rate for Marion County or the state of Oregon. The suicide rate for residents of the Fairview Training Center (for care of the mentally retarded and developmentally disabled) is zero.     

The descriptive epidemiology of unnatural deaths in Oregon's state institutions: a 25-year (1963-1987) study. III. A 25-year overview of unnatural deaths in the mental and correctional facilities.

I document 25 consecutive years (1963-1987) of unnatural deaths within the State of Oregon's mental and correctional institutions in Marion County. This study includes 93 unnatural deaths in the Oregon State Hospital, 18 in the Forensic Psychiatric Program, 52 in the Fairview Training Center, and 45 in the Corrections Department facilities. These institutional unnatural deaths are compared with the 2,618 unnatural deaths that occurred during this same period in Marion County (exclusive of these state facilities). Death rates are shown in five 5-year blocks of time to illustrate death trends. Accidents and suicides were the predominant types of unnatural death in the Oregon State Hospital; suicides predominated in the Forensic Psychiatric Program and the corrections facilities; and accidents predominated in the Fairview Training Center. Extremely high total unnatural death rates were found in the Oregon State Hospital (approximately 520/100,000 or 8.46 times that found in Marion County) and the Forensic Psychiatric Program (approximately 561/100,000 or 9.13 times that found in Marion County). The overall accident death rate for the Fairview Training Center was approximately 119/100,000 or 2.84 times that found in Marion County. The overall total unnatural death rate for the corrections facilities was approximately 75/100,000 or 1.23 times that found in Marion County. I compare these data with those of other investigators in the United States, Canada, and western Europe. The total unnatural death rate appears to represent a valid criterion of violent death within a community.     

Increased risk of suicide with exposure to pesticides in an intensive agricultural area. A 12-year retrospective study

Several reports have suggested that exposure to agricultural pesticides (mainly chronic exposure to organophosphates) produces depression, and depression is a major risk factor for suicide. A retrospective epidemiological study of 251 suicide cases was undertaken to explore the possible relationship between the high suicide rates in an intensive agricultural area, and a specific group of population at risk, namely farmers with chronic exposure to pesticides, who are at risk to develop mood disorders (mainly depression). Our data show that the suicide rate in that area is significantly higher than the suicide rates from other geographic areas with very similar socioeconomic and demographic features. In addition, the mortality from suicide in this population (farmers) does differ significantly from that of the rest of the population.     

Patients’ views of the quality of Danish forensic psychiatric inpatient care

The present study describes the quality of psychiatric care among forensic inpatients in Denmark who answered the Danish version of the Quality in Psychiatric Care–Forensic In-Patient (QPC–FIP) instrument. A sample of 143 patients (response rate 53%) from 25 of the 27 specialized forensic units in Denmark participated in the study. The patients’ ratings of the quality of care were generally high. The highest rating was found for the quality of the secluded environment and the lowest for patient participation in the care. The results showed that several factors influenced the patients’ ratings. Women rated the quality of care lower in comparison to men. Patients living together with someone before admission, patients with a lower level of education, and patients who were better informed regarding their diagnosis, who was the responsible physician, and where to complain rated the quality of care higher. We can recommend the use of the Danish version of the QPC–FIP instrument for measuring and improving the quality of care in forensic inpatient care.     

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.     

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.     

An analysis of self-reported suicide attempts and ideation in a national sample of incarcerated individuals convicted of sexual crimes

ABSTRACT

Suicide is the leading cause of preventable death in US jails and prisons, with rates three to nine times higher than those of the general population. Although suicide in correctional settings has been recognised as a serious problem, the research on suicide among incarcerated individuals remains limited. Individuals who have committed sexual offenses may be at an elevated risk for suicide. Specifically, they have been found to report high rates of hopelessness and depressive mood, and approximately 14% of individuals convicted of sexual offenses have reported a suicide attempt at some point in their lives. Most of these data are based upon official reports and may represent an underreporting of the true prevalence of the problem. The current study provides an analysis of the prevalence and factors associated with self-reported suicidal thoughts and behaviours in a large national sample of individuals convicted of a sexually based crime. Overall, 17.9% of the offenders reported an attempted suicide in their lifetime, 15.1% reported experiencing suicidal ideation but never made an attempt. Risk factors for suicide attempts and ideation for this population are reported. The findings are discussed in the context of suicide prevention and intervention efforts among those who have committed sex offenses.     

Evaluation of a cognitive-behavioral program for chronically psychotic forensic inpatients

The present study evaluated the progress of four groups of chronically psychotic patients in treatment at De Kijvelanden Forensic Psychiatric Hospital. The psychotic patients were offered a cognitive-behavioral program, including psycho education, grief processing, stress management, functional training, coping with psychotic symptoms (Liberman module) and social skills training. Nine patients dropped out of the program. Sixteen patients who completed it scored significantly better than a control group of 16 psychotic patients, who had not yet participated in the program, on the "social skills" and "negative coping behavior" subscales of one of two observation scales used. On the other observation instrument (REHAB), however, no significant improvement in the general level of functioning was found in the group of treated patients, as compared to the control group. Apart from these two observation scales, the PANSS (structured interview for positive, negative and general psychopathological symptoms) and the SIG (self-report questionnaire for social anxiety and social responses) were used to evaluate treatment progress. Significant improvements were not found on these scales, except for a slight positive effect on the PANSS negative symptoms scale. These results illustrate the difficulties and limitations of treating chronically psychotic offenders, who often also suffer from cluster B personality disorders.     

Mortality in maximum security psychiatric hospital patients

Numerous studies have mentioned to the high percentage of violent deaths in prison psychiatric hospitals, with suicide being the principal cause. The aim of this study was to analyze the circumstances related with the deaths recorded in a high security institution. Postmortem reports on all the deaths at the Alicante Psychiatric Prison between 1984 and 1997 were studied (36 cases of unnatural death and 28 of natural death). Of the violent deaths recorded 34 (94.4%) were suicides. Demographic, clinical and interpersonal variables factors were registered. In the cases of suicides, the method used, the place of death, season, month and time of suicide were analyzed. In our study, 64.7% of suicides were schizophrenic and 32.4% had inflicted self-harm previously. We found a statistically significant association between the cause of death (natural, suicide or homicide) and age, 47.1% of suicides being between the ages of 18 and 30 and 29.4% between the ages of 30 and 45. Natural causes predominated in older subjects. The prison population studied showed grave negative traits, mental illness and criminal behavior having forced them to the very edge of society. Our results were compared with the death and suicide rates of the general Spanish population.     

Motives for maternal filicide: results from a study with female forensic patients

The objective of this study was to examine different motivational factors, leading mothers to commit neonaticidal, infanticidal or filicidal acts. This study was based on data gathered through a retrospective chart review of all filicidal women admitted to the Mid-Hudson Forensic Psychiatric Hospital in New York State (MHFPC) between 1976 and 2000 (n=57). Because our sample was drawn from MHFPC records it excludes filicidal mothers who went directly to prison. Our women were either found not competent to stand trial, or found not guilty by reason of insanity, or were convicted offenders who were seriously mentally ill and were not sent to prison. Fourteen percent committed neonaticide, meaning that they killed their child within the first day of its life; 21% killed the child after the first day but before it reached its first birthday (infanticide); and 65% committed filicide by murdering a child older than one. Two groups of women could be identified as having different motivational profiles: The neonaticidal mothers were mostly troubled by psychosis and social problems while the filicidal women were defined as severely depressed, with a history of self-directed violence and a high rate of suicide attempts following the filicidal offense.     

Psychological assessment of forensic psychiatric outpatients

The 1960s decrease in long-term residential mental health care resulted in former psychiatric patients being admitted to correctional and forensic psychiatric facilities. Although psychologists face challenges in managing and treating this displaced population, assessment data plays a pivotal role in the determination of appropriate aftercare for the mentally ill parolee. This article discusses the assessment protocol utilized by the Forensic Conditional Release Program (CONREP) in California, summarizes data from these patients, and uses case excerpts to illustrate the potential value of assessment with a forensic psychiatric (outpatient) population. Special emphasis is given to the use of the MMPI-2 and Rorschach.     

Fatal falls from heights in and around Diyarbakir, Turkey

Falls from high places, such as from a building, are frequently encountered in suicides, in some accidents, and sometimes in homicides. In this study, we evaluated the demographic data, mortality rates, fall causes, and post-mortem findings of individuals who fell from heights. Our cases were collected retrospectively from the files of the Branch of the Council of Forensic Medicine in Diyarbakir between 1996 and 2001. There were 431 accidental and 53 suicidal deaths due to blunt injury resulting from falls. Of the victims, 188 were female and 296 were male. The average age of the 484 victims was 27.05 years (range: 4 months-100 years). For buildings, the height ranged from 3 to 8 stories for suicides and from 1 to 8 stories for accidents. We proceeded to analyse the characteristics of accidental falls as follows. The majority of falls were from balconies or rooftops due to the tendency of people to sit and sleep on these places during the hotter months of the year. Some 54.5% of all falls occurred in May-August. The 53 suicidal jumps all occurred off buildings. The victims ranged in age from 15 to 70 years, and comprised 29 women and 24 men. One of the deceased jumped from the roof of a school in which he was boarding, and another from the seventh story of a hospital in which he was receiving treatment. The remaining 51 jumped from heights ranging from 3 to 8 stories. Psychiatric illness was reported in 18 (33.9%) of the suicide deaths, while 10 (18.8%) of the 53 suicides were single women. The results of this study were at variance with literature data with respect to the following: falls from heights were most common in the 0-5 year age group, females had a higher suicide rate than males, and the majority of accidental falls occurred at home rather than in the workplace.     

The modification of criminogenic factors on addicted offenders. The effectiveness of the Reasoning and Rehabilitation Program

At the Clinic of Forensic Psychiatry in Rostock, Germany, we treat addicted offenders in a closed psychiatric setting. In 2009 we implemented the "Reasoning and Rehabilitation Program" (R & R, Ross & Fabiano, 1986), a cognitive skills program, in our clinic. There are several international studies confirming the efficacy of this training in diminishing recidivism. We examined a sample of 31 inpatients randomly distributed among the experimental (R & R) and the control group. Most of the study participants had committed homicide or other serious violent offenses. Prisoners with schizophrenia, organic mental disorders and mental retardation were excluded from the study. The target skills were assessed by treating psychotherapists, primary nurses and by the patients themselves. Our findings indicated that problem-solving, awareness of consequences, social perspective-taking, cognitive style, the ability to learn by experience, and persistence in the experimental group were significantly improved. The awareness of consequences has changed significantly in the assessment of the treating psychotherapists, the primary nurses, and the offenders themselves. Our current data are similar to our recent work, where we found significant changes in mental flexibility, planning, and problem-solving and positively assessed tendencies in some skills (Wettermann et al., 2012, 2011). Verification of these findings in a larger sample would strengthen the research foundation for this important training to diminish prisoner recidivism.     

Circumstances and macropathologic findings in 1590 consecutive cases of bodies found in water

The diagnosis of drowning relies primarily on critical examination of the subject's individual characteristics, circumstances, and postmortem macropathologic changes. In this retrospective study, based on 1590 consecutive cases of bodies found in water and undergoing autopsy at the Department of Forensic Medicine, University of Helsinki, from 1976 to 1998, the frequency of circumstantial data and macropathologic changes crucial for the diagnosis of drowning were determined. The fatal events were eyewitnessed in 403 cases (25.3%), and suicide notes were found in 83 cases (5.2%). External foam, frothy fluid in airways, and overlap of the anterior margins of lungs were found in 275 (17.3%), 739 (46.5%), and 669 (42.1%) of the cases, respectively, but no one of these changes, tested against dry-land controls, were specific for drowning. The association of external foam and overlap of the lung margins was exclusive of drowning but was observed in only 176 cases (11.1%). After cross-analysis, 964 (60.6%) of the cases had no circumstantial data or macromorphologic pathologic findings that allowed a definite diagnosis of drowning. The diagnostic problems in putative drowning cases, based on this study sample, have not been overrated. Studies to investigate and improve the reliability of complementary methods for the diagnosis of drowning are warranted.     

Recidivism Rates Among Child Molesters and Rapists: A Methodological Analysis

We address the high variability in sex offender recidivism rates by examining several of the critical methodological differences that underlie this variability. We used a dataset on 251 sex offenders (136 rapists and 115 child molesters) who were discharged over a 25-year period to examine changes in recidivism as a function of changes in dispositional definition of reoffense (e.g., arrest or conviction), changes in the domain of criminal offenses that are considered, and changes in the length of exposure time. The data indicate that: (a) both rapists and child molesters remain at risk to reoffend long after their discharge, in some cases 15–20 years after discharge; (b) there was a marked underestimation of recidivism when calculating a simple proportion (%) consisting of those who were known to have reoffended during the follow-up period, and (c) there was a marked underestimation of recidivism when the criterion was based on conviction or imprisonment. Forensic, clinical and policy implications of this high variability are discussed.     

Homicide‐Suicide in Konya,Turkey Between 2000 and 2007*

Abstract: Homicide followed by the suicide of the murderer is a relatively rare lethal incident in which an individual kills another person and subsequently dies by suicide. Cases involving a homicide and a suicide in which death examinations and autopsies were performed at The Konya Branch of the Forensic Medicine Council between 2000 and 2007 were retrospectively investigated. During the studied time period, there were 10 homicide‐suicide cases identified with 10 perpetrators killing 12 victims. Nine of the perpetrators were men and eight of the victims were women. The precipitating motive was an impending divorce in four of the cases. Two perpetrators were described as severely depressed, one had a diagnosis of antisocial personality disorder, and one was a pedophile who had reactive depression. Firearms were used in eight of the homicide cases and seven of the suicides. Constricting the use of firearms may reduce/prevent future homicide‐suicide cases, as it is the most commonly used method to carry out homicide‐suicides.     

The suicide mortality rates between 1997-1998 and 2000-2001 in Nantou County of Taiwan following the earthquake of September 21 in 1999.

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.     

National study comparing the characteristics of patients diagnosed with schizophrenia who committed homicide vs. those who died by suicide

Associations between serious mental disorder and violence are well-documented, but there is little epidemiological evidence linking these disorders and homicide risk. The reported study compares socio-demographic and clinical characteristics of people diagnosed with schizophrenia who committed homicide vs. those who died by suicide. The study is a national case series of male patients in England & Wales diagnosed with schizophrenia and convicted of homicide during 1997–2012 (n = 168), and a randomly selected comparison group of male patients with schizophrenia who died by suicide and who were matched to the homicide case series by age (n = 777). There are different patterns of behaviour in people with schizophrenia preceding homicide and suicide. Homicide perpetrators have frequently disengaged with services whilst patients who die by suicide are often in recent contact. This is important knowledge for clinical services as it indicates a different preventive emphasis despite the existence of other shared characteristics.     

Observed Characteristics of Suicidal Hangings: An 11-year Retrospective Review

Many studies have been published regarding suicidal hanging deaths, and most forensic pathologists and coroners are very familiar with such causes of death. Forensic pathologists are challenged over their rulings regarding manner of death in part because the general public has a limited scope of knowledge. One such challenge centers on the question of whether a hanging can be a suicide if the individual is not fully suspended. The authors designed a retrospective study to review suspension in hangings and to analyze other criteria used to help in deciding manner of death. We examined 229 suicidal hanging deaths over an 11-year period (1997 through early 2009) using the data from two separate jurisdictions in Ohio. In conclusion, we found that the vast majority (83.4%) of people who hanged themselves were found partially suspended. Among other criteria analyzed, only the presence of petechial hemorrhages and acute neck injury was statistically significant.