Fatal self-injury in the United States, 1999–2018: Unmasking a national mental health crisis

Background Suicides by any method, plus ‘nonsuicide’ fatalities from drug self-intoxication (estimated from selected forensically undetermined and ‘accidental’ deaths), together represent self-injury mortality (SIM)—fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999–2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification. Methods For this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the ‘nonsuicide’ SIM component. Findings The national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p6.0% increase (p<0.05). Interpretation Depiction of rising SIM trends across states and major regions unmasks a burgeoning national mental health crisis. Geographic variation is plausibly a partial product of local heterogeneity in toxic drug availability and the quality of medicolegal death investigations. Like COVID-19, the nation will only be able to prevent SIM by responding with collective, comprehensive, systemic approaches. Injury surveillance and prevention, mental health, and societal well-being are poorly served by the continuing segregation of substance use disorders from other mental disorders in clinical medicine and public health practice

Covert suicide among elderly Japanese females: Questioning unintensional drownings

A hypothesis is generated that despite high reported rates, suicide among elderly Japanese females is substantially underestimated due to misclassification of drowning suicides (ICD-9 E954) as unintensional drownings (ICD-9 E910). Data are adapted from 1979-1981 age-, sex- and cause-specific mortality tabulations for Japan, the United States, Australia, France, New Zealand, Norway, Sweden and the United Kingdom. Between ages 55 and 74 years, unintensional drowning rates for males and females in Japan begin to diverge sharply from those of comparison countries. By ages 75 and older, the rate for Japanese females is 13.5 per 100,000, which exceeds comparison rates by 7- to 15-fold. Although drowning suicide rates in this population are also high, its ratio of drowning suicides to unintensional drownings declines precipitously beyond ages 35-44. Excess drowning suicide underestimation among Japanese females is suggested by the absence of a similar change among the males and evidence of both a lack of drowning witnesses and sex differentials in life expectancy, living arrangements and suicide methods. A preliminary test of the drowning suicide hypothesis is proposed which incorporates psychological autopsies.suicide drowning injury elderly

The black-white suicide paradox: Possible effects of misclassification

This research addresses the paradox that the crude and age-adjusted suicide rates of United States blacks are less than half those of whites despite similar risks. Upper and lower limits for true suicide rates are estimated to assess the potential for differential suicide misclassification by race. Construction of these two rate scenarios respectively incorporate one or all of the three cause-of-death categories identified in the literature as most prone to obscure suicides: injury of undetermined intent and unintentional poisonings and drownings. The data source is the US Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, and the observation period is 1999-2002. We found that as in the official rates, the racial suicide gap persists within the lower and upper limit scenarios. However, there is marked shrinkage under the upper limit scenario. That scenario even generates rate crossovers for males ages 45-54 years and females ages 85 years and older. Suicide data appear relatively more deficient for black females than for black males. Racial data disparities are minimal for youth and young adults, and maximal for middle-aged males and the oldest and younger middle-aged females. Results strongly indicate greater susceptibility of medico-legal authorities to misclassify black suicides than white suicides. To demystify the racial suicide paradox, research is needed on medical histories and other biographical information that are accessible by the authorities in equivocal cases. To meet the standards of evidence-based medicine and public health, high-quality suicide data are an imperative for risk group delineation; risk factor identification; policy formulation; program planning, implementation, and evaluation; and ultimately, effective prevention.United States Suicide Race Gender Health inequalities Validity