Suicide Among Roofers: Injury, Pain & Substance Misuse.

OBJECTIVE: CDC has called for suicide research on the construction industry, an industry with a high suicide rate. The present study addresses this gap and focuses on roofers. It assesses which risk factors distinguish suicides by roofers from those of the general population. Alcohol and drug misuse, related to their high incidence of injury and pain, are seen as key potential drivers of roofer suicide. METHODOLOGY: Data refer to 30,570 suicides and are taken from the National Violent Death Reporting System (NVDRS). Drawing from previous work on the health professions, 15 core predictors are selected, representing psychiatric morbidity, social strains, and demographics. Since the analysis seeks to differentiate roofers' suicides from others, the dependent variable is a dichotomy where roofers' suicides (=1) and other suicides (=0). RESULTS: After adjusting for the other 14 risk factors, a multivariate logistic regression analysis found that roofers' suicides were 76% more apt (Odds ratio = 1.76, CI: 1.18, 2.63) than other suicides to have a known substance or alcohol problem that contributed to their suicide. Other constructs differentiating roofers' suicides from other suicides included marital status, gender, and race. Roofers were less protected by marriage. CONCLUSION: The results inform prevention efforts and substance misuse can serve as a key warning sign for roofers' suicide. This is the first investigation of the drivers of suicide among roofers, and one of a few drawing links between occupational injury and suicide.

Roofers' suicides are linked to a high occupational injury rate.A high injury rate is associated with a high incidence of pain.Substance abuse is a way of coping with pain and increases suicide risk.Roofers' suicides were 76% more likely than other suicides to involve substance misuse.Substance misuse is a key warning sign for suicide prevention among roofers.Roofers' suicides are marked by relatively weak ties to marital integration.

Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study.

BACKGROUND: Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as 'accidents,' and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. METHODS: Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention's (CDC's) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC's Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. RESULTS: 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%-from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and - 1%, respectively. CONCLUSION: The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs-fiscal, social, and personal-incurred by deaths due to self-injurious behaviors.

Suicide among lawyers: Role of job problems.

INTRODUCTION: Suicide research has neglected the legal profession. The present investigation determines what risk factors distinguish lawyers' suicides from those of the general population. Given the substantial investment in their careers, client dependency, and ongoing stress of work, job problems are seen as key potential drivers of lawyers' suicides. METHODOLOGY: Data are from the National Violent Death Reporting System (NVDRS). They refer to 30,570 suicides. Fifteen predictors, including social strains, psychiatric morbidity, and demographics, are assessed as possible drivers of lawyers' suicides. The dependent variable is a dichotomy where lawyers' suicides = 1 and other suicides = 0. RESULTS: The results of a multivariate logistic regression analysis showed that after adjusting for the other 14 risk factors, lawyers' suicides were 91% more apt (Odds ratio = 1.91, CI: 1.17, 3.14) than other suicides to have job problems that contributed to their suicide. Other constructs differentiating lawyers' suicides from other suicides included presence of a known mental health problem, age, presence of a known substance abuse problem, and marital status. The full model correctly classified 99.57% of the suicides. CONCLUSION: Job problems can serve as a key warning sign for lawyers' suicides. This is the first investigation of the drivers of lawyers' suicides.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States.

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design. Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification. Design, Setting, and Participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021. Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type. Main Outcomes and Measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification. Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (ß = 4.362), labor underutilization rate (ß = 0.728), manufacturing employment (ß = -0.056), homelessness rate (ß = -0.125), percentage nonreligious (ß = 0.041), non-Hispanic White race and ethnicity (ß = 0.087), prescribed opioids for 30 days or more (ß = 0.117), and percentage without health insurance (ß = -0.013) and 5 factors associated with the suicide rate: percentage male (ß = 1.046), military veteran (ß = 0.747), rural (ß = 0.031), firearm ownership (ß = 0.030), and pain reliever misuse (ß = 1.131). Conclusions and Relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Effects of media stories of hope and recovery on suicidal ideation and help-seeking attitudes and intentions: systematic review and meta-analysis.

BACKGROUND: There is strong evidence that suicides increase after media stories about suicides by celebrities, particularly those that highlight the suicide method (the Werther effect). Much less is known about the Papageno effect-the protective effects of media stories of hope and recovery from suicidal crises. A synthesis of the retrievable evidence is lacking. We aim to summarise findings from randomised controlled trials about the effects of stories of hope and recovery on individuals with some degree of vulnerability to suicide. METHODS: For this systematic review and individual participant data meta-analysis, we searched PubMed (including MEDLINE), Scopus, Embase, PsycInfo, Web of Science, and Google Scholar published from inception to Sept 6, 2021, without language restrictions. We included trials that reported suicidal ideation (the primary outcome) or help-seeking attitudes or intentions (the secondary outcome) and tested a media narrative of hope and recovery. Studies were excluded if they did not feature a clearly positive story of hope and recovery, or had a control group exposed to suicide-related stimulus material. We contacted the lead or senior authors of all original studies to obtain participant-level data for this study. The primary analysis was restricted to individuals with some vulnerability to suicide. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomised trials. The study is registered with PROSPERO, number CRD42020221341. FINDINGS: Our search yielded 7347 records. 3920 records were screened by title and abstract, and 25 full-text records assessed for eligibility. There were eight eligible studies with 2350 participants for which individual participant data were sought. For suicidal ideation, six studies met the inclusion criteria for the primary analysis. Follow-up responses were available for 569 (90%) of 633 participants who were randomised with high vulnerability (345 [55%] allocated to the intervention group and 288 [45%] to the control group). The pooled standardised mean difference (SMD) indicated a small reduction in suicidal ideation of -0·22 (95% CI -0·39 to -0·04, p=0·017; six studies) in the intervention group. For help-seeking attitudes and intentions, four studies met the inclusion criteria and follow-up data were available for 362 (86%) of 420 participants (247 [59%] allocated to the intervention group and 173 [41%] to the control group). The pooled SMD showed no evidence of a difference between the groups (SMD=0·14, 95% CI -0·15 to 0·43, p=0·35; four studies). Low levels of cross-study heterogeneity effects were observed for both analyses (I2=5% [suicidal ideation] and I2=36% [help-seeking attitudes and intentions]). We found no evidence of publication bias. INTERPRETATION: Media narratives of hope and recovery from suicidal crises appear to have a beneficial effect on suicidal ideation in individuals with some vulnerability, but there is insufficient evidence regarding help-seeking attitudes and intentions. These findings provide new evidence about narratives for suicide prevention. FUNDING: None.

Contributing factors to suicide: Political, social, cultural and economic.

This review summarizes recent research in four environmental areas affecting risk of deaths by suicide. Politically, the weight of the evidence suggests that laws increasing social welfare expenditures and other policies assisting persons with low incomes (e.g., minimum wage) tend to lower suicide rates. Other legal changes such as those restricting firearms and alcohol availability can also prevent suicides. The social institutions of marriage, as well as parenting, continue to serve as protective factors against suicide, although the degree of protection is often gendered. Religiousness tends to be inversely associated with suicide deaths at the individual level of analysis, but the mediators need exploration to determine what accounts for the association: social support, better mental health, better physical health, less divorce, or other covariates. Cultural definitions of the traditional male role (e.g., breadwinner culture) continue to help explain the high male to female suicide ratio. New work on the "culture of suicide" shows promise. The degree of approval of suicide is sometimes the single most important factor in predicting suicide. At the individual level of analysis, two of the strongest predictors of suicide are economic ones: unemployment and low socio-economic status. Attention is drawn to enhancing the minimum wage as a policy known to lower state suicide rates. Limitations of research include model mis-specification, conflicting results especially when ecological data are employed, and a need for more research exploring moderators of established patterns such as that between religiousness and suicide.

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%; p<0.001) versus 1.8% (95% CI: 1.6%, 2.0%; p<0.001) for the suicide rate. By 2017/2018, all states except Nebraska (19.9) posted a SIM rate of at least 21.0 deaths per 100,000 population-the floor of the rate range for the top 5 ranking states in 1999/2000. The rank-order correlation coefficient for SIM and suicide rates was 0.82 (p<0.001) in 1999/2000 versus 0.34 (p = 0.02) by 2017/2018. Seven states in the West posted a ≥ 5.0% reduction in their standardised mortality ratios of 'nonsuicide' drug fatalities, relative to the national ratio, and 6 states from the other 3 major regions a >6.0% 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. FUNDING: This study was partially funded by the National Centre for Injury Prevention and Control, US Centers for Disease Control and Prevention (R49CE002093) and the US National Institute on Drug Abuse (1UM1DA049412-01; 1R21DA046521-01A1).

Social distancing predicts suicide rates: Analysis of the 1918 flu pandemic in 43 large cities, research note.

Social distancing (e.g., school and business closings) has been emphasized in current sociopolitical efforts in controlling COVID-19. Such policies are assumed to increase suicide risk through lowering social integration. While two studies have linked the presence of a pandemic to suicide rates, no study has assessed the degree of social distancing on suicide rates during a pandemic. The present study fills this gap with data on the extent of social distancing during the Spanish flu epidemic in 43 large cities. The results find that increasing social distancing increases suicide rates independent of the influenza mortality rate.

Association between suicide reporting in the media and suicide: systematic review and meta-analysis.

OBJECTIVE: To examine the association between reporting on suicides, especially deaths of celebrities by suicide, and subsequent suicides in the general population. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed/Medline, PsychInfo, Scopus, Web of Science, Embase, and Google Scholar, searched up to September 2019. REVIEW METHODS: Studies were included if they compared at least one time point before and one time point after media reports on suicide; follow-up was two months or less; the outcome was death by suicide; and the media reports were about non-fictional suicides. Data from studies adopting an interrupted time series design, or single or multiple arm before and after comparisons, were reviewed. RESULTS: 31 studies were identified and analysed, and 20 studies at moderate risk of bias were included in the main analyses. The risk of suicide increased by 13% in the period after the media reported a death of a celebrity by suicide (rate ratio 1.13, 95% confidence interval 1.08 to 1.18; 14 studies; median follow-up 28 days, range 7-60 days). When the suicide method used by the celebrity was reported, there was an associated 30% increase in deaths by the same method (rate ratio 1.30, 95% confidence interval 1.18 to 1.44; 11 studies; median follow-up 28 days, range 14-60 days). For general reporting of suicide, the rate ratio was 1.002 (0.997 to 1.008; five studies; median follow-up 1 day, range 1-8 days) for a one article increase in the number of reports on suicide. Heterogeneity was large and partially explained by celebrity and methodological factors. Enhanced funnel plots suggested some publication bias in the literature. CONCLUSIONS: Reporting of deaths of celebrities by suicide appears to have made a meaningful impact on total suicides in the general population. The effect was larger for increases by the same method as used by the celebrity. General reporting of suicide did not appear to be associated with suicide although associations for certain types of reporting cannot be excluded. The best available intervention at the population level to deal with the harmful effects of media reports is guidelines for responsible reporting. These guidelines should be more widely implemented and promoted, especially when reporting on deaths of celebrities by suicide. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019086559.

Media guidelines and suicide: A critical review.

By providing information on help-seeking resources (HSR), Google's Suicide Prevention Results (SPR) fill a void, because less than 30% of news reports provide such information. This article addresses larger issues on media guidelines and suicide prevention. First, studies on the effects of providing HSR provide little support for a reduction in suicide. Second, research on the effects of other media guidelines often does not report the anticipated reductions in suicide. Third, although research does tend to support an increase in suicide after publicized suicides of celebrities, it does not necessarily happen for all categories of celebrity suicides. Fourth, there has been a lack of integration of (a) research on imitative effects of publicized suicides and (b) content analysis of stories' adherence to guidelines. Fifth, an associated puzzle is that (a) most research findings (64.2%) show no increase in suicide rates after suicide stories, while (b) most content analyses document widespread violations of media guidelines. Apparently, stories often violate media guidelines, but there is often no anticipated increase in suicide deaths. Rigorous research is needed to fully evaluate which media guidelines matter, and to determine the efficacy of Google's SPR program.

Social Integration and Indigenous Suicidality.

Aspects of social integration including religion and residential stability have often been found to serve as protective factors against suicide in sociological analyses. However, empirical research on Canadian indigenous suicidality has neglected these dimensions of integration. The present study fills this gap, while controlling for other major predictors of suicide ideation (SI). Methods: Data are from a national representative sample (N = 15,294) from the 2012 Aboriginal Peoples Survey. The dependent variable is a dichotomy: lifetime prevalence of SI. Measures of social integration include religious affiliation, marital status, family ties, and residential stability. Controls are incorporated for alternative predictors of SI including psychiatric symptoms (e.g., mood disorder), economic strain, ethnicity, and demographics. Results: Findings from a multivariate logistic regression analysis confirmed an association between SI and most measures of social integration (e.g., married persons were 14% less apt to report SI than non married persons), but not with religious affiliation. Further, each unit increase in income reduced the risk of SI by 3.8%. Psychiatric symptoms increased risk of SI (e.g., mood disorder, OR = 3.16, substance abuse, OR = 2.38), and Inuit ethnicity increased SI risk by 57% (OR = 1.57). The model explained 26.1% of the variance in SI. Conclusions: Generally, measures of social integration, psychiatric symptoms, and economic strain predicted SI. However, there was no evidence that religion acted as a protective factor against SI. Future research is needed on other dimensions of religion such as self-reported religiousness, which may protect against suicidality.

Association of Increased Youth Suicides in the United States With the Release of 13 Reasons Why.

Importance: On March 31, 2017, Netflix released the show 13 Reasons Why, sparking immediate criticism from suicide prevention organizations for not following media recommendations for responsible suicide portrayal and for possible suicide contagion by media. To date, little research has been conducted into the associations between the show and suicide counts among its young target audience. Objective: To analyze the changes in suicide counts after the release of 13 Reasons Why. Design, Setting, and Participants: For this time series analysis, monthly suicide data for the age groups 10 to 19 years, 20 to 29 years, and 30 years or older for both US males and females from January 1, 1999, to December 31, 2017, were extracted from the Centers for Disease Control and Prevention's WONDER (Wide-ranging Online Data for Epidemiologic Research) database. Twitter and Instagram posts were used as a proxy to estimate the amount of attention the show received through social media from April 1, 2017, to June 30, 2017. Autoregressive integrated moving average time series models were fitted to the pre-April 2017 period to estimate suicides among the age groups and to identify changes in specific suicide methods used. The models were fitted to the full time series with dummy variables for (1) April 2017 and (2) April 1, 2017, to June 30, 2017. Data were analyzed in December 2018 and January 2019. Main Outcomes and Measures: Suicide data before and after the release of the show in 2017. Results: Based on social media data, public interest in the show was highest in April 2017 and was negligible after June 2017. For 10- to 19-year-old males and females, increases in the observed values from April to June 2017 were outside the 95% confidence bands of forecasts. Models testing 3-month associated suicide mortality indicated 66 (95% CI, 16.3-115.7) excess suicides among males (12.4% increase; 95% CI, 3.1%-21.8%) and 37 (95% CI, 12.4-61.5) among females (21.7% increase; 95% CI, 7.3%-36.2%). No excess suicide mortality was seen in other age groups. The increase in the hanging suicide method was particularly high (26.9% increase; 95% CI, 15.3%-38.4%). Conclusions and Relevance: Caution must be taken in interpreting these findings; however, the suicide increase in youth only and the signal of a potentially larger increase in young females all appear to be consistent with a contagion by media and seem to reinforce the need for collaboration toward improving fictional portrayals of suicide.

Religiousness as a Predictor of Suicide: An Analysis of 162 European Regions.

Research on religion as a protective factor has been marked by four recurrent limitations: (1) an overemphasis on the United States, a nation where religiosity is relatively high; (2) a neglect of highly secularized zones of the world, where religiousness may be too weak to affect suicide; (3) restriction of religiousness to religious affiliation, a construct which may miss capturing other dimensions of religiousness such as the importance of religion in one's life; and (4) an overwhelming use of the nation as a unit of analysis, which masks variation in religiousness within nations. The present article addresses these limitations by performing a cross-national test of the following hypothesis: The greater the strength of subjective religiousness, the lower the suicide rate, using small units of analysis for a secularized area of the world. All data refer to 162 regions within 22 European nations. Data were extracted from two large databases, EUROSTAT and the European Social Surveys (ESS Round 4), and merged using NUTS-2 (Nomenclature of Statistical Territorial Units) regions as the unit of analysis. Controls are incorporated for level of economic development, education, and measures of economic strain. The results of a multiple regression analysis demonstrated that controlling for the other constructs in the model, religiousness is associated with lower suicide rates, confirming the hypothesis. Even in secularized European nations, where there is a relatively weak moral community to reinforce religion, religiousness acts as a protective factor against suicide. Future work is needed to explore the relationship in other culture zones of the world.

Method overtness, forensic autopsy, and the evidentiary suicide note: A multilevel National Violent Death Reporting System analysis.

OBJECTIVE: Higher prevalence of suicide notes could signify more conservatism in accounting and greater proneness to undercounting of suicide by method. We tested two hypotheses: (1) an evidentiary suicide note is more likely to accompany suicides by drug-intoxication and by other poisoning, as less violent and less forensically overt methods, than suicides by firearm and hanging/suffocation; and (2) performance of a forensic autopsy attenuates any observed association between overtness of method and the reported presence of a note. METHODS: This multilevel (individual/county), multivariable analysis employed a generalized linear mixed model (GLMM). Representing the 17 states participating in the United States National Violent Death Reporting System throughout 2011-2013, the study population comprised registered suicides, aged 15 years and older. Decedents totaled 32,151. The outcome measure was relative odds of an authenticated suicide note. RESULTS: An authenticated suicide note was documented in 31% of the suicide cases. Inspection of the full multivariable model showed a suicide note was more likely to manifest among drug intoxication (adjusted odds ratio [OR], 1.70; 95% CI, 1.56, 1.85) and other poisoning suicides (OR, 2.12; 1.85, 2.42) than firearm suicides, the referent. Respective excesses were larger when there was no autopsy or autopsy status was unknown (OR, 1.86; 95% CI, 1.61, 2.14) and (OR, 2.25; 95% CI, 1.86, 2.72) relative to the comparisons with a forensic autopsy (OR, 1.62, 95% CI, 1.45, 1.82 and OR, 2.01; 95% CI, 1.66, 2.43). Hanging/suffocation suicides did not differ from the firearm referent given an autopsy. CONCLUSIONS: Suicide requires substantial affirmative evidence to establish manner of death, and affirmation of drug intoxication suicides appears to demand an especially high burden of proof. Findings and their implications argue for more stringent investigative standards, better training, and more resources to support comprehensive and accurate case ascertainment, as the foundation for developing evidence-based suicide prevention initiatives.

Discerning suicide in drug intoxication deaths: Paucity and primacy of suicide notes and psychiatric history.

OBJECTIVE: A paucity of corroborative psychological and psychiatric evidence may be inhibiting detection of drug intoxication suicides in the United States. We evaluated the relative importance of suicide notes and psychiatric history in the classification of suicide by drug intoxication versus firearm (gunshot wound) plus hanging/suffocation-the other two major, but overtly violent methods. METHODS: This observational multilevel (individual/county), multivariable study employed a generalized linear mixed model (GLMM) to analyze pooled suicides and undetermined intent deaths, as possible suicides, among the population aged 15 years and older in the 17 states participating in the National Violent Death Reporting System throughout 2011-2013. The outcome measure was relative odds of suicide versus undetermined classification, adjusted for demographics, precipitating circumstances, and investigation characteristics. RESULTS: A suicide note, prior suicide attempt, or affective disorder was documented in less than one-third of suicides and one-quarter of undetermined deaths. The prevalence gaps were larger among drug intoxication cases than gunshot/hanging cases. The latter were more likely than intoxication cases to be classified as suicide versus undetermined manner of death (adjusted odds ratio [OR], 41.14; 95% CI, 34.43-49.15), as were cases documenting a suicide note (OR, 33.90; 95% CI, 26.11-44.05), prior suicide attempt (OR, 2.42; 95% CI, 2.11-2.77), or depression (OR, 1.61; 95% CI, 1.38 to 1.88), or bipolar disorder (OR, 1.41; 95% CI, 1.10-1.81). Stratification by mechanism/cause intensified the association between a note and suicide classification for intoxication cases (OR, 45.43; 95% CI, 31.06-66.58). Prior suicide attempt (OR, 2.64; 95% CI, 2.19-3.18) and depression (OR, 1.48; 95% CI, 1.17-1.87) were associated with suicide classification in intoxication but not gunshot/hanging cases. CONCLUSIONS: Without psychological/psychiatric evidence contributing to manner of death classification, suicide by drug intoxication in the US is likely profoundly under-reported. Findings harbor adverse implications for surveillance, etiologic understanding, and prevention of suicides and drug deaths.

Are Suicide Note Writers Representative of All Suicides? Analysis of the National Violent Death Reporting System.

While suicide notes can offer insights into the causes of suicide and clues for prevention, there is disagreement regarding the degree to which note leavers are representative of the general population of suicides. Previous relevant research on the United States is marked by a series of limitations: small local samples, an over focus on demographic constructs, and lack of multivariable analysis. This study uses a large national sample, a wide range of predictor variables, and multivariable statistical techniques to estimate more reliable similarities and differences between note leavers and other suicides. All data are taken from the National Violent Death Reporting System, which covers 17 states. A total of 9,048 note writers were compared to 21,522 other suicides in terms of 39 variables. In both bivariable (32/39 variables) and multivariable analyses (30/39 variables), note leavers differed from other suicides in most demographic variables, stressful life events, psychiatric issues, and methods of suicide. The national evidence suggests that caution be exercised in generalizing patterns found among writers of suicide notes to suicides in general. This is the first analysis of suicide notes using US data on the issue.

Creating the Medical Schools of the Future.

Despite wide consensus on needed changes in medical education, experts agree that the gap continues to widen between how physicians are trained and the future needs of our health care system. A new model for medical education is needed to create the medical school of the future. The American Medical Association (AMA) is working to support innovative models through partnerships with medical schools, educators, professional organizations, and accreditors. In 2013, the AMA designed an initiative to support rapid innovation among medical schools and disseminate the ideas being tested to additional medical schools. Awards of $1 million were made to 11 medical schools to redesign curricula for flexible, individualized learning pathways, measure achievement of competencies, develop new assessment tools to test readiness for residency, and implement new models for clinical experiences within health care systems. The medical schools have partnered with the AMA to create the AMA Accelerating Change in Medical Education Consortium, working together to share prototypes and participate in a national evaluation plan. Most of the schools have embarked on major curriculum revisions, replacing as much as 25% of the curriculum with new content in health care delivery and health system science in all four years of training. Schools are developing new certification in quality and patient safety and population management. In 2015, the AMA invited 21 additional schools to join the 11 founding schools in testing and disseminating innovation through the consortium and beyond.