Burden of suicide presented as one of the leading causes of death: uncover facts or misrepresent statistics?

BACKGROUND: Suicide is a relatively rare incident. Nevertheless, parts of the literature on intentional self-harm behaviour state that suicide is one of the leading causes of death. We aimed to assess the evidence behind the statement that suicide is a leading cause of death across all ages, with reference to the methods of ranking causes of death. METHODS: Two sets of data were used: For the European Union (EU) we used cause specific mortality statistics from the European Statistical Office (Eurostat) for the data-year 2014, and globally and for the WHO European Region we used data from Global Health Estimates (GHE) 2015. We used different sets of rules to select mutually exclusive leading underlying causes of mortality for Europe (EU28). We also present lists with estimates of leading causes of death globally, and for the WHO European Region based on the GHE 2015. RESULTS: In 2014, 1.2% of all reported deaths in the Europe Union (EU28) were due to suicide, and 1.4% globally (2015) according to the WHO estimates. In Europe, suicide was ranked as number 11 and 15 in the two different ranking lists we used, and according to GHE-2015, suicide was ranked as the 17th leading cause globally, and number 14 in the WHO European Region. Looking at the differences by sex, suicide for males was ranked as the ninth and the tenth leading cause of death in two ranking lists for the European Union. For females, suicide was number 13 in the first and 23 in the second list, respectively. CONCLUSIONS: Different cause lists and rules for ranking produce different leading causes of mortality. The quality of data can also affect the ranking. Our rankings suggested that suicide was not among the ten leading causes of death in Europe or globally. To ensure that ranking causes of death is not driven by political motives and funding considerations, standard methods and official tabulation lists should be used. The rankings do not necessarily present the causes of mortality of greatest public health importance.

Sepsis-associated mortality in England: an analysis of multiple cause of death data from 2001 to 2010.

OBJECTIVES: To quantify mortality associated with sepsis in the whole population of England. DESIGN: Descriptive statistics of multiple cause of death data. SETTING: England between 2001 and 2010. PARTICIPANTS: All people whose death was registered in England between 2001 and 2010 and whose certificate contained a sepsis-associated International Classification of Diseases, 10th Revision (ICD-10) code. DATA SOURCES: Multiple cause of death data extracted from Office for National Statistics mortality database. STATISTICAL METHODS: Age-specific and sex-specific death rates and direct age-standardised death rates. RESULTS: In 2010, 5.1% of deaths in England were definitely associated with sepsis. Adding those that may be associated with sepsis increases this figure to 7.7% of all deaths. Only 8.6% of deaths definitely associated with sepsis in 2010 had a sepsis-related condition as the underlying cause of death. 99% of deaths definitely associated with sepsis have one of the three ICD-10 codes-A40, A41 and P36-in at least one position on the death certificate. 7% of deaths definitely associated with sepsis in 2001-2010 did not occur in hospital. CONCLUSIONS: Sepsis is a major public health problem in England. In attempting to tackle the problem of sepsis, it is not sufficient to rely on hospital-based statistics, or methods of intervention, alone. A robust estimate of the burden of sepsis-associated mortality in England can be made by identifying deaths with one of the three ICD-10 codes in multiple cause of death data. These three codes could be used for future monitoring of the burden of sepsis-associated mortality.

Burden of mortality associated with autoimmune diseases among females in the United Kingdom.

OBJECTIVES: We estimated the collective burden of mortality from autoimmune diseases among females in the United Kingdom and the effects of death certificate coding changes on this estimate. METHODS: We analyzed 1993-2003 England and Wales death certificate data for 3,150,267 females aged 1 year or older. We identified death certificates that listed autoimmune conditions as underlying or contributory causes of death. The percentages of all female deaths attributed to autoimmune disorders and to UK official mortality categories were ranked to determine the leading causes of death. RESULTS: In 2003, autoimmune diseases were the sixth or seventh most frequent underlying cause of death among females in all age groups below 75 years. Results were similar when both underlying and contributory causes of death were considered. The proportion of females dying with an autoimmune disorder remained relatively constant from 1993 to 2003. Analyses indicated that death counts for specific autoimmune diseases had been underestimated. CONCLUSIONS: Autoimmune diseases are a leading cause of death among females in England and Wales, but their collective impact remains hidden in current disease classification systems. Grouping these disorders together may help promote research needed to identify common determinants and future prevention strategies.

Effect of withdrawal of co-proxamol on prescribing and deaths from drug poisoning in England and Wales: time series analysis.

OBJECTIVE: To assess the effect of the UK Committee on Safety of Medicines' announcement in January 2005 of withdrawal of co-proxamol on analgesic prescribing and poisoning mortality. DESIGN: Interrupted time series analysis for 1998-2007. SETTING: England and Wales. DATA SOURCES: Prescribing data from the prescription statistics department of the Information Centre for Health and Social Care (England) and the Prescribing Services Unit, Health Solutions Wales (Wales). Mortality data from the Office for National Statistics. MAIN OUTCOME MEASURES: Prescriptions. Deaths from drug poisoning (suicides, open verdicts, accidental poisonings) involving single analgesics. RESULTS: A steep reduction in prescribing of co-proxamol occurred in the post-intervention period 2005-7, such that number of prescriptions fell by an average of 859 (95% confidence interval 653 to 1065) thousand per quarter, equating to an overall decrease of about 59%. Prescribing of some other analgesics (co-codamol, paracetamol, co-dydramol, and codeine) increased significantly during this time. These changes were associated with a major reduction in deaths involving co-proxamol compared with the expected number of deaths (an estimated 295 fewer suicides and 349 fewer deaths including accidental poisonings), but no statistical evidence for an increase in deaths involving either other analgesics or other drugs. CONCLUSIONS: Major changes in prescribing after the announcement of the withdrawal of co-proxamol have had a marked beneficial effect on poisoning mortality involving this drug, with little evidence of substitution of suicide method related to increased prescribing of other analgesics.

Alcohol-related and hepatocellular cancer deaths by country of birth in England and Wales: analysis of mortality and census data.

BACKGROUND: The incidence of and mortality from alcohol-related conditions, liver disease and hepatocellular cancer (HCC) are increasing in the UK. We compared mortality rates by country of birth to explore potential inequalities and inform clinical and preventive care. DESIGN: Analysis of mortality for people aged 20 years and over using the 2001 Census data and death data from 1999 and 2001-2003. SETTING: England and Wales. MAIN OUTCOME MEASURES: Standardized mortality ratios (SMRs) for alcohol-related deaths and HCC. RESULTS: Mortality from alcohol-related deaths (23 502 deaths) was particularly high for people born in Ireland (SMR for men [M]: 236, 95% confidence interval [CI]: 219-254; SMR for women [F]: 212, 95% CI: 191-235) and Scotland (SMR-M: 187, CI: 173-213; SMR-F 182, CI: 163-205) and men born in India (SMR-M: 161, CI: 144-181). Low alcohol-related mortality was found in women born in other countries and men born in Bangladesh, Middle East, West Africa, Pakistan, China and Hong Kong, and the West Indies. Similar mortality patterns were observed by country of birth for alcoholic liver disease and other liver diseases. Mortality from HCC (8266 deaths) was particularly high for people born in Bangladesh (SMR-M: 523, CI: 380-701; SMR-F: 319, CI: 146-605), China and Hong Kong (SMR-M: 492, CI: 168-667; SMR-F: 323, CI: 184-524), West Africa (SMR-M: 440, CI, 308-609; SMR-F: 319, CI: 165-557) and Pakistan (SMR-M: 216, CI: 113-287; SMR-F: 215, CI: 133-319). CONCLUSIONS: These findings show persistent differences in mortality by country of birth for both alcohol-related and HCC deaths and have important clinical and public health implications. New policy, research and practical action are required to address these differences.

Death certification following MRSA bacteraemia, England, 2004-05.

This study examined factors affecting whether or not meticillin resistant Staphylococcus aureus(MRSA) is recorded on the death certificate of individuals who died following a laboratory confirmed MRSA bacteraemia and compared this with another organism, Streptococcus pneumoniae. The study included all patients with a positive MRSA or S. pneumoniae bacteraemia reported to the Health Protection Agency between 1 January 2004 and 31 December 2005 and linked to a death registered up to 31 March 2006. It was an opportunistic analysis of infection surveillance records and death registrations that had been linked for other purposes Certifiers are most likely to record MRSA on the death certificate if they believe that a large number of conditions contributed to the patient's death, and if the patient dies between 2 and 15 days following a positive blood culture. Certifiers do not appear to be deliberately omitting MRSA from death certificates; rather they report the clinical manifestation of infection or disease the patient died from, not the microbiological diagnosis. Certifiers were significantly less likely to mention S. pneumoniae than MRSA.

Standardised mortality ratios--the effect of smoothing ward-level results.

Geographical indicators of mortality provide one of the most important means of assessing the health of populations and are particularly effective in identifying inequalities in health. Geographical mortality indicators have regularly been produced by the Office for National Statistics, but not normally for areas smaller than local authorities. In order to allow variations in mortality within local authorities to be examined, in 2006 ONS published Standardised Mortality Ratios (SMRs) for wards in England and Wales, based on deaths in 1999-2003. For mortality indicators for small populations, based on small numbers of deaths, there is however a risk that results will be unstable, making geographical patterns hard to interpret. To examine whether this problem could be overcome, methods for smoothing SMRs in time and space were considered, with conclusions published in a methodology report in 2007. This article presents results from that work, illustrating the geographical patterns in mortality that emerge following smoothing of the ward-level SMRs.

Geographical variations in deaths related to drug misuse in England and Wales, 1993-2006.

Drug misuse is a significant public health issue in England and Wales. This article examines geographical variations in drug misuse mortality in England and Wales over the period 1993 t 2006. Geographical variations in deaths related to drug misuse have generally persisted over this period, one of substantial change in these deaths (with a peak in 2001 and numbers in 2006 being almost double those in 1993), although there were some significant changes to the regional level pattern. The regions with the highest mortality rates aggregated over the whole time period were the North West, Yorkshire and The Humber, and London, although by 2004/06 the rate in London was among the lowest and the rate in the North East was higher than the North West. Three Drug Action Teams (DATs), Brighton and Hove, Blackpool, and Camden, consistently had the highest drug misuse mortality rates. Urban areas tended to have the highest rates, but the rate in the most sparsely populated areas was similar to those of towns. The mortality rate in the most deprived parts of England and Wales was five times the rate in the least deprived areas. Areas with low rates were generally large, mostly rural areas, as well as areas in outer London and the south east of England.

Patterns of suicide by occupation in England and Wales: 2001-2005.

BACKGROUND: Suicide rates vary by occupation but this relationship has not been frequently studied. AIMS: To identify the occupations with significantly high suicide rates in England and Wales in 2001-2005 and to compare these with rates from previous decades. METHOD: Mortality data from death registrations in England and Wales over the calendar years 2001-2005 were used to calculate proportional mortality ratios (PMRs) and standardised mortality ratios (SMRs) for both men and women aged 20-64 years by their occupation. RESULTS: Among men, in 2001-2005, construction workers, and plant and machine operatives had the greatest number of suicides. The highest PMRs were for health professionals (PMR=164) and agricultural workers (PMR=133). Among women, administrative and secretarial workers had the greatest number of suicides yet the highest PMRs were found for health (PMR=232), and sport and fitness (PMR=244) occupations. CONCLUSIONS: Excess mortality from suicide remains in some occupational groups. The apparent changes in suicide patterns merits further exploration, for example examining the prevalence of depression and suicidal ideation in medical practitioners, dentists, veterinarians, agricultural workers, librarians and construction workers.

Trends in suicide by marital status in England and Wales, 1982-2005.

This article examines trends in suicide by marital status in England and Wales over the period 1982 to 2005. A protective effect of marriage has been observed in a number of previous studies and this article updates figures up to 2005. The article shows that despite changes in marriage patterns over the last 25 years, those who are married still have the lowest risk of suicide, and there has generally been no obvious decline in the difference in suicide rates between those who are married and those who are not.

Antidepressant prescribing and changes in antidepressant poisoning mortality and suicide in England, 1993-2004.

BACKGROUND: In England, the impact of increased use of antidepressant medications is unclear. We examine associations between antidepressant use, suicide and antidepressant poisoning mortality, adjusted for important covariates. METHODS: Data on suicide and antidepressant poisoning mortality were provided by the Office for National Statistics. Prescription data were provided by the Department of Health. Age- and sex-specific prescribing rates were estimated from The Health Improvement Network primary care data. We measured the association between prescribing, suicide and poisoning mortality after adjusting for age, sex, calendar year, prescribing rates and use of newer antidepressants drugs. RESULTS: The prevalence of antidepressant treatment increased during the 1990s for all age and sex groups. Treatment prevalence remained constant from 2002 but declined among children and adolescents. Between 1993 and 2004, age-standardized rates for suicide decreased from 98.2 to 81.3 per million populations and for antidepressants from 9.2 to 7.4 per million populations. Before adjustment, increased antidepressant prescribing was associated with a decrease in suicide (r(s) = -0.90, P < 0.001) and antidepressant poisoning mortality rates (r(s) = -0.65, P = 0.023). This association disappeared after adjustment. CONCLUSION: In England, at a population level, there does not appear to be an association between antidepressant prescribing and antidepressant poisoning mortality or suicide.

Death toll exceeded 70,000 in Europe during the summer of 2003.

Daily numbers of deaths at a regional level were collected in 16 European countries. Summer mortality was analyzed for the reference period 1998-2002 and for 2003. More than 70,000 additional deaths occurred in Europe during the summer 2003. Major distortions occurred in the age distribution of the deaths, but no harvesting effect was observed in the months following August 2003. Global warming constitutes a new health threat in an aged Europe that may be difficult to detect at the country level, depending on its size. Centralizing the count of daily deaths on an operational geographical scale constitutes a priority for Public Health in Europe.

Alcohol-related deaths by occupation, England and Wales, 2001-05.

This article continues a long tradition of examining alcohol-related deaths by occupation in England and Wales. Results are presented for men and women which show those occupations with the highest and lowest indicators of alcohol-related mortality in 2001-05. For both sexes, many of the occupations with the highest alcohol-related mortality were found among those working in the drinks industry, including publicans and bar staff. Low indicators of alcohol-related deaths were found for men who worked as farmers and drivers, and women who worked with children.

Tends in avoidable mortality in England and Wales, 1993-2005.

Avoidable mortality is a major public health concern but there has been little consensus among researchers on how it should be defined and reported. In this article two definitions of avoidable mortality are considered. These are used to present trends in avoidable deaths in England and Wales from 1993 to 2005, using two statistical indicators of mortality. Analysis of both definitions shows a substantial decline in causes of mortality that are considered amenable to medical intervention over this period. This article discusses which mortality indicator is most appropriate for measuring avoidable deaths, and highlights key issues in developing a National Statistics definition of avoidable mortality.

Interrupted time-series analysis of regulations to reduce paracetamol (acetaminophen) poisoning.

BACKGROUND: Paracetamol (acetaminophen) poisoning is the leading cause of acute liver failure in Great Britain and the United States. Successful interventions to reduced harm from paracetamol poisoning are needed. To achieve this, the government of the United Kingdom introduced legislation in 1998 limiting the pack size of paracetamol sold in shops. Several studies have reported recent decreases in fatal poisonings involving paracetamol. We use interrupted time-series analysis to evaluate whether the recent fall in the number of paracetamol deaths is different to trends in fatal poisoning involving aspirin, paracetamol compounds, antidepressants, or nondrug poisoning suicide. METHODS AND FINDINGS: We calculated directly age-standardised mortality rates for paracetamol poisoning in England and Wales from 1993 to 2004. We used an ordinary least-squares regression model divided into pre- and postintervention segments at 1999. The model included a term for autocorrelation within the time series. We tested for changes in the level and slope between the pre- and postintervention segments. To assess whether observed changes in the time series were unique to paracetamol, we compared against poisoning deaths involving compound paracetamol (not covered by the regulations), aspirin, antidepressants, and nonpoisoning suicide deaths. We did this comparison by calculating a ratio of each comparison series with paracetamol and applying a segmented regression model to the ratios. No change in the ratio level or slope indicated no difference compared to the control series. There were about 2,200 deaths involving paracetamol. The age-standardised mortality rate rose from 8.1 per million in 1993 to 8.8 per million in 1997, subsequently falling to about 5.3 per million in 2004. After the regulations were introduced, deaths dropped by 2.69 per million (p = 0.003). Trends in the age-standardised mortality rate for paracetamol compounds, aspirin, and antidepressants were broadly similar to paracetamol, increasing until 1997 and then declining. Nondrug poisoning suicide also declined during the study period, but was highest in 1993. The segmented regression models showed that the age-standardised mortality rate for compound paracetamol dropped less after the regulations (p = 0.012) but declined more rapidly afterward (p = 0.031). However, age-standardised rates for aspirin and antidepressants fell in a similar way to paracetamol after the regulations. Nondrug poisoning suicide declined at a similar rate to paracetamol after the regulations were introduced. CONCLUSIONS: Introduction of regulations to limit availability of paracetamol coincided with a decrease in paracetamol-poisoning mortality. However, fatal poisoning involving aspirin, antidepressants, and to a lesser degree, paracetamol compounds, also showed similar trends. This raises the question whether the decline in paracetamol deaths was due to the regulations or was part of a wider trend in decreasing drug-poisoning mortality. We found little evidence to support the hypothesis that the 1998 regulations limiting pack size resulted in a greater reduction in poisoning deaths involving paracetamol than occurred for other drugs or nondrug poisoning suicide.

Trends and geographical variations in alcohol-related deaths in the United Kingdom, 1991-2004.

Alcohol-related deaths in the UK increased substantially between 1991 and 2004, from 4144 to 8221. Overall rates increased in all parts of the UK. There were, however, large differences in rates between countries and regions. This article presents these differences and also looks at patterns of alcohol-related mortality by deprivation within England and Wales. The article considers changes over time for males and females and for different age groups.

Trends in injury and poisoning mortality using the ICE on injury statistics matrix, England and Wales, 1979-2004.

This article shows trends in injury and poisoning mortality in England and Wales using a matrix of mechanism (e.g. fall, fire) by intent (e.g. accident, suicide) developed by the International Collaborative Effort (ICE) on injury statistics. Overall injury and poisoning mortality rates have declined for both males and females. Declines were greatest during the 1980s and early 1990s, with rates falling only slightly since. Rates were generally higher for males and were highest in the elderly. Transport death rates declined substantially. Death rates from falls declined to the mid 1990s but then increased. There were increases in death rates from drug abuse/dependence in both sexes and in homicide rates among males.

Mortality by deprivation and cause of death in England and Wales, 1999-2003.

The relationship between deprivation and mortality is long established and many studies report higher death rates in more deprived areas. This article examines recent patterns of mortality and deprivation and illustrates these for leading causes of death. Results are considered by age group, sex and region. Mortality rates increased with deprivation for both sexes but the relationship was generally stronger for males. The strongest positive relationships with deprivation were mostly found for smoking-related causes. Those living in the least deprived areas had similar mortality rates, independent of region. There was more geographical variation in mortality for those in the most deprived areas with highest rates generally in the north.