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.

Self-injury Mortality in the United States in the Early 21st Century: A Comparison With Proximally Ranked Diseases.

Importance: Fatal self-injury in the United States associated with deliberate behaviors is seriously underestimated owing to misclassification of poisoning suicides and mischaracterization of most drug poisoning deaths as "accidents" on death certificates. Objective: To compare national trends and patterns of self-injury mortality (SIM) with mortality from 3 proximally ranked top 10 causes of death: diabetes, influenza and pneumonia, and kidney disease. Data, Setting, and Participants: Underlying cause-of-death data from 1999 to 2014 were extracted for this observational study from death certificate data in the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research online databases. Linear time trends were compared by negative binomial regression with a log link function. Self-injury mortality was defined as a composite of suicides by any method and estimated deaths from drug self-intoxication whose manner was an "accident" or was undetermined. Main Outcomes and Measures: Mortality rates and ratios, cumulative mortality in individuals younger than 55 years, and years of life lost in 2014. Results: There were an estimated 40 289 self-injury deaths in 1999 and 76 227 in 2014. Females comprised 8923 (22.1%) of the deaths in 1999 and 21 950 (28.8%) of the 76 227 deaths in 2014. The estimated crude rate for SIM increased 65% between 1999 and 2014, from 14.4 to 23.9 deaths per 100 000 persons (rate ratio, 1.03; 95% CI, 1.03-1.04; P < .001). The SIM rate continuously exceeded the kidney disease mortality rate and surpassed the influenza and pneumonia mortality rate by 2006. By 2014, the SIM rate converged with the diabetes mortality rate. Additionally, the SIM rate was 1.8-fold higher than the suicide rate in 2014 vs 1.4-fold higher in 1999. The male-to-female ratio for SIM decreased from 3.7 in 1999 to 2.6 in 2014 (male by year: rate ratio, 0.98; 95% CI, 0.97-0.98; P < .001). By 2014, SIM accounted for 32.2 and 36.6 years of life lost for male and female decedents, respectively, compared with 15.8 and 17.3 years from diabetes, 15.0 and 16.6 years from influenza and pneumonia, and 14.5 and 16.2 years from kidney disease. Conclusions and Relevance: The burgeoning SIM [self-injury mortality] rate has converged with the mortality rate for diabetes, but there is a 6-fold differential in the proportion of SIM vs diabetes deaths involving people younger than 55 years and SIM is increasingly affecting women relative to men. Accurately characterizing, measuring, and monitoring this major clinical and public health challenge will be essential for developing a comprehensive etiologic understanding and evaluating preventive and therapeutic interventions.

Variable Classification of Drug-Intoxication Suicides across US States: A Partial Artifact of Forensics?

BACKGROUND: The 21st-century epidemic of pharmaceutical and other drug-intoxication deaths in the United States (US) has likely precipitated an increase in misclassified, undercounted suicides. Drug-intoxication suicides are highly prone to be misclassified as accident or undetermined. Misclassification adversely impacts suicide and other injury mortality surveillance, etiologic understanding, prevention, and hence clinical and public health policy formation and practice. OBJECTIVE: To evaluate whether observed variation in the relative magnitude of drug-intoxication suicides across US states is a partial artifact of the scope and quality of toxicological testing and type of medicolegal death investigation system. METHODS: This was a national, state-based, ecological study of 111,583 drug-intoxication fatalities, whose manner of death was suicide, accident, or undetermined. The proportion of (nonhomicide) drug-intoxication deaths classified by medical examiners and coroners as suicide was analyzed relative to the proportion of death certificates citing one or more specific drugs and two types of state death investigation systems. Our model incorporated five sociodemographic covariates. Data covered the period 2008-2010, and derived from NCHS's Multiple Cause-of-Death public use files. RESULTS: Across states, the proportion of drug-intoxication suicides ranged from 0.058 in Louisiana to 0.286 in South Dakota and the rate from 1 per 100,000 population in North Dakota to 4 in New Mexico. There was a low correlation between combined accident and undetermined drug-intoxication death rates and corresponding suicide rates (Spearman's rho = 0.38; p<0.01). Citation of 1 or more specific drugs on the death certificate was positively associated with the relative odds of a state classifying a nonhomicide drug-intoxication death as suicide rather than accident or undetermined, adjusting for region and type of state death investigation system (odds ratio, 1.062; 95% CI,1.016-1.110). Region, too, was a significant predictor. Relative to the South, a 10% increase in drug citation was associated with 43% (95% CI,11%-83%), 41% (95% CI,7%-85%), and 33% (95% CI,1%-76%) higher odds of a suicide classification in the West, Midwest, and Northeast, respectively. CONCLUSION: Large interstate variation in the relative magnitude of nonhomicide drug-intoxication deaths classified as suicide by medical examiners and coroners in the US appears partially an artifact of geographic region and degree of toxicological assessment in the case ascertainment process. Etiologic understanding and prevention of drug-induced suicides and other drug-intoxication deaths first require rigorous standardization involving accurate concepts, definitions, and case ascertainment.

Confronting death from drug self-intoxication (DDSI): prevention through a better definition.

Suicide and other self-directed violence deaths are likely grossly underestimated, reflecting inappropriate classification of many drug intoxication deaths as accidents or unintentional and heterogeneous ascertainment and coding practices across states. As the tide of prescription and illicit drug-poisoning deaths is rising, public health and research needs would be better satisfied by considering most of these deaths a result of self-intoxication. Epidemiologists and prevention scientists could design better intervention strategies by focusing on premorbid behavior. We propose incorporating deaths from drug self-intoxication and investigations of all poisoning deaths into the National Violent Death Reporting System, which contains misclassified homicides and undetermined intent deaths, to facilitate efforts to comprehend and reverse the surging rate of drug intoxication fatalities.

Declared and undeclared substance use among emergency department patients: a population-based study.

AIMS: To estimate both self-reported and corrected prevalences of substance use in a population-based study of general hospital emergency department (ED) patients and predict undeclared use. DESIGN: A state-wide cross-sectional, two-stage probability sample survey that incorporates toxicological screening. SETTING: Seven Tennessee EDs in acute care, adult, civilian, non-psychiatric hospitals. PARTICIPANTS: A total of 1502 Tennessee residents, 18 years of age and older, possessing intact cognition, able to give informed consent and not in police custody. Measurements Prevalence of self-reported current substance use by age, sex and type with correction for under-reporting based on toxicological screening. Covariates in the multivariate analysis of undeclared use were socio-demographics, ED visit circumstances, health-care coverage, prior health status and treatment history and tobacco addiction. FINDINGS: Declared current use was highest for alcohol (females 26%, males 47%), marijuana (males 11%, females 6%) and benzodiazepines (females 10%, males 7%). After correction for under-reporting, overall use for any of the eight targeted substances rose from 44% to 56% for females and 61% to 69% for males. Largest absolute changes involved opioids, benzodiazepines, marijuana, amphetamines and/or methamphetamine, with little change for alcohol. Patients aged 65 years and older manifested excess undeclared use relative to patients aged 18-24 years, as did patients not reporting tobacco addiction or receiving substance abuse treatment. CONCLUSION: Adjustment for under-reporting produced minimal change in the estimated prevalence of alcohol use. However, toxicological screening markedly increased estimates of other drug use, especially for the elderly, who may under-report medication use. Screening tests are useful tools for detecting undeclared substance use.

Unmet substance abuse treatment need, health services utilization, and cost: a population-based emergency department study.

STUDY OBJECTIVE: There is a high prevalence of unmet substance abuse treatment need among adult hospital emergency department (ED) patients. We examine the association between this unmet need and excess utilization of health services and estimate costs. METHODS: A statewide, 2-stage, probability sample survey was conducted in 7 Tennessee general hospital EDs from June 1996 to January 1997. Toxicologic screening augmented in-person interviews. Main outcome measures were ED case disposition; frequency of physician office visits, ED visits, and hospitalizations in the past 12 months; and costs of excess service utilization. Covariates in the multivariate model were substance abuse treatment need status, age, sex, main reason for ED visit, perceived previous health status, history of tobacco use, and health care coverage. Unmet substance abuse treatment need was assessed using 13 overlapping criteria that incorporated use, dependence, denial, and treatment history. Target substances included ethanol and selected illegal and prescription drugs but not nicotine. RESULTS: Compared with patients without substance abuse treatment need (n=1,073), patients with unmet need (n=415) were 81% more likely to be admitted to the hospital during their current ED visit (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.27 to 2.64) and 46% more likely to have reported making at least 1 ED visit in the previous 12 months (OR 1.46; 95% CI 1.12 to 1.84). Their utilization patterns accounted for an estimated 777.2 million US dollars in extra hospital charges for Tennessee in 2000 dollars, representing an additional 1,568 US dollars per ED patient with unmet substance abuse treatment need. CONCLUSION: ED patients with unmet substance abuse treatment need generated much higher hospital and ED charges than patients without such need. Given potential savings from avoidable health care costs, the future burden of substance-associated ED visits and hospitalizations may be reduced through programs that screen and, as appropriate, provide brief interventions or treatment options to these patients.

Assessing substance abuse treatment need: a statewide hospital emergency department study.

STUDY OBJECTIVE: Health care providers in hospital emergency departments rarely take substance abuse histories or assess associated treatment need. This study compares documentation of psychoactive drug-related diagnoses for adult ED patients in medical records with treatment need assessed through self-report, toxicologic screening, and Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria. METHODS: A statewide, 2-stage, probability sample survey was conducted in 7 Tennessee general hospital EDs from June 1996 to January 1997. Main outcome measures were the prevalence of diagnosed substance abuse problems, positive bioassay results, denied use, and treatment need. Sensitivity and multivariate analyses were conducted by using varied case definitions of treatment need. RESULTS: Thirty-one percent (95% confidence interval [CI] 27.3% to 34.7%) of screened ED patients (n=1,330) had positive test results for substance use. Their prevalence of denial of use in the 30 days before the survey ranged from 10% for alcohol (95% CI 5.7% to 14.3%) to 100% for phencyclidine. One percent of all ED patients (n=1,502) had a recorded diagnosis of substance abuse. By contrast, as many as 27% (95% CI 23.3% to 31.8%) were assessed as needing substance abuse treatment on the basis of a comprehensive case definition that accounted for denial and positive test results. A sensitivity analysis using other case definitions is also presented. For example, 4% (95% CI 2.8% to 5.3%) of patients met the very strict definition of DSM-IV current drug dependence only. Under the comprehensive case definition, TennCare patients (adjusted odds ratio [OR] 1.63; 95% CI 1.30 to 2.05) and Medicare patients (adjusted OR 2.50; 95% CI 1.34 to 4.65) showed excess treatment need relative to the privately insured. Excess need was also exhibited by patients reporting 1 or more prior ED visits in the past year (adjusted OR 1.62; 95% CI 1.13 to 2.31) and by patients taking 2 or more hours to reach the ED after the onset of injury or illness (adjusted OR 1.54; 95% CI 1.16 to 2.04). Treatment need was inversely associated with age. Irrespective of case definition, less than 10% of ED patients who needed substance abuse treatment were receiving such treatment. CONCLUSION: EDs can be important venues for detecting persons in need of substance abuse treatment.