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PLoS One. 2018 May 22;13(5):e0197805. doi: 10.1371/journal.pone.0197805. eCollection 2018.

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

Author information

1
Department of Epidemiology, West Virginia University, Morgantown, West Virginia, United States of America.
2
Injury Control Research Center, West Virginia University, Morgantown, West Virginia, United States of America.
3
Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, United States of America.
4
Injury Control Research Center for Suicide Prevention, University of Rochester Medical Center, Rochester, New York, United States of America.
5
Department of Criminal Justice, Wayne State University, Detroit, Michigan, United States of America.
6
Department of Psychiatry and Behavioral Neuroscience, Wayne State University, Detroit, Michigan, United States of America.
7
Division of Alcohol and Drug Abuse, McLean Hospital, Boston, Massachusetts, United States of America.
8
Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America.
9
Office of the Medical Investigator, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America.
10
Department of Biostatistics, West Virginia University, Morgantown, West Virginia, United States of America.
11
Pacific Institute for Research and Evaluation, Calverton, Maryland, United States of America.
12
Curtin University School of Public Health, Perth, Australia.
13
Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, United States of America.
14
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
15
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
16
School of Nursing, Columbia University, New York, New York, United States of America.
17
Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, United States of America.

Abstract

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.

PMID:
29787584
PMCID:
PMC5963755
DOI:
10.1371/journal.pone.0197805
[Indexed for MEDLINE]
Free PMC Article

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