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

Abstract

ObjectiveA 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.MethodsThis 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.ResultsA 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.ConclusionsWithout 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.

Discovering the Unclassified Suicide Cases Among Undetermined Drug Overdose Deaths Using Machine Learning Techniques

“…Our results also match the approximately 30% of poisoning suicides that were estimated to be missed when Rockett, Caine, Connery et al. () used the prevalence of suicide notes across methods to estimate underreporting of suicides in the NVDRS states (including Utah) 2011–2013, although national‐level results might be biased due to heterogeneous data reporting and variations in medical investigation culture and practice across the United States.…”

“…Suicide is considered largely preventable (U.S. Public Health Service, 1999). Evidence shows that effective measures can be taken, not only in clinical settings but also at various nonclinical settings (e.g., home, school, and peer groups) (Stone, Holland, Bartholow, Crosby et al, 2017;Stone, Holland, Bartholow, Logan et al, 2017;World Health Organization (WHO), 2014).…”

Adherence to psychotropic medication in completed suicide in Sweden 2006–2013: a forensic-toxicological matched case-control study

“…Exclusion of deaths by intoxication should, in this study, be seen as both a strength and a limitation. Upon forensic investigation, an overdose of prescribed medications confounds judgments regarding pharmacoadherence, and level of suicidal intentionality is more difficult to determine in medication intoxications [45]. Yet, exclusion of intoxications meant that nearly a third of all instances of completed suicide in the study period were unaccounted for-and younger individuals and women underrepresented-limiting the generalizability of the results.…”

Suicide among people treated for drug use disorders: a Danish national record-linkage study

“…First, as with any register-based study, we were not able to provide direct quality control over the process of data collection. Secondly, and perhaps more importantly, suicides by poisonings may be difficult to discriminate from overdoses [58]. This could especially lead to an under-estimation of the association between opioid use and suicide, as opioids are the drugs that are primarily involved in accidental poisonings [58].…”