Mentally abnormal offenders: manner of death.

A 23 year follow up of deaths in a population of mentally disordered patients was carried out, and a typical case history is reported. A quarter (71) of the deaths reported were unnatural, verdicts of suicide or accidental death or open verdicts having been recorded. For men in most age groups the proportion of deaths by suicide was two to three times greater than in the general population in 1982; the rate among those aged 25-29 was five times that in the general population. Differences in the rate of unnatural death among diagnostic categories of mental illness were not significant, but the proportion of unnatural deaths among the mentally handicapped will probably eventually be lower than that among psychotic offenders or those with personality disorders. Violent death occurs at an older age in those with affective disorders. Social isolation and alienation add to the handicap of mental disorder in this group of people, and these sometimes difficult but always vulnerable patients must continue to be offered asylum other than prison.     

Six-Year Follow-Up of Impact of Co-proxamol Withdrawal in England and Wales on Prescribing and Deaths: Time-Series Study

Background

The analgesic co-proxamol (paracetamol/dextropropoxyphene combination) has been widely involved in fatal poisoning. Concerns about its safety/effectiveness profile and widespread use for suicidal poisoning prompted its withdrawal in the UK in 2005, with partial withdrawal between 2005 and 2007, and full withdrawal in 2008. Our objective in this study was to assess the association between co-proxamol withdrawal and prescribing and deaths in England and Wales in 2005–2010 compared with 1998–2004, including estimation of possible substitution effects by other analgesics.

Methods and Findings

We obtained prescribing data from the NHS Health and Social Care Information Centre (England) and Prescribing Services Partneriaeth Cydwasanaethau GIG Cymru (Wales), and mortality data from the Office for National Statistics. We carried out an interrupted time-series analysis of prescribing and deaths (suicide, open verdicts, accidental poisonings) involving single analgesics. The reduction in prescribing of co-proxamol following its withdrawal in 2005 was accompanied by increases in prescribing of several other analgesics (co-codamol, paracetamol, codeine, co-dydramol, tramadol, oxycodone, and morphine) during 2005–2010 compared with 1998–2004. These changes were associated with major reductions in deaths due to poisoning with co-proxamol receiving verdicts of suicide and undetermined cause of −21 deaths (95% CI −34 to −8) per quarter, equating to approximately 500 fewer suicide deaths (−61%) over the 6 years 2005–2010, and −25 deaths (95% CI −38 to −12) per quarter, equating to 600 fewer deaths (−62%) when accidental poisoning deaths were included. There was little observed change in deaths involving other analgesics, apart from an increase in oxycodone poisonings, but numbers were small. Limitations were that the study was based on deaths involving single drugs alone and changes in deaths involving prescribed morphine could not be assessed.

Conclusions

During the 6 years following the withdrawal of co-proxamol in the UK, there was a major reduction in poisoning deaths involving this drug, without apparent significant increase in deaths involving other analgesics. Please see later in the article for the Editors'' Summary     

Mortality study of pathologists and medical laboratory technicians.

Membership lists of professional bodies were used to establish study populations of British pathologists (1955-73) and medical laboratory technicians (1963-73). The standardised mortality ratio (SMR) for pathologists was 60 and for medical laboratory technicians 67. Twenty-seven of the 310 deaths were due to suicide. These numbers gave SMRs of 250 for pathologists and 243 for medical laboratory technicians. Suicide was the commonest cause of death in female technicians. Access to lethal chemicals at work is a possible factor explaining the high proportion of suicide by poisoning compared with the general population. Suicide rates for pathologists exceed those of all medical practitioners; similary medical laboratory have higher rates than all laboratory technicians. Excess deaths from lymphatic and haemopoietic neoplasms were noted in English male pathologists (observed 8, expected 3-3; P less than 0-01). This difference is not due to Hodgkin''s disease or leukaemia and remains unexplained. No other neoplastic diseases were noted as causing excess mortality in either occupational group but a small, possibly spurious, excess number of deaths was noted for aortic aneurysm in male pathologists (observed 4, expected 1-8).     

Identifying Probable Suicide Clusters in Wales Using National Mortality Data

Background

Up to 2% of suicides in young people may occur in clusters i.e., close together in time and space. In early 2008 unprecedented attention was given by national and international news media to a suspected suicide cluster among young people living in Bridgend, Wales. This paper investigates the strength of statistical evidence for this apparent cluster, its size, and temporal and geographical limits.

Methods and findings

The analysis is based on official mortality statistics for Wales for 2000–2009 provided by the UK''s Office for National Statistics (ONS). Temporo-spatial analysis was performed using Space Time Permutation Scan Statistics with SaTScan v9.1 for suicide deaths aged 15 and over, with a sub-group analysis focussing on cases aged 15–34 years. These analyses were conducted for deaths coded by ONS as: (i) suicide or of undetermined intent (probable suicides) and (ii) for a combination of suicide, undetermined, and accidental poisoning and hanging (possible suicides). The temporo-spatial analysis did not identify any clusters of suicide or undetermined intent deaths (probable suicides). However, analysis of all deaths by suicide, undetermined intent, accidental poisoning and accidental hanging (possible suicides) identified a temporo-spatial cluster (p = 0.029) involving 10 deaths amongst 15–34 year olds centred on the County Borough of Bridgend for the period 27^th December 2007 to 19^th February 2008. Less than 1% of possible suicides in younger people in Wales in the ten year period were identified as being cluster-related.

Conclusions

There was a possible suicide cluster in young people in Bridgend between December 2007 and February 2008. This cluster was smaller, shorter in duration, and predominantly later than the phenomenon that was reported in national and international print media. Further investigation of factors leading to the onset and termination of this series of deaths, in particular the role of the media, is required.     

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

Background

The 21^st-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.     

Association Between Suicide and Environmental Variables in the North of Spain: A 14-Year Analysis

Suicide is a serious public health problem around the world. Since the nineteenth century, the impact of socio-environmental factors on suicide has attracted much public attention, especially in the context of global climate change. We have performed a retrospective correlation study that analyzes the demographic pattern of suicide in Cantabria, a northern coastland region of Spain. Moreover, we have created a multivariable binomial regression model to study the relationship between suicide and environmental factors (atmospheric pollutants and meteorological variables) among January 1, 2000, and December 31, 2013 in the province. During the 14-year study period, there was a suicide annual incidence of 4.9 cases per 100,000 population in Cantabria. The incidence was highest in adults aged 70–74 years old (11.8 per 100,000 population). The most common method group of suicide was hanging, strangulation and suffocation, accounting for 49.3% of all suicide deaths. When correlating suicide and meteorological variables, a statistically significant association was found with the level of cloudiness (p?=?0.007). According to our results, an increase of one eighth of sky cloud-cover correlated to a 7% increase in total deaths by suicide and the association was especially strong during spring.     

The Impact of Improving Suicide Death Classification in South Korea: A Comparison with Japan and Hong Kong

IntroductionThe suicide rate of South Korea has increased dramatically during the past decades, as opposed to steadily decreasing trends in Japan and Hong Kong. Although the recent increase of suicide in South Korea may be related to changing socioeconomic conditions and other contextual factors, it may also reflect, in part, a reduction of misidentified suicide cases due to improving classification of manner of death.MethodWe compared the annual proportional change of suicide, undetermined death, and accidental death from South Korea with those of Japan and Hong Kong from 1992 to 2011; a greater proportional change of the manner-of-death categories during the period is indicative of a relatively less stable registration and hence a greater potential for misclassification bias on reported suicide trends. Subgroup analyses stratifying the deaths by methods were also conducted. To estimate the impact, the age-standardized rates of these three death categories in each site were calculated.ResultsWe found that, during the 20-year observation period, the proportional change of suicide, undetermined death, and accidental death in South Korea was significantly greater than Japan and Hong Kong. Similar observations were made in subgroup analyses. While death rates of the three manners in Japan and Hong Kong generally moved in a parallel fashion, the increase of suicide in South Korea occurred concomitantly with a significant reduction of its accidental death rate. 43% of the increase in suicides could be attributed to the decrease in accidental deaths, while 57% of the increase could be due to fundamental causes.ConclusionOur data suggest that, during the mid-1990s and after, the increasing burden of suicide in South Korea initially was masked, in part, by misclassification. Thus, the later apparently rapid increase of suicides reflected steadily improving classification of manner of death, as well as a more fundamental increase in the suicide rate.     

Autopsy in California

From information complied from death certificates registered in 1952 and 1962 an examination was made of California''s autopsy performance and the characteristics of deaths in which autopsy was done. The data indicated that California had an overall autopsy rate of 37 per cent of total deaths in 1962, probably higher than any other state. In the decade reviewed, there was a 62 per cent absolute increase in autopsies and a 7 per cent increase relative to total deaths.Substantial increases in the proportion of deaths in which autopsy was done were found for physician-certified deaths in both metropolitan and nonmetropolitan counties and for coroner-certified deaths in nonmetropolitan counties. For all but two of forty-five selected natural causes of death there were increases in the proportion of deaths in which autopsy was done.Seventy per cent of deaths occurred in some type of facility. About one-half of all deaths occurred in general hospitals, and autopsy was done in 42 per cent of such cases.The dual factors of a high autopsy rate and overrepresentation of deaths brought to autopsy in white males, ages 35-64, support the validity of a reported decline in California''s death rate for arteriosclerotic heart disease.     

Clinical cosmobiology: The Lithuanian study 1990–1992

The numbers of deaths from ischaemic heart disease (IHD), stroke (CVA), all accidents except vehicular, vehicular accidents and suicide (overall total, totals for men and women) per month for 36 months (1990–1992) in Lithuania were analysed in relation to: (1) month of the year (1–12); (2) geomagnetic activity; and (3) solar activity. A total of 122227 deaths (64490 men and 57737 women) was studied, and the results compared with those obtained in an earlier study in Israel, differing geographically and climatically from Lithuania. It was shown that the time of year, solar activity, and geomagnetic activity were related to the monthly death distribution, especially regarding death from IHD and suicide. Age and gender differences were apparent in the relationship between death distribution and physical environmental factors. At age >70 years, many of these relationships change. The monthly distribution of deaths from IHD and suicide are adversely correlated with solar activity and with each other. Differences are presumed in serotoninergic effects as caused by environmental influences.     

Suicide among Arab-Americans

Background

Arab-American (AA) populations in the US are exposed to discrimination and acculturative stress—two factors that have been associated with higher suicide risk. However, prior work suggests that socially oriented norms and behaviors, which characterize recent immigrant ethnic groups, may be protective against suicide risk. Here we explored suicide rates and their determinants among AAs in Michigan, the state with the largest proportion of AAs in the US.

Methodology/Principal Findings

ICD-9/10 underlying cause of death codes were used to identify suicide deaths from among all deaths in Michigan between 1990 and 2007. Data from the 2000 U.S. Census were collected for population denominators. Age-adjusted suicide rates among AAs and non-ethnic whites were calculated by gender using the direct method of standardization. We also stratified by residence inside or outside of Wayne County (WC), the county with the largest AA population in the state. Suicide rates were 25.10 per 100,000 per year among men and 6.40 per 100,000 per year among women in Michigan from 1990 to 2007. AA men had a 51% lower suicide rate and AA women had a 33% lower rate than non-ethnic white men and women, respectively. The suicide rate among AA men in WC was 29% lower than in all other counties, while the rate among AA women in WC was 20% lower than in all other counties. Among non-ethnic whites, the suicide rate in WC was higher compared to all other counties among both men (12%) and women (16%).

Conclusions/Significance

Suicide rates were higher among non-ethnic white men and women compared to AA men and women in both contexts. Arab ethnicity may protect against suicide in both sexes, but more so among men. Additionally, ethnic density may protect against suicide among Arab-Americans.     

Epidemiology of suicide pacts in England and Wales, 1988-92.

OBJECTIVE: To describe the epidemiology of suicide pacts in England and Wales DESIGN: Analysis of the death certificates and coroners'' records of all people who died in pacts between 1 January 1988 and 31 December 1992. SUBJECTS: 124 people who committed suicide in 62 pacts. RESULTS: Suicide in a pact accounted for 0.6% of all suicides (124/19721), a rate of 0.6 per million people aged 15 and over. Forty eight pacts were between married couples and five were between family members. The mean age was 56 years. 99 of the 124 subjects were of occupational social classes I-III. Poisoning by car exhaust fumes and drugs accounted for 116 deaths, with both members of each pair using the same method. CONCLUSIONS: Suicide pacts are rare and less common than they were 35 years ago, although the epidemiological profile is similar. People who commit suicide in a pact are more likely than those who commit suicide alone to be female, older, married, and of a high social class.     

Relationship between suicide and myocardial infarction with regard to changing physical environmental conditions

In recent years, the possible association of changes in mortality from cardiovascular disease and myocardial infarction (MI) and deaths related to violence and the suicide rate has been repeatedly discussed. This study examined the relationship between cosmic physical changes (solar, geomagnetic and other space activity parameters) and changes in the total number of in-hospital and MI-related deaths and deaths from suicide to determine if a relationship exists between the distribution of total and MI-related deaths with suicide over time; some differences in the serotonergic mechanisms involved in the pathogenesis of MI and suicide were also taken into account. All suicides (n=2359) registered in the State of Israel from 1981 to 1989 (108 months) were analysed and compared with the total number of deaths (n=15601) and deaths from MI (n=1573) in a large university hospital over 180 months (1974–1989). The following were the main features of the Results. (1) Monthly suicide rate was correlated with space proton flux (r=0.42,P=0.0001) and with geomagnetic activity (r=–0.22,P=0.03). (2) Total hospital and MI-related deaths were correlated with solar activity parameters (r=0.35,P<0.001) and radiowave propagation (r=0.52-0.44,P<0.001), an with proton flux (r=–0.3 to –0.26,P<0.01). (3) Monthly suicide distribution over 108 months was correlated with MI (r=–0.33,P=0.0005) and total hospital mortality (r=–0.22,P=0.024). (4) Gender differences were prominent. We conclude that the monthly distributions of suicides and deaths from MI are adversely related to many environmental physical parameters and negatively correlated with each other.     

The Burden Attributable to Mental and Substance Use Disorders as Risk Factors for Suicide: Findings from the Global Burden of Disease Study 2010

Background

The Global Burden of Disease Study 2010 (GBD 2010) identified mental and substance use disorders as the 5^th leading contributor of burden in 2010, measured by disability adjusted life years (DALYs). This estimate was incomplete as it excluded burden resulting from the increased risk of suicide captured elsewhere in GBD 2010''s mutually exclusive list of diseases and injuries. Here, we estimate suicide DALYs attributable to mental and substance use disorders.

Methods

Relative-risk estimates of suicide due to mental and substance use disorders and the global prevalence of each disorder were used to estimate population attributable fractions. These were adjusted for global differences in the proportion of suicide due to mental and substance use disorders compared to other causes then multiplied by suicide DALYs reported in GBD 2010 to estimate attributable DALYs (with 95% uncertainty).

Results

Mental and substance use disorders were responsible for 22.5 million (14.8–29.8 million) of the 36.2 million (26.5–44.3 million) DALYs allocated to suicide in 2010. Depression was responsible for the largest proportion of suicide DALYs (46.1% (28.0%–60.8%)) and anorexia nervosa the lowest (0.2% (0.02%–0.5%)). DALYs occurred throughout the lifespan, with the largest proportion found in Eastern Europe and Asia, and males aged 20–30 years. The inclusion of attributable suicide DALYs would have increased the overall burden of mental and substance use disorders (assigned to them in GBD 2010 as a direct cause) from 7.4% (6.2%–8.6%) to 8.3% (7.1%–9.6%) of global DALYs, and would have changed the global ranking from 5^th to 3^rd leading cause of burden.

Conclusions

Capturing the suicide burden attributable to mental and substance use disorders allows for more accurate estimates of burden. More consideration needs to be given to interventions targeted to populations with, or at risk for, mental and substance use disorders as an effective strategy for suicide prevention.     

Declines in the lethality of suicide attempts explain the decline in suicide deaths in australia

Background

To investigate the epidemiology of a steep decrease in the incidence of suicide deaths in Australia.

Methods

National data on suicide deaths and deliberate self-harm for the period 1994–2007 were obtained from the Australian Institute of Health and Welfare. We calculated attempt and death rates for five major methods and the lethality of these methods. Negative binomial regression was used to estimate the size and significance of method-specific time-trends in attempts and lethality.

Results

Hanging, motor vehicle exhaust and firearms were the most lethal methods, and together accounted for 72% of all deaths. The lethality of motor vehicle exhaust attempts decreased sharply (RR = 0.94 per year, 95% CI 0.93–0.95) while the motor vehicle exhaust attempt rate changed little; this combination of motor vehicle exhaust trends explained nearly half of the overall decline in suicide deaths. Hanging lethality also decreased sharply (RR = 0.96 per year, 95% CI 0.956–0.965) but large increases in hanging attempts negated the effect on death rates. Firearm lethality changed little while attempts decreased.

Conclusion

Declines in the lethality of suicide attempts–especially attempts by motor vehicle exhaust and hanging–explain the remarkable decline in deaths by suicide in Australia since 1997.     

A Short-Term Population Model of the Suicide Risk: The Case of Spain

A relevant proportion of deaths by suicide have been attributed to other causes that produce the number of suicides remains hidden. The existence of a hidden number of cases is explained by the nature of the problem. Problems like this involve violence, and produce fear and social shame in victims’ families. The existence of violence, fear and social shame experienced by victims favours a considerable number of suicides, identified as accidents or natural deaths. This paper proposes a short time discrete compartmental mathematical model to measure the suicidal risk for the case of Spain. The compartment model classifies and quantifies the amount of the Spanish population within the age intervals (16, 78) by their degree of suicide risk and their changes over time. Intercompartmental transits are due to the combination of quantitative and qualitative factors. Results are computed and simulations are performed to analyze the sensitivity of the model under uncertain coefficients.     

Factors associated with suicide risk among Chinese adults: A prospective cohort study of 0.5 million individuals

BackgroundSuicide is a leading cause of death in China and accounts for about one-sixth of all suicides worldwide. The objective of this study was to examine the recent distribution of suicide and risk factors for death by suicide. Identifying underlying risk factors could benefit development of evidence-based prevention and intervention programs.Methods and findingsWe conducted a prospective study, the China Kadoorie Biobank, of 512,715 individuals (41% men, mean age 52 years) from 10 (5 urban, 5 rural) areas which are diverse across China in geographic locations, social economic developmental stages, and prevalence of disease patterns. After the baseline measurements of risk factors during 2004 to 2008, participants were followed up for suicide outcomes including suicide and possible suicide deaths. Risk factors, such as sociodemographic factors and physical and mental health status, were assessed by semistructured interviews and self-report questionnaires. Suicide and possible suicide deaths were identified through linkage to the local death registries using ICD-10 codes. We conducted Cox regression to calculate hazard ratios (HRs) for suicide and for possible suicide in sensitivity analyses.During an average follow-up period of 9.9 years, 520 (101 per 100,000) people died from suicide (51.3% male), and 79.8% of them lived in rural areas. Sociodemographic factors associated with increased suicide risk were male gender (adjusted hazard ratios [aHR] = 1.6 [95% CI 1.4 to 2.0], p < 0.001), older age (1.3 [1.2 to 1.5] by each 10-yr increase, p < 0.001), rural residence (2.6 [2.1 to 3.3], p < 0.001), and single status (1.7 [1.4 to 2.2], p < 0.001). Increased hazards were found for family-related stressful life events (aHR = 1.8 [1.2 to 1.9], p < 0.001) and for major physical illnesses (1.5 [1.3 to 1.9], p < 0.001). There were strong associations of suicide with a history of lifetime mental disorders (aHR = 9.6 [5.9 to 15.6], p < 0.001) and lifetime schizophrenia-spectrum disorders (11.0 [7.1 to 17.0], p < 0.001). Links between suicide risk and depressive disorders (aHR = 2.6 [1.4 to 4.8], p = 0.002) and generalized anxiety disorders (2.6 [1.0 to 7.1], p = 0.056) in the last 12 months, and sleep disorders (1.4 [1.2 to 1.7], p < 0.001) in the past month were also found. All HRs were adjusted for sociodemographic factors including gender, age, residence, single status, education, and income. The associations with possible suicide deaths were mostly similar to those with suicide deaths, although there was no clear link between possible suicide deaths and psychiatric factors such as depression and generalized anxiety disorders. A limitation of the study is that there is likely underreporting of mental disorders due to the use of self-report information for some diagnostic categories.ConclusionsIn this study, we observed that a range of sociodemographic, lifestyle, stressful life events, physical, and mental health factors were associated with suicide in China. High-risk groups identified were elderly men in rural settings and individuals with mental disorders. These findings could form the basis of targeted approaches to reduce suicide mortality in China.

In a prospective cohort study, Rongqin Yu, Yiping Chen and colleagues investigate factors related to death by suicide among Chinese adults.     

Seasonal Variation of Suicide in Brazil

Most of what is known about the seasonal variation in suicide rate originates from studies conducted in the northern hemisphere; very few studies have been done in the southern hemisphere. The purpose of the present study was to explore the possibility that in Brazil, the seasonal variation of suicides is a function of photoperiod. This was accomplished by analyzing monthly suicide data for a 12 yr period (1979 to 1990), within latitudes ranging from 2°N to 33°S. Single cosinor analyses with periods of 12 or 6 months were applied to time series of monthly total and suicidal deaths, separated by gender and state. Significant spring or early summer peaks of suicide were found only in the south of Brazil for both men and women, except for the latter in one state. These peaks did not coincide with those found for total deaths, which occurred in the autumn or winter in all areas. No significant six‐month period was found. In the present study, the chance of a suicide was typically 10–17% higher during the peak period than during the other months of the year. Although this moderate seasonal effect might not be sufficient to justify planning large scale prophylactic interventions, those dealing with patients who have suicide ideation should be aware of this high risk time.     

Seasonal variation of suicide in Brazil

Most of what is known about the seasonal variation in suicide rate originates from studies conducted in the northern hemisphere; very few studies have been done in the southern hemisphere. The purpose of the present study was to explore the possibility that in Brazil, the seasonal variation of suicides is a function of photoperiod. This was accomplished by analyzing monthly suicide data for a 12 yr period (1979 to 1990), within latitudes ranging from 2°N to 33°S. Single cosinor analyses with periods of 12 or 6 months were applied to time series of monthly total and suicidal deaths, separated by gender and state. Significant spring or early summer peaks of suicide were found only in the south of Brazil for both men and women, except for the latter in one state. These peaks did not coincide with those found for total deaths, which occurred in the autumn or winter in all areas. No significant six-month period was found. In the present study, the chance of a suicide was typically 10-17% higher during the peak period than during the other months of the year. Although this moderate seasonal effect might not be sufficient to justify planning large scale prophylactic interventions, those dealing with patients who have suicide ideation should be aware of this high risk time.     

Be your own coroner: an audit of 500 consecutive deaths in a general practice.

General practitioners'' medical records of a geographically defined population of about 1600-1800 have been retained since 1964. Details of care by general practitioners and hospital correspondence were available for 500 deaths (277 men, 223 women) from 1964 to 1985, including deaths at home, at work, in the street, in short term and long term institutional care, and within six months of release from institutional care. The periods 1964-73 and 1974-85 were compared. The proportion of men aged greater than or equal to 80 who died increased from 20 (14%) in 1964-73 to 22 (16%) in 1974-85, but the proportion of women aged greater than or equal to 80 who died increased from 21 (23%) to 50 (39%). Of all deaths, 223 (45%) were thought to have had avoidable causal factors, of which 132 (59%) were attributed to patients, 45 (20%) to the general practitioner, 9 (4%) to hospitals, and 37 (17%) to others. The number of deaths related to smoking decreased from 31 (43%) in men aged less than 70 to 19 (30%) but in women aged less than 70 increased from 4 (10%) to 11 (26%). The proportion of deaths in women who were already dependent six months before death increased from 55 (58%) to 81 (63%) but in men remained constant at 64 (46%) in the first period and 62 (46%) in the second. Nearly two thirds of all deaths occurred at home in both periods--about twice the proportion for England and Wales--but the proportion of men dying at home decreased from 87 (62%) to 76 (56%). A critical analysis of deaths in whole populations by primary care teams can identify changes that are needed both in the work and organisation of the team and in the behaviour of the population itself.