Epidemiology of Suicide and the Psychiatric Perspective.

2138 – Psychiatric Comorbidity And Mortality In Women With Anorexia Nervosa

Despite South Africa being a peaceful democracy for the past 18 years, mortality due to unnatural and violent causes still occur among the youth, who are aged between 15 and 34 years old (Presidency of the Republic of South Africa 2009). However, this is not specific to South Africa; with developed countries experiencing the same trend. In developed countries, Christoffe (1994) found that death due to unnatural causes, specifically related to violence, had increased especially among the youth. South Africa is now moving towards the same transition that is currently experienced by developed nations in the world: violent deaths as a major cause of death amongst the youth which includes some adolescents (10-19 years old) (Norman, et al, 2007). With this in mind, this paper aims to examine the different levels of male and female adolescent mortality due to five unnatural causes of death. Data from South African Death Notification Forms is analysed for the years 2000-2009. Cause-specific mortality rates and proportional mortality ratios are produced. Results show adolescents are dying from events of undetermined intent, transport accidents’ and self- harm, especially males. The selected causes of death are contributing up to 27% of all adolescent male mortality and almost 12% of all female mortality in 2009. The results of this paper allude to crime, violence and safety issues in South Africa.

To investigate mortality in anorexia nervosa (AN) with a psychiatric comorbidity. Using Swedish registers, data for 8069 female inpatients with AN were retrospectively collected for 1973-2010. Mortality patterns were assessed using standardized mortality ratios (SMRs), Cox regression-derived hazard ratios, and incidence rate ratios. A control cohort of 76,995 women was used. Patients with AN and a psychiatric comorbidity had higher mortality rates did than those without a comorbidity. The SMRs for patients with AN and a psychiatric comorbidity were 5.4 (95% confidence interval [CI] = 4.6-6.4) and 18.1 (95% CI = 15.2-21.3) for natural and unnatural causes of death, respectively. The SMRs for patients with AN without a comorbidity were 2.8 (95% CI = 2.3-3.5) and 3.1 (95% CI = 2.2-4.1) for natural and unnatural causes of death, respectively. The adjusted hazard ratios for mortality from natural or unnatural causes were 2.0 (95% CI = 1.5-2.7) and 5.7 (95% CI = 3.9-8.2), respectively. Incidence rate ratios comparing patients with AN and controls, both with psychiatric comorbidities, suggest a negative synergistic effect of comorbid AN and psychiatric disorder on mortality, which was greater for unnatural causes of death. Mortality in patients with AN was greater in the presence of a psychiatric comorbidity, and even more pronounced for unnatural causes of death and suicides. Substance abuse, especially alcohol use disorder, increased mortality from natural causes of death. These findings highlight the need for early detection and treatment of psychiatric comorbidity in AN, to potentially improve long-term outcomes.

BackgroundThe mortality rate from unnatural deaths for South Africa is nearly double the world average. Reliable data are limited by inaccurate and incomplete ascertainment of specific causes of unnatural death. This study describes trends in causes of unnatural death between 1992 and 2008 in a cohort of South African miners.Methodology/Principal FindingsThe study used routinely-collected retrospective data with cause of death determined from multiple sources including the mine's human resources database, medical records, death registration, and autopsy. Cause-specific mortality rates and Poisson regression coefficients were calculated by calendar year and age group. The cohort included 40,043 men. One quarter of all 2937 deaths were from unnatural causes (n = 805). Causes of unnatural deaths were road traffic accidents 38% (109/100,000 py), homicides 30% (88/100,000 py), occupational injuries 17% (50/100,000 py), suicides 8% (24/100,000 py), and other accidents 6% (19/100,000 py). Rates of unnatural deaths declined by 2% (95%CI -4%,-1%) per year over the study period, driven by declining rates of road traffic and other accidents. The rate of occupational injury mortality did not change significantly over time (-2% per year, 95%CI -5%,+2%). Unnatural deaths were less frequent in this cohort of workers than in the South African population (IRR 0.89, 95%CI 0.82–0.95), particularly homicides (IRR 0.48, 95%CI 0.42–0.55).Conclusions/SignificanceUnnatural deaths were a common cause of preventable and premature death in this cohort of miners. While unnatural death rates declined between 1992 and 2008, occupational fatalities remained at a high level. Evidence-based prevention strategies to address these avoidable deaths are urgently needed.

Unnatural Causes of Death and Suicide Among Former Adolescent Psychiatric Patients

Purpose Migrants historically and currently form an integral part of South Africa. Their importance and contribution to the country’s economy and development are undeniable. Yet, life for African migrants in South Africa is becoming increasingly difficult. An analysis of migrants mortality until now has not been conducted. The purpose of this paper is to compare the trends of the cause of death among South African Citizens (RSA) and African migrants from countries that form part of the South African Development Community (SADC), that make up nearly 70% of the migrants in the country. Design/methodology/approach Using Stats SA data of all registered deaths in South Africa (2002-2015), this paper compares all causes of death (COD) between RSA and SADC migrants. This paper studies the patterns in COD among these population groups for the years 2002 to 2015 in deaths due to infectious diseases and unnatural causes. Logistic regression was used to quantify the odds of dying due to infectious disease and unnatural causes for each population group. This paper included a calculation of the odds of dying due to assault, as a sub-group within unnatural deaths. Findings A total of 7,611,129 deaths were recorded for the local South African population and 88,114 for SADC migrants for the period under study (2002–2015). The burden of mortality for both infectious diseases and unnatural causes was higher for SADC migrants as compared to RSA. SADC migrants were 1.22 times more likely to die from infectious diseases than RSA (P < 0.001, 95% confidence interval (CI) (1.12, 1.23). Similarly, SADC migrants were 2.7 times more likely to die from unnatural causes than South Africans (P < 0.001, 95% CI (2.17, 2.23). The odds of dying from assault was the same as that of unnatural causes. Also, it was found that women were more likely to die from infectious diseases (OR = 1.11, P < 0.001, 95% CI (1.11, 1.11) compared to men, regardless of nationality. Research limitations/implications The bias resulting from migrants who return home to die due to illness, described in the literature as the salmon bias, is present in this paper. This paper, therefore, concludes death due to infectious diseases could be higher among migrants. Practical implications The heightened mortality among SADC migrants can be related to the impact of social determinants of health such as living and working conditions and barriers to access to health care. Moreover, the higher probability of death due to unnatural causes such as assaults constitute a proxy to estimate the impact of xenophobic violence observed in the country over the past decade. Policy interventions should focus on migrant health-care systems. Also, programmes to mitigate and curb xenophobic sentiments should be carried out to address the growing disparity of preventable unnatural causes of death. Originality/value This study offers the first quantification of mortality due to infectious diseases and unnatural causes among RSA and SADC migrants.

Autopsy profile is one of the essential inputs for National Statistics. It gives an insight into the prevailing unnatural causes of death in the vicinity and subsequently helps stake holders take appropriate measures to prevent the same. The present study was conducted in district hospital, South India in the pandemic year, 2020. A total of 808 medico legal autopsies were conducted in Government District Hospital, Tumkur which is high in spite of pandemic and lockdown in place. Among them majority of victims were male constituting 78.85% and females attributing to 21.15% of total cases. Manner of death was analysed and accidental deaths formed the major chunk of cases comprising of 351 cases (43.44%). Suicidal deaths comprised of 35.87 % of cases and homicide deaths accounted for 3.71% of cases. Among males maximum number of cases was recorded in fourth decade with 147 cases. While in females maximum cases fell in third decade of life with 51 cases. Road traffic accident was the prime most cause of death with 241 cases comprising of 30% of total cases. Second most common cause was hanging with 137 cases comprising 17% of total cases. Surprisingly natural deaths constituted third most common cause with 125 cases comprising of 15% of the cases. Majority of cases were reported in middle age group 21-50 years which form the bread winner group. With adequate safety precautions and counselling these unnatural deaths could be prevented.

Studies have shown that the causes and methods of suicides differ among young and old individuals; consequently, it is important to identify the subgroups that are at high risk for suicide to aid in suicide prevention. The present study compared the causes and methods of suicides between 2002 and 2013 among older adults aged 65-69 years, 70-74 years and ≥75 years by completed crude suicide rate and sex. Data detailing sex, the causes and methods of completed suicides in older adults aged 65-69 years, 70-74 years and ≥75 years that occurred between 2002 and 2013 were drawn from the Turkish Statistical Institute. In all age groups, crude suicide rates were threefold more frequent among men than among women. In both sexes, the most frequent suicide cause was mental illness. In the group aged 65-69 years, the most common cause of suicide was financial difficulty for men and marital conflict for women. The most frequent suicide method among older adults of both sexes was hanging. In all age groups, firearms use was more common among men and jumping from a high place was more common among women. The present findings suggest that the most common suicide cause in both sexes and in all age groups was mental illness in Turkey. To prevent suicidal behavior in older adults,; it is important to diagnose mental disorders, such as mood disorders and substance abuse, and to treat them quickly. Geriatr Gerontol Int 2019; 19: 66-69.

Profile of unnatural mortalities in Northern part of Ghana; a forensic-based autopsy study

Communications

Patients with serious mental disorders have poorer healthcare outcomes at the end of life and are at greater risk of dying from unnatural causes.AimsTo explore place of death and demographic and clinical correlates of unnatural causes of death in patients with serious mental disorders. Routinely collected patient data were used to explore bivariate and adjusted associations between covariates and natural/unnatural cause of death. In multivariable analysis (n = 1029), dying at home (odds ratio (OR) = 1.87, 95% CI 1.03-3.40), 'other' locations (OR = 16.50, 95% CI 7.57-36.00), younger age (OR = 17.26, 95% CI 8.28-36.00) and a diagnosis other than schizophrenia spectrum disorder (OR = 1.69, 95% CI 1.04-2.73) were correlates of unnatural cause of death. Deaths from unnatural causes were high and more likely to occur at home and non-healthcare settings. Unnatural causes of death were higher in younger patients with non-schizophrenia spectrum disorder diagnoses.Declaration of interestF.G. has received support or honoraria for CME, advisory work and lectures from Bristol-Myers Squibb, Janssen, Lundbeck, Otsuka, Roche, and Sunovion, and has a family member with professional links to Lilly and GSK, including shares.

Changes in our society may potentially lead to shifts in the profile of forensic autopsies. A retrospective evaluation of autopsy protocols (nges= 5.190) at the Insitute of Legal Medicine Göttingen was performed, comparing the period of two decades (1969-1978, n1= 2.501, and 1998-2007, n2= 2.689). Most of the cases evaluated (95 %) accounted for judicial autopsies, whereas the number of administrative autopsies decreased by 94% during the time span analyzed. In 59 % (-16, %) of cases an unnatural cause of death was found, while 33% (+30 %) of deaths had a natural cause. In 7% (+29 %) the cause of death remained unclear. The gender distribution further remained almost unchanged (m= 66%; f= 34%). The average age at death increased by nine years from 37.8 to 46.8 years. Regarding cases with natural cause of death, a decrease of respiratory diseases (-85 %) and infections (-46 %) was documented. Rising numbers were observed for cardiovascular diseases (+70 %), gastrointestinal disorders (+127 %), fatal embolisms (+157 %), and tumors (+175 %). Among unnatural causes of death, fatal intoxications increased by 38 %. Fatal poisonings with methadone, amphetamines, and cocaine were observed only in the recent period. Opioid intoxications furthermore increased significantly (+724 %). A strong decrease was seen for fatal intoxications with cyanide, E605, barbiturates, and hypnotics. The frequency of homicides fell by 58 %, and falling numbers were also determined for occupational accidents (-59 %) and traffic accidents (-39 %). Suicides, on the other hand, increased by 35 %. Autopsies which had been performed due to suspected medical malpractice increased (+334 %) but did not result in more confirmed errors. During the recent period, the judicial practice regarding forensic examination was mainly limited to autopsies (+60 %). Additional histological examinations (-74 %), blood alcohol analyses (-54 %), and combined histological and blood alcohol examinations (-96 %), however, were performed less often. Due to recent legal practice arrangement, a growing indifference regarding comprehensive case solutions seems to have developed. Our results for the periods examined are mainly in concordance with those of other institutions (Frankfurt, Magdeburg, Hamburg, Munich, Dresden); yet need to be considered in a differentiated manner, as the case detection rate is very strongly associated with the legal practice arrangements and the discretion authority of individual prosecutors. The results collected within a 40-year period allow for conclusions regarding the impact of changes in health policy which are reflected in the autopsy data. On the other hand, there are developments within our autopsy material which form the basis for legislative adjustments (especially in coroner´s inquest and autopsies) and should be implemented politically. With respect to increasing costs and austerity programs in healthcare and judicial system as well as the closing down of forensic institutes, the evaluation of forensic autopsy data, as part of a possible nationwide multi-center study, may preventively protect society (eg undetected homicides, drug safety, drug cases, drug-related deaths, medical malpractice, traffic safety, unrecognized hazard sources, etc.) and ensure legal certainty.

OBJECTIVE This study aims to compare blood and urinary cannabis profiles between road traffic injury (RTI) and other unnatural causes of death in the Thai population. METHODS A cross-sectional study was conducted of Thai postmortem cases where the individual who died was 15 years old or over. Sex, age, cause of death, manner of death, blood alcohol concentration (BAC), and concomitant drugs found were documented for each case. Blood and urinary concentrations of delta9-tetrahydrocannabinol (THC) and its two metabolites, 11-hydroxy-delta9-tetrahydrocannabinol (11-OH-THC) and 11-nor-9-carboxy-delta9-tetrahydrocannabinol (THC-COOH), were analyzed using gas chromatography tandem mass spectrometry (GC-MS/MS). Statistical analysis was performed using the Mann-Whitney U test and Kruskal-Wallis H test. RESULTS A total of 80 subjects were included in this study, comprising 43 RTI and 37 non-RTI subjects. All the RTI cases were motorcycle riders. Blood concentrations of THC, 11-OH-THC, and THC-COOH in the RTI group were significantly higher than those in the non-RTI group (p < 0.01). The number of subjects who had recent cannabis exposure in the RTI group was significantly higher than in the non-RTI group (p< 0.05). Furthermore, the blood concentrations of THC, 11-OH-THC, and THC-COOH in subjects who used cannabis without other drugs of abuse or medications were significantly higher than those in subjects who used cannabis with other drugs of abuse or other medications (p < 0.05). CONCLUSIONS Blood THC, 11-OH-THC, and THC-COOH concentrations in RTI cases were significantly higher than in cases with other unnatural causes of death. KEYWORDS cannabis, road traffic injury (RTI), motorcycle rider, Thai

When considering the manner of death, two categories can be distinguished, namely natural death and unnatural death. Though most physicians think that the distinction between the two is evident, this is not the case.When comparing the Netherlands, Belgium, England and Germany it is noticed that the terms natural and unnatural might be used in law but are not defined by law. In practice, the term unnatural death is used when there is an external cause of death, but even that turns out to not be sufficient in making an obvious difference between the two terms. Different countries may even label the same death differently. A, at times philosophical and semantic, discussion shows that when it comes to causes of death a very large grey area exists between natural and unnatural causes of death. The Netherlands, Belgium and Germany even have the possibility to label a death as natural (or unnatural) without actually knowing the cause of death.In conclusion, we recommend a new system in which the circumstances surrounding a death are properly investigated. This should lead to a report to an independent legal expert, who is able to decide if and what conclusion can be drawn, from a judicial and a public point of view, thereby, making the distinction and the use of the terms natural and unnatural/nonnatural obsolete.

Limited evidence reveals an elevated mortality risk in offspring of psychiatric patients after infancy. This nationwide population-based study in Taiwan aimed to investigate mortality risk in preschool children up to age 5 whose parents have severe mental illness. Three nationwide population-based data sets were linked. A total of 3,166 children with one or both parents having schizophrenia or an affective disorder were identified, together with a comparison cohort of 25,328 children matched with the study group in terms of maternal age and year of delivery. Cox proportional hazard regressions were performed to compute hazard ratios, with adjustment for sociodemographic characteristics and maternal medical comorbidities. During the preschool years, 54 (1.7%) deaths were documented among offspring of parents with severe mental illness and 155 (0.6%) in the comparison cohort. Parental mental illness was independently associated with a risk of death nearly 2.4 times higher (95% CI=1.72-3.28) than in the comparison cohort. The association was even more marked for unnatural causes of death, in which the mortality risk was 8.35 times greater (95% CI=4.04-17.24) in children of affected parents than in the comparison cohort. The proportional mortality rates were as high as 20.4% and 11.1% for accident and homicide, respectively, among offspring exposed to parental mental illness. An elevated mortality risk, especially from unnatural causes of death, was identified for offspring of parents with severe mental illness during the preschool years in an Asian society. There is an urgent need for multidisciplinary team approaches and risk management strategies to support psychiatric patients who are having difficulty with the transition to parenthood.