Race/ethnicity and potential suicide misclassification: window on a minority suicide paradox?

Ian Rh Rockett,Rheeda L Walker,Alan M Ducatman,James L Frost,Shuhui Wang,Nestor D Kapusta,Diego De Leo,Steven Stack

doi:10.1186/1471-244x-10-35

Abstract

BackgroundSuicide officially kills approximately 30,000 annually in the United States. Analysis of this leading public health problem is complicated by undercounting. Despite persisting socioeconomic and health disparities, non-Hispanic Blacks and Hispanics register suicide rates less than half that of non-Hispanic Whites.MethodsThis cross-sectional study uses multiple cause-of-death data from the US National Center for Health Statistics to assess whether race/ethnicity, psychiatric comorbidity documentation, and other decedent characteristics were associated with differential potential for suicide misclassification. Subjects were 105,946 White, Black, and Hispanic residents aged 15 years and older, dying in the US between 2003 and 2005, whose manner of death was recorded as suicide or injury of undetermined intent. The main outcome measure was the relative odds of potential suicide misclassification, a binary measure of manner of death: injury of undetermined intent (includes misclassified suicides) versus suicide.ResultsBlacks (adjusted odds ratio [AOR], 2.38; 95% confidence interval [CI], 2.22-2.57) and Hispanics (1.17, 1.07-1.28) manifested excess potential suicide misclassification relative to Whites. Decedents aged 35-54 (AOR, 0.88; 95% CI, 0.84-0.93), 55-74 (0.52, 0.49-0.57), and 75+ years (0.51, 0.46-0.57) showed diminished misclassification potential relative to decedents aged 15-34, while decedents with 0-8 years (1.82, 1.75-1.90) and 9-12 years of education (1.43, 1.40-1.46) showed excess potential relative to the most educated (13+ years). Excess potential suicide misclassification was also apparent for decedents without (AOR, 3.12; 95% CI, 2.78-3.51) versus those with psychiatric comorbidity documented on their death certificates, and for decedents whose mode of injury was "less active" (46.33; 43.32-49.55) versus "more active."ConclusionsData disparities might explain much of the Black-White suicide rate gap, if not the Hispanic-White gap. Ameliorative action would extend from training in death certification to routine use of psychological autopsies in equivocal-manner-of-death cases.

Highlights

Suicide officially kills approximately 30,000 annually in the United States
Causes of death were precoded under the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ICD-10 [30] for the 105,946 White, Black, and Hispanic residents of the 50 US states and the District of Columbia whose manner of death was either suicide, operationalized as death from intentional self-harm (ICD-10 X60.0X84.9) or its sequelae (Y87.0), or death from injury of undetermined intent (ICD-10 Y10-Y34) or its sequelae (Y87.2, Y89.9)
Suicide rates were universally much higher for Whites than for Blacks and Hispanics at all ages, and the gap was more pronounced after age 35 (Figure 1)

Summary

Introduction

Suicide officially kills approximately 30,000 annually in the United States. Analysis of this leading public health problem is complicated by undercounting. Despite persisting socioeconomic and health disparities, nonHispanic Blacks and Hispanics register suicide rates less than half that of non-Hispanic Whites. Suicide kills approximately one million people annually [1] and over 30,000 Americans [2]. Analysis of this leading public health problem in the United States is complicated by undercounting at local [3] and state levels [4]. Most official suicides are probably true suicides [11,12], and suicide appears more susceptible than homicide or unintentional injury death to misclassification under injury of undetermined intent [11,13]

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Conclusion