Cause Of Death In Individuals Research Articles

Machine-learning model to predict the cause of death using a stacking ensemble method for observational data.

Cause of death is used as an important outcome of clinical research; however, access to cause-of-death data is limited. This study aimed to develop and validate a machine-learning model that predicts the cause of death from the patient's last medical checkup. To classify the mortality status and each individual cause of death, we used a stacking ensemble method. The prediction outcomes were all-cause mortality, 8 leading causes of death in South Korea, and other causes. The clinical data of study populations were extracted from the national claims (n = 174747) and electronic health records (n = 729065) and were used for model development and external validation. Moreover, we imputed the cause of death from the data of 3 US claims databases (n = 994518, 995372, and 407604, respectively). All databases were formatted to the Observational Medical Outcomes Partnership Common Data Model. The generalized area under the receiver operating characteristic curve (AUROC) of the model predicting the cause of death within 60 days was 0.9511. Moreover, the AUROC of the external validation was 0.8887. Among the causes of death imputed in the Medicare Supplemental database, 11.32% of deaths were due to malignant neoplastic disease. This study showed the potential of machine-learning models as a new alternative to address the lack of access to cause-of-death data. All processes were disclosed to maintain transparency, and the model was easily applicable to other institutions. A machine-learning model with competent performance was developed to predict cause of death.

Associations of Depressive Symptoms With All-Cause and Cause-Specific Mortality by Race in a Population of Low Socioeconomic Status: A Report From the Southern Community Cohort Study.

Depression is a leading cause of disability in the United States, but its impact on mortality rates among racially diverse populations of low socioeconomic status is largely unknown. Using data from the Southern Community Cohort Study, 2002-2015, we prospectively evaluated the associations of depressive symptoms with all-cause and cause-specific mortality in 67,781 Black (72.3%) and White (27.7%) adults, a population predominantly with a low socioeconomic status. Baseline depressive symptoms were assessed using the 10-item Center for Epidemiological Studies Depression Scale. The median follow-up time was 10.0 years. Multivariate Cox regression was used to estimate hazard ratios and 95% confidence intervals for death in association with depressive symptoms. Mild, moderate, and severe depressive symptoms were associated with increased all-cause (hazard ratio (HR)=1.12, 95% confidence interval (CI): 1.03, 1.22; HR=1.17, 95% CI: 1.06, 1.29; HR=1.15, 95% CI: 1.03, 1.28, respectively) and cardiovascular disease-associated death (HR=1.23, 95% CI: 1.05, 1.44; HR=1.18, 95% CI: 0.98, 1.42; HR=1.43, 95% CI: 1.17, 1.75, respectively) in Whites but not in Blacks (P for interaction<0.001, for both). Mild, moderate, or severe depressive symptoms were associated with increased rates of external-cause mortality in both races (HR=1.24, 95% CI: 1.05, 1.46; HR=1.31, 95% CI: 1.06, 1.61; HR=1.42, 95% CI: 1.11, 1.81, respectively; for all study subjects, P for interaction=0.48). No association was observed for cancer-associated deaths. Our study showed that the association between depression and death differed by race and cause of death in individuals with a low socioeconomic status.

Concentrations of aripiprazole and dehydroaripiprazole in hair segments from deceased individuals with mental disorders

Segmental hair analysis provides information regarding previous long-term drug exposure, which is useful in the evaluation of cause of death for individuals with mental disorders. The aim was to analyze postmortem concentrations of the antipsychotic drug aripiprazole and its active metabolite dehydroaripiprazole in hair segments from individuals with known aripiprazole intake. Hair samples were collected during autopsy. Each sample was segmented into one to six 1cm segments, depending on the length of the hair shaft. Pulverized hair was extracted and analyzed using a previously published ultra-high-performance liquid chromatography–tandem mass spectrometric method. The 10th–90th percentile of aripiprazole concentrations in all hair segments (n=78) from 17 individuals were 0.024ng/mg–11ng/mg with a median of 2.3ng/mg, and the 10th–90th percentile concentrations of dehydroaripiprazole were 0.020ng/mg–11ng/mg, with a median of 2.6ng/mg, in all hair segments (n=71). The metabolite-to-parent drug ratios ranged from 0.21 to 1.5, with a median of 0.72. The administered doses were calculated for each individual based on aripiprazole prescription data and pharmacy pickups, giving dose estimates of 1mg–32mg daily. A positive significant correlation was observed between concentrations in hair and blood, whereas no trends were observed between the concentrations in hair and the estimated doses. Besides aripiprazole, other antipsychotic drugs were found in several hair segments, indicating a high degree of polypharmacy among all subjects. The present study establishes concentrations of aripiprazole and dehydroaripiprazole in hair segments from 17 deceased individuals with long-term aripiprazole use. In addition, hair analysis demonstrates the possibility of evaluating polypharmacy.

Population‐level impacts of natural and anthropogenic causes‐of‐death for Hawaiian monk seals in the main Hawaiian Islands

AbstractIdentifying, assessing, and ranking the impact of individual threats is fundamental to the conservation and recovery of rare and endangered species. In this analysis, we quantify not only the frequency of specific causes‐of‐death (CODs) among Main Hawaiian Island (MHI) monk seals, but also assess the impact of individual CODs on the intrinsic growth rate, λ, of the MHI population. We used gross necropsy results, histopathology, and other evidence to assign probabilities of 11 COD types to each mortality and then used Monte Carlo sampling to evaluate the influence of each COD on λ. By right censoring realizations involving specific CODs, we were able to estimate λ (and its associated uncertainty) when CODs were selectively removed from influencing survival. Applying the analysis to all known and inferred deaths believed to have occurred 2004–2019, the CODs with the largest influence on λ were anthropogenic trauma, anthropogenic drowning, and protozoal disease. In aggregate, anthropogenic CODs had a larger effect on the growth rate than either natural or disease CODs. Possible bias associated with differential carcass detection, recovery, and COD classification are discussed.

Life expectancy and cause of death in individuals with haemophilia A and B in Norway, 1986-2018.

Evaluate trends over time in age- and cause of death in males with haemophilia (PWH) in Norway compared with the general male population and investigate its correlates with improvements in haemophilia treatment. Data about age and cause of death in the period of 1986-2018, from two independent, high-quality national registries: the Norwegian Cause of Death Registry (NCoDR) and the patient registry at Centre for Rare Disorders (CRD), Oslo University Hospital. Life expectancy increased significantly from 1986 to 2018. However, PWH still had a decreased mean age at death of 56.8years (SD=24.7) in the NCoDR and 58.6years (SD=21.7) in the CRD data, compared with 73.9years (SD=16.3) in the general male population. There was a distinct shift in the most frequently reported haemophilia-related causes of death, such as haemorrhage and AIDS, to more age-related causes of death, such as cancer, reflecting an ageing population. Haemophilia treatment has improved significantly in the last three decades. Despite treatment-related improvements, PWH in Norway still have a decreased life expectancy compared with the general male population.

Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention for Chronic Total Occlusion

The optimal duration of dual antiplatelet therapy (DAPT) after treatment of chronic total occlusions (CTO) with percutaneous coronary intervention (PCI) is unknown. We aimed to determine if extended (> 12 months) DAPT was associated with a net clinical benefit. The study population included patients who underwent successful CTO PCI within Kaiser Permanente Northern California between 2009 and 2016. Baseline demographic, clinical, and procedural characteristics were compared for patients on DAPT ≤versus > 12 months. Clinical outcomes (death, myocardial infarction (MI), and≥ Academic Research Consortium type 3a bleeding) were compared beginning 12 months after PCI using Cox proportional hazards models. We also adjudicated individual causes of death. 1,069 patients were followed for a median of 3.6 years (Interquartile Range = 2.2 to 5.5) following CTO PCI. Patients on DAPT≤12 months (n = 597, 56%) were more likely to have anemia, end stage renal disease, and previous MI. After adjustment for between group differences, > 12 months of DAPT was associated with lower death or MI (hazard ratio [HR]: 0.66; 95% confidence interval [CI]: 0.47 to 0.93) and lower death (HR: 0.54; 95% CI: 0.36 to 0.82). There were no associations with MI (HR: 0.91; 95% CI: 0.55 to 1.5) or bleeding (HR 1.1; 95% CI: 0.50 to 2.4), but a numerically higher proportion of patients on shorter v. longer DAPT died of a cardiovascular cause (37% vs 20%, p = 0.10). In conclusion, > 12 months of DAPT was associated with lower death or MI, without an increase in bleeding. Prospective studies are needed to evaluate the optimal duration of DAPT in this unique subgroup.

Arterial Stiffness Predicts Mortality in Individuals With Type 1 Diabetes.

Type 1 diabetes is accompanied by a significant burden of cardiovascular disease (CVD), which is poorly explained by traditional risk factors. We therefore aimed to explore whether arterial stiffness estimated by the augmentation index (AIx) predicts mortality in individuals with type 1 diabetes. After baseline examination comprising pulse wave analysis by applanation tonometry alongside assessment of traditional cardiovascular risk factors, 906 individuals with type 1 diabetes from the Finnish Diabetic Nephropathy (FinnDiane) Study were followed up for a median of 8.2 years (interquartile range 5.7-9.7). Associations between baseline hemodynamics, including AIx, and all-cause mortality as well as a composite of cardiovascular and/or diabetes-related mortality were investigated using multivariable Cox regression models. The 67 individuals who died during follow-up had higher baseline AIx (median 28% [interquartile range 21-33] vs. 19% [9-27]; P < 0.001) compared with those alive. This association was independent of conventional risk factors (age, sex, BMI, HbA1c, estimated glomerular filtration rate [eGFR], and previous CVD event) in Cox regression analysis (standardized hazard ratio 1.71 [95% CI 1.10-2.65]; P = 0.017) and sustained in a subanalysis of individuals with chronic kidney disease. Similarly, higher AIx was associated with the composite secondary end point of cardiovascular and diabetes-related death (N = 53) after adjustments for sex, BMI, eGFR, previous CVD event, and height (standardized hazard ratio 2.30 [1.38-3.83]; P = 0.001). AIx predicts all-cause mortality as well as a composite cardiovascular and/or diabetes-related cause of death in individuals with type 1 diabetes, independent of established cardiovascular risk factors.

Turning the tide: reducing mortality among Danish merchant seafarers

ObjectivesWhile life at sea traditionally has presented a variety of potential hazards, rigorous measures have been taken in the past decades to ensure the safety and health of all aboard...

Association of Specific Mental Disorders With Premature Mortality in the Danish Population Using Alternative Measurement Methods.

The association of mental disorders with premature mortality published in the Global Burden of Disease (GBD) studies has been underestimated because these analyses have recommended using only a small number of mental disorders as causes of death to estimate years of life lost (YLL). Alternative methods have been introduced, such as estimating life-years lost (LYL), to compare individuals with mental disorders with the general population. To generate register-based YLL and LYL estimates and to use these measurement methods to assess the association of specific mental disorders with premature mortality. This population-based cohort study included all persons with and without mental disorders aged 0 to 94 years who were living in Denmark between January 1, 2000, and December 31, 2015. Data were analyzed from January to December 2019. Danish health registers were used to identify mental disorder diagnoses, dates of death, and causes of death. The YLLs were estimated for the set of mental health-associated causes of death, and all-cause and cause-specific LYLs were estimated for 18 specific mental disorders and 3 broad categories of mental disorders that were recommended for use in the GBD studies. The association between the number of comorbid mental disorders (divided into categories of persons with ≥1 type of disorder, ≥2 types of disorders, ≥3 types of disorders, and ≥4 types of disorders) and LYL estimates was also examined. A total of 6 989 627 individuals (3 481 219 male persons [49.8%] and 3 508 408 female persons [50.2%]; mean [SD] age at study enrollment, 32.2 [24.4] years) were followed up for a total of 85 911 461 person-years. The YLL rates per 100 000 person-years were highest for alcohol use disorder (for male individuals, 568.7 [95% CI, 564.4-572.7]; for female individuals, 155.5 [95% CI, 153.5-157.9]) and suicide (for male individuals, 590.1 [95% CI, 583.8-596.5]; for female individuals, 202.3 [95% CI, 198.5-206.4]). Although only 3 of 18 mental and substance use disorders could be associated with YLL, all mental disorders were associated with shorter life expectancies when LYL was used for measurement. Male and female individuals diagnosed with any mental disorder had life expectancies that were shorter by 11.2 years (95% CI, 11.1-11.3 years) and 7.9 years (95% CI, 7.8-8.0 years), respectively, and remaining life expectancy decreased further among those with comorbid mental disorders. Drug use disorders were associated with the highest excess LYL estimates; however, common mental disorders, such as depressive and anxiety disorders, were also associated with substantial premature mortality. Mental disorders were observed to be associated with reductions in life expectancy. This finding provides a foundation for future intervention programs designed to reduce the differential mortality gap associated with mental disorders. Register-based studies allow the calculation of precise individual-level YLLs and LYLs, and both measurement methods are informative for health care planning. Compared with YLL, the novel LYL measurement approach may more precisely capture the association of mental disorders with premature mortality and facilitates the exploration of comorbidity and specific causes of death in individuals with mental disorders.

Opioid sensitivity of projection‐specific Kölliker‐Fuse neurons

Opioid‐induced respiratory depression is the primary cause of death in individuals who overdose on opioids. Respiration is controlled by a highly interconnected neural network located in the pons and medulla. The Kölliker‐Fuse nucleus (KF), located in the dorsolateral pons, is an essential part of this network and projects to core respiratory nuclei in the ventrolateral medulla. Opioids injections into the KF disturb respiratory rate, volume, and pattern. Deletion of opioid receptors from KF neurons attenuates morphine‐induced respiratory depression. These studies suggest that the KF is a critical site in opioid‐induced respiratory depression. Mu opioid receptor agonists hyperpolarize a population of neurons in the KF due to activation of G protein‐mediated inwardly rectifying conductance. However, we do not know the projection target of the opioid‐sensitive KF neurons. Given the extensive projections from the KF to medullary respiratory rhythm generators, we hypothesize that opioid‐sensitive KF neurons project to respiratory rhythm generators. Fluorescent beads (FluoSpheres 580/605, ThermoFisher) were injected into the Bötzinger complex (BötC), pre‐Bötzinger complex (preBötC), and rostral ventral respiratory group (rVRG) of mice. Whole‐cell voltage‐clamp recordings were made from retrograde‐labeled KF neurons contained in brain slices. Mu opioid receptor‐mediated outward currents were identified in KF neurons that project to the preBötC, and rVRG, but not in KF neurons that project to the BötC. Opioid‐sensitive connections between the KF and respiratory rhythm generators may be a possible mechanism by which opioids reduce respiratory rate.Support or Funding InformationR00, DA038069

Multiparametric cardiac magnetic resonance imaging of the heart in people with spinal cord injury

Cardiovascular disease is the foremost cause of death for individuals with spinal cord injuries and is a patient priority in this population. To reduce cardiovascular disease, health care costs, and address key patient‐centered priorities, we must understand how and why heart health deteriorates after high‐level spinal cord injuries. Using high‐resolution cardiac magnetic resonance imaging and analysis approaches (ie., 4D strain analysis, 4D flow imaging, late gadolinium enhancement), our objective was to evaluate the impact of high‐level spinal cord injury on cardiac structure and function. Cardiac dimensions including chamber wall thickness were reduced in people with cervical spinal cord injury compared to matched controls and fibrosis was more apparent. Furthermore, we observed changes in global markers of strain in the heart including both longitudinal and circumferential strain after spinal cord injury. Cardiac magnetic resonance imaging revealed deficits in structure and function of the left ventricle after SCI. The next steps are to establish the risk factors leading to abnormal hearts after spinal cord injury, and develop strategies for prevention and treatment.Support or Funding InformationNatural Sciences and Engineering Research Council of Canada, Canadian Institutes of Health Research, Stephenson Cardiac Imaging Centre, University of Calgary, Libin Cardiovascular Institute, Hotchkiss Brain Institute, Campus Alberta Neuroscience, Clinical Neurosciences Pilot Research Fund Program, Compute Canada, Rick Hansen Institute, Wings for Life Foundation

Why Are We Not Closing the Gap in Suicide Disparities for Sexual Minority Youth?

* Abbreviation: SMY — : sexual minority youth In 2017, suicide was the second leading cause of death for individuals 10 to 24 years old.1 After a stable period from 2000 to 2007, the suicide rate among 15- to 19-year-old youth increased 76% through 2017. Sexual minority youth (SMY) have been known to be at increased risk.2 In this issue of Pediatrics , 2 groups of authors address the important question of whether the social progress toward acceptance of SMY has ameliorated this disparity. Liu et al3 report on trends of suicidal ideation and behaviors across a 23-year period (1995–2017) using data from the Massachusetts Youth Risk Behavioral Surveillance. Rates of suicidal ideation and behaviors declined for both SMY and heterosexual youth, with a steeper decline for heterosexual youth; rates remained markedly high for SMY across the 23 years with upward of 40% reporting ideation, 41% a plan, and 33% an attempt. Raifman et al4 expanded their consideration of suicide attempts among adolescents to include Youth Risk Behavioral Surveillance data (2009–2017) across 10 US states. Although suicide attempts declined among SMY, these youth were >3 times more likely to attempt suicide relative to heterosexual students in 2017. Although decreases in suicidal ideation and behaviors in both studies is encouraging, … Address correspondence to Brian Mustanski, PhD, Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N Michigan Ave, Suite 14-061, Chicago, IL 60611. E-mail: brian{at}northwestern.edu

Cystic Fibrosis Foundation consensus guidelines for the care of individuals with advanced cystic fibrosis lung disease

BackgroundAdvanced cystic fibrosis lung disease (ACFLD) is common, is associated with reduced quality of life, and remains the most frequent cause of death in individuals with cystic fibrosis (CF). These consensus guidelines provide recommendations to the CF community on management of both common and unique issues that arise when individuals reach a state of ACFLD. MethodsThe CF Foundation assembled a multidisciplinary expert panel consisting of three workgroups: Pulmonary management; Management of comorbid conditions; Symptom management and psychosocial issues. Topics were excluded if the management considerations did not differ in ACFLD from in the overall CF population or if already addressed in other published guidelines. Recommendations were based on a systematic literature review combined with expert opinion when appropriate. ResultsThe committee formulated twenty-three recommendation statements specific to ACFLD that address the definition of ACFLD, pulmonary and intensive care unit management, management of selected comorbidities, symptom control, and psychosocial issues. ConclusionsThese recommendations are intended to be paired with previously published management guidelines for the overall CF population, with the objective of reducing practice variability and improving overall care, quality of life, and survival in those with ACFLD.

Monitoring Social Media and Technology Use to Prevent Youth Suicide and School Violence

With suicide as the second leading cause of death for individuals between the ages of 10 and 34 and with mass school shootings averaging once per year, schools are exploring ways to prevent this seemingly increase in youth suicide and other forms of youth violence. School-based prevention initiatives such as social/emotional learning curricula, school-based mental health services, and internal threat assessment protocols are becoming more prevalent. Along with these prevention efforts, increases in youth use of technology and social media have created a market for social media monitoring companies that use algorithms to analyze youth social media posts for threats of harm toward themselves or others. School districts contract with these social media monitoring companies for assistance in identifying youth who may be at risk for violence. The purpose of this article is to describe one school district’s experience using social media monitoring programs as part of their comprehensive school violence prevention and mental health promotion effort. The school district was alerted to many students who made suicidal and homicidal threats on social media and after identifying those students, the students were able to receive referrals for mental health support.

Cardiovascular Sequelae of Sickle Cell Disease.

Sickle cell disease (SCD) is one of the most common hereditary hemoglobinopathies worldwide. It is a multisystem disease that causes considerable patient morbidity. Despite advances in medical treatment, cardiopulmonary complications remain the most common cause of death in individuals with SCD. A growing body of evidence has shown that SCD results in a spectrum of cardiovascular complications through a variety of mechanisms, including chronic hemolysis, local tissue hypoxia, increased oxidative stress, and autonomic instability. Herein, we will examine the pathophysiology of sickle cell vasculopathy and discuss the spectrum of cardiovascular sequelae of the disease, while highlighting the impact of SCD on the cardiovascular health of the patients.

Familial Hypertrophic Cardiomyopathy: Late Potentials and Other Prognostic Markers.

Familial hypertrophic cardiomyopathy is an autosomal dominant genetic disease considered the most common cause of sudden cardiac death in individuals under 35 years old, especially the athletes. This study aimed to investigate the association between the presence of late potentials and a family history of sudden death, syncope, and complex ventricular arrhythmias on patients with hypertrophic cardiomyopathy. A case series study was carried out from March 2001 to December 2002, including 22 patients with hypertrophic cardiomyopathy according to transthoracic echocardiogram criteria. Patients on a cardiac pacemaker, right bundle branch block, cardiac transplant, and under no possibilities to realize the exams were excluded. The results showed that asymmetric septal hypertrophy was the most common type (73%), 63% had a positive familial history of hypertrophic cardiomyopathy, 55% sudden cardiac death, and 23% syncope. Also, complex ventricular arrhythmias were detected in 14% and late potentials in 23% of patients. According to this study, the presence of late potentials was not associated with familial sudden death, syncope, and complex ventricular arrhythmias.

Coagulatory Defects in Type-1 and Type-2 Diabetes.

Diabetes (both type-1 and type-2) affects millions of individuals worldwide. A major cause of death for individuals with diabetes is cardiovascular diseases, in part since both types of diabetes lead to physiological changes that affect haemostasis. Those changes include altered concentrations of coagulatory proteins, hyper-activation of platelets, changes in metal ion homeostasis, alterations in lipid metabolism (leading to lipotoxicity in the heart and atherosclerosis), the presence of pro-coagulatory microparticles and endothelial dysfunction. In this review, we explore the different mechanisms by which diabetes leads to an increased risk of developing coagulatory disorders and how this differs between type-1 and type-2 diabetes.

The Role of Social Isolation in the Relationships Between Psychosis and Suicidal Ideation

Social isolation relates to worse mental health outcomes, including lower quality of life, depression, and both suicidal ideation and attempt. Among individuals experiencing symptoms of psychosis, suicide is a leading cause of death and data show greater isolation relates to increased negative symptoms as compared to individuals with strong support systems. While isolation has been linked with negative symptoms in the literature, less is known about its relationships with positive symptoms of psychosis (e.g., hallucinations and delusions), particularly within the context of a general population-based sample. This study examined the relationships between hallucinations, delusions, depression, social isolation, and suicidal ideation. Participants were involved in the cross-sectional Collaborative Psychiatric Epidemiology Surveys (CPES) including a large general population-based sample of households in the United States between 2001 and 2003. Participants (n = 12,195) included adults over the age of 18 in the United States, all of whom completed a psychosis assessment. Hopelessness was measured using The Calgary Depression Scale for Schizophrenia (CDSS), hallucinations and delusions by the Positive and Negative Syndrome Scale (PANSS), and social isolation by three PANSS items (keeping to self, feeling awkward in social settings, preferring to be alone), all at baseline. Data were analyzed in Mplus 8 using structural equation modeling. As hallucinations, delusions, and depression independently increased, on average there were associated increases in social isolation and the likelihood of experiencing suicidal ideation. Social isolation also related to greater suicidal ideation and ultimately functioned as a mediator. With suicide being a leading cause of death for individuals experiencing psychosis, the mediating role of social isolation in the relationships between hallucinations, delusions, depression, and suicidal ideation speaks towards the importance of social support and skills training as important treatment targets in practice.

SGLT1 inhibition boon or bane for diabetes-associated cardiomyopathy.

Chronic hyperglycaemia is a peculiar feature of diabetes mellitus (DM). Sequential metabolic abnormalities accompanying glucotoxicity are some of its implications. Glucotoxicity most likely corresponds to the vascular intricacy and metabolic alterations, such as increased oxidation of free fatty acids and reduced glucose oxidation. More than half of those with diabetes also develop cardiac abnormalities due to unknown causes, posing a major threat to the currently available marketed preparations which are being used for treating these cardiac complications. Even though impairment in cardiac functioning is the principal cause of death in individuals with type 2 diabetes (T2D), reducing plasma glucose levels has little effect on cardiovascular disease (CVD) risk. In vitro and in vivo studies have demonstrated that inhibitors of sodium glucose transporter (SGLT) represent a putative therapeutic intervention for these pathological conditions. Several clinical trials have reported the efficacy of SGLT inhibitors as a novel and potent antidiabetic agent which along with its antihyperglycaemic activity possesses the potential of effectively treating its associated cardiac abnormalities. Thus, hereby, the present review highlights the role of SGLT inhibitors as a successful drug candidate for correcting the shifts in deregulation of cardiac energy substrate metabolism together with its role in treating diabetes-related cardiac perturbations.

Rise in Youth Suicide Rates Confounds Experts

Rise in Youth Suicide Rates Confounds Experts