County Hospital, Durham
Honorary Senior Research Associate, Royal Victoria Infirmary, Newcastle upon Tyne
Department of Psychiatry, University of Newcastle upon Tyne
Correspondence: Dr Keith Linsley, Consultant Psychiatrist, County Hospital, North Road, Durham DHI 4ST. E-mail: keith.linsley{at}cddpsnhs.fsnet.co.uk
See pp. 458464, this
issue.
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ABSTRACT |
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Aims To examine similarities and differences in cases defined by the coroner as suicide and open verdicts and the implications of open verdicts for suicide research.
Method All cases of open and suicide verdicts recorded in the Newcastle Coroner's Court in the period 1985-1994 were compared on demographic and medical parameters.
Results Open and suicide verdicts had many similarities, differing only in some respects, of which logistic regression identified the most significant to be a suicide note, method used and age.
Conclusions Open verdicts should be included in all suicide research after excluding cases in which suicide was unlikely. Objective criteria are needed to facilitate comparison between different studies.
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INTRODUCTION |
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Our study compares open and suicide verdicts, excluding cases in which suicide was considered either impossible or unlikely. The process of exclusion and its significance is discussed.
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METHOD |
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All open verdicts were assessed by two of the authors (K.R.L. and K.S.) independently. Cases were classified as probable suicide, or suicide impossible or unlikely. The small number of cases in which assessment differed was jointly reviewed and, after discussion, a consensus category agreed. Examples of cases of suicide impossible included cases of babies found dead, cases of malignant disease (with no suspicion of self-harm) and deaths immediately following surgery. The category of suicide unlikely was allocated to cases such as that of a young man who in a state of solvent intoxication fell from a window and of an elderly lady with dementia and who was prone to wander, found drowned in a small stream. In these cases there was no suspicion of suicidal thinking before the event. We identified 188 suicide verdicts (139 males and 49 females) and 185 open verdicts. Of the latter, we excluded 26 cases (suicide unlikely or impossible), leaving a total of 159 open verdicts considered to be probable suicides (99 males and 60 females). The open:suicide verdict ratio (OSR) was 0.85.
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RESULTS |
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Psychiatric morbidity
This was recorded in a hierarchical fashion so that if someone had a
history of previous in-patient care, out-patient attendance was not also
recorded. No significant difference was found (see
Table 1) but the high
percentage in both groups who had received psychiatric treatment should be
noted.
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Alcohol consumption
Of those with documented alcohol levels (open verdicts, n=149;
suicide verdicts, n=186), a significantly greater proportion of those
given open verdicts had consumed alcohol at or around the time of suicide
(50%, n=74 v. 38.7%, n=72) (2=4.04,
d.f.=1, P<0.05). A significantly greater proportion of those given
open verdicts were judged to be heavily intoxicated (18.1%, n=27),
based on blood alcohol levels, than suicide verdicts (9.7%, n=18)
(
2=5.07, d.f.=1, P<0.05).
Suicide notes
Of the open verdicts, 11.3% (n=18) of persons had written a
suicide note compared with 49.5% (n=93) in suicide verdicts
(2=56.1, d.f.=1, P<0.01). As regards the content
of the suicide notes in the open verdict cases, in seven cases there was no
hint of any suicide intent and in a further seven such intent was not clearly
stated but alluded to in a euphemistic manner such as see you in
another life. Four cases stated their intent to kill themselves but
three of these were heavily intoxicated and in the remaining case an audio
tape with a suicide message was only discovered after the inquest. Among the
open verdict cases who had left suicides notes, 55.6% (n=10) had
blood alcohol levels indicating intoxication compared with only 13.0%
(n=17) of open verdict cases judged intoxicated who had not written
notes (
2=19.34, d.f.=1, P<0.01).
Method of suicide
As can be seen from Fig. 1,
there is a significantly higher frequency of hanging (2=15.4,
d.f.=1, P<0.01) and carbon monoxide (CO) poisoning
(
2=11.3, d.f.=1, P<0.01) in the suicide verdict
group, whereas drowning (
2=6.9, d.f.=1, P<0.01)
and falling from a height (
2=4.8, d.f.=1,
P<0.05) occurred more frequently within the open verdict
group.
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Influence of exclusions
In Newcastle upon Tyne there has been a considerable change in the pattern
of open verdicts recorded since 1961 (see
Fig. 2). However, this graph
illustrates all open verdicts. In our current series we excluded 26
cases (14%) of open verdicts from the analysis, judging them to be
non-suicides. Examination of the 106 open verdicts recorded between 1961 and
1965 resulted in the exclusion of 53 cases (50%) as being
non-suicides: a significant difference from the number excluded
in this series (2=44, d.f.=1, P<0.01).
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Discriminating variables
Logistic regression was undertaken to determine which variables were most
accurate in discriminating between an open and suicide verdict. A forward
stepwise model was used with an admission criterion of P<0.05 and
rejection of P>0.1. The most accurate model achieved a correct
prediction level of 76.5% (open verdicts 75.9%, suicide verdicts 77.1%). In
this model, six variables contribute to the statistical differentiation
between suicide and open verdicts (model 2=111.6, d.f.=6,
P<0.001). In descending statistical importance, the variables
were: a suicide note, hanging, CO, age, other substances and
other methods. Other substances refers to any
substance ingested or injected not already included and would cover drugs such
as insulin or chemicals such as paraquat. Other methods refers
to those not accounted for already, such as cutting. The number of correct
predictions of 261 out of a possible 341 gives a moderate Cohen's
value of 0.529. Given that 188 (58.3%) out of 347 suicide verdicts could have
been predicted correctly by chance, the information available results in a
moderate increase in accuracy of prediction.
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DISCUSSION |
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Some papers do not exclude cases (Salib, 1997; Hawton et al, 1998) while others do not report the number of open verdicts excluded (Vassilas & Morgan, 1997), exclusions here being decided on the basis of a panel of three psychiatrists. The precise criteria each used are not stated. Cooper & Milroy (1995) excluded 117 open verdict cases out of 330 (35%), judging them not to be suicides. They give a comprehensive list of criteria on which a decision was made. Appleby et al (1999) excluded 11.3% of open verdicts if "the coroner's records clearly indicated a suspected cause of death other than suicide". It is difficult, therefore, to know whether or not different authors use the same criteria and how this affects the relative contribution of open verdicts on their findings. Such variation in practice underlines the need for operational criteria to help decide which open verdicts should be included as suicides, such as have been suggested by Jobes et al (1987). We are not aware, however, of any criteria which have been validated and assessed for reliability.
The increasing importance of open verdicts to suicide statistics
Nationally, there has been an increasing number of open verdicts. Neeleman
& Wessley (1997) found the
OSR in England and Wales increased by a factor of 1.2 (males) and 1.15
(females) every 3 years from 1974 to 1991. However, open verdict cases where
suicide was unlikely or indeed impossible were not excluded from their
analysis. Moreover, the frequency of such exclusions may vary with the time
period, as we have found in our study. The OSR for England and Wales during
1989-1991 was 0.65, making open verdicts a large contributor to suicide
statistics. The OSR of 0.85 found in our study is greater than this national
rate (and would of course be higher again if we had not excluded 26 open
verdicts). This difference may reflect a relatively greater number who drowned
or fell from a height in Newcastle, which has the River Tyne spanned by
several bridges. Combining our open and suicide verdicts, 77 cases (22.2%)
used one of these methods compared with 8% in England and Wales
(Office for National Statistics,
1995). This suggests the relative importance of open verdicts
varies considerably from area to area, as well as between time periods. As the
OSR rises, it becomes increasingly important to ascertain correctly which open
verdicts should be included as probable suicides.
Comparison of open with suicide verdicts
The comparison of open with suicide verdicts revealed many similarities,
although some differences were found. Can we explain these differences based
on the fact that a coroner will only arrive at a verdict of suicide based on
information which clearly indicates beyond reasonable doubt that the deceased
intended to take their own life? A suicide note might be considered such
evidence, as would the perceived lethality of the mode of death. Taylor
(1982) has considered these as
primary suicidal clues. Our finding of suicide notes in 11.3% of
cases is lower than that reported by Jacobson et al
(1976) of 20% of cases, but
similar to that of Neeleman et al
(1997) of 12.8% of cases.
Analysis of the notes, however, failed to reveal clear suicidal intent, except
in four cases, three of which had blood alcohol levels indicating
intoxication. High blood alcohol levels were found in seven other cases of
open verdicts where notes had been left. This may have influenced the coroner
to regard intoxication as impairing the ability of the deceased to form
suicidal intent. However, that this consideration is not a sole deciding
factor is reflected by the finding that 9.7% of suicide verdict cases were
judged to be intoxicated at the time of suicide.
Taylor (1982) also refers to secondary suicidal clues, such as the deceased's psychological and medical history. Such clues, however, do not directly imply suicidal intent and so should not influence the coroner's decision. The similarities we have found between open and suicide verdicts in respect of these clues lends support to such a view.
Our findings are in agreement with similar studies using logistic regression analysis in that method used and suicide notes are the main discriminating factors between open and suicide verdicts. Salib's (1997) study of unexpected deaths in the elderly given either an open or suicide verdict, found the main determining factors influencing coroners' verdicts were: intimation of intent to die, method used and past psychiatric history. Platt et al (1988) found that the method used was the most powerful discriminator. Cooper & Milroy (1995) found certain modes of death such as drowning, jumping, poisoning, and self-immolation were more likely to receive an open verdict.
Variables such as age, gender, marital status and social class might be expected not to influence coroners' verdicts. We found that gender and social class distribution was different between the two verdicts. It is recognised, however, that different methods are used by the genders (Charlton et al, 1992; Cooper & Milroy, 1995) and, when controlled for, such a difference may disappear (Holding & Barraclough, 1978). Indeed, when using logistical regression analysis the influence of method is shown to be of prime importance and, when adjusted for, reduces the contribution of gender and social class to a non-significant level. We cannot readily explain the finding of age as a significant discriminating variable.
Implications for suicide research?
The marked similarities between the two groups lend support to the current
practice of including cases of open verdicts in epidemiological suicide
studies. However, the assumption that all open verdicts are suicides could
substantially distort the true suicide rate. This is
particularly important at a time when the Government is setting targets for
suicide reduction which include all open verdicts and an increasing number of
unnatural deaths are given legally defined open verdicts.
It is important that a standardised assessment instrument be developed to help decide which open verdicts be included as suicides and which excluded, in order to produce a more reliable picture of the epidemiology of suicide. Such an instrument will permit more valuable comparisons between populations.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication February 17, 2000. Revision received November 6, 2000. Accepted for publication November 20, 2000.
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