Original communication
Toxicology findings in suicides: Concentrations of ethanol and other drugs in femoral blood in victims of hanging and poisoning in relation to age and gender of the deceased

https://doi.org/10.1016/j.jflm.2013.06.027Get rights and content

Abstract

Over-consumption of alcohol and/or abuse of other drugs are closely linked to attempted or completed suicides. In this retrospective 10-year study (2001–2010), we compared the toxicology findings in hanging suicides (n = 4551) with drug poisoning (intoxication) suicides (n = 2468). The mean age of hanging deaths was 49 ± 19 y (±SD) and 80% were male, compared with a mean age of 52 ± 17 y and 47% males for the intoxication deaths. Poly-drug use was more common in poisoning suicides with an average of 3.6 drugs/case compared with 1.8 drugs/case in hangings. Moreover, 31% of hangings were negative for alcohol and/or drugs. Alcohol was detected (>0.20 g/L) in femoral blood in 30% of hanging suicides (mean 1.39 g/L) and 36% of drug poisonings (mean 1.39 g/L). The median BACs did not depend on the person's age or gender (p > 0.05). Ethanol, paracetamol, citalopram, diazepam, propiomazine, alimemazine and zopiclone were amongst the top-ten drugs detected in both methods of suicide. With the exception of ethanol, the concentrations of drugs in blood were considerably higher in the poisoning deaths, as might be expected. Regardless of the method of suicide, antidepressants and/or antipsychotics were common findings, which could implicate mental health as a significant suicide risk factor.

Introduction

Suicide is a major cause of unnatural death in most nations and this public health problem deserves close attention and scrutiny in order to decrease mortality rates. The risk factors for suicidal behaviour are many and varied and depend on the victims age, gender, mental health and other characteristics, including ethnicity.1, 2, 3 A prominent feature of many suicide deaths in Western nations is over-consumption of alcohol, as shown by elevated blood-alcohol concentrations (BAC) being frequently found at autopsy.4, 5, 6 Drunkenness leads to poor judgement and self control, people tend to become less inhibited, more impulsive and reckless, including self-harm, which in pre-disposed individuals might trigger a suicide attempt.7, 8, 9 The many environmental factors linked to propensity to commit suicide include long-term unemployment, family bereavement, divorce, business failures, media coverage of suicides, internet activities and the economic recession.10, 11, 12, 13

During police investigations of suicide deaths, the toxicological analysis of blood and urine samples from the deceased provides important, often crucial, information when the manner of death is determined.5, 14, 15 Restricting the availability of certain over-the-counter drugs, such as paracetamol, a drug often implicated in poisoning suicides, has proven an effective preventative measure.16, 17 A large body of research has focused on the demographics of suicide victims, the methods people use to take their own life and ways of prevention. Hanging deaths are common in male victims, whereas females prefer less violent deaths and resort to taking drug overdoses, although this depends on the person's age, maturity, nationality, and mental health status.18, 19 For example, the drugs and poisons used by people living in India or China are dominated by agricultural chemicals, such as pesticides, whereas overdosing with alcohol and/or prescription drugs occurs in Sweden and other Nordic countries.20, 21

We undertook a retrospective database study to investigate the demographics and toxicology findings in hanging and poisoning suicides, so-called intoxication deaths. The cases were selected from International Classification of Disease Codes (ICD-9) assigned by forensic pathologists following completion of the case, including autopsy findings, medical records, findings at the scene (e.g. suicide note), police investigations, interviews with spouse, neighbours, friends and/or relatives and also the results of toxicological analysis.

Section snippets

Forensic toxicology in Sweden

Forensic toxicology in Sweden (population 9.3 million) is centralized in a single accredited laboratory. The local police authorities request a forensic autopsy when a sudden and unexpected out-of-hospital death occurs or when circumstances suggest foul play. Forensic autopsies are performed at the six university teaching hospitals in Sweden and biological specimens are sent for toxicological analysis in special refrigerated containers.

We used an in-house database (TOXBASE) to retrieve

Trends in suicide deaths over time

The number of hanging suicides exceeded drug poisonings every year over the 10-year period of collection of the data (Fig. 1). In Sweden an average of 1153 suicide deaths per year were recorded and 36–42% of these were by hanging and 19–23% by poisoning. These results were remarkably consistent over the ten-year period.

Demographics of suicide victims

The mean age (±SD) of hanging suicides was 49 ± 19 y compared with 52 ± 17 y in drug poisonings (p < 0.001), as shown in Table 1. More males (80%) than females (20%) died as a

Discussion

Although a large body of research documents the epidemiology, demographics, psycho-social factors, as well as various ways to prevent suicide, comparatively few studies have reported concentrations of drugs present in the blood of suicide victims.23, 24 All suicides in Sweden (population 9.3 million) undergo a forensic autopsy and pathologists request the analysis of ethanol and other drugs in post-mortem blood and/or urine samples. This analytical work is done at one central laboratory and

Conclusion

This study verifies that death by hanging was more prevalent in males (80%) compared with females (20%) by a factor of 4:1, which has been observed earlier in other countries.42, 43 Furthermore, the results showed that in 30% of hangings and 36% of intoxication suicides victims had been drinking alcohol and many were heavily intoxicated when they died. This suggests that treatment for substance abuse might be beneficial after a failed suicide attempt as a way to lower suicide mortality. The

Ethical approval

Application to the University Ethical Committee was not considered necessary, because none of the victims, apart from their age and gender, were identifiable from the material evaluated.

Funding

There was no external funding applied for or received for preparing this manuscript.

Conflict of interest

The authors declare that there were no conflicts of interest with any institution or organization during the preparation of this article.

References (43)

  • V.J. Callanan et al.

    Gender differences in suicide methods

    Soc Psychiatry Psychiatr Epidemiol

    (2012 Jun)
  • A. Ohberg et al.

    Alcohol and drugs in suicides

    Br J Psychiatry

    (1996 Jul)
  • J. Brady

    The association between alcohol misuse and suicidal behaviour

    Alcohol Alcohol

    (2006 Sep-Oct)
  • K. Hawton et al.

    Alcoholism, alcohol and attempted suicide

    Alcohol Alcohol

    (1989)
  • A. Klimkiewicz et al.

    Suicide attempts during heavy drinking episodes among individuals entering alcohol treatment in Warsaw, Poland

    Alcohol Alcohol

    (2012 Sep-Oct)
  • M. Miller et al.

    Suicide mortality in the United States: the importance of attending to method in understanding population-level disparities in the burden of suicide

    Annu Rev Public Health

    (2012 Apr)
  • B. Barr et al.

    Suicides associated with the 2008–10 economic recession in England: time trend analysis

    BMJ

    (2012)
  • P.S. Yip et al.

    Employment status and suicide: the complex relationships between changing unemployment rates and death rates

    J Epidemiol Community Health

    (2011 Aug)
  • L. Biddle et al.

    Suicide and the internet

    BMJ

    (2008 Apr 12)
  • L.B. Shields et al.

    Toxicologic findings in suicide: a 10-year retrospective review of Kentucky medical examiner cases

    Am J Forensic Med Pathol

    (2006 Jun)
  • S. Darke et al.

    Toxicology and circumstances of completed suicide by means other than overdose

    J Forensic Sci

    (2009 Mar)
  • Cited by (31)

    • Alcohol use by suicide victims in the city of Sao Paulo, Brazil, 2011–2015

      2018, Journal of Forensic and Legal Medicine
      Citation Excerpt :

      Alcohol is a licit psychoactive, easily available and low cost drug, making it one of the most consumed substances worldwide.11 Excessive alcohol consumption and/or abuse of other drugs are closely linked to suicide deaths,12 as drunkenness can affect critical judgment and self-control and trigger suicidal behavior. It is well recognized that individuals with a history of psychoactive substances abuse are overrepresented in mortality statistics.13–15

    • Themes and trends in intentional self-poisoning: Perspectives from critical care toxicology

      2017, Psychiatry Research
      Citation Excerpt :

      As in the ToxIC data, co-occurring ethanol toxicity was common; 118 (18.8%) of the patients had evidence of alcohol intoxication at the time of ingestion. Ninety percent of the assayed serum ethanol concentrations ranged from 80 to 250 mg/dL with none in excess of 300 mg/dL, consistent with findings in studies of suicide decedents (Holmgren and Jones, 2010; Jones et al., 2013). One PinnacleHealth patient indicated that ethanol was the chosen toxin for self-poisoning—we recorded his intent to “drink [him]self to death.”

    • Demographics and post-mortem toxicology findings in deaths among people arrested multiple times for use of illicit drugs and/or impaired driving

      2016, Forensic Science International
      Citation Excerpt :

      Neither antidepressants nor antipsychotics were high on the list of drugs identified in blood samples from post-mortem examination of repeat offenders. These latter classes of drugs are more often encountered in blood samples from victims of suicide by overdosing with drugs [25]. Use of multiple drugs (four or more) was more common in poisoning deaths (46%) compared with other causes of death (14%) and the manner of death was more often considered an accidental overdose.

    View all citing articles on Scopus
    View full text