Original communicationToxicology 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
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.
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