Abstract
Objective
To identify cause-of-death categories in which suicides might be misclassified in Taiwan.
Methods
We plotted secular trends (1971–2007) in sex- and method-specific rates of deaths classified as suicide, undetermined intent and accident for the Taiwanese population aged 15+ and compared the sex, age and marital status profiles of deaths in these three categories by method of death.
Results
The demographic profiles of registered suicides generally resembled those for deaths of undetermined intent and accidents by pesticide poisoning/suffocation but differed from those for accidents from non-pesticide poisoning/drowning/falling/poisoning by non-domestic gas. For the period 1990–2007, suicide rates based on suicides alone (14.8 per 100,000) would increase by 23, 7 and 1%, respectively, when including deaths of undetermined intent, accidental pesticide poisonings and accidental suffocations.
Conclusions
Suicide rates may be underestimated by more than 30% in Taiwan because some suicides are ‘hidden’ amongst deaths certified as due to other causes.
Similar content being viewed by others
References
Ahmad O, Boschi-Pinto C, Lopez AD, Murray CJL, Lozano R, Inoue M (2001) Age standardization of rates: a new WHO standard. World Health Organization, Geneva
Allebeck P, Allgulander C, Henningsohn L, Jakobsson SW (1991) Causes of death in a cohort of 50,465 young men—validity of recorded suicide as underlying cause of death. Scand J Soc Med 19:242–247
Barraclough BM (1974) Poisoning cases: suicide or accidents. Br J Psychiatry 124:526–530
Baumert J, Erazo N, Ruf E, Ladwig KH (2008) Time trends in suicide mortality vary in choice of methods: an analysis of 145,865 fatal suicide cases in Germany 1991–2002. Soc Psychiatry Psychiatr Epidemiol 43:913–919
Breiding MJ, Wiersema B (2006) Variability of undetermined manner of death classification in the US. Inj Prev 12 Suppl 2:ii49–ii54
Charlton J, Kelly S, Dunnell K, Evans B, Jenkins R, Wallis R (1992) Trends in suicide deaths in England and Wales. Popul Trends 69:10–16
Cheng AT (1995) Mental illness and suicide. A case-control study in east Taiwan. Arch Gen Psychiatry 52:594–603
Chishti P, Stone DH, Corcoran P, Williamson E, Petridou E (2003) Suicide mortality in the European Union. Eur J Public Health 13:108–114
Connolly JF, Cullen A (1995) Under-reporting of suicide in an Irish county. Crisis 16:34–38
Cooper PN, Milroy CM (1995) The coroner’s system and under-reporting of suicide. Med Sci Law 35:319–326
de Castro EF, Pimenta F, Martins I (1989) The truth about suicide in Portugal. Acta Psychiatr Scand 80:334–339
Department of Health (2002) National Suicide Prevention Strategy for England. London
Gunnell D, Eddleston M, Phillips MR, Konradsen F (2007) The global distribution of fatal pesticide self-poisoning: systematic review. BMC Public Health 7:357
Hsu S-P (1993) The accuracy of official suicide statistics in Taiwan. MSc thesis. Institute of Public Health. National Taiwan University, Taipei, Taiwan
Jacobson S, Bagley C, Rehin A (1976) Clinical and social variables which differentiate suicide, open and accident verdicts. Psychol Med 6:417–421
Jougla E, Pequignot F, Chappert J, Rossollin F, Le Toullec A, Pavillon G (2002) Quality of suicide mortality data. Rev Epidemiol Sante Publique 50:49–62
Kolmos L (1987) Suicide in Scandinavia. An epidemiological analysis. Acta Psychiatr Scand Suppl 336:11–16
Kolmos L, Bach E (1987) Sources of error in registering suicide. Acta Psychiatr Scand Suppl 336:22–43
Lee HL, Lin HJ, Yeh ST, Chi CH, Guo HR (2008) Presentations of patients of poisoning and predictors of poisoning-related fatality: findings from a hospital-based prospective study. BMC Public Health 8:7
Lin JJ, Chen LH, Huang SM, Lu TH (2008) Problems in estimating the number of suicides by charcoal burning in Taiwan. J Epidemiol Community Health 62:566
Lin JJ, Lu TH (2008) Suicide mortality trends by sex, age and method in Taiwan, 1971–2005. BMC Public Health 8:6
Lin L-J, Lin T-J, Shih Y-L, Tsai J-L, Tsai M-S (2003) The patients presented in emergency department with poisoning exposure, 1995–2002. J Taiwan Emerg Med 5:181–189
Lindqvist P, Gustafsson L (2002) Suicide classification—clues and their use. A study of 122 cases of suicide and undetermined manner of death. Forensic Sci Int 128:136–140
Linsley KR, Schapira K, Kelly TP (2001) Open verdict v suicide-importance to research. Br J Psychiatry 178:465–468
Lu TH (2002) Changes in injury mortality by intent and mechanism in Taiwan, 1975–98. Inj Prev 8:70–73
Lu TH, Sun SM, Huang SM, Lin JJ (2006) Mind your manners: quality of manner of death certification among medical examiners and coroners in Taiwan. Am J Forensic Med Pathol 27:352–354
Maniam T (1995) Suicide and undetermined violent deaths in Malaysia, 1966–1990: evidence for the misclassification of suicide statistics. Asia Pac J Public Health 8:181–185
Marusic A, Roskar S, Zorko M (2003) Undetermined deaths: are they suicides? Croat Med J 44:550–552
Ministry of Justice, Taiwan (2007) The Code of Criminal Procedure. No. 218
Mohler B, Earls F (2001) Trends in adolescent suicide: misclassification bias? Am J Public Health 91:150–153
Neeleman J, Wessely S (1997) Changes in classification of suicide in England and Wales: time trends and associations with coroners’ professional backgrounds. Psychol Med 27:467–472
O’Carroll PW (1989) A consideration of the validity and reliability of suicide mortality data. Suicide Life Threat Behav 19:1–16
Ohberg A, Lonnqvist J (1998) Suicides hidden among undetermined deaths. Acta Psychiatr Scand 98:214–218
Phillips DP, Ruth TE (1993) Adequacy of official suicide statistics for scientific research and public policy. Suicide Life Threat Behav 23:307–319
Platt S, Backett S, Kreitman N (1988) Social construction or causal ascription: distinguishing suicide from undetermined deaths. Soc Psychiatry Psychiatr Epidemiol 23:217–221
Pritchard C, Amanullah S (2007) An analysis of suicide and undetermined deaths in 17 predominantly Islamic countries contrasted with the UK. Psychol Med 37:421–430
Pritchard C, Hean S (2008) Suicide and undetermined deaths among youths and young adults in Latin America: comparison with the 10 major developed countries—a source of hidden suicides? Crisis 29:145–153
Rockett IR, Smith GS (1993) Covert suicide among elderly Japanese females: questioning unintentional drownings. Soc Sci Med 36:1467–1472
Rockett IR, Thomas BM (1999) Reliability and sensitivity of suicide certification in higher-income countries. Suicide Life Threat Behav 29:141–149
Salib E (1997) Coroner’s verdicts in the elderly: a suicide or an open verdict? Int J Geriatr Psychiatry 12:481–483
Sheu JJ, Wang JD, Wu YK (1998) Determinants of lethality from suicidal pesticide poisoning in metropolitan HsinChu. Vet Hum Toxicol 40:332–336
Taylor SJ, Kingdom D, Jenkins R (1997) How are nations trying to prevent suicide? An analysis of national suicide prevention strategies. Acta Psychiatr Scand 95:457–463
Walsh B, Walsh D, Whelan B (1975) Suicide in Dublin: II The influence of some social and medical factors on coroners’ verdicts. Br J Psychiatry 126:309–312
Wang CS, Chou P (1997) An analysis of unnatural deaths between 1990 and 1994 in A-Lein, Taiwan. Injury 28:203–208
World Health Organization (1965) International Statistical Classification of Diseases, 8th Revision (ICD-8). World Health Organization, Geneva
World Health Organization (1977) International Statistical Classification of Diseases, Injuries, and Causes of Death, 9th Revision (ICD-9). World Health Organization, Geneva
Wu R-N, Cheng Y-W (2008) Trends in suicide mortality in Taiwan, 1959–2006. Taiwan J Public Health 27:110–120
Yang CC, Wu JF, Ong HC, Hung SC, Kuo YP, Sa CH, Chen SS, Deng JF (1996) Taiwan National Poison Center: epidemiologic data 1985–1993. J Toxicol Clin Toxicol 34:651–663
Acknowledgments
We wish to acknowledge the support for S.-S. Chang’s PhD study from the Taiwanese government (the Government Funds of the Ministry of Education), the Higher Education Funding Council for England (Overseas Research Scholarship) and University of Bristol (University of Bristol Postgraduate Research Scholarship).
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Chang, SS., Sterne, J.A.C., Lu, TH. et al. ‘Hidden’ suicides amongst deaths certified as undetermined intent, accident by pesticide poisoning and accident by suffocation in Taiwan. Soc Psychiat Epidemiol 45, 143–152 (2010). https://doi.org/10.1007/s00127-009-0049-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00127-009-0049-x