Brit.J.
P@ychiat. (i@7@), is@, 247—56
The Comparability By M. W. ATKINSON,
of Suicide Rates
NEIL KESSEL
and J. B. DALGAARD
Summary. Programmes of suicide prevention require for their planning accurateepidemiological surveys. Doubt has been caston theaccuracyofmany existing surveysbecauseofthe realization thatsuicide isunder-reported and becauseofthelackofconsistency in theprocedureforsuicide ascertainment. Two studies are described in this paper which attempt to examine the problem. The first is part of an international study supported by the World Health Organization.
In it, Denmark
and England
are compared,
and it is shown
that
therearestriking differences insuicide ascertainment procedurebetweenthetwo countries. Next, on a blind basis,coronersand theiroppositenumbers in Denmark examine a sample of each other's caserecords. It isfound thatthe Danes consistently reportmore suicides than do the Englishcoronerson the same casematerial; thusconsiderable doubt iscaston thesupposeddifference in suicide ratesbetween thetwo countries. In thesecondstudy,deathsby poisoningareexamined forcertaincoroners' districts
in England
and Wales.
It is shown
that there
is considerable
variation
from one district to another in the relative proportions of these deaths which achievean accident, an open or a suicide verdict. Thissuggests thatinEngland and Wales coroners may not be consistent in their suicide ascertainment criteria. Hypotheses
attempting
to account
for differences
in suicide
rate based on such
epidemiological surveysshouldbe viewedwith greatcaution.
IrPoDuc'rIoN acceptedto the extentthat conclusions have An effective programme ofsuicide prevention been drawn from them and hypotheses elabo must be based on carefully designed epidemio ratedto explainthe differences. Such figures logical studies. It is not enough to provide have on occasionbeen regarded as indices appropriatecentresforthe careand treatment of a country'smoral standardsor itssocio of thosewho make an attempton theirlives. psychological health.They have also been There must also be identification of those considered inevaluating thecapacityofvarious populationgroupsand thoseindividuals within social systemstoprocurehappinessand security a community who aremost at risk. fortheirmembers. The World HealthOrganization(14)collects Many have, however, agreed with Stengel and publishes the officially reported suicide (io, i i) that suicide is generally under rates of many countries and has demonstrated reported and that because the methods of wide variations from ratesof lessthan 10 per suicide ascertainment vary from one country 100,000 to over 30 per ioo,ooo of population to another these international comparisons are deaths. These and other studies suggest that unreliableand no usefulconclusions can be there
are
differences
in
suicide
rates
both
drawn
from them.
between nationsand between groups within Though a suicidal actmay be thoughtto be nations. Though ithas been argued thatsuch precise and well-defined therearemany reasons figures are unreliable, the data have been why officially reportedratescouldbe unreliable. 247
248
THE COMPARABiLITY
OF SUICIDE RATES
The World Health Organization (13) has suggested that a suicidal act should be defined
pendent
of them
as
cultural
factors
specific
country.
Walsh
and
‘¿self-injury
with
varying
degrees
of
lethal
intent' and suicide would mean ‘¿a suicidal act with fatal outcome'. Since the victim is dead, however, the degree of lethal intention is something that can only be inferred retro spectively. There may be no evidence available, as in the case of single people living alone or, for example, in the single vehicle car crashes described by Dalgaard and others (s). The evidence may be concealed by relatives for fear of social or religious disapproval, perhaps especially
in
Catholic
countries.
The
appro
priate authorities may not seek out the evidence with equal diligence, or theseauthorities may differ in the inferences they draw from given facts. Ettlinger (@) has observed that the context in which the decision of suicide is made may in itself influence that decision or decide whether the events
are even referred
for diagnosis.
This
is a view shared by Dalgaard (s),who has observedthatinsome countries, suchasEngland and Wales, inquests are held by coroners at a coroners' court,ina legalsetting, intothecauses of unnatural death. These coroners apply legal criteria in arriving at their verdict, which must be proven. In other countries, such as Sweden and Denmark, where suicide is not a matter of concern to the law, the decision is made by officially designated medical men sitting in
these
differences
similar
view
and
in
must
therefore
and presumably to
each
McCarthy
comparing
be mdc
be due to individual
(i 6) took a
Irish
rates
with
those in England and Wales. It is clearly of some importance to know which of these points of view is correct. If the international comparisons of suicide rates are unreliable because of differences in ascertain
ment procedure, then no useful purpose is served by making such comparisons, and con clusions drawn from them may be harmful. Even though they have acknowledged that international comparisons of suicide rates may be misleading, Stengel ( i o, i i ) and others have nevertheless taken within a country
argument determined acting
within
the view that may be more
is that where
all suicide
by the same method the
work comparisons meaningful.
same
cultural
are
comparisons useful. The
likely
rates are
and by officials and
legal
to
be
frame
more
There are,however, grounds for doubting this. Though in many cases it is fairly clear whether a death has been the result of suicide, thereare otherdoubtfulcases,and thesemay, by different authorities, be placedinthesuicide or the undeterminedor possibly the accidental category. Barraclough(i),though satisfied that coronersarereasonably consistent inthecriteria by which theyjudge a caseto be suicide, has privatewho arriveat theirconclusionsas they nevertheless shown that there is considerable would forany otherdiagnosis on a balanceof variationfrom one coronerto anotherin the probabilities. Both Ettlinger and Dalgaard relative proportion ofcasesin the‘¿open verdict' Thisimpliesthat,notwithstanding the considerthatthesedifferent procedurescould category. legalframework within which they operate, result in different findings, particularly in those cases where there is doubt and where the coroners vary and do not necessarily apply the same criteria in their decision making. Holding criteria formaking a decision differ. and Barraclough(is)have alsoshown thata Sainsbury and Barraclough (g), though acknowledgingthat suicideisunder-reported,high proportionof deaths recorded as open verdictwere probablysuicidal, and thatwith nevertheless have taken a different view. They criteria the populationof showed thattherank orderof thesuicide rates regard to clinical of eleven countries is very similar to the rank ‘¿openverdicts' resembled a population of orderofthesuicide ratesofgroupsofimmigrants suicides. Two studies designed to examine these from those countries who had lived and died in problems will be described.The firstis an the United States. These immigrant groups were projectcarriedout on behalfof subjectto suicideascertainmentprocedures international the World Health Organization,in which different from those of their countries of origin. comparisonsof suicideratesare The similarity inrank orderpersisted inspiteof international
BY M. W. ATKiNSON,
W. I. N. KESSEL AND J. B. DALGAARD
made (I 7). The second study examines statistics (8) referring only to England and Wales in an attempt to measure whether or not coroners are being
consistent
in their decision
making.
The International Study In the international study, two countries were initially chosen for enquiry : Denmark, which has consistently reported a higher suicide rate than the international average, and England and Wales, where a lower rate has always been reported. The study has since been extended to six other countries, but for the purposes
of
this
presentation
only
the
English
and Danish material will be described. Stengel and Farberow (12) collected formation
about
suicide
ascertainment
in
249
there was suicidal intention. The legal authority which provides guidance for coroners is Jervis on Coroners (6), wherein it is stated ‘¿Positive cvi dence of suicide : to support a verdict of suicide there should be some actual evidence pointing to the event. The verdict should not rest upon surmise.'
On rare occasions
it has happened
that
judges in a higher court have ordered inquests to be held again where suicidal intention has not been proved to their satisfaction. Evidence for the inquest is collected in the first instance by the police in the form of signed statements from various sources, such as relatives or neighbours. The coroner hears the
evidence in court and questions the witnesses; he also takes into account the post-mortem findings.
When
the coroner
considers
there
is
pro
insufficient evidence to come to a conclusion as cedures and showed that there were considerable to the cause of death and mode of death he is variations from one countryto another.Our obliged to return an open verdict. There are first task was to repeat this exercise in more about two open verdicts to every ten verdicts detail, and the findingsforDenmark and for of suicide, with considerable variation from one England and Wales were as follows: coroner to another. Doubtful cases mostly achieve an open verdict, though some may of coursebe recordedasaccidental death. i. England and Wales Coroners' courts are public, and verdicts are In Englandand Wales,wheneveritisthought commonly reported in the local press.In that a death may be due to unnatural causes England and Wales suicide has always been or whenever the deceased has not been seen by a doctor in the preceding 14 days, the socially frowned upon, and until 1961 attempted suicidewas a criminaloffence. Until the last circumstances must be reported to the coroner. The coroner'sofficer, who is a policeman, century suicide resulted in forfeiture of property and estates. Because of these social attitudes and records the details. If the death is obviously because of the legal nature of the procedure, due to natural causes the coroner, through the to suppress evidence of suicidal coroner's officer, authorizes the doctor to issue motivation intention in order to secure an open verdict is a death certificate. If there is any doubt about likely to have varied over the years. A charitable the cause of death the coroner orders a post coroner who gave more care to averting rela mortem. If this reveals natural causes no further tives' distress than to achieving statistical inquiry is made. In the minority of cases where accuracy might not press his enquiries too far. homicide, suicide, accidentor unnatural causes are suspected an inquest is then held by the coroner. Coroners
are in effect judges,
and are appoin
2. Denmark
In Denmark the statistics have since the last ted by the local authority with the approval of reporteda highersuicide theHome Secretary. In England and Wales,of centuryconsistently rate than the international average. Dreyer (ii) about 230 coroners only seventeen are full-time has shown that the figures are much the same and only forty-five have a medical qualffica now as they were a century ago. In Denmark, tion (2). The vast majority are lawyers and work on a part-time basis. The coroner is suicide has not attracted the same social dlis obliged to establish the cause of death and in approval as in this country, and it has not been a criminal offence since i866, when the law was the case of suicide must be satisfied not only changed. that the death was self-inflicted but also that
THE COMPARABILITY
250
In Denmark also the ascertainment procedure is quite different. All cases of unnatural death or cases where bodies are found dead must be reported to the police. A doctor may also report a death if he is not satisfied as to the cause of death, but there is no fourteen-day rule. The police then conduct an inquiry similar to that carried
out
in
England
by
the
coroner's
officer,
and this is followed by the medico-legal viewing of the body or Ligsyn, which is a legally defined act carried out by the district medical officer or Kredslaege together with a police superintendent. The
former
is an officially
appointed
medical
OF SUICIDE RATES
oppositenumbers and decidewhat hisverdict would be. The experimentwas carriedout as follows: A sample of fortycase records,halffrom Denmark,
half from
England,
was selected
by
thefollowing procedure:two coronersand two of the Danish medical officers were asked to go through a month's consecutive cases and assess them. Both of the coronerswere from large cities, one being medicallyqualified and the other having
Danish
only a legal qualification.
medical
Department
officers
of Forensic
came
one
Medicine
The two
from
a
and the other
from a part rural, part urban area. Having officer who has had a special training in forensic medicine. These two together consider all the assessed the cases, each participant was invited availableevidence and may make further to answer two questions: enquiries.
A thorough
external
examination
of
the body is always made, and this may include chemical examinationsof blood and urine samples. The police decide whether or not an autopsy is held. Usually there is close agreement between the police and the Kredslaege, but it may happen that
there
is disagreement,
in which
event
the
police make the decision on legal rather than medical criteria. In cases of obvious suicide an autopsy
is not necessarily
carried
(i)
Kredslaege
cating
the
signs
cause
the death
(2) What
of
death
and
the
were
indi
mode
of
death. None of these proceedings are in public, and theyare not reportedin thepress,though close relatives can have access to the information if they request it. Thus in Denmark the official diagnosis of suicide
is given
by a doctor
acting
by the coroner
in public
is your
selected
verdict?
‘¿Natural causes',
best
estimate
of the
by M.W.A.
in England
Natural Causes
@J Accident/Misadventure Suicide
@J Homicide 1J Open
and he requires
2. Yourbestestimateofthelikelihood efsuicide ON BALANCE OFPROBABILITIES
It was decided to measure the effect that these differing procedures might have on suicide using
the
case
records
by
1 Whatwasyour verdict!
METHOD
by
and
W.H.O.& THEUNIVERSITY OFMANCHESTER DEPARTMENT OF PSYCHIATRY
in private,
proof of suicidal intention before he is permitted to return his verdict of suicide.
ascertainment
likeli
on a balance of proba to boo per cert? (Fig. i.) four batches of cases ten a total of 40 in all. They
Comparability ofSuicideRates
usinga balanceofprobabilities as hiscriterion, whereas in England and Wales the verdict is given
your
hood of suicide bilities from zero From each of these were selected, making
out. In doubt
certificate
was
‘¿Accident', ‘¿Suicide', ‘¿Homicide', or ‘¿Open'.
ful cases such as poisonings an autopsy is the rule. When all the evidence has been gathered the
What
of
coroners and their opposite numbers in Den mark. Each of the participants was asked to assess the cases of his colleagues and of his
I
I
I
I
I
probably probably certain suicide fifty- NOT definitely suicide fifty NOT Fio. i.
BY M. W. ATKINSON,
W. I. N. KESSEL AND J. B. DALGAARD
251
T@a I J.B.D. in Denmark on the basis of the parti Verdicts of five Danish kredslaege andfour English cipants' answersto question2.The aim was to coronerson the same 40 case records provide a range of cases, from certain suicide to definitely not suicide. This provided a group DenmarkEnglandSuicide3231282727232!17i6Accident658126g8ioi@Open233o66 of 40 cases, a high
proportion
of which
lay in
the intermediate area, where the participant had been less than ioo per cent certain of the probability of suicide. Copies of the complete coroners'recordswere prepared with identifying
data and the verdictremoved, and thesewere circulated to the participants in England and Denmark,
the Danish
records
being
translated
into English by the staff of the Forensic Medicine Department
in Aarhus.
To thefouroriginal participants were added two extra English coroners and three more Danish
medical
officers,
making
CaUSeS0IIII2000
For differences between Danish/English verdicts:
suicide
English mean = I9@25; Danish mean = 29@0. t=5@2I;df=7;P