Factors related to suicide via firearms and hanging and leaving of suicide notes.
Holmes, Ronald M.
|Publication:||Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Men's Studies Press ISSN: 1532-6306|
|Issue:||Date: Spring, 2010 Source Volume: 9 Source Issue: 1|
|Topic:||Event Code: 310 Science & research|
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|Organization:||Government Agency: United States. Centers for Disease Control and Prevention|
One of the common causes of unnatural death for men is suicide. The
intent of the current research is to add to the understanding of
men's suicides involving the two most common methods of suicide the
use of firearm and hanging. As the results of this study show,
identification of predictors of whether men kill themselves via fire arm
or hanging suggest that younger men are more likely to use firearms and
older men use hanging with prior consumption of drugs and alcohol. The
only statistically significant difference between men who do and do not
leave suicide notes is that those who do are likely to be older and less
likely to use a gun.
Keywords: men, suicide, firearms, hanging, suicide notes
Among major health concerns are issues related to causes of death and means of intervening in both natural and unnatural forms of death. One of the common causes of death for men, which is clearly preventable, is suicide. In 2005 in the United States 32,637 suicides were reported, ranking suicide as the 11th most common cause of death for all Americans, accounting for 1.3% of all deaths (Centers for Disease Control and Prevention, 2008). Of all 2005 suicides, 79% are by men (Centers for Disease Control and Prevention, 2008). Suicide accounts for 80% more men's deaths annually than do homicides. These numbers may be underestimates, however, as the official number of suicides is also commonly believed to be under-reported (Holmes & Holmes, 2005). Many suicides may not be recognized as such by officials, and in many instances, due to religious beliefs, anticipated stigma or other reasons family members may attempt to cover evidence of a suicide or to divert attention of officials away from indications that one has taken their own life. Regardless of whether the true numbers of suicides is higher or not, suicide remains an important, but not fully understood, health problem for American men.
Patterns in Suicide
There are clear demographic patterns in suicides in the United States. Most notable is that suicide is significantly more likely among men than women; the number of men who commit suicide is more than 400% higher than the number of women (Centers for Disease Control and Prevention, 2008). While women are more likely than men to attempt suicide, men are more likely to succeed in their attempts, which is commonly attributed to men's chosen methods of suicide tending to be more lethal. Suicide has the greatest sex disparity on the rate of the 15 most common causes of death in the United States.
Other demographic factors have also been shown to be related to suicide rates. Regarding race, whites account for 90.5% of all suicides, compared with 6.1% for African-Americans and 3.4% for all other races. These numbers show a definite over-representation of whites, as according to the U.S. Census Bureau "only" 74% of Americans are white (U.S. Census Bureau, 2009). Race and sex also interact in suicide rates; for African-Americans the sex disparity is even greater than for whites. African-American males are nearly 7 times more likely than African American females to commit suicide (Centers for Disease Control and Prevention, 2008). Age also has clear patterns for suicide as rates generally increase as age increases. The highest rates are in persons over the age of 75 (16.9 per 100,000), ages 45-54 (16.5 per 100,000) and ages 35-44 (14.9 per 100,000) (Centers for Disease Control and Prevention, 2008). Marital status is also important; persons who are married are the least likely to commit suicide (Andrews & Lewinsohn, 1992; Gould, Fisher, Parides, Flory & Shaffer 1996; Trovato, 1986). Persons who are single, followed by those who are widowed and divorced are most likely to commit suicide (Mastekaasa, 1995; Pasewark & Fleer, 1993).
The specific methods by which individuals commit suicide vary widely, with important differences across demographic categories. Across all individuals, the most common methods of committing suicide reported in national data are via firearm (53.1%), suffocation/hanging (22.6%) and poisoning/overdose (17.9%) (Centers for Disease Control and Prevention, 2008). Interestingly, the number of intentional deaths due to firearms shows that suicides account for 55% of all firearms deaths, while homicide accounts for only 40.2%, with accidents accounting for the other 4.8% (Centers for Disease Control and Prevention, 2008). As with suicide rates, demographics also show patterns in methods of suicide. Men are most likely to kill themselves via firearms, suffocation/hanging or drowning while women are most likely to commit suicide via poisoning/overdose or cutting/piercing (Spicer and Miller, 2000; also see Ojima, Nakamura and Detels, 2004). Stack and Wasserman's (2005) review of 19,580 male suicides using U.S. Public Health Service data and show that despite being less likely to own firearms, African-American men are more likely to commit suicide via violent methods (especially via guns) than whites.
The issue of employment and suicide has received significant attention in the research literature, although the findings are hindered by the difficulties accessing employment data for those who commit suicide (Holmes and Holmes, 2005). Urban legends suggest that persons in certain occupations (dentists, law enforcement officers, psychologists) are more likely than others to commit suicide, although attempts to validate these beliefs have failed to show support for the claim (see Foxhall, 2001). Perhaps related to employment, some studies have suggested that suicidal deaths are more likely to occur on Mondays and Tuesdays than on weekends (Hassan, 1994; Jessen et al., 1999; Lester, 1971, 1979; Maldonado & Kraus, 1991; MacMahon, 1983; Phillips & Liu, 1980).
Popular belief (perhaps fueled by entertainment media) holds that persons who commit suicide leave notes indicating their intentions and explaining their reasons for ending their lives. However, suicide notes are found in only a minority (as few as 1 in 5) of cases (Holmes and Holmes, 2005; O'Donnell, Farmer and Catalan, 1993). The frequency of leaving suicide notes does not appear to vary with increases or decreases in the number of suicides, with a relatively stable rate of between approximately 25%--35% of incidents including notes (Shioiri, Nishimura, Akazawa, Abe, Nushida et al., 2005). What remains largely unexplored is whether there are patterns in note-leaving across method of suicide, demographics and incident characteristics. Two early studies (Beck, Morris & Lester, 1974; Tuckman, Kleiner & Lavell, 1959) report few differences between those who do and do not leave notes; note-leavers were less likely to use drugs and to have a higher vocabulary score (Beck et al., 1974). As outlined below, only a few studies have examined the characteristics of suicides and whether notes are left or not.
At least in some countries, suicide notes are most likely to be used by women (Hong Kong, see Ho, Yip, Chiu, & Halliday, 1998). However, individuals who commit suicide in public places (e.g. away from home) are less likely to leave suicide notes (O'Donnell, Farmer & Catalan, 1993). When considering method of suicide and whether a note is left or not Lester and Linn (1998) report that notes from individuals who hang themselves typically contain more statements of anger than notes from persons employing other methods. When focusing on expressed reasons for committing suicide, there are more similarities than differences across age groups (Leenaars, De Wilde, Wenckstern & Kral, 2001), although notes from teens show a greater tendency to focus on rejection (Leenaars, et al., 2001) and notes from elderly men are more likely than those from younger men to focus on interpersonal relationship problems (Leenaars, 1992). However, Shioiri et al.'s (2005) review of more than 5,100 suicides across a 20 year period in Japan suggest that "the reasons for suicide do not affect note-leaving" (p. 228). This finding, however, has yet to be examined in the United States.
The literature on suicide notes primarily comes from outside the United States and suggests that content of notes may vary by age, less educated individuals are less likely to leave notes and those who employ more lethal methods may be more likely to leave suicide notes (Chavez-Hernandez, Paramo, Leenaars & Leenars, 2006; Kuwabara, Shiori, Nishimura, Abe, Nushida et al., 2006; Lester, 1998). Elderly men have been suggested by one study as the most likely to leave suicide notes (Heim & Lester, 1990). And, one intriguing, but yet to be explained finding is that suicides occurring on a Monday are more likely than those on other days of the week to leave a note (Heim & Lester, 1990). However, the majority of research reports that there are few, if any, differences in individuals who do and do not leave suicide notes (Chavez-Hernandez et al., 2006; Demirel, Akar, Sayin, Candansayar & Leenaars, 2008; Girdhar, Leenaars, Dogra, Leenaars & Kumar, 2004; Leenaars, Haines, Wenckstern, Williams & Lester, 2003; Leenaars, Lester & Wenckserten, 1999; O'Connor & Leenaars, 2004; O'Donnell, Farmer & Catalan, 1993). However, this research is primarily from outside the United States (e.g. Mexico, Australia, England, Ireland, Turkey, India, Japan, Canada, and Germany), leaving the question of whether there are differences between Americans who commit suicide and do or do not leave suicide notes.
Current understandings of characteristics of suicides, especially if and how characteristics of the events and the individuals involved vary by method of suicide, are limited. It is the intent of the current research to add to this body of knowledge by investigating the demographics and event characteristics for the two most common methods of suicide for men: use of firearms and hanging.
The Present Study
The present study examines all male suicides in one metropolitan area (Louisville, Kentucky) for a six year period (2003 to 2008) to assess the relationship between the method of suicide (firearms and hanging) and both demographics and event characteristics. Building on the existing literature, the present study seeks to assess whether demographic variables, leaving of a note and use of alcohol and/or drugs vary by method of suicide.
Data for the present analysis come from the Jefferson County (KY) Coroner's Ofrice. All files regarding male suicides in Jefferson County, Kentucky from 2003-2008 were identified and coded. A total of 419 cases were identified. Each file was coded for demographics and incident characteristics. Demographics include race, age, height, weight (used to compute body mass index [BMI]), marital status, and whether the decedent was employed or not. Incident characteristics include method of suicide, location of death (at home or away from home), day of week, whether a suicide note was left, and presence of alcohol or any drugs (and type) in the decedent.
The study considers two methods of suicide, hanging and use of a gun as dependent variables. The dependent variable in this analysis is a dichotomous variable coded as use of a firearm = 1 and hanging = 0. Of the total sample 243 (71.1%) men killed themselves via use of a firearm and 99 (28.9%) hung themselves. Only these 342 cases are used in the analysis. (1) The independent variables included in the study are race (white or nonwhite), age, BMI, marital and employment status. Incident characteristics of leaving a suicide note and presence of alcohol or drug(s) in post-mortem toxicology tests were also considered along with demographic variables. Binomial logistic regression is used to analyze the impact of demographic and incident characteristics on suicide via hanging versus firearm. Binomial logistic regression is a non-linear transformation of the linear regression. Logistic regression can be used to predict a dependent variable on the basis of continuous and/or categorical independent variables and to determine the percent variation in the dependent variable explained by the independent variables. The impact of predictor variables is explained in terms of an odds ratio.
The majority (82.2%) of decedents are white, with a mean age was 45.2 (range of 10 to 95 years). The calculated mean body mass index was 25.6, indicating the sample is slightly overweight on average. Approximately 27.5% (n = 94) were married and only (32.2%, n = 110) were employed. Regarding incident characteristics, fully 63.5% were at the decedent's home. Alcohol (33.1%, n = 104) or drug(s) (21.6%, n = 68) were present in a minority of cases. A suicide note was left by the decedent in only a minority of cases (26.3%, n = 89). These results are shown in Table 1.
Comparison of Sample Characteristics and Community. Characteristics
A comparison of the demographic characteristics of the sample of men committing suicide with county-wide census data show that men committing suicide are more likely than the county population averages to be white, not married and unemployed. Specifically, census data for Jefferson County, Kentucky show that in 2000 77.4% of the county population was white, 27.7% of the population was single/never married and 14.7% divorced/separated and fully 61.6% of the population age 16 or older employed. Additionally, whereas the BMI for the sample shows a mean value of 25.6 (indicating a slightly overweight sample) data from the Louisville Metro Department of Health and Wellness (Louisville Metro Public Health and Wellness, 2008) indicates that 60.7% of the county residents are overweight or obese.
Predictors of Suicide via Hanging
Examination of demographics and incident characteristics associated with suicide via firearm versus hanging began proceeds with the inclusion of the nine independent variables in the logistic regression analysis. Five of these variables (race, marital status, employment, leaving of a suicide note and whether the incident was at or away from the decedent's home) failed to achieve statistical significance and were removed from the analysis. The final model, as shown in Table 2, contains four statistically significant variables. The omnibus test of chi-square for the model is significant at [alpha] [less than or equal to] .001 indicating that there is adequate fit of the data to the model.
Variables statistically significant as predictors of suicide via hanging include age, consumption of drugs, consumption of alcohol and BMI. The odds ratio (Exp(b)), representing the factor by which the odds (event) change for a one unit change in the independent variable, for age is 1.045 suggesting that for each additional year of age there is a slightly greater likelihood of the individual committing suicide via firearm. Additionally, decedents were 1.763 greater likelihood of suicide via firearm than hanging if the decedent had drugs in his system and 1.675 greater odds of suicide via firearms (rather than hanging) of alcohol was present in the decedent's body. Additionally, for every unit increase in BMI these men were 1.063 times more likely to commit suicide with a firearm than via hanging. These four variables, taken together, explain 12.2% of the variation in suicide via firearm versus hanging. (2) Table 2 presents the results of this model.
Predictors of Leaving a Suicide Note
In order to examine whether demographic or incident characteristics are related to whether a suicide note is left or not logistic regression, using the dichotomous variable of leaving a suicide note or not is performed. Nine independent variables are used in the analysis, including five demographic variables (race, age, marital status, employment status and BMI) and five incident characteristics (whether the method is via firearm or hanging, if the decedent had consumed alcohol or drugs prior to the event, whether the event occurred in/at the decedent's home. Only two variables--age and marital status--achieved statistical significance; the final model containing only these variables (see Table 3) explains approximately 5% of the variation in whether a suicide note was left or not. The omnibus test of chi-square for the model is significant at [alpha] [less than or equal to] .001 indicating that there is adequate fit of the data to the model.
In the final model, only the variable of age retains statistical significance. As shown, for every one year increase in age there is a 1.026 greater likelihood of the individual leaving a suicide note. It is apparent that these demographic and incident characteristics do not explain the variation in whether men who commit suicide do or do not leave suicide notes.
This study reports conclusions that both support the findings of previous literature, and adds to the body of knowledge regarding methods of suicide for men. Whereas previous literature has reported that the most common methods by which men commit suicide are with firearms or hanging, so too does the present study show this pattern. In the present study, 81:6% of the male suicides in the six year period (n = 419) were committed via firearms or hanging. Additionally, the data show that the sample of men who commit suicide has a greater proportion of whites than the community population, the sample is more likely to not be married and the sample is less likely to be employed. All of these findings support the existing literature. Furthermore, whereas previous studies have suggested that suicide notes are present only in a small minority of cases, so too does the present data show this; only 27.5% of men in the current sample left a suicide note.
Identification of predictors of whether men kill themselves via firearm or hanging show that suicide via firearms is more likely than suicide via hanging for older men, those of larger body mass index and those who consume either drugs or alcohol immediately prior to the incident.
Finally, the results of this study are largely in accordance with the results of previous literature which suggests few differences across individuals who do and do not leave suicide notes. In this study only two variables were statistically significant predictors of whether a man did or did not leave a suicide note. Specifically, the variables of age and use of a firearm are both statistically significant, but in combination explain only 5% of the variation in whether a man who commits suicide leaves a suicide note. Older men are more likely to leave notes and those who use guns are less likely to leave a note. Clearly, there are more similarities than differences in whether men who kill themselves do or do not leave a suicide note.
We pretty much support the existing literature showing few if any differences in those who do and do not leave notes.
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(1) The other 77 cases involve suicide via other methods, including jumping to one's death, drug overdoses, intentional vehicle accidents and cutting/stabbing.
(2) Cox and Snell's [R.sup.2] is an attempt to imitate the interpretation of multiple regression based on the log likelihood of the final model. The Nagelkerke's R square is a modification of Cox and Snell's r square by its maximum in order to achieve a measure that ranges from 0 to 1. Therefore Nagelkerke's is higher than the Cox and Snell measure but tends to run lower than the corresponding OLS R square. Both Cox and Snell's and Nagelkerke's R square are part of SPSS output in the model summary table and is the most reported of the pseudo r square estimates (Nagelkerke, 1991).
Richard Tewksbury (a), Geetha Suresh (a), and Ronald M. Holmes (a)
(a) University of Louisville.
Correspondence concerning this article should be addressed to Richard Tewksbury, Department of Justice Administration, University of Louisville, Louisville, Kentucky 40292. Email: firstname.lastname@example.org
Table 1 Sample Characteristics (N = 342) Variable Values Age Mean 45.5 Range 10-95 Body Mass Index Mean 25.6 Range 14.6-61.5 Variables # % Race White 253 84.2 Marital Status Married 94 27.5 Employment Employed 110 32.2 Location of Event At home 217 48 Away from home 63.5 11.5 Suicide Note Yes 89 26.3 Alcohol present in decedent Yes 104 33.1 Drugs present in decedent Yes 68 21.6 Table 2 Results of the Logistic Regression Model: Suicide via Firearm vs. Hanging (N = 301) Variable (a) B S.E. Wald Exp (b) Age .044 .009 24.87 1.045 * BMI .061 .029 4.42 1.063 * Drugs present .567 .318 3.18 1.763 ** Alcohol present .516 .289 3.19 1.675 ** Constant -2.876 .845 (a) Only significant variables reported. * [alpha] [less than or equal to] 5 .05, ** [alpha] [less than or equal to] .10 Cox & Snell R-square = .122 Nagelkerke R-square = .172 Table 3 Results of the Logistic Regression Model: Leaving a Suicide Note (n = 342) Variable (a) B S.E. Wald Exp (b) Age .025 .007 12.53 1.026 * Married .428 .273 2.45 1.534 * (a) Only significant variables reported. * [alpha] [less than or equal to] .05 Cox & Snell R-square = .052 Nagelkerke R-square = .172
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