Violent Death in a Metropolitan County: 11. Changing Patterns in Suicides (1959-1974) AMASA B. FORD, MD, NORMAN B. RUSHFORTH, PHD, NANCY RUSHFORTH, CHARLES S. HIRSCH, MD, AND LESTER ADELSON, MD
Abstract: Suicide rates in Cuyahoga County (metropolitan Cleveland) rose from 10.2 in 1958 to 12.5 per 100,000 population in 1974 (23 per cent increase) with the greatest rise among nonwhite males (from 5.9 to 13.1, or 122 per cent). Increased rates were observed in both the city (19 per cent increase) and suburbs (35 per cent increase). Rates increased among young nonwhite and white adults of both sexes aged 15-34 years, but decreased slightly among adults aged 65 years and older. These findings are consistent with national trends. Alcohol was present in the blood of one-fourth of the individuals who were "dead on arrival," and at intoxicating levels in 20 per cent. There were increasing percentages of victims with positive blood alcohol
and with intoxicating levels during the study period. White male victims in the city had significantly higher frequencies of such findings than their counterparts in the suburbs. The rates of suicide committed by firearms rose among all race-sex groups, with the greatest increase among city nonwhite males (2.1 to 7.7, or 267 per cent). Suicide by chemical agents (roughly one-half being barbiturates) increased in all groups except city nonwhite males, with the greatest increase among white males and suburban white females. Firearms among males and poisoning among females displaced asphyxia as the leading modes of suicide. (Am. J. Public Health 69:459-464, 1979.)
Introduction
in order to investigate changing patterns, we subdivided the 17-year interval into three periods: 1958-1962, a baseline period with a relatively low and stable homicide rate (average annual rate 5.6 victims per 100,000 of the county population); 1963-1968, an intermediate period during which the initial increase in homicide rate occurred (average, 9.2); and 1969-1974, a third period with high and slightly increasing rates (average, 19.2). The purpose of the present report is to present a more detailed study of the changing patterns of suicide in Cuyahoga County during the years 1958-1974, using the three time periods defined in the study of homicides. The time span is longer than that evaluated in most studies of suicide and permits an analysis of changes in age-, sex-, and racespecific suicide rates in relation to city and suburban location. In addition, we have documented changes in the mode of lethal violence and in blood alcohol levels and related them to suicide rates.
The 1960s were a decade of violence in American life. In addition to urban riots and the Vietnam War, interpersonal violence escalated, led by a dramatic rise in homicides. These trends affected the entire population, but the impact fell most heavily on young adult males, who also experienced higher mortality from accidents, suicides, and cirrhosis of the liver, resulting in an overall increase in mortality of 16 per cent for men 25 to 34 years old.' Taking advantage of a set of unusually complete and uniform records in the Coroner's Office of Cuyahoga County (Cleveland), Ohio, we previously reported a detailed analysis of the trends in homicides in that county from 1958 through 1974.2 In an earlier report, we also contrasted longterm trends in homicide rates with those in suicide rates from 1938 through 1971.3 In the study of homicides for 1958-1974, From Case Western Reserve University, School of Medicine, and the Cuyahoga County Coroner's Office. Address reprint requests to Amasa B. Ford, MD, Proftssor of Community Health and Family Medicine, Case Western Reserve University School of Medicine, Cleveland, OH 44106. Dr. Rushforth is Professor and Chairman, Department of Biology, and Associate Professor of Biometry; Ms. Rushforth is Research Assistant, Department of Biology, at the University. Dr. Hirsch is Deputy Coroner, and Associate Professor of Forensic Pathology; Dr. Adelson is Chief Deputy Coroner, and Professor of Forensic Pathology, both with the County Coroner's Office and the School of Medicine. This paper, submitted to the Journal May 15, 1978, was revised and accepted for publication September 5, 1978. This paper was originally prepared for presentation at the 1977 Annual Meeting of the American Public Health Association
AJPH May, 1979, Vol. 69, No. 5
Methods Cuyahoga County ("county") consists of the City of Cleveland ("city") and an adjacent aggregate of 38 cities, 18 villages, and four townships ("suburbs"). All known or suspected violent deaths (i.e., accident, homicide, and suicide) in the county must be investigated by the coroner. Because one man (Samuel R. Gerber, MD, JD) has been County Coroner since 1936, criteria for verdicts have been consistent throughout the study period. When the manner of death cannot be determined "beyond a reasonable doubt," cases 459
FORD, ET AL.
are classified as "violence of undetermined origin." Ninetysix fatalities were classified in this manner and are omitted from this analysis of 3,264 suicide victims for the 17-year study period.* We calculated annual suicide rates, using data from the Coroner's records to determine the number of victims and from U.S. Census Bureau publications for population figures. The latter include a 1965 special census for the City of Cleveland. Suburban and county populations for 1965 were estimated by linear interpolation of the decennial census figures. Average annual suicide rates for the three previously defined periods are based on population figures for 1960, 1965 and 1970, using the actual census counts as denominators rather than estimates for non-census years. Fatalities are tabulated according to the location of the suicide incident (city vs. suburbs) rather than the place of death or residence of the victim. Race is designated as white or nonwhite; the nonwhite county population was 98.7 and 97.3 per cent black in 1960 and 1970, respectively. Blood ethanol levels are routinely determined by gas chromatography at the Coroner's Office for all victims of violent or natural death 15 years of age and older who survive less than 24 hours. To avoid distortions due to absorption, metabolism, and excretion of alcohol in victims who temporarily survive the lethal event, we have restricted this phase of our study to suicide victims who were "dead on arrival." Victims with positive blood alcohol and with blood alcohol levels equal to or greater than 0.1 per cent by weight are reported. The latter value is usually designated as the lower level of blood alcohol corresponding to intoxication.4 The proportion of all suicide victims who were dead on arrival and who had blood alcohol tested did not change significantly during the study period (78-80 per cent). Similarly, this proportion did not vary significantly between sex groups (male 79-81 per cent, female 75-76 per cent) or race groups (white 79-80 per cent; nonwhite 67-78 per cent). In the following analysis of data, statistical significance of differences between rates was tested by chi square. Unless otherwise specified, all differences mentioned in this report are significant at p = .05 or less.
Results Sex and Race of Suicide Victims The number of suicide victims and suicide rates (unadjusted and age adjusted) for the total county population as well as those based on race and sex are presented in Table 1. Suicide rates adjusted for changes in the age composition of the county population over the study period are similar to corresponding unadjusted rates, indicating that shifts in the age composition of the population had little influence on crude rates. *Of the 96 fatalities of undetermined origin, 91 were fatalities in which a distinction between suicide and accidental death could be made tentatively. In another three cases, it could not be ascertained whether death was due to suicide or homicide, and in two cases the deaths were of completely unknown origin. 460
In the county, suicide rates increased from 10.2 in the baseline period of the study (1958-1962) to 11.3 in the intermediate period (1963-1968) and rose by the third period (1969-1974) to 12.5, a 22 per cent increase over the initial period. Of the four race-sex groups, white males had the highest suicide rate in each of the three study periods. This rate, however, showed little change over the 17 years, increasing only 6.5 per cent from the baseline value in the third period (P > .10). All other three groups had significant increases. The nonwhite male suicide rate showed the greatest percentage increase of the four population groups, rising from a relatively low baseline rate of 5.9 to 13.1 in the third period (122 per cent). For white females the rate increased from 5.7 (approximately equal to the non-white male rate in that period) to a value of 9.0, a rate significantly lower than the corresponding third period rate for nonwhite males. In all three periods, the nonwhite female population had the lowest suicide rate, yet the rate for this group rose 96 per cent (2.8 to 5.5) over the time span of the study.
Suicide Rates for the City of Cleveland and Suburbs Overall, the suicide rate in the City of Cleveland was consistently higher than the corresponding suburban rate for each of the three study periods (Table 1). Between 19581974 the suburban rate increased by 35 per cent, while the city rate increased by 19 per cent. The uniformly higher city suicide rates resulted from significantly higher rates for white males in the city than in the suburbs. In contrast, nonwhite rates appear to have been slightly higher in the suburbs than in the city, but comparisons are uncertain because of small numbers of nonwhite suicides in the suburbs. In the city, major increases in suicide rates occurred among nonwhites. Nonwhite male rates jumped from 5.9 to 12.5 (112 per cent), and those for nonwhite females from 2.7 to 5.4 (100 per cent). Smaller relative increases were observed among whites. The rate for white males rose slightly (9.6 per cent, p > .10); that for white females rose 52 per cent (p < .01). In the suburbs, white male rates were distinctly lower than in the city, while white female rates were similar in the suburbs and the city. Age at Suicide Suicide rates for white males showed a marked upward trend with increasing age both in the city and suburbs, and this trend persisted in spite of temporal changes during the study period (Figure 1). The overall rate remained relatively constant over the 17 years of the study (Table 1), but rates in the younger age groups became higher in the third period than corresponding baseline values; in contrast, above 60 years of age, rates in the third period were lowered. Rates for teenage and young adult white males (15-24 years) in the city rose 90 per cent (from 8.9 to 16.9) and those in the suburbs increased 34 per cent (from 9.3 to 12.5). However, rates for white males age 65-74 in the city decreased 13 per cent (from 56.8 to 49.7), and those for older white males in the suburbs dropped 26 per cent (from 39.9 to 29.4). Nonwhite males in the city, on the other hand, showed a general downward trend in suicide rates with increasing age. AJPH May, 1979, Vol. 69, No. 5
CHANGING PATTERNS IN SUICIDE TABLE 1-Suicide Rates in Cuyahoga County (Ohio) According to Race and Sex (1958-1974) Showing Number, Annual Rate and Age-Adjusted Annual Rate* (victims/100,000 population)**
Group and Location
COUNTY White males Nonwhite males White females Nonwhite females TOTALS CITY White males Nonwhite males White females Nonwhite females TOTALS SUBURBS White males Nonwhite males White females Nonwhite females TOTALS
1969-1974
1963-1968
1958-1962 Annual
Age
Annual
Age
Annual
Age
No.
Rate
Adjusted
No.
Rate
Adjusted
No.
Rate
Adjusted
570 37 204 19 830
16.9 5.9 5.7 2.8 10.2
17.1 5.8 5.2 2.8 10.2
698 72 352 20 1142
17.5 8.3 8.2 2.1 11.3
17.4 10.1 7.5 2.1 11.3
717 125 391 59 1292
18.0 13.1 9.0 5.5 12.5
17.8 14.1 8.4 5.6 12.2
350 36 95 18 499
23.0 5.9 6.0 2.7 11.4
21.3 5.8 5.4 2.6 10.8
363 65 150 19 597
23.6 8.2 9.1 2.1 12.3
22.1 10.0 8.2 2.2 12.2
331 103 130 50 614
25.2 12.5 9.1 5.4 13.6
23.8 13.6 8.6 5.4 13.5
220 1 109 1 331
11.9 9.9+ 5.5 2.3+ 8.6
13.3 9.7+ 5.1 2.3+ 9.6
335 7 202 1 545
13.7 9.9+ 7.7 2.3+ 10.4
14.1 9.7+ 7.0 2.3+ 10.4
386 22 261 9 678
14.5 17.1 9.0 6.4 11.6
14.7 16.4 8.3 6.3 10.9
*Age adjusted with US population in 1970 as standard population "Census figures for county population: 1960 = 1,647,895; 1970 = 1,721,300 + Estimated rate for period 1958-1968 since there were too few nonwhites in the suburbs to calculate meaningful rates for the period 1958-1962
This relationship, which became more pronounced during the study period, contrasts sharply with that for white males. NonWhite teenage and young adult males in the city have exper-enced large increases in suicide rates during the study period, amounting to a startling 1,313 per cent (from 1.5 to
801 White males city
801 White females city
60
60
40
40
20
20
0........
- 1958 - 1962
-
1969 - 1974
601 Nonwhite females
0 0 0
city
6
0
Eo 0
White males suburbs
60
60
40
40
20 L
20
0
20
40
60
80
White females suburbs
0
20
40
60
80
Age in Years FIGURE 1. Suicide Rates According to Age, Sex, Race, and Residence, Cuyahoga County, Ohio 1958-1962 and 196-1974.
AJPH May, 1979, Vol. 69, No. 5
21.2) at ages 15-24 years. Young nonwhite males in the city now have the highest suicide rate of any comparable group, whereas 17 years ago they had one of the lowest. All females below the age of 45 experienced increases in suicide rates during the 17 years, ranging from 56 per cent to 1,160 per cent above the baseline period. The second largest relative rate increase in any population group occurred among white females aged 15-24 years, in the city (from 0.5 to 6.3, or 1,160 per cent), although this increase, in absolute terms, was less than that experienced by white males of the same age in the city. Above age 75 years, white female suicide rates decreased from 14.1 to 7.6, or 46 per cent in the city, and from 13.6 to 7.3 , or 46 per cent in the suburbs. In general, suicide rates among females were lower than among males of the same age and race. In addition, differences related to location, race, and age were less pronounced than among males. Alcohol Levels In Table 2 the per cent of suicide victims "dead on arrival" who had positive tests for blood alcohol and those with blood alcohol levels 0.1 per cent or greater are presented for the three time periods. While the proportion of tested victims with positive blood alcohol determinations did not change significantly over the 17-year period, the percentage of victims with alcohol levels indicative of intoxication (0.1 per cent or greater) increased in the intermediate and third periods (p < .01). For white male victims, both in the city and suburbs, the percentages with intoxicating blood alcohol levels were significantly greater in the latter two periods
.01). White male suicide victims in the city had significantly higher relative frequencies of positive blood alcohol and in(p
toxicating levels than their counterparts in the suburbs (pooled data, 1958-74, p < .01). No such differences occurred between city and suburban white females. Mode of Lethal Violence The use of asphyxia, which was the most common means of suicide in the first period, dropped to second rank by 1969-1974, being displaced by firearms among males and poisoning among females (Table 3). Asphyxia (which includes drowning, suffocation, and hanging) decreased among all white males and among city females, with moderate increases in the other population groups. Firearms, asphyxia, and poisoning, in that order, became the leading means of suicide for males by 1969-1974. Together, these methods accounted for 91.7 per cent of deaths. Among females, these three modes accounted for 92.9 per cent of suicides, with poisoning the leading cause (except for nonwhite women in the city, who used firearms TABLE 3-Suicide Rates in Cuyahoga County, (Ohio) According to Mode of Lethal Violence and Sex (1958-1974), Showing Annual Rate (victims/100,000 population) and Distribution by Per Cent
Positive %
No. Tested
No(%) Positive %
a 0.1%
93 (36.6) 36 (43.3) 23 (24.7)
26 (31.3) 17 (18.3)
6(40.0)
254 83 93 36
9(25.0)
7(19.4)
58 (21.6) 22(13.7) 195 (21.6)
309 208 1006
71(23.0) 43 (20.7) 279 (27.7)
52 (16.8) 27(13.0) 203 (20.2)
-
0.1%
71(28.0)
most frequently). The use of firearms and poisoning both increased significantly over the 17-year study period. Firearm rates rose 62 per cent for men and 125 per cent for women, and poisoning rates 67 per cent for men and 112 per cent for women.
Detailed examination of the age-sex-race distribution of firearm suicides in the city (not shown) indicates that the age distribution of this fortn of suicide is approximately parallel to that of all suicides in the various groups. Again, the highest rates were among young nonwhite males and older white males, while the most extreme increases in the use of firearms occurred among young nonwhite men. When all modes of suicide are examined by sex, race, and location (also not shown), the increase in the use of firearms is found consistently in every group, most strikingly among nonwhite males in the city, where suicide by firearms increased from 2.1 to 7.7 (267 per cent). Suicide by poison (roughly one-half being barbiturates) also increased in each group except city nonwhite males, among whom it decreased from 1.1 to 0.9 (18 per cent). City white males experienced the greatest increase in suicide by poisoning, from 1.4 to 3.6 (157 per cent), while the highest rates (4.2), occurred among suburban white women.
MALES Mode of Suicide
1 95&-1962
1963-1968
1969-1974
Asphyxia Poisoning Firearms
7.1 (46.6)* 1.2 ( 7.6) 5.2 (34.4)
Cuts and Stabs
0.5( 3.1) 1.0 ( 6.8) 0.2 ( 1.5)
6.0 (37.5) 1.5 ( 9.4) 6.7 (42.3) 0.5( 2.9) 1.1 ( 7.0) 0.1 ( 0.8)
5.3 (30.8) 2.0 (11.5) 8.4 (49.4) 0.4( 2.6) 0.8 ( 4.8) 0.2( 1.1)
Jumping Other
FEMALES
Asphyxia Poisoning Firearms Cuts and Stabs Jumping Other
2.3 (43.0) 1.7 (32.7) 0.8 (14.8) 0.1 ( 2.2) 0.3( 5.8) 0.1 ( 1.3)
2.3 (32.8) 2.7 (37.6) 1.3 (18.3) 0.3( 4.6)
0.4( 5.4) 0.1 ( 1.3)
2.4 (28.2) 3.6 (42.7) 1.8 (22.0) 0.2 ( 2.0) 0.3 ( 3.8) 0.1 ( 1.3)
*Figures in parentheses denote per cent according to mode of suicide before rounding rates to one decimal 462
Discussion The most striking trend observed in this study is a marked increase in suicide among teenagers and young adults, particularly in the city and among nonwhite males, whose suicide rates were previously low. Although less dramatic than the increase in homicides, this rise in suicides among urban youth is also alarming. These data are consistent with national trends.5 During the 1960s the number of teenagers in our population increased considerably, aggravating problems afflicting this group and creating stress.6 The teenage unemployment rate has traditionally been higher than the general rate, but in the 1960s the difference became even greater. For nonwhite teenage males, rates have been reported as high as 40 per cent. Even in the late 1960s, a time of supposedly full employment, national unemployment rates for 16-17 year AJPH May, 1979, Vol. 69, No. 5
CHANGING PATTERNS IN SUICIDE
olds averaged 14.9 per cent and, for 18-19 year olds, 11 per cent.7 A recent study found a relationship between high unemployment rates and increases in the rates of several social stress indicators, including suicide.8 The second general trend evident in this study is more favorable: a significant drop from extremely high suicide rates among white males over the age of 65 in both city and suburban areas. Elderly women, who have been much less prone to suicide throughout, have also experienced some diminution in these rates. These changes in Cuyahoga County also reflect national trends.9 Factors which may have reduced stress among the elderly during this period include increased access to hospitals for older persons since the 1965 Medicare legislation,'0 the development of somewhat improved social services for the aged, and the enlargement of social and political action associations among older persons themselves. I I The differing trends among urban youth, older persons, and whites suggest that suicide is not a single entity, but a number of distinct, closely related syndromes.'2 A recent British study classified suicides into three types: "'sociopathic,"* "old and handicapped," and "depressed."'13"14 Sociopathic suicide was characterized by early disruption of family life, poor adjustment in the employment field, sociopathic traits, social isolation, and previous suicidal attempts. It predominated in central city areas and was associated with other social pathology. One population group in the present study, the inner city young people who have experienced substantial suicide rate increases, resembles this group. Old and handicapped suicides were reported to occur among older individuals who were suffering from illness, chronic pain, widowhood, loneliness, poor sleep, and depressed mood. The older men and women in the present study, whose suicide rates have decreased, possibly include such persons. Their situation may have been somewhat ameliorated by the social changes noted above. Depressed suicides were said to be those observed among chronically depressed individuals with a history of long contact with psychiatric services and who had made previous suicidal attempts. This type potentially cuts across all age, race, and sex categories. Such individuals are not clearly indentifiable in the present data but may include some of the increasing numbers who killed themselves with drugs (i.e., barbiturates) originally prescribed by physicians. This trend may also be related to the well-defined "epidemic" of drug abuse which occurred in the late 1960s.'5 More specifically, it parallels a marked increase in attempted suicide by drug ingestion.'6 Elderly white males living in the city still experience much the highest rates of suicide, in spite of some lowering of the rates. In addition, higher percentages of measurable and intoxicating levels of alcohol are found among men than *British usage of this term differs from the American. In the U.S. "sociopathic personality" refers to a personality disorder characterized primarily in terms of the pathologic relationship between the individual and the society and the moral and cultural environment in which he lives (Gould Medical Dictionary, 3rd Edition). AJPH May, 1979, Vol. 69, No. 5
among women and among city men than among suburban men. These findings, taken together, suggest that there are in the city significant numbers of white male alcoholics who are likely to become suicidal.'7 Comparing suicide and homicide trends over the 17-year study period, certain points stand out. First, although both forms of violent death have increased significantly, the countywide increase of 243% per cent for homicides far exceeds the 23 per cent increase in suicides. There are some similarities, in that the greatest increases in absolute rates of both suicide and homicide have been observed among young nonwhite city males, with young white city males a close second. Firearms became more prominent as a means of both homicides and suicides, but, again, homicides led, with 81 per cent committed by guns, compared with 46 per cent of suicides. There are, however, probably more differences than similarities in the patterns and trends of homicide and suicide. White male suicide rates still show a continuous increase with age, while homicides drop off steadily after the age of 30. Nonwhite male suicide rates do not show this age correlation at all, and, except for ages 15-24, nonwhite male rates of suicide remain consistently lower than white male rates, whereas the reverse is emphatically the case for homicides. Women have experienced definite but less striking increases in both homicides and suicides, but here again the increase in homicides has been greater than that in suicides. Certain pressures of the social environment appear to influence the tendency to both homicide and suicide, but the personal and interpersonal forces which contribute to one or the other of these violent forms of death must differ considerably among individuals of different age, sex, and race. Menninger postulates that suicide is really a displaced murder motivated by the wish to kill, the wish to be killed, or the wish to die.'8 One study in which suicide notes were classified according to Menninger's theory found that the wish to die was more prevalent among older persons while the wish to kill and be killed appeared more frequently in the notes of young people.'9 The analysis suggests that younger suicides are more often motivated by a mood of anger or hostility which may be experienced in common with homicide victims. Several homicide studies have noted that victims and assailants have similiar characteristics20 and that the victim of homicide often precipitates his own death.2' In a large industrial American city, there is reason to believe that both white and nonwhite young people who become victims of suicide and homicide share the pressures of a "sociopathic" environment. The older suicide victim, on the other hand, is more likely to have been motivated by a sincere desire to die in order to escape the infirmities and loneliness of old age. There is also evidence to suggest that for a certain per cent of older suicide victims (particularly males) the loss of status experienced upon retiring from their life's work may be a
precipitating factor.22 The increasing use of firearms in suicide raises several questions. It has generally been reported that females attempt suicide more frequently than males, but have a lower completion rate.23 Although many students of suicide have 463
FORD, ET AL.
attributed the higher rate of completed suicides among males to seriousness of intent,24 recent data suggest that the difference in rates is more closely related to mode: women die in suicide attempts less frequently because they tend to use less lethal modes, mainly drugs. On the other hand, males increasingly use firearms in the suicidal act. This can be attributed not only to the increased availability of firearms25 but also to the socialization of males to firearms in American society. A recent study reports that males are introduced to guns more frequently and earlier than females, usually by a member of the family, most often the father.26 The gun is the most lethal of weapons. In a homicidal attack it is four times more likely to wound mortally than the next most lethal mode, cutting and piercing instruments.25 In the United States, 49 percent of all households have a firearm, but estimates of ownership vary regionally, with the south having the highest rates. It has been estimated that 76 per cent of males raised in the south have shot a gun before their 13th birthday. Females are generally less likely to be socialized to guns, and suicide by firearms is less prevalent among them, except in the south, where female firearm suicide rates are highest. This would suggest that early socialization to firearms makes them culturally acceptable instruments. In times of stress, the gun provides a ready solution to personal problems.26 Females, on the other hand, have had more frequent exposure to prescribed drugs through their greater use of medical services.24 Women in our society have drugs prescribed for them approximately three times more frequently than males.27 Many drugs, of course, are relatively slow acting and allow time for intervention in a suicidal attempt. It is unlikely that complete abolition of firearms in our society would reduce the number of suicide attempts. Individuals tend to use suicide methods that are most accessible. Where a popular mode has been removed, such as coal gas in Great Britain, rates first decrease and then increase again as another mode is substituted.28 However, we would predict that if guns continue to proliferate in our society and thus become more familiar to a greater number of people, completed suicide rates will continue to rise simply because of the lethality of the instrument.
REFERENCES 1. Department of Health, Education, and Welfare, Vital Statistics of the United States, 1960 and 1970. 2. Rushforth, NB, Ford AB, Hirsch CS, et al: Violent death in a metropolitan county: changing patterns in homicide (19581974). N Engl J Med 297: 531-538, 1977. 3. Hirsch CS, Rushforth NB, Ford AB, et al: Homicide and suicide in a metropolitan county, I. Long-term trends. JAMA 223:900-905, 1973 4. American Bar Association-American Medical Association, Joint Statement of Principles Concerning Alcoholism, in American Medical Association: Manual on Alcoholism, Chicago, IL, AMA, 1977.
464
5. Weiss NS: Recent trends in violent deaths among young adults in the United States, Am J Epidemiol 103:416-422, 1976. 6. U.S. Department of Labor: Manpower Report of the President, Washington, DC, Government Printing Office, 1970, pp. 49-50. 7. Leveson I: An economist's approach to crime's future, in Sherman, M. (ed.), Long Range Thinking and Law Enforcement, Washington, DC, U.S. Law Enforcement Assistance Administration, 1976, Chapter 4 (in press) 8. Brenner H: Estimating the Social Costs of National Economic Policy: Implications for Mental and Physical Health, and Criminal Aggression, Vol. 1, Paper No. 5 in Achieving the Goals of the Employment Act of 1946-Thirtieth Anniversary Review, Joint Committee Print (94:2), U.S. Congress, Washington, DC, U.S. Government Printing Office, 1976. 9. Statistical Bulletin, Metropolitan Life Insurance Co.: Recent trends in suicide, 57 (May, 1976), 5-7. 10. Shanas E, and Maddox GL: Aging, health, and the organization of health resources, in Binstock, RH and Shanas E, (eds.), Handbook of Aging and the Social Sciences, New York, Van Nostrand Reinhold Co., 1976, pp. 608-609. 11. Butler RN: Why Survive? Being Old in America, New York, Harper & Row, 1975, pp. 334-350. 12. Jackson DD: Theories of suicide, in Shneidman ES, and Farberow NL. (eds.), Clues to Suicide, New York, McGraw-Hill, 1957, pp. 11-21. 13. Bagley C, Jacobson S, Rehin A: Completed suicide: A taxonomic analysis of clinical and social data, Psychol Med 6:429438, 1976. 14. Bagley C, Jacobson S: Ecological variation of three types of suicide, Psychol Med 6:423-427, 1976. 15. ODonnell JA, Voss HL, Clayton RR, et al: Young Men on Drugs: A Nationwide Survey, NIDA Research Monograph 5, National Institute on Drug Abuse, Rockville, MD, DHEW Publication No. (ADM) 76-311, 1976. 16. O'Brien JP: Increase in suicide attempts by drug ingestion-The Boston experience, Arch Gen Psychiatry 34:1165-69, 1977. 17. Goodwin DW: Alcohol in suicide and homicide, Quart J Stud Alc 34 144-158, 1973. 18. Menninger KA: Man Against Himself, New York, Harcourt, Brace and Company Inc., 1938. 19. Farberow NL, and Shneidman, ES: Suicide and age, in Shneidman ES and Farberow NL, (eds.), Clues to Suicide, New York, McGraw-Hill Book Company, Inc., 1957, pp. 41-49. 20. Wolfgang ME: Patterns in Criminal Homicide, New York, John Wiley & Sons, 1958. 21. Wolfgang ME: Victim-precipitated criminal homicide, in Wolfgang ME (ed.), Studies in Homicide, New York, Harper & Row, 1967. 22. Breed W: Occupational mobility and suicide among white males, in Gibbs JP, (ed.), New York, Harper & Row, 1968. 23. Dublin, LI: Suicide, New York, Ronald Press, 1963. 24. Morris JB, Kovacs M, Beck AT, and Wolffe A: Notes toward an epidemiology of urban suicide, Comprehensive Psychiatry 15: 537-547, 1974, 1974. 25. Newton GD Jr, Zimring FE: Firearms and Violence in American Life: A Staff Report Submitted to the National Commission on the Causes and Prevention of Violence. Washington, DC, U.S. Government Printing Office, 1969. 26. Marks A. and Stokes C: Socialization, firearms and suicide, Social Problems, Vol 23, no. 5, June, 1976. 27. Parry HJ, Balter MB, Mellinger GD, et al: National patterns of psychotherapeutic drug use, Arch Gen Psychiatry 28: 769-783, 1973. 28. Kreitman N: The coal-gas story: United Kingdom suicide rates, 1960-1971, Brit J Prev Soc Med 30: 86-93, 1976.
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Abstract: Suicide rates in Cuyahoga County (metropolitan Cleveland) rose from 10.2 in 1958 to 12.5 per 100,000 population in 1974 (23 per cent increase) with the greatest rise among nonwhite males (from 5.9 to 13.1, or 122 per cent). Increased rates were observed in both the city (19 per cent increase) and suburbs (35 per cent increase). Rates increased among young nonwhite and white adults of both sexes aged 15-34 years, but decreased slightly among adults aged 65 years and older. These findings are consistent with national trends. Alcohol was present in the blood of one-fourth of the individuals who were "dead on arrival," and at intoxicating levels in 20 per cent. There were increasing percentages of victims with positive blood alcohol
and with intoxicating levels during the study period. White male victims in the city had significantly higher frequencies of such findings than their counterparts in the suburbs. The rates of suicide committed by firearms rose among all race-sex groups, with the greatest increase among city nonwhite males (2.1 to 7.7, or 267 per cent). Suicide by chemical agents (roughly one-half being barbiturates) increased in all groups except city nonwhite males, with the greatest increase among white males and suburban white females. Firearms among males and poisoning among females displaced asphyxia as the leading modes of suicide. (Am. J. Public Health 69:459-464, 1979.)
Introduction
in order to investigate changing patterns, we subdivided the 17-year interval into three periods: 1958-1962, a baseline period with a relatively low and stable homicide rate (average annual rate 5.6 victims per 100,000 of the county population); 1963-1968, an intermediate period during which the initial increase in homicide rate occurred (average, 9.2); and 1969-1974, a third period with high and slightly increasing rates (average, 19.2). The purpose of the present report is to present a more detailed study of the changing patterns of suicide in Cuyahoga County during the years 1958-1974, using the three time periods defined in the study of homicides. The time span is longer than that evaluated in most studies of suicide and permits an analysis of changes in age-, sex-, and racespecific suicide rates in relation to city and suburban location. In addition, we have documented changes in the mode of lethal violence and in blood alcohol levels and related them to suicide rates.
The 1960s were a decade of violence in American life. In addition to urban riots and the Vietnam War, interpersonal violence escalated, led by a dramatic rise in homicides. These trends affected the entire population, but the impact fell most heavily on young adult males, who also experienced higher mortality from accidents, suicides, and cirrhosis of the liver, resulting in an overall increase in mortality of 16 per cent for men 25 to 34 years old.' Taking advantage of a set of unusually complete and uniform records in the Coroner's Office of Cuyahoga County (Cleveland), Ohio, we previously reported a detailed analysis of the trends in homicides in that county from 1958 through 1974.2 In an earlier report, we also contrasted longterm trends in homicide rates with those in suicide rates from 1938 through 1971.3 In the study of homicides for 1958-1974, From Case Western Reserve University, School of Medicine, and the Cuyahoga County Coroner's Office. Address reprint requests to Amasa B. Ford, MD, Proftssor of Community Health and Family Medicine, Case Western Reserve University School of Medicine, Cleveland, OH 44106. Dr. Rushforth is Professor and Chairman, Department of Biology, and Associate Professor of Biometry; Ms. Rushforth is Research Assistant, Department of Biology, at the University. Dr. Hirsch is Deputy Coroner, and Associate Professor of Forensic Pathology; Dr. Adelson is Chief Deputy Coroner, and Professor of Forensic Pathology, both with the County Coroner's Office and the School of Medicine. This paper, submitted to the Journal May 15, 1978, was revised and accepted for publication September 5, 1978. This paper was originally prepared for presentation at the 1977 Annual Meeting of the American Public Health Association
AJPH May, 1979, Vol. 69, No. 5
Methods Cuyahoga County ("county") consists of the City of Cleveland ("city") and an adjacent aggregate of 38 cities, 18 villages, and four townships ("suburbs"). All known or suspected violent deaths (i.e., accident, homicide, and suicide) in the county must be investigated by the coroner. Because one man (Samuel R. Gerber, MD, JD) has been County Coroner since 1936, criteria for verdicts have been consistent throughout the study period. When the manner of death cannot be determined "beyond a reasonable doubt," cases 459
FORD, ET AL.
are classified as "violence of undetermined origin." Ninetysix fatalities were classified in this manner and are omitted from this analysis of 3,264 suicide victims for the 17-year study period.* We calculated annual suicide rates, using data from the Coroner's records to determine the number of victims and from U.S. Census Bureau publications for population figures. The latter include a 1965 special census for the City of Cleveland. Suburban and county populations for 1965 were estimated by linear interpolation of the decennial census figures. Average annual suicide rates for the three previously defined periods are based on population figures for 1960, 1965 and 1970, using the actual census counts as denominators rather than estimates for non-census years. Fatalities are tabulated according to the location of the suicide incident (city vs. suburbs) rather than the place of death or residence of the victim. Race is designated as white or nonwhite; the nonwhite county population was 98.7 and 97.3 per cent black in 1960 and 1970, respectively. Blood ethanol levels are routinely determined by gas chromatography at the Coroner's Office for all victims of violent or natural death 15 years of age and older who survive less than 24 hours. To avoid distortions due to absorption, metabolism, and excretion of alcohol in victims who temporarily survive the lethal event, we have restricted this phase of our study to suicide victims who were "dead on arrival." Victims with positive blood alcohol and with blood alcohol levels equal to or greater than 0.1 per cent by weight are reported. The latter value is usually designated as the lower level of blood alcohol corresponding to intoxication.4 The proportion of all suicide victims who were dead on arrival and who had blood alcohol tested did not change significantly during the study period (78-80 per cent). Similarly, this proportion did not vary significantly between sex groups (male 79-81 per cent, female 75-76 per cent) or race groups (white 79-80 per cent; nonwhite 67-78 per cent). In the following analysis of data, statistical significance of differences between rates was tested by chi square. Unless otherwise specified, all differences mentioned in this report are significant at p = .05 or less.
Results Sex and Race of Suicide Victims The number of suicide victims and suicide rates (unadjusted and age adjusted) for the total county population as well as those based on race and sex are presented in Table 1. Suicide rates adjusted for changes in the age composition of the county population over the study period are similar to corresponding unadjusted rates, indicating that shifts in the age composition of the population had little influence on crude rates. *Of the 96 fatalities of undetermined origin, 91 were fatalities in which a distinction between suicide and accidental death could be made tentatively. In another three cases, it could not be ascertained whether death was due to suicide or homicide, and in two cases the deaths were of completely unknown origin. 460
In the county, suicide rates increased from 10.2 in the baseline period of the study (1958-1962) to 11.3 in the intermediate period (1963-1968) and rose by the third period (1969-1974) to 12.5, a 22 per cent increase over the initial period. Of the four race-sex groups, white males had the highest suicide rate in each of the three study periods. This rate, however, showed little change over the 17 years, increasing only 6.5 per cent from the baseline value in the third period (P > .10). All other three groups had significant increases. The nonwhite male suicide rate showed the greatest percentage increase of the four population groups, rising from a relatively low baseline rate of 5.9 to 13.1 in the third period (122 per cent). For white females the rate increased from 5.7 (approximately equal to the non-white male rate in that period) to a value of 9.0, a rate significantly lower than the corresponding third period rate for nonwhite males. In all three periods, the nonwhite female population had the lowest suicide rate, yet the rate for this group rose 96 per cent (2.8 to 5.5) over the time span of the study.
Suicide Rates for the City of Cleveland and Suburbs Overall, the suicide rate in the City of Cleveland was consistently higher than the corresponding suburban rate for each of the three study periods (Table 1). Between 19581974 the suburban rate increased by 35 per cent, while the city rate increased by 19 per cent. The uniformly higher city suicide rates resulted from significantly higher rates for white males in the city than in the suburbs. In contrast, nonwhite rates appear to have been slightly higher in the suburbs than in the city, but comparisons are uncertain because of small numbers of nonwhite suicides in the suburbs. In the city, major increases in suicide rates occurred among nonwhites. Nonwhite male rates jumped from 5.9 to 12.5 (112 per cent), and those for nonwhite females from 2.7 to 5.4 (100 per cent). Smaller relative increases were observed among whites. The rate for white males rose slightly (9.6 per cent, p > .10); that for white females rose 52 per cent (p < .01). In the suburbs, white male rates were distinctly lower than in the city, while white female rates were similar in the suburbs and the city. Age at Suicide Suicide rates for white males showed a marked upward trend with increasing age both in the city and suburbs, and this trend persisted in spite of temporal changes during the study period (Figure 1). The overall rate remained relatively constant over the 17 years of the study (Table 1), but rates in the younger age groups became higher in the third period than corresponding baseline values; in contrast, above 60 years of age, rates in the third period were lowered. Rates for teenage and young adult white males (15-24 years) in the city rose 90 per cent (from 8.9 to 16.9) and those in the suburbs increased 34 per cent (from 9.3 to 12.5). However, rates for white males age 65-74 in the city decreased 13 per cent (from 56.8 to 49.7), and those for older white males in the suburbs dropped 26 per cent (from 39.9 to 29.4). Nonwhite males in the city, on the other hand, showed a general downward trend in suicide rates with increasing age. AJPH May, 1979, Vol. 69, No. 5
CHANGING PATTERNS IN SUICIDE TABLE 1-Suicide Rates in Cuyahoga County (Ohio) According to Race and Sex (1958-1974) Showing Number, Annual Rate and Age-Adjusted Annual Rate* (victims/100,000 population)**
Group and Location
COUNTY White males Nonwhite males White females Nonwhite females TOTALS CITY White males Nonwhite males White females Nonwhite females TOTALS SUBURBS White males Nonwhite males White females Nonwhite females TOTALS
1969-1974
1963-1968
1958-1962 Annual
Age
Annual
Age
Annual
Age
No.
Rate
Adjusted
No.
Rate
Adjusted
No.
Rate
Adjusted
570 37 204 19 830
16.9 5.9 5.7 2.8 10.2
17.1 5.8 5.2 2.8 10.2
698 72 352 20 1142
17.5 8.3 8.2 2.1 11.3
17.4 10.1 7.5 2.1 11.3
717 125 391 59 1292
18.0 13.1 9.0 5.5 12.5
17.8 14.1 8.4 5.6 12.2
350 36 95 18 499
23.0 5.9 6.0 2.7 11.4
21.3 5.8 5.4 2.6 10.8
363 65 150 19 597
23.6 8.2 9.1 2.1 12.3
22.1 10.0 8.2 2.2 12.2
331 103 130 50 614
25.2 12.5 9.1 5.4 13.6
23.8 13.6 8.6 5.4 13.5
220 1 109 1 331
11.9 9.9+ 5.5 2.3+ 8.6
13.3 9.7+ 5.1 2.3+ 9.6
335 7 202 1 545
13.7 9.9+ 7.7 2.3+ 10.4
14.1 9.7+ 7.0 2.3+ 10.4
386 22 261 9 678
14.5 17.1 9.0 6.4 11.6
14.7 16.4 8.3 6.3 10.9
*Age adjusted with US population in 1970 as standard population "Census figures for county population: 1960 = 1,647,895; 1970 = 1,721,300 + Estimated rate for period 1958-1968 since there were too few nonwhites in the suburbs to calculate meaningful rates for the period 1958-1962
This relationship, which became more pronounced during the study period, contrasts sharply with that for white males. NonWhite teenage and young adult males in the city have exper-enced large increases in suicide rates during the study period, amounting to a startling 1,313 per cent (from 1.5 to
801 White males city
801 White females city
60
60
40
40
20
20
0........
- 1958 - 1962
-
1969 - 1974
601 Nonwhite females
0 0 0
city
6
0
Eo 0
White males suburbs
60
60
40
40
20 L
20
0
20
40
60
80
White females suburbs
0
20
40
60
80
Age in Years FIGURE 1. Suicide Rates According to Age, Sex, Race, and Residence, Cuyahoga County, Ohio 1958-1962 and 196-1974.
AJPH May, 1979, Vol. 69, No. 5
21.2) at ages 15-24 years. Young nonwhite males in the city now have the highest suicide rate of any comparable group, whereas 17 years ago they had one of the lowest. All females below the age of 45 experienced increases in suicide rates during the 17 years, ranging from 56 per cent to 1,160 per cent above the baseline period. The second largest relative rate increase in any population group occurred among white females aged 15-24 years, in the city (from 0.5 to 6.3, or 1,160 per cent), although this increase, in absolute terms, was less than that experienced by white males of the same age in the city. Above age 75 years, white female suicide rates decreased from 14.1 to 7.6, or 46 per cent in the city, and from 13.6 to 7.3 , or 46 per cent in the suburbs. In general, suicide rates among females were lower than among males of the same age and race. In addition, differences related to location, race, and age were less pronounced than among males. Alcohol Levels In Table 2 the per cent of suicide victims "dead on arrival" who had positive tests for blood alcohol and those with blood alcohol levels 0.1 per cent or greater are presented for the three time periods. While the proportion of tested victims with positive blood alcohol determinations did not change significantly over the 17-year period, the percentage of victims with alcohol levels indicative of intoxication (0.1 per cent or greater) increased in the intermediate and third periods (p < .01). For white male victims, both in the city and suburbs, the percentages with intoxicating blood alcohol levels were significantly greater in the latter two periods
.01). White male suicide victims in the city had significantly higher relative frequencies of positive blood alcohol and in(p
toxicating levels than their counterparts in the suburbs (pooled data, 1958-74, p < .01). No such differences occurred between city and suburban white females. Mode of Lethal Violence The use of asphyxia, which was the most common means of suicide in the first period, dropped to second rank by 1969-1974, being displaced by firearms among males and poisoning among females (Table 3). Asphyxia (which includes drowning, suffocation, and hanging) decreased among all white males and among city females, with moderate increases in the other population groups. Firearms, asphyxia, and poisoning, in that order, became the leading means of suicide for males by 1969-1974. Together, these methods accounted for 91.7 per cent of deaths. Among females, these three modes accounted for 92.9 per cent of suicides, with poisoning the leading cause (except for nonwhite women in the city, who used firearms TABLE 3-Suicide Rates in Cuyahoga County, (Ohio) According to Mode of Lethal Violence and Sex (1958-1974), Showing Annual Rate (victims/100,000 population) and Distribution by Per Cent
Positive %
No. Tested
No(%) Positive %
a 0.1%
93 (36.6) 36 (43.3) 23 (24.7)
26 (31.3) 17 (18.3)
6(40.0)
254 83 93 36
9(25.0)
7(19.4)
58 (21.6) 22(13.7) 195 (21.6)
309 208 1006
71(23.0) 43 (20.7) 279 (27.7)
52 (16.8) 27(13.0) 203 (20.2)
-
0.1%
71(28.0)
most frequently). The use of firearms and poisoning both increased significantly over the 17-year study period. Firearm rates rose 62 per cent for men and 125 per cent for women, and poisoning rates 67 per cent for men and 112 per cent for women.
Detailed examination of the age-sex-race distribution of firearm suicides in the city (not shown) indicates that the age distribution of this fortn of suicide is approximately parallel to that of all suicides in the various groups. Again, the highest rates were among young nonwhite males and older white males, while the most extreme increases in the use of firearms occurred among young nonwhite men. When all modes of suicide are examined by sex, race, and location (also not shown), the increase in the use of firearms is found consistently in every group, most strikingly among nonwhite males in the city, where suicide by firearms increased from 2.1 to 7.7 (267 per cent). Suicide by poison (roughly one-half being barbiturates) also increased in each group except city nonwhite males, among whom it decreased from 1.1 to 0.9 (18 per cent). City white males experienced the greatest increase in suicide by poisoning, from 1.4 to 3.6 (157 per cent), while the highest rates (4.2), occurred among suburban white women.
MALES Mode of Suicide
1 95&-1962
1963-1968
1969-1974
Asphyxia Poisoning Firearms
7.1 (46.6)* 1.2 ( 7.6) 5.2 (34.4)
Cuts and Stabs
0.5( 3.1) 1.0 ( 6.8) 0.2 ( 1.5)
6.0 (37.5) 1.5 ( 9.4) 6.7 (42.3) 0.5( 2.9) 1.1 ( 7.0) 0.1 ( 0.8)
5.3 (30.8) 2.0 (11.5) 8.4 (49.4) 0.4( 2.6) 0.8 ( 4.8) 0.2( 1.1)
Jumping Other
FEMALES
Asphyxia Poisoning Firearms Cuts and Stabs Jumping Other
2.3 (43.0) 1.7 (32.7) 0.8 (14.8) 0.1 ( 2.2) 0.3( 5.8) 0.1 ( 1.3)
2.3 (32.8) 2.7 (37.6) 1.3 (18.3) 0.3( 4.6)
0.4( 5.4) 0.1 ( 1.3)
2.4 (28.2) 3.6 (42.7) 1.8 (22.0) 0.2 ( 2.0) 0.3 ( 3.8) 0.1 ( 1.3)
*Figures in parentheses denote per cent according to mode of suicide before rounding rates to one decimal 462
Discussion The most striking trend observed in this study is a marked increase in suicide among teenagers and young adults, particularly in the city and among nonwhite males, whose suicide rates were previously low. Although less dramatic than the increase in homicides, this rise in suicides among urban youth is also alarming. These data are consistent with national trends.5 During the 1960s the number of teenagers in our population increased considerably, aggravating problems afflicting this group and creating stress.6 The teenage unemployment rate has traditionally been higher than the general rate, but in the 1960s the difference became even greater. For nonwhite teenage males, rates have been reported as high as 40 per cent. Even in the late 1960s, a time of supposedly full employment, national unemployment rates for 16-17 year AJPH May, 1979, Vol. 69, No. 5
CHANGING PATTERNS IN SUICIDE
olds averaged 14.9 per cent and, for 18-19 year olds, 11 per cent.7 A recent study found a relationship between high unemployment rates and increases in the rates of several social stress indicators, including suicide.8 The second general trend evident in this study is more favorable: a significant drop from extremely high suicide rates among white males over the age of 65 in both city and suburban areas. Elderly women, who have been much less prone to suicide throughout, have also experienced some diminution in these rates. These changes in Cuyahoga County also reflect national trends.9 Factors which may have reduced stress among the elderly during this period include increased access to hospitals for older persons since the 1965 Medicare legislation,'0 the development of somewhat improved social services for the aged, and the enlargement of social and political action associations among older persons themselves. I I The differing trends among urban youth, older persons, and whites suggest that suicide is not a single entity, but a number of distinct, closely related syndromes.'2 A recent British study classified suicides into three types: "'sociopathic,"* "old and handicapped," and "depressed."'13"14 Sociopathic suicide was characterized by early disruption of family life, poor adjustment in the employment field, sociopathic traits, social isolation, and previous suicidal attempts. It predominated in central city areas and was associated with other social pathology. One population group in the present study, the inner city young people who have experienced substantial suicide rate increases, resembles this group. Old and handicapped suicides were reported to occur among older individuals who were suffering from illness, chronic pain, widowhood, loneliness, poor sleep, and depressed mood. The older men and women in the present study, whose suicide rates have decreased, possibly include such persons. Their situation may have been somewhat ameliorated by the social changes noted above. Depressed suicides were said to be those observed among chronically depressed individuals with a history of long contact with psychiatric services and who had made previous suicidal attempts. This type potentially cuts across all age, race, and sex categories. Such individuals are not clearly indentifiable in the present data but may include some of the increasing numbers who killed themselves with drugs (i.e., barbiturates) originally prescribed by physicians. This trend may also be related to the well-defined "epidemic" of drug abuse which occurred in the late 1960s.'5 More specifically, it parallels a marked increase in attempted suicide by drug ingestion.'6 Elderly white males living in the city still experience much the highest rates of suicide, in spite of some lowering of the rates. In addition, higher percentages of measurable and intoxicating levels of alcohol are found among men than *British usage of this term differs from the American. In the U.S. "sociopathic personality" refers to a personality disorder characterized primarily in terms of the pathologic relationship between the individual and the society and the moral and cultural environment in which he lives (Gould Medical Dictionary, 3rd Edition). AJPH May, 1979, Vol. 69, No. 5
among women and among city men than among suburban men. These findings, taken together, suggest that there are in the city significant numbers of white male alcoholics who are likely to become suicidal.'7 Comparing suicide and homicide trends over the 17-year study period, certain points stand out. First, although both forms of violent death have increased significantly, the countywide increase of 243% per cent for homicides far exceeds the 23 per cent increase in suicides. There are some similarities, in that the greatest increases in absolute rates of both suicide and homicide have been observed among young nonwhite city males, with young white city males a close second. Firearms became more prominent as a means of both homicides and suicides, but, again, homicides led, with 81 per cent committed by guns, compared with 46 per cent of suicides. There are, however, probably more differences than similarities in the patterns and trends of homicide and suicide. White male suicide rates still show a continuous increase with age, while homicides drop off steadily after the age of 30. Nonwhite male suicide rates do not show this age correlation at all, and, except for ages 15-24, nonwhite male rates of suicide remain consistently lower than white male rates, whereas the reverse is emphatically the case for homicides. Women have experienced definite but less striking increases in both homicides and suicides, but here again the increase in homicides has been greater than that in suicides. Certain pressures of the social environment appear to influence the tendency to both homicide and suicide, but the personal and interpersonal forces which contribute to one or the other of these violent forms of death must differ considerably among individuals of different age, sex, and race. Menninger postulates that suicide is really a displaced murder motivated by the wish to kill, the wish to be killed, or the wish to die.'8 One study in which suicide notes were classified according to Menninger's theory found that the wish to die was more prevalent among older persons while the wish to kill and be killed appeared more frequently in the notes of young people.'9 The analysis suggests that younger suicides are more often motivated by a mood of anger or hostility which may be experienced in common with homicide victims. Several homicide studies have noted that victims and assailants have similiar characteristics20 and that the victim of homicide often precipitates his own death.2' In a large industrial American city, there is reason to believe that both white and nonwhite young people who become victims of suicide and homicide share the pressures of a "sociopathic" environment. The older suicide victim, on the other hand, is more likely to have been motivated by a sincere desire to die in order to escape the infirmities and loneliness of old age. There is also evidence to suggest that for a certain per cent of older suicide victims (particularly males) the loss of status experienced upon retiring from their life's work may be a
precipitating factor.22 The increasing use of firearms in suicide raises several questions. It has generally been reported that females attempt suicide more frequently than males, but have a lower completion rate.23 Although many students of suicide have 463
FORD, ET AL.
attributed the higher rate of completed suicides among males to seriousness of intent,24 recent data suggest that the difference in rates is more closely related to mode: women die in suicide attempts less frequently because they tend to use less lethal modes, mainly drugs. On the other hand, males increasingly use firearms in the suicidal act. This can be attributed not only to the increased availability of firearms25 but also to the socialization of males to firearms in American society. A recent study reports that males are introduced to guns more frequently and earlier than females, usually by a member of the family, most often the father.26 The gun is the most lethal of weapons. In a homicidal attack it is four times more likely to wound mortally than the next most lethal mode, cutting and piercing instruments.25 In the United States, 49 percent of all households have a firearm, but estimates of ownership vary regionally, with the south having the highest rates. It has been estimated that 76 per cent of males raised in the south have shot a gun before their 13th birthday. Females are generally less likely to be socialized to guns, and suicide by firearms is less prevalent among them, except in the south, where female firearm suicide rates are highest. This would suggest that early socialization to firearms makes them culturally acceptable instruments. In times of stress, the gun provides a ready solution to personal problems.26 Females, on the other hand, have had more frequent exposure to prescribed drugs through their greater use of medical services.24 Women in our society have drugs prescribed for them approximately three times more frequently than males.27 Many drugs, of course, are relatively slow acting and allow time for intervention in a suicidal attempt. It is unlikely that complete abolition of firearms in our society would reduce the number of suicide attempts. Individuals tend to use suicide methods that are most accessible. Where a popular mode has been removed, such as coal gas in Great Britain, rates first decrease and then increase again as another mode is substituted.28 However, we would predict that if guns continue to proliferate in our society and thus become more familiar to a greater number of people, completed suicide rates will continue to rise simply because of the lethality of the instrument.
REFERENCES 1. Department of Health, Education, and Welfare, Vital Statistics of the United States, 1960 and 1970. 2. Rushforth, NB, Ford AB, Hirsch CS, et al: Violent death in a metropolitan county: changing patterns in homicide (19581974). N Engl J Med 297: 531-538, 1977. 3. Hirsch CS, Rushforth NB, Ford AB, et al: Homicide and suicide in a metropolitan county, I. Long-term trends. JAMA 223:900-905, 1973 4. American Bar Association-American Medical Association, Joint Statement of Principles Concerning Alcoholism, in American Medical Association: Manual on Alcoholism, Chicago, IL, AMA, 1977.
464
5. Weiss NS: Recent trends in violent deaths among young adults in the United States, Am J Epidemiol 103:416-422, 1976. 6. U.S. Department of Labor: Manpower Report of the President, Washington, DC, Government Printing Office, 1970, pp. 49-50. 7. Leveson I: An economist's approach to crime's future, in Sherman, M. (ed.), Long Range Thinking and Law Enforcement, Washington, DC, U.S. Law Enforcement Assistance Administration, 1976, Chapter 4 (in press) 8. Brenner H: Estimating the Social Costs of National Economic Policy: Implications for Mental and Physical Health, and Criminal Aggression, Vol. 1, Paper No. 5 in Achieving the Goals of the Employment Act of 1946-Thirtieth Anniversary Review, Joint Committee Print (94:2), U.S. Congress, Washington, DC, U.S. Government Printing Office, 1976. 9. Statistical Bulletin, Metropolitan Life Insurance Co.: Recent trends in suicide, 57 (May, 1976), 5-7. 10. Shanas E, and Maddox GL: Aging, health, and the organization of health resources, in Binstock, RH and Shanas E, (eds.), Handbook of Aging and the Social Sciences, New York, Van Nostrand Reinhold Co., 1976, pp. 608-609. 11. Butler RN: Why Survive? Being Old in America, New York, Harper & Row, 1975, pp. 334-350. 12. Jackson DD: Theories of suicide, in Shneidman ES, and Farberow NL. (eds.), Clues to Suicide, New York, McGraw-Hill, 1957, pp. 11-21. 13. Bagley C, Jacobson S, Rehin A: Completed suicide: A taxonomic analysis of clinical and social data, Psychol Med 6:429438, 1976. 14. Bagley C, Jacobson S: Ecological variation of three types of suicide, Psychol Med 6:423-427, 1976. 15. ODonnell JA, Voss HL, Clayton RR, et al: Young Men on Drugs: A Nationwide Survey, NIDA Research Monograph 5, National Institute on Drug Abuse, Rockville, MD, DHEW Publication No. (ADM) 76-311, 1976. 16. O'Brien JP: Increase in suicide attempts by drug ingestion-The Boston experience, Arch Gen Psychiatry 34:1165-69, 1977. 17. Goodwin DW: Alcohol in suicide and homicide, Quart J Stud Alc 34 144-158, 1973. 18. Menninger KA: Man Against Himself, New York, Harcourt, Brace and Company Inc., 1938. 19. Farberow NL, and Shneidman, ES: Suicide and age, in Shneidman ES and Farberow NL, (eds.), Clues to Suicide, New York, McGraw-Hill Book Company, Inc., 1957, pp. 41-49. 20. Wolfgang ME: Patterns in Criminal Homicide, New York, John Wiley & Sons, 1958. 21. Wolfgang ME: Victim-precipitated criminal homicide, in Wolfgang ME (ed.), Studies in Homicide, New York, Harper & Row, 1967. 22. Breed W: Occupational mobility and suicide among white males, in Gibbs JP, (ed.), New York, Harper & Row, 1968. 23. Dublin, LI: Suicide, New York, Ronald Press, 1963. 24. Morris JB, Kovacs M, Beck AT, and Wolffe A: Notes toward an epidemiology of urban suicide, Comprehensive Psychiatry 15: 537-547, 1974, 1974. 25. Newton GD Jr, Zimring FE: Firearms and Violence in American Life: A Staff Report Submitted to the National Commission on the Causes and Prevention of Violence. Washington, DC, U.S. Government Printing Office, 1969. 26. Marks A. and Stokes C: Socialization, firearms and suicide, Social Problems, Vol 23, no. 5, June, 1976. 27. Parry HJ, Balter MB, Mellinger GD, et al: National patterns of psychotherapeutic drug use, Arch Gen Psychiatry 28: 769-783, 1973. 28. Kreitman N: The coal-gas story: United Kingdom suicide rates, 1960-1971, Brit J Prev Soc Med 30: 86-93, 1976.
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