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Methods used for suicide
Suicide searches produce disturbing, unsurprising results
Hanging 'now the most common form of suicide' among young men
US: Preference for Fall From Height as a Method of Suicide by Elderly
Dangerous Japanese 'Detergent Suicide' Technique Creeps Into U.S.
Doctors who kill themselves: a study of the methods used for suicide
PUBLIC HEALTH: METHODS OF SUICIDE AMONG ADOLESCENTS
Active & Passive Suicide Methods in the UK
Retired GPs advise terminally ill on suicide by starvation
See also:

Methods used for suicide

cebmh.warne.ox.ac.uk

We have recently completed a study funded by the Department of Health to collect information to assist in evidence-based implementation of the National Suicide Prevention Strategy for England with regard to reducing deaths involving certain methods of suicide. The study was based on Coroners' inquest records, and was undertaken in collaboration with colleagues from Bristol and Manchester universities.

A summary of the findings is available as a pdf on the CSIP website

Aim of the study
Reducing availability and lethality of methods of suicide is a key goal in the National Suicide Prevention Strategy for England (2002). In order to determine how this might best be effected, and also how the danger of specific methods might be reduced, including through improved treatment following suicidal acts, it is necessary to have detailed information on suicides in which these methods have been used. This study was established in order to achieve this aim in relation to certain specific methods of suicide, namely:

1) Hanging
2) Firearms
3) Co-proxamol poisoning
4) Self-poisoning in which the individual reached hospital alive.

For each method of suicide, selective literature reviews were conducted to provide both background information for the empirical studies and to supplement the conclusions.

A further aim of the study was to determine the extent to which coroners' records are a satisfactory source of information for studies of this kind.

Methods
The study was conducted through a collaboration involving centres in Oxford (Keith Hawton, Lesley Sutton, Sue Simkin, Camilla Haw), Bristol (David Gunnell and Olive Bennewith) and Manchester (Navneet Kapur and Pauline Turnbull). It was co-ordinated by the Centre for Suicide Research.

The study was conducted by examining coroners' records of suicides in which the methods under investigation were used. Eight coroners' jurisdictions within reasonable travelling distance of each of the three research centres were randomly selected (i.e. 24 in all). The cases included in the study were those receiving a coroner's verdict of suicide, or an open verdict in which the research team judged there to have been a high or moderate probability of suicide.

Structured data-extraction forms were used to record the following broad areas of information (detailed items were used within each area): demographic characteristics of the deceased, circumstances of the act (method, timing, location, discovery), toxicology (alcohol and blood levels), contact with psychiatric services and general practitioner, and previous self-harm. Part of the Beck Suicide Intent Scale, based on the objective circumstances of the act, was also completed. More detailed information on each specific method under investigation was recorded on additional sections of the forms. For each case a brief vignette was compiled, including any other relevant details from the inquest records.

Data were analysed using SPSS and STATA.


Main findings

Hangings: the majority occurred in the person's home or garden. A small minority occurred in prisons or psychiatric wards. Rope or cord was the most common ligature. In almost half the cases individuals were not fully suspended (i.e. feet off the ground).

Firearms: shotguns were used in over three-quarters of cases. A minority of individuals had had contact with psychiatric services and few had a history of previous self harm. Sport and occupational use were the main reasons for gun ownership.

Co-proxamol poisoning: More than 40% of individuals were aged 55 years and over. Nearly half had a history of self harm. Alcohol was involved in more than half the overdoses. These generally included fewer tablets. The co-proxamol was less often prescribed for the deceased in younger compared with older individuals. The number of tablets taken varied widely. Death occurred in most cases before the individual could reach hospital.

Self poisonings reaching hospital alive: Nearly a quarter of people who died from overdose reached hospital alive. Assistance was initially given by ambulance personnel in nearly three quarters of cases. Half the patients had a history of self harm. Cardiac monitoring occurred in at least one third of patients and approximately 4 out of 10 were ventilated and a similar proportion were admitted to an intensive care unit.

Use of coroners' records for the investigation of suicide: While coroners in general appear willing to assist with studies associated with suicide, there is considerable variation between coroners in the extent to which some information is included in their records. Some relatively important items are often not recorded, e.g. contact with psychiatric services, date of last contact with GP, blood levels for drug overdoses, source of drugs taken in overdoses, source of ligatures for hanging, and whether firearms used for suicide were licensed and whether they were kept in a locked cabinet.


Conclusions

Hanging: Since the most commonly used ligatures and ligature points are easily available, restriction of access to means is only possible in institutions such as hospitals and prisons. As death from hanging can often occur when an individual is not fully suspended, inspection of psychiatric wards and cells for potential ligature points should focus on fixtures and fittings at all heights.

Firearms: Use of firearms for suicide appears to have decreased following more restrictive firearm legislation (see Haw et al 2004 below)

Co-proxamol: Strategies to prevent co-proxamol poisoning should be based on safer prescribing and must take account of the fact that death can occur with relatively few tablets, especially if alcohol is consumed.

Self poisonings reaching hospital alive: Improved medical management could have the potential to prevent some poisoning suicides.

Use of coroners' records for the investigation of suicide: Standardisation of information recording by coroners could be valuable for investigations of suicide.


Publications:

Hanging
Bennewith, O., Gunnell, D., Kapur, N., Turnbull, P., Simkin, S., Sutton, L., Hawton, K. (2005) Suicide by hanging: a multicentre study based on coroners' records in England. British Journal of Psychiatry, 186, 260-261

Gunnell, D., Bennewith, O., Hawton, K., Simkin, S., Kapur, N. (2005) The epidemiology and prevention of suicide by hanging: a systematic review. International Journal of Epidemiology, 34, 433-442

Firearms
Sutton, L., Hawton, K., Simkin, S., Turnbull, P., Kapur, N., Bennewith, O., Gunnell, D. (2005) Gunshot suicides in England: a multicentre study based on coroners' records. Social Psychiatry and Psychiatric Epidemiology, 40, 324-328

Haw, C., Sutton, L., Simkin, S., Gunnell, D., Kapur, N., Nowers, M., Hawton, K. (2004) Suicide by gunshot in the United Kingdom: a review of the literature. Medicine Science and the Law, 44, 295-310

Co-proxamol
Hawton K, Simkin S, Gunnell D, Sutton L, Bennewith O, Turnbull P, Kapur N. (2005) A multicentre study of co-proxamol poisoning suicides based on coroners' records in England. British Journal of Clinical Pharmacology, 59, 207-212

Simkin, S., Hawton, K., Sutton, L., Gunnell, D., Bennewith, O., Kapur, N. (2005) Co-proxamol and suicide: preventing the continuing toll of overdose deaths. Quarterly Journal of Medicine, 98, 159-170

Self poisonings reaching hospital alive
Kapur, N., Turnbull, P., Hawton, K., Simkin, S., Sutton, L., Mackway-Jones, K., Bennewith, O., Gunnell, D. (2005) Self-poisoning suicides in England: a multicentre study. Quarterly Journal of Medicine, 98, 589-597 doi:10.1093/qjmed/hci089

Kapur, N., Turnbull, P., Hawton, K., Simkin, S., Mackway-Jones, K., Gunnell, D. (2006) The hospital management of fatal self-poisoning in industrialised countries: an opportunity for suicide prevention? Suicide and Life-Threatening Behavior, 36, 302-312

Use of coroners' records for the investigation of suicide
Bennewith, O., Hawton, K., Simkin, S., Sutton, L., Kapur, N., Turnbull, P., Gunnell, D. (2005) The usefulness of coroners' data on suicides for providing information relevant to prevention. Suicide and Life-Threatening Behavior, 35, 607-614


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Suicide searches produce disturbing, unsurprising results

A team of UK researchers sets out to discover just what sort of suicide info is available online.
The conclusion: whether you want to kill or save yourself, the Internet can help in myriad ways.

By Nate Anderson April 11, 2008

The Internet makes it easy to learn about anything, even suicide, and a new study out in the British Medical Journal tries to determine just how simple it is to dig up suicide information online. And when the information is found, the authors determine whether it promotes suicide or not, an important consideration since "media reporting of suicide and its fictional portrayal on television are known to influence suicidal behavior, particularly the choice of method used."

Although concern about suicide information on the Web has been growing, the UK researchers who did the study note that no one actually knows how easy it is to find this information online, nor do they know exactly what sort of information is found. To fill the knowledge gap, the researchers collected 12 broad search terms gathered in part from interviews with those how had attempted suicide: suicide, suicide methods, suicide sure methods, most effective methods of suicide, methods of suicide, ways to commit suicide, how to commit suicide, how to kill yourself, easy suicide methods, best suicide methods, pain-free suicide, and quick suicide.

The researchers then used these 12 terms on four of the top search engines (Google, Yahoo, MSN, and Ask) and looked at the first ten results for each search (based on more general research that shows Internet searchers often don't look beyond the first page of results).

The 480 results that this generated were consolidated to produce 240 unique web sites, which were then divided into 14 groups that ranged from "dedicated suicide site, pro-suicide" to "academic or policy site" to "news reports of individual suicides." With the coding done, the researchers found that 90 of the 240 sites they identified were totally dedicated to suicide, and fully half of these (45 sites) promoted or encouraged suicide. 62 of the 240 sites were for suicide prevention or support services, while another 59 were sites that forbid or discouraged the practice.

The results varied by search engine. Google produced the most dedicated suicide sites by a wide margin (nearly twice as many as MSN), while MSN topped the list when it came to prevention sites and academic sites.

But perhaps most disturbing was that the most frequent results were pro-suicide. "The three most frequently occurring sites were all pro-suicide," note the authors, who also found that "Wikipedia was the fourth most frequently occurring site." All four of these top sites provided information about methods, speed, and pain associated with suicide attempts.

The authors make little attempt to draw normative conclusions from the data, though they do note that suicide rates in England have dropped among 15- to 34-year-olds for more than a decade... just as the Internet blasted its way into the public consciousness. They also note that, while finding pro-suicide information is easier on the Internet than it used to be in the local library, finding suicide prevention and support information is also simpler. "Cases of Internet induced suicide may be offset by potential beneficial effects or other suicide prevention activities," they conclude.

The ease with which those who might be contemplating The Last Logoff can readily find sites that not only give info on how to commit suicide, but advocate it, is disturbing. In a sense, the results are also not all that surprising given how search engines index and rank sites. By way of illustration, a search for the psychoactive plant salvia divinorum turns up mostly links on where to buy it and how to use it on the first page of Google's results. You have to do a bit of digging to find anything cautionary on the plant and its use.

Note: In the course of researching this article, I stumbled across what may be the most disturbing document I have ever encountered on the Internet, and that's saying something. Let's just say that if you do want to kill yourself (and I certainly hope that you don't), the information is in fact out there. In great and excruciating detail. I had no previous knowledge of what the ingestion of lye could do to a human body. This was one of the most life-hating documents I've ever had the misfortune to read; be aware of what you're in for if you attempt to replicate the study results on your own. Now, go hug a child.

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Hanging 'now the most common form of suicide'
By Lorna Duckworth, 1 May 2001

Hanging has replaced poisoning with car exhaust fumes as the most common form of suicide among young men.

Cleaner cars ­ which are fitted with catalytic converters to reduce carbon monoxide emissions ­ have made self-poisoning more difficult, a study published in The British Journal of Psychiatry says today. Instead there has been a "substantial increase" in suicide by hanging, strangulation and suffocation among youths, Dr Mike McClure, a psychiatrist from Imperial College School of Medicine in London, reports.

He analysed the methods of death chosen by suicidal teenagers in an attempt to explain why suicide rates among young men continue to rise, despite recent decreases in other age groups and a far lower likelihood in teenage girls. The suicide rate among males aged 15 to 19 increased by 72 per cent between 1970 and 1990 and remained at an "alarmingly high" level during the 1990s, Dr McClure says. The most recent figures, for 1998, show there were 146 suicides in this age group.

In the 1970s, overdosing on tablets or drugs was the most common form of suicide. During the 1980s and early 1990s, a high proportion of suicidal youths chose to "gas" themselves in cars ­ a method that usually resulted in loss of consciousness in a few minutes and death within half an hour.

But the introduction of catalytic converters, which cut carbon dioxide emissions by 90 per cent, made this much more difficult. In one of many failed attempts, a man survived inhaling fumes for five hours.

One consequence of cleaner emissions was a temporary decrease in the male suicide rate in the mid-1990s. This echoed the impact of natural North Sea gas in the 1960s, when it replaced town gas and drastically reduced the ability of people to kill themselves by leaving on the gas in the kitchen.

But hanging and strangulation soon became a substitute. That method now accounts for 63 per cent of suicides among young men. "These three phases can be described as epidemics of suicide, first by overdosing, then by poisoning with vehicle exhaust gas and currently by hanging ­ the latter two principally affecting older male adolescents," Dr McClure says.

The reasons young men are more prone than young women to take their own lives are still not clear. Although rates of depression and mental disorders have increased, they do not account fully for the upsurge, Dr McClure says.

There is a strong link with alcohol and drug abuse, with research showing that the increased suicide rate among young men up to the 1990s coincided with much greater drinking and drug use among young people. Other factors include social exclusion, with higher suicide rates among unemployed youths and older teenage boys from disrupted family backgrounds.

Dr McClure suggests that although "psychosocial stress" affects both sexes, women may have higher self-esteem, better coping strategies and the ability to communicate with friends, while young men may feel unable to live up to expectations or cope with modern life.

Dr McClure believes the increased risk among youths up to the mid-1990s is in part explained by easy access to carbon monoxide poisoning.

But he adds: "The fact that suicide in males has remained high, due to an increase in hanging, indicates that the increase was not entirely due to availability of a new method, but was probably also related to increased psychological stress."

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Preference for Fall From Height as a Method of Suicide
by Elderly Residents of New York City

Abrams RC, Marzuk PM, Tardiff K. Am J Public Health vol. 95, 1000 - 1002, 2005

Background:
Suicide rates in the United States are higher among elderly persons (aged 65 and older) than among any other demographic group. Suicide among this population is also associated with several distinguishing characteristics: Geriatric suicide is associated more often with depression and physical illness than is suicide among younger adults. In addition, elderly persons have a higher proportion of completed suicides to attempted suicides. Among the general population, the selection of a suicide method is related to location-specific factors, such as access to firearms or tall buildings. The most frequently used method of suicide, among elderly persons is the firearm, but factors that influence the choice of suicide method are not well understood.

Suicide methods of elderly and younger adults in New York City were compared. It was hypothesized that suicide victims aged 65 years and older in New York City would have more frequently used fall from high places as a suicide method compared with suicide victims under age 65 years in that city.

Methods:
A retrospective review was conducted of all deaths of New York City residents from 1990 through 1998 that were certified as suicides by the chief medical examiner. The age, gender, race, method of suicide, and place of suicide were recorded.

Results:
From 1990 through 1998, 5062 residents aged 15 years or older committed suicide in New York City. Of these, 17% were aged 65 years or older. By comparison, 16% of the city's population during the study period was aged 65 years or older. Persons 75 years of age or older accounted for 9% of suicides during the study period and tended to have the highest suicide rates per 100,000. A significant association was observed between suicide method and age.

Fall from height was the most common method of suicide among victims 65 years of age and older. Firearms were most frequently used by persons aged 15 to 34 years. Among suicide victims who fell from height, persons aged 65 years and older were significantly more likely than younger victims to have fallen from their homes (86% vs 69%) and less likely to have fallen from other high places.

Conclusions:
Fall from height is a frequently used method of suicide among elderly persons in New York City. This method is easily accessible for elderly residents of high-rise apartment buildings and provides a more predictably lethal outcome. In addition, fall from height is a more easily accomplished method of suicide for frail elderly persons than is hanging or asphyxiation. There is a need for increased knowledge regarding depression among urban elderly residents as this condition is often untreated or inadequately treated.

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Dangerous Japanese 'Detergent Suicide' Technique Creeps Into U.S.
By Kevin Poulsen March 13, 2009
 
A suicide technique that mixes household chemicals to produce a deadly hydrogen sulfide gas became a grisly fad in Japan last year. Now it's slowly seeping into the United States over the internet, according to emergency workers, who are alarmed at the potential for innocent causalities.

At least 500 Japanese men, women and children took their lives in the first half of 2008 by following instructions posted on Japanese websites, which describe how to mix bath sulfur with toilet bowl cleaner to create a poisonous gas. One site includes an application to calculate the correct portions of each ingredient based on room volume, along with a PDF download of a ready-made warning sign to alert neighbors and emergency workers to the deadly hazard.

The first sign that the technique was migrating to the United States came in August, when  a 23-year-old California man was found dead in his car behind a Pasadena shopping center. The  VW Beetle's doors were locked, the windows rolled up and a warning sign had been posted in one of the windows. Police and firefighters evacuated the shopping crew before a hazmat crew in chemical suits extracted the body and began cleaning up the grisly scene.

Then in December, emergency workers responding to a call at Lake Allatoona in Bartow County, Georgia, found a similar scene. Inside the car — along with the body — were two buckets containing a yellow substance. A note on the window said "Caution" and identified the chemical compound by name.

Nobody connected the cases until last month, when a Texas surgeon realized that a new and dangerous suicide method was making the rounds. Dr. Paul Pepe, chief of emergency medicine at UT Southwestern Medical Center, warned emergency workers that they could become innocent casualties of the technique if they're not careful. Other experts agree.

"The normal response for an EMS, is they're going to break open the window," says August Vernon, assistant coordinator for the Forsyth County Office of Emergency Management, who was consulted by the Department of Homeland Security on the danger this week. "And that's a pretty normal call: someone unconscious inside the car. Fortunately, those people left notes, which is pretty unusual and a good thing."

"Eventually," he adds, "someone isn't going to leave a note."

The American version of the method substitutes a common insecticide for the bath sulfur used in the Japanese recipe; bath sulfur isn't available in the United States. But the tweak does nothing to make the gas less dangerous for people nearby. In one of the Japanese cases last year, 90 residents in an apartment building were sickened when a 14-year-old girl used hydrogen sulfide (H2S) to take her life.

The so-called "detergent suicides" in Japan sparked considerable and ongoing interest on the Alt.Suicide Usenet groups, where people considering suicide share tips and tricks. This week, one depressed man wrote of his plan to release hydrogen sulfide gas in his car while driving, in the hope that he'll lose consciousness and crash -- making it look like an accident.

"I got the idea to use hydrogen sulfide poisoning by reading of the  tremendous success (for lack of a better word) that the Japanese people have had with it," he wrote on Monday.  "It is their most common suicide method. I understand that the method smells but I have found the stench of  failure in my life as well."

When other newsgroup denizens pointed out the recklessness of his plan, he gave it up as too risky to innocent bystanders. After exploring other techniques, the man announced on Wednesday that he decided he'd rather live.

"With months of research I have discovered that there is no 'easy' or 'painless' or 'quick' way to die," he wrote. "So, from here on out I am going to pick up the pieces to my life! Maybe you should too."

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Doctors who kill themselves: a study of the methods used for suicide
K. HAWTON, A. CLEMENTS, S. SIMKIN and A. MALMBERG
From the Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK

Received 21 January 2000 and in revised form 13 April 2000

Medical practitioners have a relatively high rate of suicide. Death entry data for doctors who died by suicide or undetermined cause between 1979 and 1995 in England and Wales were used to compare methods used for suicide by doctors with those used by the general population. Methods used were analysed according to gender, occupational status and speciality, to assess the extent to which access to dangerous means influences the pattern of suicide. Self-poisoning with drugs was more common in the doctors than in general population suicides (57% vs. 26.6%; OR=3.65, 95% CI 2.85–4.68), including in retired doctors. Barbiturates were the most frequent drugs used. Half of the anaesthetists who died used anaesthetic agents. Self-cutting was also more frequently used as a method of suicide. The finding that the greater proportion of suicide deaths in doctors were by self-poisoning may reflect the fact that doctors have ready access to drugs, and have knowledge of which drugs and doses are likely to cause death. The specific finding that a large proportion of suicides in anaesthetists involved anaesthetic agents supports this explanation. Availability of method may be a factor contributing to the relatively high suicide rate of doctors. This fact might influence clinical management of doctors who are known to be depressed or suicidal.

Suicide risk appears to be elevated in medical practitioners.1–7 A review of studies across different countries indicated a relative risk varying between 1.1 and 3.4 in male doctors and 2.5 and 5.7 in female doctors.6 It has been suggested that the increased risk in medical practitioners is related to access to dangerous means of suicide.1–3 Greater use of drugs for suicide by doctors compared to other occupational groups has been noted in doctors in England and Wales, especially males,2 and in doctors in other countries.8,9 We conducted a detailed study of the methods used for suicide by doctors, including a focus on possible evidence that access influences choice of method. We compare methods with those used by the general population, and, within doctors, according to gender, working status, speciality and time period.

 
Study population
The Office for Population Censuses and Surveys (now Office for National Statistics) supplied us with death entries for all deaths in England and Wales, between 1979 and 1995, of individuals resident in the UK whose occupation was recorded as medical practitioner (or equivalent, e.g. ‘doctor of medicine’, ‘consultant anaesthetist’, ‘surgical registrar’) where an inquest verdict of suicide (ICD9 codes E950–E959) or undetermined cause (‘open verdicts’; E980–E989 excluding E988.8)10 had been registered. The open verdicts were included because there is ample evidence that the majority of these are suicides.11 All the deaths in these two categories are henceforth referred to as ‘suicides’. The death entries included information on gender, age, date of death, and method of suicide (including ICD9 E code).

Methods used for suicide
The methods for suicide were classified as self-poisoning (including carbon monoxide), self-injury or both. The methods of self-poisoning by drugs were subdivided into categories which reflected the important classes of drugs likely to be used by doctors (e.g. anaesthetic agents, analgesics, barbiturates), rather than the broad ICD groupings.

Comparison with general population suicides
In order to compare methods used for suicide by doctors with those in the general population we obtained data on all deaths in England and Wales in the suicide and open verdict categories for males and females between 1979 and 1995 from the Office for National Statistics.12 We subtracted the doctors' deaths for those years. For this comparison we retained the broad ICD9 categories (E950–E959), except that we subdivided E950 into E950.0–E950.5 (i.e. drugs) and E950.6–E950.9 (i.e. poisons), and similarly for E980–E989 (excluding E988.8). We have restricted the comparisons to the 25–64-year age group for males and the 25–59-year age group for females, in keeping with the traditional gender differences in ages of retirement. This was in order to focus particularly on patterns and differences during the period of working life of doctors.

Identification of working status and medical specialities
We were notified of the deaths of 329 individuals. We identified the working status (working vs. retired/not working) and specialities of the doctors from the death entries, the Medical Directory (for the relevant years), and the General Medical Council. If we were unable to obtain information about working status, we made an assumption that all males under 65 years of age and all females under 60 years of age were working. A total of 86 doctors were retired and 243 were working. We have restricted analyses by speciality to those who were working. We were able to identify the speciality in 191/243 (78.6%) cases.

Statistical analysis
The analyses were conducted using SPSS for Windows 6.1 and Epilnfo 6.13 These included 2, 2 for linear trend and odds ratios.

Study population
Of the 329 medical practitioners who died by suicide (n=273, 83.0%) or undetermined cause (n=56, 17.0%) between 1979 and 1995, 249 (75.7%) were males and 80 (24.3%) females. The characteristics of the doctors and their deaths are shown by gender in Table 1. There were similar distributions of suicides and open verdicts in the two genders (2=0.04, p=0.83). The age distribution differed between the two genders (2=10.30, 3df, p<0.02), with a greater proportion of females being <35 years of age. There was little difference between the genders in the proportions working or retired at the time of death (2=0.73, p=0.39).

Comparison with suicides in the general population
There were marked differences between the methods used for suicide by the doctors and those used by the rest of the general population of suicides (Table 2). The most notable difference was that poisoning by drugs was far more common among the doctors (OR 3.65, 95% CI 2.85–4.68), a difference which applied to both males (OR 5.00, 95% CI 3.77–6.62) and females (OR 2.06, 95% CI 1.19–3.59). The absolute percentage difference between the use of self-poisoning with drugs by the doctors and suicides in general was more marked for males (35.3%) than females (17.7%). Cutting and piercing were also significantly more common in the doctors (OR 3.18, 95% CI 1.85–5.40), although the number involved was relatively small. On the other hand, several methods were less frequent in the doctors. These included, in males only, hanging and suffocation (OR 0.44, 95% CI 0.29–0.67) and gas (including carbon monoxide) (OR 0.32, 95% CI 0.20–0.50). For both genders, fewer doctors died by drowning (OR 0.45, 95% CI 0.23–0.88), jumping from a height (OR 0.15, 95% CI 0.03–0.61), and other and unspecified means (OR 0.37, 95% CI 0.18–0.71).

Details of methods used for suicide
Self-poisoning was somewhat but not significantly more frequent in the female doctors than the male doctors (Table 1). The most common drugs used for self-poisoning were barbiturates (Table 3). A paracetamol and dextropropoxyphene combination (Distalgesic, Coproxamol) was involved in 15 of the 31 cases in which analgesics (excluding anaesthetic agents) were used. Opiate overdoses were far more common in the male doctors than the female doctors who self-poisoned (OR 11.03, 95% CI 1.72–459.17). There were no other statistically significant differences for specific categories of drugs, although larger proportions of female doctors used analgesics or antidepressants.

The most common method of self-injury was hanging . The main gender differences in methods of self-injury were that shooting was somewhat more common in the males (15.9% vs. 4.5%) and asphyxiation/suffocation was somewhat more common in the females (22.7% vs. 11.3%), but neither to a statistically significant extent. These comparisons are based on smaller numbers than those for self-poisoning.

Working doctors compared with retired doctors
There was little difference in the proportionate use of self-poisoning (67.9% vs. 62.8%) and self-injury (29.2% vs. 34.9%) between the working and the retired doctors, either for all cases combined or within each of the two genders. Nor were there major differences in the specific methods used for either self-poisoning or self-injury between the working and retired doctors, except that 8.2% (n=20) of the working doctors used anaesthetic agents for self-poisoning, compared with none of the retired doctors, and seven used insulin compared with none of the retired doctors.

Trends over time
When the specific methods used were examined over four time periods (1979–82, 1983–86, 1987–90, 1991–95), the use of barbiturates for self-poisoning had declined (36.9%, 15.6%, 20.0%, 11.1%; 2 test for linear trend=10.80, p<0.002). The use of opiates had increased in the most recent period (9.2%, 13.3%, 5.5%, 20.6%), but there was no overall statistically significant trend (2=2.26, p=0.13). Hanging was a less common method of self-injury during 1979–82 (18.8%) compared to the later three time periods (36.8%, 31.8%, 29.4%), but again there was no significant trend over time (2=0.13, p=0.72). More than half of the deaths by asphyxiation/suffocation (8/15), at least half of which involved plastic bags, occurred in 1983–86.

Methods of suicide according to speciality
The most striking finding for methods used by doctors working in particular specialities was that overdoses of anaesthetic agents were used by half of all anaesthetists (10/20) compared with a much smaller proportion of the other working doctors (10/223, 4.5%; OR 21.30, 95% CI 6.41–72.77). No other speciality associations were found. Anaesthetic agents were used by only 2/12 surgeons. It was notable that none of the psychiatrists (n=13) who self-poisoned used any type of psychotropic agent for self-poisoning. Of 59 general practitioners who self-poisoned, in 16 (27.1%) cases barbiturates were involved, in 12 (20.3%) opiates and in 10 (10.9%) carbon monoxide.

Difference between doctors' suicides and those in the general population
Marked differences were found in the methods used for suicide by doctors and those used by the general population. In particular, a greater proportion of doctors died from overdoses. A similar finding has been reported from other countries.8,9 The excess of self-poisoning deaths in the doctors compared with suicides in the general population was somewhat more marked in males than females, although self-poisoning was generally more common in females, both in doctors and the general population. There are at least two factors which may contribute to the greater use of self-poisoning as a method of suicide in doctors. The first is the ready availability of medicinal drugs to most working doctors. The second is the specific knowledge doctors have about the dangers of drugs, and hence which drugs and what doses are most likely to cause death. It also seems likely, but cannot be proven from our findings, that these factors contribute to the relatively high risk of suicide in doctors. Certainly, availability of a dangerous method appears to be an important contribution to suicide risk in general, for example in circumstances in which guns are readily available.14–16 The fact that retired doctors who committed suicide also tended to use medicinal drugs suggests that having been a doctor may also serve to model this method of suicide for some individuals, although continuing access to medication might be a further factor.

Of the methods used less often in doctors' suicides compared to suicides in the general population (hanging, strangulation and suffocation, gas, including carbon monoxide, drowning, jumping from a height), all would have been equally available to both groups (except perhaps cars, which would be owned by nearly all doctors). On the other hand it might be argued that doctors would have greater knowledge of how to ensure death by cutting and that this might explain why more doctors used this method, although the numbers involved were relatively small.

The relatively frequent use of barbiturates for self-poisoning (although this declined in parallel with reduced prescribing, as was the case in the general population)3 has been reported in other studies of doctors' suicides9 and also probably highlights the contribution of access and knowledge of what is more likely to be fatal. This may also explain the similarly frequent use of the dangerous paracetamol and dextropropoxyphene analgesic combination. The comparatively larger number of deaths by asphyxiation, often involving plastic bags, in the early to mid 1980s, reflected a pattern in the general population12 which probably resulted from the publicity surrounding the recommendation of this method by EXIT, a voluntary euthanasia organization.17

The influence of speciality
The role of availability in determining methods used for suicide is strikingly illustrated by the fact that half of the anaesthetists who committed suicide used anaesthetic agents in these acts. This may also explain the relatively frequent use of barbiturates and especially opiates for suicide by general practitioners. On the other hand it is of interest that no psychiatrists who died took a psychotropic agent in overdose. This might reflect the fact that psychiatrists rarely have direct contact with the drugs they prescribe, but is perhaps more likely to be due to the psychiatrists being aware that many psychotropic agents are less dangerous in overdose than other drugs. The greater use of opiates for self-poisoning by male doctors compared to female doctors may be due to a higher incidence of substance misuse among male doctors.

Methodological issues
This study has some methodological limitations. These mostly relate to our reliance on information from official death entries. The information contained in these is relatively sparse. There were no details, for example, of the amounts of substances used for self-poisoning that might have allowed more detailed comparison with general population suicides by overdose. We had to make assumptions about working status based on age in cases where this could not be determined from the death entries or through searching the Medical Directory and contacting the General Medical Council. Details of medical speciality were missing for nearly a quarter of the working doctors. However, the findings are based on a relatively large number of cases and, where comparison was feasible, are in keeping with those from other studies. We are confident, therefore, that the findings are reliable.

Prevention
Access to dangerous methods probably plays a role in the relatively high risk of suicide of doctors. While restricting access to dangerous methods is an important element in overall suicide prevention18,19 clearly access could not be restricted in doctors in general as this would undermine their ability to carry out their clinical responsibilities. Such a measure might, nonetheless, be relevant to decisions about whether or not a doctor should continue to work while suffering from depression, especially if suicide risk is judged to be present.

Acknowledgments 
This study is part of a programme of research on suicide in high-risk occupational groups conducted at the Centre for Suicide Research, Oxford University Department of Psychiatry, with funding from the Department of Health. Keith Hawton is supported by Oxford Mental Healthcare Trust, and he and Sue Simkin were also supported by Anglia and Oxford NHSE Research and Development Fund. We thank the Office for National Statistics for supplying the death entries, the General Medical Council for helping identify the working status of some of the doctors, and Faith Barbour for assisting with identifying the specialities of the doctors.

Notes 
Address correspondence to Professor K. Hawton, Centre for Suicide Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX. e-mail: keith.hawton@psychiatry.oxford.ac.uk

References 
1. Charlton J, Kelly S, Dunnell K, Evans B, Jenkins R. Suicide deaths in England and Wales: trends in factors associated with suicide deaths. Popul Trends1993; 71:34–42.

2. Kelly S, Charlton J, Jenkins R. Suicide deaths in England and Wales, 1982–92: the contribution of occupation and geography. Popul Trends1995; 80:16–25.

3. Kelly S, Bunting J. Trends in suicide in England and Wales, 1982–96. Popul Trends1998; 92:29–41.[Medline]

4. Steppacher RC, Mausner JS. Suicide in male and female physicians. JAMA1974; 228:323–8.[ISI][Medline]

5. Arnetz BB, Horte LG, Hedberg A, Theorell T, Allander E, Malker H. Suicide patterns among physicians related to other academics as well as to the general population. Acta Psychiat Scand1987; 75:139–43.[ISI][Medline]

6. Lindeman S, Laara E, Hakko H, Lönnqvist J. A systematic review on gender-specific suicide mortality in medical doctors. Br J Psychiatry1996; 168:274–9.[Abstract/Free Full Text]

7. Lindeman S, Laara E, Hirvonen J, Lönnqvist J. Suicide mortality among medical doctors in Finland: are females more prone to suicide than their male colleagues? Psychol Med1997; 27:1219–22.[ISI][Medline]

8. Rose KD, Rosow I. Physicians who kill themselves. Arch Gen Psychiatry1973; 29:800–5.[Abstract/Free Full Text]

9. Lindeman S, Laara E, Vuori E, Lönnqvist J. Suicides among physicians, engineers and teachers: the prevalence of reported depression, admissions to hospital and contributory causes of death. Acta Psychiatr Scand1997; 96:68–71.[Medline]

10. World Health Organisation. Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death, volume 1, (Ninth Revision). Geneva, WHO, 1977.

11. Charlton J, Kelly S, Dunnell K, Evans B, Jenkins R, Wallis R. Trends in suicide deaths in England and Wales. Popul Trends1992; 69:10–16.

12. Office for National Statistics. The Twentieth Century Mortality Files (CD Rom). London, Office for National Statistics, 1997.

13. Dean AG, Dean JA, Coulombier D, Brendel KA, Smith DC, Burton AH, Dicker RC, Sullivan K, Fagan RF, Arner TG. Epilnfo Version 6: a word processing database and statistics program for epidemiology on microcomputers. Atlanta, Centers for Disease Control & Prevention, 1994.

14. Kellermann AL, Rivara FP, Somes G, Reay DT, Francisco J, Banton JG, Prodzinski J, Fligner C, Hackman BB. Suicide in the home in relation to gun ownership. N Engl J Med1992; 327:467–72.[Abstract]

15. Youth Suicide by Firearms Task Force. Consensus statement on youth suicide by firearms. Arch Suicide Res1998; 4:89–94.

16. Hawton K, Simkin S, Malmberg A, Fagg J, Harriss L. Suicide and Stress in Farmers. London, The Stationery Office, 1998.

17. EXIT. A Guide to Self-Deliverance. London, EXIT The Voluntary Euthanasia Society, 1981.

18. Clarke R, Lester D. Suicide: closing the exits. New York, Springer-Verlag, 1989.

19. Gunnell D, Frankel S. Prevention of suicide: aspirations and evidence. Br Med J1994; 308:1227–33.[Free Full Text]


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PUBLIC HEALTH: METHODS OF SUICIDE AMONG ADOLESCENTS

The following points are made by Centers for Disease Control (MMWR 2004 53:471):

1) In 2001, suicide was the third leading cause of death among persons aged 10-19 years.(1) The most common method of suicide in this age group was by firearm (49%), followed by suffocation (mostly hanging) (38%) and poisoning (7%).(1) During 1992-2001, although the overall suicide rate among persons aged 10-19 years declined from 6.2 to 4.6 per 100,000 population,(1) methods of suicide changed substantially. To characterize trends in suicide methods among persons in this age group, CDC analyzed data for persons living in the US during 1992-2001.

2) The results of that analysis indicated a substantial decline in suicides by firearm and an increase in suicides by suffocation in persons aged 10-14 and 15-19 years. Beginning in 1997, among persons aged 10-14 years, suffocation surpassed firearms as the most common suicide method. The decline in firearm suicides combined with the increase in suicides by suffocation suggests that changes have occurred in suicidal behavior among youths during the preceding decade. Public health officials should develop intervention strategies that address the challenges posed by these changes, including programs that integrate monitoring systems, etiologic research, and comprehensive prevention activities.

3) Among persons aged 10-14 years, the rate of firearm suicide decreased from 0.9 per 100,000 population in 1992 to 0.4 in 2001, whereas the rate of suffocation suicide increased from 0.5 in 1992 to 0.8 in 2001. Rate regression analyses indicated that, during the study period, firearm suicide rates decreased an average of approximately 8.8% annually, and suffocation suicide rates increased approximately 5.1% annually. Among persons aged 15-19 years, the firearm suicide rate declined from 7.3 in 1992 to 4.1 in 2001; the suffocation suicide rate increased from 1.9 to 2.7. Rate regression analyses indicated that, during the study period, the average annual decrease in firearm suicide rates for this age group was approximately 6.8%, and the average annual increase in suffocation suicide rates was approximately 3.7%. Poisoning suicide rates also decreased in both age groups, at an average annual rate of 13.4% among persons aged 10-14 years and 8.0% among persons aged 15-19 years. Because of the small number of suicides by poisoning, these decreases have had minimal impact on changes in the overall profile of suicide methods of youths.

4) Among persons aged 10-14 years, suffocation suicides began occurring with increasing frequency relative to firearm suicides in the early- to mid-1990s, eclipsing firearm suicides by the late 1990s. In 2001, a total of 1.8 suffocation suicides occurred for every firearm suicide among youths aged 10-14 years. Among youths aged 15-19 years, an increase in the frequency of suffocation suicides relative to firearm suicides began in the mid-1990s; however, in 2001, firearms remained the most common method of suicide in this age group, with a ratio of 0.7 suffocation suicides for every firearm suicide.

5) The findings in this report indicate that the overall suicide rate for persons aged 10-19 years in the US declined during 1992-2001 and that substantial changes occurred in the types of suicide methods used among those persons aged 10-14 and 15-19 years. Rates of suicide using firearms and poisoning decreased, whereas suicides by suffocation increased. By the end of the period, suffocation had surpassed firearms to become the most common method of suicide death among persons aged 10-14 years.

6) The reasons for the changes in suicide methods are not fully understood. Increases in suffocation suicides and concomitant decreases in firearm suicides suggest that persons aged 10-19 years are choosing different kinds of suicide methods than in the past. Data regarding how persons choose among various methods of suicide suggest that some persons without ready access to highly lethal methods might choose not to engage in a suicidal act or, if they do engage in suicidal behavior, are more likely to survive their injuries.(4) However, certain subsets of suicidal persons might substitute other methods.(5) Substitution of methods depends on both the availability of alternatives and their acceptability. Because the means for suffocation (e.g., hanging) are widely available, the escalating use of suffocation as a method of suicide among persons aged 10-19 years implies that the acceptability of suicide by suffocation has increased substantially in this age group.

References (abridged):
1. CDC. Web-based Injury Statistics Query and Reporting System (WISQARSTM). Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, National Center for Injury Prevention and Control, 2004.

2. National Center for Health Statistics. Multiple cause-of-death public-use data files, 1992 through 2001. Hyattsville, Maryland: U.S. Department of Health and Human Services, CDC, 2003

3. Anderson RN, Minino AM, Fingerhut LA, Warner M, Heinen MA. Deaths: injuries, 2001. Natl Vital Stat Rep. 2004;52:1-5

4. Cook PJ. The technology of personal violence. In: Tonry M, ed. Crime and Justice: An Annual Review of Research, vol. 14. Chicago, Illinois: University of Chicago Press, 1991:1-71

5. Gunnell D, Nowers M. Suicide by jumping. Acta Psychiatrica Scandinavica. 1997;96:1-6

Centers for Disease Control and Prevention http://www.cdc.gov



Related Material:

ON THE RISK OF ATTEMPTED SUICIDE THROUGHOUT THE LIFESPAN
The following points are made by S.R. Dube et al (J. Am. Med. Assoc. 2001 286:3089):

1) Suicide was the 8th leading cause of death in the US in 1998, and particularly high rates have been reported among young persons and older adults. Each year, more than 30,000 people in the US commit suicide, but recognition of persons who are at high risk for suicide is difficult, making efforts to prevent its occurrence problematic. In 1999, the US surgeon general brought attention to this complex public health issue by recommending that the investigation and prevention suicide be a national priority.

2) An expanding body of research suggests that childhood trauma and adverse experiences can lead to a variety of negative health outcomes, including substance abuse, depressive disorders, and attempted suicide among adolescents and adults. Childhood sexual and physical abuse have been strongly associated with suicide attempts. A recent study of Norwegian drug addicts demonstrated that a high proportion of them attempted suicide and that an even higher proportion of drug addicts who had experienced childhood adversity had attempted suicide. In another study, low-income women with a history of alcohol problems and experience of childhood abuse and neglect were at increased risk for suicide attempts.

3) The authors conducted a study to examine the relationship between the risk of suicide attempts and adverse childhood experiences and the number of such experiences. 17,337 adult health maintenance organization members (54 percent female) were surveyed. The authors report that a strong graded relationship exists between adverse childhood experiences and risk of attempted suicide throughout the life span. Alcoholism, depressed affect, and illicit drug use, which are strongly associated with such experiences, appear to partially mediate this relationship.

J. Am. Med. Assoc. http://www.jama.com



MEDICAL BIOLOGY: DEPRESSION IN CHILDREN: CHEMICAL TREATMENT
The following points are made by Christopher K. Varley (J. Am. Med. Assoc. 2003 290:1091):

1) An increasing body of knowledge confirms that depression is a common and serious illness in youth, affecting 3% to 8% of children and adolescents. Moreover, rates of depression increase dramatically as children move into adolescence. An estimated 20% of adolescents have had at least 1 episode of major depressive disorder (MDD) by age 18 years, while 65% report transient, less severe depressive symptoms.

2) Depression compromises the developmental process; feelings of worthlessness, low self-esteem, and thoughts of suicide are common, as are difficulties with concentration and motivation. As many as 20% of adolescents each year have suicide ideation and 5% to 8% attempt suicide. While the majority of attempts are not lethal, suicide is a leading cause of death in adolescents and is a major health care concern. One of the major risk factors associated with suicide is depression.

3) Depressive disorders in children and adolescents can be chronic and recurrent. The mean length of a major depressive episode in youth aged 6 to 17 years is 7 to 9 months, with remittance commonly occurring over a 1- to 2-year period. Longitudinal studies suggest a strong potential for recurrence; 48% to 60% of this age group have recurrence of major depression after an initial MDD episode within 5 years.

4) Although depression in youth is now recognized as a significant health concern, identification of safe and effective treatment has been challenging. The recent study by Wagner et al (2003) is the fourth published double-blind, placebo-controlled study demonstrating efficacy in the treatment of MDD in children and adolescents; all studies included selective serotonin uptake inhibitors (SSRIs). A number of psychotropic medications established as safe and effective in the treatment of MDD in adults have been investigated in youth but may not be effective, including tricyclic antidepressants, monoamine oxidase inhibitors, and venlafaxine. There are also safety concerns regarding the use of tricyclic antidepressants in children and adolescents, including lethality in overdose and cardiac conduction delays (and possibly increased risk of sudden death) in therapeutic dosages.

J. Am. Med. Assoc. http://www.jama.com


Related Material:
ON ADOLESCENT DEPRESSION

The following points are made by D.A. Brent and B. Birmaher (New Engl. J. Med. 2002 347:667):

1) In children and adolescents, depression is not always characterized by sadness, but instead by irritability, boredom, or an inability to experience pleasure. Depression is a chronic, recurrent, and often familial illness that frequently first occurs in childhood or adolescence. Any child can be sad, but depression is characterized by a persistent irritable, sad, or bored mood and difficulty with familial relationships, school, and work(1). In the absence of treatment, a major depressive episode lasts an average of eight months. The risk of recurrence is approximately 40 percent at two years and 72 percent at five years.(2) Longer depressive episodes occur in patients who have a dysthymic disorder (a milder, but chronic and insidious form of depression) that gradually evolves into major depression. More prolonged episodes are also associated with coexisting psychiatric conditions, parental depression, and parent-child discord.(2)

2) At least 20 percent of those with early-onset depressive disorders (those beginning in childhood or adolescence) are at risk for bipolar disorder, particularly if they have a family history of bipolar disorder, psychotic symptoms, or a manic response to antidepressant treatment.(2,3) Bipolar disorder is characterized by depressive episodes that alternate with periods of mania, defined by a decreased need for sleep, increased energy, grandiosity, euphoria, and an increased propensity for risk-taking behavior. Often in children and adolescents, mania and depression occur as "mixed states", in which the lability of mania is combined with depression, or there is rapid cycling between depression and mania over a period of days or even hours.(4)

3) Suicidal behavior is closely associated with depression. Risk factors for suicide during a depressive episode include chronic depression, coexisting substance abuse, impulsivity and aggression, a history of physical or sexual abuse, same-sex attraction and sexual activity, a personal or family history of a suicide attempt, and access to an effective means of suicide, such as a gun.(5) Girls are more likely to attempt suicide, and boys to complete suicide. Among adolescents, the annual rate of suicide attempts requiring medical attention is 2.6 percent. Completed suicide is much rarer: among 15-to-19-year-olds, the rates in 1998 were 14.6 per 100,000 in boys and 2.9 per 100,000 in girls.

4) Depression is present in about 1 percent of children and 5 percent of adolescents at any given time. Before puberty, boys and girls are at equal risk for depression, whereas after the onset of puberty, the rate of depression is about twice as high in girls. Having a parent with a history of depression increases a child's risk of a depressive episode by a factor of 2 to 4.7 Anxiety, particularly social phobia, may be a precursor of depression.

References (abridged):
1. Diagnostic and statistical manual of mental disorders, 4th ed.: DSM-IV. Washington, D.C.: American Psychiatric Association, 1994.

2. Birmaher B, Ryan ND, Williamson DE, et al. Child and adolescent depression: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1996;35:1427-1439.

3. Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL. Bipolar disorder at prospective follow-up of adults who had prepubertal major depressive disorder. Am J Psychiatry 2001;158:125-127.

4. Geller B, Zimerman B, Williams M, et al. Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder. J Child Adolesc Psychopharmacol 2000;10:157-164.

5. Brent DA. Mood disorders and suicide. In: Green M, Haggerty RJ, eds. Ambulatory pediatrics. 5th ed. Philadelphia: W.B. Saunders, 1999:447-54.


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Active & Passive Suicide Methods in the UK
George Stewart, suicideandmentalhealthassociationinternational.org

For some people the choice of a suicide method is a carefully considered decision while others reach spontaneously for the nearest available means when they reach desperation. Suicides can be divided roughly between what are termed "active" and "passive" methods.

Active methods of suicide include hanging, shooting and jumping, methods that tend to be swift and effective and allow little scope for interruption or time to reconsider. Passive methods include overdose, gassing and drowning, methods which are less overtly violent and which may allow scope for intervention, or time to reconsider.

The most commonly used method in suicide attempts is self-poisoning, by both men and women. There has been an enormous rise in the use of paracetamol over the past 20 years and it is now the most common drug, involved in nearly half of all adolescent overdoses and 70 per cent of overdoses by children.

Paracetamol overdoses are particularly dangerous in the sense that they are frequently not immediately fatal, and people can believe that they have suffered no ill-effects, but it can cause severe long-term liver damage.

In the 1960s overdose and gassing accounted for 75 per cent of female suicides and 50 per cent of male suicides. Today half of female suicides are a result of overdose compared with 25 per cent of male suicides.

Men are more likely to gas themselves, either by domestic supplies or by car exhaust fumes, with 50 per cent choosing one of these methods. There has been a 339 per cent rise in the number of men hanging themselves, compared with a 191 per cent increase in women.

Drowning has decreased by about 30 per cent for both sexes. The replacement of barbiturates as sedatives by the less toxic benzodiazepines is partly responsible for the 36 per cent fall in female suicide deaths in the 20 years to 1995, although the number of non-fatal overdoses increased.

Increases in hangings and other suicide methods were found to pre-date the decline in overdose suicides. "This suggests that the social or other problems that underlie recent rises in male suicide rates may also affect women but are not mirrored by increases in suicide rates because the method they favour has become less lethal," David Gunnell reports in The Lancet. [53]

Self-poisoning is a more common method of suicide used by men and women in health care professions than in the population as a whole, partly due to the fact that they may have more ready access to prescription drugs.

Firearms are a common method of suicide for male farmers, accounting for 38 per cent of farming suicide deaths. Again, farmers often have easy access to firearms.

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Retired GPs advise terminally ill on suicide by starvation
By Simon Johnson  08 Mar 2009

Retired doctors are helping patients starve and dehydrate themselves to death to circumvent the legal ban on medically assisted dying.
 
The former GPs have advised those who are terminally ill or suffer from a degenerative disease that they can end their lives by refusing food and drink.

They admit the process is "horrific", with one woman starving herself for 25 days before she died, but said there is no alternative in Britain as long as euthanasia remains illegal.
The doctors are members of the campaign group Friends at the End (Fate), which lobbies for the introduction of assisted dying and gives practical advice on suicide.

Their book, A Hastened Death by Self-Denial of Food and Drink, has been sent to about 30 British patients in the past four months.

The group has also distributed a leaflet with tips on starvation and dehydration, including a warning to patients not to prolong their lives by rinsing their parched mouths with water.

"Once a person has decided to stop eating and drinking, it is essential that all relatives and carers in touch with the patient agree to support the decision made and abide by the 'no liquids' rule," it states.

"Sometimes well-meaning people have given a drink which delays the end."

The leaflet was written by Dr Libby Wilson, a retired GP from Glasgow, and Nan Maitland, assistant editor of the group's newsletter, from London.

In May the group will hold a meeting in London to lobby for a voluntary refusal to eat or drink becoming a legal method for suicide in Britain.

It is illegal to aid and abet a suicide, but campaigners think it highly unlikely anyone would be prosecuted for suggesting starvation or dehydration.

However, the families of two women who consulted Fate for advice on the method said their mothers' deaths were horrific.

Efstratia Tuson, an 85-year-old retired teacher from Middlesex, was terminally ill but her requests for a lethal dose of barbiturates were refused by her doctors.

She was told she would have to wait for a month for an appointment in a Swiss euthanasia clinic so began refusing food and drink in January. It took her five agonising days to die.

Mrs Tuson's daughter, Pamela, said: "Her body mass reduced, her face became drawn, her skin very dry. She was dying of thirst. It was like being in the desert. I feel my mother was tortured until she died."

But a 75-year-old from Scotland, who had advanced motor neurone disease, took 25 days to starve and dehydrate to death after consulting Fate for advice.

As the days turned into weeks, however, she used a communication aid to write: "You wouldn't put a dog through this. You would give it a lethal injection."

Dr Wilson, who was in contact with the woman, whose Christian name was Lily, said her agony had been prolonged by her sucking ice cubes and frequently rinsing her mouth with water.

See also
Epidemiology of Suicides in Scotland 1989 - 2004 [1246KB PDF]
Some thoughts on suicide
Dutch to publish DIY suicide manual
Male suicide rates
UK Suicide Stats 1979-2001

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