Suicide registration in eight European countries: A qualitative analysis of procedures and practices

Abstract

Objective

To compare suicide registration in eight European countries and provide recommendations for quality improvement.

Method

Qualitative data were collected from country experts using a structured questionnaire.

Results

Suicide registration was based on the medico-legal system in six countries and the coronial system in two. Differences not only between, but also within these two systems emerged. Several elements crucial to the consistency of suicide registration were identified.

Conclusion

A precise model for recording suicides should include: an accurate legal inquiry and clarification of suicidal intent; obligatory forensic autopsy for injury deaths; reciprocal communication among authorities; electronic data transmission; final decision-makers’ access to information; trained coders.

Introduction

Validity and reliability of suicide statistics have been addressed in a number of studies. Stengel [1] declared that international comparisons of suicide rates are unreliable. Subsequent studies, with less critical and firm conclusions, asserted that errors in the reporting of suicides are fairly randomized over the years and that official statistics are nonetheless reliable [2], [3], [4], [5] although care should be taken in regional comparisons [5], [6], [7].

One universal opinion among researchers is that suicides tend to be underreported [3], [4], [8], [9], [10], [11], [12] and that, accordingly, the number of false-positive suicide cases is negligible [2]. The extent of underestimation has been found to be 10–20% [8], [13], [14]. The most common category for ‘hidden suicides’ is ‘undetermined death’ [6], [8], [9], [10], [11], [14], [15], [16], [17] but also accidents such as ‘poisoning’ [8] and ‘drowning’ [16], [18].

Suicides can be underestimated for several reasons. Besides socio-cultural factors, such as criminalization and religiousness [4], [15], [19], methodological variations in death-registration procedures contribute to differences in suicide rates [6], [8], [10], [15], [19], [20], [21], [22]. Suicide registration is a complicated, multilevel procedure that includes medical and legal issues, involving several responsible authorities, that vary from one country to another [5], [13], [21], [23], [24], [25]. Two distinct approaches are identifiable in different countries: the legal approach, which is applied mainly in coronial systems, and the medical approach, applied mainly in medico-legal systems. When legal criteria are used, the decision to classify a death as suicide is expected to be ‘beyond reasonable doubt’ [10], [11], [12], [21], [24]. In the medical approach, decisions about causes of death are reached in the same way as for any other diagnosis, i.e. on the basis of the ‘balance of probabilities’ [14], [21], [24]. The legal approach may result in systematic exclusion of particular types of suicide, since death is classified as suicide only when there is significant evidence indicating suicidal intent [9], [10], [11], [21].

Some systematic comparative studies of suicide-registration procedures are available [1], [10], [16], [21], [23], [24], [25] but none of these studies are recent. Exploring suicide registration across the EU with a view to promoting a standardized approach has been proposed [15]. The accuracy of coding and registration of underlying cause of death is important for the quality of mortality statistics [26]. Failing an improvement in the reliability of suicide statistics, any evaluation of the efficacy of suicide-prevention programs is questionable.

The aims of the present study were:

• To describe and compare procedures for suicide registration in eight European countries.

• To pinpoint potential deficiencies in these countries’ suicide-registration systems.

• To provide recommendations on how best to improve the quality of suicide registration in the EU.