Thursday, March 13, 2014

Homicide Rates, Suicide Rates, and Modern Medicine

Homicide rates in the United States have been falling for decades. Some have attributed this to people becoming more civilized and peaceful, a hypothesis Steven Pinker expores in The Better Angels of Our Nature. From 1931 to 1998, the United States homicide rate dropped by about 25%. But during that time, rates of aggravated assault increased by about 700%. This calls the peacefulness hypothesis into question.

Homicide is a metric that links a behavior (a violent act) to an outcome (a death). Modern medicine has drastically increased the survival rates for serious injuries in the past several decades. Since death from a given injury has become less common, especially in urban areas close to high-tech hospitals, metrics attached to death - such as homicide - will drop even if there is no change in the frequency of the kind of violent assaults that would have been murders if only 1931 technology were available. Since those kinds of violent attacks have increased dramatically, it appears that using the homicide rate as a metric allows improvements in medical technology to mask a major increase in violence in recent decades.

This trend continues into the twenty-first century; violent attacks increase, but homicide deaths decrease because of improvements in medical technology (see graphic).

Keep that in mind when you consider that American suicide rates have been mostly flat since 1950 - not decreasing, like homocide rates, even though medical technology and injury survivability has vastly improved. In fact, suicide rates have been increasing since 1999. Suicides in the 35-64 age group increased by 28% between 1999 and 2010.

Suicide, like homicide, is a metric that links a behavior (a self-injury) to an outcome (a death). Like homicide, the reduction in death for a given injury should reduce the suicide rate even if self-injuries are constant. We do not see the suicide rate decreasing; in recent years, even as the homicide rate continues to drop, the suicide rate is increasing. Medical technology may be masking an even greater rise in suicidal behavior than the completed suicide rate would indicate.

Case-fatality rates are three to four times higher for self-inflicted gunshots than for gunshots inflicted intentionally by others; that is, suicide attempts by gunshot are more lethal than assaultive shootings. In 2007, 21% of intentional gunshot wounds inflicted by someone other than the victim were lethal; 80% of self-inflicted gunshot wounds were lethal. Gunshot is the most common method of suicide in the United States, accounting for 54% of suicides.

However, almost half of completed suicides have used methods other than firearms - and methods other than gunshot are only 10-15% likely to be fatal. Since 20% of self-inflicted gunshot wounds are currently nonfatal, the firearm suicide rate would "only" rise by about 25% of its current level if modern medicine were not aggresively saving lives that are unwanted by their possessors. But in the absence of modern medicine, up to ten times as many people who poison, cut, hang, or suffocate themselves might succeed in killing themselves.

Proximity to a hospital is a major factor in trauma survival. This may partly explain why rural suicide rates have leapt ahead of urban rates in recent decades: suicidal behavior may be similar, but rural people die from their injuries more frequently than urbanites.


Note: St. Rev hates this graphic as the graphs for weapon injury are of radically different scales (inter alia) and indeed it is probably seriously flawed but it provides a cheap and tasty way of immediately visualizing the phenomenon.

23 comments:

  1. Nice to see you back.

    Suicide rates where I am are rising ominously:

    http://www.theguardian.com/society/2013/jan/22/alarm-rise-uk-suicide-rate

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  2. I have nothing against suicide as an alternative to unbearable circumstances. It's just too bad gunshot accounts for the vast majority of suicides. Strangling-jumping, cutting, shooting, are unnecessary and gruesome. There are a number of readily available methods based on science that are non-violent -peaceful ways to go, with a 95+ percent success rate. On top of that, the failures are due to straying from procedure. One only needs to study the literature diligently for a period.
    Cheers.

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    1. "There are a number of readily available methods based on science that are non-violent -peaceful ways to go, with a 95+ percent success rate."

      Sorry, but this just isn't the case. Not at all. Especially with current legislation, narcotic or otherwise.

      I've lived with severe, chronic illness much of my life and have researched this endlessly and read all the Right to Die publications with the goal of finding out what is the best way to achieve a peaceful death reliably.

      The only surefire method is a lethal administration of barbiturates, as used where assisted suicide/euthanasia is legal. Specifically Pentobarbital (not Phenobarbital or other barbs with longer half-lives).

      Seen as this is a very highly regulated drug and is rare even on the black market, obtaining it is an extraordinary hassle. Thus, despite it's reliability, the limits to it's attainability essentially forces people to use the more traditional, messier methods (which of course often end in failure).

      There are other drugs that would be lethal in overdose (try-cyclic antidepressants, anti-malarials such as Chloroquine etc) but time taken to death, adverse complications during dying, and risks of vomiting negates their status as consistently reliable.

      Non-pharmalogical methods such as using inert gasses (helium, nitrogen) and a plastic bag around your head to induce hypoxia, are also certainly not fail safe. I am a member of a right to die group and we unfortunately report many failures with this method.

      Dying - if you want to go peacefully, quickly, non-violently and with a certain amount of dignity - is most certainly not a simple business.
      You can thank both a cowardly government, and a more diffuse cultural denial of suffering for that....

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  3. Succinct analysis as usual, Sister Y.

    Take home message, if you want increase your odds at a successful suicide (and if you're certain that's what you want) - facilitate a discovery time-frame making sure someone can't get you to a hospital to 'save' you...

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  4. Great to hear from you after so long! Is Every Cradle Is A Grave still on track to be published and shipped in April? That's the latest from Amazon, where I have a pre-order. :-)

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    1. On track to be finished in April - thanks!

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  5. people are becoming crazier, not working, on every pill-prescribed or otherwise and have no-regard for others, arm yourself for the real walking dead!

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  6. Of course non-discovery period is sensible. I'll have to respectfully disagree with you, Jack, on the rest of your analysis. I am a member of a right to die group as well, and the latest research is; there are numerous ( 5 off hand come to mind) methods that are practically (95+) fail safe, granted you follow procedure. If you are relying on he said-she said failures as reported on the internet, I would reread the literature. Who would you prefer to trust, authors, doctors and chemists or some teen posting on suicide project. You are mistaken friend.

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    1. Hmmm...

      I can readily assure you, as would anyone taking this subject seriously, I've read everything from the credible sources at the sharp end of this movement - those, as you put it, 'authors, doctors and chemists'. Certainly not any pseudo-accounts of teenage cry for help failures nor other spur of the moment suicide mistakes. ...

      They all agree that Pentobarbital (and to be frank it is axiomatic anyway) is the nearest thing you can get to a magic bullet. That is if you can obtain it and self-administer it - which many sick people can't.
      Any other methods (and we're talking non-violent one's here) are going to carry not insignificant probabilities of failure. Seeing that the consequences of failure can be catastrophic, it behooves one NOT to be a gambling man/woman.

      The other methods: helium/nitrogen and plastic bag, charcoal burner in a confined space, self-tourniquet ligature etc are indeed options of sorts, but certainly, certainly not full proof and there have been a significant amount of failures despite sensible protocol.

      Simply, I can't entertain the notion - none for one second - of a 95% chance of success rate.
      All methods ultimately carry risks and I simply don't know where you're pulling this figure from...




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  7. Those are all methods recommended and condoned by right to die organizations in Australia, America, the UK. If they say they are extremely effective and practically fail safe if performed correctly, sorry guy, I'll take their advice over yours. Of course all methods carry risks, but the brain cannot survive without oxygen and the risks reside in a botched procedure, otherwise said methods wouldn't be condoned as the best out there. Sure, even barbiturates carry risks, as evidenced in the book Final Exit, but even that was from not planning thoroughly. Watch any video from Dr, Philip Nitschke, and he'll use words like fail safe, extremely peaceful, effective, quick, painless. Are you saying he's in the wrong and your friends are right.? Do they know something he does not? If so it behooves his organization to change their recommendations. I'm in contact with scientists, chemists and 2 dr's on a daily basis, and I'm sure they might have warned me if said procedures carried significant risk, but if carried out correctly they have assured me they do not. Again, they key is researching heavily, and learning from the mistakes your contacts are making. '

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  8. The figure comes from the the organizations I am in contact, which have experienced no failures in their presence. (hence the 95+ figure/ which accounts for the seeming failures of unknown persons on the net- which is also known by the right to die organizations- but discredited as lack of successful procedure, ie planning and orchestration.

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  9. "Many hundreds of known, successful helium suicides should be balanced against the very isolated instances of failure. Air crashes make big news, yet they are statistically the safest way to travel. And helium failure is much rarer than an aeroplane crash. We have come across totally fictitious failures written by anti-euthanasia activists where we can see that they are concocted to scare people as the details don't add up. The physical certainty of death when helium is breathed for several minutes is so undeniable, it is hard to fathom how anyone could make a bad mistake." - Five last Acts-The Exit Path-Chris Docker (2013)

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    1. It should be noted that not everybody who would be psychologically capable to take barbiturates to fall asleep is also psychologically capable to suffocate themselves to death, even without feeling of suffocation. I planned helium suicide three times and aborted it every time due to this psycholocial barrier. Yet I do not like living. I would call that a failure, even though it is not strictly a physical one.

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  10. How do you reconcile the purported increase in assault with the data collected here?:

    http://www.disastercenter.com/crime/uscrime.htm

    The 20 year decline looks to fairly consistent per capita across categories, including for "assault."

    Off the cuff, I think the discrepancy may be due to a divergence in the ER-reported and police-reported data, which could mean a bias effect from increasing sensitivity/diligence in the ER-reported data. If that's what's going on, it would be ironically consistent with Pinker's larger thesis.

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    1. Is Pinker the chap you believes the world has become a kinder, gentler, less violent place, Chip?

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    2. Replied on twitter - UCR is the source of data that Harris et al. are using in the "Murder and Medicine" piece. Their analysis goes to 1998. I find it entirely possible that crime has fallen since the crack epidemic and the practice of locking everybody up in prison became widespread, but notice that murder is the only crime that in 2012 has reached 1960 levels. Survivability increases ever year, so even with a recent fall in crime, homicide rates are still becoming less and less reliable as an indication of overall crime.

      The biggest surprise from studying this was how much less survivable suicide gunshot wounds are compared to other-inflicted gunshot wounds. This is the big insight that explains why a larger and larger proportion of gun deaths are suicides (now more than half) and why suicide rates are increasing while homicide rates fall. Still, it's terrifying to realize that 20-30% of people who shoot themselves survive.

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    3. Whoops! I meant to say who instead of you, Chip. Sorry.

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    4. Unknown: Yeah, That's Pinker. And I think he makes a very strong case. My pessimism runs much deeper, of course.

      Sister Y: Well, the case is stronger than I assumed, which doesn't mean that reporting bias and changes in sensitivity to what is regarded as "assault" can be discounted as contaminants. The researchers acknowledge this and make strong efforts to account for error, but I will state my gut-sense that the secular decline in violence is to some considerable extent real, meaning culturally rooted. It's very complicated to investigate because a real decline would be expected to track with greater sensitivity to violence, including greater sensitivity to assault and greater emphasis on medical care for victims. No question that the crack wars constituted an El Nino event in the annals of crime data, or that imprisonment -- and increased policing -- played major roles in the recent decline. But those events, too, cannot be tidily isolated from the broader culture.

      It makes perfect sense to me that suicide gunshots would be more lethal than other-inflicted (I'm tempted to say "interpersonal," but that sounds so polite) wounds. Range is one thing. Solitude is another. And yes, 20-30% is still terrifyingly high and should give pause to those who think self-destruction is easy. Think of the ones who shoot themselves multiple times, or who linger in excruciating pain for long hours before bleeding out.

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  11. The murder-page of wikipedie for my country says that not only has the number of murders decreased in the last 21 years, but also the number of attempted murders. So maybe people really are a bit less inclined to kill each other?
    What as also fallen is the success-rate for murder, i.e. the number of attempts falls slower than the number of completed murders. That might be due to higher survival rates/medical advances. Or to the also falling percentage of assailants who carry firearms.
    Oh, numbers for aggravated assault are going up, during the same period.
    A very complex topic!

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  12. Sister Y, you are a work horse. How can you have so much output, that is so thorough, lucid and depressing? Loved the archives. We are all genetic slaves, and you 'sister' moniker even suggests there were others in your family. In that case, 'sister' your slave name. From now on you are to be know as X. Y X. Y not?

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  13. Very well said. Thanks for the analysis

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  14. According to some, the drop in rates of violence and homicde seen recently are due to reduced amounts of lead in the environment : America's Real Criminal Element: Lead (Mother Jones) http://www.motherjones.com/environment/2013/01/lead-crime-link-gasoline

    It's likely that elevated levels of lead throughout the Industrial Revolution linked with overcrowding lead (no pun intended) to elevated violence and assault levels.

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  15. A big question about technology ostensibly turning murder into attempted murder: wouldn't this make many of today's criminals simply more thorough in finishing the victim off? That's what I would expect to happen with robberies, gang wars and other cases where the killer has a reason to end someone permanently.

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