Race/Ethnicity and Potential Suicide Misclassification: Window on a Minority Suicide Paradox?

Background: Suicide officially kills approximately 30,000 annually in the United States. Analysis of this leading public health problem is complicated by undercounting. Despite persisting socioeconomic and health disparities, non-Hispanic Blacks and Hispanics register suicide rates less than half that of non-Hispanic Whites. Objective: To assess whether race/ethnicity and other decedent characteristics were associated with differential potential for suicide misclassification. Data and Methods: In this cross-sectional study of 105,946 decedents aged 15 years and older, we performed multiple logistic regression analyses using multiple cause-of-death data for 2003-2005 from the National Center for Health Statistics. Our outcome variable was a binary measure of manner of death: injury of undetermined intent (containing misclassified suicides) versus suicide. Results: Blacks (adjusted odds ratio, 2.38; 95% confidence interval, 2.22-2.57) and Hispanics (1.17, 1.07-1.28) manifested excess potential for suicide misclassification relative to Whites. Decedents aged 35-54 (0.88, 0.84-0.93), 55-74 (0.52, 0.49-0.57), and 75+ years (0.51, 0.46-0.57) showed diminished potential relative to decedents aged 15-34. Decedents with 0-8 years (1.82, 1.75-1.90) and 9-12 years of education (1.43, 1.40-1.46) showed excess potential relative to the most educated (13+ years). Excess potential was apparent for decedents whose mode or method of injury was “less active” (46.33, 43.32-49.55) versus “more active”, and for decedents without (3.12, 2.78-3.51) versus those with psychiatric documentation on their death certificates. Interpretation: Record-keeping disparities may explain much of the Black-White suicide rate gap, if not the White-Hispanic gap. Ameliorative action would extend from training in death certification to routine use of psychological autopsies in equivocal manner-of-death cases.