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consistencies across jurisdictions. Yet Dr. Mościcki expressed the belief that, in general, the classification system works, and “by and large we can be fairly confident that when a death is classified as a suicide, that it is a genuine classification.”

In 1998 suicide was the eighth leading cause of death. The age-adjusted rate was 10.4 per hundred thousand (as compared to the leading cause of death, diseases of the heart at a rate of 127 per hundred thousand). The suicide rate has declined very slowly since the time of the adoption of the ICD-9 coding system in 1979. There are differences in rates across states, and across sub-groups within the U.S. population. Western and frontier states have the highest suicide rates, with the lowest rates in the mid-Atlantic states. For example, Alaska had the highest, and New Jersey the lowest rate in 1998. There are striking differences in rates across racial and ethnic groups, and across gender. Men, older people and Americans of European decent have higher rates of suicide. Widowed persons have higher rates of suicide than married people. There are similarities between rates across the lifespan for African American men, Native Americans, and Alaska Natives: the rates are higher in the younger age range. In contrast, the peak for Caucasian men is during old age. Women do not show large rate changes over the life-span; there is no peak for women of any race or ethnicity.

The suicide rates in the U.S. are largely driven by rates for white men.

Eve Mościcki

Dr. Mościcki reported that the mechanism of choice in the United States is firearms. Among men, firearms account for about 62 percent of all suicide deaths; among women, about 39 percent. Hanging and self-poisoning are the distant second and third mechanisms of death.

Dr. Mościcki noted that there are few national data on rates of suicide attempts. Estimates for life-time prevalence range from 1 percent to over 7 percent. The 12-month prevalence estimates range from about 0.2 to 2.6 percent. Women report greater rates of attempted suicide than men across the lifetime, but no significant difference is found when asking about recent attempts. Younger people, those with lower educational achievement, and previously married persons (as compared with married) all have higher rates of suicide attempts. The data from one of the studies, The National Co-Morbidity Study, investigated the degree of intent of the non-fatal attempts, and found that approximately half of the attempters indicated they did not really intend to die.

The current data indicate that suicide is the result of interactions among risk and protective factors. Risk factors can be broken down into distal (underlying vulnerability) and proximal (precipitants), which is an important distinction in terms of prevention strategies because the strategy will be different depending on the category of risk being targeted.

The primary risk factor for suicide is psychopathology.

Eve Mościcki

The co-occurrence of distal and proximal risk factors leads to the necessary and sufficient conditions for attempted or completed suicide. Strong epidemiologic evidence suggests that psychopathology is the most critical distal risk factor for suicide. Over 90 percent of completed adult and 67 percent of completed youth suicides meet diagnostic criteria of a psychiatric diagnosis. Psychopathology has also been found in the large majority of serious suicide attempts in the few published case-controlled studies. The most common diagnoses are mood disorders, substance abuse disorders, personality disorders, and schizophrenia. Dr. Mościcki stated that although there



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