title: Race/ethnicity and potential suicide misclassification: window on a minority suicide paradox?
abstract: 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.
  
  
  METHODS
  This cross-sectional study uses multiple cause-of-death data from the US National Center for Health Statistics to assess whether race/ethnicity, psychiatric comorbidity documentation, and other decedent characteristics were associated with differential potential for suicide misclassification. Subjects were 105,946 White, Black, and Hispanic residents aged 15 years and older, dying in the US between 2003 and 2005, whose manner of death was recorded as suicide or injury of undetermined intent. The main outcome measure was the relative odds of potential suicide misclassification, a binary measure of manner of death: injury of undetermined intent (includes misclassified suicides) versus suicide.
  
  
  RESULTS
  Blacks (adjusted odds ratio [AOR], 2.38; 95% confidence interval [CI], 2.22-2.57) and Hispanics (1.17, 1.07-1.28) manifested excess potential suicide misclassification relative to Whites. Decedents aged 35-54 (AOR, 0.88; 95% CI, 0.84-0.93), 55-74 (0.52, 0.49-0.57), and 75+ years (0.51, 0.46-0.57) showed diminished misclassification potential relative to decedents aged 15-34, while 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 suicide misclassification was also apparent for decedents without (AOR, 3.12; 95% CI, 2.78-3.51) versus those with psychiatric comorbidity documented on their death certificates, and for decedents whose mode of injury was "less active" (46.33; 43.32-49.55) versus "more active."
  
  
  CONCLUSIONS
  Data disparities might explain much of the Black-White suicide rate gap, if not the Hispanic-White gap. Ameliorative action would extend from training in death certification to routine use of psychological autopsies in equivocal-manner-of-death cases.
authors.affiliation: Department of Community Medicine and the Injury Control Research Center, PO Box 9190 West Virginia University, Morgantown, West Virginia 26506, USA. irockett@hsc.wvu.edu
authors.forename: Ian R H
authors.initials: IR
authors.lastname: Rockett
authors.forename: Shuhui
authors.initials: S
authors.lastname: Wang
authors.forename: Steven
authors.initials: S
authors.lastname: Stack
authors.forename: Diego
authors.initials: D
authors.lastname: De Leo
authors.forename: James L
authors.initials: JL
authors.lastname: Frost
authors.forename: Alan M
authors.initials: AM
authors.lastname: Ducatman
authors.forename: Rheeda L
authors.initials: RL
authors.lastname: Walker
authors.forename: Nestor D
authors.initials: ND
authors.lastname: Kapusta
mesh_terms: D000293:Adolescent; D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D017677:Age Distribution; D000368:Aged; D002423:Cause of Death / Q000639:trends*; D015897:Comorbidity; D003430:Cross-Sectional Studies; D004522:Educational Status; D005006:Ethnicity / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys; D054624:Health Status Disparities; D054625:Healthcare Disparities; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D008913:Minority Groups / Q000706:statistics & numerical data; D044469:Racial Groups / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D013405:Suicide / Q000145:classification* / Q000208:ethnology* / Q000706:statistics & numerical data; D014481:United States / Q000208:ethnology; D044465:White People / Q000706:statistics & numerical data