Ian Rockett spent a lot of his career working closely alongside medical examiners and coroners to study the epidemiology of suicide. Over many years, West Virginia University’s investigator has been trying to figure out why suicide rates among Black Americans in the U.S. are a third of those among white people ..
Rockett’s recent research has begun to provide some answers. It illustrates how medical examiners have struggled to determine the causes of death. Rockett’s 2010 study published in BMC Psychiatry found that Black American deaths are 2.3 times more likely than white deaths to be classified as undetermined at the time they occur.
Rockett and his colleagues were concerned that the Centers for Disease Control and Prevention report earlier this year about a 5.5% increase of Black suicides was likely to be underestimated. Rockett says that the numbers were likely higher than what the data show.
There are many reasons statistics are not good. Black Americans have been excluded from the mental health system for many years. The pandemic has made it harder to find help. Black people are less likely than other races to receive a mental diagnosis. There may also be no record of suicide attempts before their death.
In a January 2021 study published in the Journal of Racial and Ethnic Health Disparities, researchers at various institutions found that Black suicides were more apt to be categorized as undetermined because coroners and medical examiners have less information to go on when investigating Black deaths. Rockett, who co-authored the paper, said that if there is less psychological documentation, they are more likely to be classified as undetermined intent. “This leads to suicide misclassification.”
This conclusion is supported by The language most often found in death reports tends be . An April 2022 study published in the journal Suicide and Life-Threatening Behavior documented a greater frequency of mental health information in reports of white suicides, likely resulting from more widespread access to care. White narratives had more words like “depression” or “anxiety”, as well as medication information, family problems, and other indicators that could indicate suicide risk factors. Black narratives had less specific language. Black narratives used fewer words and phrases like “questionable,” nothing, and “no further detail”. The study revealed that Black accounts had fewer words and more “lexical diversity” (the number of words used to describe the manner in which death occurs).
“Our research showed that when a medical examiner is writing a narrative for a Black person, there’s consistently less information recorded for a Black case, be it a suicide, homicide or an undetermined death,” says Nusrat Rahman, an author of the study and now a senior researcher at the American Psychiatric Association. She says that the absence of suicide notes is also a factor in the disparities in death investigations for Black people. A 2018 study that looked at data from the National Violent Death Reporting System found that a fifth of Black Americans who die by suicide leave notes, compared with a third of white Americans.
The reasons for these differences are still being investigated, though the stigma surrounding suicide in the Black community could be a contributing factor. Rahman states that more research is needed to determine why Black death reports are shorter, and whether racial biases are motivating factors. The consequences are clear: “In these undetermined death, there’s not enough information to conclude whether a person died intentionally.” Without information about mental-health-related diagnoses, suicide notes or interviews with family members, medical examiners are less likely to label the cause of death as a suicide, especially in the case of a death from a drug overdose, which is often difficult to classify as intentional or accidental.
Nora D. Volkow, director of the National Institute on Drug Abuse, says that there’s a higher prevalence of suicide in individuals who misuse drugs, although we don’t know the “direction of the association”–whether drugs cause suicides or those who are suicidal are relying on drugs. She believes the explanation is a combination of both. Volkow states that drug users are more likely to commit suicide because they don’t see a way out.
Black Americans initially were less vulnerable to the opioid epidemic than other people, as they were less likely to be prescribed painkillers. Volkow states that this is an example of discriminatory practices towards minority groups that helped them to be protected early on. The landscape changed after the introduction fentanyl, a narcotic that is mixed with illegal drugs like heroin and cocaine and sold illicitly. The drug overdose mortality rate increased by 44 percent in Black Americans in 2020, according to the CDC.
In general, medical examiners and coroners are unlikely to consider drug deaths suicides if there is no clear evidence. Black suicides are often misclassified as drug overdoses. “I would conservatively estimate that 15 percent of drug overdoses labeled undetermined are likely suicides,” Volkow says. CDC information from 2019 to 2020 shows that if 15 percent of the 15,907 Black undetermined overdose deaths were misclassified suicides, their estimated suicide rate for Black Americans would be 12.5 per 100,000 people versus the official rate of 7.5 per 100,000–a 67 percent higher rate than previous calculations.
It’s not surprising that so many drug deaths are not properly investigated. Even before the pandemic, coroners and medical examiners were spread too thin, says Kathryn Pinneri, president of the National Association of Medical Examiners. “The increasing number of drug-related and violent deaths has meant that the medical examiner/coroner community has struggled with an increasing caseload for many decades. The COVID-19 pandemic exacerbated the problem,” she says. Pinneri notes that some deaths that would have been brought to an external examination (when coroners examine the victim’s body, including scars and medical devices) are now being investigated using only medical records. These records are not available in many cases for Black Americans.
Clinicians are trained to identify suicides in white men, as statistics show that they are the most likely to commit suicide. However, a Black man’s suicide risk might be overlooked. “At a very basic level, this data impacts a doctor’s risk assessment in emergency rooms across the country,” says Paul Nestadt, a psychiatrist who specializes in the epidemiology of suicide at Johns Hopkins University.
If the rate of Black suicides exceeds what is officially recognized, it means that more resources must be directed towards prevention. When Nestadt sounded the alarm in a research study about high suicide rates in Baltimore County, lawmakers took action by starting a task force to take on the issue and installing a suicide prevention coordinator for the city of Baltimore. He says that once we realized that our predominantly Black population was at high risk of suicide, we took the necessary steps to prevent it. Nestadt hopes that Black people at high risk of suicide will feel less isolated as they gain a better understanding of the true numbers. He says, “Knowing that they are not alone normalizes their struggles and makes them feel like they are not the only ones going through these struggles.”
HELP IS AVAILABLE IF YOU NEED IT. If you or someone close to you are struggling with suicide thoughts or have thoughts, there is help. Call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK), use the online Lifeline Chat or contact the Crisis Text Line by texting TALK to 741741.