Gaps in Crisis Mental Health: Suicide and Homicide–Suicide

Archives of Psychiatric Nursing xxx (2015) xxx–xxx

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Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu

Gaps in Crisis Mental Health: Suicide and Homicide–Suicide Carrie M. Carretta a,⁎, Ann W. Burgess b, Michael Welner c a b c

School of Nursing, Rutgers The State University of New Jersey, Newark, NJ William F. Connell School of Nursing, Boston College, Chestnut Hill, MA The Forensic Panel, New York, NY

a b s t r a c t Gaps in crises of mental health emerge from poor distinction between the qualities of people who suicide and those who murder and then kill themselves. The role, if any, that substance use has in such lethal violence is an example of such a lack of distinction. In this study, a sample of medical examiner investigative and toxicology reports from Los Angeles and Orange counties in California were available for analysis for 432 suicide cases and 193 homicide–suicide cases. This informed clearer toxicological and pharmacological distinction of suicide from homicide–suicide. Blood alcohol levels were higher in persons committing suicide than in homicide–suicide perpetrators (p = .004). Homicide–suicide perpetrators had almost twice the level of stimulants in their system than people who suicide (p = .022) but did not have comparatively elevated levels of drugs or alcohol. Predictors of suicide included the following: substance abuse history, high number of drugs in system, death inside a house, and legal impairment by alcohol. Predictors of homicide–suicide included gunshot as the cause of death, female gender, domestic conflict, children living in the home, and prior arrest for substance abuse. © 2015 Elsevier Inc. All rights reserved.

Reducing violent death is a national imperative (Institute of Medicine, 2002). It is estimated that 50,000 persons die annually in the United States as a result of violence-related injuries (CDC, 2013). Suicide, homicide, and homicide–suicide indelibly impact families, the community and society. More than 38,000 people died by suicide in the United States in 2010—an average of 105 each day, making it the tenth leading cause of death for all ages in 2010 in the United States (CDC, 2013). Homicide claimed another 16,000 people (CDC, 2013). Homicide–suicides are relatively rare events, but account for approximately 1000–1500 violent deaths annually or 20–30 violent deaths weekly (Logan et al., 2008; Marzuk, Tardiff, & Hirsch, 1992). According to the 2007 National Survey on Drug Use and Health, 7.6% of Americans 12 years or older met the criteria for alcohol abuse or dependence, and the prevalence of illicit drug use in the same year was as high as 14.5% (U.S. Department of Health and Human Services, 2007). Alcohol and drug abuse are second only to depression and other mood disorders as the most frequent risk factors for suicidal behavior (Borges, Walters, & Kessler, 2000). The CDC analyzed test results of persons who committed suicide in the 13 states that collected data for the National Violent Death Reporting System (NVDRS) in 2004. The findings noted that (1) of

those persons tested, 33.3% were positive for alcohol, and 16.4% were positive for opiates; and (2) similar percentages of poisoning suicide (i.e., suspected intentional overdose) and non-poisoning suicide victims tested positive for alcohol or other drugs, with the exception of opiates. The relationship between potentially addictive prescription drugs and violence, (including narcotic pain killers, sedatives, psychotropic drugs, stimulants as well as drugs used to treat sleep disorders) is also emerging as an important area of research interest (Mahfoud, Talih, Streem, & Budhur, 2009). Despite a sizable literature on violent deaths, there is minimal understanding on comparing differences between individuals who commit suicide and people who kill others before killing themselves, and there are few studies to date that have examined these phenomenon related to prescription drug abuse (PDA). In this pilot study of data from two counties in California, we were particularly interested in comparing suicide cases to homicide–suicide cases and sought to compare toxicology findings on autopsy between the two types of violent deaths. The research questions were as follows: What distinctions would emerge among demographics and postmortem toxicology in suicide, homicide and homicide–suicide cases; and, what predictors, if any, could be identified for suicide compared to homicide–suicide cases? METHOD

⁎ Corresponding Author: Carrie M. Carretta, PhD, APN, AHN-BC, FPMHNP, Assistant Professor/Research Faculty. E-mail addresses: [email protected] (C.M. Carretta), [email protected] (A.W. Burgess), [email protected] (M. Welner).

Permission to conduct the study was obtained from the University of Medicine and Dentistry of New Jersey Institutional Review Board (IRB). Protection of human subjects was achieved through de-identification of

http://dx.doi.org/10.1016/j.apnu.2015.06.002 0883-9417/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Carretta, C.M., et al., Gaps in Crisis Mental Health: Suicide and Homicide–Suicide, Archives of Psychiatric Nursing (2015), http://dx.doi.org/10.1016/j.apnu.2015.06.002

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C.M. Carretta et al. / Archives of Psychiatric Nursing xxx (2015) xxx–xxx

data at the time of data collection to ensure anonymity of the subject to anyone other than the principal investigator. Permission to inspect the files was granted by the offices of the respective California County Medical Examiners.

DEMOGRAPHIC RESULTS

Sample

Homicide–Suicide Deaths

Autopsy reports for suicide and homicide–suicide deaths were examined at the Orange County (OC) and Los Angeles County (LA) Department of Medical Examiner-Coroner. A random sample for suicide cases from both counties of approximately 7% was then drawn for data collection from the archival files for suicides spanning 2001 and 2011. Every 50th suicide case that met criteria was selected. Orange County had a total of 1596 cases of suicide of which we sampled 10% or 160 cases. LA County had a total of 4396 cases of suicide of which a sample of 272 cases or 6% were used in this study. Due to the much smaller pool of homicide–suicides, all such cases (n = 193) were included in this study. Data were collected by hand onto paper copies of the Homicide–Suicide Assessment Tool that had been developed for the project. The development of historical inventory was based on five major concepts: cause (how the person died); mode (circumstances that led to the death(s); motive (why the person was killed); intent (resolve to carry out the crime); and lethality (likelihood that the nature of injury would cause death). The coding of the demographic variables included age, gender, race, marital status, employment stability, cause of death, motive, living alone or with family or partner, children present or not in the home. Other variables included history of substance abuse, prior suicide attempts, and whether a suicide note was present or not. The presence of illicit substances was established on toxicology testing by the presence of any of the following: cannabis, morphine, methamphetamine, cocaine, heroin or methylenedioxymethamphetamine (MDMA). The sample included 431 records of suicides and 193 records of homicide–suicide for the period 2001–2010 from two counties in California. In some cases, information needed for the instrument was not available (i.e., demographics in homicide–suicide cases, prior history data, and toxicology reports for various cases). Toxicology information was not available when (1) the perpetrator died 24 or more hours after the homicide and post-mortem toxicology screen would not yield useful data for this study, (2) in early 2001–2004 toxicology screens were not performed, and (3) the body had decomposed and toxicology screens were not completed.

There were 193 perpetrators of homicide–suicide events in the twocounty California study of whom over 90% (177 or 91.7%) were male offenders and 16 (8.3%) were female offenders. Of their 240 victims, the majority were female (185 or 77.1%) and 54 (22.5%) were male. Our data are consistent with the NVDRS homicide–suicide data where most perpetrators in their study were male (91.9%) or female (8.1%) and most of their victims were female (74.6%) or male (25.4%) (see Table 1). Age indicated some trends. The incidence of homicide–suicide increased with age for the two-county California study offenders between ages 20 and 49 (55.7%) with the remaining 82 (44.6%) 50 and older. Over half of the study offenders (99 or 55%) were also partnered with 45% not partnered, e.g., single (48 or 26.7%) or separated/divorced (33 or 18.3%). The NVDRS study population had fewer partnered offender subjects (64 or 30.9%), single (33 or 15.9%), separated/divorced (23 or 11.1%), but more in the “other” category (28.5%) or unknown (24.6%). Victims of homicide–suicide in the NVDRS study were significantly more likely to be single at the time of the incident (Bossarte et al., 2006). Our two-county California sample had highest representation of Caucasian (39.7%) offenders, followed closely by Hispanic (34.9%), then African-American (11.1%), Asian (10.6%), and others (3.7%). Hispanic offenders were higher in the California study than the NVDRS study; African American offenders were lower than 20% of perpetrators identified in the NVDRS study as non-Hispanic Black (Bossarte et al., 2006). Perpetrators killed their victims (212 or 88%) by gunshot and themselves 168 (87%) of the time by gunshot. The NVDRS study findings were fairly consistent with the two-county California study in that firearms were used for both homicides (82.7%) and subsequent suicides (80.4%) (Bossarte et al., 2006). Of the 240 victims of the two-county California homicide–suicide, the overwhelming majority of victims were female (185 or 77.1%) with only 54 (22.5%) male victims including 32 (13.4%) children. In the NVDRS study a comparable proportion of the victims (13.7%) were the children of the perpetrator (Bossarte et al., 2006). The relationship between perpetrator and victim was most frequently an intimate partner (145 or 60.5%), followed by family member (49 or 20.4%), parent (12 or 5%), peer (8 or 3%), stranger (7 or 2.9%), other (8 or 3%) and no data 5 (2%).

Statistical Analysis Statistical software tested the relationships between cases of suicide versus homicide–suicide relative to age-related factors (such as motive for death, life stresses, etc.), or death-related factors (such as location, weapon used, method, cause). For missing data, we used the average value of the variables with data for the variables with missing data. Where distributions were highly skewed, medians and inter-quartile ranges (IQR) were reported, otherwise means were presented. For bivariate comparisons, t-test or odds ratios (OR) with 95% confidence intervals (CI) were reported. All analyses were conducted using SPSS version 19 for Windows (IBM, 2010). THE NATIONAL VIOLENT DEATH REPORTING SYSTEM (NVDRS) DATA Although California criminal justice statistics on homicide have been collected and published for over 56 years, they do not publish separate statistics for homicide followed by suicide. Because we do not know the size of the population at risk in the two California counties studied, where possible, we provide comparable figures from the NVDRS as population-based rates for homicide–suicide. The National Violent Death Reporting System (NVDRS) data base of 209 cases of homicide–

suicide derives from 20 states between 2003 and 2004 (Bossarte, Simon, & Barker, 2006).

Suicide Deaths In the two-county California study, of the 431 suicide deaths, the majority were male (335 or 77.7%) with 96 (22.3%) female. These data are consistent with CDC statistics on suicide deaths that find almost four times as many males as females die by suicide (CDC, 2013). Ages of the suicides in this study ranged from 12 to 95 including 20 (4.6%) teenagers. Among the cases, 206 (47.8%) cases were between the ages of 20–49 and 205 (47.6%) were over age 50. Age of the suicides steadily increased and peaked at age 50–59. Caucasians had the highest number of suicide deaths at almost twothirds (271 or 62.9%) compared to Hispanic (18.3%), Asian (10%), AfricanAmerican (6.5%), and, other (2.3%). CDC findings for 2005–2009 report differed from the two-county California study in that the highest suicide rates were among American Indian/Alaskan Native males and females while the Non-Hispanic Blacks had the lowest suicide rate among females (CDC, 2013). More than two-thirds of persons who suicide were not in a partner relationship, as 67.8% were either single at the time of their death

Please cite this article as: Carretta, C.M., et al., Gaps in Crisis Mental Health: Suicide and Homicide–Suicide, Archives of Psychiatric Nursing (2015), http://dx.doi.org/10.1016/j.apnu.2015.06.002

C.M. Carretta et al. / Archives of Psychiatric Nursing xxx (2015) xxx–xxx

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Table 1 Comparison of Suicides and Homicide–Suicides with NVDRS Data. Suicide cases

Homicide–suicide cases

NVDRS

Perpetrator

Victims

Perpetrator

Victim

n = 431

n = 193a

n = 240b

209

248

Male Female 0–14 15–24 25–34 35–44 45–54 55–64 65+ Marital status Single status Partnered Separated/divorced Employed Unemployed Death by gunshot Death by hanging Death by overdose Other method (asphyxiation, car, jumping, etc.)

335 (77.7%) 96 (22.3%) 3 (.7) 52 (12.1) 57 (13.2) 70 (16.2) 96 (22.3) 74 (17.1) 79 (18.3)

177 (91.7%) 16 (8.3%) – 7 (3.6) 37 (19.2) 42 (21.8) 35 (18.1) 27 (14.0) 37 (19.2)

54 (22.5%) 185 (77.1%) 38 (15.8) 22 (9.2) 35 (14.6) 48 (20.0) 33 (13.8) 24 (10.0) 38 (15.8)

192 (91.9) 17 (8.1) – 18 (8.6) 47 (22.5) 52 (24.9) 43 (20.6) 21 (10.1) 28 (13.4)

63 (25.4) 185 (74.6) 30 (12.1) 38 (15.4) 41 (16.6) 51 (20.6) 35 (14.2) 16 (6.5) 35 (14.2)

184 (43.6%) 136 (31.5%) 102 (24.2%) 235 (54.2%) 139 (32.2%) 143 (33.1%) 131 (30.5%) 59 (13.7%) 98 (20.4%)

48 (26.7%) 99 (55%) 33 (18.3%) 111 (74.6 %) 34 (23.4%) 168 (87%) 7 (4%)

Suicide note Prior suicide attempt History of substance abuse

146 (33.8%) 87 (20.1%) 146 (33.8%)

a b

33 (15.9) 64 (30.9) 36 (17.4)

212 (88%) 6 (2.5%)

7 (4%) 7 (4%) 5 (3%) 61 (32%) 12 (6%) 21 (11%)

168 (80.4) 6 (2.9)

3 (1.3%) 12 (5%) 5 (2.1%)

205 (82.7) 11 (4.4) 32 (12.9)

30 (15.5%) 5 (2.6%) 19 (9.1)

8 cases (4.1%) missing age of perpetrator. 2 cases missing age of victim.

(184 or 43.6%) or were separated or divorced (102 or 24.2%). Just over 30% of those who suicide were partnered at the time of their death (132 or 31.5%) Over half of the suicide individuals (235 or 54.2%) were employed full or part-time and for cases with data, 164 or 57.1% had attended some college. The primary cause of death in 143 (33.1%) of the suicide cases was by gunshot with slightly less (131 or 30.5%) by hanging. Other methods 98 (20.4%) for suicide cases included jumping out of a car or a bridge, asphyxiation, blunt force trauma. Overdose occurred in 59 (13.7%) of the suicides. Suicide notes were available in 33.8% of suicide cases, and 26.2% of homicide–suicide cases. Of those who committed suicide, 20.1% had made prior suicide attempts while only 6% of the homicide–suicide group had prior suicide attempts. The NVDRS study reported lower rates of persons with a history of previous suicide attempts (2.6%) and those who left a note (15.5%). The two-county California statistics of

suicide deaths by gunshot were much lower than U.S. statistics as cause of death (Table 2). MULTIPLE DRUGS IN TOXICOLOGY Toxicology reports, available for 64.7% of suicide cases, reflected negative results in 34.6% of suicide cases and 5% of homicide–suicide cases. Alcohol only was reported in 33.5% of suicides, and both alcohol and drugs were reported in 25% of the suicide cases. Alcohol only was reported in 9.8% of homicide–suicide cases and both alcohol and drugs were reported in 22.5% of homicide–suicide perpetrators. In the NVDRS study, nearly 1 in 10 perpetrators (9.1%) had evidence of a drug or alcohol abuse problem, a lower percentage than the two-county California study. A key point of this study was an analysis of the variety and role of drugs found in the two types of violent death. A total of 85 different drugs were identified in the 2 death groups. Stimulant drugs were the

Table 2 Variables in the Equation.

Step 1

Location of crime Suicide note present Prior arrest for drug/substance abuse Victim's living situation Children present in living situation Was the victim legally impaired by alcohol History of suicide attempt Drug/substance abuse history Domestic problems Cause of Victim gender Number of drugs in body Constant

B

S.E.

Wald

Sig.

Exp(B)

−1.261 −.696 1.743 −.420 4.662 −2.215 −4.367 −4.100 3.505 −1.737 6.503 −1.035 2.624

.586 1.152 1.646 .578 1.424 1.313 3.001 1.550 1.174 .438 1.663 .632 2.276

4.640 .365 1.122 .528 10.723 2.848 2.117 7.001 8.917 15.747 15.289 2.683 1.330

.031 .546 .289 .468 .001 .091 .146 .008 .003 .000 .000 .101 .249

.283 .499 5.717 .657 105.893 .109 .013 .017 33.297 .176 667.342 .355 13.792

Please cite this article as: Carretta, C.M., et al., Gaps in Crisis Mental Health: Suicide and Homicide–Suicide, Archives of Psychiatric Nursing (2015), http://dx.doi.org/10.1016/j.apnu.2015.06.002

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C.M. Carretta et al. / Archives of Psychiatric Nursing xxx (2015) xxx–xxx

most prevalent class of drug found in homicide–suicide perpetrators (22.4%), followed by pain killers (17.9%), anti-anxiety (14.9%), antidepressant (11.9%), hypnotic/sleep (6%), illegal (7.5%), antipsychotic (4.5%), and other (4.5%). In suicide cases, pain killers were the most prevalent class of drug (21.3%), followed by anti-anxiety (17%), antidepressant (15.5%), stimulants (12.2%), hypnotic/sleep (9.7%), antipsychotic (7%), illegal drugs (6.4%), and other (2.7%). Many cases involved multiple drugs. There were 268 suicide cases with toxicology reports. Of these, 123 cases had no drugs, 64 had 1 drug and 81 had 2 or more drugs in their system. The maximum number of drugs in a suicide was 8. Of the cases with data for homicide–suicide perpetrators, 2 had no drugs in their system, and 24 had 1 or more drugs detected in their body. The maximum number of drugs found in an offender was 4 (6 offenders). One significant difference between type of drug and type of death was related to the higher presence of stimulants in homicide–suicide perpetrators (24.4%) compared to 12.1% of suicide deaths (F = 5.223, df = 1, p = .022). Further analysis of prescription drug and illegal drug use in suicide deaths and homicide–suicide perpetrators revealed that of the suicides, only 6.4% had illegal drugs reported while slightly more (7.5%) of homicide–suicide perpetrators had illegal drugs. The suicide victims occasionally had both prescription drugs and illegal drugs (4.9%) while the homicide–suicide perpetrators had either prescription drugs or illegal but not both. About 1/3 of homicide–suicide perpetrators took prescription drugs to treat pain, anxiety, and depression. Barbiturates, illegal drugs and hypnotics were found in less than 10%. In the total sample, 42.5% of males and females had alcohol present in their toxicology report. The more alcohol in the system of the subjects across both groups, the more likely death was by suicide. More suicide victims (90 or 29%) were legally impaired (e.g. presenting with a blood alcohol level of greater than or equal to 0.08) compared to 29 (18%) of homicide–suicide cases. (F = 11.011, df = 2, p = .004). In homicide–suicide, 11.7% of the males were legally impaired or approximate half the number legally impaired who commit suicide. The females who committed homicide suicide were not legally impaired. The percentage of people with prior drug/alcohol use was higher among those who used illegal drugs (F = 6.345, df = 1, p = .012). There were 21.6% of people with a prior history of substance abuse who had illegal drugs in their system while those without a history had illegal drugs in their system only 8% of the time. People with a reported history of prior substance abuse had higher illegal drug use than those with prescription drug use. LOGISTIC REGRESSION ANALYSIS A logistic regression model was developed to examine variables to predict if the death was a homicide–suicide case versus suicide only. Suicide only is given the value of 0 and homicide–suicide value of 1. Each of the variables in the model was evaluated as to the underlying importance of each variable in the model. However, many of these variables which are significant in the logistic regression are not bound to be statistically significant when it comes to difference between male and female and homicide suicide drug usage, location of crime, cause of death perpetrator, and the gender of the victim. The negative B levels predict for suicide and the positive B predicts for homicide–suicide (please see Table 3).

Predictors of suicide

Predictors of homicide–suicide

Drug/substance abuse history

Victim gender Domestic conflict

Higher number of drugs in system Death inside a house Legally impaired by alcohol

Children living in home Prior arrest for substance abuse

Table 3 Predictors of Suicide and Homicide–Suicide. Observed

Predicted Type of crime

Type of crime

Suicide Homicide–suicide Overall percentage

Suicide

Homicide–suicide

205 7

3 25

Percentage correct 98.6 78.1 95.8

The leading motive of homicide–suicide was domestic dispute. This motive was attributed to male perpetrators as well as female perpetrators (60.8%, 53.3% respectively). Victim gender was important because if the victim was female there was a higher probability the crime was homicide–suicide thus the positive valued beta. The male offender had a different profile. The victims of a male perpetrator were 17.2% male compared to 82.8% of their victims were female. In contrast, female perpetrators of homicide–suicide had 53.6% male victims and 46.49% female victims. When the perpetrator was a female living in a home with children, she was more likely to kill the child and then commit suicide rather than just suicide. However the male offender in the same type of environment had almost an equal chance of suicide as homicide–suicide. The cause of death has some interesting trends. In homicide–suicide, gunshot was 87.7% of the cause of death whereas in suicide deaths it was only 32.9%. The second highest mode of committing suicide was by hanging. Hanging in the homicide suicide after committing murder was only 2.7%. Alcohol usage was very similar. Among the study sample, the more alcohol in one's system, the more likely the case was a suicide. The male who was legally impaired occurred in 24.41% of cases with the female legally impaired 22.7% of the time. Among homicide–suicide perpetrators, 11.7% of the males were legally impaired or approximate half the number legally impaired who commit suicide. The lone female who committed homicide–suicide for whom toxicology data were available was not legally impaired. Living with children was an additional point of distinction between suicides versus homicide–suicide. The data reflected that 9.4% of females who committed suicide were living with children whereas 57.1% of them committed homicide–suicide when a child was in the home. There were 15.9% of males who committed suicide that were living with children compared to 33.5% who committed homicide–suicide that were living with children. Location of the homicide also demonstrated differences between suicide and homicide–suicide. Suicides occurred 50% of the time in the house whereas homicide–suicide occurred 80.5% of the time in the house. DISCUSSION Psychiatric nurses are called upon to assess a wide variety of crisis situations. Such situations could involve the person who contemplates a shooting rampage, the hospital being sued for negligence for discharging someone who commits suicide, the surviving driver of a vehicular homicide, the mother who endangers her children days after her medication dose is lowered, the soldier accused of blowing up his commanding officer, the repeatedly hospitalized person with a suicidal and violent history, or the distressed person whose primary conflict is domestic strife. These are examples of crisis mental health that include determining contemplated violence, unfettered impulsivity, destructive behavioral symptoms, suicidal urges, explosive abuse, descending chemical dependency and neglect of the vulnerable child (Welner, 2014). This pilot project has important implications for psychiatric nursing practice and suggests several directions related to the role of drugs and alcohol to minimize gaps in crisis mental health. On the assessment side,

Please cite this article as: Carretta, C.M., et al., Gaps in Crisis Mental Health: Suicide and Homicide–Suicide, Archives of Psychiatric Nursing (2015), http://dx.doi.org/10.1016/j.apnu.2015.06.002

C.M. Carretta et al. / Archives of Psychiatric Nursing xxx (2015) xxx–xxx

there is first a need to increase knowledge of the substance use in violent death. Findings of the presence of prescription medication may could indicate recent contact with health care providers and identify an additional important source of information in death investigation. Toxicology examination for prescribed psychoactive medications may also be useful to estimate the frequency and type of psychiatric treatment before death reconstructing a timeline preceding a suicide or a homicide–suicide, as well as identifying triggers or pertinent changes in a clinical condition (Dhossche, 2007). Second, toxicology results can suggest trends as to the number and amount of drugs found in decedents of suicide vs. homicide–suicide. Evidence for multiple drug use was common among both study populations. Higher blood alcohol was more frequently seen in suicide offenders. Homicide–suicides also distinguished themselves from suicides by a distinctively higher prevalence of stimulants. These distinctions contribute to resolving cases of equivocal death. Toxicology data among homicide–suicide perpetrators were less consistently available, so the presence of trends demonstrates that broader testing, for example, for designer drugs in the ever-inventive pharmacopeia may identify other drugs associated with suicide or homicide–suicide risk. Findings about stimulant use would be further informed by information about the distribution of drugs by age. If the group of those under 30 skewed the stimulant representation, it might suggest more about the prevalence of stimulant use than it does about causation and association. Third, and from a death investigation standpoint, our data also support prior researchers' findings that suggest that homicide–suicide characteristics differ from suicide. Individuals who committed suicide in this sample were more frequently male, Caucasian, single or separated, over age 50, had attended college, and died by gunshot or hanging. In homicide–suicide, offenders were more frequently male, Caucasian or Hispanic, between ages 20 and 49, partnered, shot their female partner and suicide by gunshot. This latter finding is notable to consider in cases in which the perpetrator asserts a failed suicide attempt as well, especially when the victim has been shot and the perpetrator employs a different method to “attempt” suicide. When a method is available with highest likelihood of lethality, these data support the conclusion that use of another method may reflect a staged suicide attempt to avoid criminal responsibility. The findings of this study have important implications for clinical practice as well. Data support the importance of containment of alcohol use in particular in those with fragile suicidal histories. The study data do not differentiate among those who are dependent on alcohol or who abuse it or who merely use it recreationally. Rather, it demonstrates the presence, and in a higher amount, of alcohol in the system of people who choose to end their lives. Promoting very responsible drinking in populations at higher risk for suicide is good disease management. A person with uncertain suicide risk is distinctly more at risk when drinking to an amount above legal intoxication. Likewise, the notably higher representation of amphetamine use among homicide–suicide perpetrators introduces opportunities for a clinician to recognize at risk families and individuals. A person, for example, may be referred for uncertain homicide risk. Such an individual, especially when encountering an examiner not on his own initiative but after being prompted to do so, may be defensive and secret about homicidal motivation or even underlying conflicts that fuel an entitles rage. In such instances, knowledge of stimulant use enables patient education and may provide a portal through which the examinee can be engaged about, for example, how much domestic conflict is weighing upon him. The significance of other history of impulse control problems is magnified in the person who uses amphetamines. The percentage of child victims of homicide suicide is not so modest as it appears. Considering that the larger groups of homicide–suicide perpetrators were less than age 50, a point when children would be in the home, the data may speak to underappreciated risk or to defenseless child bystanders in homes with disintegrating parental relationships.

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Finally, the two-county California statistics of suicide deaths by gunshot were much lower than U.S. statistics as cause of death. With California having strict gun laws, these data embed in the empirical evidence linking suicide risk in the United States to the presence of firearms in the home. Miller and Hemenway cite a dozen U.S. case-control studies in the peer-reviewed literature, all of which have found that a gun in the home is associated with an increased risk of suicide. The increase in risk is large, typically 2 to 10 times than in homes without guns, depending on the sample population (e.g., adolescents vs. older adults) and on the way in which the firearms were stored. Moreover, the increased risk of suicide is not explained by increased psychopathologic characteristics, suicidal ideation, or suicide attempts among members of gun-owning households (Miller & Hemenway, 2008). At the clinical level, these data promote discussion about the responsible storage of firearms in the homes of higher risk populations. Limitations of the Study There are several factors related to data available that limit the conclusions to this pilot study. First, toxicology reports were unavailable for many cases of the total sample. Moreover, there were missing data for variables such as drug/substance use history (53.4%), prior arrest for drug/substance use (44.5%), and number of drugs in the body (27.2%). For homicide–suicide cases, there were substantially fewer cases with toxicology data available during the measurement period. As a consequence, the homicides-suicide cases may not be a representative sample of the population. Second, the toxicology results were reported in different ways in autopsy reports. For example, the level of the alcohol or drug was not always included (27.2%), but the substance was instead reported as present or absent. Results demonstrating the frequency of blood alcohol above the legal limit in suicide may therefore be underestimates. Third, inadequate information existed to identify variables that might increase the probability of homicide–suicide. On further study, added variables might increase a stronger prediction for homicide–suicide versus suicide only. However, this preliminary study might also signal to medical examiners' offices, which have particular interest in public health, that the demographic information they are collecting is inadequate to inform prevention efforts. Real progress may ultimately originate from rethinking the data that are gathered in death investigation at medical examiners' offices, and enhancing record keeping. Fourth, we compared the local findings to existing national statistics, but the comparison was limited to a few states and not all 50 states. Closing the Gap General approaches such as efforts to educate psychiatric nurses and other mental health care providers about diagnosing and treating depressive and other psychiatric disorders, and to restrict access to lethal means (e.g., excess prescription medication, weapons) have been supported as most promising ways to reduce suicides. However, other methods including public education, screening programs, and media education have been noted to be equivocal and require more testing (Mann, Apter, Bertolote, et al., 2005) This perspective engages depression as an antecedent to suicide rather than hopelessness, which separately has established even more robust links (Beck, Brown, Berchick, Stewart, & Steer, 2006). That perspective also presupposes that there is no suicidogenic quality of the drugs themselves. Data from this study do not resolve questions of whether a state of mind or the creation of a state of mind by prescription or illicit drugs is ultimately responsible. What our findings do show, however, is that legal and illicit substances have a frequent enough association to more closely study the nature of the linkage and contribution to risk. Data from this pilot project also have to take into account the effects of stimulant crashes. The presence of benzodiazepines may reflect people with anxiety including the possibility of panic attacks, which have

Please cite this article as: Carretta, C.M., et al., Gaps in Crisis Mental Health: Suicide and Homicide–Suicide, Archives of Psychiatric Nursing (2015), http://dx.doi.org/10.1016/j.apnu.2015.06.002

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been associated with suicide. Short-acting benzodiazepines in particular are responsible for rebound anxiety when continuing dosing is skipped or otherwise abruptly discontinued. Thus the possibilities are varied enough to defuse some of the certainty of what one draws about prevention. For those admitted to hospitals with suicidal thinking, the importance of admission toxicology testing is supported by the findings of this study. Psychiatric nurses need to take detailed and clear data about a patient's prescription and illicit drug and alcohol use at times of confirmed suicidal thinking as such evidence is useful to patient education efforts during hospitalization. The complexity of gathering a complete such history is illustrated in the death investigations of our samples. Psychiatric nurses considering the importance of our findings may allocate multiple interviews in order to more fully establish a valid record of the examinee's substance use history and patterns. The frequency of child victims in the homicide–suicide group, especially among female perpetrators, necessitates closer questioning about homicidal fantasy and thinking. Such an assessment is critical in cases of domestic conflict settings in homes in which children reside, particularly those in which the examinee has a prior history of arrest for substance use. For hospitalized patients, discharge planning may benefit from accounting for the safety of children in the home of a patient with fluctuating levels of suicidality. Risks of family annihilation in homicide–suicide may be extremely difficult to eliminate, for the crime may be impulsive. In instances in which there is forethought, parents recognize the implications of revealing their own risk on future parental rights and access. Getting access to care when a person is in distress or conflict is not sufficient to incentivize some lethal individuals to be open to external intervention, be it psychotherapeutic or psychopharmacologic. One promising care model is the Naylor Transitional Care Nurse Model (Naylor et al., 1999). Although originally designed for elder care, the model has been adapted to persons with serious mental illness (Hanrahan, Delaney & Merwin, 2010). The Transitional Care Nurse differs from a traditional nursing position as it incorporates the skills of a nurse, care manager, and patient advocate. In addition, the position requires experience in the use of evidence-based care, managing complexity, active engagement of family caregivers, interdisciplinary team care, and individualized care and behavioral change across an episode of acute care. This model should be considered in working with patients with serious depression, anxiety and chronic pain especially when on multiple prescription drugs. RECOMMENDATIONS Our study agrees with Dhossche (2007) recommendation that toxicologic analysis should be conducted in every suspected suicide and other types of unnatural death as an integral component in the investigation. It is important to correlate testing with a detailed scene inspection, an exploration into the decedent's medical and social background, and both gross and microscopic findings, to uncover suicidal ideation or intent. Toxicological results can be useful for reconstructing some events before a suicide or homicide or homicide–suicide, and may suggest impaired mental functioning due to intoxication with alcohol or other drugs either acutely, chronically, or both. Items such as route of administration, acute versus chronic dose, and consistency between drug concentrations and behavioral effects may be critical factors in assessing the manner of death (Dhossche, 2007). A second recommendation relates to the application of data on guns. Recognizing the issue has political implications, psychiatric nurses especially advanced practice nurses could advocate for screening questions to be included in electronic records. Our findings do not encroach on Constitutional rights in America, but rather relate to risk management for the individual patient as well as to concern about children in precarious households. It is simply not adequate to only define the need for gun vigilance to someone who has been involuntarily committed in the past.

FUTURE STUDIES Currently, there are no empirically-based studies that examine directly the relationship between abuse of classes of drugs or blood levels of drugs at time of successful suicide or homicide–suicide. Forensic science does not know if some classes of drugs place someone at higher suicide risk than others, if there is a “dose effect” or whether certain combinations of drugs yield a higher likelihood of a completed suicide. Further, it is unknown whether differences exist between illegal and prescription drugs in the incidence or nature of suicide, and homicide–suicide. Dhossche (2007) recommends that future study designs need to collect and correlate three pieces of information. First, all violent deaths in a defined geographic area need be identified over a period of time. Second, comprehensive toxicological findings need to be collected in all cases. Third, prescription medication data in the years preceding suicide needs to be gathered. This design will allow for better informing questions of whether illness is responsible for suicide or homicide–suicide or whether the treatment for said illness and related symptoms is even responsible. The availability of such data enables two hypotheses. First, the positive detection rate of prescription psychotropic medications will be higher in suicidal individuals who have been prescribed such medications in the last year before death than in suicidal persons who have not been prescribed psychotropic medication. A second hypothesis to test is that positive detection rate of alcohol, cocaine, and cannabis will be higher in suicidal individuals who have not been prescribed psychotropic medications during the year before death than in suicidal persons who have been prescribed such medications. Cause of death by overdose is complex. In this pilot project, we coded overdose and whether (or not) a suicide note was found as one way to suggest if the death was accidental or intentional and/or if the medical examiner staff recorded the death as an overdose. Separate study is necessary to resolve which overdoses are intentional vs. accidental and fueled just as much by drug interaction. Motive also needs clarity. The most common motives for male initiated homicide–suicide are financial ruin, morbid jealousy, infidelity and suspected non-parentage, and pending separation–divorce. Toxicology data specific to these categories could provide more focused guidance to prevention interventions. Better indication of motive can resolve questions of impulsive choices as opposed to premeditation. This distinction may better delineate how alcohol and prescription and illicit drug use relate to these tragedies. With more data, for example, we can better appreciate the relative frequency in suicides and homicide–suicide of substance use as incidental, an unintended accelerant, or lubricant to diminish inhibitions. The availability of suicide notes affords yet another opportunity for comparison between groups and between genders, based on close scrutiny of their contents. In both suicide and homicide–suicide groups in this study, suicide notes were common. Given the potential informative value of this evidence, investigators should carefully sweep the death scene, or remote workplace and home, garbage cans, personal computer, email correspondence, text messages, or social media for suicide notes that may not be immediately noticed, yet may provide key answers in plain sight. Closer study of suicide notes informs the importance of different drugs, polypharmacy, and the nature of their impact on the individual. Untoward fallout from prescription psychotropic use is a growing concern among clinicians. Journal articles are beginning to report on homicidal ideation causally related to therapeutic medications (Marks, Breggin, & Braslow, 2008), although much of the impetus for this is the antipsychiatry sentiments of profitable organizations who attack psychiatry as they would a business competitor. The questions raised, however, are complex and sometimes fair game. When stimulants are found, for example. what other drugs are found with them? Does stimulant presence reflect psychopharmacologic prescribing patterns for treatment resistant depression or abuse and

Please cite this article as: Carretta, C.M., et al., Gaps in Crisis Mental Health: Suicide and Homicide–Suicide, Archives of Psychiatric Nursing (2015), http://dx.doi.org/10.1016/j.apnu.2015.06.002

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self-medicating patterns, based on the companion drugs identified by the toxicology analysis? In conclusion, every dangerous mental health crisis is different and requires proactive intervention to prevent tragedy. This is what distinguishes crisis in any aspect of healthcare and in society. By the time a murderer decides to act, it is often too late to stop him because that perpetrator will make sure the nurses and doctors never know. One important step for the mental health system is to get the specialized crisis intervention to those who, ironically, are so ill that their disturbed insight alone drives them away from competent care. Crisis psychiatry is an emerging specialty within mental health. It enhances the partnerships between families and mental health and the vital bridges between mental health and law enforcement, corrections and other front line first responders who need to be mobilized when those in crisis reject mental health support (Welner, 2014). Acknowledgment This research was supported, in part, by a grant from the UMDNJ Dean's Discretionary Funds for travel, data collection and statistical analysis. We wish to thank the collaborating institutions of Los Angeles County and Orange County Medical Examiner's Offices for their generous time in identifying and redacting files for us. References Beck, A., Brown, G., Berchick, R. J., Stewart, B. L., & Steer, R. A. (2006). Relationship between hopelessness and ultimate suicide: A replication with psychiatric outpatients. Focus, 4, 291–296. Borges, G., Walters, E. E., & Kessler, R. C. (2000). Associations of substance use, abuse and dependence with subsequent suicidal behavior. American Journal of Epidemiology, 15, 781–789.

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Please cite this article as: Carretta, C.M., et al., Gaps in Crisis Mental Health: Suicide and Homicide–Suicide, Archives of Psychiatric Nursing (2015), http://dx.doi.org/10.1016/j.apnu.2015.06.002