- Email: [email protected]
Are suicides by jumping off bridges preventable?
Accident Analysis and Prevention 36 (2004) 691–694
Short communication
Are suicides by jumping off bridges preventable? An analysis of 50 cases from Sweden Per Lindqvist a,∗ , Anders Jonsson b , Anders Eriksson a , Annika Hedelin b , Ulf Björnstig b b
a Section of Forensic Medicine, Department of Community Medicine and Rehabilitation, Umeå University, Umeå SE-907 12, Sweden The Umeå Accident Analysis Group, Department of Surgery and Perioperative Sciences, Surgery, Umeå University, Umeå SE-901 85, Sweden
Received 13 November 2002; received in revised form 4 June 2003; accepted 23 June 2003
Abstract This is a community-based sequential case series of 50 individuals who committed suicide by jumping from bridges in two regions of Sweden. Of the 50 subjects, 32 were men and 18 women, with a median age of 35 years. At least 40 had psychiatric problems. The frequency of suicide was highest during the summer months and during the weekends. A total of 27 bridges were used, with a total length of just under 9 km. Three bridges accounted for almost half of all suicides. Limiting the availability of one method of committing suicide is reported to reduce the overall suicide rate; why suicide and injury suicide preventive measures might be considered. Since this study demonstrates that few bridges attract suicide candidates, this injury mechanism needs to be acknowledged by the road system owners and included in the safety work. © 2003 Elsevier Ltd. All rights reserved. Keywords: Suicide; Manner of death; Mental disorders; Substance-related disorders; Alcohol drinking; Preventive measures
1. Background During the 1990s between 1200 and 1500 individuals committed suicide each year in Sweden (Statistical Yearbook of Sweden, 2002). Individuals who die after jumping from a bridge are not presented separately in the official statistics. However, jumping from a height constitutes approximately 4% of all suicides in Sweden (Statistical Yearbook of Sweden, 2002), England and Wales (Gunnell and Nowers, 1997). The main focus in Swedish suicide research and prevention is on the identification of high-risk groups. However, this strategy is limited by the low predictive value when applied to individuals (Geddes, 1999). Most people with mental disorders (Allgulander et al., 1992; Harris and Barraclough, 1997; Joukamaa et al., 2001) and persons who have attempted suicide (Cullberg et al., 1988; Harris and Barraclough, 1997) or even suicide attempts by jumping from bridges (Seiden, 1978) do not eventually commit suicide. Yet individual suicide risk assessment and management by the health professionals is indispensable, although ∗ Corresponding author. Present address: Section for Emergency Treatment, Stockholm Dependency Center, S:t Görans Hospital, Plan 12, Stockholm SE-112 81, Sweden. Tel.: +46-9-010-0701; fax: +46-8-672-4921. E-mail address: [email protected] (P. Lindqvist).
0001-4575/$ – see front matter © 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0001-4575(03)00089-7
the number of persons who are out of reach for medical intervention is considerable. Thus, there is a need to consider general preventive strategies in suicide prevention by applying what could be termed an injury control model (Haddon, 1980), e.g. barriers on high buildings. However, such actions are meaningful only if a reduction in the number of suicides at specific places is not counteracted by an increase at other places or by an increase in other suicide methods. A number of European and Australian studies have reported on the positive association between interventions that limit the access to or decrease the attraction of a specific suicide method and a reduced overall suicide rate (Hawton et al., 1998; Kreitman, 1976; Sonneck et al., 1994). The methodological problems of establishing the overall effects of suicide proofing have been discussed by O’Carroll et al. (1994). They used as an example a bridge in Washington, DC, USA, attracting many suicidees, which prompted the construction of a barrier, resulting in a dramatic drop in the number of suicides. 2. Aims With this study, we wanted to (i) describe the characteristics of individuals who commit suicide by jumping from a bridge;
692
P. Lindqvist et al. / Accident Analysis and Prevention 36 (2004) 691–694
(ii) examine where and when this happens; and (iii) consider the feasibility of prevention by building barriers at high-risk stretches/places.
3. Material and methods The material comprises all 50 registered cases of suicide by jumping from bridges from 1983 to 1997 in two regions of Sweden; an urban and rural southwestern area with a population of 770,000 inhabitants (including the city of Gothenburg and the county of Bohuslän) and a rural region comprising 900,000 inhabitants of the four northernmost counties of Sweden. The cases were identified by a manual and computerized search of all death certificates issued at the Departments of Forensic Medicine in Umeå and Gothenburg, respectively. We included all certified cases of suicide by jumping off a bridge crossing water, a road or a railroad among cases assigned the external causes of death E954 (suicide by drowning) or E957 (suicide by jumping from height) according to ICD-9 (WHO, 1977). The autopsy rate in Sweden for these types of suicide is close to 100% (Öström et al., 2001). Autopsy protocols, police records, and, when available, medical records, were analyzed. Eye witnesses verified the circumstances in 22 of the 50 cases. Information from the Swedish National Road Administration about the design of the 27 bridges in question was available in 24 instances. There are innumerable bridges crossing water in the study areas.
4. Results Thirty-two victims (64%) were men and 18 (36%) were women. Their ages varied between 16 and 83 years with median and mean ages of 35 and 40 years, respectively. The average incidence was 0.2 per 100,000 inhabitants per year.
At least 32 of the 50 individuals had been treated in a psychiatric clinic and in an additional eight cases, information suggestive of mental health problems was retrieved through the police investigations. At the time of the suicide, at least 17 people were receiving psychiatric care. Of these, eight were patients in psychiatric wards and committed suicide while on leave (n = 6) or after absconding (n = 2). Twenty individuals had a diagnosis of depression, 10 of which were of a psychotic nature. At least nine were diagnosed as substance abusers. Nineteen people had previously attempted suicide and seven had left a suicide note. Fourteen individuals (12 males) tested positive for alcohol in the blood. No alcohol was detected in 29 cases and in six cases, the presence of alcohol could not be evaluated due to extensive decomposition. Eleven of the 14 who were under the influence of alcohol committed suicide on weekends (Friday–Sunday), whereas all the sober and the seven unevaluated subjects showed an even spread over the weekdays (Fig. 1). Six had blood alcohol concentrations exceeding 1.0 g/l. Cannabis was detected in the urine in one case. Six subjects tested positive by screening for licit drugs, all of whom were considered having therapeutic concentrations of the psychoactive drugs concerned. Just over half of the suicides, 26 cases, occurred during the four summer months from May to August. The suicide frequency was highest during the weekends (Fig. 1). The 24 bridges had a combined total length of 8975 m, including the bridge abutments, which yields an annual death rate of 3.5 deaths per 10 km. The railings of the bridges varied but none of these bridges were built to deter a person from jumping. All 18 people from Gothenburg and Bohuslän jumped off bridges with a drop of more than 20 m. All of these died from traumatic injuries while drowning was a contributing cause of death in five cases. Out of the 32 people from the northern sample, 15 jumped from bridges lower than 10 m, two from bridges between 10 and 19 m and 12 from bridges more than 20 m high. Drowning was stated as
Fig. 1. Number of suicides by weekday and alcohol inebriation.
P. Lindqvist et al. / Accident Analysis and Prevention 36 (2004) 691–694
the underlying cause of death in 23 cases while the remaining nine cases died from traumatic injuries. Three bridges, in the vicinity of, or in major cities, accounted for almost half of all suicides; Alnöbron (n = 8), Älvsborgsbron (n = 8) and Angeredsbron (n = 5). Twenty-seven subjects resided within a distance of 20 km from the bridge that they jumped from. In three other cases, the bridge was situated close to a psychiatric hospital where the suicidee was admitted.
5. Discussion In a total stretch of less than 9 km bridge roadway, 50 people committed suicide during a 15 year period. This represents minimum figures, since it is possible that actual suicides are classified as accidents or as undetermined manner of death. Three bridges attracted considerably more victims than the others. As in other studies (Nowers and Gunnell, 1996; Rosen, 1975; Shah and Ganesvaran, 1999), many of the suicide victims had their residence in the vicinity of the bridge, or were inpatients in a psychiatric clinic close-by. Most of the suicidees were in the active working age with a high degree of psychiatric morbidity. A number of studies have found that preference of suicide method is dependent of the mental health profile (de Moore and Robertson, 1999; Kreitman, 1976; Fischer et al., 1993; Prasad and Lloyd, 1983), and this study reinforces the conclusions that people who prefer to commit suicide by jumping from bridges are more severely mentally disordered than other suicidees (Cantor et al., 1989; Coman et al., 2000; de Moore and Robertson, 1999; Gunnell and Nowers, 1997). The results of this study adhere to other studies reporting that certain bridges are more attractive to leap from than others, e.g. Golden Gate Bridge in San Francisco, California (Rosen, 1975); Bosphorus Bridge in Istanbul, Turkey (Cetin et al., 2001); and The Gateway Bridge in Brisbane, Australia (Cantor et al., 1989). Further, jumping from well-known sites such as Mt. Mihara, Eiffel Tower, Sidney Harbour Bridge, and Empire State Building, has become less frequent or ceased following the installation of fences (Nowers and Gunnell, 1996. A salient feature emerging from the research into the dynamics, and reversibility, of suicidal process are the reports that demonstrate that most of those who are prevented from (Nowers and Gunnell, 1996) or survive suicide attempts by leaping from bridges (Gunnell and Nowers, 1997), do not commit suicide later. Although jumping from heights, regardless of landing surface, probably is considered by many laymen to result in certain death, the presence of open water seems to be of personal significance in the suicide plan; few jumps were made in the winter period when the water always freezes in the northern part of Sweden and occasionally in the southern parts of Sweden. This finding is in line with a report from the high Westgate Bridge in Melbourne where most people
693
jumped from a small section crossing the river rather than the longer sections crossing land (Cantor and Hill, 1990). The peak of alcohol-related suicides during weekends suggests that some of these suicides could be an act of impulse. Thus, the facts presented above indicate that the physical appeal of a bridge may be of importance in suicide prevention. High bridge parapets and other arrangements, which make it more difficult to jump, give a suicidal person extra time to re-consider the suicide plan, to seek or receive help or to completely abandon the idea. Furthermore, such obstructions may give any passers-by a chance to intervene. High fences also prevent individuals under the influence of alcohol from walking on bridge railings and “accidentally” falling or deliberately jumping. These few kilometers of roadway were proven to be high-risk stretches and the owners of the road system should take this fact into account in the injury preventing road safety work. We suggest that priority is given to bridges situated in built-up areas or close to psychiatric hospitals.
References Allgulander, C., Allebeck, P., Przybeck, T.R., Rice, J.P., 1992. Risk of suicide by psychiatric diagnosis in Stockholm County. A longitudinal study of 80,970 psychiatric inpatients. Eur. Arch. Psychiatry Clin. Neurosci. 241, 323–326. Cantor, C.H., Hill, M.A., 1990. Suicide from river bridges. Aust. N. Z. J. Psychiatry 24, 377–380. Cantor, C.H., Hill, M.A., McLachlan, E.K., 1989. Suicide and related behaviour from river bridges. A clinical perspective. Br. J. Psychiatry 155, 829–835. Cetin, G., Günay, Y., Fincanci, S.K., Kolusayin, R.Ö., 2001. Suicides by jumping from Bosphorus Bridge in Istanbul. Forensic Sci. Int. 116, 157–162. Coman, M., Meyer, A.D.M., Cameron, P.A., 2000. Jumping from the Westgate Bridge, Melbourne. Med. J. Aust. 172, 67–69. Cullberg, J., Wasserman, D., Stefansson, C.G., 1988. Who commits suicide after a suicide attempt? An 8 to 10 year follow up in a suburban catchment area. Acta Psychiatr. Scand. 77, 598–603. de Moore, G.M., Robertson, A.R., 1999. Suicide attempts by firearms and by leaping from heights: a comparative study of survivors. Am. J. Psychiatry 156, 1425–1431. Fischer, E.P., Comstock, G.W., Monk, M.A., Sencer, D.J., 1993. Characteristics of completed suicides: implications of differences among methods. Suicide Life Threat. Behav. 23, 91–100. Geddes, J., 1999. Suicide and homicide by people with mental illness. We still don’t know how to prevent most of these deaths. Br. Med. J. 318, 1225–1226. Gunnell, D., Nowers, M., 1997. Suicide by jumping. Acta Psychiatr. Scand. 96, 1–6. Haddon, W., 1980. Options for the prevention of motor vehicle crash injury. Isr. J. Med. Sci. 16, 45–65. Harris, E.C., Barraclough, B., 1997. Suicide as an outcome for mental disorders. A meta-analysis. Br. J. Psychiatry 170, 205–228. Hawton, K., Fagg, J., Simkin, S., Harriss, L., Malmberg, A., 1998. Methods used for suicide by farmers in England and Wales. The contribution of availability and its relevance to prevention. Br. J. Psychiatry 173, 320–324. Joukamaa, M., Heliövaara, M., Knekt, P., Aromaa, A., Raitasalo, R., Lehtinen, V., 2001. Mental disorders and cause-specific mortality. Br. J. Psychiatry 179, 498–502.
694
P. Lindqvist et al. / Accident Analysis and Prevention 36 (2004) 691–694
Kreitman, N., 1976. The coal gas story. United Kingdom suicide rates, 1960-71. Br. J. Prev. Soc. Med. 30, 86–93. Nowers, M., Gunnell, D., 1996. Suicide from the Clifton Suspension Bridge in England. J. Epidemiol. Community Health 50, 30–32. O’Carroll, P.W., Silverman, M.M., Berman, A.L., 1994. Community suicide prevention: the effectiveness of bridge barriers. Suicide Life Threat. Behav. 24, 89–99. Öström, M., Ahlm, K., Eriksson, A., 2001. Bristfällig handläggning av onaturliga dödsfall. Läkartidningen 98, 955–959. Prasad, A., Lloyd, G.G., 1983. Attempted suicide by jumping. Acta Psychiatr. Scand. 68, 394–396. Rosen, D.H., 1975. Suicide survivors: a follow-up study of persons who survived jumping from the Golden Gate and San Francisco–Oakland Bay Bridges. West. J. Med. 122, 289–294.
Seiden, R.H., 1978. Where are they now? A follow-up study of suicide attempters from the Golden Gate Bridge. Suicide Life Threat. Behav. 8, 203–216. Shah, A., Ganesvaran, T., 1999. Suicide among psychiatric in-patients with schizophrenia in an Australian mental hospital. Med. Sci. Law 39, 251–259. Sonneck, G., Etzersdorfer, E., Nagel-Kuess, S., 1994. Imitative suicide on the Viennese subway. Soc. Sci. Med. 38, 453–457. Statistical Yearbook of Sweden, 2002. Official Statistics of Sweden. Statistics Sweden, Stockholm. WHO. International Classification of Diseases 1977. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, 9th rev. Geneva.
Short communication
Are suicides by jumping off bridges preventable? An analysis of 50 cases from Sweden Per Lindqvist a,∗ , Anders Jonsson b , Anders Eriksson a , Annika Hedelin b , Ulf Björnstig b b
a Section of Forensic Medicine, Department of Community Medicine and Rehabilitation, Umeå University, Umeå SE-907 12, Sweden The Umeå Accident Analysis Group, Department of Surgery and Perioperative Sciences, Surgery, Umeå University, Umeå SE-901 85, Sweden
Received 13 November 2002; received in revised form 4 June 2003; accepted 23 June 2003
Abstract This is a community-based sequential case series of 50 individuals who committed suicide by jumping from bridges in two regions of Sweden. Of the 50 subjects, 32 were men and 18 women, with a median age of 35 years. At least 40 had psychiatric problems. The frequency of suicide was highest during the summer months and during the weekends. A total of 27 bridges were used, with a total length of just under 9 km. Three bridges accounted for almost half of all suicides. Limiting the availability of one method of committing suicide is reported to reduce the overall suicide rate; why suicide and injury suicide preventive measures might be considered. Since this study demonstrates that few bridges attract suicide candidates, this injury mechanism needs to be acknowledged by the road system owners and included in the safety work. © 2003 Elsevier Ltd. All rights reserved. Keywords: Suicide; Manner of death; Mental disorders; Substance-related disorders; Alcohol drinking; Preventive measures
1. Background During the 1990s between 1200 and 1500 individuals committed suicide each year in Sweden (Statistical Yearbook of Sweden, 2002). Individuals who die after jumping from a bridge are not presented separately in the official statistics. However, jumping from a height constitutes approximately 4% of all suicides in Sweden (Statistical Yearbook of Sweden, 2002), England and Wales (Gunnell and Nowers, 1997). The main focus in Swedish suicide research and prevention is on the identification of high-risk groups. However, this strategy is limited by the low predictive value when applied to individuals (Geddes, 1999). Most people with mental disorders (Allgulander et al., 1992; Harris and Barraclough, 1997; Joukamaa et al., 2001) and persons who have attempted suicide (Cullberg et al., 1988; Harris and Barraclough, 1997) or even suicide attempts by jumping from bridges (Seiden, 1978) do not eventually commit suicide. Yet individual suicide risk assessment and management by the health professionals is indispensable, although ∗ Corresponding author. Present address: Section for Emergency Treatment, Stockholm Dependency Center, S:t Görans Hospital, Plan 12, Stockholm SE-112 81, Sweden. Tel.: +46-9-010-0701; fax: +46-8-672-4921. E-mail address: [email protected] (P. Lindqvist).
0001-4575/$ – see front matter © 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0001-4575(03)00089-7
the number of persons who are out of reach for medical intervention is considerable. Thus, there is a need to consider general preventive strategies in suicide prevention by applying what could be termed an injury control model (Haddon, 1980), e.g. barriers on high buildings. However, such actions are meaningful only if a reduction in the number of suicides at specific places is not counteracted by an increase at other places or by an increase in other suicide methods. A number of European and Australian studies have reported on the positive association between interventions that limit the access to or decrease the attraction of a specific suicide method and a reduced overall suicide rate (Hawton et al., 1998; Kreitman, 1976; Sonneck et al., 1994). The methodological problems of establishing the overall effects of suicide proofing have been discussed by O’Carroll et al. (1994). They used as an example a bridge in Washington, DC, USA, attracting many suicidees, which prompted the construction of a barrier, resulting in a dramatic drop in the number of suicides. 2. Aims With this study, we wanted to (i) describe the characteristics of individuals who commit suicide by jumping from a bridge;
692
P. Lindqvist et al. / Accident Analysis and Prevention 36 (2004) 691–694
(ii) examine where and when this happens; and (iii) consider the feasibility of prevention by building barriers at high-risk stretches/places.
3. Material and methods The material comprises all 50 registered cases of suicide by jumping from bridges from 1983 to 1997 in two regions of Sweden; an urban and rural southwestern area with a population of 770,000 inhabitants (including the city of Gothenburg and the county of Bohuslän) and a rural region comprising 900,000 inhabitants of the four northernmost counties of Sweden. The cases were identified by a manual and computerized search of all death certificates issued at the Departments of Forensic Medicine in Umeå and Gothenburg, respectively. We included all certified cases of suicide by jumping off a bridge crossing water, a road or a railroad among cases assigned the external causes of death E954 (suicide by drowning) or E957 (suicide by jumping from height) according to ICD-9 (WHO, 1977). The autopsy rate in Sweden for these types of suicide is close to 100% (Öström et al., 2001). Autopsy protocols, police records, and, when available, medical records, were analyzed. Eye witnesses verified the circumstances in 22 of the 50 cases. Information from the Swedish National Road Administration about the design of the 27 bridges in question was available in 24 instances. There are innumerable bridges crossing water in the study areas.
4. Results Thirty-two victims (64%) were men and 18 (36%) were women. Their ages varied between 16 and 83 years with median and mean ages of 35 and 40 years, respectively. The average incidence was 0.2 per 100,000 inhabitants per year.
At least 32 of the 50 individuals had been treated in a psychiatric clinic and in an additional eight cases, information suggestive of mental health problems was retrieved through the police investigations. At the time of the suicide, at least 17 people were receiving psychiatric care. Of these, eight were patients in psychiatric wards and committed suicide while on leave (n = 6) or after absconding (n = 2). Twenty individuals had a diagnosis of depression, 10 of which were of a psychotic nature. At least nine were diagnosed as substance abusers. Nineteen people had previously attempted suicide and seven had left a suicide note. Fourteen individuals (12 males) tested positive for alcohol in the blood. No alcohol was detected in 29 cases and in six cases, the presence of alcohol could not be evaluated due to extensive decomposition. Eleven of the 14 who were under the influence of alcohol committed suicide on weekends (Friday–Sunday), whereas all the sober and the seven unevaluated subjects showed an even spread over the weekdays (Fig. 1). Six had blood alcohol concentrations exceeding 1.0 g/l. Cannabis was detected in the urine in one case. Six subjects tested positive by screening for licit drugs, all of whom were considered having therapeutic concentrations of the psychoactive drugs concerned. Just over half of the suicides, 26 cases, occurred during the four summer months from May to August. The suicide frequency was highest during the weekends (Fig. 1). The 24 bridges had a combined total length of 8975 m, including the bridge abutments, which yields an annual death rate of 3.5 deaths per 10 km. The railings of the bridges varied but none of these bridges were built to deter a person from jumping. All 18 people from Gothenburg and Bohuslän jumped off bridges with a drop of more than 20 m. All of these died from traumatic injuries while drowning was a contributing cause of death in five cases. Out of the 32 people from the northern sample, 15 jumped from bridges lower than 10 m, two from bridges between 10 and 19 m and 12 from bridges more than 20 m high. Drowning was stated as
Fig. 1. Number of suicides by weekday and alcohol inebriation.
P. Lindqvist et al. / Accident Analysis and Prevention 36 (2004) 691–694
the underlying cause of death in 23 cases while the remaining nine cases died from traumatic injuries. Three bridges, in the vicinity of, or in major cities, accounted for almost half of all suicides; Alnöbron (n = 8), Älvsborgsbron (n = 8) and Angeredsbron (n = 5). Twenty-seven subjects resided within a distance of 20 km from the bridge that they jumped from. In three other cases, the bridge was situated close to a psychiatric hospital where the suicidee was admitted.
5. Discussion In a total stretch of less than 9 km bridge roadway, 50 people committed suicide during a 15 year period. This represents minimum figures, since it is possible that actual suicides are classified as accidents or as undetermined manner of death. Three bridges attracted considerably more victims than the others. As in other studies (Nowers and Gunnell, 1996; Rosen, 1975; Shah and Ganesvaran, 1999), many of the suicide victims had their residence in the vicinity of the bridge, or were inpatients in a psychiatric clinic close-by. Most of the suicidees were in the active working age with a high degree of psychiatric morbidity. A number of studies have found that preference of suicide method is dependent of the mental health profile (de Moore and Robertson, 1999; Kreitman, 1976; Fischer et al., 1993; Prasad and Lloyd, 1983), and this study reinforces the conclusions that people who prefer to commit suicide by jumping from bridges are more severely mentally disordered than other suicidees (Cantor et al., 1989; Coman et al., 2000; de Moore and Robertson, 1999; Gunnell and Nowers, 1997). The results of this study adhere to other studies reporting that certain bridges are more attractive to leap from than others, e.g. Golden Gate Bridge in San Francisco, California (Rosen, 1975); Bosphorus Bridge in Istanbul, Turkey (Cetin et al., 2001); and The Gateway Bridge in Brisbane, Australia (Cantor et al., 1989). Further, jumping from well-known sites such as Mt. Mihara, Eiffel Tower, Sidney Harbour Bridge, and Empire State Building, has become less frequent or ceased following the installation of fences (Nowers and Gunnell, 1996. A salient feature emerging from the research into the dynamics, and reversibility, of suicidal process are the reports that demonstrate that most of those who are prevented from (Nowers and Gunnell, 1996) or survive suicide attempts by leaping from bridges (Gunnell and Nowers, 1997), do not commit suicide later. Although jumping from heights, regardless of landing surface, probably is considered by many laymen to result in certain death, the presence of open water seems to be of personal significance in the suicide plan; few jumps were made in the winter period when the water always freezes in the northern part of Sweden and occasionally in the southern parts of Sweden. This finding is in line with a report from the high Westgate Bridge in Melbourne where most people
693
jumped from a small section crossing the river rather than the longer sections crossing land (Cantor and Hill, 1990). The peak of alcohol-related suicides during weekends suggests that some of these suicides could be an act of impulse. Thus, the facts presented above indicate that the physical appeal of a bridge may be of importance in suicide prevention. High bridge parapets and other arrangements, which make it more difficult to jump, give a suicidal person extra time to re-consider the suicide plan, to seek or receive help or to completely abandon the idea. Furthermore, such obstructions may give any passers-by a chance to intervene. High fences also prevent individuals under the influence of alcohol from walking on bridge railings and “accidentally” falling or deliberately jumping. These few kilometers of roadway were proven to be high-risk stretches and the owners of the road system should take this fact into account in the injury preventing road safety work. We suggest that priority is given to bridges situated in built-up areas or close to psychiatric hospitals.
References Allgulander, C., Allebeck, P., Przybeck, T.R., Rice, J.P., 1992. Risk of suicide by psychiatric diagnosis in Stockholm County. A longitudinal study of 80,970 psychiatric inpatients. Eur. Arch. Psychiatry Clin. Neurosci. 241, 323–326. Cantor, C.H., Hill, M.A., 1990. Suicide from river bridges. Aust. N. Z. J. Psychiatry 24, 377–380. Cantor, C.H., Hill, M.A., McLachlan, E.K., 1989. Suicide and related behaviour from river bridges. A clinical perspective. Br. J. Psychiatry 155, 829–835. Cetin, G., Günay, Y., Fincanci, S.K., Kolusayin, R.Ö., 2001. Suicides by jumping from Bosphorus Bridge in Istanbul. Forensic Sci. Int. 116, 157–162. Coman, M., Meyer, A.D.M., Cameron, P.A., 2000. Jumping from the Westgate Bridge, Melbourne. Med. J. Aust. 172, 67–69. Cullberg, J., Wasserman, D., Stefansson, C.G., 1988. Who commits suicide after a suicide attempt? An 8 to 10 year follow up in a suburban catchment area. Acta Psychiatr. Scand. 77, 598–603. de Moore, G.M., Robertson, A.R., 1999. Suicide attempts by firearms and by leaping from heights: a comparative study of survivors. Am. J. Psychiatry 156, 1425–1431. Fischer, E.P., Comstock, G.W., Monk, M.A., Sencer, D.J., 1993. Characteristics of completed suicides: implications of differences among methods. Suicide Life Threat. Behav. 23, 91–100. Geddes, J., 1999. Suicide and homicide by people with mental illness. We still don’t know how to prevent most of these deaths. Br. Med. J. 318, 1225–1226. Gunnell, D., Nowers, M., 1997. Suicide by jumping. Acta Psychiatr. Scand. 96, 1–6. Haddon, W., 1980. Options for the prevention of motor vehicle crash injury. Isr. J. Med. Sci. 16, 45–65. Harris, E.C., Barraclough, B., 1997. Suicide as an outcome for mental disorders. A meta-analysis. Br. J. Psychiatry 170, 205–228. Hawton, K., Fagg, J., Simkin, S., Harriss, L., Malmberg, A., 1998. Methods used for suicide by farmers in England and Wales. The contribution of availability and its relevance to prevention. Br. J. Psychiatry 173, 320–324. Joukamaa, M., Heliövaara, M., Knekt, P., Aromaa, A., Raitasalo, R., Lehtinen, V., 2001. Mental disorders and cause-specific mortality. Br. J. Psychiatry 179, 498–502.
694
P. Lindqvist et al. / Accident Analysis and Prevention 36 (2004) 691–694
Kreitman, N., 1976. The coal gas story. United Kingdom suicide rates, 1960-71. Br. J. Prev. Soc. Med. 30, 86–93. Nowers, M., Gunnell, D., 1996. Suicide from the Clifton Suspension Bridge in England. J. Epidemiol. Community Health 50, 30–32. O’Carroll, P.W., Silverman, M.M., Berman, A.L., 1994. Community suicide prevention: the effectiveness of bridge barriers. Suicide Life Threat. Behav. 24, 89–99. Öström, M., Ahlm, K., Eriksson, A., 2001. Bristfällig handläggning av onaturliga dödsfall. Läkartidningen 98, 955–959. Prasad, A., Lloyd, G.G., 1983. Attempted suicide by jumping. Acta Psychiatr. Scand. 68, 394–396. Rosen, D.H., 1975. Suicide survivors: a follow-up study of persons who survived jumping from the Golden Gate and San Francisco–Oakland Bay Bridges. West. J. Med. 122, 289–294.
Seiden, R.H., 1978. Where are they now? A follow-up study of suicide attempters from the Golden Gate Bridge. Suicide Life Threat. Behav. 8, 203–216. Shah, A., Ganesvaran, T., 1999. Suicide among psychiatric in-patients with schizophrenia in an Australian mental hospital. Med. Sci. Law 39, 251–259. Sonneck, G., Etzersdorfer, E., Nagel-Kuess, S., 1994. Imitative suicide on the Viennese subway. Soc. Sci. Med. 38, 453–457. Statistical Yearbook of Sweden, 2002. Official Statistics of Sweden. Statistics Sweden, Stockholm. WHO. International Classification of Diseases 1977. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, 9th rev. Geneva.