Classifying undetermined poisoning deaths
A E Donaldson, G Y Larsen, L Fullerton-Gleason, L M Olson
............................................................... ............................................................... .
See end of article for
Ms A E Donaldson,
Control Research Center,
Department of Pediatrics,
University of Utah School
of Medicine, PO Box
581289, Salt Lake City, UT
84158-0289, USA; amy.
Accepted 8 May 2006
Injury Prevention 2006;12:338–343. doi: 10.1136/ip.2005.011171
Objective: To classify poisoning deaths of undetermined intent as either suicide or unintentional and to
estimate the extent of underreported poisoning suicides.
Methods: Based on 2002 statewide death certificate and medical examiner data in Utah, the authors
randomly selected one half of undetermined and unintentional poisoning deaths for data abstraction and
included all suicides. Bivariate analyses assessed differences in demographics, death characteristics,
forensic toxicology results, mental health history, and other potentially contributing factors. Classification
and regression tree (CART) analysis used information from unintentional and suicide poisoning deaths to
create a classification tree that was applied to undetermined poisoning deaths.
Results: The authors analyzed 41 unintentional, 87 suicide, and 84 undetermined poisonings.
Undetermined and unintentional decedents were similar in the presence of opiates, physical health
problems, and drug abuse. Although none of the undetermined decedents left a suicide note, previous
attempt or intent to commit suicide was reported for 11 (13%) of these cases. CART analysis identified
suicidal behavior, drug abuse, physical health problems, depressed mood, and age as discriminating
between suicide and unintentional poisoning. It is estimated that suicide rates related to poisoning are
underreported by approximately 30% and overall suicide rates by 10%. Unintentional poisoning death
rates were underreported by 61%.
Conclusions: This study suggests that manner of death determination relies on circumstance dependent
variables that may not be consistently captured by medical examiners. Underreporting of suicide rates has
important implications in policy development, research funding, and evaluation of prevention programs.
proportion of deaths for which intent cannot be determined
(referred to as ‘‘undetermined deaths’’) are in fact self-
inflicted (suicide). Several studies have shown that a
proportion of undetermined deaths are likely unreported
suicides, and suggest that reported suicide rates under-
estimate the true rate by 10–30%.1 3–7Determination of intent
is especially difficult in the case of ingested poisoning
deaths.3 5 8–10Poisoning deaths account for over two thirds
of all undetermined deaths nationally.11
According to 2002 National Vital Record data, Utah has the
fourth highest rate of undetermined deaths (7.3 per 100 000
person-years), over four times the national rate.11Nearly all
(95%) of undetermined deaths in Utah are the result of
poisoning. The objective of this study was to classify
poisoning deaths of undetermined intent as either suicide
or unintentional and to estimate the extent of underreported
suicides from poisoning. As a related objective, we sought to
characterize undetermined poisoning deaths in Utah and
descriptively compare them to suicide and unintentional
fficial suicide rates are used to monitor trends,
compare suicide rates across regions, and assess risk
factors.1 2However, these statistics are not valid if any
The National Violent Death Reporting System (NVDRS) was
developed by the Centers for Disease Control and Prevention
and launched in 2003 to collect and analyze data from
violence related deaths.12The Harvard School of Public Health
and collaborating institutions in 11 states and metropolitan
areas launched the pilot study for this program in 2000, the
National Violent Injury Statistics System (NVISS).13As part
of Utah’s participation in NVISS, we abstracted data for all
poisoning deaths certified as suicide in Utah during 2002
(n=87). We then randomly selected approximately one half
of the 85 unintentional and 168 undetermined poisoning
deaths occurring in 2002 for data abstraction and inclusion in
the study. Poisoning deaths of all intents were identified
based on International Classification of Disease (10th
Revision) codes reported in Utah death certificate data. The
ranges used were as follows: suicide poisoning, X60 to X69;
unintentional poisoning, X40 to X49; and undetermined
poisoning, Y10 to Y19. All unintentional and undetermined
death records were abstracted in the same manner as suicide
records using standard NVISS definitions and methods.
Death certificates provided decedents’ demographic data.
Medical examiner reports provided more detailed informa-
tion on circumstances, toxicology, and mental health history.
Because Utah has a centralized medical examiner system,
these reports were easily accessed from a central location for
death investigations occurring anywhere in the state.
The NVISS data collection form was designed to capture
data for violence related deaths based primarily on informa-
tion from toxicology reports, narratives, and other evidence
collected through the medical examiner or coroner’s inves-
tigation. Abstractors were trained using standard forms and
definitions. Toxicology reports provided data on drugs tested.
Information on mental health history and potentially
contributing circumstances were captured through the
medical examiner’s narrative. These narratives are unstruc-
tured and rarely include information regarding circumstances
not present—for example, if the investigation determined
that the decedent had no known history of mental health
problems. As a result, circumstances were coded as present or
This study was approved by the University of Utah
Institutional Review Board in Salt Lake City, Utah.
Abbreviations: CART, classification and regression tree; NVDRS,
National Violent Death Reporting System; NVISS, National Violent Injury
As described above, manner or intent of death was classified
as either suicide (self-inflicted), unintentional, or undeter-
mined. For convenience, we refer to decedents who died from
self-inflicted poisoning as suicide decedents, those who died
from unintentional poisoning as unintentional decedents, and
those who died from poisoning of undetermined intent as
The variables included in the analysis were: age, sex, race,
employed, injury occurred at residence, any medical contact
in the interval between administration of the poison and
death (emergency medical services, emergency department,
or inpatient admission), primary poisoning agent(s) resulting
in death, the presence or absence (based on toxicology
results) of alcohol, antidepressants, street drugs (cocaine,
amphetamines, and marijuana), opiates, and other drugs,
depressed mood at the time of the incident, any mental
health problem or diagnosis, mental health treatment
(current or past), alcohol or other substance abuse problem,
alcohol or drug abuse treatment, suicidal behavior (consid-
ered positive if decedent left a suicide note, declared intent to
commit suicide, or had previously attempted suicide), same
day or recent crisis in decedent’s life, physical health problem,
and the presence of one or more other contributing factors.
Examining the presence of a suicide note separately from
declared intent or previous attempt to commit suicide did not
add to the analysis, and these behaviors were combined.
Counts and percentages were tabulated by medical exam-
iner’s assessment of intent for demographic information,
circumstances related to the death, forensic toxicology
results, mental health and drug abuse history, and other
potentially contributing factors. We used x2tests to assess
differences in categorical variables and analysis of variance to
assess differences in mean age. The primary poisoning agent
was only summarized descriptively due to small sample sizes
across groups and was classified as pharmacy prescription
versus other for the classification tree analysis. Drugs tested
were reported as present, not present, or not tested. Mental
health history and potentially contributing circumstances
were classified as either present or not present/unknown.
Classification and regression tree (CART) analysis used the
available information to create a classification rule, or
decision tree, to determine whether a poisoning death was
unintentional or suicide. In this method, predictor variables
are partitioned recursively into the two subgroups that are
most different with respect to the outcome.14The final result
is a decision tree that accurately classifies as many cases as
possible without overfitting the data. When the goal is to
correctly classify an outcome, CART is preferable to tradi-
tional statistical methods, such as logistic regression, because
it deals well with a large number of predictor variables,
allows missing data, and requires no assumptions regarding
the underlying distribution of the predictor variables.14 15Our
primary reasons for using CART were to identify key
predictors in determining intent of death and to obtain an
estimate of the number of undetermined deaths that could be
classified as suicide. Due to a limited sample size, our
application of this technique was not intended to provide a
decision rule that can be widely applied to other datasets.
We applied CART analysis to all cases for which the intent
of poisoning was known (unintentional and suicide). We
Demographic and death characteristics of poisoning decedents by intent in
Unintentional (n=41)Suicide (n=87)Undetermined (n=84)
Age 41 years
Injured at residence
*Sample size reduced to n=211 due to missing information.
?Sample size reduced to n=210 due to missing information.
`Defined as any medical contact in the interval between administration of the poison and death (emergency
medical services, emergency department, or inpatient admission).
1Reflects analysis of variance for age and x2test for all other variables.
Primary poisoning agent(s) by intent of death in Utah, 2002 (up to two identified
Primary poisoning agent
Unintentional (n=41)Suicide (n=87)Undetermined (n=84)
Pharmacy—over the counter
Carbon monoxide or other gas
Other poison or unspecified
Undetermined poisoning deaths339
then applied the resulting classification algorithm to the
undetermined poisoning deaths. Because our sample size was
method—random forests—to evaluate the stability of the
CART results. This method is an extension of CART that
provides accurate and robust classification of an outcome.16 17
Descriptive and bivariate analyses were conducted in SAS
version 9 (SAS Institute Inc, NC, USA). CART and random
forests analyses were conducted in R version 2.1.
There were 41 unintentional injury poisonings, 87 suicide
poisonings, and 84 undetermined poisonings included in this
study. Table 1 presents the demographic characteristics and
table 2 provides information on the primary poisoning
agent(s) used. The average age among decedents whose
deaths were coded as undetermined was 38 years, slightly
younger than both the unintentional and suicide decedents.
Undetermined and unintentional decedents were also more
likely than suicide decedents to be male. Medical contact
subsequent to poisoning and before death was less likely for
suicide decedents than for others. General poisoning char-
acteristics were similar for all three groups, with over three
fourths of all deaths occurring at the decedents’ homes, and
most deaths involving prescription medications. However,
the poisoning agent for non-prescription poisoning deaths
was primarily illicit drugs for unintentional and undeter-
mined deaths and primarily carbon monoxide for suicides.
Table 3 presents a summary of substances tested for and
identified in toxicological testing after death. This includes,
but is not limited to, drugs and other substances directly
involved in the death. Opiates were found in 83% of tested
cases for both unintentional and undetermined cases
compared to only 50% of suicide cases. The presence of other
drugs (for example, diazepam, acetaminophen, cyanide) was
highest for suicide cases, and suicide cases had a relatively
low percentage of street drugs.
Table 4 summarizes the prevalence of factors related to
alcohol and drug use, mental and physical health, and
personal difficulties such as job loss or relationship problems.
Undetermined decedents had the highest percentage of
reported current or past mental health treatment. While
none of the undetermined decedents left a suicide note,
suicidal behavior (previous attempt or intent to commit
suicide) was reported for 11 (13%) of these cases. The
undetermined decedents were similar to unintentional
decedents with respect to recent crisis, physical health
problems, and alcohol or drug abuse problems. Of the three
groups, suicide decedents were the most likely to be reported
as depressed at the time of incident and the most likely to
have a diagnosis of mental illness.
The results of the CART analysis are presented in figure 1.
Each split of the tree represents a decision point for
classifying a poisoning death record as unintentional or
suicide. Using this analytic technique, suicidal behavior was
identified as the single most important discriminating factor
between unintentional and self-inflicted poisonings.
To interpret the tree, follow each decision point to a
terminal node where the classification of suicide or uninten-
tional death is given. For example, a poisoning death with no
history of alcohol or drug abuse and no physical health
problems would be classified as suicide. As another example,
if an alcohol or drug problem was identified, and there was
no indication of a depressed mood at the time of the incident,
then the record was classified as unintentional.
poisoning deaths in Utah, 2002
Substances tested and present by intent in forensic toxicological testing following
Unintentional (n=41)Suicide (n=87)Undetermined (n=84)
*Reflects x2test for association between each variable and intent of death.
?Street drugs refers here to cocaine, amphetamines, and/or marijuana.
poisoning deaths in Utah, 2002
Mental health history and potentially contributing factors by intent among
Unintentional (n=41) Suicide (n=87)Undetermined (n=84)
Any mental diagnosis
Mental health treatment 21
*Suicidal behavior was considered positive if the decedent left a suicide note, declared intent to commit suicide, or
had previously attempted suicide.
?Factors included are relationship problems, job, school, and financial problems, recent suicide or death of a
friend or family member, criminal or legal problems, perpetrator or victim of interpersonal violence, and other
circumstances potentially related to the death.
`Reflects x2test for association between each variable and intent of death.
340 Donaldson, Larsen, Fullerton-Gleason, et al
The tree misclassified four of the 128 unintentional and
suicidal poisonings resulting in an apparent misclassification
rate of 3%. No data were available to obtain a true
misclassification rate which would be calculated by applying
this decision tree to a new dataset with the same variables
and known classification.
When applied to undetermined poisoning deaths, 18 of the
84 deaths (21%) were classified as suicides. The majority of
these (n=11) received this classification based on the
presence of suicidal behaviors. The remainder of undeter-
mined poisoning deaths (n=66) were classified as uninten-
tional. If we apply this result to all undetermined poisoning
deaths reported for 2002 (n=168), a total of 36 would be
classified as suicide. Thus, according to this model, the
poisoning suicide rate in Utah for 2002 is underestimated by
29% (36/(87+36)). There were 342 suicides from all causes in
2002, resulting in an overall underreporting due to unde-
termined poisoning suicides of just under 10% (36/(342+36)).
The underreporting for unintentional poisoning deaths is
estimated at 61% (132/(85+132)).
Similar to the CART analysis, our random forests analysis
identified suicidal behavior, depressed mood, physical health,
alcohol/drug problems, and age as key predictors of intent of
death. In addition, the primary poisoning agent (pharmacy
prescription v other) was also highlighted as a key predictor.
The percentage of undetermined poisoning deaths classified
as suicide using the random forests technique was 13%,
slightly lower than the 21% from our CART analysis.
Suicide is a complex phenomenon which often evokes strong
opinions in individuals and communities regarding philoso-
phical, cultural, religious, social, and medico-legal issues.1 2
Without explicit evidence of suicidal intent, these pressures
may decrease the likelihood that a death is certified as a
suicide. While there has been substantial debate over what
portion of undetermined deaths may be attributable to
suicide, there is general agreement that at least some
undetermined deaths are suicides.1 3–6 18 19Poisoning deaths
are particularly difficult to classify by intent. Similar to other
studies,9 20our study showed that most undetermined
poisoning decedents have alcohol or drug abuse problems,
test positive for opiates, and have physical health problems.
These characteristics mirror unintentional poisoning deaths
in many ways and may only be distinguished by anecdotal
information or circumstances that suggest suicidal intent.3 20
For example, we found that depression and suicidal
behaviors, known risk factors for suicide, were more
prevalent in undetermined than unintentional poisoning
cases. Assigning intent is further complicated because many
drug users demonstrate an ambivalence or reckless disregard
for life that can be difficult to distinguish from suicidal
intent, especially if other circumstances, such as relationship
problems or recent death of a loved one, are present.20 21
Another obstacle to correctly assessing intent is the lack of
routine forensic toxicological examination, physical evidence,
and circumstantial data collected by medical examiners and
others who investigate poisoning deaths. Most medical
examiners and coroners agree on the fundamental premise
that manner of death (intent) is circumstance dependent, not
autopsy dependent.22However, risk factors for suicide such as
depression and precipitating circumstances in the decedent’s
life may not be consistently known or reported. Studies have
advocated for standardized guidelines for death investigation
deaths.10 20 23Standardized data collection forms that facil-
itate consistent and detailed medico-legal investigation into
poisoning deaths of all intents would not only strengthen
research regarding suicide and undetermined deaths, but also
improve understanding of the self-destructive or risk taking
behaviors that play a role in many unintentional poisoning
Many studies of suicide treat all undetermined deaths as
suicide; others exclude this group entirely. Both approaches
are flawed and miscount the number and possibly the nature
of suicide.2 24Our classification tree analysis showed that one
in five undetermined poisoning deaths is likely self-inflicted,
underestimating the poisoning suicide rate by approximately
30%, and the overall suicide rate by 10%. These findings have
implications for surveillance efforts which aid in health
planning and are used to track trends in rates, identify new
problems, and assess the impact of interventions. Although
not the primary focus of this manuscript, our results show an
even greater degree of underreporting for unintentional
Efforts to address surveillance issues must account for
regional differences in suicide and undetermined death rates.
These rates are affected by variations in legal requirements
1+ count of factors
Age > 47 years
Physical health problem
(suicide v unintentional) based on CART
analysis. Note: this figure highlights
suicidal behavior, alcohol or drug
abuse/dependence, physical health
problems, depression, one or more
contributing factors (see table 4
footnotes), and age .47 years as
discriminating between suicide and
unintentional poisoning. Parenthetical
numbers represent the total cases in
each terminal node for those having
reported manner of death of either
suicide or unintentional (n=128).
Classification of intent
Undetermined poisoning deaths341
and definitions, differences in the extent to which cases are
investigated, and area specific risk factors.1 6 8Because there
are no standardized guidelines for manner of death classifi-
cation, it is difficult to compare manner of death statistics
across states, regions, or even individual medical examiners
and coroners.25Utah, for example, has unique demographic
and cultural influences, a centralized medical examiner
system, and as a general policy certifies all recreational drug
deaths as undetermined unless there is clear evidence for a
more specific manner of death (Todd Grey, MD, Utah Chief
Medical Examiner, personal communication, 2005). Utah is
one of four states (also Maryland, Massachusetts, and Rhode
Island) with an undetermined death rate that is more than
four times the national rate.11As a result, although general
conclusions from this study are likely to extend to other
localities, specific conclusions related to the extent of
underreporting may not be generalizable.
This study has limitations. First, due to funding constraints
we were only able to include a relatively small sample size
over a one year period. Collection of data over multiple years
and inclusion of all cases would allow further investigation
into the study hypothesis. Second, we found that documen-
tation was often unavailable for mental health history and
other factors in the medical examiner record, especially for
unintentional or undetermined poisoning deaths. This makes
it difficult to correctly classify undetermined deaths based on
these characteristics. The differences we observed in circum-
stances by manner of death may represent actual differences
in prevalence, but could also be due to whether or not these
factors were reported. In addition, abstractors were not
blinded to the intent of death assigned by the medical
examiner. This could have resulted in differential capture or
interpretation of information. Finally, our CART analysis
assumes that all suicide and unintentional deaths were
classified correctly by the medical examiner. A systematic
review and reclassification of manner of death by someone
other than the medical examiner was not within the scope of
Overall, our results show that while the characteristics of
undetermined poisonings do have striking similarities to both
unintentional and suicidal poisonings, they are distinct from
either group. It may be these distinct characteristics that
make it difficult for a medical examiner to classify these
deaths as either suicide or unintentional. Using the novel
approach of classification tree analysis, we identified suicidal
behavior, drug abuse, physical health problems, depressed
mood, and age as discriminating between suicide and
unintentional poisoning and estimated that suicides rates
related to poisoning are underreported by approximately 30%
in our state. This underreporting has important implications
in suicide surveillance efforts including policy development,
funding, and evaluation of prevention programs.
We gratefully acknowledge the assistance of Anna Davis, Andrea
Genovesi, and Lee Anne Gabor in abstracting and entering data from
the medical examiner records. We also acknowledge Dr Todd Grey
and Sarah Kay North at the Utah Office of the Medical Examiner for
facilitating the data collection process, and Catherine Barber, Todd
Grey, and Lisa Hyde for their insightful reviews before submission of
A E Donaldson, G Y Larsen, L M Olson, Intermountain Injury Control
Research Center, Department of Pediatrics, University of Utah School of
Medicine, Salt Lake City, UT, USA
L Fullerton-Gleason, Department of Emergency Medicine, University of
New Mexico School of Medicine, Albuquerque, NM, USA
This research was partially supported by Centers for Disease Control and
Prevention grant number U49/CCU915983/06 and a grant from the
Harvard Injury Control Research Center’s National Violent Injury
Statistics System project.
Competing interests: none.
Ethics approval: this study was approved by the University of Utah
Institutional Review Board.
Partially presented at the American Public Health Association’s (APHA)
133rd Annual Meeting, Philadelphia, Pennsylvania, December 2005.
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N Classification tree analysis identified suicidal behavior,
drug abuse, physical health problems, depressed
mood, and age as discriminating between suicide
and unintentional poisoning.
N We estimated that the poisoning suicide rate in Utah is
underreported by approximately 30% and the overall
suicide rate is underreported by 10%.
N Standards that promote consistent and detailed
medico-legal investigation into poisoning deaths of
all intents would strengthen research regarding suicide
and undetermined deaths.
342Donaldson, Larsen, Fullerton-Gleason, et al
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LACUNAE ............................................................... ............................................
Raising awareness about cycle safety
Four University of Toronto Medical Students ‘‘biked off’’ for
the summer to raise awareness about bicycle helmet use.
Alun Ackery, Marieke Gardner, Scott Smith, and Peter
Ceponis spent June and July biking across Canada to raise
awareness about safe cycling, especially the use of bicycle
helmets. They also raised money for ThinkFirst, a national
injury prevention organization. With help from sponsors
including the Insurance Bureau of Canada, TD Bank, and
McDonalds, they have already raised over $20,000 for the
organization and had much attention from local and national
press, radio, and television. They averaged 150 km a day from
Vancouver, British Columbia to St John’s, Newfoundland
encouraging people to keep up with their summer wheeled
activities, but to do it safely by properly wearing their
helmets. These future clinicians strongly believe in the idea of
injury prevention and the benefits that it can reap for our
society. Each year ThinkFirst reports that 100 people die from
bicycle mishaps and 85% of these deaths could be prevented
with the use of a helmet. Suffering a traumatic brain injury
or spinal cord injury can have tremendous emotional and
financial repercussions on the victims and their families. The
average lifelong cost of taking care of someone with one of
these catastrophic injuries is approximately 5–7 million
Canadian dollars. If you would like more information about
their trip, visit http://www.headsacrosscanada.com.
At the top of Signal Hill, St John’s, Newfoundland, 25 July 2006. Left to
right: Peter Ceponis, Scott Smith, Marieke Gardner, Alun Ackery.
Undetermined poisoning deaths343