Declining Autopsy Rates and Suicide Misclassification A Cross-national Analysis of 35 Countries

Context: Suicides are prone to misclassification during death ascertainment procedures. This problem has generated frequent criticism of the validity of suicide mortality statistics. Objective: To employ an external measure of the validity of cause-of-death statistics (ie, national autopsy rates) and to examine potential misclassification of suicide across countries from Europe to Central and Northern Asia. Design: Cross-national analysis. Setting: Thirty-five countries. Participants: Aggregated mortality data. Main Outcome Measures: Data from 35 countries during the period from 1979 to 2007 were used to analyze the association of suicide rates with autopsy rates and death rates of undetermined and ill-defined causes, respectively. Analyses were cross-sectional and longitudinal. Results: Cross-sectionally, a 1% difference in autopsy rates among nations was associated with a suicide rate difference of 0.49 per 100 000 population. Longitudinally, a 1% decrease in the autopsy rate aligned with a decrease of 0.42 per 100 000 population in the suicide rate. These cross-sectional and longitudinal associations were robust after adjustment for unemployment, degree of urbanization, and prevalence of undetermined or ill-defined deaths. Associations strengthened when analyses were confined to 19 European Union member countries. Conclusion: Autopsy rates may spatially and temporally affect the validity of suicide mortality statistics. Caution should be exercised in comparing international suicide rates and evaluating interventions that target suicide rate reduction.