Category: Psychiatry

Doctors who have been on long term sick leave find it hard to return to work because they are overwhelmed with feelings of shame and failure, and fear the disapproval of colleagues, finds research published in the online journal BMJ Open.

The authors call for cultural change, starting in medical school, to allow doctors to recognise their own vulnerabilities and cope better with both their own and their colleagues' ill health.

The authors carried out semi-structured interviews with 19 doctors, all of whom had been on sick leave for six months or more within the past year. Their ages ranged from 27 to 67, with the average age 46.

All but one doctor had a mental health or addiction problem, which included depression, anxiety, bipolar disorder and alcohol dependence. Seven also had physical health problems.

Fourteen of the doctors had come to the attention of the doctors' professional regulator, the General Medical Council.

The main themes to emerge during the interviews, which lasted between 1 and 3 hours, were professional identity; relationships with family, friends, and work colleagues; and the way in which they perceived themselves.

Illness had taken many of the interviewees by surprise and had shattered their professional identity.

One doctor said that without this, he realised "there wasn't much left of me." Another described it as having "everything taken from you."

Several doctors described good levels of support from friends and family, but many reported the opposite, and felt that they had become "a nuisance," or "an outsider in my own family," or that they were no longer highly thought of.

Some said they deliberately hid their illness (and its treatment) from their families because they feared that coming clean would have a detrimental impact on their personal relationships.

Some doctors said that they did feel supported by work colleagues, but not especially by other doctors.

One commented: "We're meant to be caring people, but we don't seem to care about each other at all, in my experience."

Interviewees said that they felt "judged," and perceived as "weak," and that others considered they were no longer fit to be a doctor because they had become ill.

They frequently described feelings of emptiness, guilt, shame and failure, and blamed themselves for what had happened.

When they experienced difficulties, once back at work, their confidence plummeted, which further worsened their self esteem and made work even harder to cope with, they said.

The authors point out that doctors' rates of mental ill health, drug and alcohol misuse and suicide are at least as high as those of the general population, but the prevailing culture in medicine is that they are "invincible."

This must change, say the authors. "Aspects of personal and colleague health, especially mental health, should be part of the curriculum for all medical students," they write.

And they conclude that:"Doctors must learn to provide themselves and their colleagues with the same level of excellent care that they provide for their patients."

— University of Illinois at Chicago researchers are conducting a study to determine if treating mothers with Attention Deficit Hyperactivity Disorder — either with medication or parent training — will help children at risk for ADHD.

"About 25 percent of the time, when a child has ADHD, there's a parent that has ADHD," said Mark Stein, UIC professor of pediatrics and psychiatry and principal investigator of the study. "We realize this is a weakness in our service delivery models, because often clinicians focus on just treating the child and ignore the fact that another family member has ADHD."

Two treatments are very effective for children with ADHD: behavior modification and stimulant medication. Both require "a very dedicated, organized person, which, if you have ADHD, that's going to be a challenge for you," said Stein, who noted that treatment is often administered by the mother, and that women are less likely to have their ADHD identified.

The Treating Mothers First Study will identify mothers of children between ages 4 and 8 with behavior problems who are at risk for ADHD — and evaluate both the mother and child.

Mothers with ADHD will receive either a long-acting stimulant or behavioral training for eight weeks. Afterward, the mother, family and child will be re-evaluated and then receive treatment for another eight weeks with the same treatment or a combination of medication and parent training.

Parents with ADHD may have difficulty implementing consistent rules and consequences, and they may not respond to a child's appropriate or positive behavior, Stein said. As part of the study "we observe the parent trying to play with the child, trying to get the child to do things like homework or cleaning up their room," he said.

The goal is to determine if the need for stimulant medication in children can be delayed if the mother is treated first.

ADHD is often misdiagnosed as depression or anxiety in women, and it often contributes to marital, parenting, sleep and medical problems, Stein said. Many health care providers have not been trained in diagnosing and treating adult ADHD.

"When a mom complains about how bad her life is, she's given a prescription for Prozac versus understanding that she's always had issues with inattention, distractibility, or impulsivity, and that's why she's having problems," Stein says.

"When you think of ADHD, you think of a 7-year-old boy, not a mom who says 'I am overwhelmed, easily distracted, and just can't get things done,'" he said.

Co-investigators include Drs. Joshua Nathan, Janine Rosenberg, Evelyn Figueroa and Edwin Cook of UIC; and Dr. Andrea Chronis-Tuscano of the University of Maryland.

 Attention Deficit Hyperactivity Disorder is both under and over diagnosed. That's the result of one of the largest studies conducted on ADHD in the United States, published in the Journal of Attention Disorders.

A substantial number of children being treated for ADHD may not have the disorder, while many children who do have the symptoms are going untreated, according to the 10-year Project to Learn about ADHD in Youth (PLAY) study funded by the National Center on Birth Defects and Developmental Disabilities of the Centers of Disease Control and Prevention

"Childhood ADHD is a major public health problem. Many studies rely on parent reporting of an ADHD diagnosis, which is a function of both the child's access to care in order to be diagnosed, and the parent's perception that there is a problem," said Robert McKeown, of the University of South Carolina's Arnold School of Public Health, who led the South Carolina portion of the study.

"Further complicating our understanding of the prevalence of ADHD and its treatment is that the diagnosis often is made by a clinician who has little experience assessing and diagnosing mental disorders. As a result, ADHD is both under and over diagnosed," said McKeown, distinguished professor emeritus in the department of epidemiology and biostatistics.

The study, conducted between 2002-2012, was a collaborative research project with the University of South Carolina's Arnold School and School of Medicine and the University of Oklahoma's Health Sciences Center.

"To our knowledge, this is the largest community-based epidemiologic study of ADHD to date," McKeown said.

The study found that 8.7 percent of children in the community sample in South Carolina had enough symptoms to fit the ADHD diagnosis at the time of the initial assessment. The percentage was 10.6 in Oklahoma.

The report also revealed that the number of parents in the community sample who reported that their children were taking ADHD medication was 10.1 percent in South Carolina and 7.4 percent in Oklahoma. Yet, of the children taking ADHD medication, only 39.5 percent in South Carolina and 28.3 percent in Oklahoma actually met the case definition of ADHD.

"ADHD is not a snap diagnosis. It requires data from several sources and across several domains and considerable expertise to diagnose accurately and differentiate from other possible problems," McKeown said.

The CDC reports that ADHD is one of the most common neurobehavioral disorders of childhood. Often first diagnosed in childhood, ADHD affects a child's ability to do well in school and his or her ability to make and keep friends. While many children "outgrow" the disorder, ADHD can continue into adulthood, impacting the individual's ability to work and function in society.

McKeown said the study found that many children taking ADHD medication did not meet the ADHD diagnostic criteria.

"These children had more ADHD symptoms, on average, than the other comparison children. Many children meeting case criteria had not been previously identified and were not receiving medication treatment, suggesting that the condition remains underdiagnosed," he said.

The study was designed to follow children from elementary school through adolescence (ages 5 — 13) and investigate the short- and long-term outcomes of children with ADHD. Teachers screened 10,427 children in four school districts across the two states where the study was conducted. ADHD ratings by teacher and parent reports of diagnosis and medication treatment were used to determine whether children were high or low risk for ADHD.

Study questions focused on the prevalence and treated prevalence of ADHD in children; the existence of other health problems in children with ADHD, and the types and rates of health risk behaviors in children with ADHD. The study also looked at treatment patterns, both past and current, of children with ADHD.

"The findings of our study suggest that a fair number of children are being treated who do not meet case criteria and that there are children who do meet criteria but are not being treated," McKeown said. "ADHD is not a snap diagnosis. It requires data from several sources and across several domains and considerable expertise to diagnose accurately and differentiate from other possible problems."

Children and adolescents with ADHD also were found to have high rates of other disorders, including oppositional defiant disorder and conduct disorder. They also were more likely to engage in risky or impulsive behaviors, he said.

"We will follow up on these initial reports as the children age to determine what, if any, changes have occurred in the symptom patterns, as well as in the types of health risk behaviors," McKeown said.

"We hope that this will shed light on the prevalence and the treatment of ADHD and will lead practitioners to seek consultation if they are not trained to assess, diagnose and treat ADHD," he said. "We also hope it will lead parents and practitioners to assess all the treatment options to determine what works best for each child."

USC researchers involved in the study included Dr. Steven Cuffe of the University of Florida College of Medicine-Jacksonville, formerly of the USC School of Medicine; Arnold School doctoral student Lorie L. Geryk; and Matteo Botai of the Karolinska Institutet in Sweden and Joseph R. Holbrook of the CDC, both formerly at the Arnold School.

Researchers, doctors and patients tend to agree that during the high-risk period after an attempted suicide, the treatment of choice is close contact, follow-up and personal interaction in order to prevent a tragic repeat. Now, however, new research shows that this strategy does not work.

These surprising results from Mental Health Services in the Capital Region of Denmark and the University of Copenhagen have just been published in the British Medical Journal.

Researchers from Mental Health Services in the Capital Region of Denmark and the University of Copenhagen have just concluded a large study on the effect of an assertive outreach and intervention programme for young people after an attempted suicide. The surprising conclusion is that increased attention and support for the patient do not have a significant effect.

– Our results show that there is no difference between receiving standard treatment after an attempted suicide, or receiving assertive outreach intervention in addition, explains Britt Morthorst, research assistant, Psychiatric Centre Copenhagen and the Faculty of Health and Medical Sciences, who led the study.

The study was conducted at the Research Unit of Psychiatric Centre Copenhagen from 2007 to 2010. A total of 243 patients who had recently attempted suicide participated in the study; 123 in the additional intervention group and 120 in the control group. In the study, the frequency of repeated attempt was 17% for both groups. This figure can also be found in the international literature on this topic, and describes the risk factor entailed by a prior suicide attempt.

Standard treatment just as good

Standard treatment after an attempted suicide is usually provided by the patient's own general practitioner or a psychologist, and is adapted to the patient's physical and mental health. Generally it is up to the patient to seek help and initiate a course of treatment. In the study reported here, standard treatment was supplemented by treatment at the Competence Centre for Suicide Prevention under the auspices of Mental Health Services in the Capital Region of Denmark.

Under the additional intervention programme, specially-trained nurses visited patients a few days after their discharge from hospital and maintained especially close contact with them for up to six months, with between eight and 20 out-reach consultations in addition to standard treatment. Contact covered meetings with patients in the patient's home, and also included accompanying patients to doctors' appointments and meetings with social services. The option of telephone and texting contact was also part of the package.

Greater focus on danger signals prior to first suicide attempt

However, close contact is not what it takes to stop the negative spiral involved in repeated suicide attempts. At the end of the study, researchers were forced to conclude that in the year after treatment, there were as many attempted suicides in the group that had received additional intervention as in the control group that received standard treatment. Thus there is no difference to be found in either hospital registers or in the data gathered from self-reporting by participants in the study:

– Unfortunately, the conclusion must be that neither standard treatment nor additional assertive outreach is good enough. My suggestion is that we try to get hold of young people at risk before they attempt suicide the first time. We are looking with interest at some American Teen-Screen programmes, which look at young people's mental health generally, to see if we can identify any danger signals to which we could respond earlier, explains Britt Morthorst.

— With no lab tests to guide the clinician, psychiatric diagnostics is challenging and controversial. Antisocial personality disorder is defined as "a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood," according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association.

DSM-IV provides formal diagnostic criteria for every psychiatric disorder. This process may be guided by rating scales that measure the traits and features associated with a personality disorder. But, until now, no one has studied the dimensional structure associated with the DSM antisocial personality disorder criteria.

Dr. Kenneth Kendler of Virginia Commonwealth University and colleagues examined questionnaire and genetic data from adult twins. They found that the DSM-IV criteria do not reflect a single dimension of liability but rather are influenced by two dimensions of genetic risk reflecting aggressive-disregard and disinhibition.

"When psychiatrists, as clinicians or researchers, think about our psychiatric disorders, we tend to think of them as one thing — one kind of disorder — a reflection of one underlying dimension of liability," said Dr. Kendler. "This is also true of genetics researchers. We tend to want to identify and then detect 'the' risk genes underlying disorder X or Y."

Kendler added, "What is most interesting about the results of this paper is that they falsify this inherent and rather deeply held assumption. Genetic risk factors for antisocial personality disorder are not one thing. Rather, the disorder, as conceptualized by DSM-IV, reflects two distinct genetic dimensions of risk."

"The findings from this study make sense. The distinction between the two sets of heritable traits contributing to antisocial personality disorder, aggressive-disregard and disinhibition, highlights the complexity of unraveling the genes contributing to this personality style. We now have some puzzle pieces, but we have a long way to go to fit these pieces together," commented Dr. John Krystal, editor of Biological Psychiatry.

A new study led by the Neuroscience Institute of Alicante reveals how manipulating the endocannabinoid system can modulate high levels of impulsivity. This is the main problem in psychiatric illnesses such a schizophrenia, bipolar disorder and substance abuse.

Spanish researchers have for the first time demonstrated that the CB2 receptor, which has modulating functions in the nervous system, is involved in regulating impulsive behaviour.

"Such a result proves the relevance that manipulation of the endocannabinoid system can have in modulating high levels of impulsivity present in a wide range of psychiatric and neurological illness," explains Jorge Manzanares Robles, a scientist at the Alicante Neuroscience Institute and director of the study.

Carried out on mice, the study suggests the possibility of undertaking future clinical trials using drugs that selectively act on the CB2 and thus avoid the psychoactive effects deriving from receptor CB1 manipulation, whose role in impulsivity has already been proven.

However, the authors of the study published in the British Journal of Pharmacology remain cautious. Francisco Navarrete, lead author of the study, states that "it is still very early to be able to put forward a reliable therapeutic tool."

The study assessed the actions of two cannabinoid drugs that stimulate and block CB2 in the mouse strain showing high levels of impulsivity. The scientists then analysed whether these drugs were capable of modulating impulsive behaviour and the cerebral modifications associated with this change in behaviour.

The authors concluded that CB2 receptor activity modulation reduced impulsive behaviour in mice, depending on the patterns that governed the administration of each drug. Furthermore, the genetic expression levels of CB2 tended to return to normal, leaning towards strains that had little impulsivity.

The Endocannabinoid System

The Endocannabinoid System mainly comprises two receptors (CB1 and CB2), two endogenous ligands and two metabolism enzymes. It regulates many aspects of embryonic development and is involved in many homeostatic mechanisms.

Although it was thought that CB2 only regulates immune response on a peripheral level, a study published in the 'Science' journal in 2005 showed that it was found in the brain under normal conditions. Since then many authors have linked it to the regulation of emotional behaviour and cognitive functions.

For example, the same group of Spanish researchers has contributed greatly in applying this receptor in regulating anxiety and depression. Furthermore, others studies have demonstrated how their altered role is linked to increased chances of becoming depressed or anxious or taking drugs.

Virtue or defect?

Impulsivity is a personality trait characterised by behavioural actions that lack forethought or in which the subsequent consequences are not considered. The authors outline that this is "a normal behaviour that allows us as human beings to adapt to our surroundings under certain circumstances that require an immediate reaction."

Nonetheless, such behaviour can cause a disproportionate response and lead to a pathological state. There a multitude of psychiatric illness that are characterised by a high level of impulsivity. One of these includes substance abuse, which is extremely problematic for society in general.

Recent research has found striking links between psychotic disorders such as schizophrenia and certain types of international immigration. Now for the first time, a major study has found that immigrating in early childhood appears to carry the highest risk. The study, conducted in the Netherlands, found that the younger the age at migration, the higher the risk of psychotic disorders. Those who immigrated when under the age of five had a twofold higher risk than those who immigrated at age 10-14 years, and a threefold higher risk than those who immigrated as adults. The study — the first to include data on age at migration — suggests that there may be an early window of vulnerability.

The study, conducted by investigators at Columbia University's Mailman School of Public Health and the Parnassia Psychiatric Institute, The Hague, was published online in the December issue of the American Journal of Psychiatry.

"Our findings are consistent with the hypothesis that early life is an important risk period for psychotic disorders. They join the growing body of literature suggesting that adverse social experiences in early life, such as childhood trauma or parental separation raise the risks," said Ezra Susser, MD, DrPh, senior author and director of the Imprints Center for Genetic and Environmental Life Course Studies at the Mailman School of Public Health and the New York State Psychiatric Institute.

Researchers focused on the four largest immigrant groups in the Dutch city of The Hague–immigrants from Surinam, the Netherlands Antilles, Turkey, and Morocco. They compared the incidence of psychotic disorders among immigrants who migrated at various ages to the incidence among second-generation citizens and among Dutch citizens. Second-generation citizens (Dutch-born citizens with at least one foreign-born parent) were included to determine if migration itself contributed to the risk or if the long-term experience of being an ethnic minority was the more relevant factor.

Researchers sought to identify and diagnose every citizen of The Hague, ages 15-54, who contacted a physician over a 7-year period from 1997 to 2005 for a possible psychotic disorder. All diagnoses were confirmed by two psychiatrists. Patients diagnosed with any form of psychotic disorder were included in the analysis and were classified according to country of birth and country of parents' birth. In total, 273 immigrants, 119 second-generation citizens, and 226 Dutch citizens were diagnosed as having a psychotic disorder.

"Compared with the risk of psychotic disorders among Dutch citizens, the risk among immigrants was most significantly elevated among non-Western immigrants who migrated between the ages of 0 and 4 years," observed Dr. Susser. "We also found that the risk gradually decreased among those who migrated at older ages and this was the case among male and female immigrants and among all the immigrant groups in this large study."

Researchers allow that there are many possible reasons for the increased risk. The stress of minority ethnic status appears to contribute. The study found, for example, that second-generation immigrants have higher rates of psychotic disorders than native Dutch. Previous studies also suggest that the social changes associated with cultural and geographic dislocation may be an important factor. Other factors might include vitamin D deficiencies that are common among immigrants.

"This study also goes a long way toward ruling out 'selective migration' as an explanation for the increased rates of psychosis among immigrants to The Hague. Young children are unlikely to influence their parents' decision to migrate," noted lead author Dr. Wim Veling.

Once the reasons for the increased risk of psychosis are better established and understood, it might be possible to mitigate them, the authors suggest. "It might be useful," they write, "to develop interventions aimed at social empowerment and identity development."

The study was funded by the Theodore and Vada Stanley Foundation and the Netherlands Organization for Health Research and Development. Dr. Susser is also supported by a Distinguished Researcher Award from NARSAD.

Roughly 1 million people die by suicide each year. In the U.S., where nearly 36,000 people take their own lives annually, more than 4,600 victims are between the ages of 10 and 24, making suicide the third leading cause of death in this age group.

Youths treated at hospital emergency rooms for suicidal behavior remain at very high risk for future suicide attempts. But despite the urgent need to provide them with mental health follow-up care, many don't receive any such care after their discharge. Consequently, a major goal of the U.S. Department of Health and Human Service's National Strategy for Suicide Prevention has been to increase rates of follow-up care after discharge for patients who come to the emergency department (ED) due to suicidal behavior.

Now, a new study by UCLA researchers shows that a specialized mental health intervention for suicidal youth can help. Reporting in the November issue of the journal Psychiatric Services, Joan Asarnow, a professor of psychiatry at the Semel Institute for Neuroscience and Human Behavior at UCLA, and colleagues show that a family-based intervention conducted while troubled youths were still being treated in the ED led to dramatic improvements in linking these youths to outpatient treatment following their discharge.

"Youths who are treated for suicidal behavior in emergency departments are at very high risk for future attempts," said Asarnow, the study's first author. "Because a large proportion of youths seen in the ED for suicide don't receive outpatient treatment after discharge, the United States National Strategy for Suicide Prevention identifies the ED as an important suicide prevention site. So, a national objective is to increase the rates of mental health follow-up treatment for suicidal patients coming out of EDs."

But how to encourage this with youths when they are at their most vulnerable? The study involved 181 suicidal youths at two EDs in Los Angeles County, with a mean age of 15. Sixty-nine percent were female, and 67 percent were from racial or ethnic minority groups. For 53 percent of the participants, their emergency department visit was due to a suicide attempt. The remainder were seen because they had thoughts of suicide.

The youths were randomly assigned to either the usual ED treatment or an enhanced mental health intervention that involved a family-based crisis-therapy session designed to increase motivation for outpatient follow-up treatment and improve the youths' safety, supplemented by telephone contacts aimed at supporting families in linking to further outpatient treatment.

The results of the study show that the enhanced mental health intervention was associated with higher rates of follow-up treatment. Of the participants in the enhanced intervention, 92 percent received follow-up treatment after discharge, compared with 76 percent in the standard ED treatment arm — a clinically significant difference.

While the results are positive, the study is only a first step, according to Asarnow, who also directs UCLA's Youth Stress and Mood Program.

"The results underscore the urgent need for improved community outpatient treatment for suicidal youths," she said. "Unfortunately, the follow-up data collected at about two months after discharge did not indicate clinical or functioning differences among youths who received community outpatient treatment and those who did not."

Still, Asarnow said, the data from the new study underscores the critical importance of this work. To address the need for effective follow-up treatment for troubled youths, the UCLA Youth Stress and Mood Program has major research trials in progress aimed at evaluating outpatient treatments for preventing suicide and suicide attempts.

Funding for the study was provided by the Centers for Disease Control and Prevention, the National Institute of Mental Health and the American Foundation for Suicide Prevention.

Other authors included Larry Baraff, Robert Suddath, John Piacentini, Mary Jane Rotheram-Borus and Lingqi Tang, all of UCLA; Michele Berk and Charles Grob of Harbor-UCLA Medical Center, Los Angeles Biomedical Research Institute; Mona Devich-Navarro of Santa Monica College; and Daniel Cohen of Johns Hopkins University.

Asarnow reports receiving honoraria from Hathaways-Sycamores, Casa Pacifica, the California Institute of Mental Health and the Melissa Institute. Piacentini has received royalties from Oxford University Press for treatment manuals and from Guilford Press and the American Psychological Association Press for books on child mental health. In addition, he has received a consultancy fee from Bayer Schering Pharma. The other authors report no competing interests.

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Journal Reference:

1. Joan Rosenbaum Asarnow, Larry J. Baraff, Michele Berk, Charles S. Grob, Mona Devich-Navarro, Robert Suddath, John C. Piacentini, Mary Jane Rotheram-Borus, Daniel Cohen, Lingqi Tang. An Emergency Department Intervention for Linking Pediatric Suicidal Patients to Follow-Up Mental Health Treatment. Psychiatric Services, 2011; 62: 1303-1309 

Criminality can be an indicator of a higher risk of suicide in young people. A new study from Karolinska Institutet and the National Board of Health and Welfare in Sweden shows that repeat offenders between the ages of 15 and 19 are three times more likely to commit suicide than young people who have not been convicted for a crime during these years.

"The association is clear, even when controlling for risk factors such as substance abuse and mental illness," says Emma Björkenstam of the Swedish National Board of Health and Welfare and Doctoral Student at the medical university Karolinska Institutet.

For the study, which is published online in the International Journal of Epidemiology, the researchers examined almost one million young people born between 1972 and 1981, and then followed them up with respect to suicide up to the ages of 25 — 34.

The results show a correlation between suicide risk and number of convictions, with a peak being reached at five or more. The group also included young people who had received more severe sentences, such as prison or probation. The same pattern was observed amongst young males and females, although the suicide rate was higher for the former.

The researchers controlled for a number of other variables, such as parental educational attainment, parental receipt of social assistance or disability pension, single parenthood, parental mental illness and substance abuse, and adoption. One finding was that the educational level of the parents per se seems to have no impact on the risk of suicide.

"Our most important finding is how important it is to identify and support the young people who relapse back into crime," says Emma Björkenstam.

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Journal Reference:

1. Björkenstam E, Björkenstam C, Vinnerljung B, Hallqvist J, Ljung R. Juvenile delinquency, social background, and suicide – A Swedish national cohort study of 992 881 young adults. International Journal of Epidemiology, 14 September 2011 DOI: 10.1093/ije/dyr127

 Medical examiners and appointed coroners are less likely to under-report suicides than are elected coroners, that's according to a new study from Temple University.

Many of us view suicide as an intensely private and personal act and commonly seek to explain it by focusing on the mental and emotional health of the individual. However, because suicides tend to cluster in specific populations and places, sociologists are very interested in how social contexts can affect a person's propensity to commit suicide.

In order to examine those social contexts, however, researchers must rely on official death reporting. "Mortality statistics are crucial because they tell us not just about how people die, but how they lived. To understand the social determinants of health and well-being at the community level, we need to be confident that area-level mortality statistics are relatively unbiased," said Temple sociologist Joshua Klugman, the study's lead author.

So Klugman, along with his Temple sociology colleagues Gretchen Condran and Matt Wray, set out to answer the question: Does the type of office responsible for reporting on deaths impact the suicide rates, potentially biasing estimates of the social causes of suicide, such as income or divorce rates?

Specifically, in a study presented next week at the Annual Meeting of the American Sociological Association in Las Vegas, Klugman analyzed reported suicide rates in counties with elected coroners, appointed coroners and appointed medical examiners.

Klugman found that elected coroners have slightly lower official suicide rates than medical examiners (all of whom are appointed) and appointed coroners.

"Contrary to arguments that medical examiners' greater scientific training makes them more likely to underreport suicides, we conclude that medical examiners and appointed coroners demonstrate less suicide under-reporting due to their insulation from public pressure," said Klugman.