IJE Advance Access originally published online on January 19, 2005
International Journal of Epidemiology 2005 34(2):433-442; doi:10.1093/ije/dyh398
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Mental Health |
The epidemiology and prevention of suicide by hanging: a systematic review
1 Department of Social Medicine, University of Bristol, Bristol BS8 2PR, UK
2 Centre for Suicide Research, University of Oxford Department of Psychiatry, Warneford Hospital, Headington, Oxford OX3 7JX, UK
3 Centre for Suicide Prevention, Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK
* Corresponding author. David Gunnell, Department of Social Medicine, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK. E-mail: D.J.Gunnell{at}Bristol.ac.uk
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Abstract |
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Background Hanging is one of the most commonly used methods for suicide worldwide. In England and a number of other countries, its incidence has increased over the last 30 years. This review summarizes the published literature on suicide by hanging. The focus is on its epidemiology in England and on identifying potential means of prevention.
Methods We searched Medline (1966–2003), Embase (1980–2003), CINAHL (1982–2003) and PsycINFO (1967–2003). As considerable research on suicides occurring in prisons and psychiatric hospitals in England and Wales has been carried out by the National Confidential Inquiry into Suicide and Homicide (Manchester) and the Prison Service's Safer Custody Group, we obtained additional information from these sources.
Results Only a small proportion (around 10%) of hanging suicides occur in the controlled environments of hospitals, prisons, and police custody; the remainder occur in the community. The most commonly used ligatures (rope, belts, flex) and ligature points (beams, banisters, hooks, door knobs, and trees) are widely available; thus prevention strategies focused around restriction of access to means of hanging are of limited value. Around 50% of hanging suicides are not fully suspended—ligature points below head level are commonly used. Case fatality following attempted suicide by hanging is around 70%; the majority (80–90%) of those who reach hospital alive survive.
Conclusion Strategies to reduce suicide by hanging should focus on the prevention of suicide in controlled environments, the emergency management of ‘near-hanging’ and on the primary prevention of suicide in general. More research is required to better understand the recent rise in popularity of this method.
Keywords Suicide, systematic review, hanging, suicide prevention
Accepted 4 November 2004
Hanging is a frequently used method of suicide in many countries.1 In England, there are around 2000 hanging suicides per year and it is the most commonly used suicide method. Its popularity as a means of suicide dates back to medieval times at least, when it accounted for around half of all suicides.2 The last 30 years have seen an increase in hanging suicides, particularly amongst young males, in Australia,3 New Zealand,4 and elsewhere. In England, suicide by hanging has increased markedly in males aged <65 years (Figure 1).5,6 There have also been increases amongst young (aged <45 years) females but rates in older females have been declining since the mid-1980s (Figure 2). Amongst older (>75 years) females in England and Wales, deaths by suffocation using a plastic bag account for around a third of suicides coded as due to hanging, strangulation, or suffocation using the International Classification of Diseases (ICD). In all other age/sex groups hanging accounts for 80–90% of deaths in these categories.
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Hanging is a particularly lethal method of suicide with an estimated fatality rate of over 70%.78–9 In contrast to overdose there is little opportunity to change one's mind as death generally occurs rapidly after suspension. The usual cause of death is asphyxia as, unlike judicial hanging, the height of the drop is generally insufficient to cause spinal cord injury.
National suicide prevention strategies in England10 and internationally11 place emphasis on restricting access to commonly used methods of suicide as a means of reducing suicide rates. Most commentators agree that this approach is generally not possible for hanging suicides as the ligature points and ligatures commonly used are universally available. An exception to this is suicide in institutional settings—police custody, prisons and hospitals.4 Such deaths, however, comprise only around 10% of all hanging suicides.12–14
This review summarizes the published literature on suicide by hanging. The focus is on its epidemiology in England and in identifying potential means of prevention. We divide the published studies into those concerned with suicides in (i) the general population and (ii) institutional settings. These are considered separately because the opportunities for prevention depend upon the setting. We also review aspects of the emergency medical management of near-hanging victims who reach hospital alive.
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Methods |
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Literature search strategy
We searched Medline for the years 1966–2003, Embase 1980–2003, CINAHL 1982–2003 and PsycINFO 1967–2003, using the following search strategy to identify relevant papers: suicide as a mesh heading and text word combined with the following text words: hanging, asphyxia (also as a key word), and strangulation. We limited the search to English language papers.
From the 734 papers identified using this strategy we selected those which focused on hanging as a method of suicide or where the abstract suggested that the paper would include details concerning hanging suicides. We identified additional relevant papers from the reference lists of retrieved literature.
For our summary of data on ligature points and ligatures used for hanging we excluded small case series (<50 cases) and general reviews of the epidemiology of suicide in countries where hanging was mentioned but there was no specific focus on this method. In addition we excluded papers dealing specifically with asphyxia from plastic bags/self-strangulation. We included data presented in an MD thesis examining a large case series of hanging suicides, through personal contact with its author.13 We excluded papers that only described the pathological features of hanging suicides.15,16
Sources of suicide data for England & Wales
As considerable research on suicides occurring in prisons and psychiatric hospitals in England and Wales has been carried out by the National Confidential Inquiry into Suicide and Homicide (Manchester) and the Prison Service's Safer Custody Group, we obtained additional information from these sources. We used Office for National Statistics (ONS) mortality statistics to investigate secular trends in the use of hanging.
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Results |
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General population studies
We identified fifteen studies based on population samples and describing the characteristics of individuals and the methods they used for suicide by hanging (Appendix 1). The place of death in approximately three-quarters of the cases was the person's home. Deaths in custody or hospital accounted for
10% of deaths and the remainder occurred in public places. A range of different ligatures were used—most commonly rope, belts, and electric flex. The main ligature points were rafters and beams, banisters, hooks, door knobs, and trees. In studies reporting the position of the deceased, generally around half of the victims or fewer were found freely suspended with both their feet off the ground.9,12,17,18 In one Australian series 8% of the 261 cases studied were found kneeling and 8% sitting.12 A forensic analysis by Khokhlov investigated tensions on the noose of a ligature exerted by different postures.19 He found that in the standing posture (with both feet on the ground) the ligature supports 65% of body weight; 54–74% in the kneeling position; 17–32% when sitting; and 18% when recumbent. Thus asphyxiation may be achieved without complete suspension.
Suicide by hanging whilst in custody
Suicides in custody have generated considerable concern in many countries.20 In 1999/2000 there were 172 prison suicide deaths in England and Wales, 159 (92%) of which were by hanging or self-strangulation.21 Over this 2-year period these constituted 3.9% (159/4061) of national suicides by hanging.22 Hanging accounts for a similarly high proportion of deaths in custody in the USA, Australia, Canada, and Holland.23–29 The number of deaths by suicide in police custody in England and Wales is much lower than those in prisons. Between 1999/2000 and 2002/2003 deaths by hanging in police custody have averaged two a year. [Home Office: www.homeoffice.gov.uk/rds/pdfs/deaths2000.pdf; www.homeoffice.gov.uk/docs/deaths2001.pdf; www.homeoffice.gov.uk/docs/death_in_custody.pdf; www.homeoffice.gov.uk/docs2/deathpolcustody2002_2003.pdf (Accessed December 23, 2003)].
Suicide by hanging in prisons
In England and Wales, cell window bars are the suspension point used in nearly half of prison suicides (48%)21,30 Other points of suspension are the bed (11%), cell fittings such as lights, pipes, cupboards, sinks or toilets (13%), or the cell door (5%).21 Suggestions for prevention have included changes to cell window frame design,30 the removal of bars,21 or the covering of bars with Plexiglas.31 Other recommendations for the removal of suspension points have been the installation of recessed lighting or lighting that collapses under strain,28,31 and the removal of clothes hooks and bunk beds, replacing the latter with concrete sleeping benches.31,32 It has been suggested that in areas where ‘at risk’ prisoners are kept, all potential ligature points should be removed. These include prison health care centres, where one in six prison suicides in England and Wales occur.21
In 1989 Atlas suggested a wide range of changes to cell design which involved removing all possible means of suicide,33 but it is only recently that ‘safer cells’, designed to be ligature-free, have been piloted in prisons in England and Wales (see Appendix 2). There are now 3000 ‘safer cells’ out of a total of 47 000 cells in the correctional and prison services. In designing these the Safer Custody Group have sought to strike a balance between the need for removal of ligature points and the construction of a humane environment. Specific criteria have been laid down for furniture and sanitary ware so that ligatures cannot be attached.34 (John Doohan, Safer Custody Group, HM Prisons, personal communication) Bars in ‘safer cells’ are covered with transparent polycarbonate sheeting and a ventilator inserted. Lights are recessed, pipes covered, and the bed base is fixed. Garment hanging space is constructed so that the rail is collapsible or a shelf lip is provided for hanging garments using cardboard hangers. Shelving is fitted flush against walls, button water controls are used on washbasins instead of taps and a button flush is used on toilets. Toilet seats, a potential ligature point, are not used but the pedestal is covered with an acrylic resin.34 Recently, fixed plugs on washbasins have been removed as it was found that these could be used as a ligature point. Individual cells are tested with a fishing line and if the line snags behind shelves or pipes, gaps are filled with an anti-pick mastic. (John Doohan, Safer Custody Group, HM Prisons, personal communication)
A recently published evaluation of ‘safer cells’ in six prisons in England and Wales identified that five suicides by hanging or self-strangulation have taken place in these cells.34 The ligature point used in the prison where the three cases of hanging took place was the upper hinge of the cell door—the design of these has subsequently been changed. A system is in place to develop and disseminate information on appropriate modifications when new ligature points are identified and used.
The most common forms of ligature used in prison suicides in England and Wales in 1999/2000 were bedding (56%) and shoe laces (13%).21 For this reason bedding made of fabric that is resistant to tearing is being piloted (John Doohan, Safer Custody Group, HM Prisons, personal communication). The replacement of shoe laces with Velcro fastening has been recommended.28 Modifying the availability of ligatures, particularly those utilizing clothing, is difficult to control while maintaining the dignity of the individual.
The World Health Organization (WHO) has issued guidelines for Prison Officers regarding the prevention of suicide.35,36 These guidelines include advice on commonly used ligatures and the need to minimize ligature points.
Suicide by hanging in police custody
In over half (52%, 38/73) the cases of suicide by hanging in police cells in England and Wales during the years 1990–1996, the hatch/bolt hole to the cell door was used as the ligature point. The door or door hinge were used in about one-quarter of the cases (26%).37 All police forces have since been instructed to keep cell hatches closed when cells are occupied and some forces have introduced inspections to identify potential ligature points.37 In addition a Home Office Circular published in 2002 provided guidance on changes that need to be introduced if police cells are to be ligature-free.
Shoe or boot-laces were used as the ligature in about one-third (32%) of the cases of death by hanging in police custody during 1990–1996. Clothing, or cord removed from clothing, was used in about one-quarter (24%) and one-fifth of the cases (20%), respectively. Bedding was used in only 15% of hangings. Some forces now use replacement clothing and blankets that will not tear.37 The Home Office has recommended that items like shoelaces and belts that can be easily used as a ligature should always be removed.
Suicide by hanging in psychiatric inpatients
In the 4 years from April 1, 1996, there were 234 suicides on psychiatric wards in England and Wales—three-quarters of these (175/234) were caused by hanging. Such deaths accounted for around 3% of the 6554 suicides by hanging in England between 1997 and 2001.38 Hanging makes a similar contribution to inpatient suicides in other countries.39,40
In England and Wales, nearly one-third (23/74) of ward hangings between October 2001 and September 2003 were located in the toilet or bathroom. Recently it has become a legal requirement in England and Wales for all non-collapsible frames, such as bed, shower, and curtain rails to be removed from psychiatric wards (by March 2002).41 In the 2 years up to September 2003 a hook or handle (27%), part of the bed (20%), or door/wardrobe (17%) were the most common ligature points. These were used in nearly two-thirds of the suicides by hanging on psychiatric wards (Table 1).
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The National Institute for Mental Health in England is developing guidance on conducting environmental audits of inpatient units to identify ligature points and so minimize the risk of hanging.41 Where it is not possible to remove structures identified as ligature points or where obstructions to the observation of patients have been identified and cannot be removed, it has been suggested that such wards should not be used for the admission of acutely ill patients.38
The main ligatures used in suicides occurring on psychiatric wards in the 2 years up to September 2003 were: belts/dressing gown cords (50%), sheet or towel (13%), and shoe laces (9%) (see Table 2). It has been suggested that high-risk patients should be given or asked to wear clothes that do not need belts and shoes that do not have laces, though it is acknowledged that this would need to be sensitively discussed with such patients.38
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Medical management of cases of suicide by hanging
Case fatality following attempted suicide by hanging is high. One French study has estimated the case fatality as 79%.7 In an American case series 78% of the victims were declared dead at the scene of discovery.8 Aufderheide et al. describe a series of 306 cases of hanging in WI, USA, of whom 22% were referred to hospital and 64% of these survived.8 Higher mortality rates have been reported in other case series—around 3% of people who hanged themselves reached hospital alive in one case series from the USA9 whereas a more recent paper suggests case fatality is
60%.42 Those who reach hospital alive have a relatively high probability of survival.43 In a recent Australian study, 68 (94%) of the 72 patients brought to A&E between 1995 and 2000 after ‘near hanging’ left hospital alive.44 In a Canadian review of 17 cases the survival rate was 76%; four people suffered severe neurological and cognitive impairments and four mild to moderate impairments.45 All four of those who died had required cardiopulmonary resuscitation at the scene of the hanging. In contrast to these relatively high levels of morbidity and mortality, a recent Australian case series (n = 44)46 reported an 88% survival rate amongst those reaching hospital alive and a low incidence of persistent severe neurological impairment (5%). As in other studies, all those who died in this case series were pulseless when they were discovered.46
Survival following attempted suicide by hanging is possible even if the victim has been suspended for >5 min. In one small case series 57% (4/7) survived after more than 5 min suspension.47 In another series three subjects, all with Glasgow coma scale (GCS) of 3, survived without memory defects.48 In an Australian case series, 9 (64%) of the 14 patients with a GCS of 3 at the scene were discharged alive, although one was discharged to a nursing home with severe neurological disabilities. Seven of these patients were reported as having fixed dilated pupils at the scene and left hospital with no neurological sequelae.46 Altogether, amongst the 42 people included in this series 5 (12%) died and 2 were left with severe neurological problems.
Immediate death following attempted suicide by hanging may occur in one of three ways:43,49
- Mechanical constriction of the neck structures (asphyxia; venous occlusion or arterial occlusion). Only 2 kg of pressure is needed to block the jugular veins, arterial occlusion requires 2.3–30.0 kg. About 15 kg of pressure is required to obstruct the trachea.
- Cardiac arrest, possibly facilitated by pressure on the carotid sinus and its effects on vasoactive centres.
- Injury of spinal cord and brain stem. Fractures of the cervical spine are, however, very rare in suicidal hanging43 because the drop before tension on the noose is achieved is usually minimal.
The most frequently reported causes of subsequent death amongst people who are brought to hospital alive following a suicide attempt by hanging are bronchopneumonia, pulmonary oedema and adult respiratory distress syndrome.45,50 In one series of 67 cases of hanging presenting to A&E, 8 (12%) developed pulmonary oedema, pneumomediastinum or pulmonary infiltrates. Rarer complications include hyperthermia, status epilepticus and oesophageal rupture.43 Several signs indicating a poor prognosis have been identified. These include: pre-hospital cardiopulmonary arrest, need for intubation, and spontaneous respiratory rate of less than four breaths per minute.8 Admission to ITU is indicated for respiratory support and monitoring neurological and pulmonary complications. Endotracheal intubation is recommended for all patients with significantly impaired conscious level to avoid aspiration.43
There are no authoritative evidence-based guidelines on the medical management of near-hanging. Table 3 highlights a number of aspects of the pre-hospital and emergency department treatment modified from a review published in 198449 to include suggestions from more recent reviews43,45 and comments from A&E specialists (see Acknowledgements). Some physicians have questioned the value of high levels of positive end-expiratory pressure (PEEP) because of the danger of worsening intracranial hypertension.51 Krol and Wolfe, however, advocate endotracheal intubation and hyperventilation to decrease intracranial pressure and protect the airway from aspiration.47
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While bone injury or dislocation of the cervical spine is rare (<1%),43 physicians recommend using precautionary measures (immobilization) until such an injury can be ruled out by X-ray and neck CT scan.434952 Soft tissue films of the neck are useful to detect tracho-laryngeal injury (indicated by difficulty in swallowing/hoarseness).47 Adams suggests that, once stabilized, patients with neurological signs suggestive of cervical spine injury require CT or MRI scans;43 although others47 suggest these are not needed routinely. Patients with neurological signs consistent with a stroke should be investigated with a CT brain scan and Doppler ultrasound of the carotid arteries (Adams N, personal communication). Those involved in the initial management of cases of suicidal hanging should also bear in mind that the person may have taken a drug overdose or have some other injury.8
Of note, whilst existing guidelines for health care in prison give a detailed account of the emergency treatment of self-poisoning and overdose, they do not include advice on the management of hanging.36
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Discussion |
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Suicide by hanging has increased in England and Wales and a number of other countries over the last 30 years. Hanging is a highly lethal method of suicide in that around 70% of those who attempt suicide using this method die. It is to be noted that only half of those who die by hanging are found fully suspended with their feet above the ground. Ligature points used by those in prisons and hospitals are often below head height. Most hanging deaths occur in the community—only around 10% occur in prisons and psychiatric hospitals.
The controlled environments of prisons and psychiatric hospital do provide opportunities for reducing the incidence of hanging suicides. The fact that complete suspension is not required to successfully hang oneself needs to be understood and communicated to those reviewing potential ligature points in institutional settings. Table 4 summarizes possible approaches to prevention of hanging suicides in prisons and hospitals. In Britain, many of the recommendations for prisons are being introduced: all prisons screen for high-risk patients and identify those appropriate for a safer cell, trauma resuscitation training for prison nurses is being piloted and prisons provide emergency response kits in each wing or office for use by staff. Furthermore many of the staff carry personal issue cut-down knives to ensure they respond immediately in the event of a hanging (John Doohan, personal communication). The approaches to medical management of hanging suicide attempts (Table 3) might usefully be incorporated in guidelines for health care workers and prison staff.36
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In contrast to the situation in prisons and psychiatric hospitals, the ligatures and suspension points used by those who kill themselves by hanging in the community are universally available. Therefore approaches to prevention based around limiting access to ligature and suspension points or reducing the lethality of suicide attempts by hanging are unlikely to be successful.53
Improved pre-hospital and acute medical management of victims may have some impact on the current death toll as around 20% of those who die from hanging are found alive. In the absence of randomized trials, consensus guidelines on the management of hanging should be drawn up and made available to ambulance and A&E staff. Prison and hospital staff should be trained in the emergency medical management of individuals who have hung themselves.
There are two main limitations of our review. First, we did not search the grey literature or non-English language papers and so may have excluded some relevant studies. We feel this is unlikely to influence our main findings as, unlike systematic reviews of treatment effectiveness or disease risk factors, descriptive studies of suicide by hanging and its management are less likely to be subject to publication bias. Second, the treatment guidelines (Table 3) are based on expert opinion and evidence from non-randomized studies. We did not identify any randomized trials of the management of suicide by hanging—this is most likely to reflect the relative rarity with which survivors of hanging are encountered in clinical practice.
A range of different factors lie behind the choice of a particular method of suicide.54 Socio-cultural acceptability appears to be an important factor.53 It has been argued that the previously low rates of suicide by hanging in the UK and other countries was due to the stigma associated with the use of this method in judicial executions.1,55 Recent increase in the cases of hanging may in part be due to substitution from other methods, such as gassing, which have become less lethal.56,57 The most fruitful approach to tackling the rise in hanging suicides may therefore be through population-based initiatives to reduce the popularity of this method. This may be achieved through working with the media to reduce the portrayal of fictional suicides by hanging and the reporting of hanging suicides. Qualitative studies are required to better understand explanations for choice of method. Until a greater understanding of these issues is available, preventive approaches to hanging suicides may be better focused more broadly on the primary and secondary prevention of factors associated with suicide risk.58
KEY MESSAGES
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Acknowledgments |
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We thank Anita Brock, Office for National Statistics, for providing data on suicide by hanging in 2001/2002 used in her published report of suicide in England and Wales 1979–2001.6 Jon Doohan and Jo Borrill, from the Safer Custody Group, HM Prisons, for providing key information on the Safer Cells initiative. Nick Adams, The Alfred Emergency and Trauma Centre, Melbourne, Australia; Mr Kevin Mackway-Jones, Department of Emergency Medicine, Manchester Royal Infirmary; and Mr Nigel Rawlinson, Department of Emergency Medicine, United Bristol Hospitals Trust for advice on the emergency medical management of attempted suicide by hanging. Mike Nowers for access to his MD thesis on suicides using violent methods in Bristol and Ms Harriet Bickley from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness for providing unpublished data concerning inpatient suicides. This research was funded by the Department of Health for England. Views expressed in this paper are those of the authors and not necessarily those of the Department of Health.
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