Homicides and Suicides --- National Violent Death Reporting System, United States, 2003--2004

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Violent deaths claimed 49,639 lives in the United States during 2003, and the prevention of violent deaths is an integral part of the public health agenda (1). In 2003, CDC launched the National Violent Death Reporting System (NVDRS) to provide detailed information on the circumstances of violent deaths. The system can be used to develop and evaluate prevention policies, programs, and strategies at the national, state, and local levels (2). This report describes the analysis of violent deaths from seven states that participated in NVDRS in 2003, plus six additional states that participated in 2004. Homicide circumstance information revealed that most victims knew the suspects involved and that intimate partner conflicts continued to be among the most important contributing factors. Suicide circumstance information indicated that mental health disorders and intimate partner problems had important roles. These findings underscore the value of NVDRS data for effective planning and targeting of violence-prevention programs.

NVDRS is an active, state-based surveillance system that collects information on homicides, suicides, deaths of undetermined intent (i.e., those for which available information is insufficient to enable a medical or legal authority to make a distinction among unintentional injury, self-harm, or assault*), deaths from legal intervention (e.g., involving a person killed by an on-duty police officer), and unintentional firearm deaths. Seven states provided data in 2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, and Virginia), and six additional states contributed in 2004 (Colorado, Georgia, North Carolina, Oklahoma, Rhode Island, and Wisconsin). NVDRS uses a multisource approach (i.e., death certificates, coroner/medical examiner reports, law enforcement records, and crime laboratory data) for analysis of violent deaths. Using information from all of these sources, data abstractors in each state assign a manner of death (i.e., suicide, homicide, unintentional firearm deaths, legal interventions, and undetermined deaths) to each case. NVDRS also collects the International Classification of Diseases, 10th Revision (ICD-10) code for underlying cause of death (UCOD), circumstances contributing to the death, and characteristics of the death, including victim-suspect relationship and victim toxicology results. The UCOD is categorized as suicide or homicide using standard definitions from the National Vital Statistics System (NVSS) (3--5). For 2004, ICD-10 codes for the UCOD were not reported to NVDRS for 2,773 (19.9%) of the deaths. Because of the high percentage of missing UCOD codes, this report categorizes deaths only by the manner of death assigned by abstractors. The abstractor-assigned manner of death and UCOD ICD-10 codes were consistent in 99.0% and 96.5% of the suicides and homicides, respectively, in 2003, and 95.3% and 93.1%, respectively, of the suicides and homicides in 2004. Analysis of rates was restricted to in-state deaths, including both residents and nonresidents. This report reflects NVDRS data collected through June 2005.

The combined seven states collecting 2003 data accounted for 12.5% of the 2003 U.S. population and for 11.2% of all suicides and 11.5% of homicides in the United States during 2003. The 13 states participating in 2004 accounted for 23.4% of the U.S. population in 2003 and for 23.4% of all suicides and 22.6% of homicides in the United States during 2003. By June 2005, the seven states collecting 2003 data had reported 7,732 violent deaths, and the 13 states collecting 2004 data had reported 13,922.

For the seven states that collected data in 2003 and the 13 that collected data in 2004, suicide accounted for 46.6% (3,603) and 53.0% (7,379) of all NVDRS deaths, respectively. Nearly 26% of deaths reported in NVDRS in both years (2,023 in 2003 and 3,758 in 2004) were homicides. For both years, deaths from legal interventions and unintentional firearm deaths were rare (63 [0.8%] and 54 [0.7%], respectively, in 2003 and 123 [0.9%] and 104 [0.7%], respectively, in 2004).

Deaths of undetermined intent, as determined by state medical examiners according to each state's policies, constituted 25.2% (1,951) of cases in 2003 and 14.8% (2,067) in 2004. The rates of death of undetermined intent varied substantially among states. The 2004 crude death rate for all 13 reporting states was 3.0 per 100,000 population, varying from 0.5 per 100,000 population in South Carolina and North Carolina to 11.0 per 100,000 population in Rhode Island and Maryland. The variation is attributable, in part, to differences in state policies for classifying deaths.

Suicide

The age-adjusted suicide rate^† for the seven states collecting both 2003 and 2004 data decreased from 9.7 per 100,000 population in 2003 to 9.1 in 2004. In the seven states that collected data in both 2003 and 2004, the 2004 age-adjusted suicide rate for men (15.2 per 100,000 population) was more than four times higher than the rate for women (3.6 per 100,000 population). For the 13 states collecting data in 2004, the age-adjusted suicide rate for 2004 (10.6 per 100,000 population) was similar to the preliminary rate reported for the United States overall in NVSS for 2004 (10.7 per 100,000 population) (6). Overall in 2004, the highest suicide rates were among persons aged >35 years (12.6 per 100,000 population for persons aged 35--64 years and 12.1 per 100,000 population for persons aged >65 years). The highest suicide rate among males was in the >65 years age group (28.9 per 100,000 population); the highest suicide rate for females was in the 25--64 years age group (6.9 per 100,000 population).

For the 3,603 reported suicides in 2003, circumstance information was available for 88.5% (3,189) of cases (Figure 1). For the 7,379 suicides in 2004, information was available for 80.6% (5,951). Circumstances contributing to suicide were similar in both years, with nearly half of the suicide cases involving at least one documented mental health diagnosis. The most frequently reported mental health diagnoses were depression (85.2%), bipolar disorder (7.4%), and schizophrenia (3.3%) in 2004. Roughly half of victims were described by family or friends as being depressed before the time of death. Problems with a current or former intimate partner contributed to 27.9% of suicides. Physical health problems, most commonly in older adults, contributed to approximately 24.9% of the suicides. Nearly 19.0% of suicide victims had made previous attempts, and 16.5% had alcohol dependence problems.

Homicide

The age-adjusted homicide rate^§ for the seven states collecting both 2003 and 2004 data was 5.6 per 100,000 population in 2003 and 5.1 in 2004. The 2003 and 2004 rates for the United States overall in NVSS were 6.1 and 5.6 per 100,000 population, respectively (6,7). For the seven states, the highest rate (12.4 per 100,000 population) was reported among victims aged 15--24 years. Homicide rates tended to decrease with age for victims aged >24 years. In 2004, the homicide rate for men (8.3 per 100,000 population) was 3.3 times higher than the rate for women (2.5 per 100,000 population). In 2004, the age-adjusted homicide rate for the 13 NVDRS states was 5.4 per 100,000 population.

For the 2,023 reported homicides in 2003, circumstance information was available for 63.2% (1,278) of cases (Figure 2). For the 3,758 homicides in 2004, information was available for 58.1% (2,183). In 25.5% of cases in 2004, a homicide was precipitated by a felony-level crime, most frequently a robbery (44.9%). In 31.8% of these cases, suspects were known to victims, and 20.0% of homicides were directly associated with intimate partner conflict (i.e., one in which an intimate partner killed another partner). Intimate partner violence resulting in death was most common among victims aged 40--44 years. Drugs were involved in approximately 16% of homicides in 2004 with known circumstances, most commonly among victims aged 20--29 years.

Reported by: N Patel, K Webb, D White, Office of Statistics and Programming; L Barker, A Crosby, M DeBerry, L Frazier, D Karch, N Lipskiy, K Shaw, M Steenkamp, S Thomas, Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note:

Preliminary 2004 national homicide and suicide data from NVSS indicate a decline in rates from 2003 levels (6); data from the seven states in NVDRS collecting data in both 2003 and 2004 also indicate a decline. Violent deaths continue to be among the 10 leading causes of death in the United States for persons aged <65 years (3).

Because NVDRS collects circumstance information for the deaths, the data can be used to describe and monitor the characteristics of suicide and homicide and the prevalence of certain risk factors among homicide and suicide victims. This report demonstrates that mental health disorders and intimate partner conflicts played the largest roles in suicide, whereas felony crimes and intimate partner violence played the largest role in homicide.

The findings in this report are subject to at least three limitations. First, data for 2003 and 2004 are only available from a small proportion of U.S. states, although the intent of NVDRS is to include all U.S. states. Therefore, these data might not be generalizable to the entire U.S. population. Second, processes for classifying of the manner of death differed by jurisdiction. These differences might be attributed to laws governing death investigations or medical examiner/coroner practices. For example, although NVDRS attempts to capture all suicides by investigating cases and collecting data from multiple sources, certain suicides might not be identified as such (e.g., when no evidence of suicidal intent such as a suicide note is present). Finally, circumstance information is collected through medical examiner/coroner and law enforcement reports. Families, friends, and other witnesses might not reveal all the precipitating circumstances to the investigative agencies, possibly resulting in inaccurate or incomplete reports.

Numerous circumstances and personal characteristics contribute to suicides and homicides. NVDRS is the only surveillance system that regularly collects and consolidates information from multiple sources on all violent deaths occurring in participating states. Collecting data on the circumstances of violent deaths will clarify the association of personal and social risk factors with violence and how these factors might change over time (8,9). Thus, NVDRS is in a unique position not only to evaluate the incidence of these events but also to enhance understanding of the associated causes and circumstances. This understanding can be used to improve risk factor identification and design programs that might reduce the number of victims. Additional studies using NVDRS data will allow interpretation of trends in violent deaths and will help identify potential prevention strategies.

Acknowledgments

The findings in this report are based, in part, on contributions of the 13 funded states that collected violent death data and their partners, including personnel from law enforcement, vital records, medical examiners/coroners, and crime laboratories. Contributions also were made by the NVDRS Team, Office of Statistics and Programming staff, and other staff at the National Center for Injury Prevention and Control, CDC.

References

1. Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R, eds. World report on violence and health. Geneva, Switzerland: World Health Organization; 2002.
2. CDC. Homicide and suicide rates---National Violent Death Reporting System, six states, 2003. MMWR 2005;54:377--80.
3. CDC. Web-based injury statistics query and reporting system (WISQARS^™). Available at http://www.cdc.gov/ncipc/wisqars.
4. Miniño AM, Anderson RN, Fingerhut LA, Boudreault MA, Warner M. Deaths: injuries, 2002. Natl Vital Stat Rep 2006;54(10):1--125.
5. National Center for Health Statistics. ICD-10 framework. External cause of injury mortality matrix. Hyattsville, MD: National Center for Health Statistics. Available at http://www.cdc.gov/nchs/about/otheract/ice/matrix10.htm.
6. Miniño AM, Heron MP, Smith BL. Deaths: preliminary data for 2004. Natl Vital Stat Rep 2006;54(19).
7. Hoyert DL, Heron MP, Murphy SL, Kung H. Deaths: final data for 2003. Natl Vital Stat Rep 2006;54(13).
8. Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE, eds. Reducing suicide: a national imperative. Washington, DC: National Academies Press; 2002.
9. CDC. Best practices of youth violence prevention: a sourcebook for community action. Atlanta, GA: US Department of Health and Human Services, CDC; 2000.

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Date last reviewed: 7/6/2006