Racial Differences in Suicide and Undetermined Deaths in Maryland

Undetermined manner of death may obscure the true prevalence of suicide, particularly among Black decedents, and contribute to inequities in health care and autopsy reviews.

To identify and compare health care utilization patterns and classification of death by suicide or undetermined manner of death among Black and White decedents.

This retrospective cohort study used data from the Maryland Suicide Data Warehouse (2012-2020), linking Office of the Chief Medical Examiner records with Maryland Health Care Commission claims. The study included Black and White decedents classified by the Office of the Chief Medical Examiner as suicide or undetermined deaths. The analysis focused on Black and White decedents to align with the study's aim of examining disparities between these groups, and they were the only groups with sufficient sample sizes for meaningful comparison. Data were analyzed from January 2024 to March 2024.

Primary outcomes were manner of death classification and health care use-outpatient, psychiatry, and emergency department visits-in the 12, 6, and 1 month before death. Racial differences by death classification were assessed with χ2 tests.

Among 15 832 Black and White decedents (4798 Black individuals [30.3%] and 11 034 White individuals [69.7%]; 11 572 [73.1%] male; mean [SD] age, 44 [15.1] years), Black decedents' deaths were disproportionately classified as undetermined rather than suicide (3984 [83.0%]) compared with White decedents (7160 [64.8%]) despite similar patient characteristics. Firearms were the most common method of suicide, while overdose or poisoning predominated among undetermined deaths. White decedents compared with Black decedents were more likely to access outpatient care before death (suicide: 595 [49.5%] compared with 105 [41.5%]; χ2 = 5.0; P = .02; undetermined: 504 [20.8%] compared with 193 [14.9%]; χ2 = 18.9; P < .001). Additionally, more White decedents than Black decedents had psychiatry visits before death: 400 (33.3%) compared with 61 (24.1%) at 12 months (χ2 = 7.7; P = .006), 283 (23.5%) compared with 39 (15.4%) at 6 months (χ2 = 7.5; P = .006), and 187 (15.5%) compared with 23 (9.1%) at 1 month (χ2 = 6.5; P = .01). Emergency department visits were also higher among White decedents compared with Black decedents before death: 94 (7.8%) compared with 10 (4.0%) at 12 months (χ2 = 4.1; P = .04) and 73 (6.1%) compared with 6 (2.4%) at 6 months (χ2 = 4.9; P = .03). However, emergency department visit rates for decedents with undetermined deaths were similar across groups.

These findings suggest possible undercounting of suicides and misclassification of undetermined deaths among Black decedents. Addressing these disparities is vital for accurate surveillance and targeted suicide prevention efforts.