Johns Hopkins University Press · Hardcover & e‑book
A Forward Path
Suicide in the United States is undercounted, and the drug overdose epidemic has made the problem worse. Drawing on more than 35 years of research, injury epidemiologist Ian Rockett shows why our official numbers fall short, who gets missed, and how a broader measure, self-injury mortality, can reveal the true scale of the crisis.
Prefer to read on screen? The digital e-book edition is available now.
About the book
Suicide carries a heavy stigma, and it is often recorded as something else: an accident, a death of undetermined intent, or a natural death. Insurance rules, religious prohibitions, family pressure and overstretched, under-resourced medical examiner and coroner systems all push suicide counts down. Most people affected by suicide, and many researchers, don't know how large this gap is.
The book follows the story from the early pioneers of suicide research to the twin epidemics of suicide and opioid overdose, and the COVID-19 pandemic. It asks why registered suicide rates for Black Americans are far lower than for White Americans, and whether that gap is partly an artifact of how deaths are investigated. It shows that drug-poisoning suicides are especially hard to detect when there is no note, no record of a prior attempt and no psychiatric history, which is the usual situation.
Rockett's answer is to change what we measure. Self-injury mortality (SIM) counts all registered suicides plus the drug deaths that reflect patterns of repeated self-injury, whether or not the person intended to die that day. Seen through SIM, America's mental health crisis is national, not confined to the West and Mountain states, and it has grown faster for women and minorities than official suicide rates suggest. The book closes with a practical proposal: a self-injury checkbox on the US death certificate.
The big idea
To record a death as suicide, a medical examiner or coroner must judge what the person intended. With drug deaths there is usually no note, no record of a prior attempt and no psychiatric history to go on, so most are recorded as accidents. Rockett and colleagues stopped trying to guess intent after death and looked instead at what people did before they died.
DDSI looks at behavior before death, such as the repeated acquisition and misuse of drugs, rather than inferring intent afterward. Seen this way, most drug intoxication deaths are the end point of patterned, repeated self-harm. A DDSI can name the drugs involved, for example DDSI (heroin) or DDSI (ethanol, temazepam).
SIM builds on DDSI to go beyond registered suicides. It counts every registered suicide, by any method, plus drug self-intoxication deaths officially recorded as accidents or of undetermined intent, whether or not the person meant to die that day.
How SIM is estimated: all registered suicides at any age, plus 80% of “accidental” and 90% of undetermined-intent drug poisoning deaths among people aged 15 and older.
Today researchers have to estimate SIM. A self-injury checkbox on the US death certificate, spanning suicide, accident and undetermined deaths, would let medical examiners and coroners record it directly.
Why it matters. Seen through SIM, America's mental health crisis is national rather than regional, and it has grown faster for women and racial/ethnic minorities than official suicide rates suggest. SIM also brings suicide prevention and overdose prevention together, two efforts that are usually funded, researched and treated separately.
From the foreword
“This book has immediate appeal to a broad collaborative of specialists involved in finding improved solutions for the nation’s relentless problem of premature deaths due to drug use and suicide.”
Hilary S. Connery, MD, PhD
MGB McLean Hospital; Harvard Medical School
Contents
Also includes a preface, foreword, executive summary, glossary, references and index.
Excerpt
Suicide is a highly emotional and socially stigmatized phenomenon which often goes unreported. Undercounting and differential misclassification of suicide under other mortality categories, such as accident or undetermined intent, distort observed suicide trends, patterns, and their interpretation.
I admit there are formidable impediments to remediation, in sharing this cautionary story of suicide undercounting and differential misclassification. That said, the quest for perfection should not shackle us. To lessen the challenges of suicide accounting, I will propose broadening the fatal self-injury domain by deploying a concept that is a more appropriate representative than registered suicides alone.
Losing a loved one through suicide is excruciating for families and other intimates of the deceased. The impact of such losses often reverberates through neighborhoods and communities.
Most people affected by suicide, and seemingly many suicide researchers as well, are oblivious to the problems inherent in suicide undercounting. Forces depressing suicide counts include social stigma, religious prohibitions, punitive provisions in life insurance policies, training deficits among first responders and death investigators, scarce resources, and inadequate infrastructures for conducting comprehensive medicolegal death investigations.
If the popular adage “we get what we pay for” is true, then suicide accounting in the United States is in a dubious and fragile state and a simultaneous threat to clinical medicine and public and population health.
Reviews
“This book stands out as the definitive overview of research on suicide classification… Hidden Suicides and Fatal Overdoses will likely become an essential reference for scholars studying suicide, death and dying, medicolegal systems, mental health and addiction, and the social production of health data.”
“The book is confronting, but is strongly recommended for clinicians, suicidologists and coroners.”
“Ian Rockett argues persuasively that suicide misclassification in the United States presents a huge barrier to addressing one of our major causes of death and suggests a creative solution… an accessible window into a ballooning crisis.”
“Professor Rockett’s essential book reveals unacceptable deficiencies in the way America counts suicide and overdose fatalities, while presenting a groundbreaking framework for understanding self-injury. He highlights the serious and mounting consequences of conceptualizing suicide and overdose deaths as separate threats and establishes a robust basis for revitalizing preventative initiatives.”
“This is a unique and remarkable book, tracing both the development of a field of inquiry and the author’s academic/intellectual journey. It brings together a very diverse literature in a compelling and rigorous fashion.”
“This book has significant implications for how the American medicolegal death investigation system investigates and classifies deaths. The author employs a pragmatic approach to push past the limitations and challenges in characterizing the antemortem intent and certifying the manner of death of a decedent who dies of a drug overdose.”
“Ian Rockett tackles the neglected problem of suicide mismeasurement and proposes a solution from a sociology of knowledge perspective. He compellingly illustrates how suicide undercounting adversely impacts the understanding of a phenomenon and the adequacy of proposed policy interventions.”
“An authoritative book that should appeal to an educated general audience as well as to professionals immersed in suicide investigation, research and prevention.”
“Reading Ian Rockett’s elegant, eloquent summation of his work to illuminate and elevate American and world suicide data… Repeatedly, I also was gripped by ‘aha’ moments.”
In the media
Ian Rockett wrote a Hidden Suicides and Fatal Overdoses blog for Psychology Today. The magazine posted it digitally around the world.
America’s suicide rate is rising. The real number of suicides may be much higher than the official one.
About the author
Ian Rockett is a population scientist and injury epidemiologist who has studied the quality of suicide data for more than 35 years. Rockett introduced the concepts of death from drug self-intoxication (DDSI) and self-injury mortality (SIM), which bring suicides and self-injury drug deaths into a single measure for research and prevention.
Raised in Perth, Western Australia, Rockett studied history at the University of Western Australia, sociology at Western University in Canada, demography and medical sociology at Brown University (PhD), and epidemiology and biostatistics at Harvard University (MPH). Most of the research described in this book was carried out at West Virginia University's Health Sciences Center. This is Rockett's first book.
Get the book
Published January 2026 by Johns Hopkins University Press. Available in hardcover and as a digital e-book, each $59.95. ISBN 978-1-4214-5364-4.
Also available from Waterstones · Blackwell’s · World of Books · AbeBooks · Walmart · Indigo · Woodslane Health and other booksellers worldwide.
Talks, media and contact
Ian Rockett speaks to clinicians, public health and forensic audiences, students and the public about suicide data quality, the overdose crisis and self-injury mortality.
Get in touch