Introduction. Suicides are not uncommonly hidden among undetermined/other causes of death. Do concealed suicides represent an “elephant in the room” scenario for suicide research?
Methods. Literature review (PubMed). Keywords: Suicide, classification, undetermined deaths, underreporting.
Results. Seven articles closely matched our search. Suicide deaths appear underestimated by approximately 10%. Underreporting could be due to the severe social stigma and the difficulty to categorize “suspect” deaths as suicides in the absence of witness(-es), suicide notes or known psychiatric history. Occasionally, forensic experts want to spare the family of the defunct from additional pain, particularly when younger people or children are involved. “Slow” suicides -conscious decision of protracted malnutrition, substance abuse or neglect of somatic therapies with a lethal intention- is another issue. Furthermore, deaths following hospitalization for a past suicide attempt are frequently attributed to the medical complications rather than to the suicidal act itself. Deaths by “active” methods -firearm use, cutting or hanging- are more easily attributed to suicide than “passive” ones, like poisoning or drowning. The latter appear more frequently chosen by females; hence, an underestimation of female suicides seems more probable. Finally, some deaths due to jumping from a height, being victim of fire or getting run over may conceal suicides unrecognized as such without reliable supportive evidence.
Conclusion. Concealed suicides do not seem to fit the bill for an “elephant in the room” scenario. Nevertheless, better and constant training of forensic experts and continuous anti-stigma efforts are needed for further ameliorating the quality of suicide mortality statistics.

CONCEALED SUICIDES: WHAT DO THEY (NOT) TELL US?