Suicide mortality following the implementation of tobacco packaging and pricing policies in Korea: an interrupted time-series analysis.

BACKGROUND: To prevent tobacco use in Korea, the national quitline number was added to tobacco packages in December 2012, tobacco prices were raised by 80% in January 2015, and graphic health warning labels were placed on tobacco packages in December 2016. This study evaluated the association of these tobacco packaging and pricing policies with suicide mortality in Korea. METHODS: Monthly mortality from suicide was obtained from Cause-of-Death Statistics in Korea from December 2007 to December 2019. Interrupted time-series analysis was performed using segmented Poisson regression models. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated adjusted for suicide prevention strategies. RESULTS: Suicide mortality was 20 per 1,000,000 in December 2007 and showed a downward trend over the study period. After the implementation of tobacco packaging and pricing policies, suicide mortality immediately declined by - 0.09 percent points (95% CI = - 0.19 to 0.01; P > 0.05) for the national quitline number, - 0.22 percent points (95% CI = - 0.35 to - 0.09; P < 0.01) for tobacco prices, and - 0.30 percent points (95% CI = - 0.49 to - 0.11; P < 0.01) for graphic health warning labels. The corresponding RRs for these post-implementation changes compared with the pre-implementation level were 0.91 (95% CI = 0.83 to 1.00), 0.80 (95% CI = 0.70 to 0.91), and 0.74 (95% CI = 0.61 to 0.90), respectively. Significant associations between tobacco control policies and suicide mortality were observed even when stratified by sex and region. CONCLUSIONS: The findings of this study provide new evidence for an association between tobacco control policies and deaths by suicide. An array of effective tobacco control policies should be considered for prevention programs targeting suicide.

Suicide disparities across metropolitan areas in the US: A comparative assessment of socio-environmental factors using a data-driven predictive approach.

Disparity in suicide rates across various metropolitan areas in the US is growing. Besides personal genomics and pre-existing mental health conditions affecting individual-level suicidal behaviors, contextual factors are also instrumental in determining region-/community-level suicide risk. However, there is a lack of quantitative approach to model the complex associations and interplays of the socio-environmental factors with the regional suicide rates. In this paper, we propose a holistic data-driven framework to model the associations of socio-environmental factors (demographic, socio-economic, and climate) with the suicide rates, and compare the key socio-environmental determinants of suicides across the large and medium/small metros of the vulnerable US states, leveraging a suite of advanced statistical learning algorithms. We found that random forest outperforms all the other models in terms of both in-sample goodness-of-fit and out-of-sample predictive accuracy, which is then used for statistical inferencing. Overall, our findings show that there is a significant difference in the relationships of socio-environmental factors with the suicide rates across the large and medium/small metropolitan areas of the vulnerable US states. Particularly, suicides in medium/small metros are more sensitive to socio-economic and demographic factors, while that in large metros are more sensitive to climatic factors. Our results also indicate that non-Hispanics, native Hawaiian or Pacific islanders, and adolescents aged 15-29 years, residing in the large metropolitan areas, are more vulnerable to suicides compared to those living in the medium/small metropolitan areas. We also observe that higher temperatures are positively associated with higher suicide rates, with large metros being more sensitive to such association compared to that of the medium/small metros. Our proposed data-driven framework underscores the future opportunities of using big data analytics in analyzing the complex associations of socio-environmental factors and inform policy actions accordingly.

Economic uncertainty and suicide in the United States.

Previous studies have found an association between recessions and increased rates of suicide. In the present study we widened the focus to examine the association between economic uncertainty and suicides. We used monthly suicide data from the US at the State level from 2000 to 2017 and combined them with the monthly economic uncertainty index. We followed a panel data econometric approach to study the association between economic uncertainty and suicide, controlling for unemployment and other indicators. Economic uncertainty is positively associated with suicide when controlling for unemployment [coeff: 8.026; 95% CI: 3.692-12.360] or for a wider range of economic and demographic characteristics [coeff: 7.478; 95% CI: 3.333-11.623]. An increase in the uncertainty index by one percent is associated with an additional 11-24.4 additional monthly suicides in the US. Economic uncertainty is likely to act as a trigger, which underlines the impulsive nature of some suicides. This highlights the importance of providing access to suicide prevention interventions (e.g. hotlines) during periods of economic uncertainty.

Sociodemographic Factors, Health Behaviors, and Biological Indicators Associated With Suicide Mortality Among Young Adults in South Korea: A Nationwide Cohort Study Among 15 Million Men and Women.

OBJECTIVE: The role of sociodemographic factors, health behaviors, and biological indicators as potential risk factors for suicide is relatively understudied among young adults. The aim of this study is to explore the association of these variables with the risk of death by suicide among young adults. METHODS: The study population consisted of 15,534,438 individuals aged 20-39 years from the Korean National Health Insurance Service. Sociodemographic factors associated with death by suicide during 2006-2015 were evaluated. 3,396,353 individuals who underwent health examinations between 2002 and 2005 were separately assessed for health behaviors and biological indicators associated with death by suicide. Cox proportional hazards regression analysis was used to determine the hazard ratios (HRs) and 95% confidence intervals (CIs) for suicide mortality according to sociodemographic factors (age, household income, job status, residence, and Charlson comorbidity index score), health behaviors (physical activity, smoking, and alcohol consumption), and biological indicators (blood pressure, total cholesterol level, body mass index, and fasting serum glucose level). RESULTS: Low household income, self- and non-employment, increased comorbidity, smoking, and normal weight elevated the risk of death by suicide among young adults. While older age was associated with elevated risk for death by suicide among men (adjusted HR [aHR] = 2.11; 95% CI, 2.02-2.20 for men aged 35-39 years), older age reduced the risk for death by suicide among women (aHR = 0.72; 95% CI, 0.69-0.75 for women aged 35-39 years). Elevated blood pressure and fasting serum glucose level were associated with increased risk for death by suicide among men (aHR = 1.16; 95% CI, 1.05-1.28 and aHR = 1.48; 95% CI, 1.26-1.75, respectively). Finally, high total cholesterol levels were associated with increased risk for death by suicide among women (aHR = 1.59; 95% CI, 1.19-2.13). CONCLUSIONS: Sociodemographic factors, health behaviors, and biological indicators were associated with suicide mortality among young adults.

Small but protective social capital against suicide ideation in poor communities: A community-based cross-sectional study.

Coupled with the lowest level of social connectedness, South Korea has the highest suicide rate among the Organization for Economic Co-operation and Development countries. A possible link between community and suicide is social capital imprinted in social connectedness. This study explores whether social capital is protective against suicide ideation in relation to the poverty level of communities, and whether the associations are specific to certain elements of social capital.A total of 908 participants were included to assess cross-sectional association of social capital at individual level with suicide ideation by comparing between poor (government-leased apartments) and non-poor communities (nongovernment-leased apartments). Logistic regression analyses were performed to examine various social capital dimensions in relation to suicide ideation.Suicide ideation was far higher among those living in the poor communities (poor communities 12%; non poor communities 6.3%) and the level of social capital was lower in the poor communities. Nevertheless, the protective effect of social capital, in particular, the cognitive dimension against suicide ideation was demonstrated only in the poor communities (eg, odds ratio = 0.27, 95% confidence interval: 0.12-0.58 for trust in the poor communities). Low income was significantly associated with suicide ideation only in the poor communities, but depression and resilience were associated with suicide ideation both in the poor and non-poor communities.To increase the reliability of the results, established measures based on relevant literature were utilized, but measures on bridging social capital and social network might have relatively low reliability.As to protection against suicide ideation, the extent of reliance on social capital was higher in poor communities than in non-poor communities, in particular, the cognitive dimension was likely to activate in this regard.

Income inequality and suicide in the United States: A spatial analysis of 1684 U.S. counties using geographically weighted regression.

BACKGROUND: Suicide rates vary considerably across U.S. counties. Spatial non-stationarity may explain mixed findings on the relationship between suicide and income inequality. METHODS: This ecological study analyzed county-level income inequality and suicide rates for the timespan 2012-2016. Ordinary least squares regression, multilevel regression, and geographically weighted regression models were constructed while adjusting for age, race/ethnicity, gender, education, median income, unemployment, and urbanicity. RESULTS: Ordinary least squares regression and multilevel models found no significant association between income inequality and county suicide rates after adjusting for confounding variables. However, the geographically weighted regression model identified two main areas in which income inequality was negatively associated with suicide rates, as well as several counties across central U.S. in which income inequality was positively associated with suicide rates. CONCLUSION: Income inequality's effect on county suicide rates may vary across space. Future research should consider spatial non-stationarity when studying suicide and macro-level socioeconomic conditions.

Aggregated COVID-19 suicide incidences in India: Fear of COVID-19 infection is the prominent causative factor.

Many Indian COVID-19 suicide cases are turning the press-media attention and flooding in the social media platforms although, no particular studies assessed the COVID-19 suicide causative factors to a large extent. Therefore, the present study presents 69 COVID-19 suicide cases (aged 19 to 65 years; 63 cases were males). The suicide causalities are included as follows - fear of COVID-19 infection (n=21), followed by financial crisis (n=19), loneliness, social boycott and pressure to be quarantine, COVID-19 positive, COVID-19 work-related stress, unable to come back home due to lockdown, unavailability of alcohol etc. Considering the extreme psychological impacts related to COVID-19, there emerges a need for countrywide extensive tele-mental health care services.

Projected increases in suicide in Canada as a consequence of COVID-19.

Macroeconomic indicators, notably unemployment, are significant moderators of suicide. We projected the number of excess suicides in Canada as a consequence of the impact of COVID-19 on unemployment. Annual suicide mortality (2000-2018) and unemployment (2000-2019) data were derived from Statistics Canada. Time-trend regression models were used to evaluate and predict the number of excess suicides in 2020 and 2021 for two possible projection scenarios following the COVID-19 pandemic: 1) an increase in unemployment of 1.6% in 2020, 1.2% in 2021, or 2) an increase in unemployment of 10.7% in 2020, 8.9% in 2021. A percentage point increase in unemployment was associated with a 1.0% increase in suicide between 2000 and 2018. In the first scenario, the rise in unemployment rates resulted in a projected total of 418 excess suicides in 2020-2021 (suicide rate per 100,000: 11.6 in 2020). In the second scenario, the projected suicide rates per 100,000 increased to 14.0 in 2020 and 13.6 in 2021, resulting in 2114 excess suicides in 2020-2021. These results indicate that suicide prevention in the context of COVID-19-related unemployment is a critical priority. Furthermore, timely access to mental healthcare, financial provisions and social/labour support programs, as well as optimal treatment for mental disorders is urgently needed.

Economic and epidemiological impact of youth suicide in countries with the highest human development index.

This research estimates the economic and epidemiological impact of youth suicide in countries with the highest human development index. The study relied on secondary analysis of suicide mortality data for youth aged between 15-24 years in countries with the highest human development index-Norway, Australia, Switzerland, Germany, Denmark, Singapore, Netherlands, Ireland, Canada and the United States. The impact of youth suicide is measured using years of life lost, years of productive life lost and present economic value of lost productivity. Costs are expressed in 2014 International dollars. Future earning potential is estimated using adjusted gross domestic product per capita, employment potential and historical trends in productivity and real interest rates. In 2014, an estimated 6,912 young people living in the most developed countries in the world lost their lives to suicide. These preventable deaths resulted in a loss of 406,730 years of life at a cost of $5.53 billion in lost economic income with the average cost of suicide estimated at $802,939. The United States stands out as a country with the most significant youth suicide problem accounting for 77% of total costs. Reducing youth suicide requires a multifaceted approach and significant investment by governments.

The cost of hospitalisation for youth self-harm: differences across age groups, sex, Indigenous and non-Indigenous populations.

OBJECTIVE: To report the comparative rates, average length of stay and cost per episode of hospital management for self-harm in three age cohorts: 15-19 years, 20-24 years and 25-29 years; by sex and indigeneity. DESIGN, SETTING, PARTICIPANTS: A secondary data analysis of the Australian Institute of Health and Welfare (AIHW) dataset between 1st January 2014 and 31st December 2014 inclusive. MAIN OUTCOME MEASURES: Cost per episode of hospitalised self-harm and rates by age group, sex and Indigenous status. RESULTS: The rate of hospitalised self-harm among Australian youth was 254.0 per 100,000 population. This rate resulted in an annual cost to the healthcare system of AU$55 million or an average cost per episode of $4649 (95% CI $4488:$4810). Hospitalised self-harm was 21 times higher than the rate of suicide (11,820 episodes of hospitalised self-harm/564 suicides). Indigenous youth had on average a 1.4 times higher rate of hospitalised self-harm and 2.2 times higher rate of suicide than non-Indigenous counterparts. When controlling for age and sex, the average cost per episode was significantly lower for Indigenous youth compared to non-Indigenous youth, estimated marginal means $4538 and $4954, respectively (p < 0.001). CONCLUSIONS: Hospitalised self-harm among Australian youth resulted in a substantial cost to the healthcare system. This cost is only part of the overall burden associated with self-harm. The rate of hospitalised self-harm was significantly higher in Indigenous youth, but the associated cost per episode was significantly lower.

Individual and socio-demographic determinants of suicide: An examination on WHO countries.

BACKGROUND: Suicide cases have psychological, socio-economic and cultural aspects, and such cases may have catastrophic impacts in societies due to their outcomes. PURPOSE: This study was aimed to reflect the effect of psychological, behavioral, socio-demographic and economic determinants on suicide. METHODS: The Ordinary Least Square (OLS) Regression Analysis was utilized for the purposes of this study. Five models were established. In this contex, the first model includes the variables on psychological determinants; the second model with the variables on behavioral determinants; the third model with the variables on socio-demographic determinants; the fourth model with the variables on economic determinants and finally the fifth model with all of the independent variables. CONCLUSION: According to the results, the variables of depression prevalence, alcohol consumption and unemployment rates had statistically significant effect on the suicide cases (p < .05). The study's outcomes are considered to contribute on the evidence-based policy development process.

Can Financial Support Reduce Suicide Mortality Rates?

After the launch of governmental financial support for the development of a regional suicide prevention programme, 'Emergency Fund to Enhance Community-Based Suicide Countermeasure' in 2009, suicide mortality rates in Japan have decreased from 25.7 (in 2009) to 16.5 (in 2018) per 100,000 population. Therefore, to explore the effects of governmental financial support on suicide mortality rates in Japan, the present study determined the relationship between the trends of empirical Bayes standardised Mobile Ratio of suicide mortality ratio in all 47 Japanese prefectures (EBSMR-RR) and the execution amounts of 10 sub-divisions of 'Emergency Fund to Enhance Community-Based Suicide Countermeasure' using stepwise multiple regression analysis. The female EBSMR-RR was only significantly/inversely related to the municipal 'development of listeners and leaders', whereas male EBSMR-RR was significantly/inversely related to prefectural 'enlightenment', and 'intervention models', but significantly/directly related to prefectural 'personal consultation support'. The present findings suggest the inverse relationship between financial support and the suicide mortality rates in Japan. Furthermore, the independent factors in the reduction of suicide mortality rates between males and females provide important information for planning a scientifically evidence-based and more cost-effective regional suicide prevention programmes.

Heroin overdose masquerades as methomyl poisoning: a case report.

BACKGROUND: Methomyl is the most common cause of suicidal death but heroin is the most common cause of accidental death. The problem is to determine the exact cause and manner of death between methomyl or heroin toxicity. The evidence from autopsy includes crime scene investigation, toxicological analysis by liquid chromatography with mass spectrometry, and knowledge of methomyl and heroin intoxication. CASE PRESENTATION: A 35-year-old Thai man and a 30-year-old Thai woman were found showing evidence of cyanosis, with a fine froth around the nose and mouth. Postmortem interval time was 24 hours. According to the police's and hotel owner's records, the couple stayed together for 1 day before being found dead in bed, naked, with a foul and a fine froth around the nose and mouth. A methomyl insecticide sachet and a plastic box containing white powder form of heroin were found at the scene. Laboratory tests of the male corpse identified the presence of methomyl in the blood of the stomach and morphine, codeine, methadone, and tramadol in the systemic blood. Blood cholinesterase enzyme activity and morphine concentration was 3416 U/L or 53% (normal 6400 U/L) and 0.058 µg/ml respectively. Laboratory test of the female corpse identified the presence of methomyl in the stomach and blood, and cholinesterase enzyme activity was 1965 U/L or 30.7%. CONCLUSIONS: Cause of death of the male corpse was deemed to be due to heroin intoxication as the blood concentration of morphine was more than the lethal concentration with a morphine/codeine ratio of more than 1:1. Methomyl intoxication of the male corpse was unlikely to be the cause of death because methomyl systemic blood concentration was found to be very low, < 2.5 µg/ml, and cholinesterase enzyme levels did not indicate lethal activity (< 10-15% of normal). The main problem regarding an insurance claim is that the policy will not pay out in the case of heroin-associated deaths, as it is an addictive drug. The policy would pay out on death by suicide with methomyl insecticide, which was not prohibited by the insurance company after 1 year of insurance. So, it is not clear whether or not the family will receive money from the insurance company.

Estimating the government health-care costs of treating pesticide poisoned and pesticide self-poisoned patients in Sri Lanka.

Background: Pesticide self-poisoning as a method of suicide is a major global health problem.Objectives: To estimate the cost and per patient cost of treating pesticide self-poisoning at different hospital levels in a Sri Lankan district, and to examine the distribution of cost components. Another objective was to investigate changes in total cost of treatment of pesticide poisoning for all causes at different administrative levels in Sri Lanka in 2005 and 2015.Methods: The economic framework was a costing analysis, adopting a government perspective. Cost data were collected prospectively over a 4-month period in 2016 for patients admitted for pesticide self-poisoning to six hospitals in the Anuradhapura District. Assumption-based scenario analyses were run to determine changes in total pesticide poisoning treatment costs.Results: We included 67 self-poisoned patients in the study. The total cost of treatment was US$ 5,714 at an average treatment cost of US$ 85.3 (9.7-286.6) per patient (across all hospital levels). Hospital costs constituted 67% of the total cost for treating self-poisoning cases and patient-specific costs accounted for 29%. Direct cost of patient hospital transfer constituted the smallest share of costs (4%) but accounted for almost half of the total costs at primary level. The estimated total cost of treating all causes of pesticide poisoning in Sri Lanka was US$ 2.5 million or 0.19% of the total government health expenditure (GHE) in 2015.Conclusion: Our findings indicate that the average per patient cost of pesticide self-poisoning treatment has increased while the total cost of pesticide poisoning treatment as a percentage of the total GHE in Sri Lanka has declined over the past decade. A continuous focus on banning the most hazardous pesticides available would likely further drive down the cost of pesticide self-poisoning and pesticide poisoning to the government.

Socioeconomic predictors of suicide risk among cancer patients in the United States: A population-based study.

OBJECTIVE: To assess the socioeconomic predictors of suicide risk among cancer patients in the United States. METHODS: Cancer patients available within Surveillance, Epidemiology and End Results (SEER) database who were diagnosed between 2000-2010 have been reviewed. Linkage analysis to Census 2000 SF files was conducted to determine area-based socioeconomic attributes. Observed/ Expected ratios were calculated for the overall cohort as well as for clinically and socioeconomically defined subgroups. "Observed" is the number of observed completed suicide cases in the studied cohort; while "Expected" is the number of completed suicide cases in a demographically similar cohort within the United States and within the same period of time. RESULTS: The current study reviews a total of 3,149,235 cancer patients (diagnosed 2000-2010) within the SEER database. Regarding socioeconomic county attributes, higher risk of suicide seems to be associated with lower educational attainment (O/E for counties with > 20% individuals with less than high school education: 1.41; 95% CI: 1.35-1.47), poverty rates (O/E for counties with > 5% individuals below poverty line: 1.39; 95% CI: 1.34-1.43), unemployment rates (O/E for counties with >5% families below poverty line: 1.36; 95% CI: 1.31-1.41) and less people living in urban areas (O/E for counties with < 50% individuals living in urban areas: 1.63; 95% CI: 1.50-1.77). On the other hand, risk of suicide seems to be inversely related to a higher representation of foreign-born individuals (O/E for counties with < 5% foreign-born individuals: 1.56; 95% CI: 1.47-1.65); and inversely related to a higher representation with recent immigrants to the US (O/E for counties with < 5% recent immigrants: 1.33; 95% CI: 1.29-1.38). CONCLUSIONS: Cancer patients living in a socioeconomically vulnerable environment (lower educational status, poverty, and unemployment) seem to have higher suicide risk compared to other cancer patients.

An association of economic hardship with depression and suicidality in times of recession in Greece.

The interplay between objective and subjective measures of economic hardship on influencing mental health has not been explored during a period of enduring recession. The present study aims to fill this gap by investigating the relationship between income and economic difficulties in evoking major depression and suicidality in Greece, while taking into consideration gender differences. A random and representative sample of 2188 adults participated in a telephone survey in 2013 (response rate = 81%). Major depression and suicidality were assessed with the pertinent modules of SCID-IV; while financial difficulties were measured by the Index of Personal Economic Distress. Information on confounder variables was also gleaned. Income exerted an independent effect on major depression (OR = 0.37, 95%CI = 0.22-0.63), which was more pronounced among men than women. On the contrary, financial difficulties exerted a strong and independent effect on depression (OR = 1.16, 95%CI = 1.13-1.2). Income was found to bear a strong association with suicidality only among men; whereas financial difficulties were unrelated in both genders. Subjective and objective indices of economic hardship exert a differential impact on mental health outcomes amid recession. Gender-sensitive policies and interventions should be geared towards softening the social effects of the recession in the country.

Socioeconomic position and suicidal behaviour in rural Sri Lanka: a prospective cohort study of 168,000+ people.

PURPOSE: Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high income countries, but this association is not established in low- and middle-income countries (LMIC). METHODS: We investigated the association of SEP with suicidal behaviour in a prospective cohort study of 168,771 Sri Lankans followed up for episodes of attempted suicide and suicide. SEP data were collected at baseline at the household and individual level at the start of the follow-up period. We used multilevel Poisson regression models to investigate the association of SEP at community, household and individual levels with attempted suicide/suicide. RESULTS: Lower levels of asset ownership [IRR (95% CI) suicide 1.74 (0.92, 3.28); attempted suicide 1.67 (1.40, 2.00)] and education [suicide 3.16 (1.06, 9.45); attempted suicide 2.51 (1.70, 3.72)] were associated with an increased risk of suicidal behaviour. The association of these measures of SEP and attempted suicide was stronger in men than women. Individuals living in deprived areas [1.42 (1.16, 1.73)] and in households with a young female head of household [1.41 (1.04, 1.93)] or a temporary foreign migrant [1.47 (1.28, 1.68)] had an elevated risk of attempted suicide. Farmers and daily wage labourers had nearly a doubling in risk of attempted suicide compared to other occupations. CONCLUSIONS: Improved employment opportunities, welfare and mental health support services, as well as problem-solving skills development, may help support individuals with poorer education, farmers, daily wage labourers, individuals in young female-headed households and temporary foreign migrant households.