Suicide, Alcohol Intoxication, and Age Among Whites and American Indians/Alaskan Natives.

BACKGROUND: Among American Indians/Alaskan Natives (AI/ANs), suicides are disproportionately high among those younger than 40 years of age. This paper examines suicide and alcohol intoxication (postmortem BAC ≥ 0.08 g/dl) by age among Whites and AI/ANs to better understand the reasons for the high rate of suicide among AI/ANs for those younger than 40. METHODS: Data come from the restricted 2003 to 2016 National Violent Death Reporting System (NVDRS), with postmortem information on 79,150 White and AI/AN suicide decedents of both genders who had a BAC test in 32 states of the United States. RESULTS: Among Whites, 39.3% of decedents legally intoxicated are younger than 40 years of age, while among AI/ANs the proportion is 72.9% (p < 0.001). Multivariable logistic regression with data divided by age shows that in the 18 to 39 age group, AI/ANs are about 2 times more likely than Whites to have a postmortem BAC ≥ 0.08. Veteran status compared to nonveteran, and history of alcohol problems prior to suicide were also associated with BAC ≥ 0.08. Suicide methods other than by firearm and a report of the presence of 2 or more suicide precipitating circumstances were protective against BAC ≥ 0.08. Results for the age group 40 years of age and older mirror those for the younger group with 1 exception: Race/ethnicity was not associated with BAC level. CONCLUSIONS: The proportion of suicide decedents with a BAC ≥ 0.08 is higher among AI/ANs than Whites, especially among those 18 to 39 years of age. However, acute alcohol intoxication does not fully explain differences in suicide age structure between AI/ANs and Whites.

Heavy Alcohol Use Among Suicide Decedents Relative to a Nonsuicide Comparison Group: Gender-Specific Effects of Economic Contraction.

BACKGROUND: The primary objective of this gender-stratified study was to assess the rate of heavy alcohol use among suicide decedents relative to a nonsuicide comparison group during the 2008 to 2009 economic crisis. METHODS: The National Violent Death Reporting System and the Behavioral Risk Factor Surveillance System were analyzed by gender-stratified multiple logistic regression to test whether change in acute intoxication (blood alcohol content ≥0.08 g/dl) before (2005 to 2007), during (2008 to 2009), and after (2010 to 2011) the Great Recession mirrored change in heavy alcohol use in a living sample. RESULTS: Among men, suicide decedents experienced a significantly greater increase (+8%) in heavy alcohol use at the onset of the recession (adjusted ratio of odds ratio = 1.15, 95% confidence interval = 1.10 to 1.20) (relative to the prerecession period) than did men in a nonsuicide comparison group (-2%). Among women, changes in rates of heavy alcohol use were similar in the suicide and nonsuicide comparison groups at the onset and after the recession. CONCLUSIONS: Acute alcohol use contributed to suicide among men during the recent economic downturn. Among women who died by suicide, acute alcohol use mirrored consumption in the general population. Women may show resilience (or men, vulnerability) to deleterious interaction of alcohol with financial distress.

Precipitating Circumstances of Suicide and Alcohol Intoxication Among U.S. Ethnic Groups.

BACKGROUND: Our goal was to assess the prevalence of 9 different types of precipitating circumstances among suicide decedents, and examine the association between circumstances and postmortem blood alcohol concentration (BAC ≥ 0.08 g/dl) across U.S. ethnic groups. METHODS: Data come from the restricted 2003 to 2011 National Violent Death Reporting System, with postmortem information on 59,384 male and female suicide decedents for 17 U.S. states. RESULTS: Among men, precipitating circumstances statistically associated with a BAC ≥ 0.08 g/dl were physical health and job problems for Blacks, and experiencing a crisis, physical health problems, and intimate partner problem for Hispanics. Among women, the only precipitating circumstance associated with a BAC ≥ 0.08 g/dl was substance abuse problems other than alcohol for Blacks. The number of precipitating circumstances present before the suicide was negatively associated with a BAC ≥ 0.08 g/dl for Whites, Blacks, and Hispanics. CONCLUSIONS: Selected precipitating circumstances were associated with a BAC ≥ 0.08 g/dl, and the strongest determinant of this level of alcohol intoxication prior to suicide among all ethnic groups was the presence of an alcohol problem.

Short-term variability in outpatient pain intensity scores in a national sample of older veterans with chronic pain.

OBJECTIVE: The Department of Veterans Affairs (VA) uses the 11-point pain numeric rating scale (NRS) to gather pain intensity information from veterans at outpatient appointments. Yet, little is known about how NRS scores may vary over time within individuals; NRS variability may have important ramifications for treatment planning. Our main objective was to describe variability in NRS scores within a 1-month timeframe, as obtained during routine outpatient care in older patients with chronic pain treated in VA hospitals. A secondary objective was to explore for patient characteristics associated with within-month NRS score variability. DESIGN: Retrospective cohort study. SUBJECTS: National sample of veterans 65 years or older seen in VA in 2010 who had multiple elevated NRS scores indicating chronic pain. METHODS: VA datasets were used to identify the sample and demographic and clinical variables including NRS scores. For the main analysis, we identified subjects with two or more NRS scores obtained in each of two or more months in a 12-month period; we examined ranges in NRS scores across the first two qualifying months. RESULTS: Among 4,336 individuals in the main analysis cohort, the mean and median of the average NRS score range across the 2 months were 2.7 and 2.5, respectively. In multivariable models, main significant predictors of within-month NRS score variability were baseline pain intensity, overall medical comorbidity, and being divorced/separated. CONCLUSIONS: The majority of patients in the sample had clinically meaningful variation in pain scores within a given month. This finding highlights the need for clinicians and their patients to consider multiple NRS scores when making chronic pain treatment decisions.

Correlates of suicide among veterans treated in primary care: case-control study of a nationally representative sample.

BACKGROUND: Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death. OBJECTIVE: Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care. DESIGN: This was a retrospective case-control study. SUBJECTS: The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician. MAIN MEASURES: Demographic, diagnosis, and utilization data were obtained from VA's Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide. KEY RESULTS: Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR = 0.51; 95 % CI = 0.27-0.98) and VA service-connected disability (OR = 0.54; 95 % CI = 0.36-0.80) were associated with decreased odds of suicide, while anxiety disorder (OR = 3.52; 95 % CI = 1.79-6.92), functional decline (OR = 2.52; 95 % CI = 1.55-4.10), depression (OR = 1.82; 95 % CI = 1.07-3.10), and endorsement of suicidal ideation (OR = 2.27; 95 % CI = 1.07-4.83) were associated with greater odds of suicide. CONCLUSIONS: Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.

The effects of misclassification biases on veteran suicide rate estimates.

OBJECTIVES: We assessed the impact that possible veteran suicide misclassification biases (i.e., inaccuracy in ascertainment of veteran status on the death certificate and misclassification of suicide as other manner of death) have on veteran suicide rate estimates. METHODS: We obtained suicide mortality data from the 2003-2010 National Violent Death Reporting System and the 2003-2010 Department of Defense Casualty Analysis System. We derived population estimates from the 2003-2010 American Community Survey and 2003-2010 Department of Veterans Affairs data. We computed veteran and nonveteran suicide rates. RESULTS: The results showed that suicide rates were minimally affected by the adjustment for the misclassification of current military personnel suicides as veterans. Moreover, combining suicides and deaths by injury of undetermined intent did not alter the conclusions. CONCLUSIONS: The National Violent Death Reporting System is a valid surveillance system for veteran suicide. However, more than half of younger (< 25 years) male and female suicides, labeled as veterans, were likely to have been current military personnel at the time of their death and misclassified on the death certificate.

Acute use of alcohol and methods of suicide in a US national sample.

OBJECTIVES: We explored age, gender, and racial/ethnic differences with alcohol use and firearms, hanging or asphyxiation, and poisoning methods of suicide. METHODS: We analyzed data for 37,993 suicide decedents aged 18 years and older from the 2005-2010 National Violent Death Reporting System database. Multinomial logistic regressions examined associations of method with alcohol use defined by blood alcohol content. Two-way interactions tested the effects of age, gender, and race/ethnicity on the associations between alcohol use and method of suicide. RESULTS: Alcohol was present among decedents who used the 3 leading methods of suicide: firearm (35.0%), hanging (36.8%), and poisoning (32.7%). Two-way interaction tests suggested that in young and middle adulthood, individuals were more likely to drink alcohol when they used a firearm or hanging (compared with poisoning), but in older adulthood, the reverse was true, with alcohol use more likely with poisoning. Interaction tests also suggested that Asians and Pacific Islanders were most likely to use alcohol in poisonings and that Blacks were least likely to use alcohol in hangings. CONCLUSIONS: The results suggested that alcohol use before suicide was influenced by several factors, including age, race/ethnicity, and suicide method.

Acute alcohol intoxication and suicide among United States ethnic/racial groups: findings from the national violent death reporting system.

BACKGROUND: To assess the prevalence and sociodemographic correlates of suicide involving acute alcohol intoxication among U.S. ethnic minorities. METHODS: Data were derived from the restricted 2003 to 2009 National Violent Death Reporting System. The study focused on the sociodemographic and toxicological information of 59,384 male and female suicide decedents for 16 states of the United States. Acute alcohol intoxication was defined as having a blood alcohol content (BAC) ≥0.08 g/dl. Overall, 76% of decedents were tested for the presence of alcohol. RESULTS: The proportion of suicide decedents with a positive BAC ranged from 47% among American Indians/Alaska Natives (AIs/ANs) to 23% among Asians/Pacific Islanders (PIs). Average BAC was highest among AIs/ANs. Among those who were tested for BAC, the proportion of decedents legally intoxicated prior to suicide was as follows: Blacks, 15%; AIs/ANs, 36%; Asians/PIs, 13%; and Hispanics, 28%. Bivariate associations showed that most suicide decedents who were legally intoxicated were male, younger than 30 years of age, with a high school education, not married, nonveterans, lived in metropolitan areas, and used a firearm to complete suicide. However, with the exception of Whites, most of these associations became not statistically significant in multivariate analysis. CONCLUSIONS: Alcohol use and legal intoxication prior to completing suicide are common among U.S. ethnic groups, especially among men and those who are younger than 30 years of age. The AI/AN group had the highest mean BAC, the highest rate of legal intoxication and decedents who were particularly young. Suicide prevention strategies should address alcohol use as a risk factor. Alcohol problems prevention strategies should focus on suicide as a consequence of alcohol use, especially among AI/AN youth and young adults.

Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System.

OBJECTIVES: Although it is well known that people with alcohol dependence are at a markedly elevated risk for suicide, much less is known about the role of acute alcohol use in suicidal behaviours. The primary aims of this epidemiological study were to assess the prevalence and factors associated with acute alcohol intoxication among 57 813 suicide decedents in 16 states. METHODS: Data from the restricted National Violent Death Reporting System 2003-2009 for male and female suicide decedents aged 18 years and older were analysed by multiple logistic regression to compare decedents with and without acute alcohol intoxication (defined as blood alcohol concentration (BAC) ≥0.08 g/dl). RESULTS: Among men, those who were younger, American Indian/Alaska Native, Hispanic, veterans, of lower educational attainment, deceased from a self-inflicted firearm injury or hanging/suffocation and residing in rural areas were more likely to have been intoxicated at the time of death. Among women, the factors associated with a BAC ≥0.08 g/dl were younger age, being American Indian/Alaska Native, and using a firearm, hanging/suffocation or falling as method of death. CONCLUSIONS: In both men and women, alcohol intoxication was associated with violent methods of suicide and declined markedly with age, suggesting that addressing risks associated with acute alcohol use may be of the greatest aid in the prevention of violent suicides among young and middle age adults.

Longitudinal trajectories of sleep duration in the general population.

BACKGROUND: Sleep duration has been associated with overall health status, health behaviours, and mortality. Little is known about habitual longitudinal patterns of sleep in the general population. Furthermore, evidence about whether sleep duration has declined in recent years is contradictory. DATA AND METHODS: The study was based on 8,673 adults aged 18 or older in 2002/2003 (cycle 5 of the National Population Health Survey) and used five self-reported biennial measurements of sleep duration spanning eight years. Multiple distinct trajectories of sleep duration were estimated using latent class growth modeling. RESULTS: Four modelled trajectories of sleep duration were identified: short (11.1% of the population); low-normal (49.4%); high-normal (37.0%); and long (2.4%). The short, low-normal and high-normal sleep trajectories each exhibited a slight linear decline in hours of sleep over the eight years of follow-up. Poor sleep quality was predictive of trajectory group membership and associated with a decrease in sleep duration for three of the four groups. Age and sex were also significant predictors of trajectory group membership. INTERPRETATION: Trajectory analysis is a useful descriptive tool in the investigation of sleep duration over time.