Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study.

BACKGROUND: Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as 'accidents,' and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. METHODS: Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention's (CDC's) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC's Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. RESULTS: 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%-from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and - 1%, respectively. CONCLUSION: The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs-fiscal, social, and personal-incurred by deaths due to self-injurious behaviors.

The Colorado National Collaborative: A public health approach to suicide prevention.

OBJECTIVE: Suicide rates in the United States have risen dramatically during the 21st century despite national, state and local level commitments to prevention, improvements in the development and delivery of evidence-informed prevention approaches, and advances in epidemiological capacity to identify areas for targeted intervention. Complex problems require comprehensive solutions. In Colorado, that solution is a comprehensive, integrated public health collaboration that aligns diverse community and programmatic efforts across the prevention continuum. The Colorado National Collaborative (CNC) is pursuing a real-world test of the public health approach to suicide prevention by helping community coalitions deliver a package of evidence-informed activities in geographically defined community systems. METHODS: The CNC began by identifying six diverse Colorado counties with high suicide rates or number of deaths. Working closely with community, state, and national partners, CNC identified existing community-level risk and protective factors, programs, and policies. This process provided insight on the overlay between existing efforts and identified burden centers and drivers. RESULTS: The CNC team identified six components for strategic implementation: (1) connectedness, (2) economic stability and supports, (3) education and awareness, (4) access to suicide safer care, (5) lethal means safety, and (6) postvention. Evaluation is being conducted through a collaborative, participatory, and empowerment approach that incorporates stakeholders as leaders in all aspects of the process. CONCLUSION: The CNC includes data-driven identification of populations at risk of suicide, community identification of protective factors, and true collaboration between prevention experts at the national, state, and local level in implementing a comprehensive approach to prevention. Lessons learned are discussed.

Overcoming the limitations of 'accident' as a manner of death for drug overdose mortality: case for a death certificate checkbox.

Collectively, the epidemic increases in the United States of opioid-related deaths and suicides during the first two decades of the 21st century have exposed shortcomings in current forensic and epidemiological approaches for determining and codifying manner of death-a vital function fulfilled by medical examiners, coroners and nosologists-the foundation for the National Violent Death Reporting System (NVDRS), an incident-based surveillance system providing individual-level information on decedent characteristics, manner, cause and circumstances of suicide, homicide and other violent injury deaths. Drug intoxication deaths are generally classified as 'accidents' or unintentional, a fundamental mischaracterisation; most arose from repetitive self-harm behaviours related to substance acquisition and misuse. Moreover, given the burden of affirmative evidence required to determine suicide, many of these 'accidents' likely reflected unrecognised intentional acts-that is, suicides. Addition of a simple checkbox for self-injury mortality on the death certificate would enrich the National Death Index and NVDRS, and in turn, inform prevention and clinical research, and enhance the evaluation of prevention programmes and therapeutic regimens.

Experiences and perceptions of perinatal depression among new immigrant Chinese parents: a qualitative study.

BACKGROUND: Immigrant status, acculturation level, race and ethnicity have been found to contribute to the utilization of mental health services in the perinatal period. This study explored perinatal experiences and perceptions among Chinese immigrant mothers and their spouses, as well as the possible barriers and facilitators that affect their health care utilization. METHODS: We recruited 13 women ages 18-35 years born in mainland China, living in Rochester, New York, and residing less than 5 years in the United States. Participants primary language was Mandarin Chinese and all had given birth to at least one live infant within the past 7 years. Participants' age was at least 18 years old at the time of delivery. Five spouses also participated. We divided women in two focus groups and held one focus group for men, with data collection including demographic questionnaires and semi-structured focus group questions conducted in December 2014. Data were analyzed following thematic analysis. RESULTS: Four themes emerged: experiences of perinatal depression; perceptions of perinatal depression; general preventive and coping strategies; and attitudes toward the supportive use social media applications (apps) and text messaging during the perinatal period. Participants had limited knowledge of perinatal depression and had difficulty distinguishing between normal perinatal mood fluctuations and more severe symptoms of depression. They discussed immigrant-related stress, conflicts with parents/in-laws while "doing the month", the perceived gap between the ideal of "perfect moms" and reality, and challenges with parenting as the causes of perinatal depression. Women approved of screening for the condition but were conservative about follow-up interventions. As for the management of perinatal depression, participants preferred to deal with the problem within the family before seeking external help, due to potential stigma as well as Chinese traditional culture. They were receptive to obtaining pertinent health information from anonymous social media apps, preferring these to personal text messages. CONCLUSION: The recent immigrant Chinese parents to the United States in the study had limited knowledge of perinatal depression and did not make full use of mental health services for support due to language and cultural barriers. Screening for perinatal depression is only the first step. Future research should explore what interventions may serve as an acceptable approach to overcoming these gaps.

Unrecognised self-injury mortality (SIM) trends among racial/ethnic minorities and women in the USA.

AIM: To assess whether an enhanced category combining suicides with nonsuicide drug self-intoxication fatalities more effectively captures the burden of self-injury mortality (SIM) in the USA among US non-Hispanic black and Hispanic populations and women irrespective of race/ethnicity. METHODS: This observational study used deidentified national mortality data for 2008-2017 from the CDC's Web-based Injury Statistics Query and Reporting System. SIM comprised suicides by any method and age at death plus estimated nonsuicide drug self-intoxication deaths at age ≥15 years. Measures were crude SIM and suicide rates; SIM-to-suicide rate ratios; and indices of premature mortality. RESULTS: While the suicide rate increased by 29% for blacks, 36% for Hispanics and 25% for non-Hispanic whites between 2008 and 2017, corresponding SIM rate increases were larger at 109%, 69% and 55% (p<0.0001). SIM:suicide rate ratio gaps were widest among blacks but similar for the other two groups. Gaps were wider for females than males, especially black females whose ratios measured ≥3.71 across the observation period versus <3.00 for white and Hispanic counterparts. Total lost years of life for Hispanic, white and black SIM decedents in 2017 were projected to be 42.6, 37.1 and 32.4, respectively. CONCLUSION: Application of SIM exposed substantial excess burdens from substance poisoning relative to suicide for minorities, particularly non-Hispanic blacks and for women generally. Results underscored the need to define, develop, implement and evaluate comprehensive strategies to address common antecedents of self-injurious behaviours.

High prevalence of health and social risk behaviours among men experiencing suicidal thoughts and behaviour: The imperative to undertake holistic assessments.

OBJECTIVE: We aimed to examine whether suicidal thoughts and behaviour were independently associated with a wide range of health and social risk behaviours. METHODS: We conducted cross-sectional analyses of data collected from 13,763 adult males who participated in The Australian Longitudinal Study on Male Health. We fit generalised linear models to estimate the relative risk of engaging in a range of health and social risk behaviours across several domains by suicidal thoughts and behaviour status. RESULTS: Men with recent suicidal ideation (relative risk range, 1.10-5.25) and lifetime suicide attempts (relative risk range, 1.10-7.65) had a higher risk of engaging in a broad range of health and social risk behaviours. The associations between suicidal thoughts and behaviour and health and social risk behaviours were typically independent of socio-demographics and in many cases were also independent of depressive symptoms. CONCLUSION: Suicidal thoughts and behaviour overlaps with increased risk of engagement in a wide range of health and social risk behaviours, indicating the need for an alignment of broader public health interventions within clinical and community-based suicide prevention activities. The experience of suicidality may be an important catalyst for a broader psychosocial conversation and assessment of health and social risk behaviours, some of which may be modifiable. These behaviours may not carry an imminent risk of premature death, such as from suicide, but they carry profound health and social consequences if left unaddressed.

Psychosocial Effects of the COVID-19 Pandemic: Large-scale Quasi-Experimental Study on Social Media.

BACKGROUND: The COVID-19 pandemic has caused several disruptions in personal and collective lives worldwide. The uncertainties surrounding the pandemic have also led to multifaceted mental health concerns, which can be exacerbated with precautionary measures such as social distancing and self-quarantining, as well as societal impacts such as economic downturn and job loss. Despite noting this as a "mental health tsunami", the psychological effects of the COVID-19 crisis remain unexplored at scale. Consequently, public health stakeholders are currently limited in identifying ways to provide timely and tailored support during these circumstances. OBJECTIVE: Our study aims to provide insights regarding people's psychosocial concerns during the COVID-19 pandemic by leveraging social media data. We aim to study the temporal and linguistic changes in symptomatic mental health and support expressions in the pandemic context. METHODS: We obtained about 60 million Twitter streaming posts originating from the United States from March 24 to May 24, 2020, and compared these with about 40 million posts from a comparable period in 2019 to attribute the effect of COVID-19 on people's social media self-disclosure. Using these data sets, we studied people's self-disclosure on social media in terms of symptomatic mental health concerns and expressions of support. We employed transfer learning classifiers that identified the social media language indicative of mental health outcomes (anxiety, depression, stress, and suicidal ideation) and support (emotional and informational support). We then examined the changes in psychosocial expressions over time and language, comparing the 2020 and 2019 data sets. RESULTS: We found that all of the examined psychosocial expressions have significantly increased during the COVID-19 crisis-mental health symptomatic expressions have increased by about 14%, and support expressions have increased by about 5%, both thematically related to COVID-19. We also observed a steady decline and eventual plateauing in these expressions during the COVID-19 pandemic, which may have been due to habituation or due to supportive policy measures enacted during this period. Our language analyses highlighted that people express concerns that are specific to and contextually related to the COVID-19 crisis. CONCLUSIONS: We studied the psychosocial effects of the COVID-19 crisis by using social media data from 2020, finding that people's mental health symptomatic and support expressions significantly increased during the COVID-19 period as compared to similar data from 2019. However, this effect gradually lessened over time, suggesting that people adapted to the circumstances and their "new normal." Our linguistic analyses revealed that people expressed mental health concerns regarding personal and professional challenges, health care and precautionary measures, and pandemic-related awareness. This study shows the potential to provide insights to mental health care and stakeholders and policy makers in planning and implementing measures to mitigate mental health risks amid the health crisis.

Lay health supporters aided by mobile text messaging to improve adherence, symptoms, and functioning among people with schizophrenia in a resource-poor community in rural China (LEAN): A randomized controlled trial.

BACKGROUND: Schizophrenia is a leading cause of disability, and a shift from facility- to community-based care has been proposed to meet the resource challenges of mental healthcare in low- and middle-income countries. We hypothesized that the addition of mobile texting would improve schizophrenia care in a resource-poor community setting compared with a community-based free-medicine program alone. METHODS AND FINDINGS: In this 2-arm randomized controlled trial, 278 community-dwelling villagers (patient participants) were randomly selected from people with schizophrenia from 9 townships of Hunan, China, and were randomized 1:1 into 2 groups. The program participants were recruited between May 1, 2015, and August 31, 2015, and the intervention and follow-up took place between December 15, 2015, and July 1, 2016. Baseline characteristics of the 2 groups were similar. The patients were on average 46 years of age, had 7 years of education, had a duration of schizophrenia of 18 years with minimal to mild symptoms and nearly one-fifth loss of functioning, and were mostly living with family (95%) and had low incomes. Both the intervention and the control groups received a nationwide community-based mental health program that provided free antipsychotic medications. The patient participants in the intervention group also received LEAN (Lay health supporters, E-platform, Award, and iNtegration), a program that featured recruitment of a lay health supporter and text messages for medication reminders, health education, monitoring of early signs of relapses, and facilitated linkage to primary healthcare. The primary outcome was medication adherence (proportion of dosages taken) assessed by 2 unannounced home-based pill counts 30 days apart at the 6-month endpoint. The secondary and other outcomes included patient symptoms, functioning, relapses, re-hospitalizations, death for any reason, wandering away without notifying anyone, violence against others, damaging goods, and suicide. Intent-to-treat analysis was used. Missing data were handled with multiple imputations. In total, 271 out of 278 patient participants were successfully followed up for outcome assessment. Medication adherence was 0.48 in the control group and 0.61 in the intervention group (adjusted mean difference [AMD] 0.12 [95% CI 0.03 to 0.22]; p = 0.013; effect size 0.38). Among secondary and other outcomes we noted substantial reduction in the risk of relapse (26 [21.7%] of 120 interventional participants versus 40 [34.2%] of 117 controls; relative risk 0.63 [95% CI 0.42 to 0.97]; number needed to treat [NNT] 8.0) and re-hospitalization (9 [7.3%] of 123 interventional participants versus 25 [20.5%] of 122 controls; relative risk 0.36 [95% CI 0.17 to 0.73]; NNT 7.6). The program showed no statistical difference in all other outcomes. During the course of the program, 2 participants in the intervention group and 1 in the control group died. The limitations of the study include its lack of a full economic analysis, lack of individual tailoring of the text messages, the relatively short 6-month follow-up, and the generalizability constraint of the Chinese context. CONCLUSIONS: The addition of texting to patients and their lay health supporters in a resource-poor community setting was more effective than a free-medicine program alone in improving medication adherence and reducing relapses and re-hospitalizations. Future studies may test the effectiveness of customization of the texting to individual patients. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR-ICR-15006053.

Peer-adult network structure and suicide attempts in 38 high schools: implications for network-informed suicide prevention.

BACKGROUND: Strengthening social integration could prevent suicidal behavior. However, minimal research has examined social integration through relationship network structure. To address this important gap, we tested whether structural characteristics of school networks predict school rates of ideation and attempts. METHODS: In 38 US high schools, 10,291 students nominated close friends and trusted adults to construct social networks. We used mixed-effects logistic regression models to test individual student networks and likelihood of suicidal ideation (SI) and suicide attempts (SA); and linear regression models to estimate associations between school network characteristics and school rates of SI, SA, and SA among all with ideation. RESULTS: Lower peer network integration and cohesion increased likelihood of SI and SA across individual and school-level models. Two factors increased SA: student isolation from adults and suicidal students' popularity and clustering. A multivariable model identified higher SA in schools where youth-adult relationships were concentrated in fewer students (B = 4.95 [1.46, 8.44]) and suicidal students had higher relative popularity versus nonsuicidal peers (B = 0.93 [0.10, 1.77]). Schools had lower SA rates when more students named the same trusted adults named by friends and many students named the same trusted adults. When adjusting for depression, violence victimization and bullying, estimates for adult network characteristics were substantially unchanged whereas some peer effects decreased. CONCLUSIONS: Schoolwide peer and youth-adult relationship patterns influence SA rates beyond individual student connections. Network characteristics associated with suicide attempts map onto three theory-informed domains: social integration versus thwarted relational needs, group cohesion, and suicidal students' social influence. Network interventions addressing these processes, such as maximizing youth-adult connections schoolwide and heightening influence of youth with healthy coping, could create more protective schools. Longitudinal and intervention studies are needed to determine how schools differentiate in network structure and clarify reciprocal dynamics between network characteristics and suicidal behavior.

Feasibility of peer support services among people with severe mental illness in China.

BACKGROUND: Peer-delivered services potentially provide broad, multifaceted benefits for persons suffering severe mental illness. Most studies to date have been conducted in countries with well-developed outpatient mental health systems. The objective of this study was to examine the feasibility for developing a community-based peer service in China. METHODS: Thirteen peer service providers and 54 consumers were recruited from four communities in Beijing. We initiated the program in two communities, followed by another two in order to verify and add to our understanding of potential scalable feasibility. Semi-structured face-to-face interviews were conducted 12 month after initiation at each site to measure satisfaction and perceived benefits from perspectives of peer service providers, and consumers and their caregivers. RESULTS: Key stakeholders reported that peer support services were satisfying and beneficial. Eleven of 13 peer service providers were willing to continue in their roles. Ten, 8, and 7 of them perceived improvements in working skills, social communication skills, and mood, respectively. Among consumers, 39 of 54 were satisfied with peer services. Improvements in mood, social communication skills, illness knowledge, and illness stability were detected among 23, 18, 13, and 13 consumers, respectively. For caregivers, 31 of 32 expressed a positive view regarding peer services. Caregivers reported improvement in their own mood, confidence in recovery of their family members, and reduction in caretaker burdens. CONCLUSIONS: The findings highlight that peer-delivered services have promise in China for benefiting persons with severe mental illness and their family caregivers, as well as the peer service providers themselves.

Mortality in the United States from self-injury surpasses diabetes: a prevention imperative.

This report uses an enhanced conceptualisation of self-injury mortality (SIM), which comprised registered or known suicides by any method and estimated non-suicide deaths from opioid and other drug self-intoxication. SIM surpassed diabetes as a cause of death in the USA in 2015. The gap expanded in 2016 with respective rates of 29.1 and 24.8 per 100 000 population. Facing similar social and psychologically complex health problems to SIM, the USA has initiated and sustained successful broad-based prevention efforts that have reduced deaths from cardiovascular diseases, smoking-related lung cancer, HIV and motor vehicular injury-given both necessary epidemiological understanding to define the problem and sufficient political will to address it. Development of strategies to prevent SIM will be facilitated by focusing on factors that are common risks for diverse outcomes. Like premature mortality frequently associated with diabetes, deaths from self-injurious behaviours are preventable.

A randomized controlled trial of suicide prevention training for primary care providers: a study protocol.

BACKGROUND: Suicide is a national public health crisis and a critical patient safety issue. It is the 10th leading cause of death overall and the second leading cause of death among adolescents and young adults (15-34 years old). Research shows 80% of youth who died by suicide saw their primary care provider within the year of their death. It is imperative that primary care providers develop the knowledge and skills to talk with patients about distress and suicidal thoughts, and to assess and respond in the context of the ongoing patient - primary care provider relationship. METHODS: This study examines the effectiveness of simulation on suicide prevention training for providers-in-training by comparing two conditions: 1) a control group that receives online teaching on suicide prevention in primary care via brief online videos and 2) an experimental group that includes the same online teaching videos plus two standardized patient (SP) interactions (face-to-face and telehealth, presentation randomized). All SP interactions are video-recorded. The primary analysis is a comparison of the two groups' suicide prevention skills using an SP "test case" at 6-month follow-up. DISCUSSION: The primary research question examines the impact of practice (through SP simulation) over and above online teaching alone on suicide prevention skills demonstrated at follow-up. We will assess moderators of outcomes, differences among SP simulations (i.e., face-to-face vs. telehealth modalities), and whether the experimental group's suicide prevention skills improve over the three SP experiences. TRIAL REGISTRATION: The study was registered on Clinical Trials Registry ( clinicaltrials.gov ) on December 14, 2016. The Trial Registration Number is NCT02996344 .

A community-based peer support service for persons with severe mental illness in China.

BACKGROUND: Peer support services for patients with severe mental illness (SMI) originated from Western countries and have become increasingly popular during the past twenty years. The aim of this paper is to describe a peer service model and its implementation in China, including the model's feasibility and sustainability. METHODS: A peer support service was developed in four Chinese communities. Implementation, feasibility and sustainability were assessed across five domains: Service process, service contents, peer training and supervision, service satisfaction, and service perceived benefit. RESULTS: Service process: 214 peer support activities were held between July 2013 and June 2016. No adverse events occurred during three years. Each activity ranged from 40 to 120 min; most were conducted in a community rehabilitation center or community health care center. Service content: Activities focused on eight primary topics-daily life skills, social skills, knowledge of mental disorders, entertainment, fine motor skill practice, personal perceptions, healthy life style support, emotional support. Peer training and supervision: Intensive training was provided for all peers before they started to provide services. Regular supervision and continued training were provided thereafter; online supervision supplemented face to face meetings. Service satisfaction: Nineteen consumers (79.2%) (χ2(1) = 12.76, p < 0.001) were satisfied with the peers and 17 consumers (70.8%) (χ2(1) = 8.05, p = 0.005) expressed a strong desire to continue to participate in the service. Fourteen caregivers (93.3%) (χ2(1) = 11.27, p = 0.001) wanted the patients to continue to organize or participate in the service. Service perceived benefit: Six peers (85.7%) (χ2(1) = 3.57, p = 0.059) reported an improvement of working skills. Ten consumers (41.7%) (χ2(1) = 0.05, p = 0.827) reported better social communication skills. Six caregivers (40%) (χ2(1) = 1.67, p = 0.197) observed patients' increase in social communication skills, five (33.3%) (χ2(1) = 1.67, p = 0.197) found their own mood had been improved. CONCLUSIONS: Peer support services for patients with SMI can be sustainably implemented within Chinese communities without adverse events that jeopardize safety and patient stability. Suggestions for future service development include having professionals give increased levels of support to peers at the beginning of a new program. A culturally consistent peer service manual, including peer role definition, peer training curriculum, and supervision methods, should be developed to help implement the service smoothly.

Comprehensive, integrated approaches to suicide prevention: practical guidance.

BACKGROUND: Efforts in the USA during the 21st century to stem the ever-rising tide of suicide and risk-related premature deaths, such as those caused by drug intoxications, have failed. Based primarily on identifying individuals with heightened risk nearing the precipice of death, these initiatives face fundamental obstacles that cannot be overcome readily. OBJECTIVE: This paper describes the step-by-step development of a comprehensive public health approach that seeks to integrate at the community level an array of programmatic efforts, which address upstream (distal) risk factors to alter life trajectories while also involving health systems and clinical providers who care for vulnerable, distressed individuals, many of whom have attempted suicide. CONCLUSION: Preventing suicide and related self-injury morbidity and mortality, and their antecedents, will require a systemic approach that builds on a societal commitment to save lives and collective actions that bring together diverse communities, service organisations, healthcare providers and governmental agencies and political leaders. This will require frank, data-based appraisals of burden that drive planning, programme development and implementation, rigorous evaluation and a willingness to try-fail-and-try-again until the tide has been turned.

CDC Grand Rounds: Preventing Suicide Through a Comprehensive Public Health Approach.

Suicide in the United States is a major public health problem with approximately 42,000 reported suicides in 2014 among persons aged >10 years (1). The overall suicide rate is increasing, with a 27% increase from 2000 (12.1 per 100,000 population) to 2014 (15.4 per 100,000) (Figure 1). Males, youths and young adults, and certain racial/ethnic groups have historically had higher rates of suicide. In 2014, suicide rates were approximately four times higher among males (24.3 per 100,000) than females (6.8 per 100,000), and suicide was the second leading cause of death among youths and young adults aged 10-34 years (1). Among persons aged 10-24 years, the 2014 suicide rate among non-Hispanic American Indian/Alaska Natives was 20.2 per 100,000, 1.9 times higher than non-Hispanic whites (10.5 per 100,000), 3.5 times higher than non-Hispanic blacks (5.8 per 100,000), and 3.7 times higher than Hispanics (5.5 per 100,000) (1). Adults aged 35-64 years are an emerging group at risk, with suicide rates increasing 33% since 2000 and accounting for the largest proportion of suicides (1).

Depression, social support and associated factors among women living in rural China: a cross-sectional study.

BACKGROUND: Few studies have focused on depression and social support in Eastern populations, especially women in rural China. Our research investigated depression among women in rural China, and studied the relationships between social support and depression. METHODS: We recruited women ages 16 years and older from north Sichuan. Participants completed socio-demographic measures, the Center for Epidemiologic Studies Depression Scale, and the Duke Social Support Index. The analysis method included descriptive statistics and logistic regression. RESULTS: The final sample included 1,898 participants with a mean age of 48.6 years, and the prevalence of significant depressive symptoms was 12.4%. Results suggest being unemployed, having poorer perceived health/economic status, and lower social support were positively associated with depression. Younger age and greater social support were negatively associated with depression. CONCLUSIONS: This study provides insights on the psychological health of women in rural China and potential directions for future research. These issues are especially pertinent during this time of rapid economic transformation and outmigration in rural China.

Internal migration, mental health, and suicidal behaviors in young rural Chinese.

PURPOSE: There is a dearth of data on the association of internal migration with mental health in young rural Chinese. This study aims to explore the associations between migrant status, mental health, and suicidal behaviors in young rural Chinese. METHODS: We recruited 1,646 rural subjects aged 16-34 years, of whom 756 were migrant workers and 890 non-migrants, from ten representative villages in rural Sichuan Province, the southwestern part of China. To assess subject's depressive symptoms and general psychological quality of life (psycho-QOL), the study protocol included the Centre for Epidemiological Studies Depression Scale, and psycho-QOL subscale of the World Health Organization's QOL Questionnaire-Brief Version, in addition to structured questions regarding one-year suicidal thoughts and behaviors (serious ideation, plan, and attempt), socio-demographic, social support, and physical health information. RESULTS: After adjustment for confounders, migrant workers had relative to non-migrant rural residents a decreased risk for depression (OR = 0.69, P = 0.026), but comparable risk for poor psycho-QOL (OR = 0.91, P = 0.557) and one-year suicidal behaviors (OR = 0.59-1.10, P = 0.19-0.90). Migrant status only accounted for 0.5, 2.8, 4.7, 9.8, and 12.6% of the total explainable variance for suicide attempt, poor psycho-QOL, suicide plan, depression and serious suicide ideation, respectively. CONCLUSION: Our findings suggested that among young rural Chinese there were no significant associations involving migrant status and poor psycho-QOL or one-year suicidal behaviors, while migrant status significantly correlated with a decreased risk of depression. The unique contribution of migrant status to mental health among young rural Chinese participants in this study was very small.