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.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States.

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design. Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification. Design, Setting, and Participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021. Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type. Main Outcomes and Measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification. Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (ß = 4.362), labor underutilization rate (ß = 0.728), manufacturing employment (ß = -0.056), homelessness rate (ß = -0.125), percentage nonreligious (ß = 0.041), non-Hispanic White race and ethnicity (ß = 0.087), prescribed opioids for 30 days or more (ß = 0.117), and percentage without health insurance (ß = -0.013) and 5 factors associated with the suicide rate: percentage male (ß = 1.046), military veteran (ß = 0.747), rural (ß = 0.031), firearm ownership (ß = 0.030), and pain reliever misuse (ß = 1.131). Conclusions and Relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Racial/Ethnic Differences in Preceding Circumstances of Suicide and Potential Suicide Misclassification Among US Adolescents.

PURPOSE: There is a paucity of research on racial/ethnic differences in preceding circumstances of suicide among adolescents aged 10-19 years and consequential potential misclassification of suicide deaths (i.e., manner of death classified as injury of undetermined intent). This study (1) examined preceding circumstances of suicide among non-Hispanic White, non-Hispanic Black, non-Hispanic Asian/Pacific Islander (A/PI), non-Hispanic American Indian/Alaskan Native (AI/AN), and Hispanic adolescent decedents; and (2) investigated potential suicide misclassification of racial/ethnic minority decedents. METHODS: We used data from the 2006-2015 National Violent Death Reporting System Restricted Access Database. Multivariable logistic regression analyses examined differences in depressed mood, mental health problem and treatment, crisis in the past 2 weeks, problems with school, intimate partner, family relationship, and other relationships (e.g., friend) among racial/ethnic minority decedents compared to White decedents. A separate logistic regression analysis assessed potential suicide misclassification of racial/ethnic minority decedents relative to White counterparts. RESULTS: Adjusting for sex and suicide history and circumstances, all racial/ethnic minority decedents had significantly lower odds of documented mental health problem and treatment compared to White decedents. Racial/ethnic differences in relationship problems were also identified. Black decedents had significantly higher odds of manner-of-death classification as undetermined intent than did White decedents, suggesting greater likelihood of suicide misclassification. CONCLUSIONS: Circumstances contributing to suicide among adolescents differ by race/ethnicity, indicating the need for culturally tailored suicide prevention efforts.

Variable Circumstances of Suicide Among Racial/Ethnic Groups by Sex and Age: A National Violent-Death Reporting System Analysis.

Suicide rates vary by race/ethnicity, but little is known about how the circumstances that contribute to suicide differ across racial/ethnic groups. This study investigated suicide circumstances among non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic Asian/Pacific Islanders, non-Hispanic Native American/Alaskan Natives, and Hispanics by sex and age. Using de-identified National Violent Death Reporting System (NVDRS) Restricted Access Database files from 2006-2015, we examined proximal circumstances of suicide among decedents aged 10 years and older. Hierarchical logistic regression analysis revealed racial/ethnic differentials in non-alcohol substance abuse problem, intimate partner problem, and physical health problem across sex and age, controlling for potential confounders. Study findings highlight priority areas for suicide interventions.

National medical expenditures by smoking status in American adults: an application of Manning's two-stage model to nationally representative data.

OBJECTIVES: To assess the medical expenditures of American adults by their smoking status-Current, Former or Never smokers. We update these expenditures through 2015 controlling for personal characteristics and medical history and assess the impact of years-since-quitting and decade of life. SETTING AND PARTICIPANTS: Weighted sample of American adults, 2011-2015. The linked National Health Interview Survey (NHIS) and Medical Expenditure Panel Survey (MEPS) are annual weighted representations of approximately 250 million adults. Sampling of NHIS is multistage with data collected throughout the year. PRIMARY OUTCOME MEASURES: Using data from NHIS and MEPS, we collected demographic data, self-reported medical history and current smoking status. Smoking status was designated as Never, Current and Former, along with years-since-quitting. Total medical expenditures were collected from MEPS for 2011-2015. We used Manning's two-part model to estimate average expenditures per individual and marginal costs for individuals at all levels of smoking status. RESULTS: American adults averaged US$4830 in average medical expenditures. Never smokers (US$4360, 95% CI 4154.3 to 4566.3), had lower expenditures than Current (US$5244, 95% CI 4707.9 to 5580.3) and Former (US$5590, 95% CI 5267.4 to 5913.5) smokers. CI for Current and Former smokers overlapped. Results were similarly significant when controlling for disease history. Years-since-quitting did not affect expenditures. In each decade of adult life, Former smokers had the highest annual medical expenditures, followed by Current and then Never smokers. CONCLUSIONS: We updated annual medical expenditures during the Affordable Care Act era by smoking status using the current best practice model. While we identify Former smokers as having higher medical expenditures than Current smokers, we do not examine how care-seeking behaviour varies between levels of each risk factor.

Attitudes about violence and involvement in peer violence among youth: findings from a high-risk community.

Peer violence perpetration and victimization are the most common types of violence among youth. This study determined the associations among violent attitudes toward peers, involvement in peer violence perpetration, and experience with peer violence victimization among boys and girls in a high-risk, urban community. Analyses were based on data from the 2004 Youth Violence Survey, which was administered to over 80% of public school students in grades 7, 9, 11, and 12 (N = 4,131) in a disadvantaged, urban, school district in the USA. Logistic regression analyses were conducted to test the associations between attitudes in support of violence and involvement in violent behaviors. Results show that among youth, attitudes supporting boys hitting boys significantly increased the odds of peer violence perpetration after controlling for potential confounders (adjusted odds ratio [AOR], 1.35; 95% confidence interval [CI] = 1.07, 1.72). However, stratified analyses for boys and girls show that attitudes supporting boys hitting boys increased the odds of peer violence perpetration for girls only after controlling for potential confounders (AOR, 1.49; 95% CI = 1.05, 2.13). The findings demonstrate that there are important differences between boys and girls in terms of their associations with violent attitudes and involvement in actual violent behaviors. However, additional research is needed to determine how attitude modifications can be incorporated into youth violence prevention programs.