Changes in suicide in California from 2017 to 2021: a population-based study.

BACKGROUND: Suicide is a major public health problem with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of suicide in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years. METHODS: We used California-wide death data to summarize suicide and firearm suicide across race/ethnicity, age, education, gender, and urbanicity. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages. RESULTS: Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10 to 19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20 to 29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. The proportion of suicides that involved a firearm in 2020 and 2021 decreased in rural areas compared to prior years, while there were modest increases in urban areas. CONCLUSIONS: The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of suicide across the California population. Marginalized racial groups and younger people experienced increased risk for suicide, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal self-harm injuries and reduce related inequities.

Neighborhood Racial and Economic Segregation and Disparities in Violence During the COVID-19 Pandemic.

Objectives. To describe associations between neighborhood racial and economic segregation and violence during the COVID-19 pandemic. Methods. For 13 US cities, we obtained zip code-level data on 5 violence outcomes from March through July 2018 through 2020. Using negative binomial regressions and marginal contrasts, we estimated differences between quintiles of racial, economic, and racialized economic segregation using the Index of Concentration at the Extremes as a measure of neighborhood privilege (1) in 2020 and (2) relative to 2018 through 2019 (difference-in-differences). Results. In 2020, violence was higher in less-privileged neighborhoods than in the most privileged. For example, if all zip codes were in the least privileged versus most privileged quintile of racialized economic segregation, we estimated 146.2 additional aggravated assaults (95% confidence interval = 112.4, 205.8) per zip code on average across cities. Differences over time in less-privileged zip codes were greater than differences over time in the most privileged for firearm violence, aggravated assault, and homicide. Conclusions. Marginalized communities endure endemically high levels of violence. The events of 2020 exacerbated disparities in several forms of violence. Public Health Implications. To reduce violence and related disparities, immediate and long-term investments in low-income neighborhoods of color are warranted. (Am J Public Health. 2022;112(1):144-153. https://doi.org/10.2105/AJPH.2021.306540).

Assessment of Extreme Risk Protection Order Use in California From 2016 to 2019.

Importance: A total of 19 states and the District of Columbia now have extreme risk protection order (ERPO) or similar policies, and others are considering them; however, little research exists describing their use. Objective: To characterize early use of California's ERPO policy by providing the first aggregate, statewide description of ERPOs, individuals subject to them, and petitioners. Design, Setting, and Participants: This cross-sectional study analyzed 1076 respondents to ERPOs recorded in the California Department of Justice California Restraining and Protective Order System from 2016 to 2019. Descriptive analyses of orders issued between January 1, 2016, and December 31, 2019 in California were performed, and univariate Moran I was calculated to examine county-level spatial autocorrelation of the policy's use. Main Outcomes and Measures: The primary study outcomes included the characteristics of ERPO respondents (demographic characteristics), petitioners (law enforcement vs family or household members), and orders (type and service) as well as temporal and spatial variation in policy use during the first 4 years of implementation. Results: Of 1076 respondents during the study period, most were men (985 [91.5%]) and white individuals (637 [59.2%]), with a mean age of 41.8 years (range, 14 to 98 years). A law enforcement officer was the petitioner in 1038 cases (96.5%). The number of respondents increased during the study period from 70 in 2016 to 700 in 2019, and there was substantial county-level variation in ERPO use (ranging from 0 to 354 respondents), with significant spatial clustering in counts of ERPO respondents among neighboring counties (observed Moran I, 0.18, mean [SD] Moran I from reference distribution, -0.01 (0.05); z value, 3.58; P = .004). Conclusions and Relevance: This study, among the first to describe the early utilization of an ERPO or similar policy, found a substantial increase in the use of ERPOs in California from 2016 to 2019. These results could inform policy makers and other stakeholders involved in policy implementation and outreach in California and elsewhere. Similar studies in other states would be useful to understand variation.

Distress level and daily functioning problems attributed to firearm victimization: sociodemographic-specific responses.

PURPOSE: The purpose of this study was to estimate the effect of firearm involvement during violent victimization on the level of distress experienced and daily functioning within sociodemographic subgroups. METHODS: We used cross-sectional data from the National Crime Victimization Survey (n = 5698) and Targeted Maximum Likelihood Estimation. Sociodemographic subgroups were defined by age, race, sex, and socioeconomic position. Outcomes included experiencing the victimization as severely distressing and problems in the workplace or at school, or with peers or family. RESULTS: Among people victimized with a firearm, nearly 40% experienced the victimization as severely distressing and 28% reported daily functioning problems as a result of the victimization, compared with 25% and 27% of those victimized without a firearm. In most of the subgroups examined, a greater proportion of people described the event as severely distressing when a firearm was involved in the victimization, ranging up to 19 percentage points higher among women and among black respondents (95% CI for women = 10%-28%; for blacks = 6%-31%). CONCLUSIONS: Our findings suggest an almost universal negative response to firearm involvement during a violent victimization as compared with violent victimizations involving other or no weapons. These findings highlight the need for efforts by medical and mental health practitioners to address the potential sequelae of experiencing severe distress during a firearm victimization.

Association of Prior Convictions for Driving Under the Influence With Risk of Subsequent Arrest for Violent Crimes Among Handgun Purchasers.

Importance: Alcohol use is a risk factor for firearm-related violence, and firearm owners are more likely than others to report risky drinking behaviors. Objective: To study the association between prior convictions for driving under the influence (DUI) and risk of subsequent arrest for violent crimes among handgun purchasers. Design: In this retrospective, longitudinal cohort study, 79 678 individuals were followed up from their first handgun purchase in 2001 through 2013. The study cohort included all legally authorized handgun purchasers in California aged 21 to 49 years at the time of purchase in 2001. Individuals were identified using the California Department of Justice (CA DOJ) Dealer's Record of Sale (DROS) database, which retains information on all legal handgun transfers in the state. Exposures: The primary exposure was DUI conviction prior to the first handgun purchase in 2001, as recorded in the CA DOJ Criminal History Information System. Main Outcomes and Measures: Prespecified outcomes included arrests for violent crimes listed in the Crime Index published by the Federal Bureau of Investigation (murder, rape, robbery, and aggravated assault), firearm-related violent crimes, and any violent crimes. Results: Of the study population (N=79 678), 91.0% were males and 68.9% were white individuals; the median age was 34 (range, 21-49) years. The analytic sample for multivariable models included 78 878 purchasers after exclusions. Compared with purchasers who had no prior criminal history, those with prior DUI convictions and no other criminal history were at increased risk of arrest for a Crime Index-listed violent crime (adjusted hazard ratio [AHR], 2.6; 95% CI, 1.7-4.1), a firearm-related violent crime (AHR, 2.8; 95% CI, 1.3-6.4), and any violent crime (AHR, 3.3; 95% CI, 2.4-4.5). Among purchasers with a history of arrests or convictions for crimes other than DUI, associations specifically with DUI conviction remained. Conclusions and Relevance: This study's findings suggest that prior DUI convictions may be associated with the risk of subsequent violence, including firearm-related violence, among legal purchasers of handguns. Although the magnitude was diminished, the risk associated with DUI conviction remained elevated even among those with a history of arrests or convictions for crimes of other types.

Limiting Alcohol Outlet Density to Prevent Alcohol Use and Violence: Estimating Policy Interventions Through Agent-Based Modeling.

Increasing alcohol outlet density is well-documented to be associated with increased alcohol use and problems, leading to the policy recommendation that limiting outlet density will decrease alcohol problems. Yet few studies of decreasing problematic outlets and outlet density have been conducted. We estimated the association between closing alcohol outlets and alcohol use and alcohol-related violence, using an agent-based model of the adult population in New York City. The model was calibrated according to the empirical distribution of the parameters across the city's population, including the density of on- and off-premise alcohol outlets. Interventions capped the alcohol outlet distribution at the 90th to the 50th percentiles of the New York City density, and closed 5% to 25% of outlets with the highest levels of violence. Capping density led to a lower population of light drinkers (42.2% at baseline vs. 38.1% at the 50th percentile), while heavy drinking increased slightly (12.0% at baseline vs. 12.5% at the 50th percentile). Alcohol-related homicides and nonfatal violence remained unchanged. Closing the most violent outlets was not associated with changes in alcohol use or related problems. Results suggest that focusing solely on closing alcohol outlets might not be an effective strategy to reduce alcohol-related problems.

Urban-rural variation in the socioeconomic determinants of opioid overdose.

BACKGROUND: Prescription opioid overdose (POD) and heroin overdose (HOD) rates have quadrupled since 1999. Community-level socioeconomic characteristics are associated with opioid overdoses, but whether this varies by urbanicity is unknown. METHODS: In this serial cross-sectional study of zip codes in 17 states, 2002-2014 (n = 145,241 space-time units), we used hierarchical Bayesian Poisson space-time models to analyze the association between zip code-level socioeconomic features (poverty, unemployment, educational attainment, and income) and counts of POD or HOD hospital discharges. We tested multiplicative interactions between each socioeconomic feature and zip code urbanicity measured with Rural-Urban Commuting Area codes. RESULTS: Percent in poverty and of adults with ≤ high school education were associated with higher POD rates (Rate Ratio [RR], 5% poverty: 1.07 [95% credible interval: 1.06-1.07]; 5% low education: 1.02 [1.02-1.03]), while median household income was associated with lower rates (RR, $10,000: 0.88 [0.87-0.89]). Urbanicity modified the association between socioeconomic features and HOD. Poverty and unemployment were associated with increased HOD in metropolitan areas (RR, 5% poverty: 1.12 [1.11-1.13]; 5% unemployment: 1.04 [1.02-1.05]), and median household income was associated with decreased HOD (RR, $10,000: 0.88 [0.87-0.90]). In rural areas, low educational attainment alone was associated with HOD (RR, 5%: 1.09 [1.02-1.16]). CONCLUSIONS: Regardless of urbanicity, elevated rates of POD were found in more economically disadvantaged zip codes. Economic disadvantage played a larger role in HOD in urban than rural areas, suggesting rural HOD rates may have alternative drivers. Identifying social determinants of opioid overdoses is particularly important for creating effective population-level interventions.