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.

Contributing factors to suicide: Political, social, cultural and economic.

This review summarizes recent research in four environmental areas affecting risk of deaths by suicide. Politically, the weight of the evidence suggests that laws increasing social welfare expenditures and other policies assisting persons with low incomes (e.g., minimum wage) tend to lower suicide rates. Other legal changes such as those restricting firearms and alcohol availability can also prevent suicides. The social institutions of marriage, as well as parenting, continue to serve as protective factors against suicide, although the degree of protection is often gendered. Religiousness tends to be inversely associated with suicide deaths at the individual level of analysis, but the mediators need exploration to determine what accounts for the association: social support, better mental health, better physical health, less divorce, or other covariates. Cultural definitions of the traditional male role (e.g., breadwinner culture) continue to help explain the high male to female suicide ratio. New work on the "culture of suicide" shows promise. The degree of approval of suicide is sometimes the single most important factor in predicting suicide. At the individual level of analysis, two of the strongest predictors of suicide are economic ones: unemployment and low socio-economic status. Attention is drawn to enhancing the minimum wage as a policy known to lower state suicide rates. Limitations of research include model mis-specification, conflicting results especially when ecological data are employed, and a need for more research exploring moderators of established patterns such as that between religiousness and suicide.

Religiousness as a Predictor of Suicide: An Analysis of 162 European Regions.

Research on religion as a protective factor has been marked by four recurrent limitations: (1) an overemphasis on the United States, a nation where religiosity is relatively high; (2) a neglect of highly secularized zones of the world, where religiousness may be too weak to affect suicide; (3) restriction of religiousness to religious affiliation, a construct which may miss capturing other dimensions of religiousness such as the importance of religion in one's life; and (4) an overwhelming use of the nation as a unit of analysis, which masks variation in religiousness within nations. The present article addresses these limitations by performing a cross-national test of the following hypothesis: The greater the strength of subjective religiousness, the lower the suicide rate, using small units of analysis for a secularized area of the world. All data refer to 162 regions within 22 European nations. Data were extracted from two large databases, EUROSTAT and the European Social Surveys (ESS Round 4), and merged using NUTS-2 (Nomenclature of Statistical Territorial Units) regions as the unit of analysis. Controls are incorporated for level of economic development, education, and measures of economic strain. The results of a multiple regression analysis demonstrated that controlling for the other constructs in the model, religiousness is associated with lower suicide rates, confirming the hypothesis. Even in secularized European nations, where there is a relatively weak moral community to reinforce religion, religiousness acts as a protective factor against suicide. Future work is needed to explore the relationship in other culture zones of the world.

Economic Deprivation as a Predictor of the Direction of Lethal Violence: An Analysis of Italian Provinces.

Research on suicide and homicide rates has neglected an integrated model seeking to explain social variation in the direction of lethal violence. The present investigation explores the association between measures of social deprivation on the relative incidence of suicide over homicide in Italian provinces. Data refer to official government sources on lethal violence rates and measures of social deprivation. The central dependent variable (SHR) is the tendency towards suicide measured as the suicide rate divided by the sum of the suicide and homicide rates. Data were available for 102 Italian provinces in the Census year 2001. The percentage of the population marked by two indicators of deprivation (low education, household population density) were negatively associated with the SHR. The results are largely consistent with a stream of previous research that connects deprivation with a relatively high probability for disadvantaged populations to direct aggression outwardly in the form of homicide rather than inwardly in the form of suicide. The present study specifies which elements of deprivation best predict the direction of violence and is the first study for the Italian context.

Suicide by cop in film and society: dangerousness, depression, and justice.

Provoking police officers to kill oneself or "suicide by cop" (SBC) has received scholarly as well as public attention. The extent to which film representations of SBC reflect SBC in society in relation to danger, depression, and other features was assessed in this study. Data on cinematic portrayals of SBC are from 16 American films; corresponding data on SBC in the real world are taken from 19 empirical studies. While the demographic features of SBC in the real world are largely reflected in film, major differences exist on motivations and incident characteristics. Motives for cinematic SBC were unlike SBC in society, wherein, respectively, 0% vs. 35% had attempted suicide in the past, 6% vs. 47% were chronically depressed, and 77% vs. 7% had recently killed someone. Cinematic SBC events disproportionately involve murderous, dangerous persons who are not depressed, and their deaths convey a sense of justice. While such media distortions can be profitable and entertain the audience, they also contribute to public misunderstandings of the nature of deviance and hinder the development of effective suicide and violence prevention programs.

Religion and suicide acceptability: a cross-national analysis.

Four perspectives (moral community thesis, religious integration, religious commitment, and social networks) guide the selection of variables in this study. Data are from the combined World Values/European Values Surveys for 2000 (50,547 individuals nested in 56 nations). The results of a multivariate hierarchical linear model support all four perspectives. Persons residing in nations with relatively high levels of religiosity, who are affiliated with one of four major faiths, are religiously committed, and are engaged with a religious network are found to be lower in suicide acceptability. The religious integration perspective, in particular, is empirically supported; affiliation with Islam is associated with low suicide acceptability. The findings provide strong support for an integrated model and demonstrate the usefulness of the moral community thesis in understanding suicide acceptability.

The effect of survivalism--self-expressionism culture on black male suicide acceptability: a cross-national analysis.

Cultural explanations of black suicide have focused on the US and stressed religiosity as a protective factor. This paper adds to this literature by (1) expanding the analysis of the impact of religiosity on black suicide to 10 nations, and (2) assessing the extent to which a broader cultural construct (self expressionism) affects black suicide acceptability. Data are from Wave 4 of the World Values Surveys 1991-2001 and refer to 3580 black males nested in ten countries. A hierarchical linear regression model determined that religiosity predicted black suicide acceptability across ten nations. Self expressionism was positively associated with individual level suicide acceptability. Further, a cross-level interaction was found wherein individual level and societal level self expressionism combined to affect suicide acceptability. The variability in suicide acceptability among black males is predicted, in part, by both individual and group levels of adherence to values contained in a major cultural axis of nations: self expressionism. These new found associations compliment the impact of a standard predictor, religiosity, on suicide acceptability.

Race/ethnicity and potential suicide misclassification: window on a minority suicide paradox?

BACKGROUND: Suicide officially kills approximately 30,000 annually in the United States. Analysis of this leading public health problem is complicated by undercounting. Despite persisting socioeconomic and health disparities, non-Hispanic Blacks and Hispanics register suicide rates less than half that of non-Hispanic Whites. METHODS: This cross-sectional study uses multiple cause-of-death data from the US National Center for Health Statistics to assess whether race/ethnicity, psychiatric comorbidity documentation, and other decedent characteristics were associated with differential potential for suicide misclassification. Subjects were 105,946 White, Black, and Hispanic residents aged 15 years and older, dying in the US between 2003 and 2005, whose manner of death was recorded as suicide or injury of undetermined intent. The main outcome measure was the relative odds of potential suicide misclassification, a binary measure of manner of death: injury of undetermined intent (includes misclassified suicides) versus suicide. RESULTS: Blacks (adjusted odds ratio [AOR], 2.38; 95% confidence interval [CI], 2.22-2.57) and Hispanics (1.17, 1.07-1.28) manifested excess potential suicide misclassification relative to Whites. Decedents aged 35-54 (AOR, 0.88; 95% CI, 0.84-0.93), 55-74 (0.52, 0.49-0.57), and 75+ years (0.51, 0.46-0.57) showed diminished misclassification potential relative to decedents aged 15-34, while decedents with 0-8 years (1.82, 1.75-1.90) and 9-12 years of education (1.43, 1.40-1.46) showed excess potential relative to the most educated (13+ years). Excess potential suicide misclassification was also apparent for decedents without (AOR, 3.12; 95% CI, 2.78-3.51) versus those with psychiatric comorbidity documented on their death certificates, and for decedents whose mode of injury was "less active" (46.33; 43.32-49.55) versus "more active." CONCLUSIONS: Data disparities might explain much of the Black-White suicide rate gap, if not the Hispanic-White gap. Ameliorative action would extend from training in death certification to routine use of psychological autopsies in equivocal-manner-of-death cases.

Economic strain and suicide risk: a qualitative analysis.

Research at the individual level on economic strain and suicide has focused on unemployment; yet it remains unclear how unemployment and other economic strains actually affect suicide risk for the individual. In the present study Agnew's (1992, 2002), General Strain Theory was applied to a qualitative analysis of case files. Strain issues assessed include the role of goal blockage, economic loss, noxious work environments, anticipated strain, strain clusters, and vicarious strain in the generation of suicide risk. Data are from 62 cases of suicide involving economic strain from the files of an urban county medical examiner's office. The cases were classified into strain categories. Suicide risk was related to all categories of strain; however, economic strains were typically comorbid with additional strains in the genesis of suicide. Key auxiliary strains included anticipated loss of a home place, loss of a car, noxious social relationships, medical problems, death of loved ones, and involvement with the criminal justice system. Some evidence was found linking economic strain to the suicides of nonimpoverished persons. Economic strain and suicide would especially benefit by testing additional hypotheses on strain comorbidity. Unemployment combined with an anticipated eviction from one's home is recommended as a particular point of departure for future work.

Societal economic costs and benefits from death: another look.

B. Yang and D. Lester (2007) have produced an innovative contribution to the relevant literature. Unlike previous studies, they incorporate estimates of cost savings from suicide. Their argument could be strengthened in 3 ways. First, they may have underestimated some of the cost savings by relying on inflated estimates of mental health usage by suicidal persons. The present analysis shows that only 20% of suicidal individuals see a mental health professional during the last year of life, much lower than previous estimates. Further, persons dying of cancer are 4 times more likely than suicides to report high usage of medical services. Second, our economy relies heavily on the health care sector for job creation, so that we need to exercise caution in interpreting savings in medical care; such savings may also represent costs in employment opportunities for nurses, doctors, and other medical personnel. Third, an anticipated criticism, the costs of the grieving of significant others, needs to be considered. Suicidal persons are shown to have less dense social networks, a sign of fewer potential grievers than in the case of natural deaths. Future work is needed to adjust lost earnings for the lower occupational status of suicides; this is another reason why Yang and Lester may be underestimating cost savings from suicide.

Race and method of suicide: culture and opportunity.

The present study assesses the link between choice of violent methods of suicide and race from the standpoint of two perspectives: differential socio-acceptability and differential availability. To the extent that African Americans form a subculture of violence, and are more exposed to violence, we would expect them to choose violent methods of suicide. Data are from the 1990 mortality detail file of the U.S. Public Health Service and correspond to 19,580 male suicides. The results of a multivariate logistic regression analysis indicate that African Americans are 2.24 times more likely than Caucasians to choose violent methods of suicide. Although they are less likely to own firearms, African Americans are more likely than Caucasians to choose violent methods of suicide.