Racial and Ethnic Disparities in All-Cause and Cause-Specific Mortality Among US Youth.

Importance: Mortality rates in US youth have increased in recent years. An understanding of the role of racial and ethnic disparities in these increases is lacking. Objective: To compare all-cause and cause-specific mortality trends and rates among youth with Hispanic ethnicity and non-Hispanic American Indian or Alaska Native, Asian or Pacific Islander, Black, and White race. Design, Setting, and Participants: This cross-sectional study conducted temporal analysis (1999-2020) and comparison of aggregate mortality rates (2016-2020) for youth aged 1 to 19 years using US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Data were analyzed from June 30, 2023, to January 17, 2024. Main Outcomes and Measures: Pooled, all-cause, and cause-specific mortality rates per 100 000 youth (hereinafter, per 100 000) for leading underlying causes of death were compared. Injuries were classified by mechanism and intent. Results: Between 1999 and 2020, there were 491 680 deaths among US youth, including 8894 (1.8%) American Indian or Alaska Native, 14 507 (3.0%) Asian or Pacific Islander, 110 154 (22.4%) Black, 89 251 (18.2%) Hispanic, and 267 452 (54.4%) White youth. Between 2016 and 2020, pooled all-cause mortality rates were 48.79 per 100 000 (95% CI, 46.58-51.00) in American Indian or Alaska Native youth, 15.25 per 100 000 (95% CI, 14.75-15.76) in Asian or Pacific Islander youth, 42.33 per 100 000 (95% CI, 41.81-42.86) in Black youth, 21.48 per 100 000 (95% CI, 21.19-21.77) in Hispanic youth, and 24.07 per 100 000 (95% CI, 23.86-24.28) in White youth. All-cause mortality ratios compared with White youth were 2.03 (95% CI, 1.93-2.12) among American Indian or Alaska Native youth, 0.63 (95% CI, 0.61-0.66) among Asian or Pacific Islander youth, 1.76 (95% CI, 1.73-1.79) among Black youth, and 0.89 (95% CI, 0.88-0.91) among Hispanic youth. From 2016 to 2020, the homicide rate in Black youth was 12.81 (95% CI, 12.52-13.10) per 100 000, which was 10.20 (95% CI, 9.75-10.66) times that of White youth. The suicide rate for American Indian or Alaska Native youth was 11.37 (95% CI, 10.30-12.43) per 100 000, which was 2.60 (95% CI, 2.35-2.86) times that of White youth. The firearm mortality rate for Black youth was 12.88 (95% CI, 12.59-13.17) per 100 000, which was 4.14 (95% CI, 4.00-4.28) times that of White youth. American Indian or Alaska Native youth had a firearm mortality rate of 6.67 (95% CI, 5.85-7.49) per 100 000, which was 2.14 (95% CI, 1.88- 2.43) times that of White youth. Black youth had an asthma mortality rate of 1.10 (95% CI, 1.01-1.18) per 100 000, which was 7.80 (95% CI, 6.78-8.99) times that of White youth. Conclusions and Relevance: In this study, racial and ethnic disparities were observed for almost all leading causes of injury and disease that were associated with recent increases in youth mortality rates. Addressing the increasing disparities affecting American Indian or Alaska Native and Black youth will require efforts to prevent homicide and suicide, especially those events involving firearms.

Trends in cancer-related suicide in the United States: a population-based epidemiology study spanning 40 years of data.

Large cohort studies examining trends in cancer-related suicide are lacking. We analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database, encompassing a total of 4,870,410 patients diagnosed with cancer from 1975 to 2017 in the United States. Joinpoint regression was used to estimate the annual percent change (APC) and average annual percentage change (AAPC) of age-adjusted rates of suicide. In the past 40 years, we revealed a gradual increase in cancer-related suicide rates from 1975 to 1989, followed by a gradual decrease from 1989 to 2013, and a marked decrease from 2013 to 2017. These trends suggested the potential impact of advancements in psychosocial care for patients with cancer in contributing to the observed decrease in suicide rates.

Parental Legal System Involvement, Positive Childhood Experiences, and Suicide Risk.

OBJECTIVES: To examine whether adverse parental legal system involvement (incarceration, arrest) was associated with suicide risk, accounting for other adverse childhood experiences, and whether there was a moderating relationship between positive childhood experiences (PCEs) and parental legal system involvement in suicide risk. METHODS: This cross-sectional study used 2-year follow-up data from the Adolescent Brain Cognitive Development Study when children were age 11 to 12 years. Outcomes were lifetime suicidal ideation, attempts, and nonsuicidal self-injury (NSSI). Exposures were parent incarceration or arrest. We used generalized linear models to estimate the relative risk of suicide outcomes from adverse parent legal involvement and whether there was an interaction between parent legal system involvement and PCE count, controlling for adverse childhood experiences and demographic factors. RESULTS: Among our sample (n = 10 532;), 687 children (6.5%) reported parent incarceration and 1265 (12.0%) reported parent arrest. Suicidal ideation was the most frequent risk outcome (n = 490; 4.7%). Children whose parents had been incarcerated had a relative risk of suicidal ideation of 1.74 (95% CI: 1.32-2.31). Children whose parents had been arrested had a relative risk of suicidal ideation of 1.89 (95% CI: 1.53-2.37) and a relative risk of suicide attempt of 2.69 (95% CI: 1.7-4.25). Parental incarceration/arrest were not associated with NSSI. PCEs were associated with reduced relative risk of suicidal ideation and NSSI, though there was no significant interaction between PCEs and adverse parent legal system involvement exposures. CONCLUSIONS: Parental legal system involvement may negatively affect child mental health. Strengthening PCEs in childhood may mitigate suicide-related risks.

Time-varying living arrangements and suicide death in the general population sample: 14-year causal survival analysis via pooled logistic regression.

AIMS: While past research suggested that living arrangements are associated with suicide death, no study has examined the impact of sustained living arrangements and the change in living arrangements. Also, previous survival analysis studies only reported a single hazard ratio (HR), whereas the actual HR may change over time. We aimed to address these limitations using causal inference approaches. METHODS: Multi-point data from a general Japanese population sample were used. Participants reported their living arrangements twice within a 5-year time interval. After that, suicide death, non-suicide death and all-cause mortality were evaluated over 14 years. We used inverse probability weighted pooled logistic regression and cumulative incidence curve, evaluating the association of time-varying living arrangements with suicide death. We also studied non-suicide death and all-cause mortality to contextualize the association. Missing data for covariates were handled using random forest imputation. RESULTS: A total of 86,749 participants were analysed, with a mean age (standard deviation) of 51.7 (7.90) at baseline. Of these, 306 died by suicide during the 14-year follow-up. Persistently living alone was associated with an increased risk of suicide death (risk difference [RD]: 1.1%, 95% confidence interval [CI]: 0.3-2.5%; risk ratio [RR]: 4.00, 95% CI: 1.83-7.41), non-suicide death (RD: 7.8%, 95% CI: 5.2-10.5%; RR: 1.56, 95% CI: 1.38-1.74) and all-cause mortality (RD: 8.7%, 95% CI: 6.2-11.3%; RR: 1.60, 95% CI: 1.42-1.79) at the end of the follow-up. The cumulative incidence curve showed that these associations were consistent throughout the follow-up. Across all types of mortality, the increased risk was smaller for those who started to live with someone and those who transitioned to living alone. The results remained robust in sensitivity analyses. CONCLUSIONS: Individuals who persistently live alone have an increased risk of suicide death as well as non-suicide death and all-cause mortality, whereas this impact is weaker for those who change their living arrangements.

Sexual and Gender Minority Status and Suicide Mortality: An Explainable Artificial Intelligence Analysis.

Objectives: Suicide risk is elevated in lesbian, gay, bisexual, and transgender (LGBT) individuals. Limited data on LGBT status in healthcare systems hinder our understanding of this risk. This study used natural language processing to extract LGBT status and a deep neural network (DNN) to examine suicidal death risk factors among US Veterans. Methods: Data on 8.8 million veterans with visits between 2010 and 2017 was used. A case-control study was performed, and suicide death risk was analyzed by a DNN. Feature impacts and interactions on the outcome were evaluated. Results: The crude suicide mortality rate was higher in LGBT patients. However, after adjusting for over 200 risk and protective factors, known LGBT status was associated with reduced risk compared to LGBT-Unknown status. Among LGBT patients, black, female, married, and older Veterans have a higher risk, while Veterans of various religions have a lower risk. Conclusion: Our results suggest that disclosed LGBT status is not directly associated with an increase suicide death risk, however, other factors (e.g., depression and anxiety caused by stigma) are associated with suicide death risks.

Disease burden of mental disorders among children and adolescents considering both co-morbidities and suicide in Northeastern China.

BACKGROUND: Few studies have assessed the burden of mental disorders among children and adolescents considering the impact of co-morbidities and suicide on disability adjusted life years (DALYs). METHODS: This was a multicenter cross-sectional study. Our survey data in Liaoning Province (LN) were used to estimate the burden of six mental disorders, supplemented with data from other investigative studies conducted in China to assess four other disorders. DALYs were derived from the sum of years lived with a disability (YLDs) adjusted for co-morbidities, and the years of life lost (YLLs) adjusted for suicide. The changes in DALYs, YLDs, and YLLs were compared with and without adjustment for co-morbidities and suicide. RESULTS: The DALYs rate of mental disorders among children and adolescents in LN decreased from 1579.6/105 to 1391.4/105, after adjusting for both co-morbidities and suicide (-11.9%). The DALYs rate for major depression, anxiety disorder, and conduct disorder (-80.8/105, -75.0/105 and -30.2/105, respectively) were the top three contributors to the DALYs reduction (-188.2/105). The YLDs decreased from 72724.8 to 62478.5 after co-morbidity adjustment (-17.8%), mainly due to the reduction by major depression (-35.3%) and attention deficit/hyperactivity disorder [ADHD] (-34.2%). The YLLs increased from 130 to 1697.8 after adjusting for suicides (+ 56.9% of all suicide YLLs), mainly due to the contribution of major depression (+ 32.4%) and anxiety disorder (+ 10.4%). Compared to GBD 2010, the estimated DALY rate for mental disorders in LN was to be about 80%, with the proportion of DALYs and DALY rates explained by major depressive disorder accounted for only approximately one-third (14.6% vs. 41.9% and 202.6 vs. 759.9, respectively). But the proportion and absolute level of DALY rates explained by anxiety disorders were approximately 2-fold higher (39.7% vs. 19.6% and 552.2 vs. 323.3, respectively). CONCLUSIONS: The DALYs of mental disorders among Chinese children and adolescents were approximately 80% of the global level, with anxiety disorders imposing about 2 times the global level. Co-morbidity and suicide must be adjusted when calculating DALYs.

"There's room to do more": a mixed-methods study of the Temporary Assistance for Needy Families (TANF) diversion program and intimate partner violence in Georgia.

Introduction: Intimate partner violence (IPV) is a risk factor for homicides and suicides. As poverty is both a predictor and a consequence of IPV, interventions that alleviate poverty-related stressors could mitigate IPV-related harms. Temporary Assistance for Needy Families (TANF), a monthly cash assistance program, is one such potential intervention. In the state of Georgia, the TANF diversion program, which provides a non-recurrent lump-sum payment to deter individuals from monthly TANF benefits, is an understudied component of TANF that may influence the effectiveness of state TANF programs in supporting IPV survivors. Aim: This study quantifies and qualifies the role of Georgia's TANF diversion program in shaping IPV-related mortality. Methods: This study relies on a mixed-methods sequential explanatory design. Using data from the Georgia Violent Death Reporting System (GA-VDRS), an interrupted time series analysis was conducted to estimate the effect of TANF diversion on IPV-related homicides and suicides. Semi-structured interviews were then administered with TANF policy experts and advocates, welfare caseworkers, and benefit recipients (n = 20) to contextualize the quantitative findings. Results: The interrupted time series analysis revealed three fewer IPV-related deaths per month after implementing TANF diversion, compared to pre-diversion forecasts (coefficient = -3.003, 95%CI [-5.474, -0.532]). However, the qualitative interviews illustrated three themes regarding TANF diversion: (1) it is a "band-aid" solution to the access barriers associated with TANF, (2) it provides short-term relief to recipients making hard choices, and (3) its limitations reveal avenues for policy change. Discussion: While diversion has the potential to reduce deaths from IPV, it may be an insufficient means of mitigating the poverty-related contributors to IPV harms. Its limitations unveil the need for improved programs to better support IPV survivors.

The long-term changing patterns of suicide mortality in China from 1987 to 2020: continuing urban-rural disparity.

BACKGROUND: Over the past three decades, China has experienced significant changes in urban-rural, gender, and age-specific suicide mortality patterns. This study aimed to investigate the long-term trends in suicide mortality in China from 1987 to 2020. METHODS: Suicide mortality data were obtained from China's National Health Commission. Joinpoint regression analysis was used to examine changes in trends and age-period-cohort modeling to estimate age, period, and cohort effects on suicide mortality from 1987 to 2020. Net drift, local drift, longitudinal age curves, and period relative risks were also calculated. RESULTS: Crude and age-standardized suicide mortality in China showed continuing downward trends from 1987 to 2020, with a more pronounced decrease in rural areas (net drift = -7.07%, p<0.01) compared to urban areas (net drift = -3.41%, p<0.01). The decline curve of urban areas could be divided into three substages. Period and cohort effects were more prominent in rural areas. Suicide risk was highest among individuals aged 20-24 and gradually increased after age 60. Females, particularly those of childbearing age, had higher suicide risk than males, with a reversal observed after age 50. This gender reversal showed distinct patterns in urban and rural areas, with a widening gap in urban areas and a relatively stable gap in rural areas. CONCLUSIONS: Suicide mortality in China has consistently declined over the past three decades. However, disparities in age, gender, and urban-rural settings persist, with new patterns emerging. Targeted suicide prevention programs are urgently needed for high-risk groups, including females of childbearing age and the elderly, and to address the slower decrease and reversing urban-rural gender trends.

The Spatio-Temporal Distribution of Suicide-related Emergency Calls in a European City: Age and Gender Patterns, and Neighborhood Influences.

Objective: The aim of this study was to conduct a comprehensive spatio-temporal analysis of suicide-related emergency calls in the city of Valencia (Spain) over a six-year period. To this end we first examined age and gender patterns and, second, the influence of neighborhood characteristics on general and gender-specific spatio-temporal patterns of suicide-related emergency calls. Method: Geocoded data on suicide-related emergency calls between 2017 and 2022 (N = 10,030) were collected from the 112 emergency service in Valencia. Data were aggregated at the census block group level, used as a proxy for neighborhoods, and trimesters were considered as the temporal unit. Two set of analyses were performed: (1) demographic (age and gender) and temporal descriptive analyses and (2) general and gender-specific Bayesian spatio-temporal autoregressive models. Results: Descriptive analyses revealed a higher incidence of suicide-related emergency calls among females and an increase in calls among the 18-23 age group from 2020 onwards. The general spatio-temporal model showed higher levels of suicide-related emergency calls in neighborhoods characterized by lower education levels and population density, and higher residential mobility, aging population, and immigrant concentration. Relevant gender differences were also observed. A seasonal effect was noted, with a peak in calls during spring for females and summer for males. Conclusions: These findings highlight the need for comprehensive mental health targeted interventions and preventive strategies that account for gender-specific disparities, age-related vulnerabilities, and the specific characteristics of neighborhoods.

Specific effects of cumulative childhood trauma on suicidality among youths.

BACKGROUND: Suicidality was very high among individuals who suffered from childhood trauma. The distribution of cumulative childhood trauma among youths remains unclear, as well as the specific effects of cumulative childhood trauma on suicidality. This study attempted to explore the distribution of cumulative childhood trauma and examine the specific effects of cumulative childhood trauma on suicidality. METHODS: A cross-sectional design was employed in this study, with 117,769 college students recruited from 63 universities in Jilin Province, China. All variables were measured by corresponding self-report questionnaires. The Venn diagram was used to represent the distribution of single and cumulative childhood trauma. ANOVA and chi-square tests were conducted to identify the high-risk suicide groups. Multiple linear regression analysis was performed to examine risk factors for suicidality for overlapping subtypes. RESULTS: 27,671 (23.5%) participants reported suffering from childhood trauma, of which 49.5% were male (Mage = 19.59, SD = 1.76). The "physical neglect" group accounted for the largest proportion (31.5%). Suicidality was the highest in the "overlap of childhood neglect, emotional abuse, and physical abuse" group (2.0%). Depression, obsessive-compulsive disorder, and post-traumatic stress disorder were common risk factors for suicidality. LIMITATIONS: This study was limited by cross-sectional studies and self-report bias. CONCLUSIONS: The childhood trauma subtype group with the largest proportion was not necessarily the highest suicidality. Both the largest group and the highest-risk suicide group require special attention to their respective risk factors.

Risk factors and their association network for young adults' suicidality: a cross-sectional study.

BACKGROUND: Understanding the intricate influences of risk factors contributing to suicide among young individuals remains a challenge. The current study employed interpretable machine learning and network analysis to unravel critical suicide-associated factors in Chinese university students. METHODS: A total of 68,071 students were recruited between Sep 2016 and Sep 2020 in China. Students reported their lifetime experiences with suicidal thoughts and behaviors, categorized as suicide ideation (SI), suicide plan (SP), and suicide attempt (SA). We assessed 36 suicide-associated factors including psychopathology, family environment, life events, and stigma. Local interpretations were provided using Shapley additive explanation (SHAP) interaction values, while a mixed graphical model facilitated a global understanding of their interplay. RESULTS: Local explanations based on SHAP interaction values suggested that psychoticism and depression severity emerged as pivotal factors for SI, while paranoid ideation strongly correlated with SP and SA. In addition, childhood neglect significantly predicted SA. Regarding the mixed graphical model, a hierarchical structure emerged, suggesting that family factors preceded proximal psychopathological factors, with abuse and neglect retaining unique effects. Centrality indices derived from the network highlighted the importance of subjective socioeconomic status and education in connecting various risk factors. CONCLUSIONS: The proximity of psychopathological factors to suicidality underscores their significance. The global structures of the network suggested that co-occurring factors influence suicidal behavior in a hierarchical manner. Therefore, prospective prevention strategies should take into account the hierarchical structure and unique trajectories of factors.

Variations in healthcare utilization for mental health problems prior to suicide by socioeconomic status: a Norwegian register-based population study.

BACKGROUND: Suicide poses a major public health challenge, claiming around 650 lives annually in Norway. There is limited understanding of mental healthcare utilization patterns preceding suicide, particularly relating to socioeconomic status (SES). This study analyzes mental health service use among Norwegian citizens aged 20-64 from 2009 to 2021, emphasizing disparities related to SES. METHODS: This is a population-wide registry-based study. We include mental health consultations with both primary and specialist healthcare services, and investigate patterns of service use regarding educational attainment, employment status and income and compare this to the population in general. All suicides in the period (N = 4731) are included in the study. The aim is to investigate potential discrepancies in service use the year and month preceding suicide, seeking to enhance targeted preventive interventions. RESULTS: Our results show significant variations in healthcare use for mental health problems the last year preceding suicide, according to the components of SES, for both men and women. Those with higher education utilize the mental healthcare services prior to suicide to a higher degree than men and women with high school education or less, whereas employed men and men with high income level have significantly lower mental healthcare usage prior to suicide both the last year and month compared to the non-employed men and men with low-income level. Employed women also had a lower mental healthcare usage, whereas the results regarding income are not significant for women. CONCLUSION: Mental healthcare use prior to suicide varies across the SES components. Notably, the SES groups exhibit heterogeneity, with gendered patterns. Targeted interventions for low consultation rates among employed men, and men with high income and lower education are needed, while women, and men in at-risk groups, such as the non-employed and those with low income, demonstrate higher mental healthcare utilization, warranting comprehensive suicide prevention measures.

Machine Learning-Based Prediction of Suicidal Thinking in Adolescents by Derivation and Validation in 3 Independent Worldwide Cohorts: Algorithm Development and Validation Study.

BACKGROUND: Suicide is the second-leading cause of death among adolescents and is associated with clusters of suicides. Despite numerous studies on this preventable cause of death, the focus has primarily been on single nations and traditional statistical methods. OBJECTIVE: This study aims to develop a predictive model for adolescent suicidal thinking using multinational data sets and machine learning (ML). METHODS: We used data from the Korea Youth Risk Behavior Web-based Survey with 566,875 adolescents aged between 13 and 18 years and conducted external validation using the Youth Risk Behavior Survey with 103,874 adolescents and Norway's University National General Survey with 19,574 adolescents. Several tree-based ML models were developed, and feature importance and Shapley additive explanations values were analyzed to identify risk factors for adolescent suicidal thinking. RESULTS: When trained on the Korea Youth Risk Behavior Web-based Survey data from South Korea with a 95% CI, the XGBoost model reported an area under the receiver operating characteristic (AUROC) curve of 90.06% (95% CI 89.97-90.16), displaying superior performance compared to other models. For external validation using the Youth Risk Behavior Survey data from the United States and the University National General Survey from Norway, the XGBoost model achieved AUROCs of 83.09% and 81.27%, respectively. Across all data sets, XGBoost consistently outperformed the other models with the highest AUROC score, and was selected as the optimal model. In terms of predictors of suicidal thinking, feelings of sadness and despair were the most influential, accounting for 57.4% of the impact, followed by stress status at 19.8%. This was followed by age (5.7%), household income (4%), academic achievement (3.4%), sex (2.1%), and others, which contributed less than 2% each. CONCLUSIONS: This study used ML by integrating diverse data sets from 3 countries to address adolescent suicide. The findings highlight the important role of emotional health indicators in predicting suicidal thinking among adolescents. Specifically, sadness and despair were identified as the most significant predictors, followed by stressful conditions and age. These findings emphasize the critical need for early diagnosis and prevention of mental health issues during adolescence.

Suicide prevention: reflections on progress over the past decade.

Interest in preventing suicides has increased greatly in recent years. In this Personal View, we consider the general global developments related to suicide prevention that have occurred in the decade since The Lancet Psychiatry was first published in 2014. We then review specific advances during this period, first, in relation to public health initiatives, and second, with regard to clinical developments. Finally, we examine some of the challenges that currently confront individuals and organisations responsible for designing and implementing suicide prevention measures.