Older Suicide Decedents: Intent Disclosure, Mental and Physical Health, and Suicide Means

INTRODUCTION

This study examined: (1) associations of suicide intent disclosure with depressed mood and health problems; (2) age-group differences in those associations; and (3) relationship between disclosure and suicide means among suicide decedents aged ≥50 years (N=46,857).

METHODS

Data came from the National Violent Death Reporting Systems, 2005-2014. Data analysis was conducted in 2017. Chi-square tests were used to compare disclosers and nondisclosers on sociodemographic and precipitating factors and suicide means. Logistic regression analyses were used to examine the research questions.

RESULTS

The overall disclosure rate was 23.4%. Logistic regression results showed that both depressed mood (AOR=1.57, 95% CI=1.50, 1.65, p<0.001) and health problems (AOR=1.56, 95% CI=1.48, 1.64, p<0.001) were associated with increased odds of disclosure. Compared with decedents aged 50-59 years, those aged 70-79 years and ≥80 years had greater disclosure odds. When interaction terms of age group X health problems were entered in the model, disclosure odds increased among those with health problems in the groups aged 60-69 years (ratio of AOR=1.19, 95% CI=1.06, 1.34, p=0.003), 70-79 years (ratio of AOR=1.29, 95% CI=1.13, 1.48, p<0.001), and ≥80 years (ratio of AOR=1.41, 95% CI=1.20, 1.66, p<0.001). Compared with other suicide means, both firearm use and hanging/suffocation were associated with lower disclosure odds.

CONCLUSIONS

The older the decedents were, the more likely they were to have disclosed suicidal intent, and health problems largely explained their higher odds of disclosure. Healthcare providers need better preparation to screen and aid those in need to prevent suicide. Social support system members should also be assisted in identifying warning signs and linking older adults to services.

Economic Recession, Alcohol, and Suicide Rates: Comparative Effects of Poverty, Foreclosure, and Job Loss

INTRODUCTION

Suicide rates and the proportion of alcohol-involved suicides rose during the 2008-2009 recession. Associations between county-level poverty, foreclosures, and unemployment and suicide rates and proportion of alcohol-involved suicides were investigated.

METHODS

In 2015, National Violent Death Reporting System data from 16 states in 2005-2011 were utilized to calculate suicide rates and a measure of alcohol involvement in suicides at the county level. Panel models with year and state fixed effects included county-level measures of unemployment, foreclosure, and poverty rates.

RESULTS

Poverty rates were strongly associated with suicide rates for both genders and all age groups, were positively associated with alcohol involvement in suicides for men aged 45-64 years, and negatively associated for men aged 20-44 years. Foreclosure rates were negatively associated with suicide rates for women and those aged ≥65 years but positively related for those aged 45-64 years. Unemployment rate effects on suicide rates were mediated by poverty rates in all groups.

CONCLUSIONS

Population risk of suicide was most clearly associated with county-level poverty rates, indicating that programs addressing area poverty should be targeted for reducing suicide risk. Poverty rates were also associated with increased alcohol involvement for men aged 45-64 years, indicating a role for alcohol in suicide for this working-aged group. However, negative associations between economic indicators and alcohol involvement were found for four groups, suggesting that non-economic factors or more general economic effects not captured by these indicators may have played a larger role in alcohol-related suicide increases.

Alcohol Policies and Suicide: A Review of the Literature

Both intoxication and chronic heavy alcohol use are associated with suicide. There is extensive population-level evidence linking per capita alcohol consumption with suicide. While alcohol policies can reduce excessive alcohol consumption, the relationship between alcohol policies and suicide warrants a critical review of the literature. This review summarizes the associations between various types of alcohol policies and suicide, both in the United States and internationally, as presented in English-language literature published between 1999 and 2014. Study designs, methodological challenges, and limitations in ascertaining the associations are discussed. Because of the substantial between-states variation in alcohol policies, U.S.-based studies contributed substantially to the literature. Repeated cross-sectional designs at both the ecological level and decedent level were common among U.S.-based studies. Non-U.S. studies often used time series data to evaluate pre-post comparisons of a hybrid set of policy changes. Although inconsistency remained, the published literature in general supported the protective effect of restrictive alcohol policies on reducing suicide as well as the decreased level of alcohol involvement among suicide decedents. Common limitations included measurement and selection bias and a focus on effects of a limited number of alcohol policies without accounting for other alcohol policies. This review summarizes a number of studies that suggest restrictive alcohol policies may contribute to suicide prevention on a general population level and to a reduction of alcohol involvement among suicide deaths.

Suicide Risk Documented During Veterans' Last Veterans Affairs Health Care Contacts Prior to Suicide

A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow-up (n = 168; 57%). Fifty-three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide.

Heavy Alcohol Use Among Suicide Decedents Relative to a Nonsuicide Comparison Group: Gender-Specific Effects of Economic Contraction

BACKGROUND

The primary objective of this gender-stratified study was to assess the rate of heavy alcohol use among suicide decedents relative to a nonsuicide comparison group during the 2008 to 2009 economic crisis.

METHODS

The National Violent Death Reporting System and the Behavioral Risk Factor Surveillance System were analyzed by gender-stratified multiple logistic regression to test whether change in acute intoxication (blood alcohol content ≥0.08 g/dl) before (2005 to 2007), during (2008 to 2009), and after (2010 to 2011) the Great Recession mirrored change in heavy alcohol use in a living sample.

RESULTS

Among men, suicide decedents experienced a significantly greater increase (+8%) in heavy alcohol use at the onset of the recession (adjusted ratio of odds ratio = 1.15, 95% confidence interval = 1.10 to 1.20) (relative to the prerecession period) than did men in a nonsuicide comparison group (-2%). Among women, changes in rates of heavy alcohol use were similar in the suicide and nonsuicide comparison groups at the onset and after the recession.

CONCLUSIONS

Acute alcohol use contributed to suicide among men during the recent economic downturn. Among women who died by suicide, acute alcohol use mirrored consumption in the general population. Women may show resilience (or men, vulnerability) to deleterious interaction of alcohol with financial distress.

Precipitating Circumstances of Suicide and Alcohol Intoxication Among U.S. Ethnic Groups

BACKGROUND

Our goal was to assess the prevalence of 9 different types of precipitating circumstances among suicide decedents, and examine the association between circumstances and postmortem blood alcohol concentration (BAC ≥ 0.08 g/dl) across U.S. ethnic groups.

METHODS

Data come from the restricted 2003 to 2011 National Violent Death Reporting System, with postmortem information on 59,384 male and female suicide decedents for 17 U.S. states.

RESULTS

Among men, precipitating circumstances statistically associated with a BAC ≥ 0.08 g/dl were physical health and job problems for Blacks, and experiencing a crisis, physical health problems, and intimate partner problem for Hispanics. Among women, the only precipitating circumstance associated with a BAC ≥ 0.08 g/dl was substance abuse problems other than alcohol for Blacks. The number of precipitating circumstances present before the suicide was negatively associated with a BAC ≥ 0.08 g/dl for Whites, Blacks, and Hispanics.

CONCLUSIONS

Selected precipitating circumstances were associated with a BAC ≥ 0.08 g/dl, and the strongest determinant of this level of alcohol intoxication prior to suicide among all ethnic groups was the presence of an alcohol problem.

Acute alcohol use among suicide decedents in 14 US states: impacts of off-premise and on-premise alcohol outlet density

AIMS

To estimate the association between per capita alcohol retail outlet density and blood alcohol concentration (BAC) from 51 547 suicide decedents and to analyse the relationship between alcohol outlet density and socio-demographic characteristics among alcohol-positive suicide decedents in the United States by racial/ethnic groups and method of suicide.

DESIGN

Analysis of US data, 2003-11, National Violent Death Reporting System.

SETTING

Suicide decedents from 14 US states.

PARTICIPANTS

A total of 51 347 suicide decedents tested for BAC.

MEASUREMENTS

BAC and levels were derived from coroner/medical examiner reports. Densities of county level on-premises and off-premises alcohol retail outlets were calculated using the 2010 Census.

FINDINGS

Multi-level logistic regression models suggested that higher off-premises alcohol outlet densities were associated with greater proportions of alcohol-related suicides among men-for suicides with alcohol present [BAC >0; adjusted odds ratio (AOR) = 1.08, 95% confidence interval (CI) = 1.03-1.13]. Interactions between outlet density and decedents' characteristics were also tested. There was an interaction between off-premises alcohol availability and American Indian/Alaska Native race (AOR = 1.36; 95% CI = 1.10-1.69) such that this subgroup had highest BAC positivity. On-premises density was also associated with BAC >0 (AOR = 1.07; 95% CI = 1.03-1.11) and BAC ≥0.08 (AOR = 1.05; 95% CI = 1.02-1.09) among male decedents.

CONCLUSIONS

In the United States, the density of both on- and off-premises alcohol outlets in a county is associated positively with alcohol-related suicide, especially among American Indians/Alaska Natives.

A Comparison of Suicides and Undetermined Deaths by Poisoning among Women: An Analysis of the National Violent Death Reporting System

The study compared the prevalence of common suicide risk factors between poisoning deaths classified as injuries of undetermined intent or suicides among women. Data were derived from the 2003-10 National Violent Death Reporting System. Multiple logistic regression assessed the factors associated with 799 undetermined deaths (relative to 3,233 suicides). Female decedents with lower education, a substance use problem, and a health problem were more likely to be classified as undetermined death. Older women, those with an intimate partner problem, financial problem, depressed mood, mental health problem, attempted suicide, and disclosed intent to die were less likely to be classified as undetermined death. The present study raises the possibility that many (perhaps most) undetermined female poisoning deaths are suicides.

Correlates of suicide among veterans treated in primary care: case-control study of a nationally representative sample

BACKGROUND

Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.

OBJECTIVE

Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.

DESIGN

This was a retrospective case-control study.

SUBJECTS

The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.

MAIN MEASURES

Demographic, diagnosis, and utilization data were obtained from VA's Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.

KEY RESULTS

Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR = 0.51; 95 % CI = 0.27-0.98) and VA service-connected disability (OR = 0.54; 95 % CI = 0.36-0.80) were associated with decreased odds of suicide, while anxiety disorder (OR = 3.52; 95 % CI = 1.79-6.92), functional decline (OR = 2.52; 95 % CI = 1.55-4.10), depression (OR = 1.82; 95 % CI = 1.07-3.10), and endorsement of suicidal ideation (OR = 2.27; 95 % CI = 1.07-4.83) were associated with greater odds of suicide.

CONCLUSIONS

Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.

Physical activity matters: associations among body mass index, physical activity, and health-related quality of life trajectories over 10 years

BACKGROUND

The objective of this study was to assess the associations among body mass index (BMI), leisure time physical activity (LTPA) and health-related quality of life (HRQL) trajectories among adults.

METHODS

Self-reported data were drawn from the Canadian National Population Health Survey, with respondents being interviewed every 2 years between 1996-97 and 2006-07. Using growth curve modeling, HRQL trajectories for individuals aged 18 and over were associated with measures of BMI and LTPA. Growth models were constructed separately for males and females.

RESULTS

Findings suggested that, for males, BMI categories had little impact on baseline HRQL, and no impact on the rate of change in HRQL. Among women, higher BMI categories were associated with significantly lower baseline HRQL. However, BMI had no impact on the rate of change of HRQL. Conversely, for both men and women and regardless of BMI category, LTPA had significant impacts on baseline HRQL, as well as the rate of change in HRQL. Individuals who were inactive or sedentary had much steeper declines in HRQL as they aged, as compared with individuals who were active in their leisure time.

CONCLUSIONS

The results underscore the importance of LTPA in shaping trajectories of HRQL.

Economic contraction, alcohol intoxication and suicide: analysis of the National Violent Death Reporting System

OBJECTIVES

Although there is a large and growing body of evidence concerning the impact of contracting economies on suicide mortality risk, far less is known about the role alcohol consumption plays in the complex relationship between economic conditions and suicide. The aims were to compare the postmortem alcohol intoxication rates among male and female suicide decedents before (2005-2007), during (2008-2009) and after (2010-2011) the economic contraction in the USA.

METHODS

Data from the restricted National Violent Death Reporting System (2005-2011) for male and female suicide decedents aged 20 years and older were analysed by Poisson regression analysis to test whether there was significant change in the fractions of suicide decedents who were acutely intoxicated at the time of death (defined as blood alcohol content ≥0.08 g/dL) prior, during and after the downturn.

RESULTS

The fraction of all suicide decedents with alcohol intoxication increased by 7% after the onset of the recession from 22.2% in 2005-2007 to 23.9% in 2008-2011. Compared with the years prior to the recession, male suicide decedents showed a 1.09-fold increased risk of alcohol intoxication within the first 2 years of the recession. Surprisingly, there was evidence of a lag effect among female suicide decedents, who had a 1.14-fold (95% CI 1.02 to 1.27) increased risk of intoxication in 2010-2011 compared with 2005-2007.

CONCLUSIONS

These findings suggest that acute alcohol intoxication in suicide interacts with economic conditions, becoming more prevalent during contractions.

Use of alcohol before suicide in the United States

PURPOSE

Few studies have compared acute use of alcohol in suicide decedents with that in a nonsuicide group. This study provides the first national analysis of acute use of alcohol before suicide compared with an estimate of acute use of alcohol in a living sample.

METHODS

Pooled 2003-2011 National Violent Death Reporting System data were used to estimate the prevalence of postmortem blood alcohol content positivity (blood alcohol content >0.0 g/dL) and intoxication (blood alcohol content ≥0.08 g/dL). Population estimates of comparable use of alcohol (within the past 48 hours) were based on the National Epidemiologic Survey on Alcohol and Related Conditions.

RESULTS

Compared with the living sample, male and female suicide decedents showed, respectively, a 1.83-fold (95% confidence interval [CI], 1.73-1.93) and 2.40-fold (95% CI, 2.24-2.57) increased risk of alcohol ingestion before their death after age, race/ethnicity, and chronic alcohol problems were controlled. Furthermore, male and female decedents exhibited, respectively, a 6.18-fold (95% CI, 5.57-6.86) and a 10.04-fold (95% CI, 8.67-11.64) increased risk of being intoxicated before their death after confounders were considered.

CONCLUSIONS

The findings underscore the crucial need to include among the essential components of suicide prevention policies programs that minimize the use of alcohol, particularly drinking to intoxication.

The association between alcohol use and long-term care placement among older Canadians: a 14-year population-based study

Studies have shown that moderate alcohol use confers protection against some of the dominant predictors of long-term care placement, including diminished cognitive functioning, physical disability, and injury. But little is known about the association between alcohol use and the likelihood of placement in long-term care facilities. A nationally representative sample of 5404 community-dwelling Canadians ages 50 years and older at baseline (1994/95) was obtained from the longitudinal National Population Health Survey. Alcohol use categories were developed based on the quantity and frequency of use in the 12 months before the interview. Cox proportional hazards models were used to estimate the association between alcohol use at baseline and subsequent placement in long-term care facilities after adjusting for covariates measured at baseline. During the 14-year follow-up period, 14% of lifetime abstainers, 10% of former drinkers, 7% of infrequent drinkers, 4% of moderate drinkers, and 3% of heavy drinkers were placed in long-term care facilities. Furthermore, the multivariate analysis revealed that abstainers, former drinkers, and infrequent drinkers were more than twice as likely to be placed in long-term care as moderate drinkers. Moderate drinking was protective against placement in long-term care facilities even after adjusting for an array of well-known confounders. The strong protective effect of moderate alcohol use on long-term care entry is likely due to a complex mix of physical, cognitive and psychosocial health factors.

The effects of misclassification biases on veteran suicide rate estimates

OBJECTIVES

We assessed the impact that possible veteran suicide misclassification biases (i.e., inaccuracy in ascertainment of veteran status on the death certificate and misclassification of suicide as other manner of death) have on veteran suicide rate estimates.

METHODS

We obtained suicide mortality data from the 2003-2010 National Violent Death Reporting System and the 2003-2010 Department of Defense Casualty Analysis System. We derived population estimates from the 2003-2010 American Community Survey and 2003-2010 Department of Veterans Affairs data. We computed veteran and nonveteran suicide rates.

RESULTS

The results showed that suicide rates were minimally affected by the adjustment for the misclassification of current military personnel suicides as veterans. Moreover, combining suicides and deaths by injury of undetermined intent did not alter the conclusions.

CONCLUSIONS

The National Violent Death Reporting System is a valid surveillance system for veteran suicide. However, more than half of younger (< 25 years) male and female suicides, labeled as veterans, were likely to have been current military personnel at the time of their death and misclassified on the death certificate.

Acute use of alcohol and methods of suicide in a US national sample

OBJECTIVES

We explored age, gender, and racial/ethnic differences with alcohol use and firearms, hanging or asphyxiation, and poisoning methods of suicide.

METHODS

We analyzed data for 37,993 suicide decedents aged 18 years and older from the 2005-2010 National Violent Death Reporting System database. Multinomial logistic regressions examined associations of method with alcohol use defined by blood alcohol content. Two-way interactions tested the effects of age, gender, and race/ethnicity on the associations between alcohol use and method of suicide.

RESULTS

Alcohol was present among decedents who used the 3 leading methods of suicide: firearm (35.0%), hanging (36.8%), and poisoning (32.7%). Two-way interaction tests suggested that in young and middle adulthood, individuals were more likely to drink alcohol when they used a firearm or hanging (compared with poisoning), but in older adulthood, the reverse was true, with alcohol use more likely with poisoning. Interaction tests also suggested that Asians and Pacific Islanders were most likely to use alcohol in poisonings and that Blacks were least likely to use alcohol in hangings.

CONCLUSIONS

The results suggested that alcohol use before suicide was influenced by several factors, including age, race/ethnicity, and suicide method.

Acute alcohol intoxication and suicide among United States ethnic/racial groups: findings from the national violent death reporting system

BACKGROUND

To assess the prevalence and sociodemographic correlates of suicide involving acute alcohol intoxication among U.S. ethnic minorities.

METHODS

Data were derived from the restricted 2003 to 2009 National Violent Death Reporting System. The study focused on the sociodemographic and toxicological information of 59,384 male and female suicide decedents for 16 states of the United States. Acute alcohol intoxication was defined as having a blood alcohol content (BAC) ≥0.08 g/dl. Overall, 76% of decedents were tested for the presence of alcohol.

RESULTS

The proportion of suicide decedents with a positive BAC ranged from 47% among American Indians/Alaska Natives (AIs/ANs) to 23% among Asians/Pacific Islanders (PIs). Average BAC was highest among AIs/ANs. Among those who were tested for BAC, the proportion of decedents legally intoxicated prior to suicide was as follows: Blacks, 15%; AIs/ANs, 36%; Asians/PIs, 13%; and Hispanics, 28%. Bivariate associations showed that most suicide decedents who were legally intoxicated were male, younger than 30 years of age, with a high school education, not married, nonveterans, lived in metropolitan areas, and used a firearm to complete suicide. However, with the exception of Whites, most of these associations became not statistically significant in multivariate analysis.

CONCLUSIONS

Alcohol use and legal intoxication prior to completing suicide are common among U.S. ethnic groups, especially among men and those who are younger than 30 years of age. The AI/AN group had the highest mean BAC, the highest rate of legal intoxication and decedents who were particularly young. Suicide prevention strategies should address alcohol use as a risk factor. Alcohol problems prevention strategies should focus on suicide as a consequence of alcohol use, especially among AI/AN youth and young adults.

Predictors of smoking patterns after first stroke

Persistent smoking following stroke is associated with poor outcomes including development of secondary stroke and increased mortality risk. This study uses longitudinal data from the U.S. Health and Retirement Study (1992-2008) to investigate whether depression and duration of inpatient hospital care impact smoking outcomes among stroke survivors (N = 745). Longer duration of care was associated with lower likelihood of persistent smoking. Depression was associated with greater cigarette consumption. Interaction effects were also significant, indicating that for survivors who experienced longer inpatient care there was a weaker association between depression and cigarette consumption. Implications for practice and research are discussed.

Health behaviour changes after diagnosis of chronic illness among Canadians aged 50 or older

Changes in health behaviours (smoking, physical activity, alcohol consumption, and fruit and vegetable consumption) after diagnosis of chronic health conditions (heart disease, cancer, stroke, respiratory disease, and diabetes) were examined among Canadians aged 50 or older. Results from 12 years of longitudinal data from the Canadian National Population Health Survey indicated relatively modest changes in behaviour. Although significant decreases in smoking were observed among all groups except those with respiratory disease, at least 75% of smokers did not quit. No significant changes emerged in the percentage meeting physical activity recommendations, except those with diabetes, or in excessive alcohol consumption, except those with diabetes and respiratory disease. The percentage reporting the recommended minimum fruit and vegetable intake did not increase significantly among any group.