Economic uncertainty and suicide in the United States

Risk and protective factors for suicidality among lesbian, gay, bisexual, transgender, and queer (LGBTQ+) young people, from countries with a high global acceptance index (GAI), within the context of the socio-ecological model: A scoping review

INTRODUCTION

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) young people experience higher prevalence rates of suicidality than their heterosexual and/or cisgender peers. However, there is limited research that can inform suicide prevention efforts. Our aim was to synthesize quantitative, qualitative, and mixed methods research on risk and protective factors among LGBTQ+ young people, from countries with a high Global Acceptance Index.

METHODS

A scoping review guided by Arksey and O'Malley's five-stage framework, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews protocol. Five databases and grey literature were searched for relevant studies. Identified factors were clustered by thematic type, according to the socio-ecological model to identify empirical trends and knowledge gaps. The mixed methods appraisal tool was used for quality assessment of studies.

RESULTS

Sixty-six studies met our inclusion criteria. Overall, 59 unique risk factors and 37 unique protective factors were identified. Key risk factors include past suicidality, adverse childhood experiences, internalized queerphobia, minority stress, interpersonal violence, bullying, familial conflict, and anti-LGBTQ+ policies/legislation. Key protective factors include self-affirming strategies, adult/peer support, at-school safety, access to inclusive healthcare, family connectedness, positive coming out experiences, gender-affirming services and LGBTQ+ inclusive policies and legislation.

CONCLUSIONS

Overall, our findings affirm that multiple risk and protective factors, at all levels of the socio-ecological model, interact in complex, unique and diverse ways upon suicidality among LGBTQ+ young people. Implications for suicide prevention are discussed. Further empirical studies are required, particularly at the communities, policies, and societal levels of the socio-ecological model, and these studies should include a focus on protective factors and significant within-group differences.

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.

The association between economic uncertainty and suicide in Japan by age, sex, employment status, and population density: an observational study

Background

Suicide is one of the ten leading causes of death globally, and previous research has revealed a link between economic conditions and mental health. However, the literature has focused primarily on recessions and unemployment, i.e. actual economic developments, as opposed to uncertainty, which relates to economic developments that have not (yet) materialised. This study examines the differential association between economic uncertainty and suicide in Japan, depending on age, sex, employment status, and population density, in order to identify the groups that are affected the most.

Methods

Using monthly prefectural suicide mortality data from the Ministry of Health, Labour and Welfare and a monthly economic uncertainty index for the period 2009 to 2019, we employed a fixed effects panel data approach to examine the association between uncertainty and suicide by population group.

Findings

We found that a 1% increase in economic uncertainty is associated with a 0.061 increase in the monthly number of suicides per 100,000 people per prefecture, on average (coefficient: 6.08; 95% CI: 5.07-7.08), which constitutes a 3.62% increase. Self-employed people, as well as men in their 50s and unemployed men, experience the highest additional risk of suicide when uncertainty increases. The association was approximately three times stronger for males than for females, and a strong association was observed for self-employed males living in more densely-populated areas.

Interpretation

Uncertainty appears to relate to suicides for most groups, but self-employed people, males, and those living in more densely populated areas appear to be more at risk of suicide in periods of increased economic uncertainty. Our results provide an indication of which groups mental health services and prevention strategies can focus on in times of economic uncertainty.

Funding

None.

Impacts of Working Hours, Wages, and Regular Employment Opportunity on Suicide Mortalities of Employed and Unemployed Individuals before and during the COVID-19 Pandemic in Japan

Standardized suicide mortality rates per 100,000 population (SMRs) in Japan consistently decreased from 2009-2019, but these decreasing trends were reversed to increase in 2020. To clarify the mechanisms of recent increasing suicide in Japan, temporal fluctuations of SMRs disaggregated by sex and employment status (employed and unemployed individuals) and labor indices such as working hours, wages, and regular employment opportunity index (REO) from January 2012 to June 2023 were analyzed using interrupted time-series analysis. Additionally, temporal causalities from labor indices to SMRs were analyzed using vector autoregressive and non-linear auto-regressive distributed lag analyses. Decreasing trends among employed SMRs of both sexes were attenuated after the enactment of the "Work Style Reform Program" in 2018, but male SMRs were unaffected by the COVID-19 pandemic. However, female employed SMRs sharply increased, synchronized with the "Work Style Reform Act" and the COVID-19 pandemic outbreak (the COVID-19 impact was greater than the "Work Style Reform Act"). Additionally, unemployed SMRs of both sexes sharply increased with the revision and scale-down of countermeasures against economic deterioration caused by COVID-19 ("revision of economic supportive countermeasures against economic deterioration caused by COVID-19"). Unexpectedly, after enacting the "Work Style Reform Act", wages decreased due to possibly decreasing working hours. Increasing REO, which consistently increased, was a protective factor for male suicides, but unemployed SMRs were not affected by any labor indices. It has been established that controlling a heavy workload plays an important role in suppressing the deterioration of physical and mental conditions, including suicide; however, this study suggested that, at least within appropriate ranges of working hours, decreasing working hours due to excessive management probably contributes to increasing suicides of some vulnerable individuals via de-creasing their wages. Although governmental welfare and economic support measures had to be revised according to rapidly changing situations during the COVID-19 pandemic, this study also suggested that temporal gaps among a part of revisions of several welfare and economic support measures were unexpectedly involved in drastically/sharply increasing suicides of unemployed individuals in 2022.

State-level economic uncertainty and cardiovascular disease deaths: evidence from the United States

The relationship between economic recessions and cardiovascular mortality has been widely explored. However, there is limited evidence on whether economic uncertainty alone is linked to cardiovascular disease deaths. This study examines the association between economic uncertainty and mortality from diseases of the circulatory system in the United States. We obtained monthly state-level mortality data from 2008 to 2017 and used indices capturing economic uncertainty from national/international sources and local sources. Panel data modelling was used to account for unobserved time-invariant differences between the states. Our findings suggest that economic uncertainty is independently linked to cardiovascular mortality. Uncertainty arising from national/international sources is associated with cardiovascular deaths, whereas the respective index capturing uncertainty from state/local sources is not. Deaths respond asymmetrically with respect to uncertainty fluctuations - with high levels of uncertainty driving the association. One- and two-month lagged uncertainty levels are also associated with mortality. Several robustness checks further validate the baseline findings. Overall, economic uncertainty is an independent predictor of cardiovascular mortality which appears to act as a psychosocial stressor and a short-term trigger. Public health strategies for cardiovascular disease need to consider factors driving economic uncertainty. Preventive measures and raising awareness can intensify in periods of economic uncertainty.

Economic policy uncertainty and subjective health: A gender perspective

This study utilizes data from the World Values Survey (WVS) and the country-level Economic Policy Uncertainty (EPU) index to explore the relationship between the EPU and subjective health status. Unlike studies that use suicide as the investigated variable, we find that the adverse association between subjective health and the EPU for women is no less than that for men. The adverse impact is robust for men of prime working age (25-54). It is also robust for women younger than 25, the age range (15-25) among women that suffer from depression at the highest rate. In addition, an asymmetric effect occurs for males of prime working age (25-54) and women older than 55. Specifically, the asymmetric effect indicates that the association between subjective health status and the EPU differs when the EPU is declining and increasing for both sexes, with the effect of the former greater than the latter. This might reflect that the EPU affects both sexes through different mechanisms, with men of prime working age being breadwinners and older women's long life expectancy and poverty caused by shorter careers.

The associations between suicides, economic conditions and social isolation: Insights from Spain

Suicide is among the main challenges that need to be addressed in developed countries. In this paper, we analyse suicides across the 17 Spanish regions over the period 2014-2019. More precisely, our objective is to re-study the determinants of suicides focusing on the latest economic expansion period. We use count panel data models and sex stratification. A range of aggregate socioeconomic regional-level factors have been identified. Our empirical results show that: (1) a socioeconomic urban-rural suicide gaps exist; (2) there are significant gender differences, for the women a Mediterranean suicide pattern appears whereas unemployment levels have a significant importance for men, (3) social isolation factors, when significant, they show an (a priori) surprisingly positive result. We provide new highlights for suicide prevention in Spain. Precisely, it is highlighted that jointly policies by gender and attending to vulnerable groups are both necessary.

Casino accessibility and suicide: A county-level study of 50 US states, 2000 to 2016

BACKGROUND AND AIMS

Suicide is the tenth leading cause of death in the United States (US). Research over many decades identifies that its etiology is complex, with risk factors operating in multiple domains. One such risk factor is gambling. Over the past three decades, exposure to gambling has increased dramatically in the United States. The aim of this study was to measure the magnitude of the association between casino density and absolute risk of suicide in US counties.

DESIGN, SETTING, CASES

This spatial panel analysis used data for 3131 counties from 50 US states from 2000 to 2016, for an overall sample of 53 227 county-year units. Using Bayesian conditional autoregressive Poisson models, we measured incidence rate ratios and credible intervals for the association between the density per population of casinos and other gambling outlets and the incidence of suicide.

MEASUREMENTS

The outcome of interest was counts of suicides. The main exposures of interest were casinos and other gambling outlets.

FINDINGS

A total of 527 401 suicides occurred during the study period. On average, there was a mean of 1.3 casinos (SD = 9.1) and 1.4 other gambling venues (SD = 5.9) in each county-year. After controlling for confounding, the incidence rate ratio for casinos was 1.016, and the credible interval was between 1.010 and 1.023.

CONCLUSIONS

The density of casinos and other gambling venues is positively associated with suicide mortality in the United States.

Suicide and economic uncertainty: New findings in a global setting

This study extends the previous literature on the association between country-level economic uncertainty and suicide rate to 141 countries by introducing the World Uncertainty Index. We first examine the role of economic uncertainty on the suicide rates in a global setting for the period 2000-2019 and then analyze if the association varied across different income groups. Our primary findings suggest that a rise in economic uncertainty is related to an increased suicide rate. According to the estimates based on various income levels, higher economic uncertainty is associated with increased suicide risk in high-income countries. For middle- and low-income countries, we find no such impact. Overall, we conclude that contemporaneous and lagged economic uncertainty is a concern for the increased risk of suicide, especially in high-income countries. The results highlight the need for proactive suicide-prevention strategies in uncertain times.

Road traffic mortality and economic uncertainty: Evidence from the United States

Previous studies have shown that financial turbulence is associated with a short-term increase in road traffic collisions, largely due to drivers' emotional state, distraction, sleep deprivation and alcohol consumption. In this paper we advance this debate by studying the association between economic uncertainty and road traffic mortality in the United States. We used a State-level uncertainty index and State fatalities for the period 2008-2017 and found that a one standard deviation increase in economic uncertainty is associated with an additional 0.013 monthly deaths per 100,000 people per State, on average (a 1.1% increase) - or 40 more monthly deaths in total nationwide. Results are robust to different model specifications. Our findings show that, similar to drink-driving, it is important to raise awareness about driving when distracted due to financial worries and during periods of economic uncertainty.

Suicidality in psychiatric emergency department situations during the first and the second wave of COVID-19 pandemic

Psychiatric patients are prone to mental health deterioration during the Covid-19 pandemic. Little is known about suicidality in psychiatric patients during the Covid-19 pandemic. This study is a retrospective chart review of psychiatric emergency department (pED) presentations with present or absent suicidality (5634 pED attendances, 4110 patients) in an academic pED in Berlin, Germany. Poisson regression analysis was performed on the effect of Covid-19 period on suicidality (suicidal ideation (SI), suicide plans (SP) or suicide attempt (SA)) during the first (3/2/2020-5/24/2020 "first-wave") and second (9/15/2020-3/1/2021 "second-wave") wave of the Covid-19 pandemic compared to the same periods one year earlier. During the first-wave the number of pED visits per person with SI, SP and SA was higher compared to one year earlier (SI RR = 1.614; p = 0.016; SP RR = 2.900; p = 0.004; SA RR = 9.862; p = 0.003). SI and SP were predicted by interaction between substance use disorder (SUD) and second-wave (SI RR = 1.305, p = 0.043; SP RR = 1.645, p = 0.018), SA was predicted by interaction between borderline personality disorder (BPD) and second-wave (RR = 7.128; p = 0.012). Suicidality increased during the first-wave of Covid-19 pandemic in our sample. In the second-wave this was found in patients with SUD and BPD. These patients may be at particular risk of suicidality during the Covid-19 pandemic.

Can additional funding improve mental health outcomes? Evidence from a synthetic control analysis of California’s millionaire tax

California is the only one of its peers with a state-wide tax earmarked for mental health programs. The voter-approved levy applies to personal income above $1 million and has generated over $20 billion since 2005. But whether the additional funding improved population mental health remains unknown. This study applies the synthetic control method to the CDC’s National Vital Statistics System data to determine how the tax affected suicide deaths in California. Findings show that the state’s suicide mortality rate increased more gradually after the tax’s implementation than it would have otherwise. By 2019, the cumulative impact was approximately 5,500 avoided deaths. Multiple robustness and sensitivity checks confirm that result. However, the effect did not appear immediately, nor was it present within all demographic groups. Nevertheless, additional revenue was associated with improved mental health in California. Other governments may likewise yield beneficial outcomes.

Global economic uncertainty and suicide: Worldwide evidence

Economic uncertainty is a driver of the business cycle. Its leading properties make it a key advanced indicator to assess the impact of socioeconomic factors on suicide for prevention purposes. This paper evaluates the effect of economic uncertainty on suicide rates worldwide. Uncertainty is gauged by a global economic policy uncertainty index. Suicide rates from 183 countries between 2000 and 2019 are matched to annual economic uncertainty, controlling for unemployment and economic growth in a fixed-effects panel model. Overall, the analysis suggests that increases in lagged economic uncertainty, as well as in unemployment and economic growth, may lead to an increased risk of suicide. When replicating the experiment for different regions of the world, the greatest impact of an increase in economic uncertainty can be found in Africa and the Middle East. Given the anticipatory nature of economic uncertainty regarding the evolution of economies, and its relationship with suicide rates, the results highlight the usefulness of uncertainty indicators as tools for the early detection of periods of increased suicide risk and the design of suicide prevention strategies.

Police killings and suicide among Black Americans

Black Americans are killed at higher rates by police than whites. Previous studies have shown that discrimination can lead to suicidal ideation, and that mental health of Black Americans deteriorates after police killings. The objective of this study is to examine whether police killings are associated with an increase in suicide rates amongst Black Americans. Controlling for a number of factors, we found that on months with at least one killing of a Black person by police, there were, on average, 0.0472 additional suicides per 100,000 Black Americans in the U.S. Census Division where the killing occurred. We did not find any spillover effects on other divisions. This association persisted when controlling for gun ownership, and did not seem to be a result of variance in deaths by assault. There was no association between killings of Black Americans and white suicides; white killings and Black suicides; or white killings and white suicides. This study highlights another reason for urgent action on reducing police killings.

Revisiting the relationship between economic uncertainty and suicide: An alternative approach

Previous research provides evidence that economic uncertainty is powerful enough to precipitate suicide. This study examines whether the relationship between economic uncertainty and suicide in the US is (i) context dependent and (ii) asymmetric. To answer these questions, we link US monthly total- age- and gender-specific suicide rates to the US Economic Policy Uncertainty index between 1999 and 2019, controlling for month fixed effects, year fixed effects and unemployment rates. We find that the relationship between economic uncertainty and the suicide rates of males in their mid-career (aged 25-54) and late career (aged 55-64) is context dependent. Our results show that absolute monthly changes in economic uncertainty have no effect on suicide rates of males aged 25-54 and 55-64, whereas when these changes are unexpected - departing from the economic uncertainty regime during which they occur - they precipitate the suicide of these age- and gender-specific groups. Additionally, our findings provide evidence of the presence of negativity bias in these relationships. We show that extreme unexpected increases in economic uncertainty induce suicide of males aged 25-54 and 55-64, while extreme unexpected decreases in economic uncertainty do not significantly decrease suicide rates of these age- and gender-specific groups. Females, with the exception of those aged 65 plus, are perceived to be predominantly insulated from changes in economic uncertainty. Our results suggest that females aged 65 plus are particularly affected by extreme unexpected increases in economic uncertainty, suggesting that the relationship for females aged 65 plus is context dependent and exhibits negativity bias.