Did the Great Recession increase suicides in the USA? Evidence from an interrupted time-series analysis

National trends of suicidality 1999-2020 among Asian American Pacific Islander young adults across sex

This study analyzes 21 years of suicide trend among Asian American Pacific Islander (AAPI) young adults aged 18-25. Analyzing NCHS data (1999-2020) through the Joinpoint Regression, we examined temporal trends of suicide death across sexes and identified trend shifts. Findings indicate a significant and steady increasing trend in AAPI female suicides from 1999 to 2020. Alarmingly, AAPI males displayed a significant and sharp increasing trend of suicide from 2008 onwards. It is important to consider other risk factors of suicide, including cultural factors and gendered racial experiences, to understand the context of AAPI young adults' suicide patterns.

"Deaths of despair" over the business cycle: New estimates from a shift-share instrumental variables approach

This study presents new evidence of the effects of short-term economic fluctuations on suicide, fatal drug overdose, and alcohol-related mortality among working-age adults in the United States from 2003-2017. Using a shift-share instrumental variables approach, I find that a one percentage point increase in the aggregate employment rate decreases current-year non-drug suicides by 1.7 percent. These protective effects are concentrated among working-age men and likely reflect a combination of individual labor market experiences as well as the indirect effects of local economic growth. I find no consistent evidence that short-term business cycle changes affect drug or alcohol-related mortality. While the estimated protective effects are small relative to secular increases in suicide in recent decades, these findings are suggestive of important, short-term economic factors affecting specific causes of death and should be considered alongside the longer-term and multifaceted social, economic, and cultural determinants of America's "despair" epidemic.

Institutional Failures as Structural Determinants of Suicide: The Opioid Epidemic and the Great Recession in the United States

We investigate recent trends in U.S. suicide mortality using a "structural determinants of health" framework. We access restricted-use multiple cause of death files to track suicide rates among U.S. Black, White, American Indian/Alaska Native, and Latino/a men and women between 1990 and 2017. We examine suicide deaths separately by poisonings and nonpoisonings to illustrate that (1) women's suicide rates from poisonings track strongly with increases in prescription drug availability and (2) nonpoisoning suicide rates among all adult Americans track strongly with worsening economic conditions coinciding with the financial crash and Great Recession. These findings suggest that institutional failures elevated U.S. suicide risk between 1990 and 2017 by increasing access to more lethal means of self-harm and by increasing both exposure and vulnerability to economic downturns. Together, these results support calls to scale up to focus on the structural determinants of U.S. suicide.

The Influence of the Great Recession on Adolescent Major Depressive Episodes and Treatment in the United States: An Interrupted Time Series Analysis

PURPOSE

In the United States, adolescent depression increased beginning in 2008-2010, coinciding with the Great Recession. We investigated whether this time of changing economic circumstances impacted adolescent depression and treatment.

METHODS

We analyzed data for adolescents aged 12-17 years from the 2004-2019 National Survey on Drug Use and Health (N = 256,572). Adolescents' past-year major depressive episodes (MDEs) were measured by self-reported symptoms. MDE treatment included seeing a health professional or receiving MDE medication. We tested how MDE and MDE treatment changed from pre-Great Recession (2004 to Fall 2007) to post-Great Recession (Winter 2007-2019) using interrupted time-series segmented regression models, accounting for seasonality and autocorrelation and testing for moderation by household poverty.

RESULTS

The Great Recession was not associated with an immediate increase in MDE prevalence (β:-0.77 [i.e., quarter-year change in prevalence], 95% confidence interval (CI): -2.23, 0.69). However, the increase in MDE prevalence accelerated following the Great Recession (β: 0.29, 95% CI: 0.13, 0.44). The Great Recession was not associated with immediate or long-term changes in adolescent MDE treatment (immediate β: -2.87, 95% CI: -7.79, 2.04; long-term β: 0.03, 95% CI: -0.46, 0.51). Effects were similar for households by poverty status.

DISCUSSION

The Great Recession was not associated with increased adolescent depression prevalence, although there was an acceleration in the trend of adolescent MDE following the recession. The prevalence of MDE treatment remained stable. Adolescent depression prevention efforts should be heightened as prevalence increases, including actively engaging caregivers as family supports to alleviate potential negative implications of economic distress for adolescent MDE.

The impact of national and international financial crises on mental health and well-being: a systematic review

BACKGROUND

Evidence suggests that financial crises and poor mental health are reciprocally related, but no systematic review has been conducted to synthesise the existing literature on the impact of national and international financial crises on population-level mental health and well-being.

AIMS

The aim of this study was to systematically review the available literature on the global impact of financial crises on mental health and well-being outcomes.

METHODS

After registration on PROSPERO, a systematic search was conducted in PsycINFO, MEDLINE, Wiley, and Web of Science for papers published until 21 November 2022. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, 98 papers were identified as meeting eligibility criteria. Included studies were assessed using the Mixed Methods Appraisal Tool (MMAT) and results were presented in a formal narrative synthesis.

RESULTS

Our findings show that financial crises are significantly associated with well-being and occurrence of psychological conditions. Several socio-demographic, cultural, and country-specific characteristics played a crucial role in the prevention of population mental health decline in periods of financial crises.

CONCLUSIONS

Based on the findings of this review, evidence-based recommendations were developed to guide the design of policy actions that protect population mental health during and after financial crises.

Impact of a vaccine passport on first-dose SARS-CoV-2 vaccine coverage by age and area-level social determinants of health in the Canadian provinces of Quebec and Ontario: an interrupted time series analysis

BACKGROUND

In Canada, all provinces implemented vaccine passports in 2021 to reduce SARS-CoV-2 transmission in non-essential indoor spaces and increase vaccine uptake (policies active September 2021-March 2022 in Quebec and Ontario). We sought to evaluate the impact of vaccine passport policies on first-dose SARS-CoV-2 vaccination coverage by age, and area-level income and proportion of racialized residents.

METHODS

We performed interrupted time series analyses using data from Quebec's and Ontario's vaccine registries linked to census information (population of 20.5 million people aged ≥ 12 yr; unit of analysis: dissemination area). We fit negative binomial regressions to first-dose vaccinations, using natural splines adjusting for baseline vaccination coverage (start: July 2021; end: October 2021 for Quebec, November 2021 for Ontario). We obtained counterfactual vaccination rates and coverage, and estimated the absolute and relative impacts of vaccine passports.

RESULTS

In both provinces, first-dose vaccination coverage before the announcement of vaccine passports was 82% (age ≥ 12 yr). The announcement resulted in estimated increases in coverage of 0.9 percentage points (95% confidence interval [CI] 0.4-1.2) in Quebec and 0.7 percentage points (95% CI 0.5-0.8) in Ontario. This corresponds to 23% (95% CI 10%-36%) and 19% (95% CI 15%-22%) more vaccinations over 11 weeks. The impact was larger among people aged 12-39 years. Despite lower coverage in lower-income and more-racialized areas, there was little variability in the absolute impact by area-level income or proportion racialized in either province.

INTERPRETATION

In the context of high vaccine coverage across 2 provinces, the announcement of vaccine passports had a small impact on first-dose coverage, with little impact on reducing economic and racial inequities in vaccine coverage. Findings suggest that other policies are needed to improve vaccination coverage among lower-income and racialized neighbourhoods and communities.

Sanctuary city policies and Latinx immigrant mental health in California

This quasi-experimental study examined whether "sanctuary city" policies are an effective mechanism for reducing mental health inequalities by immigrant origin status in Latinx populations in California. Ample evidence indicates that people experience mental health problems when restrictive immigration policies are imposed. It remains unclear whether sanctuary city policies can improve population mental health in the groups targeted by restrictive immigration policies: undocumented immigrant Latinxs, documented immigrant Latinxs, and native-born Latinxs. We combined data on California's 482 cities concerning whether and when they implemented a sanctuary policy with health data on approximately 142,000 adults, 6400 adolescents and 13,000 children from the multi-year California Health Interview Survey. After using propensity score matching to identify non-sanctuary cities comparable to sanctuary cities, we estimated respondent-level difference-in-differences models to determine whether sanctuary city policies had beneficial mental health effects on three age groups: adults, adolescents, and children during the period 2007-2018. There was a trend toward improved mental health in sanctuary cities after policy enactment, but the patterns of mental health in the three Latinx immigration sub-groups of each age group did not conform to our hypotheses. Buffering the adverse effects of harsh federal immigration policies may need to involve other approaches, such as expanded local mental health care access. We discuss these results in terms of alternative treatment interference, residents' policy awareness, the policy's capacity to address past health impacts, methodological issues, and potential policy momentum.

The impact of the COVID-19 pandemic on hospital-treated self-harm in Sydney (Australia)

OBJECTIVES

This study investigated trends in hospital-treated self-harm and hospital presenting suicidal ideation in the period before and after COVID-19 public health responses by key socio-demographic groups among those presenting to hospitals in the Western Sydney (Australia) population catchment.

METHODS

Emergency department presentations for the period January 2016 to June 2021 were used to specify a series of interrupted time-series models to compare the observed and expected event rates of (1) hospital-treated self-harm and (2) hospital presenting suicidal ideation in the period following the onset of COVID-19 public health measures in March 2020. Rate differences between observed and expected rates in the post-implementation period were also estimated in models stratified by sex, age group, country of birth and socio-economic status.

RESULTS

There was no significant increase in hospital-treated self-harm in the period post-implementation of public health orders (March 2020) compared to the previous period, although there were lower than expected rates of emergency department presentations among non-Australian-born males, males aged 0-14 years and 25-44 years, and females aged 45-64 years. In contrast, there was a significant increase in hospital presenting suicidal ideation, particularly among women (rate difference per 100,000 = 3.91, 95% confidence interval = [1.35, 6.48]) and those aged 15-24 years (both males and females, rate differences ranging from 8.91 to 19.04), and among those residing in lower socio-economic status areas (both males and females, rate differences ranging from 0.90 to 2.33).

CONCLUSION

There was no increase in hospital-treated self-harm rates in the 15 months post-implementation of COVID-19 public health orders in Western Sydney; however, there was a significant increase in hospital presenting suicidal ideation. The limited change in suicidal behaviour may reflect the success of social and economic supports during this period, the benefits of which may have been different for young people, and those of lower socio-economic status.

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.

Impact of the COVID-19 pandemic on temporal patterns of mental health and substance abuse related mortality in Michigan: An interrupted time series analysis

Background

The emergence of SARS-CoV2 (COVID-19) had wide impacts to health and mortality and prompted unprecedented containment efforts. The full impact of the COVID-19 pandemic and resulting responses on mental health and substance abuse related mortality are unknown.

Methods

We obtained records for deaths from suicide, alcohol related liver failure, and overdose from the Michigan Department of Health and Human Services (MDHHS) for 2006 to 2020. We compared mortality within sex, age, marital, racial and urban/rural groups using basic statistical methods. We compared standardized mean daily mortality incidence before and after the onset of the pandemic using t-tests. We used an interrupted time series approach, using generalized additive Poisson regression models with smoothed components for time to assess differences in mortality trends before and after the onset of the pandemic within demographic groups.

Findings

There were 19,365 suicides, 8,790 deaths from alcohol related liver failure, and 21,778 fatal drug overdoses. Compared with 2019, suicides in 2020 declined by 17.6%, overdose mortality declined by 22.5%—while alcohol deaths increased by 12.4%. Crude comparisons suggested that there were significant declines in suicides for white people, people 18 to 65 and increases for rural decedents, overdoses increased for Black people, females and married/widowed people, and alcohol mortality increased for nearly all groups. ITS models, however, suggested increased suicide mortality for rural residents, significantly increased alcohol related mortality for people ≥65 and increased overdose mortality in men.

Interpretation

The onset of the pandemic was associated with mixed patterns of mortality between suicide, alcohol and overdose deaths. Patterns varied within demographic groups, suggesting that impacts varied among different groups, particularly racial and marital groups.

Funding

This work was supported by the United States National Institute of Environmental Health Sciences [K99/R00ES026198] and their Michigan Center on Lifestage Environmental Exposures and Disease [grant number P30ES017885]; and the Institute for Global Biological Change at the University of Michigan.

The Recent Rise of Suicide Mortality in the United States

Suicide is a major public health concern in the United States. Between 2000 and 2018, US suicide rates increased by 35%, contributing to the stagnation and subsequent decrease in US life expectancy. During 2019, suicide declined modestly, mostly owing to slight reductions in suicides among Whites. Suicide rates, however, continued to increase or remained stable among all other racial/ethnic groups, and little is known about recent suicide trends among other vulnerable groups. This article (a) summarizes US suicide mortality trends over the twentieth and early twenty-first centuries, (b) reviews potential group-level causes of increased suicide risk among subpopulations characterized by markers of vulnerability to suicide, and (c) advocates for combining recent advances in population-based suicide prevention with a socially conscious perspective that captures the social, economic, and political contexts in which suicide risk unfolds over the life course of vulnerable individuals.

Declining Life Expectancy in the United States: Missing the Trees for the Forest

In recent years, life expectancy in the United States has stagnated, followed by three consecutive years of decline. The decline is small in absolute terms but is unprecedented and has generated considerable research interest and theorizing about potential causes. Recent trends show that the decline has affected nearly all race/ethnic and gender groups, and the proximate causes of the decline are increases in opioid overdose deaths, suicide, homicide, and Alzheimer's disease. A slowdown in the long-term decline in mortality from cardiovascular diseases has also prevented life expectancy from improving further. Although a popular explanation for the decline is the cumulative decline in living standards across generations, recent trends suggest that distinct mechanisms for specific causes of death are more plausible explanations. Interventions to stem the increase in overdose deaths, reduce access to mechanisms that contribute to violent deaths, and decrease cardiovascular risk over the life course are urgently needed to improve mortality in the United States.

Swedish nationwide time series analysis of influenza and suicide deaths from 1910 to 1978

OBJECTIVES

There is concern that the COVID-19 pandemic will be associated with an increase in suicides, but evidence supporting a link between pandemics and suicide is limited. Using data from the three influenza pandemics of the 20th century, we aimed to investigate whether an association exists between influenza deaths and suicide deaths.

DESIGN

Time series analysis.

SETTING

Sweden.

PARTICIPANTS

Deaths from influenza and suicides extracted from the Statistical Yearbook of Sweden for 1910-1978, covering three pandemics (the Spanish influenza, the Asian influenza and the Hong Kong influenza).

MAIN OUTCOME MEASURES

Annual suicide rates in Sweden among the whole population, men and women. Non-linear autoregressive distributed lag models was implemented to explore if there is a short-term and/or long-term relationship of increases and decreases in influenza death rates with suicide rates during 1910-1978.

RESULTS

Between 1910 and 1978, there was no evidence of either short-term or long-term significant associations between influenza death rates and changes in suicides (β coefficients of 0.00002, p=0.931 and β=0.00103, p=0.764 for short-term relationship of increases and decreases in influenza death rates, respectively, with suicide rates, and β=-0.0002, p=0.998 and β=0.00211, p=0.962 for long-term relationship of increases and decreases in influenza death rates, respectively, with suicide rates). The same pattern emerged in separate analyses for men and women.

CONCLUSIONS

We found no evidence of short-term or long-term association between influenza death rates and suicide death rates across three 20th century pandemics.

COVID-19 economic impacts in perspective: A comparison to recent U.S. disasters

This paper places the COVID-19 pandemic into perspective by comparing it to other recent disasters in terms of impacts on the macroeconomy of the U.S. We present a short summary of advances in the state-of-the-art of economic consequence analysis, as well as estimates this approach yields on economic impacts of 9/11, a variety of natural disasters, the Great Recession, and COVID-19. The prevention of these negative impacts represents the benefits of various types of risk management tactics and strategies. In light of the enormously greater economic impact of COVID-19 as compared to natural and man-made disasters, it is reasonable to question whether adequate investments are being made to prevent future pandemics.

Economic uncertainty and suicide in the United States

Previous studies have found an association between recessions and increased rates of suicide. In the present study we widened the focus to examine the association between economic uncertainty and suicides. We used monthly suicide data from the US at the State level from 2000 to 2017 and combined them with the monthly economic uncertainty index. We followed a panel data econometric approach to study the association between economic uncertainty and suicide, controlling for unemployment and other indicators. Economic uncertainty is positively associated with suicide when controlling for unemployment [coeff: 8.026; 95% CI: 3.692-12.360] or for a wider range of economic and demographic characteristics [coeff: 7.478; 95% CI: 3.333-11.623]. An increase in the uncertainty index by one percent is associated with an additional 11-24.4 additional monthly suicides in the US. Economic uncertainty is likely to act as a trigger, which underlines the impulsive nature of some suicides. This highlights the importance of providing access to suicide prevention interventions (e.g. hotlines) during periods of economic uncertainty.

Real-time suicide mortality data from police reports in Queensland, Australia, during the COVID-19 pandemic: an interrupted time-series analysis

BACKGROUND

Deaths by suicide can increase during infectious disease outbreaks. This study analysed suspected suicide rates in 2020 relative to 2015-19 to assess any early effects of the COVID-19 pandemic in Queensland, Australia.

METHODS

We analysed data from the interim Queensland Suicide Register (iQSR), a state-wide real-time suicide surveillance system, using an interrupted time-series design. The data source for the iQSR is the Form 1 police report of a death to a coroner. Two QSR staff independently classed the probability of a death by suicide as possible, probable, or beyond reasonable doubt. The analysis included the probable or beyond reasonable doubt categories as suspected suicides. The primary outcome was the monthly suspected suicide rate. We applied Poisson and negative binomial regressions to assess whether Queensland's Public Health Emergency Declaration on Jan 29, 2020, affected suspected suicides from Feb 1 to Aug 31, 2020. Secondary outcomes included absolute or relative changes in police-reported motives of recent unemployment, financial problems, domestic violence, and relationship breakdown.

FINDINGS

3793 suspected suicides were recorded with an unadjusted monthly rate of 14·85 deaths per 100 000 people (from Jan 1, 2015, to Jan 31, 2020) before the declaration, and 443 suspected suicides were recorded with an unadjusted monthly rate of 14·07 deaths per 100 000 people (Feb 1, 2020, onwards) after the declaration. An interrupted time-series Poisson regression model unadjusted (rate ratio [RR] 0·94, 95% CI 0·82-1·06) and adjusted for overdispersion, seasonality, and pre-exposure trends (RR 1·02, 95% CI 0·83-1·25) indicated no evidence of a change in suspected suicide rates. We found no absolute or relative increases in the motives for suspected suicides, including recent unemployment, financial problems, relationship breakdown, or domestic violence from February to August, 2020, compared with the pre-exposure period.

INTERPRETATION

There does not yet appear to be an overall change in the suspected suicide rate in the 7 months since Queensland declared a public health emergency. Despite this, COVID-19 has contributed to some suspected suicides in Queensland. Ongoing community spread and increasing death rates of COVID-19, and its impact on national economies and mental health, reinforces the need for governments to maintain the monitoring and reporting of suicide mortality in real time.

FUNDING

None.

Ecological factors associated with suicide mortality among non-Hispanic whites

BACKGROUND

In this paper, we examine the ecological factors associated with death rates from suicide in the United States in 1999 and 2017, a period when suicide mortality increased in the United States. We focus on Non-Hispanic Whites, who experienced the largest increase in suicide mortality. We ask whether variation in suicide mortality among commuting zones can be explained by measures of the social and economic environment and access to lethal means used to kill oneself in one's area of residence.

METHODS

We use vital statistics data on deaths and Census Bureau population estimates and define area of residence as one of 704 commuting zones. We estimate separate models for men and women at ages 20-64 and 65 and above. We measure economic environment by percent of the workforce in manufacturing and the unemployment rate and social environment by marital status, educational attainment, and religious participation. We use gun sellers and opioid prescriptions as measures of access to lethal means.

RESULTS

We find that the strongest contextual predictors of higher suicide mortality are lower rates of manufacturing employment and higher rates of opiate prescriptions for all age/sex groups, increased gun accessibility for men, and religious participation for older people.

CONCLUSIONS

Socioeconomic characteristic and access to lethal means explain much of the variation in suicide mortality rates across commuting zones, but do not account for the pervasive national-level increase in suicide mortality between 1999 and 2017.

An empirical investigation of the relationship between business performance and suicide in the US

Previous research suggests that mortality rates behave pro-cyclically with respect to economic growth, with suicides representing a notable exception that consistently increase in economic downturns. Over recent years, there is ample evidence in the literature that the working environment in the US has deteriorated significantly, suggesting that suicide rates may not necessarily behave in a counter-cyclical manner with business performance. Utilising recent suicide data, this study empirically tests the hypothesis that adverse working conditions over recent years may have resulted in a pro-cyclical relationship between business performance and suicide. Unlike previous studies, we use a stock market index, a leading macroeconomic indicator, to measure economic conditions from a business perspective. We employ the Autoregressive Distributed Lag (ARDL) co-integration methodology to study the long-run relationship between monthly S&P500 stock market data and age and gender-specific suicide rates during the period January 1999 to July 2017. Our results highlight substantial differences in age groups responses to fluctuations in business performance. We find a clear positive association between business performance and suicide rates for the youngest males and females aged 15-34 years, indicating that there is a human cost associated with improved business performance. Additionally, we investigate the association between economic insecurity, a unique aspect of the recent deterioration in the working environment, using the Implied Volatility Index "VIX" and age and gender-specific suicide rates. Our findings do not support a population-wide adverse impact of economic insecurity on suicide incidences. The exception was males aged 15-24, and females aged 55-64 for whom we find a significant positive association. Teaching work-life management and problem-solving skills to manage everyday work stressors may be important strategies to mitigate the psychological cost of business successes.

Age, period and cohort effects in firearm homicide and suicide in the USA, 1983–2017

Background

Rates of firearm homicide and suicide have varied over time. These variations are due to a number of factors including temporal trends, age, birth year and gender. We sought to conduct an age–period–cohort analysis to understand the intersection of these factors with firearm homicide and suicide.

Methods

We used data on firearm homicide and suicide for the years 1983–2017 from the Centers for Disease Control and Prevention’s Web-based Injury Statistics Query and Reporting System for this analysis. We restricted our analysis on firearm homicide to persons aged 10–44 years and our analysis on firearm suicide to persons aged 50–84 years, as these age groups are most at risk of each outcome. We calculated annual incidence rates for both outcomes per 100 000 population, overall and by gender.

Results

Across all age groups, rates of firearm homicide increased dramatically in the late 1980s and early 1990s. The peak age for firearm homicide varied across cohorts, although it was generally between ages 15 and 29 years. Rates of firearm homicide were substantially higher among men than women, regardless of age, period or cohort. Firearm suicide rates varied significantly by gender. Among men, older cohorts had higher firearm suicide rates, although the rate of firearm suicide increased with age across all cohorts. Among women, firearm suicide rates were also highest among older cohorts; however, firearm suicide rates decreased or remained relatively constant with age.

Conclusion

There are important differences in rates of firearm homicide and suicide with respect to gender, age, period and cohort.

The negative growth of a brief depressive spell among U.S. adolescents

OBJECTIVE

Studying adolescent-onset brief depressive spells, we saw a chance to adapt a cross-cohort approach for successive cross-sectionally gathered epidemiological estimates on birth cohorts.

METHODS

The United States (US) study population estimates are for noninstitutionalized community-dwelling 17- to 18-year-olds, sampled, recruited, and assessed using audio computer assisted self-interviews for the National Surveys on Drug Use and Health each year, 2008-2016. Estimated age and year-specific lifetime history cumulative incidence proportions are presented, with 95% confidence intervals, as well as age-specific meta-analysis summary estimates.

RESULTS

Occurrence of a brief depressive spell (BDS) among the 2008 U.S. 17-year-olds showed a surprising difference with the 2009 statistically independent sample of that same "birth cohort" assessed at age 18 years. "Negative growth" was seen instead of an expected increase in those affected. Independent replication estimates of this BDS negative growth difference were seen in multiple successive birth cohorts.

CONCLUSIONS

This well-replicated difference in BDS estimates offers a fascinating puzzle to be solved with focused inquiry. The puzzle's solution is important because National Surveys on Drug Use and Health does not assess Major Depression unless a BDS lifetime history is ascertained.

Racial/Ethnic Disparities in Arrests for Drug Possession After California Proposition 47, 2011-2016

OBJECTIVES

To evaluate the effects of California Proposition 47, which reclassified felony drug offenses to misdemeanors in 2014, on racial/ethnic disparities in drug arrests.

METHODS

Using data on all drug arrests made in California from 2011 to 2016, we compared racial/ethnic disparities in drug arrests between Whites, Blacks, and Latinos, immediately and 1 year after policy changes, controlling for secular and seasonal trends.

RESULTS

In the month following passage, absolute Black-White disparities in monthly felony drug arrests decreased from 81 to 44 per 100 000 and continued to decrease over time. There was an immediate increase of 27% in the relative disparity, however, because a higher proportion of felony offense types among Whites was reclassified. Total drug arrest rates also declined, suggesting drug law enforcement was deprioritized. During the first year after enactment, felony drug arrests fell by an estimated 51 985 among Whites, 15 028 among Blacks, and 50 113 among Latinos.

CONCLUSIONS

Reducing criminal penalties for drug possession can reduce racial/ethnic disparities in criminal justice exposure and has implications for improving health inequalities linked to social determinants of health.

Suicide Trends Among and Within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanism of Death - United States, 2001-2015

PROBLEM/CONDITION

Suicide is a public health problem and one of the top 10 leading causes of death in the United States. Substantial geographic variations in suicide rates exist, with suicides in rural areas occurring at much higher rates than those occurring in more urban areas. Understanding demographic trends and mechanisms of death among and within urbanization levels is important to developing and targeting future prevention efforts.

REPORTING PERIOD

2001-2015.

DESCRIPTION OF SYSTEM

Mortality data from the National Vital Statistics System (NVSS) include demographic, geographic, and cause of death information derived from death certificates filed in the 50 states and the District of Columbia. NVSS was used to identify suicide deaths, defined by International Classification of Diseases, 10th Revision (ICD-10) underlying cause of death codes X60-X84, Y87.0, and U03. This report examines annual county level trends in suicide rates during 2001-2015 among and within urbanization levels by select demographics and mechanisms of death. Counties were collapsed into three urbanization levels using the 2006 National Center for Health Statistics classification scheme.

RESULTS

Suicide rates increased across the three urbanization levels, with higher rates in nonmetropolitan/rural counties than in medium/small or large metropolitan counties. Each urbanization level experienced substantial annual rate changes at different times during the study period. Across urbanization levels, suicide rates were consistently highest for men and non-Hispanic American Indian/Alaska Natives compared with rates for women and other racial/ethnic groups; however, rates were highest for non-Hispanic whites in more metropolitan counties. Trends indicate that suicide rates for non-Hispanic blacks were lowest in nonmetropolitan/rural counties and highest in more urban counties. Increases in suicide rates occurred for all age groups across urbanization levels, with the highest rates for persons aged 35-64 years. For mechanism of death, greater increases in rates of suicide by firearms and hanging/suffocation occurred across all urbanization levels; rates of suicide by firearms in nonmetropolitan/rural counties were almost two times that of rates in larger metropolitan counties.

INTERPRETATION

Suicide rates in nonmetropolitan/rural counties are consistently higher than suicide rates in metropolitan counties. These trends also are observed by sex, race/ethnicity, age group, and mechanism of death.

PUBLIC HEALTH ACTION

Interventions to prevent suicides should be ongoing, particularly in rural areas. Comprehensive suicide prevention efforts might include leveraging protective factors and providing innovative prevention strategies that increase access to health care and mental health care in rural communities. In addition, distribution of socioeconomic factors varies in different communities and needs to be better understood in the context of suicide prevention.