Achieving health equity in US suicides: a narrative review and commentary

Surveillance for Violent Deaths - National Violent Death Reporting System, 48 States, the District of Columbia, and Puerto Rico, 2021

Problem/Condition

In 2021, approximately 75,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 48 states, the District of Columbia, and Puerto Rico in 2021. Results are reported by sex, age group, race and ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics. This report introduces additional incident and circumstance variables, which now include child victim-specific circumstance information. This report also incorporates new U.S. Census Bureau race and ethnicity categories, which now account for more than one race and Native Hawaiian or other Pacific Islander categories and include updated denominators to calculate rates for these populations.

Period Covered

2021.

Description of System

NVDRS collects data regarding violent deaths from death certificates, coroner and medical examiner records, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2021. Data were collected from 48 states (all states with exception of Florida and Hawaii), the District of Columbia, and Puerto Rico. Forty-six states had statewide data, two additional states had data from counties representing a subset of their population (31 California counties, representing 64% of its population, and 13 Texas counties, representing 63% of its population), and the District of Columbia and Puerto Rico had jurisdiction-wide data. NVDRS collates information for each violent death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident.

Results

For 2021, NVDRS collected information on 68,866 fatal incidents involving 70,688 deaths that occurred in 48 states (46 states collecting statewide data, 31 California counties, and 13 Texas counties), and the District of Columbia. The deaths captured in NVDRS accounted for 86.5% of all homicides, legal intervention deaths, suicides, unintentional firearm injury deaths, and deaths of undetermined intent in the United States in 2021. In addition, information was collected for 816 fatal incidents involving 880 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 70,688 deaths, the majority (58.2%) were suicides, followed by homicides (31.5%), deaths of undetermined intent that might be due to violence (8.2%), legal intervention deaths (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm injury deaths (<1.0%). The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.Demographic patterns and circumstances varied by manner of death. The suicide rate was higher for males than for females. Across all age groups, the suicide rate was highest among adults aged ≥85 years. In addition, non-Hispanic American Indian or Alaska Native (AI/AN) persons had the highest suicide rates among all racial and ethnic groups. Among both males and females, the most common method of injury for suicide was a firearm. Among all suicide victims, when circumstances were known (84.4%), suicide was most often preceded by a mental health, intimate partner, or physical health problem or by a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was higher for males than for females. Among all homicide victims, the homicide rate was highest among persons aged 20-24 years compared with other age groups. Non-Hispanic Black or African American (Black) males experienced the highest homicide rate of any racial or ethnic group. Among all homicide victims, the most common method of injury was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Nearly all victims of legal intervention deaths were male, and the legal intervention death rate was highest among men aged 30-34 years. The legal intervention death rate was highest among AI/AN males, followed by Black males. A firearm was used in the majority of legal intervention deaths. When circumstances were known, the most frequent circumstances reported for legal intervention deaths were as follows: the victim used a weapon in the incident and the victim had a substance use problem (other than alcohol use). Other causes of death included unintentional firearm injury deaths and deaths of undetermined intent. Unintentional firearm injury deaths were most frequently experienced by males, non-Hispanic White (White) persons, and persons aged 15-24 years. These deaths most frequently occurred while the shooter was playing with a firearm and were precipitated by a person unintentionally pulling the trigger. The rate of deaths of undetermined intent was highest among males, particularly among AI/AN and Black males, and among adults aged 30-54 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances.

Interpretation

This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2021. The suicide rate was highest among AI/AN and White males, whereas the homicide rate was highest among Black males. Intimate partner violence precipitated a large proportion of homicides for females. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary precipitating circumstances for multiple types of deaths examined.

Public Health Action

Violence is preventable, and data can guide public health action. NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs, policies, and practices to reduce and prevent violent deaths. NVDRS data can be used to enhance prevention efforts into actionable strategies. States or jurisdictions have used their Violent Death Reporting System (VDRS) data to guide suicide prevention efforts and highlight where additional focus is needed. For example, North Carolina VDRS program data have played a significant role in expanding activities related to firearm safety and injury prevention. The program served as a primary data source for partners, which led to the creation of the Office of Violence Prevention in the state, focusing on combatting firearm-related deaths. In Maine, the VDRS provided data on law enforcement officer suicides that were used to help support a bill mandating mental health resiliency and awareness training in the state's law enforcement training academy, along with plans for similar training addressing mental health, substance use, and alcohol problems among corrections officers. In addition, states and jurisdictions have also used their VDRS data to examine factors related to homicide in their state or jurisdiction. For example, Georgia VDRS collaborated with the City of Atlanta Mayor's Office of Violence Reduction to develop two public dashboards that not only offer comprehensive data on violent deaths but also present data on the geographic distribution of populations disproportionately affected by violence to help inform violence prevention interventions.

Suicide Prevention Programming: Comparing Four Prominent Frameworks

OBJECTIVE

Suicide is a significant public health concern. About 48,000 individuals died by suicide in 2021 in the United States, and approximately one in 100 deaths globally are due to suicide. Continuing efforts in program development and evaluation are vital to preventing suicide. Multiple frameworks have been developed to reduce suicide rates, but they have not been compared to assess their comprehensiveness, nor have their components been classified.

METHODS

In 2019, the authors conducted a narrative review of the literature and identified four major frameworks for suicide prevention: the U.S. Department of Veterans Affairs (VA) Suicide Prevention Program, the Defense Suicide Prevention Program of the U.S. Department of Defense, Zero Suicide in Health and Behavioral Health Care, and the technical package developed by the Centers for Disease Control and Prevention. Program components for these frameworks were identified and classified by using two prevention strategy classification systems: the National Academy of Medicine's (NAM's) continuum-of-care model and the Substance Abuse and Mental Health Services Administration's (SAMHSA's) prevention model.

RESULTS

The cross-program comparison revealed that no single program included all components of suicide prevention programs. However, the VA program was the most comprehensive in terms of the number of components and their spread across prevention strategy classifications. The programs used few components categorized under NAM's promotion or selective prevention strategy classifications. The SAMHSA prevention strategy classifications of information dissemination, community-based processes, and positive alternatives were also used infrequently.

CONCLUSIONS

Organizations, health care systems, and policy makers may use these findings as they develop, improve, and implement suicide prevention programs.

Trends in Suicides and Homicides in 21st Century America

BACKGROUND

Violent deaths, including suicides and homicides, pose a significant public health challenge in the United States. Understanding the trends and identifying associated risk factors is crucial for targeted intervention strategies.

AIM

To examine the trends in suicides and homicides over the past two decades and identify demographic and contextual predictors using the Center for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System online database.

METHODS

A retrospective analysis of mortality records from 2000 to 2020 was conducted, utilizing multivariate regression analyses. Covariates included age, race, sex, education, mental health conditions, and time period. Age-adjusted rates were employed to assess trends.

RESULTS

Over the 20 years, there was an upward trajectory in suicide rates, increasing from approximately 10/100,000 to over 14/100,000 individuals, which is a notable increase among American Indians (100.8% increase) and individuals aged 25 years and younger (45.3% increase). Homicide rates, while relatively stable, exhibited a significant increase in 2019-2020, with African Americans consistently having the highest rates and a significant increase among American Indians (73.2% increase). In the multivariate regression analysis, Individuals with advanced education (OR= 1.74, 95% CI= 1.70 - 1.78), depression (OR = 13.47, 95% CI = 13.04 - 13.91), and bipolar disorder (OR = 2.65, 95% CI = 2.44 - 2.88) had higher odds of suicide. Risk factors for homicide include African Americans (OR = 4.15, 95% CI = 4.08 - 4.23), Latinx (OR = 2.31, 95% CI = 2.26 - 2.37), people aged 25 years and younger, and those with lower educational attainment.

CONCLUSION

This study highlights the changing demographic pattern in suicides and homicides in the United States and the need for targeted public health responses. Means restriction, universal suicide screening, addressing mental health stigma, and implementing broad interventions that modify societal attitudes toward suicide and homicides are essential components of a comprehensive strategy.

Recent anti-infective exposure as a risk factor for first episode of suicidal thoughts and/or behaviors in pediatric patients

Objectives

We conducted a retrospective cohort study of medical records from a large, Maryland, U.S.-based cohort of pediatric primary care patients for potential associations between antibacterial, antifungal and antiviral prescriptions and subsequent suicidal thoughts and/or behaviors.

Methods

Using first suicide-related diagnosis as the outcome and prior prescription of antibacterial, antifungal, and/or antiviral use as the exposure, we employed a series of multivariate Cox proportional hazards models. These models examined the hazard of developing newly recognized suicidal thoughts and/or behaviors, controlling for age, sex, race, insurance, number of encounters during the study period, prior mood disorder diagnosis and number of chronic health conditions. We constructed the same series of models stratified by the groups with and without a prior recorded mental or behavioral health diagnosis (MBHD).

Results

Suicidal thoughts and/or behaviors were associated with the previous prescription of an antibacterial, antifungal and/or antiviral medication (HR 1.31, 95 %-CI 1.05-1.64) as well as the total number of such medications prescribed (HR 1.04, 95 %-CI 1.01-1.08), with the strongest relationship among patients with three or more medications (HR 1.44, 95 %-CI 1.06-1.96). Among individual medications, the strongest association was with antibacterial medication (HR 1.28, 95 %-CI 1.03-1.60). Correlations were strongest among the subgroup of patients with no previous (MBHD).

Interpretation

Infections treated with antimicrobial medications were associated with increased risks of a suicide-related diagnosis among patients who had not had a previous mental or behavioral health diagnosis. This group should be considered for increased levels of vigilance as well as interventions directed at suicide screening and prevention.

Funding

National Institutes of Health, Stanley Medical Research Institute.

Examining the unique impacts of Potentially Traumatic Experiences (PTE) and discrimination events on Post-Traumatic Stress Disorder (PTSD) and suicidal thoughts and behaviors among Multiracial/ethnic adults in the United States

BACKGROUND

Suicide and PTSD are pressing public health issues in the US, with discrimination and potentially traumatic experiences (PTEs) influencing mental health. However, the unique effects of these factors on Multiracial/ethnic adults' PTSD and suicidal thoughts/behaviors (STB) are not thoroughly researched.

METHODS

Using a cross-sectional design, an online survey was conducted (N = 1012) from October to December 2022. Multivariable logistic regression models analyzed relationships between PTEs, discriminatory events, and mental health outcomes, accounting for sociodemographics.

RESULTS

After adjusting for demographics, exposure to PTEs and discrimination correlated with heightened odds of PTSD and STB. Individual lifetime discrimination experiences and specific PTEs demonstrated varying associations with STB and PTSD. The study underscores discrimination's relevance as a risk factor.

LIMITATIONS

The study's cross-sectional nature restricts causality or temporality interpretations. Moreover, the convenience sample of English-speaking online participants might not be reflective of all Multiracial/ethnic US adults.

CONCLUSIONS

Findings underscore PTEs and discrimination's interconnectedness in Multiracial/ethnic mental health outcomes. Discrimination might pose similar risks to PTEs. Acknowledging discrimination as potential precursors for PTSD and STB aids accurate diagnosis and effective treatment planning. Incorporating racial/ethnic discrimination and traumatic experiences into PTSD conceptualization and assessment is pivotal. This knowledge informs tailored interventions and mental health education for this population.

Mental health and Multiracial/ethnic adults in the United States: a mixed methods participatory action investigation

Introduction

Addressing gaps in the integration of justice, diversity, equity, and inclusion (J-DEI) in public health research and practice, this study investigates the mental health of Multiracial and multiethnic adults in the United States (U.S.). A rapidly growing racial/ethnic group in the U.S., Multiracial and multiethnic populations are often excluded or underrepresented in standard public health research and practice, and little is known about their mental health or associated risk and protective factors.

Methods

To investigate this knowledge gap, an electronic cross-sectional survey was conducted in two waves in 2022, pulling from various community sources, with 1,359 respondents in total. Complementing this, seventeen semi-structured interviews were performed with a subset of survey participants. Data were analyzed using a mix of statistical methods and staged hybrid inductive-deductive thematic analysis.

Results

Findings indicate over half of the participants endorsed at least one mental health concern with prevalence of anxiety, depression, post-traumatic stress disorder, and suicidal thoughts and behaviors surpassing available national estimates. Exposure to trauma, discrimination, and microaggressions were found to play a significant role in these outcomes. Conversely, strong social support and strong ethnic identity emerged as protective factors. Qualitative insights brought forward the challenges faced by individuals in navigating bias and stigma, especially in the context of mental health care. Despite these barriers, emerging themes highlighted resilience, the importance of secure identity formation, and the critical role of community and cultural support.

Conclusions

The marked prevalence of mental health concerns among Multiracial and multiethnic populations emphasizes the pressing need for tailored interventions and inclusive research methodologies. Recognizing and addressing the unique challenges faced by these communities is imperative in driving mental health equity in the U.S. The findings advocate for community-engaged practices, interdisciplinary collaborations, and the importance of addressing mental health challenges with cultural sensitivity, particularly in historically oppressed and marginalized groups. Future efforts must focus on refining these practices, ensuring that public health initiatives are genuinely inclusive and equitable.

Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 5

PURPOSE

To assess the evidence regarding safety and efficacy of psychiatric medications to treat mental health conditions during pregnancy and lactation. The conditions reviewed include depression, anxiety and anxiety-related disorders, bipolar disorder, and acute psychosis. For information on screening and diagnosis, refer to American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline Number 4, "Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum" (1).

TARGET POPULATION

Pregnant or postpartum individuals with mental health conditions with onset that may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum or may have been exacerbated in that time.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology and one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on treatment and management of perinatal mental health conditions including depression, anxiety, bipolar disorders, and acute postpartum psychosis, with a focus on psychopharmacotherapy. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Understanding Suicide over the Life Course Using Data Science Tools within a Triangulation Framework

Suicide and suicidal behaviors are important global health concerns. Preventing suicide requires a nuanced understanding of the nature of suicide risk, both acutely during periods of crisis and broader variation over the lifespan. However, current knowledge of the sources of variation in suicide risk is limited due to methodological and conceptual challenges. New methodological approaches are needed to close the gap between research and clinical practice. This review describes the life course framework as a conceptual model for organizing the scientific study of suicide risk across in four major domains: social relationships, health, housing, and employment. In addition, this review discusses the utility of data science tools as a means of identifying novel, modifiable risk factors for suicide, and triangulation as an overarching approach to ensuring rigor in suicide research as means of addressing existing knowledge gaps and strengthening future research.