Catherine Barber

Suicide Mortality in the United States: The Importance of Attending to Method in Understanding Population-Level Disparities in the Burden of Suicide

Suicide mortality varies widely across age, sex, race, and geography, far more than does mortality from the leading causes of natural death. Unlike the tight correlation between cancer mortality and the incidence of cancer, suicide mortality is only modestly correlated with the incidence of suicidal acts and other established risk factors for suicidal behavior, such as major psychiatric disorders. An implication of this modest correlation is that the proportion of all suicidal acts that prove fatal (the case fatality ratio) must account for a substantial portion of the (nonrandom) variation observed in suicide mortality. In the United States, the case fatality ratio is strongly related to the availability of household firearms. Findings from ecologic and individual-level studies conducted over the past two decades illustrate the importance of accounting for the availability of highly lethal suicide methods in efforts to understand (and ultimately reduce) disparities in suicide mortality across populations.

Prescription Opioid Duration of Action and the Risk of Unintentional Overdose Among Patients Receiving Opioid Therapy

IMPORTANCE The unprecedented increase in unintentional overdose events that has occurred in tandem with escalating sales of prescription opioids over the past 2 decades has raised concerns about whether the therapeutic use of opioids has contributed to increases in overdose injury. Few controlled studies have examined the extent to which ecologic measures of increases in opioid prescribing and overdose injuries reflect risk among patients prescribed opioids, let alone whether some opioid regimens are safer than others. OBJECTIVE To examine whether the risk of unintentional overdose injury is associated with the duration of opioid action (ie, long-acting vs short-acting formulations). DESIGN, SETTING, AND PARTICIPANTS A propensity score-adjusted cohort study was conducted using population-based health care utilization data from the Veterans Administration Healthcare System. The patients were veterans with chronic painful conditions who began therapy with opioid analgesics between January 1, 2000, and December 31, 2009. MAIN OUTCOMES AND MEASURES Unintentional overdoses that are explicitly coded using International Classification of Disease, Ninth Revision codes as drug or medication poisonings of accidental intent (E850.x-860.x) or undetermined intent (E980.x or drug poisoning [960.x-980.x] without an accompanying external cause of injury code). RESULTS A total of 319 unintentional overdose events were observed. Patients initiating therapy with long-acting opioids were more than twice as likely to overdose compared with persons initiating therapy with short-acting opioids. After adjustment for age, sex, opioid dose, and other clinical characteristics, patients receiving long-acting opioids had a significantly higher rate of overdose injury than did those receiving short-acting opioids (hazard ratio [HR], 2.33; 95% CI, 1.26-4.32). The risk associated with long-acting agents was particularly marked during the first 2 weeks after initiation of treatment (HR, 5.25; 1.88-14.72). CONCLUSIONS AND RELEVANCE To our knowledge, the findings of the present study provide the first evidence that the risk of unintentional overdose injury is related to the prescribed opioids duration of action. If replicated in other cohorts, our findings suggest that clinicians weighing the benefits and risks of initiating different opioid regimens should consider not only the daily dose prescribed but also the duration of opioid action, favoring short-acting agents whenever possible, especially during the first 2 weeks of therapy.

Firearms and Suicide in the United States: Is Risk Independent of Underlying Suicidal Behavior?

On an average day in the United States, more than 100 Americans die by suicide; half of these suicides involve the use of firearms. In this ecological study, we used linear regression techniques and recently available state-level measures of suicide attempt rates to assess whether, and if so, to what extent, the well-established relationship between household firearm ownership rates and suicide mortality persists after accounting for rates of underlying suicidal behavior. After controlling for state-level suicide attempt rates (2008-2009), higher rates of firearm ownership (assessed in 2004) were strongly associated with higher rates of overall suicide and firearm suicide, but not with nonfirearm suicide (2008-2009). Furthermore, suicide attempt rates were not significantly related to gun ownership levels. These findings suggest that firearm ownership rates, independent of underlying rates of suicidal behavior, largely determine variations in suicide mortality across the 50 states. Our results support the hypothesis that firearms in the home impose suicide risk above and beyond the baseline risk and help explain why, year after year, several thousand more Americans die by suicide in states with higher than average household firearm ownership compared with states with lower than average firearm ownership.

Recent psychopathology, suicidal thoughts and suicide attempts in households with and without firearms: findings from the National Comorbidity Study Replication

Objective: To assess the relationship between firearm ownership and possible psychiatric confounders of the firearm–suicide relationship. Methods: Multivariate logistic regression was used to estimate the association between living in a home with firearms and 12-month occurrence of major Diagnostic and statistical manual of mental disorders (DSM)-IV disorders and suicidal behaviour among respondents to the National Comorbidity Survey Replication, a household survey of 9282 adults aged 18+. Analyses controlled for sociodemographic characteristics including age, sex, race/ethnicity, educational attainment and poverty. Results: Approximately one in three Americans reported living in a home with firearms. People living in a home with firearms were no more or less likely than people in homes without firearms to have recent (past year) anxiety disorders (OR = 1.0, 95% CI 0.8 to 1.2), mood disorders (OR = 0.9, 95% CI 0.7 to 1.1) or substance dependence and/or abuse (OR = 0.9, 95% CI 0.6 to 1.3). Past year suicidal ideation (OR = 0.8, 95% CI 0.5 to 1.3) and suicide planning (OR = 0.5, 95% CI 0.2 to 1.4) were also not associated with living in households with firearms. Having made a suicide attempt over the previous year was the only outcome more common among participants reporting that they currently lived in a home with firearms. Conclusions: The previously reported association between household firearm ownership and heightened risk of suicide is not explained by a higher risk of psychopathology among gun-owning families. As there are Americans with suicidal ideation and/or significant and recent psychiatric disorders currently living in homes with firearms, future work should focus on understanding the impediments to effectively communicating the suicide risk associated with household firearms.

Homicide–suicide and other violent deaths: An international comparison

Homicides followed by the suicide of the perpetrator constitute a serious form of interpersonal violence. Until now no study has directly compared homicide-suicides to other violent deaths from multiple countries, allowing for a better understanding of the nature of these violent acts. Using country-specific data, this study describes and compares the incidence and patterns of homicide-suicide as well as the relationship between homicide-suicide, homicide, suicide and domestic homicide in the Netherlands, Switzerland and the United States. The results indicate that cross-nationally, homicide-suicides are more likely than other types of lethal violence to involve a female victim, multiple victims, take place in a residential setting and to be committed by a firearm. Although homicide-suicides display many similarities across the different countries, differences exist regarding age and the use of firearms in the offence. This study indicates that homicides followed by suicides differ from both homicides and suicides in similar ways internationally. Cross-national differences in the availability of firearms may explain the international variation of homicide-suicide rates and patterns.

Suicide Among US Veterans: A Prospective Study of 500,000 Middle-aged and Elderly Men

Expert opinion is divided about whether US military veterans, the vast majority of whom are middle-aged or older, are at increased risk of suicide. To assess the risk of suicide associated with veteran status, the authors conducted a prospective cohort study of 499,356 male participants in the Cancer Prevention Study II. Participants reported their veteran status and other characteristics in 1982 and were followed for mortality through 2004. The relative risk of mortality from suicide according to veteran status at baseline was estimated by using Cox proportional hazards models. During follow-up, 1,248 veterans and 614 nonveterans died by suicide. In age-adjusted analyses, the risk of suicide did not differ by veteran status. Additional adjustment for several sociodemographic, behavioral, and clinical factors had little effect on hazard ratios. The authors concluded that the risk of death from suicide among middle-aged and older US males is independent of veteran status and suggest that policies to prevent veteran suicide should focus on factors that may heighten suicide risk rather than on veteran status per se.

Suicidal behavior and firearm access: results from the second injury control and risk survey.

The association between home firearms and the likelihood and nature of suicidal thoughts and plans was examined using the Second Injury Control and Risk Survey, a 2001-2003 representative telephone survey of U.S. households. Of 9,483 respondents, 7.4% reported past-year suicidal thoughts, 21.3% with a plan. Similar proportions of those with and without a home firearm reported suicidal thoughts, plans, and attempts. Among respondents with suicidal plans, the odds of reporting a plan involving a firearm were over seven times greater among those with firearms at home, compared with those without firearms at home. The results suggest people with home firearms may not be more likely to be suicidal, but when suicidal they may be more likely to plan suicide by firearm.

Identification of hospitalizations for intentional self-harm when E-codes are incompletely recorded.

Suicidal behavior has gained attention as an adverse outcome of prescription drug use. Hospitalizations for intentional self‐harm, including suicide, can be identified in administrative claims databases using external cause of injury codes (E‐codes). However, rates of E‐code completeness in US government and commercial claims databases are low due to issues with hospital billing software.

Characteristics of Infant Homicides: Findings From a U.S. Multisite Reporting System

OBJECTIVE: The purpose of this study was to describe homicides of infants (children <2 years of age) in the U.S. METHODS: Cases were derived from the National Violent Injury Statistics System; 71 incidents involving 72 infant homicides were in the data set. Type 1 involved beating/shaking injuries inflicted by a caretaker; type 2 involved all other homicides (including neonaticide, intimate partner problem-related homicide, crime-related death, and other types). RESULTS: Seventy-five percent of the incidents were type 1 incidents, perpetrated mainly by men (83%; typically the infants father or the boyfriend of the infants mother). In 85% of the type 1 incidents, the infant was transported to the hospital, usually at the initiative of the perpetrator or another household member. In almost one half of the type 1 incidents, a false story was offered initially to explain the injuries. In contrast, the type 2 incidents (16 cases) were perpetrated mainly by women (11 of 16 cases) and involved methods such as poisoning, drowning, sharp instruments, or withdrawal of food and water; most infants were not taken to the hospital. Although 93% of incidents were perpetrated by caretakers, the large differences between the 2 incident types suggest different avenues for prevention. CONCLUSIONS: The circumstances involved in the type 1 homicides (beatings by caretakers) suggested that those attacks occurred impulsively, death was unintended, and emergency care was summoned, often with a false story. Previous abuse was suspected in more than one half of those incidents.

Lethal means restriction for suicide prevention: beliefs and behaviors of emergency department providers.

We sought to examine the beliefs and behaviors of emergency department (ED) providers related to preventing suicide by reducing suicidal patients’ access to lethal methods (means restriction) and identify characteristics associated with asking patients about firearm access.