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Comparative Study
. 2022 Feb 1;5(2):e2146591.
doi: 10.1001/jamanetworkopen.2021.46591.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States

Ian R H Rockett  1   2 , Haomiao Jia  3 , Bina Ali  4 , Aniruddha Banerjee  5 , Hilary S Connery  6   7 , Kurt B Nolte  8   8 , Ted Miller  4   9 , Franklin M M White  10 , Bernard D DiGregorio  11 , G Luke Larkin  12 , Steven Stack  13 , Kairi Kõlves  14   15 , R Kathryn McHugh  6   7 , Vijay O Lulla  5 , Jeralynn Cossman  16 , Diego De Leo  17 , Brian Hendricks  1 , Paul S Nestadt  18 , James H Berry  19 , Gail D'Onofrio  20 , Eric D Caine  2
Affiliations
Comparative Study

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States

Ian R H Rockett et al. JAMA Netw Open. .

Erratum in

  • Error in Figure 1.
    [No authors listed] [No authors listed] JAMA Netw Open. 2022 Mar 1;5(3):e222576. doi: 10.1001/jamanetworkopen.2022.2576. JAMA Netw Open. 2022. PMID: 35244707 Free PMC article. No abstract available.

Abstract

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design.

Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification.

Design, setting, and participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021.

Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type.

Main outcomes and measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification.

Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (β = 4.362), labor underutilization rate (β = 0.728), manufacturing employment (β = -0.056), homelessness rate (β = -0.125), percentage nonreligious (β = 0.041), non-Hispanic White race and ethnicity (β = 0.087), prescribed opioids for 30 days or more (β = 0.117), and percentage without health insurance (β = -0.013) and 5 factors associated with the suicide rate: percentage male (β = 1.046), military veteran (β = 0.747), rural (β = 0.031), firearm ownership (β = 0.030), and pain reliever misuse (β = 1.131).

Conclusions and relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

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Conflict of interest statement

Conflict of Interest Disclosures: Drs Ali and Miller reported receiving personal fees from governments litigating against the opioid industry. Dr Berry reported receiving personal fees from Celero Systems, Addiction Policy Forum, and National Integration Academy Council and grants from the National Institute on Drug Abuse, Health Resources and Services Administration, and Substance Abuse and Mental Health Services Administration outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Type of Medicolegal Death Investigation System by State, 2018
CME indicates centralized medical examiner; DC/DME, decentralized county or district medical examiner; DCC, decentralized county or district coroner; and hybrid, medical examiner and coroner hybrid.
Figure 2.
Figure 2.. Graphed Annualized Crude Self-injury Mortality to Suicide Rate Ratios by State and Period
Figure 3.
Figure 3.. Mapped Annualized Crude Self-injury Mortality to Suicide Rate Ratios by State and Period
Yellow lines indicate borders of geographic regions.
See this image and copyright information in PMC

References

    1. Rockett IRH, Caine ED, Banerjee A, et al. . Fatal self-injury in the United States, 1999-2018: unmasking a national mental health crisis. EClinicalMedicine. 2021;32:100741. doi:10.1016/j.eclinm.2021.100741 - DOI - PMC - PubMed
    1. Rockett IRH, Lilly CL, Jia H, et al. . Self-injury mortality in the United States in the early 21st century: a comparison with proximally ranked diseases. JAMA Psychiatry. 2016;73(10):1072-1081. doi:10.1001/jamapsychiatry.2016.1870 - DOI - PMC - PubMed
    1. Rockett IRH, Caine ED, Connery HS, et al. . Unrecognised self-injury mortality (SIM) trends among racial/ethnic minorities and women in the USA. Inj Prev. 2020;26(5):439-447. doi:10.1136/injuryprev-2019-043371 - DOI - PMC - PubMed
    1. Rockett IRH, Caine ED, Connery HS, et al. . Discerning suicide in drug intoxication deaths: Paucity and primacy of suicide notes and psychiatric history. PLoS One. 2018;13(1):e0190200. doi:10.1371/journal.pone.0190200 - DOI - PMC - PubMed
    1. Rockett IRH, Hobbs GR, Wu D, et al. . Variable classification of drug-intoxication suicides across US states: a partial artifact of forensics? PLoS One. 2015;10(8):e0135296. doi:10.1371/journal.pone.0135296 - DOI - PMC - PubMed

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