Preventive Medicine 78 (2015) 14–16
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Brief Original Report
Updated trends in suicidal ideation among U.S. adults, 2005–2012 Paul D. Loprinzi a,⁎, Daphne S. Cain b a b
Center for Health Behavior Research, The University of Mississippi, University, MS, United States Department of Social Work, The University of Mississippi, University, MS, United States
a r t i c l e
i n f o
Available online 16 June 2015 Keywords: Epidemiology NHANES Suicide
a b s t r a c t Objective. Provide a recent update in the trends of suicidal ideation among adults in the United States from 2005 to 2012. Methods. : Data from four 2-year cycles (2005–2012) of the National Health and Nutrition Examination Survey (NHANES) were used (analyzed in 2015). Suicidal ideation was assessed via self-report. Results. For the entire sample, as well as across age-groups, gender and race-ethnicity, there was no statistically significant change in “any suicidal ideations” from 2005–2006 to 2011–2012 (2.95% in 2005–2006 to 3.24% in 2011–2012; P-trendlinear = 0.75). However, significant changes in suicidal ideations occurring nearly every day were observed. A linear trend (P = 0.03) was present for the entire sample and for men; among the entire sample, the prevalence of having suicidal ideations nearly every day increased from 0.19% in 2005–2006 to 0.52% in 2011–2012. However, a quadratic trend was present for non-Hispanic white women (P = 0.03) and Mexican American women (P = 0.001). Conclusion. Suicidal ideation occurring nearly every day has increased for men, but recent decreases have been observed for women of non-Hispanic white and Mexican American race-ethnicity. Continued outreach efforts, particularly among men, are needed to help prevent the development of suicidal ideations into suicidal behavior and occurrence. © 2015 Elsevier Inc. All rights reserved.
Introduction Suicide is one of the leading causes of death worldwide (Centers for Disease Control and Prevention, 2009). Although only a minority of suicidal ideators complete suicide or engage in overt self-harm, most individuals attempting suicide or parasuicides have had suicidal ideations prior to the act (Shneidman, 1996; Glenn and Nock, 2014; Victor and Klonsky, 2014). Understanding the prevalence and trends in suicidal ideations will help inform the development and evaluation of policies to reduce suicide and suicide-related behaviors. Epidemiologic studies of 12-month suicide ideation and attempts tell us that approximately 2% of adults report past-year suicide ideation with a 0.3% suicide attempt report (Glenn and Nock, 2014). Lifetime suicide ideation and attempt studies tell us that approximately 9.2% of adults have seriously considered suicide, and 2.7% have attempted suicide in their lifetime (Glenn and Nock, 2014). And, while the literature has many limitations with regard to predicting suicidal behavior due in part because suicide is a low base rate event, research has started to identify risk factors that differentiate suicide attempters from ideators including younger age; low income or unemployment; history ⁎ Corresponding author at: Center for Health Behavior Research, The University of Mississippi, 229 Turner Center, University, MS 38677, United States. Fax: +1 662 915 5525. E-mail address: [email protected] (P.D. Loprinzi).
http://dx.doi.org/10.1016/j.ypmed.2015.06.003 0091-7435/© 2015 Elsevier Inc. All rights reserved.
of childhood adversities; disorders characterized by agitation, impulsivity, and aggression; parental history of panic and antisocial behavior; history of sexual violence (Glenn and Nock, 2014; Pan et al., 2013); and coping with multiple stressful life events including interpersonal conflict, financial crisis, and minor life stressors (McFeeters et al., 2015). The American Foundation for Suicide Prevention reports the latest U.S. data available (2013) from the Centers for Disease Control and Prevention (CDC) on fatal injury and reveals that the highest rate of suicide is among those aged 45 to 64 (19.1% per 100,000), followed closely by those 85 years old and older (18.6% per 100,000) (American Foundation for Suicide Prevention, 2015). Younger cohorts have consistently lower suicide rates—adolescents and young adults aged 15 to 24 had a suicide rate of 10.9% per 100,000 (American Foundation for Suicide Prevention, 2015). U.S. men are about 4 times more likely to commit suicide than women (20.2 % and 5.5% respectively); however, women attempt suicide 3 times as often as men (American Foundation for Suicide Prevention, 2015). The male to female ratio of suicide attempt to completion is due in part to the suicide methods most commonly used by men and women. Men tend to choose more violent and thus more lethal suicide methods, whereas women are more likely to choose self-poisoning. Overall the most common methods of death by suicide in the U.S. are firearms (51.4%) followed by suffocation (including hangings) (24.5%), and poisoning (16.1%) (American Foundation for Suicide Prevention, 2015). Caucasians have the highest U.S. suicide rate (14.2%) followed by American Indians and Alaska Natives (11.7%)
P.D. Loprinzi, D.S. Cain / Preventive Medicine 78 (2015) 14–16
(American Foundation for Suicide Prevention, 2015). The lowest rates of U.S. suicide are found among Asian and Pacific Islanders (5.8%), Latinos (5.7%), and African–Americans (5.4%) (American Foundation for Suicide Prevention, 2015). The risk of suicide is significantly elevated in people with depression and related psychiatric disorders. Treating depression and suicide ideation, and preventing suicide completion, is an area of growing empirical investigation. Cognitive therapies for suicide prevention including cognitive-behavioral therapy, dialectical behavior therapy, problemsolving therapy, mentalization-based treatment, and psychodynamic interpersonal therapy have evidenced positive effects for preventing suicide attempts and self-harm in adults (Brown and Jager-Hyman, 2014). However, data suggest that psychotherapy for depression may not be considered a sufficient treatment for suicidality, and little is known about the use of primary suicide preventive interventions such as classroom instruction and gatekeeper training on suicidal behavior (Cuijpers et al., 2013; Harrod et al., 2014). Further, there are few approved pharmacologic treatments for suicidal ideation; however, ketamine, a rapidly acting antidepressant, has shown profound therapeutic benefit for suicidal ideation and is the subject of current investigation (Ballard et al., 2014; Mann and Durrier, 2012). There has been considerable scholarship on suicide among Asian countries since 2008 when the World Health Organization produced a monograph on the growing issue of suicide in Asian countries (World Health Organization, 2008). More than half of annual global suicides (60%) come from the South-East Asia and Western Pacific regions (World Health Organization, 2008; Beautrais, 2006). Suicide is among the leading causes of death—and is the leading cause of death among young people—in many Asian countries (World Health Organization, 2008). Rates are highest in Korea (26.1% per 100,000), Sri Lanka (23.9% per 100,000), Japan (23.8% per 100,000), and China (20.8% per 100,000) (World Health Organization, 2008). Rural rates of suicide tend to be higher than urban rates, and the ratio of male to female suicides is much lower than in European countries, and indeed in China, the female suicide rate is higher than that of males (25.9% female to 20.7% male per 100,000) (World Health Organization, 2008). The most common methods of suicide in Asian countries include hanging, poisoning, and jumping (World Health Organization, 2008). Suicide rates are the highest among sub-groups that have remained socio-economically disadvantaged in the rapidly developing and more prosperous of the Asian countries (World Health Organization, 2008). It is difficult to predict who is at risk for attempting suicide, but among the strongest correlates of suicide attempts is having a history
15
of suicidal ideation (Victor and Klonsky, 2014). Studying trends in suicidal ideation is important due to its correlation with suicide attempts and completions. Between 1990 and 2003, the prevalence of suicidal ideation among U.S. adults did not significantly change (2.8% vs 3.3%, P = 0.43) (Kessler et al., 2005). Its trend in recent years, however, is unknown. Therefore, the objective of this brief report was to provide a recent update in the trends of suicidal ideation among adults in the United States from 2005 to 2012. Methods Data from four 2-year cycles (2005–2012) of the National Health and Nutrition Examination Survey (NHANES) were used, which includes a representative sample of non-institutionalized U.S. civilians. Participants provided consent to participate, with the study procedures approved by the NCHS ethics committee. Measurement of suicidal ideation Question 9 of the reliable and valid Patient Health Question-9 (PHQ-9) questionnaire (Kroenke et al., 2001) was used as a measure of suicidal ideation: “Over the last 2 weeks, how often have you been bothered by the following problems: Thoughts that you would be better off dead or of hurting yourself in some way?” Response options included not at all, several days, more than half of the days, and nearly every day. Analysis Analyses, conducted in Stata (v. 12), took into account the NHANES complex sampling design (analyzed in 2015). Prevalence of suicidal ideation across the four 2-year cycles was determined. Because unadjusted and age-adjusted results were similar, only the latter are reported. Age adjustments were performed using the direct method using the projected year 2000 U.S. population aged 20 years and older. Tests for trend were conducted using linear, quadratic and cubic-specific orthogonal polynomial coefficients. A two-sided P b 0.05 was considered statistically significant.
Results In the 2005–2012 NHANES cycles, 22,692 adults (≥20 yrs) were enrolled. Among these, 19,452 (86%) provided data on the suicide ideation variable. Age-adjusted prevalence and trends of any suicidal ideation (i.e., reporting “several days”, “more than half of the days” or “nearly every day”) in the past 2-weeks are shown in Table 1. For the entire sample, as well as across age-groups, gender and race-ethnicity, there was no statistically significant linear change in “any suicidal ideations”
Table 1 Age-adjusted a proportion of U.S. adults with any suicidal ideation in the past 2 weeks, 2005–2012 National Health and Nutrition Examination Survey (N = 19,452). % Any suicidal ideation in the past 2 weeks (95% CI) 2005–2006
2007–2008
2009–2010
2011–2012
P-trendlinear b
P-trendquadratic b
P-trendcubic b
Overall sample Overall—20–39 yrs Overall—40–59 yrs Overall—60+ yrs Overall—men Overall—women
2.95 (2.42–3.47) 2.64 (1.76–3.51) 3.79 (2.61–4.98) 2.12 (1.31–2.92) 2.75 (2.03–3.47) 3.14 (2.22–4.06)
3.37 (2.66–4.07) 3.00 (2.36–3.64) 3.91 (2.72–5.10) 3.11 (2.06–4.16) 3.46 (2.42–4.51) 3.26 (2.55–3.97)
3.17 (2.46–3.89) 3.09 (2.43–3.76) 4.19 (2.59–5.78) 1.67 (1.08–2.26) 2.76 (1.90–3.61) 3.57 (2.71–4.42)
3.24 (2.30–4.18) 3.07 (1.26–4.87) 3.78 (2.73–4.83) 2.68 (1.33–4.03) 3.08 (2.03–4.13) 3.37 (2.07–4.67)
0.75 0.65 0.92 0.92 0.89 0.74
0.64 0.72 0.68 0.98 0.65 0.78
0.58 0.93 0.78 0.01 0.26 0.75
Non-Hispanic white Men Women
2.34 (1.48–3.21) 2.17 (0.85–3.50)
3.42 (1.89–4.94) 2.37 (1.33–3.41)
2.63 (1.46–3.81) 2.95 (2.00–3.90)
2.77 (1.39–4.15) 2.72 (1.45–3.99)
0.85 0.56
0.52 0.76
0.30 0.70
Non-Hispanic black Men Women
3.76 (2.58–4.94) 4.22 (1.62–6.81)
3.89 (2.52–5.25) 3.75 (2.06–5.44)
3.48 (1.57–5.40) 4.65 (2.49–6.81)
3.88 (2.50–5.27) 3.73 (1.76–5.70)
0.94 0.94
0.89 0.72
0.79 0.49
Mexican American Men Women
2.12 (1.39–2.85) 6.27 (3.15–9.39)
4.84 (2.64–7.05) 6.07 (3.39–8.76)
3.33 (0.64–6.02) 5.84 (3.30–8.38)
2.56 (0.0–5.17) 4.00 (1.79–6.21)
0.93 0.41
0.25 0.81
0.37 0.79
N = 19,452; 2005–2006 (n = 4319), 2007–2008 (n = 5183), 2009–2010 (5296), 2011–2012 (n = 4654). a Age adjustment was performed using the direct method using the projected year 2000 US Population aged 20 years or older. b Tests for linear trend were conducted using linear, quadratic and cubic-specific orthogonal polynomial coefficients.
16
P.D. Loprinzi, D.S. Cain / Preventive Medicine 78 (2015) 14–16
Table 2 Age-adjusted a proportion of U.S. adults with suicidal ideation nearly every day in the past 2 weeks, 2005–2012 National Health and Nutrition Examination Survey (N = 19,452). % Suicidal ideation nearly every day over past 2 weeks (95% CI) 2005–2006
2007–2008
2009–2010
2011–2012
P-trendlinear b
P-trendquadratic b
P-trendcubic b
Overall sample Overall—20–39 yrs Overall—40–59 yrs Overall—60+ yrs Overall—men Overall—women
0.19 (0.06–0.32) 0.22 (0.06–0.38) 0.23 (0.0–0.53) 0.07 (0.0–0.22) 0.16 (0.01–0.31) 0.23 (0.0–0.47)
0.46 (0.19–0.72) 0.33 (0.09–0.56) 0.66 (0.08–1.23) 0.36 (0.11–0.62) 0.42 (0.0–0.86) 0.50 (0.26–0.73)
0.39 (0.22–0.56) 0.16 (0.0–0.36) 0.51 (0.13–0.90) 0.58 (0.20–0.97) 0.37 (0.07–0.66) 0.40 (0.13–0.68)
0.52 (0.27–0.76) 0.15 (0.0–0.33) 0.92 (0.40–1.43) 0.49 (0.0–1.01) 0.69 (0.25–1.12) 0.36 (0.07–0.64)
0.03 0.33 0.05 0.08 0.03 0.57
0.50 0.58 0.96 0.29 0.88 0.22
0.30 0.36 0.30 0.74 0.39 0.58
Non-Hispanic white Men Women
0.18 (0.0–0.44) 0
0.48 (0.0–1.07) 0.29 (0.01–0.58)
0.27 (0.0–0.62) 0.27 (0.01–0.53)
0.77 (0.16–1.37) 0.11 (0.0–0.27)
0.12 0.24
0.71 0.03
0.25 0.93
Non-Hispanic black Men Women
0.20 (0.0–0.58) 0.97 (0.0–2.07)
0.19 (0.0–0.59) 1.06 (0.0–2.37)
0.38 (0.0–0.95) 0.37 (0.0–1.18)
0.58 (0.0–1.43) 1.31 (0.07–2.54)
0.40 0.92
0.81 0.45
0.80 0.32
Mexican American Men Women
0 0.24 (0.0–0.75)
0.22 (0.0–0.63) 0.92 (0.35–1.49)
0.64 (0.0–1.36) 1.38 (0.45–2.32)
0.40 (0.0–1.21) 0
0.08 0.76
0.16 0.004
0.18 0.35
N = 19,452; 2005–2006 (n = 4319), 2007–2008 (n = 5183), 2009–2010 (5296), 2011–2012 (n = 4654). The bolded values in the tables indicate statistical significance (Pb0.05) a Age adjustment was performed using the direct method using the projected year 2000 US Population aged 20 years or older. b Tests for linear trend were conducted using linear, quadratic and cubic-specific orthogonal polynomial coefficients.
from 2005–2006 to 2011–2012; for the entire sample, the prevalence of any suicidal ideation changed from 2.95% in 2005–2006 to 3.24% in 2011–2012 (P-trendlinear = 0.75). There were no significant changes in suicidal ideations occurring several days or more than half of the days over the past 2-weeks (data not shown). However, significant changes in suicidal ideations occurring nearly every day were observed (Table 2). A linear trend (P = 0.03) was present for the entire sample and for men; among the entire sample, the prevalence of having suicidal ideations nearly every day increased from 0.19% in 2005–2006 to 0.52% in 2011–2012. However, a quadratic trend was present for non-Hispanic white women (P = 0.03) and Mexican American women (P = 0.001). Discussion Previous analyses from the 1990–1992 National Comorbidity Survey and the 2001–2003 National Comorbidity Survey Replication demonstrate no significant changes in suicidal ideation among U.S. adults (2.8% vs. 3.3%, p = 0.43) (Kessler et al., 2005). The updated NHANES trend analyses demonstrated herein also demonstrate no significant changes in any suicidal ideation between 2005–2006 and 2011–2012. However, careful inspection in the frequency of suicidal ideation suggests slight changes over this time period. Suicidal ideation occurring nearly every day has increased for men (0.16% to 0.69%, P = 0.03), but recent decreases have been observed for women of non-Hispanic white and Mexican American race-ethnicity. These results suggest that the overall rate of suicidal ideation in the adult US population has not statistically changed from 2005 to 2012. However, for men who contemplate suicide, their suicidal ideations occur more frequently—nearly every day—than in the past. While there is little empirical support to suggest that having suicidal ideations occurring nearly every day increases the rate of suicide attempt or completion, these findings do suggest that for men contemplating self-harm, the thoughts are frequent and thus medical screenings that assess suicidal ideation may be beneficial for high risk groups among men (Glenn and Nock, 2014). It was also found that among women who reported suicidal ideation, that white women and women of Mexican– American ethnicity had less frequent suicidal ideations than in the past. This is good news, but it is difficult to explain these findings without additional contextual and risk factors being taking into consideration. Indeed, findings from this study may be associated with recall
bias or the need to positively represent oneself. Regardless, continued outreach efforts, particularly among men, are needed to help prevent the development of suicidal ideations into suicidal behavior and occurrence. Conflicts of interest No funding was used to prepare this manuscript and the authors disclose no conflicts of interest.
References American Foundation for Suicide Prevention, 2015. Understanding and preventing suicide through research, education, and advocacy Accessed at: https://www.afsp.org/ understanding-suicide/facts-and-figures. Ballard, E.D., Ionescu, D.F., Vande Voort, J.L., et al., 2014. Improvement in suicidal ideation after ketamine infusion: relationship to reductions in depression and anxiety. J. Psychiatr. Res. 58, 161–166. Beautrais, A.L., 2006. Suicide in Asia. Crisis 27, 55–57. Brown, G.K., Jager-Hyman, S., 2014. Evidence-based psychotherapies for suicide prevention. Am. J. Prev. Med. 47 (3S2), S186–S194. Centers for Disease Control and Prevention, 2009. National Suicide Statistics at a Glance Accessed at: http://www.cdc.gov/violenceprevention/suicide/statistics/leading_ causes.html. Cuijpers, P., de Beurs, D.P., van Spijker, B.A.J., et al., 2013. The effects of psychotherapy for adult depression on suicidality and hopelessness: a systematic review and metaanalysis. J. Affect. Disord. 144, 183–190. Glenn, C.R., Nock, M.K., 2014. Improving the short-term prediction of suicidal behavior. Am. J. Prev. Med. 47 (3S2), S176–S180. Harrod, C.S., Goss, C.W., Stallones, L., et al., 2014. Interventions for primary prevention of suicide in university and other post-secondary educational settings. Cochrane Database Syst. Rev. (10). http://dx.doi.org/10.1002/14651858.CD009439.pub2 (Art. No.:CD009439). Kessler, R.C., Berglund, P., Borges, G., et al., 2005. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. JAMA 293 (20), 2487–2495. Kroenke, K., Spitzer, R.L., Williams, J.B., 2001. The PHQ-9: validity of a brief depression severity measure. J. Gen. Intern. Med. 16 (9), 606–613. Mann, J.J., Durrier, D., 2012. Medication in suicide prevention insights from neurobiology of suicidal behavior. In: Dwivedi, Y. (Ed.), The Neurobiological Basis of Suicide. CRC Press, Boca Raton, FL. McFeeters, D., Boyda, D., O'Neill, S., 2015. Patterns of stressful life events: distinguishing suicide ideators from suicide attempts. J. Affect. Disord. 175, 192–198. Pan, Y.J., Stewart, R., Chang, C.K., 2013. Socioeconomic disadvantage, mental disorders and risk of 12-month suicide ideation and attempt in the National Comorbidity Survey Replication (NCS-R) in US. Soc. Psychiatry Psychiatr. Epidemiol. 48, 71–79. Shneidman, E.S., 1996. The Suicidal Mind. Oxford University Press, New York. Victor, S.E., Klonsky, E.D., 2014. Correlates of suicide attempts among self-injurers: a meta-analysis. Clin. Psychol. Rev. 34, 282–297. World Health Organization, 2008. Suicide and suicide prevention in Asia Accessed at: http://www.who.int/mental_health/resources/suicide_prevention_asia.pdf.
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Brief Original Report
Updated trends in suicidal ideation among U.S. adults, 2005–2012 Paul D. Loprinzi a,⁎, Daphne S. Cain b a b
Center for Health Behavior Research, The University of Mississippi, University, MS, United States Department of Social Work, The University of Mississippi, University, MS, United States
a r t i c l e
i n f o
Available online 16 June 2015 Keywords: Epidemiology NHANES Suicide
a b s t r a c t Objective. Provide a recent update in the trends of suicidal ideation among adults in the United States from 2005 to 2012. Methods. : Data from four 2-year cycles (2005–2012) of the National Health and Nutrition Examination Survey (NHANES) were used (analyzed in 2015). Suicidal ideation was assessed via self-report. Results. For the entire sample, as well as across age-groups, gender and race-ethnicity, there was no statistically significant change in “any suicidal ideations” from 2005–2006 to 2011–2012 (2.95% in 2005–2006 to 3.24% in 2011–2012; P-trendlinear = 0.75). However, significant changes in suicidal ideations occurring nearly every day were observed. A linear trend (P = 0.03) was present for the entire sample and for men; among the entire sample, the prevalence of having suicidal ideations nearly every day increased from 0.19% in 2005–2006 to 0.52% in 2011–2012. However, a quadratic trend was present for non-Hispanic white women (P = 0.03) and Mexican American women (P = 0.001). Conclusion. Suicidal ideation occurring nearly every day has increased for men, but recent decreases have been observed for women of non-Hispanic white and Mexican American race-ethnicity. Continued outreach efforts, particularly among men, are needed to help prevent the development of suicidal ideations into suicidal behavior and occurrence. © 2015 Elsevier Inc. All rights reserved.
Introduction Suicide is one of the leading causes of death worldwide (Centers for Disease Control and Prevention, 2009). Although only a minority of suicidal ideators complete suicide or engage in overt self-harm, most individuals attempting suicide or parasuicides have had suicidal ideations prior to the act (Shneidman, 1996; Glenn and Nock, 2014; Victor and Klonsky, 2014). Understanding the prevalence and trends in suicidal ideations will help inform the development and evaluation of policies to reduce suicide and suicide-related behaviors. Epidemiologic studies of 12-month suicide ideation and attempts tell us that approximately 2% of adults report past-year suicide ideation with a 0.3% suicide attempt report (Glenn and Nock, 2014). Lifetime suicide ideation and attempt studies tell us that approximately 9.2% of adults have seriously considered suicide, and 2.7% have attempted suicide in their lifetime (Glenn and Nock, 2014). And, while the literature has many limitations with regard to predicting suicidal behavior due in part because suicide is a low base rate event, research has started to identify risk factors that differentiate suicide attempters from ideators including younger age; low income or unemployment; history ⁎ Corresponding author at: Center for Health Behavior Research, The University of Mississippi, 229 Turner Center, University, MS 38677, United States. Fax: +1 662 915 5525. E-mail address: [email protected] (P.D. Loprinzi).
http://dx.doi.org/10.1016/j.ypmed.2015.06.003 0091-7435/© 2015 Elsevier Inc. All rights reserved.
of childhood adversities; disorders characterized by agitation, impulsivity, and aggression; parental history of panic and antisocial behavior; history of sexual violence (Glenn and Nock, 2014; Pan et al., 2013); and coping with multiple stressful life events including interpersonal conflict, financial crisis, and minor life stressors (McFeeters et al., 2015). The American Foundation for Suicide Prevention reports the latest U.S. data available (2013) from the Centers for Disease Control and Prevention (CDC) on fatal injury and reveals that the highest rate of suicide is among those aged 45 to 64 (19.1% per 100,000), followed closely by those 85 years old and older (18.6% per 100,000) (American Foundation for Suicide Prevention, 2015). Younger cohorts have consistently lower suicide rates—adolescents and young adults aged 15 to 24 had a suicide rate of 10.9% per 100,000 (American Foundation for Suicide Prevention, 2015). U.S. men are about 4 times more likely to commit suicide than women (20.2 % and 5.5% respectively); however, women attempt suicide 3 times as often as men (American Foundation for Suicide Prevention, 2015). The male to female ratio of suicide attempt to completion is due in part to the suicide methods most commonly used by men and women. Men tend to choose more violent and thus more lethal suicide methods, whereas women are more likely to choose self-poisoning. Overall the most common methods of death by suicide in the U.S. are firearms (51.4%) followed by suffocation (including hangings) (24.5%), and poisoning (16.1%) (American Foundation for Suicide Prevention, 2015). Caucasians have the highest U.S. suicide rate (14.2%) followed by American Indians and Alaska Natives (11.7%)
P.D. Loprinzi, D.S. Cain / Preventive Medicine 78 (2015) 14–16
(American Foundation for Suicide Prevention, 2015). The lowest rates of U.S. suicide are found among Asian and Pacific Islanders (5.8%), Latinos (5.7%), and African–Americans (5.4%) (American Foundation for Suicide Prevention, 2015). The risk of suicide is significantly elevated in people with depression and related psychiatric disorders. Treating depression and suicide ideation, and preventing suicide completion, is an area of growing empirical investigation. Cognitive therapies for suicide prevention including cognitive-behavioral therapy, dialectical behavior therapy, problemsolving therapy, mentalization-based treatment, and psychodynamic interpersonal therapy have evidenced positive effects for preventing suicide attempts and self-harm in adults (Brown and Jager-Hyman, 2014). However, data suggest that psychotherapy for depression may not be considered a sufficient treatment for suicidality, and little is known about the use of primary suicide preventive interventions such as classroom instruction and gatekeeper training on suicidal behavior (Cuijpers et al., 2013; Harrod et al., 2014). Further, there are few approved pharmacologic treatments for suicidal ideation; however, ketamine, a rapidly acting antidepressant, has shown profound therapeutic benefit for suicidal ideation and is the subject of current investigation (Ballard et al., 2014; Mann and Durrier, 2012). There has been considerable scholarship on suicide among Asian countries since 2008 when the World Health Organization produced a monograph on the growing issue of suicide in Asian countries (World Health Organization, 2008). More than half of annual global suicides (60%) come from the South-East Asia and Western Pacific regions (World Health Organization, 2008; Beautrais, 2006). Suicide is among the leading causes of death—and is the leading cause of death among young people—in many Asian countries (World Health Organization, 2008). Rates are highest in Korea (26.1% per 100,000), Sri Lanka (23.9% per 100,000), Japan (23.8% per 100,000), and China (20.8% per 100,000) (World Health Organization, 2008). Rural rates of suicide tend to be higher than urban rates, and the ratio of male to female suicides is much lower than in European countries, and indeed in China, the female suicide rate is higher than that of males (25.9% female to 20.7% male per 100,000) (World Health Organization, 2008). The most common methods of suicide in Asian countries include hanging, poisoning, and jumping (World Health Organization, 2008). Suicide rates are the highest among sub-groups that have remained socio-economically disadvantaged in the rapidly developing and more prosperous of the Asian countries (World Health Organization, 2008). It is difficult to predict who is at risk for attempting suicide, but among the strongest correlates of suicide attempts is having a history
15
of suicidal ideation (Victor and Klonsky, 2014). Studying trends in suicidal ideation is important due to its correlation with suicide attempts and completions. Between 1990 and 2003, the prevalence of suicidal ideation among U.S. adults did not significantly change (2.8% vs 3.3%, P = 0.43) (Kessler et al., 2005). Its trend in recent years, however, is unknown. Therefore, the objective of this brief report was to provide a recent update in the trends of suicidal ideation among adults in the United States from 2005 to 2012. Methods Data from four 2-year cycles (2005–2012) of the National Health and Nutrition Examination Survey (NHANES) were used, which includes a representative sample of non-institutionalized U.S. civilians. Participants provided consent to participate, with the study procedures approved by the NCHS ethics committee. Measurement of suicidal ideation Question 9 of the reliable and valid Patient Health Question-9 (PHQ-9) questionnaire (Kroenke et al., 2001) was used as a measure of suicidal ideation: “Over the last 2 weeks, how often have you been bothered by the following problems: Thoughts that you would be better off dead or of hurting yourself in some way?” Response options included not at all, several days, more than half of the days, and nearly every day. Analysis Analyses, conducted in Stata (v. 12), took into account the NHANES complex sampling design (analyzed in 2015). Prevalence of suicidal ideation across the four 2-year cycles was determined. Because unadjusted and age-adjusted results were similar, only the latter are reported. Age adjustments were performed using the direct method using the projected year 2000 U.S. population aged 20 years and older. Tests for trend were conducted using linear, quadratic and cubic-specific orthogonal polynomial coefficients. A two-sided P b 0.05 was considered statistically significant.
Results In the 2005–2012 NHANES cycles, 22,692 adults (≥20 yrs) were enrolled. Among these, 19,452 (86%) provided data on the suicide ideation variable. Age-adjusted prevalence and trends of any suicidal ideation (i.e., reporting “several days”, “more than half of the days” or “nearly every day”) in the past 2-weeks are shown in Table 1. For the entire sample, as well as across age-groups, gender and race-ethnicity, there was no statistically significant linear change in “any suicidal ideations”
Table 1 Age-adjusted a proportion of U.S. adults with any suicidal ideation in the past 2 weeks, 2005–2012 National Health and Nutrition Examination Survey (N = 19,452). % Any suicidal ideation in the past 2 weeks (95% CI) 2005–2006
2007–2008
2009–2010
2011–2012
P-trendlinear b
P-trendquadratic b
P-trendcubic b
Overall sample Overall—20–39 yrs Overall—40–59 yrs Overall—60+ yrs Overall—men Overall—women
2.95 (2.42–3.47) 2.64 (1.76–3.51) 3.79 (2.61–4.98) 2.12 (1.31–2.92) 2.75 (2.03–3.47) 3.14 (2.22–4.06)
3.37 (2.66–4.07) 3.00 (2.36–3.64) 3.91 (2.72–5.10) 3.11 (2.06–4.16) 3.46 (2.42–4.51) 3.26 (2.55–3.97)
3.17 (2.46–3.89) 3.09 (2.43–3.76) 4.19 (2.59–5.78) 1.67 (1.08–2.26) 2.76 (1.90–3.61) 3.57 (2.71–4.42)
3.24 (2.30–4.18) 3.07 (1.26–4.87) 3.78 (2.73–4.83) 2.68 (1.33–4.03) 3.08 (2.03–4.13) 3.37 (2.07–4.67)
0.75 0.65 0.92 0.92 0.89 0.74
0.64 0.72 0.68 0.98 0.65 0.78
0.58 0.93 0.78 0.01 0.26 0.75
Non-Hispanic white Men Women
2.34 (1.48–3.21) 2.17 (0.85–3.50)
3.42 (1.89–4.94) 2.37 (1.33–3.41)
2.63 (1.46–3.81) 2.95 (2.00–3.90)
2.77 (1.39–4.15) 2.72 (1.45–3.99)
0.85 0.56
0.52 0.76
0.30 0.70
Non-Hispanic black Men Women
3.76 (2.58–4.94) 4.22 (1.62–6.81)
3.89 (2.52–5.25) 3.75 (2.06–5.44)
3.48 (1.57–5.40) 4.65 (2.49–6.81)
3.88 (2.50–5.27) 3.73 (1.76–5.70)
0.94 0.94
0.89 0.72
0.79 0.49
Mexican American Men Women
2.12 (1.39–2.85) 6.27 (3.15–9.39)
4.84 (2.64–7.05) 6.07 (3.39–8.76)
3.33 (0.64–6.02) 5.84 (3.30–8.38)
2.56 (0.0–5.17) 4.00 (1.79–6.21)
0.93 0.41
0.25 0.81
0.37 0.79
N = 19,452; 2005–2006 (n = 4319), 2007–2008 (n = 5183), 2009–2010 (5296), 2011–2012 (n = 4654). a Age adjustment was performed using the direct method using the projected year 2000 US Population aged 20 years or older. b Tests for linear trend were conducted using linear, quadratic and cubic-specific orthogonal polynomial coefficients.
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Table 2 Age-adjusted a proportion of U.S. adults with suicidal ideation nearly every day in the past 2 weeks, 2005–2012 National Health and Nutrition Examination Survey (N = 19,452). % Suicidal ideation nearly every day over past 2 weeks (95% CI) 2005–2006
2007–2008
2009–2010
2011–2012
P-trendlinear b
P-trendquadratic b
P-trendcubic b
Overall sample Overall—20–39 yrs Overall—40–59 yrs Overall—60+ yrs Overall—men Overall—women
0.19 (0.06–0.32) 0.22 (0.06–0.38) 0.23 (0.0–0.53) 0.07 (0.0–0.22) 0.16 (0.01–0.31) 0.23 (0.0–0.47)
0.46 (0.19–0.72) 0.33 (0.09–0.56) 0.66 (0.08–1.23) 0.36 (0.11–0.62) 0.42 (0.0–0.86) 0.50 (0.26–0.73)
0.39 (0.22–0.56) 0.16 (0.0–0.36) 0.51 (0.13–0.90) 0.58 (0.20–0.97) 0.37 (0.07–0.66) 0.40 (0.13–0.68)
0.52 (0.27–0.76) 0.15 (0.0–0.33) 0.92 (0.40–1.43) 0.49 (0.0–1.01) 0.69 (0.25–1.12) 0.36 (0.07–0.64)
0.03 0.33 0.05 0.08 0.03 0.57
0.50 0.58 0.96 0.29 0.88 0.22
0.30 0.36 0.30 0.74 0.39 0.58
Non-Hispanic white Men Women
0.18 (0.0–0.44) 0
0.48 (0.0–1.07) 0.29 (0.01–0.58)
0.27 (0.0–0.62) 0.27 (0.01–0.53)
0.77 (0.16–1.37) 0.11 (0.0–0.27)
0.12 0.24
0.71 0.03
0.25 0.93
Non-Hispanic black Men Women
0.20 (0.0–0.58) 0.97 (0.0–2.07)
0.19 (0.0–0.59) 1.06 (0.0–2.37)
0.38 (0.0–0.95) 0.37 (0.0–1.18)
0.58 (0.0–1.43) 1.31 (0.07–2.54)
0.40 0.92
0.81 0.45
0.80 0.32
Mexican American Men Women
0 0.24 (0.0–0.75)
0.22 (0.0–0.63) 0.92 (0.35–1.49)
0.64 (0.0–1.36) 1.38 (0.45–2.32)
0.40 (0.0–1.21) 0
0.08 0.76
0.16 0.004
0.18 0.35
N = 19,452; 2005–2006 (n = 4319), 2007–2008 (n = 5183), 2009–2010 (5296), 2011–2012 (n = 4654). The bolded values in the tables indicate statistical significance (Pb0.05) a Age adjustment was performed using the direct method using the projected year 2000 US Population aged 20 years or older. b Tests for linear trend were conducted using linear, quadratic and cubic-specific orthogonal polynomial coefficients.
from 2005–2006 to 2011–2012; for the entire sample, the prevalence of any suicidal ideation changed from 2.95% in 2005–2006 to 3.24% in 2011–2012 (P-trendlinear = 0.75). There were no significant changes in suicidal ideations occurring several days or more than half of the days over the past 2-weeks (data not shown). However, significant changes in suicidal ideations occurring nearly every day were observed (Table 2). A linear trend (P = 0.03) was present for the entire sample and for men; among the entire sample, the prevalence of having suicidal ideations nearly every day increased from 0.19% in 2005–2006 to 0.52% in 2011–2012. However, a quadratic trend was present for non-Hispanic white women (P = 0.03) and Mexican American women (P = 0.001). Discussion Previous analyses from the 1990–1992 National Comorbidity Survey and the 2001–2003 National Comorbidity Survey Replication demonstrate no significant changes in suicidal ideation among U.S. adults (2.8% vs. 3.3%, p = 0.43) (Kessler et al., 2005). The updated NHANES trend analyses demonstrated herein also demonstrate no significant changes in any suicidal ideation between 2005–2006 and 2011–2012. However, careful inspection in the frequency of suicidal ideation suggests slight changes over this time period. Suicidal ideation occurring nearly every day has increased for men (0.16% to 0.69%, P = 0.03), but recent decreases have been observed for women of non-Hispanic white and Mexican American race-ethnicity. These results suggest that the overall rate of suicidal ideation in the adult US population has not statistically changed from 2005 to 2012. However, for men who contemplate suicide, their suicidal ideations occur more frequently—nearly every day—than in the past. While there is little empirical support to suggest that having suicidal ideations occurring nearly every day increases the rate of suicide attempt or completion, these findings do suggest that for men contemplating self-harm, the thoughts are frequent and thus medical screenings that assess suicidal ideation may be beneficial for high risk groups among men (Glenn and Nock, 2014). It was also found that among women who reported suicidal ideation, that white women and women of Mexican– American ethnicity had less frequent suicidal ideations than in the past. This is good news, but it is difficult to explain these findings without additional contextual and risk factors being taking into consideration. Indeed, findings from this study may be associated with recall
bias or the need to positively represent oneself. Regardless, continued outreach efforts, particularly among men, are needed to help prevent the development of suicidal ideations into suicidal behavior and occurrence. Conflicts of interest No funding was used to prepare this manuscript and the authors disclose no conflicts of interest.
References American Foundation for Suicide Prevention, 2015. Understanding and preventing suicide through research, education, and advocacy Accessed at: https://www.afsp.org/ understanding-suicide/facts-and-figures. Ballard, E.D., Ionescu, D.F., Vande Voort, J.L., et al., 2014. Improvement in suicidal ideation after ketamine infusion: relationship to reductions in depression and anxiety. J. Psychiatr. Res. 58, 161–166. Beautrais, A.L., 2006. Suicide in Asia. Crisis 27, 55–57. Brown, G.K., Jager-Hyman, S., 2014. Evidence-based psychotherapies for suicide prevention. Am. J. Prev. Med. 47 (3S2), S186–S194. Centers for Disease Control and Prevention, 2009. National Suicide Statistics at a Glance Accessed at: http://www.cdc.gov/violenceprevention/suicide/statistics/leading_ causes.html. Cuijpers, P., de Beurs, D.P., van Spijker, B.A.J., et al., 2013. The effects of psychotherapy for adult depression on suicidality and hopelessness: a systematic review and metaanalysis. J. Affect. Disord. 144, 183–190. Glenn, C.R., Nock, M.K., 2014. Improving the short-term prediction of suicidal behavior. Am. J. Prev. Med. 47 (3S2), S176–S180. Harrod, C.S., Goss, C.W., Stallones, L., et al., 2014. Interventions for primary prevention of suicide in university and other post-secondary educational settings. Cochrane Database Syst. Rev. (10). http://dx.doi.org/10.1002/14651858.CD009439.pub2 (Art. No.:CD009439). Kessler, R.C., Berglund, P., Borges, G., et al., 2005. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. JAMA 293 (20), 2487–2495. Kroenke, K., Spitzer, R.L., Williams, J.B., 2001. The PHQ-9: validity of a brief depression severity measure. J. Gen. Intern. Med. 16 (9), 606–613. Mann, J.J., Durrier, D., 2012. Medication in suicide prevention insights from neurobiology of suicidal behavior. In: Dwivedi, Y. (Ed.), The Neurobiological Basis of Suicide. CRC Press, Boca Raton, FL. McFeeters, D., Boyda, D., O'Neill, S., 2015. Patterns of stressful life events: distinguishing suicide ideators from suicide attempts. J. Affect. Disord. 175, 192–198. Pan, Y.J., Stewart, R., Chang, C.K., 2013. Socioeconomic disadvantage, mental disorders and risk of 12-month suicide ideation and attempt in the National Comorbidity Survey Replication (NCS-R) in US. Soc. Psychiatry Psychiatr. Epidemiol. 48, 71–79. Shneidman, E.S., 1996. The Suicidal Mind. Oxford University Press, New York. Victor, S.E., Klonsky, E.D., 2014. Correlates of suicide attempts among self-injurers: a meta-analysis. Clin. Psychol. Rev. 34, 282–297. World Health Organization, 2008. Suicide and suicide prevention in Asia Accessed at: http://www.who.int/mental_health/resources/suicide_prevention_asia.pdf.
