Investigating the full spectrum of suicide

A recent study published in Injury Prevention described a method for categorizing self-injury mortality (SIM) to help us better examine national trends for today’s epidemics of suicide and drug-related deaths.

This SIM study compared trends among non-Hispanic blacks and Hispanics with those of whites. SIM included all suicides, regardless of method. The study also viewed most drug overdoses as self-injury, even where evidence did not meet the standard for a suicide classification. This approach is due to the observed pattern of intentionally repeated self-injury behaviors found in most drug deaths.

The SIM investigation, according to the researchers, underscores the need to view suicides and drug deaths as two fatal outcomes associated with common risk factors. In some cases, these outcomes also share symptoms of hopelessness and loss of behavioral control that may be amenable to targeted prevention efforts.

The researchers also said that their findings highlight the need for the US health care system to address data surveillance and health care delivery disparities that have important implications for innovative strategies to reduce “deaths of despair.” The study was led by West Virginia University’s Ian Rockett, PhD, MPH, MA. McLean Hospital’s Hilary S. Connery, MD, PhD, was a co-investigator.

According to Rockett, SIM is important for several reasons. “SIM recognizes that suicides are not accurately accounted for,” he said. “It allows most drug deaths to belong in the suicide category because they are not true accidents, providing a perspective on total death burden. This lens is important for revealing more granular data trends that may guide allocation of prevention and treatment resources. Examining SIM helps us better see the trends of the current mental health crisis for women and minorities as well as for white men.”

While the SIM rate for whites rose by 55% between 2008 and 2017, it increased by 109% for blacks and 69% for Hispanics. Women in all three groups were more likely to die from drug overdoses than men. Although Hispanics had the lowest rates of SIM, they died at a younger age. Hispanics dying from self-injury in 2017 were projected to have lost 43 years of life versus 37 and 32 for whites and blacks, respectively.

The SIM study finds that suicide is likely underreported for females because women tend to use methods that are less violent and less obvious than those of men. Women who take their own lives are more likely to do so with drugs than by hanging or with guns.

The study also indicates that evidence of suicide is rarer for blacks and Hispanics than for whites because of unequal access to health care or because of different use of health care, when accessible. Black and Hispanic people who died by suicide had fewer previously documented mental health conditions than their white counterparts.

Connery provided more treatment context.

“The health care system has a long history of separating people coming for mental health disorders care from those coming for substance use disorders care,” she said. “Considering today’s concurrent epidemics, this system doesn’t work well at a population level because of the high rates of co-occurrence of substance use disorders and other mental health disorders. It’s extremely common for a depressed person to be misusing substances but asking only for help for depression. Likewise, a person asking for help with opioid use disorder may seek medical treatment but not report suicidal thoughts and planning. In both cases, screening for suicide risk factors and overdose risk factors will improve early detection, which may then allow targeted, integrated treatments to prevent SIM deaths.”

The other major barrier to understanding and preventing self-injury deaths, according to Connery, is that they are portrayed as either “intentional” or “unintentional.”

“This false dichotomy leads to depictions of self-injury deaths as either intentional suicide or accidental substance poisoning,” she said. “The desire to die prior to self-injury deaths occurs along a spectrum of low to high desire to die, which may influence risk-taking behaviors even if a person’s conscious intentions are not fully suicidal.”

The study shows how the nation as well as states and local communities could improve prevention programs. Strategies would include greater emphasis on screening for common risk factors and consistently asking patients about their substance use and suicidal thoughts and behaviors.

“Too often, academic publications and mass media show suicides and drug deaths in the 21st century as separate problems,” said Rockett. “To the contrary, these issues are intertwined, and constitute a mental health catastrophe.”