Standardized Mortality Ratios For Suicide Research Articles

Suicide in people prescribed opioid-agonist therapy in Scotland, United Kingdom, 2011-2020: A national retrospective cohort study.

Opioid dependence is associated with an increased risk of suicide. Drug-related mortality among people with opioid dependence in Scotland has more than tripled since 2010; less is known about changes in suicide risk. We aimed to determine if opioid agonist therapy (OAT) in Scotland is protective against suicide and to measure trends in suicide rates in those with opioid dependence over time. Retrospective cohort study. Scotland, UK. 46 453 individuals in Scotland who received at least one prescription for OAT between 2011 and 2020 with over 304 000 person-years (pys) of follow-up. We calculated standardised mortality ratios (SMR) using the age- and sex-specific suicide rates in Scotland for years 2011-2020. We fitted multivariable competing-risk regression models to estimate suicide rates by OAT exposure and to estimate trends over time, adjusting for potential confounders. There were 575 deaths classed as suicide among the cohort and the overall suicide rate was 1.89 (95% confidence interval [CI] = 1.74-2.05) per 1000 pys. Age and sex SMR for suicide was 7.05 times (95% CI = 6.50-7.65) higher than in the general population. After adjustment, OAT was shown to be highly protective against suicide, with rates more than three times greater (adjusted hazard ratio: 3.07; 95% CI = 2.60-3.62) off OAT compared with on OAT. Suicide rates decreased over time, falling from 2.57 (95% CI = 2.19-3.02) per 1000 pys in 2011-12 to 1.48 (95% CI = 1.21-1.82) in 2019-20. People with opioid dependence in Scotland appear to have a greater risk of suicide than the general population. Treatment is protective, with rates of suicide lower among those on opioid agonist therapy. Suicide rates have decreased over time, during a period in which drug-related death rates in Scotland have risen to globally high levels.

Non-cancer-related Deaths in Cancer Survivors: A Nationwide Population-Based Study in Japan.

Advancements in cancer care have improved survivorship, potentially leading to changes in mortality causes. This study aimed to investigate the causes of death among cancer survivors, specially focusing on non-cancer-related mortality. This nationwide population-based cohort study analyzed the causes of death based on the time since cancer diagnosis using data from the National Cancer Registry in Japan between January 2016 and December 2019. Non-cancer-related deaths were identified, and mortality risks associated with non-cancer diseases were compared to those of the Japanese general population using standardized mortality ratios (SMRs) with 95% confidence intervals (CIs). Follow-up period was up to 4 years after cancer diagnosis. A total of 3,990,661 patients (45.8%, women) were included in the analysis, yielding 6,237,269 person-years of follow-up. Of these, 1,001,857 (25.1%) patients died during the study period. Cancer-related and non-cancer-related causes accounted for 86.6% and 13.4% of deaths, respectively. The proportion of non-cancer-related deaths increased from 10.2% at 6 months to 31.6% at 4 years after cancer diagnosis. Heart disease (21.8%), cerebrovascular disease (9.8%), and pneumonia (9.1%) were the leading cause of non-cancer-related deaths: The SMRs for these diseases were 2.69 (95% CI, 2.66-2.72), 2.07 (95% CI, 2.03-2.10), and 2.41 (95% CI, 2.36-2.45), respectively. The SMR for suicide was 1.81 (95% CI, 1.74-1.89); however, it lost significance in males and females 2 and 2.5 years after cancer diagnosis, respectively. The proportion of non-cancer-related deaths among cancer patients has increased over time, emphasizing the need to manage cancer and its comorbidities carefully.

Mortality of working-age physicians compared to other high-skilled occupations in Austria from 1998 to 2020.

Physicians have been shown to have lower mortality compared to the general population, particularly regarding lifestyle-associated causes of death. Prior literature is divided on whether this is due to higher socioeconomic position (SEP), healthier lifestyle, or other specific occupational characteristics. This study analyzed the mortality of Austrian physicians compared to the general population and other (health) professionals with a similar SEP, and investigated patterns of lifestyle-associated mortality among physicians. Data from professional associations and cause-of-death statistics were collated to determine causes of death for all occupational groups. Gender-specific age-standardized mortality rates (ASMR) and standardized rate ratios (SRR) were calculated to compare main causes of death [cancer, cardiovascular disease (CVD), external causes] among physicians to other (health) professionals and the general population. Standardized mortality ratios (SMR) were calculated for more detailed causes of death in physicians compared to the general population. Physicians had lower all-cause mortality than the general population [SRR 0.45, 95% confidence interval (CI) 0.41-0.49 for males and SRR 0.60, 95% CI 0.54-0.66 for females] and health professionals (SRR 0.72, 95% CI 0.60-0.88 for males and SRR 0.77, 95% CI 0.63-0.93 for females), mostly due to low CVD and cancer mortality. SMR for detailed causes of death among physicians exhibited a pattern of particularly low mortality in lifestyle-associated causes of death and an increased SMR for suicide among female physicians (SMR 1.58, 95% CI 1.22-2.02). This study confirmed lower mortality among physicians compared to the general population and compared to other (health) professionals. Low physician mortality can be primarily explained by lifestyle-associated causes of death.

Share of Adult Suicides After Recent Jail Release

Although people released from jail have an elevated suicide risk, the potentially large proportion of this population in all adult suicides is unknown. To estimate what percentage of adults who died by suicide within 1 year or 2 years after jail release could be reached if the jail release triggered community suicide risk screening and prevention efforts. This cohort modeling study used estimates from meta-analyses and jail census counts instead of unit record data. The cohort included all adults who were released from US jails in 2019. Data analysis and calculations were performed between June 2021 and February 2024. The outcomes were percentage of total adult suicides within years 1 and 2 after jail release and associated crude mortality rates (CMRs), standardized mortality ratios (SMRs), and relative risks (RRs) of suicide in incarcerated vs not recently incarcerated adults. Taylor expansion formulas were used to calculate the variances of CMRs, SMRs, and other ratios. Random-effects restricted maximum likelihood meta-analyses were used to estimate suicide SMRs in postrelease years 1 and 2 from 10 jurisdictions. Alternate estimate was computed using the ratio of suicides after release to suicides while incarcerated. Included in the analysis were 2019 estimates for 7 091 897 adults (2.8% of US adult population; 76.7% males and 23.3% females) who were released from incarceration at least once, typically after brief pretrial stays. The RR of suicide was 8.95 (95% CI, 7.21-10.69) within 1 year after jail release and 6.98 (95% CI, 4.21-9.76) across 2 years after release. A total of 27.2% (95% CI, 18.0%-41.7%) of all adult suicide deaths occurred in formerly incarcerated individuals within 2 years of jail release, and 19.9% (95% CI, 16.2%-24.1%) of all adult suicides occurred within 1 year of release (males: 23.3% [95% CI, 20.8%-25.6%]; females: 24.0% [95% CI, 19.7%-36.8%]). The alternate method yielded slightly larger estimates. Another 0.8% of adult suicide deaths occurred during jail stays. This cohort modeling study found that adults who were released from incarceration at least once make up a large, concentrated population at greatly elevated risk for death by suicide; therefore, suicide prevention efforts focused on return to the community after jail release could reach many adults within 1 to 2 years of jail release, when suicide is likely to occur. Health systems could develop infrastructure to identify these high-risk adults and provide community-based suicide screening and prevention.

Suicide Risk Among Individuals Diagnosed With Cancer in the US, 2000-2016

Individuals diagnosed with cancer have elevated suicide risks compared with the general population. National estimates of suicide risks among individuals with cancer are lacking in the US, and knowledge about risk factors is limited. To provide contemporary estimates of suicide risks associated with cancer and to identify sociodemographic and clinical factors associated with suicide risks among individuals diagnosed with cancer. A population-based cohort of individuals diagnosed with cancer from January 1, 2000, to December 31, 2016, from 43 states in the US were followed up through December 31, 2016. Standardized mortality ratios (SMRs) were calculated adjusting for attained age at death, sex, and race and ethnicity groups to compare suicide risks in the cancer cohort vs the general US population. Cox proportional hazards regression models were fitted to identify cancer-specific risk factors of suicide among the cancer cohort. Analyses were conducted from October 27, 2020, to May 13, 2022. The main outcomes were risk of suicide death compared with the general population, measured by the standardized mortality ratio; and risk of suicide death associated with sociodemographic and clinical factors among individuals with cancer. Diagnosis of cancer. Among a total of 16 771 397 individuals with cancer, 8 536 814 (50.9%) were 65 years or older at cancer diagnosis, 8 645 631 (51.5%) were male, 13 149 273 (78.4%) were non-Hispanic White, and 20 792 (0.1%) died from suicide. The overall SMR for suicide was 1.26 (95% CI, 1.24-1.28), with a decreasing trend (from an SMR of 1.67 [95% CI, 1.47-1.88] in 2000 to 1.16 [95% CI, 1.11-1.21] in 2016). Compared with the general population, elevated suicide risks were observed in the cancer cohort across all sociodemographic groups, with particularly high SMRs among Hispanic individuals (SMR, 1.48; 95% CI, 1.38-1.58), Medicaid-insured individuals (SMR, 1.72; 95% CI, 1.61-1.84), Medicare-insured individuals 64 years or younger (SMR, 1.94; 95% CI, 1.80-2.07), or uninsured individuals (SMR, 1.66; 95% CI, 1.53-1.80). Moreover, the highest SMR was observed in the first 6 months after the cancer diagnosis (SMR, 7.19; 95% CI, 6.97-7.41). Among individuals diagnosed with cancer, relatively higher suicide risks (ie, hazard ratios) were observed for cancer types with a poor prognosis and high symptom burden in the first 2 years after diagnosis, including cancers of oral cavity and pharynx, esophagus, stomach, brain and other nervous system, pancreas, and lung. After 2 years, individuals with cancers subject to long-term quality-of-life impairments, such as oral cavity and pharynx, leukemia, female breast, uterine, and bladder, had higher suicide risks. In this cohort study of individuals with cancer, elevated suicide risks remained despite a decreasing trend during the past 2 decades. Suicide risks varied by sociodemographic and clinical factors. Timely symptom management and targeted psychosocial interventions are warranted for suicide prevention in individuals diagnosed with cancer.

Trends in patient suicide rate after psychiatric discharge in Korea from 2010 to 2018: A nationwide population-based study

BackgroundThere is limited quantitative evidence to investigate short-term suicide rates although the risk of suicide in psychiatric patients is exceptionally high in the early post-discharge period. This study aimed to explore the trends of the 30 days suicide rate after discharge using population-based data from Korea. MethodsThis study was conducted on psychiatric patients aged 15 years or older discharged between 2010 and 2018. Patients were extracted from the National Health Insurance Claim Database (NHICD) and information on suicide was obtained from the National Statistical Office. Age-standardized suicide rate (ASR) and Standardized Mortality Ratio (SMR) within 30 days after discharge was estimated and tested using joinpoint regression. ResultsOf the 1,576,028 patients discharged from hospitals from 2010 to 2018, 53.9 % were male and 47.9 % were aged between 40 and 59 years. The 30 days ASRs for psychiatric patients after discharge varied from 174.9 to 218.0 per 100,000 patients with no clear trend excluding patients with schizophrenia and anxiety disorder. The SMR for suicide within 30 days after discharge was 66.8 in 2016–2018, and patients aged 20 to 39, female, and patients with depression had high SMRs compared to other groups. LimitationsFactors that may impact the suicide were not considered in this study. Since the NHICD data is collected for payment of medical expenses, there may be scope for inaccuracies. ConclusionsThe 30 days suicide rate after psychiatric discharge has failed to decrease between 2010 and 2018. This study recommends early interventions after discharge and intensive interventions for patient groups who may be vulnerable to suicide.

Suicide risk among patients with cancer in the United States, 2000-2016.

12119 Background: Individuals diagnosed with cancer have elevated suicide risk in the US, although little is known about risk associated with state of residence, health insurance coverage, or time since diagnosis by cancer types. This study used a recent national dataset to examine a wide range of patients’ sociodemographic and clinical factors that may be associated with suicide risks. Methods: We identified patients diagnosed with cancer from 43 population-based state cancer registries in 2000-2016 with follow-up through Dec 31, 2016. Standardized Mortality Ratios (SMR) and 95% confidence intervals (95CI) were calculated by state of residence, attained age group, sex, and race/ethnicity to compare suicide risks in the cohort vs. the general US population. Hazard Ratios (HR) and 95CI from multivariable Cox proportional hazard models were derived to identify cancer-specific risk factors of suicide among the cohort, controlling for competing risks from other causes of death. Results: Among 16,771,397 patients, 7,972,782 (47.5%) died during the study period, and 20,792 (0.3%) from suicide. The overall SMR for suicide was 1.26 (95CI = 1.24-1.28), decreasing from 1.67 (95CI 1.47-1.88) in 2000 to 1.16 (95CI 1.11-1.21) in 2016. Patients from Alaska, Colorado and Idaho, those aged 65-69 years (SMR = 1.44, 95CI = 1.39-1.50), Hispanic patients (SMR = 1.48, 95CI = 1.38-1.58), those uninsured (SMR = 1.66, 95CI = 1.53-1.80) or insured with Medicaid (SMR = 1.72, 95CI = 1.61-1.84) or ≤64 years of age with Medicare (SMR = 1.94, 95CI = 1.80-2.07) had the highest suicide risks compared to the general population. Moreover, the highest suicide risk occurred within two years of diagnosis (SMR [95CI] = 7.19 [6.97-7.41], 5.60 [5.35-5.84] and 4.18 [4.03-4.33] for ≤5 months, 6-11 months, and 12-23 months after cancer diagnosis, respectively). In the first two years following diagnosis, the risk of suicide was higher in patients diagnosed with distant-stage than early-stage diseases (HR = 1.29, 95CI = 1.21-1.37), and in patients with more cancer types with poor prognoses and high symptom burdens, such as cancers of oral cavity & pharynx, esophagus, stomach, brain, lung and pancreas (HRs ranged 1.23-2.10 vs. colorectal cancer, all P≤0.001). After two years, patients diagnosed with cancers subject to long-term quality of life impairment, such as cancers of oral cavity & pharynx, female breast, bladder, and leukemia (HRs ranged 1.17-1.54 vs. colorectal cancer, all P≤0.01), had higher suicide risks. Conclusions: Suicide risk among patients diagnosed with cancer decreased during the past two decades but remained elevated compared to the general population. Different geographic, racial/ethnic, socioeconomic, and clinical factors, some of which are modifiable, contribute to increased suicide risk among patients diagnosed with cancer. Tailored social and psych-oncological interventions are warranted for suicide prevention in this vulnerable population.

Excess mortality by suicide in high-risk subgroups of suicide attempters: a prospective study of standardised mortality rates in suicide attempters examined at a medical emergency inpatient unit

ObjectivesThe primary aim of the present study was to investigate the putative excess mortality by suicide in suicide attempters. As a secondary aim, we investigate excess mortality in specific, clinically...

Inequalities in External-Cause Mortality in 2018 across Industries in Republic of Korea

BackgroundExternal-cause mortality is an important public health issue worldwide. Considering its significance to workers’ health and inequalities across industries, we aimed to describe the state of external-cause mortality and investigate its difference by industry in Republic of Korea based on data for 2018. MethodsData obtained from the Statistics Korea and Korean Employment Information System were used. External causes of death were divided into three categories (suicide, transport accident, and others), and death occurred during employment period or within 90 days after unemployment was regarded as workers’ death. We calculated age- and sex-standardized mortalities per 100,000, standardized mortality ratios (SMRs) compared to the general population and total workers, and mortality rate ratios (RRs) across industries using information and communication as a reference. Correlation analyses between income, education, and mortality were conducted. ResultsAge- and sex-standardized external-cause mortality per 100,000 in all workers was 29.4 (suicide: 16.2, transport accident: 6.6, others: 6.6). Compared to the general population, all external-cause and suicide SMRs were significantly lower; however, there was no significant difference in transport accidents. When compared to total workers, wholesale, transportation, and business facilities management showed higher SMR for suicide, and agriculture, forestry, and fishing, mining and quarrying, construction, transportation and storage, and public administration and defense showed higher SMR for transport accidents. A moderate to strong negative correlation was observed between education level and mortality (both age- and sex-standardized mortality rates and SMR compared to the general population). ConclusionInequalities in external-cause mortalities from suicide, transport accidents, and other causes were found. For reducing the differences, improved policies are needed for industries with higher mortalities.

Suicide rates by ethnic group among patients in contact with mental health services: an observational cohort study in England and Wales

Recent evidence on suicide rates among psychiatric patients from minority ethnic backgrounds is scarce. We aimed to examine suicide rates among minority ethnic psychiatric patients and describe their social and clinical characteristics. We did a retrospective observational cohort study on a national case-series of patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2007 and 2018. Data were collected as part of the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates and standardised mortality ratios (SMRs) were estimated for South Asian (Indian, Pakistani, and Bangladeshi), Black African, Black Caribbean, Chinese, and White patients. A total of 698 patients in the four minority ethnic groups of South Asian, Black Caribbean, Black African, and Chinese were included (482 [69%] men; 216 [31%] women; mean age 41 years [SD 14·9, range 12-91] and compared with 13 567 White patients (9030 [66·6%] men; 4537 [33·4%] women; mean age 48 years [SD 15·8, range 10-100]). Rates and SMRs for suicide among minority ethnic patients were lower than for White patients (2·73 deaths, 95% CI 2·68-2·78) per 100 000 population. Differences were found between ethnic groups with higher suicide rates in Black Caribbean patients (1·89 deaths [95% CI 1·55-2·23] per 100 000 population) and lower rates in South Asian patients (1·49 deaths [1·33-1·64] per 100 000 population). There was an increase in rates among White patients in 2007-12 followed by a fall but no change among other ethnic groups. Schizophrenia was more common among Black African patients (54%) and Black Caribbean patients (44%), while affective disorder was more common among South Asian patients (41%). Minority ethnic patients overall showed markers of social adversity and received higher intensity care yet were viewed by clinicians as at lower risk than White patients. Effective approaches to prevention might differ between minority ethnic groups. Clinicians and the services in which they work should be aware of the common and distinct social and clinical needs of minority ethnic patients with mental illness. The Healthcare Quality Improvement Partnership.

Suicide Risk Among Adults With Mental Health Emergency Department Visits With and Without Suicidal Symptoms.

Objective: To describe risk factors and suicide rates during the year following discharge from mental health emergency department (ED) visits by adults with suicide attempts, suicidal ideation, or neither.Methods: National cohorts of patients with mental health ED visits for suicide attempts or self-harm (n = 55,323), suicidal ideation (n = 435,464), or other mental health visits (n = 9,144,807) from 2008 to 2012 Medicaid data were followed for suicide for 1 year after discharge. Suicide rates per 100,000 person-years were determined from National Death Index data. Poisson regression models, adjusted for age, sex, and race/ethnicity, estimated suicide rate ratios (RRs). Suicide standardized mortality ratios (SMRs) were estimated from National Vital Statistics System data.Results: Suicide rates per 100,000 person-years were 325.4 for suicide attempt or self-harm visits (RR = 5.51, 95% CI, 4.64-6.55), 156.6 for suicidal ideation visits (RR = 2.59, 95% CI, 2.34-2.87), and 57.0 for the other mental health ED visits (1.0, reference). Compared to expected suicide general population rates, SMRs were 18.2 (95% CI, 13.0-23.4) for suicide attempt or self-harm patients, 10.6 (95% CI, 9.0-12.2) for suicidal ideation patients, and 3.2 (95% CI, 3.1-3.4) for other ED mental health patients. Among patients with suicide attempt ED visits in the 180 days before their index mental health ED visit, suicide rates per 100,000 person-years were 687.2 (95% CI, 396.5-978.0) for attempt or self-harm visits, 397.4 (95% CI, 230.6-564.3) for ideation visits, and 328.4 (95% CI, 241.5-415.4) for other mental health visits.Conclusions: In the year following discharge, emergency department patients with suicide attempts or self-harm, especially repeated attempts, have a high risk of suicide.

Suicide Risk in Medicare Patients With Schizophrenia Across the Life Span

Although adults with schizophrenia have an increased risk of suicide, sample size limitations of previous research have hindered characterizations of suicide risk across the life span. To describe suicide mortality rates and correlates among adults with schizophrenia across the life span and standardized mortality ratios (SMRs) for suicide compared with the general US population. Five national retrospective longitudinal cohorts of patients with schizophrenia in the Medicare program from January 1, 2007, to December 31, 2016, were identified by age: 18 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 years or older. Death record information was obtained from the National Death Index. The total cohort included 668 836 Medicare patients with schizophrenia, 2 997 308 years of follow-up, and 2218 suicide deaths. Data were analyzed from September 30, 2020, to March 10, 2021. For each age group, suicide mortality rates per 100 000 person-years and adjusted hazard ratios (aHRs) with 95% CIs of suicide were determined. Suicide SMRs were estimated for the total cohort and by sex and age cohorts standardized to the general US population by age, sex, and race/ethnicity. The study population of adults 18 years and older included 668 836 Medicare recipients with schizophrenia (52.5% men, 47.5% women). The total suicide rate per 100 000 person-years was 74.00, which is 4.5 times higher than that for the general US population (SMR, 4.54; 95% CI, 4.35-4.73) and included a rate of 88.96 for men and 56.33 for women, which are 3.4 (SMR, 3.39; 95% CI, 3.22-3.57) and 8.2 (SMR, 8.16; 95% CI, 7.60-8.75) times higher, respectively, than the rates for the general US population. Suicide rates were significantly higher for men (aHR, 1.44; 95% CI, 1.29-1.61) and those with depressive (aHR, 1.32; 95% CI, 1.17-1.50), anxiety (aHR, 1.15; 95% CI, 1.02-1.30), drug use (aHR, 1.55; 95% CI, 1.36-1.76), and sleep disorders (aHR, 1.22; 95% CI, 1.07-1.39), suicidal ideation (aHR, 1.41; 95% CI, 1.22-1.63), and suicide attempts or self-injury (aHR, 2.48; 95% CI, 2.06-2.98). The adjusted hazards of suicide were lower for Hispanic patients (aHR, 0.66; 95% CI, 0.54-0.80) or Black patients (aHR, 0.29; 95% CI, 0.24-0.35) than White patients. The suicide rate declined with age, from 141.95 (SMR, 10.19; 95% CI, 9.29-11.18) for patients aged 18 to 34 years to 24.01 (SMR, 1.53; 95% CI, 1.32-1.77) for patients 65 years or older. The corresponding declines per 100 000 person-years were from 153.80 (18-34 years of age) to 34.17 (65 years or older) for men and from 115.70 (18-34 years of age) to 18.66 (65 years or older) for women. In the group aged 18 to 34 years, the adjusted hazards of suicide risk were significantly increased for patients with suicide attempt or self-injury (aHR, 2.57; 95% CI, 18.20-2.04) and with comorbid drug use disorders (aHR, 1.48; 95% CI, 1.17-1.88), but not with comorbid depressive disorders (aHR, 0.99; 95% CI, 0.38-1.26) during the year before the start of follow-up. In this cohort study of adult Medicare patients with schizophrenia, suicide risk was elevated, with the highest absolute and relative risk among young adults. These patterns support suicide prevention efforts with a focus on young adults with schizophrenia, especially those with suicidal symptoms and substance use.

Suicide Risk in the First Year Following Dementia Diagnosis: A National Study of U.S. Older Adults

<h3>Introduction</h3> Many aging adults fear developing Alzheimer's disease or a related dementia (ADRD). After being diagnosed with ADRD, feelings of loss, anger, and uncertainty are common. At a time when the U.S. suicide rate among older adults has accelerated and the prevalence of ADRD is increasing, research is needed to quantify suicide risk in persons with newly diagnosed dementia and to identify patient characteristics that are associated with short-term risk for suicide. Past research is mostly limited to small samples with cross-sectional or case series designs. Prior cohort studies primarily come from Denmark or Asia and are limited by narrowly selected samples and inconsistent accounting for time since dementia diagnosis. We present results from a U.S. national study of suicide risk in adults aged >65 years during the first year following newly diagnosed dementia. Competing risk regression was used to identify risk factors of suicide. Standardized mortality ratios (SMRs) were calculated to quantify suicide risk using the U.S. Compressed Mortality File. <h3>Methods</h3> We extracted a cohort of adults aged >65 years with newly diagnosed ADRD (2011-2016) from Medicare claims linked to the National Death Index. After identifying patients with an ADRD diagnosis on an outpatient or inpatient claim, we limited the cohort to those without any claim for an ADRD diagnosis in the prior 12 months. Dementia included Alzheimer's, vascular, Lewy bodies, frontotemporal, or unspecified. Suicide was defined as cause of death coded as intentional self-injury/suicide (ICD-10 codes X60-X84, Y87.0, U03). Recent mental health and substance use disorders were defined as >1 inpatient or >2 outpatient diagnoses within 180 days prior to index ADRD diagnosis date. Severity of medical comorbidity was evaluated with the Elixhauser Comorbidity Scale, excluding mental health, substance use, and neurological disorders. Chronic pain was classified using a previously developed research algorithm for administrative data. Crude suicide rates per 100,000 person-years were estimated for the first year after ADRD diagnosis. Time-to-event analysis for suicide mortality was conducted using Fine and Gray's competing risks analysis. <h3>Results</h3> Of the 2,667,987 older adults with ADRD, 62.2% were women, 82.5% were non-Hispanic White, and 46.5% aged 85+ years. The suicide rate was 26.42 per 100,000 person-years. After adjusting for demographic variables, rural residence, recent mental health and substance use disorders, and chronic pain conditions were associated with increased risk. Relative to the general population, the overall SMR for suicide was 1.54 (95%CI=1.42, 1.65) with the highest risk among ADRD adults aged 65-74 years (SMR=3.43, 95%CI=2.96, 3.89). Approximately half of all suicide deaths occurred within 90 days. <h3>Conclusions</h3> In this national U.S. study of over two million older adults, we found that the number of observed suicide deaths within the first year of dementia diagnosis was approximately 54% higher than expected when compared to the general geriatric population. The risk of suicide mortality was particularly elevated among adults aged 65-74 years and within the first 90 days of dementia diagnosis. Our study identified a number of specific factors associated with higher risk of suicide, which may assist health care providers in decisions regarding appropriate, potentially life-saving care during the critical period following initial diagnosis of dementia. Limitations include our inability to validate the accuracy of dementia diagnoses in Medicare claims data, which may not include all cases of dementia. Second, our analyses did not include Medicare Advantage enrollees or older adults who receive health care from the Veterans Health Administration. Third, information was not available concerning additional suicide risk factors, such as other proximal stressful life events, social disconnection (e.g., marital status, loneliness), and access to lethal means. Third, the data used to estimate SMRs were based on mortality patterns from January 1, 2011, to December 31, 2016, which was a period marked by increasing U.S. suicide rates for males and females aged 65-74 years, and may not generalize to other epochs. Finally, competing mortality risks may complicate detection of and contribute to underestimated counts of suicide deaths in older adults, particularly in the >75 years of age group. The clinical and policy implications of these results highlight the importance of suicide risk screening and support at the time of diagnosing incident dementia, particularly for patients who are younger (i.e., aged 65-74 years) and for those with a history of chronic pain or mental health or substance use disorders. These findings also support mental health care, thorough assessment of patient and caregiver needs, initiating referrals for services and supports, and lethal means restriction and safety counseling during the critical transitional period following diagnosis of dementia. <h3>Funding</h3> This research was supported by grants from NIMH (R01MH107452-02S1) and American Foundation for Suicide Prevention (YIG-0-148-19).

Incidence and method of suicide mortality in patients with schizophrenia: a Nationwide Cohort Study.

Suicide is a leading cause of death in patients with schizophrenia. This nationwide cohort study investigated the incidence of each suicide method in patients with schizophrenia compared with the general population. In total, records of 174,039 patients with schizophrenia were obtained from the National Health Insurance Research Database in Taiwan from 2001 to 2016. This schizophrenia cohort was linked with the national mortality database, and 26,926 patients died during this follow-up period. Of the deceased, 3033 had died by suicide. Univariate Cox regression was used to estimate the demographic variables associated with suicide. We estimated the difference in the proportion of each suicide method used in patients with schizophrenia compared with the general population. The incidence and standardized mortality ratio (SMR) of each suicide method were calculated and stratified based on sex. Patients aged 25-34years exhibited the highest suicide risk. Compared with the general population, patients with schizophrenia were more likely to commit suicide by jumping and drowning and less likely to use charcoal-burning and hanging. Women showed a higher incidence of suicide by drowning and jumping than did men. Comorbidity with substance use disorders (SUDs) was associated with a high suicide SMR (26.9, 95% confidence interval [CI] = 23.4-28.9), particularly for suicide by jumping (61.2, 95% CI = 48.3-76.3). Patients with schizophrenia had higher suicide rates for all methods than did the general population. Suicide method differed based on sex. Patients with SUDs exhibit a high SMR for each suicide method and warrant intensive clinical attention.

Geography of suicide in Japan: spatial patterning and rural\u2013urban differences

PurposeThere are notable geographic variations in incidence rates of suicide both in Japan and globally. Previous studies have found that rurality/urbanity shapes intra-regional differences in suicide mortality, and suicide risk associated with rurality can vary significantly by gender and age. This study aimed to examine spatial patterning of and rural–urban differences in suicide mortality by gender and age group across 1887 municipalities in Japan between 2009 and 2017.MethodsSuicide data were obtained from suicide statistics of the Ministry of Health, Labour and Welfare in Japan. We estimated smoothed standardized mortality ratios for suicide for each of the municipalities and investigated associations with level of rurality/urbanity using Bayesian hierarchical models before and after adjusting for socioeconomic characteristics.ResultsThe results of the multivariate analyses showed that, for males aged 0–39 and 40–59 years, rural residents tended to have a higher suicide risk compared to urban ones. For males aged 60+ years, a distinct rural–urban gradient in suicide risk was not observed. For females aged 0–39 years, a significant association between suicide risk and rurality was not observed, while for females aged 40–59 years and females aged 60 years or above, the association was a U-shaped curve.ConclusionOur results showed that geographical distribution of and rural–urban differences in suicide mortality in Japan differed substantially by gender and age. These findings suggest that it is important to take demographic factors into consideration when municipalities allocate resources for suicide prevention.

Lithium in drinking water and suicide prevention: The largest nationwide epidemiological study from Japan.

The aims of the present study thus were (a) to further investigate the association between lithium levels in drinking water and suicide rates by adjusting relevant factors using the so far largest available dataset in Japan, (b) to confirm sex differences, (c) to estimate the effects of long-term exposure to trace lithium, (d) to investigate the effects of drinking bottled instead of tap water, and (e) to exploratorily investigate which lithium levels may be associated with lower suicide rates. Mean lithium levels in drinking water of all 808 cities and wards (ie, 785 cities of 46 prefectures and 23 wards of Tokyo) in Japan were examined in relation to mean suicide standardized mortality ratios (SMRs) during the 7years from 2010 to 2016. Multiple regression analyses adjusted for the size of each population were used to investigate the association of lithium levels with suicide SMRs with adjustments for relevant factors. The adjusted model showed significant inverse associations of lithium levels with total and male SMRs, but not with female SMRs. Neither the proportion of residents who continued to live in the same city nor the consumption of bottled water changed the association between lithium levels and suicide SMRs. Finally, it was 30μg/L or more that was associated with lower suicide SMRs. The present findings reconfirm the inverse association between lithium levels in drinking water and suicide rates particularly in the male population.

Association between lithium in tap water and suicide mortality rates in Miyazaki Prefecture

BackgroundMost studies have reported that suicide mortality rates are negatively associated with lithium levels in tap water; however, a few studies showed either no association or a positive association. Thus, the association between suicide mortality and lithium levels in tap water remains controversial. To clarify the association, our study evaluated the association between lithium levels in tap water and suicide mortality rates in Miyazaki Prefecture of Japan, after adjusting for confounding factors.MethodsWe measured lithium levels in tap water across the 26 municipalities of Miyazaki Prefecture in Japan. We examined the standardized mortality ratio (SMR) for suicide in each municipality and used the data as the average suicide SMRs over 5 years (2009–2013). Weighted least-squares regression analysis, adjusted for the size of each municipality’s population, was used to investigate the association between lithium levels in tap water and suicide SMRs. In addition to a crude model, in an adjusted model, potential confounding factors (proportion of elderly people, proportion of one-person households, annual marriage rate, annual mean income, unemployment rate, the density of medical doctors per 100,000 people, annual total rainfall, and proportion of people with a college education or higher) were added as covariates.ResultsWe showed that male and female suicide SMRs were not associated with lithium levels in tap water in Miyazaki Prefecture. After adjusting for confounders, male suicide SMRs were significantly and positively associated with the proportion of elderly people in the population and annual total rainfall, and female suicide SMRs were associated with the proportion of elderly people in the population.ConclusionsNo association between lithium levels in tap water and suicide mortality rates was found in Miyazaki Prefecture.

Association Between Community Social Capital and Suicide Mortality in Rural Areas of Japan: An Evaluation of Temporal Changes

Background: Although previous studies have reported that suicide mortality was associated with social capital, the relation between social capital and suicide mortality has remained controversial. Thus, we evaluated the relation between social capital and suicide mortality in rural areas of Japan, and examined the association between temporal changes in social capital and suicide mortality over the last ten years. Methods: We examined the Standardized Mortality Ratio (SMR) for suicide for 26 municipalities of Miyazaki Prefecture and used the data to calculate the average suicide SMRs for two five-year periods: an earlier period, 2004–2008; and a later period, 2012–2016. Social capital (social cohesion and social participation of older people) was measured using information from questionnaire surveys. A multiple linear regression analysis of suicide SMR was conducted for each social capital variable, adjusting for potential confounding factors (population density, the proportion of older people, annual divorce rate, unemployment rate, and proportion of workers engaged in primary industries). Results: We demonstrated that male suicide SMR for the earlier period was significantly and positively associated with social cohesion after the adjustment of confounding factors. Temporal changes in male suicide SMRs were significantly and negatively associated with temporal changes in the social participation of older people in the adjusted model. No association was found for female suicide SMRs in either period. Conclusion: The present findings suggest that the social participation of older people might reduce suicide among males.

Association of Geomagnetic Disturbances and Suicide Attempts in Taiwan, 1997-2013: A Cross-Sectional Study.

Background: A previous study in Japan found that monthly mean K index values were related to the monthly number of male, but not female, suicides. Correlations between geomagnetic disturbances and suicide/depression have also been reported in countries such as Canada, South Africa, Finland, Australia, Russia, and Japan. We have previously shown that stronger geomagnetism is linked to a higher standardized mortality ratio for suicide. To date, however, no published studies have reported the correlation between geomagnetic disturbances and suicide attempts in Taiwan. Methods: Data on the monthly number of suicide attempts in Taiwan from January 1997 to December 2013 were obtained. We performed a multivariable analysis, with the number of suicide attempts as the response variable and monthly Kp10 index, F10.7 index, sulfur dioxide, carbon monoxide, ozone, fine particulate matter (PM2.5), temperature, humidity, unemployment rate, and cosmic rays as the explanatory variables. Results: The multivariable analysis showed that Kp10 index, temperature, humidity, unemployment rate, and cosmic rays were associated with the number of male suicide attempts and that Kp10 index, F10.7 index, carbon monoxide, temperature, humidity, and unemployment rate were associated with the number of female suicide attempts. Conclusion: This is the first article reporting statistically significant relationships between the monthly number of male and female suicide attempts and the monthly mean Kp10 value in Taiwan.

Suicide Rates, Social Capital, and Depressive Symptoms among Older Adults in Japan: An Ecological Study.

Depression is considered the primary risk factor for older people’s suicide. When considering suicide measures, it is necessary to clarify the relationship between depressive symptoms, social capital, and suicide rates. Therefore, we aimed to clarify the relationship between community-level social capital, depressive symptoms, and suicide rates among older people in Japan. We analyzed the data gathered from 63,026 men and 72,268 women aged 65 years and older, totaling 135,294 subjects in 81 municipalities with a population of over 100,000 participants in the 2013 Sixth Long-Term Care Needs Survey and another survey conducted by Japan Gerontological Evaluation Study (JAGES) in 2013 including the same question items as the survey in Japan. Multiple regression analysis revealed that the male suicide standardized mortality ratio (SMR) was positively correlated with depressive symptoms (B = 2.318, p = 0.002), and received emotional support (B = −2.622, p = 0.014) had a negative correlation with the male suicide SMR. In older males particularly, the received emotional support in the community was independently associated with the suicide rate. Therefore, fostering social support in a community could act as a countermeasure to suicide among older males in Japan.