Clinical and Health Affairs
Suicide Rates in 2009
Do the Economy and Wars Have an Effect?
By Timothy W. Lineberry, M.D.
Suicide is a public health problem that claims the lives of approximately 1 million people around the world each year. This article describes suicide rates in the United States and Minnesota and discusses potential effects of the economy on the rate, concerns regarding suicides in the Army, and what clinicians can do to make a difference in the lives of patients who may be at risk.
The dramatic economic downturn that’s taken place since the end of 2007 has brought the issue of suicide to the forefront, triggering memories of ruined bankers and financiers jumping from windows during the Great Depression. High-profile suicides covered in the media and anecdotal reports from a variety of sources have fueled speculation about whether the economy is contributing to a rise in suicide rates. In the popular press, there also have been concerning reports of increasing numbers of suicides in the U.S. Army. This article describes U.S. and Minnesota suicide rates and discusses potential effects of the economy on the suicide rate in this country, concerns regarding suicides in the Army, and what clinicians can do to make a difference.
Suicide in the United States and Minnesota
Suicide is an uncommon but profoundly tragic event that affects not only the victim but everyone in their lives. It is the 11th leading cause of death in the United States; in 2006 (the year for which the most current figures are available*), more than 33,000 individuals died by suicide, resulting in an annual rate of 11.1/100,000 (Table 1).1 Although the national suicide rate has remained relatively stable following a decrease in the mid-1990s, Minnesota has seen an increase in the rate of suicide in recent years.2 Following a low of 8.9 suicides per 100,000 population in 2000, 554 individuals died by suicide in the state in 2006 (a rate of 10.7/100,000), while 571 died from suicide in 2007 (a rate of 11 per 100,000).2
To illustrate the impact of suicide, it’s important to note that suicide takes far more lives than homicide. In 2006, 18,573 people in the United States died by homicide, compared with 33,300 who died by suicide.1 The contrast is even more striking in Minnesota data for 2007: 118 homicides were reported in the state that year compared with 571 deaths by suicide.3
The Economy and Suicide
Concerns have been raised about the adverse effect the economy is having on suicide rates—especially among individuals who have lost their jobs and their homes. Headlines have attributed some recent suicides to losses in the stock market and foreclosures. This oversimplification of the multifactorial nature of suicide neglects the most common variable associated with suicide—psychiatric illness. Almost 90% of the people who commit suicide are retrospectively diagnosed as having a mental health disorder.4 With that caveat in mind, however, there are real public health concerns about the possible effect the economy may have on individuals who suffer from psychiatric illness or who may have poor coping skills.5 According to studies done in Japan during the Asian economic crisis of the 1990s and an analysis of British economic and unemployment trends, economic crises do appear to have an impact on people with mental disorders who already may be at risk for suicide with the result being increased suicide rates.5-7 A June 2009 Lancet study analyzing the effects of unemployment on suicide in 26 European countries found that for each 1% rise in unemployment, suicide rates increased by 0.79% in people younger than 65 years of age.8 The effects were more dramatic with steeper rises in unemployment; for an unemployment rate increase of greater than 3%, the authors found a corresponding increase in the suicide rate of 4.45% among people in that same age group. Notably, they also found that spending on programs that retrain and support the unemployed mitigated this risk. Previous studies have also reflected concerns about the effect of debt, decreased benefits for the unemployed, and decreased access to mental health services on suicide rates.5
We do not know what effect the current rising U.S. unemployment rate will have on people’s mental health and whether it will cause suicide rates to increase. It does appear that males, who account for 72% of suicides in the United States, are being disproportionately affected by job losses during this current economic crisis. However, extrapolating from the previously described research findings is concerning. One issue in Minnesota is whether decreased funding for social services, both from cuts in state spending and donations from the public, and inability to pay for psychiatric care may make it more difficult for people who have lost their jobs and insurance coverage to get the care they need.
Suicide in the Army
In 2008, the suicide rate in the U.S. Army exceeded population-adjusted rates for the country as a whole for the first time since they were recorded. The Army reported 128 confirmed suicides and 15 suspected suicides in cases under investigation for a rate of 20.2/100,000 population in 2008.9 Of those suicides, 65% involved soldiers who had been deployed or redeployed; 35% involved those who had not been deployed.9 The final rate for 2009 may be even higher based on trends reported thus far. Data released in July 2009 described 88 total confirmed or suspected suicides among soldiers on active duty during the first half of 2009.10 This is 21 more than were reported during the first half of 2008. Among reserve soldiers not on active duty, there were 39 confirmed or suspected suicides during the first half of 2009 compared with 29 at the end of June 2008.10 Concerns have been raised about the cumulative effect of multiple deployments on troops, the possible impact of post-traumatic stress disorder (PTSD), and difficulties associated with reintegrating into civilian life.
There are a number of challenges with interpreting military data and making comparisons with the general population. First, the military has both physical and psychiatric health standards for entrance. Members of the military are generally younger (suicide is the second-leading cause of death nationally among 18 to 24 year olds) and predominantly male.1 Second, those with new onset serious mental illness or severe personality disorders incompatible with military service are medically retired or discharged. Also, unlike the general population, everyone in the military has access to health care.
Conversely, those serving in the military during wartime may be at increased risk for development of depression, relationship problems, and substance abuse or dependence.11 Soldiers are subject to remarkable stress during deployments, as they are separated from their families and often encounter life-threatening situations. When they return home, they face the inherent challenges of going back to civilian life. In addition, those who are deployed have a greater likelihood of developing PTSD.12,13 The odds of developing PTSD increase in association with the intensity of combat, injury, and cumulative exposure.12,14,15 Service members also may be less likely to seek psychiatric care while in the military because of their concern about the stigma associated with it.12
Compounding this is the unprecedented involvement of Reserve and National Guard soldiers in the current wars. In past conflicts, soldiers—primarily active-component—would return to their home bases where health care, support, and community resources were readily available. Now, many Reserve and National Guard members who are activated and then deployed return to their hometowns and receive health care from their primary care physicians. Thus, it is important for all physicians to be aware of the fact that they may be seeing patients who have returned from active duty who may be struggling with their experience and with reintegrating into family and civilian life.
Public Health Approaches to Suicide Prevention Suicide is a global public health problem, with an estimated 1 million people annually dying by suicide according to the World Health Organization. Some countries have attempted to address suicide prevention through nonclinical public health policy interventions. The most commonly used strategy is reducing access to means for suicide. For example, the United Kingdom restricts the sale of acetaminophen (paracetamol) to pharmacies, limits the number of pills that may be purchased at one time, and places those pills in blister packs.16-18 Since these restrictions took effect, sales of acetaminophen have remained steady but admissions to intensive care units secondary to acetaminophen toxicity decreased by 30%. In the United States, firearms were used in 50% of suicides in 2006 (Table 2). Public health interventions to restrict access to firearms including waiting periods in order to prevent impulsive purchases and background checks by local authorities have shown promise.19
The U.S. Army is developing programs to identify populations most at risk for suicide and intervene on both a population and an individual level.9 The Army is funding research into evidence-based treatments for depression and PTSD and working with civilian experts in order to implement interventions that can decrease risk.9 There is some hope that adapting elements from the U.S. Air Force suicide prevention program may be helpful. This program, implemented following the 1996 suicide of Adm. Jeremy Boorda, the highest-ranking officer in the U.S. Navy, has shown efficacy in research analyses.20 This public health-based program consists of interventions to decrease the stigma associated with receiving psychiatric care, increase commander involvement in suicide prevention, improve identification and referral of service members at risk, concurrently monitor trends in suicide attempts and completions, integrate community agencies that can provide assistance, and standardize protocols for treatment and handoffs of those at risk.
What Physicians Can Do
Although there is no way of predicting who will die by suicide, physicians can do three things to potentially decrease the risk among patients.
First, systematically identify patients with depression and ask about suicidal thoughts. Recent research reflects improvements in identification of patients with depression in clinical practice. However, in a 2007 study, less than half of simulated patients with depression who asked for an antidepressant were asked about thoughts of suicide.21 Follow up with patients using standardized depression-assessment tools to determine response to treatment and adjust treatment as needed. In addition, check in with patients shortly after starting them on medication and advise them of the potential for worsening of anxiety, agitation, and suicidal ideation or behaviors. Tell patients to contact you if these arise. Also, keep in mind that beyond the risk for suicide, untreated or inadequately treated depression carries significant burdens both medically and psychosocially for patients.
Second, screen patients for alcohol and substance abuse. Many patients with alcohol dependence report lifetime depressive symptoms.22 The lifetime risk of suicide among those with alcohol dependence is approximately 7%.23 This compares with a lifetime risk of suicide among individuals with affective disorders of 8.6% for those who have been hospitalized secondary to concerns about suicide, 4% for those admitted for psychiatric issues without concerns for suicide, and 2% for those who have been treated for depression as outpatients.24 If you find a patient is abusing alcohol and other drugs, discuss treatment options and provide referrals to services that offer treatment.
Third, ask patients with depression/substance use disorders about access to firearms and provide guidance about safe storage or removal. Even in psychiatry, research reflects that patients are not regularly provided with recommendations about firearms safety.21
Suicide is a public health problem that can be affected by public health interventions and improved clinical care. By systematically identifying depression and substance use disorders in patients, instituting evidence-based treatment for them and adjusting interventions based on the patient’s response, and providing guidance on limiting access to the means for suicide, physicians can reduce their patients’ risk of suicide.
Timothy Lineberry is an assistant professor of psychiatry and medical director of Mayo Clinic Rochester’s Psychiatric Hospital. He is a subject matter expert for suicide treatment and prevention for the Department of Defense’s Military Operational Medicine Research Program and chair of the board of the American Association of Suicidology.
The opinions expressed in this article are those of the author and do not represent the views of the Mayo Clinic or the Department of Defense. The author has not received any medical industry funding.
1. McIntosh J (for the American Association of Suicidology). U.S.A. suicide: 2006 Official final data. Washington, DC: American Association of Suicidology; 2009. Available at: www.suicidology.org. Accessed July 14, 2009.
2. Minnesota Department of Health. Suicide Prevention Fact Sheet. St. Paul, MN: Minnesota Department of Health; January 2009. 3. Minnesota Department of Health. 2007 Minnesota Health Statistics Annual Summary: General Mortality. St. Paul, MN: Minnesota Department of Health; 2009.
4. Arsenault-Lapierre G, Kim C, Turecki G. Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC Psychiatry. 2004;4:37. 5. Gunnell D, Platt S, Hawton K. The economic crisis and suicide. BMJ. 2009;338:b1891.
6. Lundin A, Hemmingsson T. Unemployment and suicide. Lancet. Published online July 8, 2009.
7. Chang SS, Gunnell D, Sterne JA, Lu TH, Cheng AT. Was the economic crisis 1997-1998 responsible for rising suicide rates in East/Southeast Asia? A time-trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Soc Sci Med. 2009;68(7):1322-31.
8. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet. Published online July 8, 2009;doi:10.1016/S0140-6736(09)61124-7.
9. Carden MJ. Army Works to Combat Rising Suicide Rates. American Forces Press Service. Jan 2009.
10. U.S. Department of Defense. Army Releases June Suicide Data. DefenseLink.