Living Alone and Suicide Risk in the United States, 2008‒2019

Long-term trends in mortality by living arrangements and the role of socioeconomic factors, Finland 1991-2020

Recent decades have witnessed major changes in living arrangements, potentially impacting their well-established associations with mortality. However, research considering long-term trends in these differentials is scarce. We used individual-level register data on the total Finnish population aged 30 years and over from 1991 to 2020 to examine trends in the association between living arrangements and all-cause, as well as external and alcohol-related mortality. We calculated age-standardized mortality rates, quantified group differentials in absolute and relative terms, and assessed the contribution of socioeconomic factors with Poisson-models. Analyses were conducted separately for men and women in age groups 30-49, 50-69, and 70+. All-cause mortality was consistently lowest among men and women living with a partner. Highest rates were observed in the growing group of individuals living alone or with persons other than a partner or child, who experienced up to a five-fold excess mortality compared to those living with a partner and children. Mortality declined across all living arrangement groups over time. While absolute rate differences mostly narrowed, relative differences widened across all ages. Adjustments for socioeconomic factors somewhat attenuated mortality differentials, with their contribution increasing modestly by the end of the study period. In conclusion, over the past 30 years, relative mortality differences by living arrangement have increased at all ages for both men and women. These widening differentials pose a growing public health burden, particularly for the growing group of individuals living alone. Our results suggest that factors beyond socioeconomic differentiation are contributing to these trends.

The association between loneliness, suicidal ideation, and psychological distress considering family compositions: a cross-sectional study in a Japanese rural area

Research on how loneliness, as a subjective experience, affects suicide risk remains insufficient. It also remains unclear whether the effects vary according to family composition. This study aimed to investigate the associations among loneliness, suicidal ideation, and psychological distress in a rural population in Japan. A cross-sectional survey was conducted between August and September 2023 in a rural town in Akita Prefecture. Of the 5,000 surveyed residents, data from 1,842 respondents were analyzed. The exposure variable was loneliness, as assessed by the University of California Los Angeles Loneliness Scale short form. The main outcome was the presence or absence of suicidal ideation, which was measured using a self-reported questionnaire. The secondary outcome was psychological distress, which was measured using the Kessler Psychological Distress Scale (K6). The collected data were analyzed using multivariate logistic regression and stratified analysis based on family composition. Loneliness was strongly associated with suicidal ideation and psychological distress. The loneliness-psychological distress association persisted regardless of family composition. Loneliness independently affected suicidal ideation and psychological distress among rural residents in Japan. To develop effective suicide prevention strategies in rural areas, it is essential to address both social isolation and the subjective experience of loneliness.

Suicide Risk and Living Alone With Depression or Anxiety

Importance

Living alone and mental health disorders, including depression and anxiety, are associated with high suicide risk, but their combined impact remains underexplored.

Objective

To examine the association of living arrangements and depression or anxiety with suicide risk.

Design, Setting, and Participants

This population-based cohort study used data from the Korean National Health Insurance Service database from January 1, 2009, to December 31, 2021, that included adults aged 20 years or older who participated in the General Health Screening Program in Korea in 2009. Individuals with incomplete data and those who died by suicide within the first year were excluded to minimize the possibility of reverse causation. Data were analyzed from December 28, 2023, to December 27, 2024.

Exposures

Living arrangements, categorized as living alone (≥5 years) or living with others, and depression and anxiety, determined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.

Main Outcomes and Measures

The primary outcome was death by suicide, identified through national death records. Multivariable Cox proportional hazards regression models were used to estimate adjusted hazard ratios (AHRs) and 95% CIs for suicide risk.

Results

The study included 3 764 279 adults (mean [SD] age, 47.2 [14.0] years; 55.8% male). Of these individuals, 112 460 (3.0%) had depression, 232 305 (6.2%) had anxiety, and 319 993 (8.5%) lived alone. Compared with individuals who had neither depression nor anxiety nor lived alone, individuals living alone with both depression and anxiety exhibited a 558% increased risk of suicide (AHR, 6.58 [95% CI, 4.86-8.92]). Living alone with depression was associated with a 290% increased risk (AHR, 3.91 [95% CI, 2.96-5.16]), and living alone with anxiety was associated with a 90% increased risk (AHR, 1.90 [95% CI, 1.48-2.43]). The AHRs were higher for the association between living alone and suicide among middle-aged individuals (aged 40 to 64 years) and men compared with other demographic groups.

Conclusions and Relevance

In this cohort study of 3 764 279 individuals, living alone with depression or anxiety was associated with an increased risk of suicide, particularly among middle-aged individuals and men. These findings underscore the importance of preventing mental illness, such as depression and anxiety, while addressing living arrangements as a critical factor in suicide risk assessments for individuals with these conditions.

States' COVID-19 policy contexts and suicide rates among US working-age adults

Despite expectations that suicide rates would surge during the pandemic, the national suicide rate declined in the United States in 2020 before returning to pre-pandemic levels in 2021. Explanations of the decline in suicides at the national level include a "pulling-together effect" in the face of a crisis and a shorter than expected pandemic recession. However, suicide rates and the change over time in suicide rates vary substantially across US states. At various times during the pandemic states enacted physical-distancing and economic support policies that may have affected suicide rates. We examined the association between state-level physical-distancing and economic support policy contexts and suicide rates among US adults ages 25-64 years during the COVID-19 pandemic. We found that a 1-SD increase in the stringency of a state's physical-distancing policies was associated with a 5.3% reduction in male suicide rates but was not associated with female suicide rates. Economic support policies were not associated with suicide rates for the period as a whole. The results support the growing evidence that COVID-19 policies had indirect and unintended consequences beyond their direct effect on COVID-19 transmission and death, in this case to reduce suicides among working-age males.

National Trends and Disparities in Suicidal Ideation, Attempts, and Health Care Utilization Among U.S. Adults

OBJECTIVE

Recent trends in U.S. suicide rates underscore a need for research on the risk for suicidality. The authors aimed to estimate national trends in suicidal ideation, suicide attempts, and health care utilization by using data from the 2015-2019 National Survey on Drug Use and Health.

METHODS

Logistic regression was used to estimate the adjusted odds of past-year suicidal ideation and, among individuals with ideation, past-year suicide attempts, with separate interaction models estimating time trends by sex, age, and race-ethnicity. Time trends were further examined with logistic regression to estimate annual prevalence, overall and by sociodemographic, behavioral, and clinical characteristics. Logistic regression was used to estimate past-year general and mental health care utilization among adults with suicidal ideation. Analyses were survey weighted.

RESULTS

Overall, 4.3% (N=13,195) of adults (N=214,505) reported suicidal ideation, and 13.0% (N=2,009) of those with ideation reported suicide attempts. Increases in prevalence of suicidal ideation, from 4.0% in 2015 to 4.9% in 2019, were significantly higher for young adults ages 18-25 years (p=0.001) than for older adults. Decreases in prevalence of suicide attempts among White adults (by 32.9%) were offset by increases among adults reporting Black (by 48.0%) and multiracial or other (by 82.3%) race-ethnicity. Less than half of adults with suicidal ideation (47.8%) received past-year mental health care, with significantly lower receipt for nearly all minoritized racial-ethnic groups, compared with White adults.

CONCLUSIONS

Widening racial-ethnic disparities in suicide attempts and lower mental health care utilization for minoritized groups underscore the importance of developing and implementing equity-focused, evidence-based suicide prevention strategies across health care settings.

Inverse association between obesity and suicidal death risk

BACKGROUND

Suicide is a significant yet preventable public health issue. Body mass index (BMI) is a readily measurable indicator associated with various health outcomes. However, the relationship between BMI and suicidal death risk is complex and warrants further investigation, particularly within contemporary, non-Western contexts with consideration of potential confounders. The purpose of this study was to investigate the relationship between BMI and the risk of suicidal death.

METHODS

This study was nationwide, retrospective, observational study based on Korean National Health Insurance Service database. We analyzed 4,045,081 participants who were aged > 19 years and underwent national health surveillance in 2009. The participants were categorized according to their BMI (underweight: < 18.5 kg/m², normal weight: 18.5-23 kg/m², overweight: 23-25 kg/m², class I obesity: 25-30 kg/m², and class II obesity: > 30 kg/m²). The primary outcome was the death events caused by suicide which was defined by International Classification of Disorders (ICD-10) codes (X60-X84) and death records documented by the Korea National Statistical Office. Multivariate Cox proportional hazard regression analysis was performed to estimate the risk of suicidal death with respect to BMI categories after adjusting for potential confounders (age, sex, income, diabetes, hypertension, dyslipidemia, smoking, drinking, exercise, self-abuse, waist circumference, schizophrenia, bipolar disorder, eating disorder, cancer, anxiety, and substance use disorder).

RESULTS

Underweight individuals had an increased risk (hazard ratio [HR] 1.44, 95% confidence interval [CI] 1.31-1.57) while overweight (HR 0.79, 95% CI 0.76-0.83), class I (HR 0.76, 95% CI 0.71-0.80) and class II obesity (HR 0.71, 95% CI 0.63-0.81) were associated with decreased risks of suicidal deaths compared to those of the normal weight individuals (BMI 18.5-23). This trend was consistent regardless of the presence of major depressive disorder (MDD) or the type of living arrangements of the participants.

CONCLUSIONS

Suicidal death risk was inversely correlated with BMI categories, independent of MDD or living arrangements. Our data suggests the importance of physiological factors associated with body mass in understanding suicidal death risk. Furthermore, these data provide valuable insights to where the public health resources should be invested to reduce suicidal death rates.

Association between living alone and generalized anxiety disorder in Korean adults

BACKGROUND

Globally, the rise in single-person households poses a potential risk to mental health, with generalized anxiety disorder (GAD) being a prominent concern. The proliferation of single-person households may exacerbate social isolation and foster loneliness and anxiety. Notably, research investigating the association between single-person households and GAD remains limited. Therefore, this study aimed to investigate the association between single-person households and GAD across sexes in Korea.

METHODS

We utilized data from the Korea National Health and Nutrition Examination Survey conducted in 2021 and 2022, comprising a sample of 9936 participants aged 19 or older. The Generalized Anxiety Disorder Screening Tool (GAD-7) was employed to assess anxiety levels in adults. Multiple logistic regression analysis was conducted to investigate the correlation between single-person households and GAD.

RESULTS

The reference variable used in the analysis was multi-person households (consisting of two or more individuals). The association between single-person households and GAD was statistically significant across sexes (male: odds ratio [OR]: 1.92, 95 % CI: 1.15-3.20; female: OR: 1.56, 95 % CI: 1.03-2.36). Participants in single-person households exhibited higher scores on the GAD-7 compared with those in multi-person households. Notably, marital status and education level displayed disparate effects based on sex, whereas physical activity demonstrated consistent effects irrespective of sex.

LIMITATIONS

Given the use of cross-sectional data, only correlations could be established.

CONCLUSION

The findings indicate an elevated risk of GAD in single-person households compared with multi-person households. Furthermore, promoting physical activity emerged as a potential strategy for mitigating GAD in single-person households.

Time-varying living arrangements and suicide death in the general population sample: 14-year causal survival analysis via pooled logistic regression

AIMS

While past research suggested that living arrangements are associated with suicide death, no study has examined the impact of sustained living arrangements and the change in living arrangements. Also, previous survival analysis studies only reported a single hazard ratio (HR), whereas the actual HR may change over time. We aimed to address these limitations using causal inference approaches.

METHODS

Multi-point data from a general Japanese population sample were used. Participants reported their living arrangements twice within a 5-year time interval. After that, suicide death, non-suicide death and all-cause mortality were evaluated over 14 years. We used inverse probability weighted pooled logistic regression and cumulative incidence curve, evaluating the association of time-varying living arrangements with suicide death. We also studied non-suicide death and all-cause mortality to contextualize the association. Missing data for covariates were handled using random forest imputation.

RESULTS

A total of 86,749 participants were analysed, with a mean age (standard deviation) of 51.7 (7.90) at baseline. Of these, 306 died by suicide during the 14-year follow-up. Persistently living alone was associated with an increased risk of suicide death (risk difference [RD]: 1.1%, 95% confidence interval [CI]: 0.3-2.5%; risk ratio [RR]: 4.00, 95% CI: 1.83-7.41), non-suicide death (RD: 7.8%, 95% CI: 5.2-10.5%; RR: 1.56, 95% CI: 1.38-1.74) and all-cause mortality (RD: 8.7%, 95% CI: 6.2-11.3%; RR: 1.60, 95% CI: 1.42-1.79) at the end of the follow-up. The cumulative incidence curve showed that these associations were consistent throughout the follow-up. Across all types of mortality, the increased risk was smaller for those who started to live with someone and those who transitioned to living alone. The results remained robust in sensitivity analyses.

CONCLUSIONS

Individuals who persistently live alone have an increased risk of suicide death as well as non-suicide death and all-cause mortality, whereas this impact is weaker for those who change their living arrangements.

Variations in Suicide Risk and Risk Factors After Hospitalization for Depression in Finland, 1996-2017

Importance

Although incidence of suicide in depression varies remarkably temporally, risk factors have been modeled as constant and remain uncharted in the short term. How effectively factors measured at one point in time predict risk at different time points is unknown.

Objective

To examine the absolute risk and risk factors for suicide in hospitalized patients with depression starting from the first days after discharge up to 2 years and to evaluate whether the size of relative risk by factor displays temporal patterns over consecutive phases of follow-up.

Design, Setting, and Participants

This population-based study using Finnish registers (hospital discharge, population, and cause of death registers) included all hospitalizations for depression as the principal diagnosis in Finland from 1996 to 2017, with a maximum follow-up of 2 years. Data were analyzed from January 2022 to November 2023.

Main Outcomes and Measures

Incidence rate (IR), IR ratios, hazard functions, and hazard ratios for suicide by consecutive time periods (0 to 3 days, 4 to 7 days, 7 to 30 days, 31 to 90 days, 91 to 365 days, and 1 to 2 years) since discharge.

Results

This study included 193 197 hospitalizations among 91 161 individuals, of whom 51 197 (56.2%) were female, and the mean (SD) age was 44.0 (17.3) years. Altogether, patients were followed up to 226 615 person-years. A total of 1219 men and 757 women died of suicide. Incidence of suicide was extremely high during the first days after discharge (IR of 6062 [95% CI, 4963-7404] per 100 000 on days 0 to 3; IR of 3884 [95% CI, 3119-4835] per 100 000 on days 4 to 7) and declined thereafter. Several factors were associated with risk of suicide over the first days after discharge. Current suicide attempt by hanging or firearms increased the risk of suicide most on days 0 to 3 (IR ratio, 18.9; 95% CI, 3.1-59.8) and on days 0 to 7 (IR ratio, 10.1; 95% CI, 1.7-31.5). Temporal patterns of the size of the relative risk diverged over time, being constant, declining, or increasing. Clinical factors had the strongest association immediately. Relative risk remained constant among men and even increased among those with alcohol or substance use disorder.

Conclusions and Relevance

In this study, patients hospitalized for depression had extremely high risk of suicide during the first days after discharge. Thereafter, incidence declined steeply but remained high. Within the periods of the highest risk of suicide, several factors increased overall risk manyfold. Risk factors' observed potencies varied over time and had characteristic temporal patterns.

Systemic White supremacy: U.S. state policy, policing, discrimination, and suicidality across race and sexual identity

Although suicide rates are stable or decreasing among White communities, rates are increasing among Black communities, a trend that appears to be disproportionately affecting Black lesbian, gay, bisexual, and queer (LGBQ) people. To understand the structural drivers and mechanisms of these trends, we examined associations between U.S. state-level racist and heterosexist criminal legal policies and policing, discrimination, and suicidality among White and Black, heterosexual and LGBQ, communities. We recruited 5,064 participants in 2021 using online census-driven quota sampling. Structural equation modeling estimated associations from objective indicators of racist and heterosexist criminal legal policies to self-reported police stops, discrimination, and suicidal ideation and behavior. For White heterosexual participants, racist (β = -.22, SE = 0.03, p < .001) and heterosexist (β = -.26, SE = 0.03, p < .001) policies were negatively associated with police stops. For White LGBQ participants, racist and heterosexist policies were not significantly associated with police stops. For Black heterosexual participants, racist (β = .30, SE = 0.11, p = .005), but not heterosexist, policies were positively associated with police stops. For Black LGBQ participants, racist (β = .57, SE = 0.08, p < .001) and heterosexist (β = .65, SE = 0.09, p < .001) policies were positively associated with police stops which, in turn, were positively associated with discrimination and suicidal ideation and behavior. Results provide evidence that racist and heterosexist state policies are linked to policing and interpersonal drivers of suicide inequities and suggest that repealing/preventing oppressive policies should be a suicide prevention imperative. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Emotional regulation and suicidal ideation-Mediating roles of perceived social support and avoidant coping

Introduction

Recent research has uncovered a wide prevalence variation of suicidal ideation in university students ranging from 9.7% to 58.3%. India has witnessed a 4.5% increase in suicide rates in the year 2021. The interplay between cognitive reappraisal of a stressful situation, suppression of emotional expression, and coping strategies for suicidal ideation of Indian University students is yet to be explored. We aim to determine whether suicidal ideation would differ across different types of family units, and to predict the extent to which perceived social support and avoidant coping could mediate the relation between emotion regulation processes and suicidal ideation.

Methods

Two hundred randomly selected University students (Mean age = 19.9, SD = 1.43) participated. Kruskal-Wallis, Pearson's product-moment correlation, and GLM mediation model were computed.

Results and discussion

Lifetime suicidal ideation significantly differed between those who stay alone and those who live in a nuclear family (p < 0.01), and also those who stay in a joint family (p < 0.05). Cognitive reappraisal predicted a reduction in suicidal ideation mediated by perceived social support (B = -0.06, p < 0.05) and avoidant coping (B = -0.07, p < 0.05). Whereas, expressive suppression predicted induced levels of suicidal ideation through perceived social support (B = 0.05, p < 0.05), and avoidant coping (B = 0.06, p < 0.05) as mediators.

Conclusion

Though our sample size restricts the generalization, our findings implied the importance of regular psychological consultation regarding the efficacy of the said coping processes in dealing with suicidal ideation.

Social disconnection and suicide mortality among Japanese older adults: A seven-year follow-up study

BACKGROUND

Few prospective studies have examined the association between social disconnection and late-life suicide. Therefore, we conducted a large-scale prospective study of older adults in Japan to examine differences in suicide mortality according to specific aspects of social disconnectedness.

METHODS

We conducted a nationwide baseline survey of functionally independent older adults (age ≥65 years) from 12 municipalities in Japan from 2010 to 2011. We followed the participants (n = 46,144) for cause of death through December 2017 using vital statistics. Social disconnection was assessed based on the indicators of eating alone, a lack of instrumental/emotional support, no participation in community activities, and no contact with friends. We adopted Cox regression models with multiple imputation for missing values and calculated the population-attributable fraction (PAF).

RESULTS

A total of 55 suicide deaths were recorded during an average follow-up of 7 years. Older adults with social disconnection had a marginally increased risk of suicide. The hazard ratio for eating alone vs. eating together was 2.81 (95% confidence interval [CI]: 1.47-5.37). The direction of these associations and point estimations did not largely change after controlling for depressive symptoms, an evident risk factor for suicidal behavior. The PAF indicated that eating alone was attributable to around 1800 (29%) of the suicide deaths among older adults annually in Japan.

CONCLUSION

Avoidance of not only depressive symptoms, but also social disconnection including eating alone, is useful in suicide prevention among older adults.

BMI categories across different living arrangements

INTRODUCTION

Research on the prevalence of body mass index (BMI) categories across different living arrangements remains limited. We aimed to quantify the prevalence of BMI categories among those living alone (LA) and those not living alone (NLA).

METHODS

In this population-based cross-sectional study, we used individual-level data from the 2011-2021 Behavioral Risk Factor Surveillance System. Main outcomes were prevalence of BMI categories in LA and NLA, adjusted for age, gender, and race/ethnicity, and socioeconomic status, using logistic regression and model-predicted marginal prevalence to estimate BMI categories prevalence.

RESULTS

Between 2011 and 2021, we quantified BMI categories prevalence in 4,195,414 adults in the BRFSS, with 1,197,787 (28.5%) adults LA and 2,997,627 (71.5%) adults NLA. In comparison to NLA, LA consistently demonstrates lower adjusted obesity prevalence across genders and age groups, with the highest prevalence observed in the 45-64 age range, particularly within the 45-54 group (LA: 37.4%, 95% CI: 37.1-37.8%; NLA: 34.3%, 95% CI: 33.8-34.7%). Additionally, LA displays an overall lower adjusted prevalence of overweight compared to NLA, notably in the 18-34 and >64 age groups.

CONCLUSIONS

Heterogeneity in BMI categories prevalence exists between LA and NLA. Future studies and public health efforts should consider this heterogeneity.

Living Alone and Drug Overdose Deaths in the US

This cohort study examines the risk of drug overdose death in individuals who live alone.

Epidemiology and nomogram for predicting the cancer-specific survival of ovarian granulosa cell tumor: A seer database study

OBJECTIVE

ovarian granulosa cell tumor (OGCT) is a kind of infrequent ovarian malignant tumor with limited epidemiological data available. we established a predictive nomograph to verify the clinical prognosis.

METHODS

1005 diagnosed with ovarian granulosa cell tumor (OGCT) were extracted from Surveillance, Epidemiology, and End Results (SEER) public database from 2000-2018. Kaplan-Meier analysis was applied to distinguish risk factors, univariate and multivariate Cox analyses were used to determine the independent prognostic factors for cancer-specific survival (CSS) of OGCT patients. The obtained prognostic variables were combined to construct a nomogram model for predicting CSS in OGCT patients.

RESULTS

Model performance was detected and evaluated with ROC curves and calibration plots. Data collected from 1005 patients were divided into two groups: training cohort(n=703,70%) and validation cohort(n=302,30%). The multivariate Cox model identified five covariates including age, marital status, AJCC stages, surgery and chemotherapy as independent interfering factors of CSS. The nomogram has shown a promising and excellent accuracy in evaluating 3 -, 5 -, 8-year CSS in OGCT patients. In terms of the CSS of the training cohort, the AUC values of the 3 -, 5 -, 8-year ROC curves were 0.819,0.8,0.819, while in terms of the CSS of the validation cohort, the AUC values of the validation cohort were 0.822,0.84,0.823, respectively. All the calibration curves showed pleasant consistency between predicted and actual survival rates. The nomogram model established in the study can improve the veracity of prognosis prediction, thereby improving the accuracy of individualized survival risk assessment, and providing targeted and constructive recommendations for specific treatment options.

CONCLUSION

Age, advanced clinical stage, widower and without surgery therapy are independent risk factors for poor prognosis and the nomogram we constructed can help clinicians efficiently recognize high-risk OGCT patients to guide targeted therapies and improve their outcomes.