Skip to main content

Advertisement

SpringerLink
Log in

Estimating the Association Between Mental Health Disorders and Suicide: a Review of Common Sources of Bias and Challenges and Opportunities for US-Based Research

  • Injury Epidemiology (S Marshall, Section Editor)
  • Published:
Current Epidemiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The purpose of this review is to (1) illuminate prevalent methodological approaches and estimates of association between mental health diagnoses and suicide from the meta-analytic literature; (2) discuss key internal and external validity concerns with these estimates; and (3) highlight some of the unique attributes and challenges in US-based suicide research and opportunities to move the evidence base forward.

Recent Findings

Globally, there is considerable variability in measures of association between mental health disorders and suicide and a growing debate over methodological approaches to this research. A high suicide incidence makes the US an outlier, and the decentralized nature of US administrative data poses a unique challenge to data linkage that could otherwise advance this research.

Summary

We offer methodological considerations for future research and discuss opportunities made possible by the recent expansion of the US National Violent Death Reporting System to a nationwide registry.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Naghavi M. Global Burden of Disease Self-Harm C. Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016. BMJ. 2019;364:l94.

    PubMed  Google Scholar 

  2. Hedegaard H, Curtin SC, Warner M. Suicide Mortality in the United States, 1999-2017. NCHS Data Brief. 2018(330):1–8.

  3. Suicide: National Institute of Mental Health; [Available from: https://www.nimh.nih.gov/health/statistics/suicide.shtml.

  4. 2012 National strategy for suicide prevention: goals and objectives for action: a report of the US Surgeon General and of the National Action Alliance for suicide prevention. Publications and Reports of the Surgeon General. Washington (DC)2012.

  5. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med. 2003;33(3):395–405.

    PubMed  CAS  Google Scholar 

  6. Hjelmeland H, Knizek BL. Suicide and mental disorders: a discourse of politics, power, and vested interests. Death Stud. 2017;41(8):481–92.

    PubMed  Google Scholar 

  7. Pridmore S. Mental disorder and suicide: a faulty connection. Aust N Z J Psychiatry. 2015;49(1):18–20.

    PubMed  Google Scholar 

  8. Pouliot L, De Leo D. Critical issues in psychological autopsy studies. Suicide Life Threat Behav. 2006;36(5):491–510.

    PubMed  Google Scholar 

  9. Haw C, Hawton K. Suicide is a complex behaviour in which mental disorder usually plays a central role. Aust N Z J Psychiatry. 2015;49(1):13–5.

    PubMed  Google Scholar 

  10. Hjelmeland H, Dieserud G, Dyregrov K, Knizek BL, Leenaars AA. Psychological autopsy studies as diagnostic tools: are they methodologically flawed? Death Stud. 2012;36(7):605–26.

    PubMed  PubMed Central  Google Scholar 

  11. Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry. 1997;170:205–28.

    CAS  PubMed  Google Scholar 

  12. Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry. 2014;13(2):153–60.

    PubMed  PubMed Central  Google Scholar 

  13. Too LS, Spittal MJ, Bugeja L, Reifels L, Butterworth P, Pirkis J. The association between mental disorders and suicide: a systematic review and meta-analysis of record linkage studies. J Affect Disord. 2019;259:302–13.

    PubMed  Google Scholar 

  14. Conner KR, Bridge JA, Davidson DJ, Pilcher C, Brent DA. Metaanalysis of mood and substance use disorders in proximal risk for suicide deaths. Suicide Life Threat Behav. 2019;49(1):278–92.

    PubMed  Google Scholar 

  15. Mortensen PB, Agerbo E, Erikson T, Qin P, Westergaard-Nielsen N. Psychiatric illness and risk factors for suicide in Denmark. Lancet. 2000;355(9197):9–12.

    PubMed  CAS  Google Scholar 

  16. Sonderman JS, Munro HM, Blot WJ, Tarone RE, McLaughlin JK. Suicides, homicides, accidents, and other external causes of death among blacks and whites in the Southern Community Cohort Study. PLoS One. 2014;9(12):e114852.

    PubMed  PubMed Central  Google Scholar 

  17. Boggs JM, Beck A, Hubley S, Peterson EL, Hu Y, Williams LK, et al. General medical, mental health, and demographic risk factors associated with suicide by firearm compared with other means. Psychiatr Serv. 2018;69(6):677–84.

    PubMed  PubMed Central  Google Scholar 

  18. Kapur N. Suicide in the mentally ill. Psychiatry. 2009;8(7):257–60.

    Google Scholar 

  19. Bertolote JM, Fleischmann A, De Leo D, Wasserman D. Psychiatric diagnoses and suicide: revisiting the evidence. Crisis. 2004;25(4):147–55.

    PubMed  Google Scholar 

  20. Rothman KJ, Greenland S, Lash TL. Modern Epidemiology. 2008.

  21. Howards PP, Schisterman EF, Poole C, Kaufman JS, Weinberg CR. “Toward a clearer definition of confounding” revisited with directed acyclic graphs. Am J Epidemiol. 2012;176(6):506–11.

    PubMed  PubMed Central  Google Scholar 

  22. Rothman KJ, Greenland S, Lash TL. 3 ed2008.

  23. Hamza CA, Stewart SL, Willoughby T. Examining the link between nonsuicidal self-injury and suicidal behavior: a review of the literature and an integrated model. Clin Psychol Rev. 2012;32(6):482–95.

    PubMed  Google Scholar 

  24. Hawton K, van Heeringen K. Suicide. Lancet. 2009;373(9672):1372–81.

    PubMed  Google Scholar 

  25. Westreich D. Berkson’s bias, selection bias, and missing data. Epidemiology. 2012;23(1):159–64.

    PubMed  PubMed Central  Google Scholar 

  26. Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med. 2014;160(2):101–10.

    PubMed  Google Scholar 

  27. Brent DA, Perper JA, Allman CJ, Moritz GM, Wartella ME, Zelenak JP. The presence and accessibility of firearms in the homes of adolescent suicides. A case-control study. JAMA. 1991;266(21):2989–95.

    PubMed  CAS  Google Scholar 

  28. Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, Roth C. Firearms and adolescent suicide. A community case-control study. Am J Dis Child. 1993;147(10):1066–71.

    PubMed  CAS  Google Scholar 

  29. Kellermann AL, Rivara FP, Somes G, Reay DT, Francisco J, Banton JG, et al. Suicide in the home in relation to gun ownership. N Engl J Med. 1992;327(7):467–72.

    PubMed  CAS  Google Scholar 

  30. Miller M, Azrael D, Hemenway D. Firearm availability and unintentional firearm deaths, suicide, and homicide among 5-14 year olds. J Trauma. 2002;52(2):267–74 discussion 74-5.

    PubMed  Google Scholar 

  31. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med. 2015;79:5–14.

    PubMed  PubMed Central  Google Scholar 

  32. Bohnert ASB, Ilgen MA. Understanding links among opioid use, overdose, and suicide. N Engl J Med. 2019;380(1):71–9.

    PubMed  Google Scholar 

  33. Huguet N, Kaplan MS, McFarland BH. Rates and correlates of undetermined deaths among African Americans: results from the National Violent Death Reporting System. Suicide Life Threat Behav. 2012;42(2):185–96.

    PubMed  Google Scholar 

  34. O'Neill S, Graham B, Ennis E. Prescribed pain and mental health medication prior to suicide: a population based case control study. J Affect Disord. 2019;246:195–200.

    PubMed  CAS  Google Scholar 

  35. Weiser M, Goldberg S, Werbeloff N, Fenchel D, Reichenberg A, Shelef L, et al. Risk of completed suicide in 89,049 young males assessed by a mental health professional. Eur Neuropsychopharmacol. 2016;26(2):341–9.

    PubMed  CAS  Google Scholar 

  36. de la Cruz LF, Rydell M, Runeson B, D'Onofrio B, Brander G, Rück C, et al. Suicide in obsessive–compulsive disorder: a population-based study of 36 788 Swedish patients. Mol Psychiatry. 2017;22(11):1626–32.

    Google Scholar 

  37. Qin P, Agerbo E, Westergard-Nielsen N, Eriksson T, Mortensen PB. Gender differences in risk factors for suicide in Denmark. Br J Psychiatry. 2000;177:546–50.

    CAS  PubMed  Google Scholar 

  38. Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981-1997. Am J Psychiatry. 2003;160(4):765–72.

    PubMed  Google Scholar 

  39. Madsen T, Agerbo E, Mortensen PB, Nordentoft M. Predictors of psychiatric inpatient suicide: a national prospective register-based study. J Clin Psychiatry. 2012;73(2):144–51.

    PubMed  Google Scholar 

  40. Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry. 2005;62(4):427–32.

    PubMed  Google Scholar 

  41. Nordentoft M, Mortensen PB, Pedersen CB. Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry. 2011;68(10):1058–64.

    PubMed  Google Scholar 

  42. Steele IH, Thrower N, Noroian P, Saleh FM. Understanding suicide across the lifespan: a United States perspective of suicide risk factors, assessment & management. J Forensic Sci. 2018;63(1):162–71.

    PubMed  Google Scholar 

  43. Sheftall AH, Asti L, Horowitz LM, Felts A, Fontanella CA, Campo JV, et al. Suicide in elementary school-aged children and early adolescents. Pediatrics. 2016;138(4).

  44. Roche AM, Giner L, Zalsman G. Suicide in early childhood: a brief review. Int J Adolesc Med Health. 2005;17(3):221–4.

    PubMed  Google Scholar 

  45. Fontanella CA, Warner LA, Steelesmith DL, Bridge JA, Brock GN, Campo JV. A national comparison of suicide among Medicaid and non-Medicaid youth. Am J Prev Med. 2019;56(3):447–51.

    PubMed  PubMed Central  Google Scholar 

  46. Turvey CL, Conwell Y, Jones MP, Phillips C, Simonsick E, Pearson JL, et al. Risk factors for late-life suicide: a prospective, community-based study. Am J Geriatr Psychiatry. 2002;10(4):398–406.

    PubMed  Google Scholar 

  47. Bartels SJ, Coakley E, Oxman TE, Constantino G, Oslin D, Chen H, et al. Suicidal and death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Am J Geriatr Psychiatry. 2002;10(4):417–27.

    PubMed  Google Scholar 

  48. Blaauw E, Kerkhof AJ, Hayes LM. Demographic, criminal, and psychiatric factors related to inmate suicide. Suicide Life Threat Behav. 2005;35(1):63–75.

    PubMed  Google Scholar 

  49. Bohnert KM, Ilgen MA, Louzon S, McCarthy JF, Katz IR. Substance use disorders and the risk of suicide mortality among men and women in the US Veterans Health Administration. Addiction. 2017;112(7):1193–201.

    PubMed  Google Scholar 

  50. Copeland LA, Finley EP, Bollinger MJ, Amuan ME, Pugh MJ. Comorbidity correlates of death among new veterans of Iraq and Afghanistan deployment. Med Care. 2016;54(12):1078–81.

    PubMed  Google Scholar 

  51. Zivin K, Yosef M, Miller EM, Valenstein M, Duffy S, Kales HC, et al. Associations between depression and all-cause and cause-specific risk of death: a retrospective cohort study in the Veterans Health Administration. J Psychosom Res. 2015;78(4):324–31.

    PubMed  Google Scholar 

  52. Conner KR, Bohnert AS, McCarthy JF, Valenstein M, Bossarte R, Ignacio R, et al. Mental disorder comorbidity and suicide among 2.96 million men receiving care in the Veterans Health Administration health system. J Abnorm Psychol. 2013;122(1):256–63.

    PubMed  Google Scholar 

  53. Conner KR, Bossarte RM, He H, Arora J, Lu N, Tu XM, et al. Posttraumatic stress disorder and suicide in 5.9 million individuals receiving care in the veterans health administration health system. J Affect Disord. 2014;166:1–5.

    PubMed  Google Scholar 

  54. Basham C, Denneson LM, Millet L, Shen X, Duckart J, Dobscha SK. Characteristics and VA health care utilization of U.S. Veterans who completed suicide in Oregon between 2000 and 2005. Suicide Life Threat Behav. 2011;41(3):287–96.

    PubMed  Google Scholar 

  55. Shepardson RL, Kosiba JD, Bernstein LI, Funderburk JS. Suicide risk among Veteran primary care patients with current anxiety symptoms. Fam Pract. 2019;36(1):91–5.

    PubMed  Google Scholar 

  56. Jones JE, Hermann BP, Barry JJ, Gilliam FG, Kanner AM, Meador KJ. Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy. Epilepsy Behav. 2003;4(Suppl 3):S31–8.

    PubMed  Google Scholar 

  57. Glowinski AL, Bucholz KK, Nelson EC, Fu Q, Madden PA, Reich W, et al. Suicide attempts in an adolescent female twin sample. J Am Acad Child Adolesc Psychiatry. 2001;40(11):1300–7.

    PubMed  PubMed Central  CAS  Google Scholar 

  58. Arias SA, Miller I, Camargo CA Jr, Sullivan AF, Goldstein AB, Allen MH, et al. Factors associated with suicide outcomes 12 months after screening positive for suicide risk in the emergency department. Psychiatr Serv. 2016;67(2):206–13.

    PubMed  Google Scholar 

  59. Olfson M, Wall M, Wang S, Crystal S, Bridge JA, Liu SM, et al. Suicide after deliberate self-harm in adolescents and young adults. Pediatrics. 2018;141(4).

  60. Olfson M, Wall M, Wang S, Crystal S, Liu SM, Gerhard T, et al. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016;73(11):1119–26.

    PubMed  PubMed Central  Google Scholar 

  61. Brown GK, Beck AT, Steer RA, Grisham JR. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol. 2000;68(3):371–7.

    PubMed  CAS  Google Scholar 

  62. Black DW, Winokur G, Warrack G. Suicide in schizophrenia: the Iowa Record Linkage Study. J Clin Psychiatry. 1985;46(11 Pt 2):14–7.

    PubMed  CAS  Google Scholar 

  63. Fontanella CA, Saman DM, Campo JV, Hiance-Steelesmith DL, Bridge JA, Sweeney HA, et al. Mapping suicide mortality in Ohio: a spatial epidemiological analysis of suicide clusters and area level correlates. Prev Med. 2018;106:177–84.

    PubMed  Google Scholar 

  64. Fontanella CA, Warner LA, Hiance-Steelesmith DL, Sweeney HA, Bridge JA, McKeon R, et al. Service use in the month and year prior to suicide among adults enrolled in Ohio Medicaid. Psychiatr Serv. 2017;68(7):674–80.

    PubMed  Google Scholar 

  65. Web-based Injury Statistics Query and Reporting System (WISQARS): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2005 [Available from: www.cdc.gov/injury/wisqars.

  66. Denneson LM, Basham C, Dickinson KC, Crutchfield MC, Millet L, Shen X, et al. Suicide risk assessment and content of VA health care contacts before suicide completion by veterans in Oregon. Psychiatr Serv. 2010;61(12):1192–7.

    PubMed  Google Scholar 

  67. Weis MA, Bradberry C, Carter LP, Ferguson J, Kozareva D. An exploration of human services system contacts prior to suicide in South Carolina: an expansion of the South Carolina Violent Death Reporting System. Inj Prev. 2006;12(Suppl 2):ii17–21.

    PubMed  PubMed Central  Google Scholar 

  68. Becker M, Brown L, Ochshorn E, Diamond R. Risk for suicide among medicaid beneficiaries. Suicide Life Threat Behav. 2009;39(2):172–81.

    PubMed  Google Scholar 

  69. Pan YJ, Stewart R, Chang CK. 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. 2013;48(1):71–9.

    PubMed  Google Scholar 

  70. Nock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA, Zaslavsky AM, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013;70(3):300–10.

    PubMed  Google Scholar 

  71. Nock MK, Kessler RC. Prevalence of and risk factors for suicide attempts versus suicide gestures: analysis of the National Comorbidity Survey. J Abnorm Psychol. 2006;115(3):616–23.

    PubMed  Google Scholar 

  72. Nock MK, Kazdin AE, Hiripi E, Kessler RC. Prevalence, subtypes, and correlates of DSM-IV conduct disorder in the National Comorbidity Survey Replication. Psychol Med. 2006;36(5):699–710.

    PubMed  PubMed Central  Google Scholar 

  73. Hoertel N, Franco S, Wall MM, Oquendo MA, Kerridge BT, Limosin F, et al. Mental disorders and risk of suicide attempt: a national prospective study. Mol Psychiatry. 2015;20(6):718–26.

    CAS  PubMed  Google Scholar 

  74. Rossom RC, Simon GE, Beck A, Ahmedani BK, Steinfeld B, Trangle M, et al. Facilitating action for suicide prevention by learning health care systems. Psychiatr Serv. 2016;67(8):830–2.

    PubMed  PubMed Central  Google Scholar 

  75. Ahmedani BK, Westphal J, Autio K, Elsiss F, Peterson EL, Beck A, et al. Variation in patterns of health care before suicide: a population case-control study. Prev Med. 2019;127:105796.

    PubMed  PubMed Central  Google Scholar 

  76. Blair JM, Fowler KA, Jack SP, Crosby AE. The National Violent Death Reporting System: overview and future directions. Inj Prev. 2016;22(Suppl 1):i6–11.

    PubMed  Google Scholar 

  77. Cerel J, Singleton MD, Brown MM, Brown SV, Bush HM, Brancado CJ. Emergency department visits prior to suicide and homicide: linking statewide surveillance systems. Crisis. 2016;37(1):5–12.

    PubMed  Google Scholar 

Download references

Funding

Financial support for this work was provided by the University of North Carolina at Chapel Hill Injury Prevention Research Center through an award (R49/CE0042479) from the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. In addition, this research was partially supported by a National Research Service Award Pre-Doctoral/Post-Doctoral Traineeship from the Agency for Healthcare Research and Quality sponsored by The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Grant No. T32-HS000032.

Author information

Authors and Affiliations

  1. Department of Epidemiology and Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Josie J. Caves Sivaraman & Rebecca B. Naumann

  2. Carrboro, USA

    Josie J. Caves Sivaraman

Authors
  1. Josie J. Caves Sivaraman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rebecca B. Naumann
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Injury Epidemiology

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Caves Sivaraman, J.J., Naumann, R.B. Estimating the Association Between Mental Health Disorders and Suicide: a Review of Common Sources of Bias and Challenges and Opportunities for US-Based Research. Curr Epidemiol Rep 7, 352–362 (2020). https://doi.org/10.1007/s40471-020-00250-5

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40471-020-00250-5

Keywords

Search

Navigation