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Factors associated with suicide/self-inflicted injuries among women aged 18–65 years in the United States: A 13-year retrospective analysis of the National Inpatient Sample database

  • Oluwasegun Akinyemi ,

    Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft

    ‡ OA and TO are co-first authors on this work.

    Affiliation Clive O Callender Department of Surgery, Howard University, Washington, D.C., United States of America

  • Temitope Ogundare ,

    Roles Conceptualization, Methodology, Resources, Supervision, Writing – original draft, Writing – review & editing

    ogundare@bu.edu

    ‡ OA and TO are co-first authors on this work.

    Affiliations Department of Psychiatry, Boston Medical Center, Boston, MA, United States of America, Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States of America

  • Adeolu Funsho Oladunjoye,

    Roles Methodology, Writing – original draft

    Affiliation Department of Obstetrics and Gynecology, Howard University, Washington, D.C., United States of America

  • Kindha Elleissy Nasef,

    Roles Writing – original draft

    Affiliation Department of Obstetrics and Gynecology, Howard University, Washington, D.C., United States of America

  • Christina Lipscombe,

    Roles Writing – original draft

    Affiliation Department of Obstetrics and Gynecology, Howard University, Washington, D.C., United States of America

  • John Akinshola Akinbote,

    Roles Writing – original draft

    Affiliation Department of Obstetrics and Gynecology, Howard University, Washington, D.C., United States of America

  • Maureen Bezold

    Roles Resources, Supervision, Writing – review & editing

    Affiliation Department of Health Sciences and Social Work, Western Illinois University, Macomb, Illinois, United States of America

Abstract

Background

Suicide is a significant cause of mortality in the United States, accounting for 14.5 deaths/100,000. Although there are data on gender disparity in suicide/self-inflicted injury rates in the United States, few studies have examined the factors associated with suicide/self-inflicted injury in females.

Objective

To determine factors associated with suicide/self-inflicted injuries among women aged 18–65 years in the United States.

Methods

Hospitalizations for suicide or self-inflicted injuries were identified using the National Inpatient Sample database from 2003–2015 using sample weights to generate national estimates. Independent predictors of suicide/self-inflicted injuries were identified using multivariable regression models. Interaction term analysis to identify the interaction between race/ethnicity and income were conducted.

Results

There were 1,031,693 adult women hospitalizations in the U.S. with a primary diagnosis of suicide/self-inflicted injury in the study period. The highest suicide/self-inflicted injury risk was among women aged 31-45years (OR = 1.23, CI = 1.19–1.27, p < 0.05). Blacks in the highest income strata had a 20% increase in the odds of suicide/self-inflicted injury compared to Whites in the lowest socioeconomic strata (OR = 1.20, CI = 1.05–1.37, p <0.05). Intimate partner violence increased suicide/self-inflicted injury risk 6-fold (OR = 5.77, CI = 5.01–6.65, p < 0.05).

Conclusion

Suicide risk is among women aged 31–45 years, higher earning Black women, intimate partner violence victims, uninsured, and current smokers. Interventions and policies that reduce smoking, prevents intimate partner violence, addresses racial discrimination and bias, and provides universal health coverage are needed to prevent excess mortality from suicide deaths.

Introduction

Suicide is a significant cause of mortality in the United States, accounting for 14.5 deaths per 100,000 population [1]. It is the second leading cause of death among individuals aged 10 and 34 years and the fourth leading cause of death for individuals aged 35–44 years in the United States [1]. Suicide attempts and self-inflicted injuries represent a major risk factor for completed suicides [2, 3]. In 2020, over 1.2 million people over the age of 18 reported a suicide attempt in the United States and hundreds of thousands more presenting to hospitals with self-harm injuries [4]. Suicide attempts can be defined as a non-fatal self-directed potentially injurious behavior with any intent to die as a result of the behavior; although self-inflicted injuries often include non-suicidal intent, it remains a powerful predictor of suicide [5].

Since 1999, there has been a significant increase in suicide/self-inflicted injuries rates with a disproportionate increase in females compared to males in the United States [6]. Women are three times more likely to attempt suicide, while men are more likely to complete suicide [7]. According to a study by Curtin and colleagues [8], from 2000 to 2014, the age-adjusted suicide rate among women in the United States increased from 4.0 to 5.8 per 100,000. In 2017, the suicide rate was the highest among non-Hispanic white females aged 45–64 years (12.8/100,00) and non-Hispanic American Indian/Alaskan Native females aged 25–44 years (20.7/100,00) in the United States [9]. Traditionally, suicide research has focused on the mortality of suicidal behaviors, which for the most parts favor males, who tend to die 2–4 times more than females; and have often viewed suicide attempts in females as manipulative or inept, overlooking the clear suicidal intent behind many of these suicide attempts [1012]. However, when mortality and morbidity of suicide are considered, females contribute far more to the burden [10]. Therefore, more research on suicidal behaviors in women is warranted.

Women’s greater vulnerability to suicidal behaviors have been explained in part by a greater vulnerability to psychopathology and psychosocial stressors [10]. Regarding psychopathology, previous studies have found associations between depressive disorders, anxiety disorders, borderline personality disorder, eating disorders, PTSD, antisocial personality disorders, history of violence, substance use disorder and suicide [1319]. Except for antisocial personality disorders, and substance use disorders, women report higher rates of these mental disorders [2022]. In addition, other psychosocial factors associated with suicide include: being a victim of domestic violence; physical, emotional, and sexual abuse; lower levels of education, being single, and financial instability [10, 13, 2325]. Women are more likely to be victims of domestic abuse, more likely to have experienced abuse (including physical, emotional, and sexual abuse), and more likely to have less education and lower socioeconomic status compared to males [10, 2628]. In addition, marriage, which is deemed protective for males, has not been shown to be protective for females [10, 29]. Domestic violence and family dysfunction have been shown to predict suicidality in females but not in males [24].

There is fewer research on suicide risk factors in the general population compared to high-risk populations, and even fewer specific to women [10, 23, 30, 31]. About 33% of suicide attempts occur in people who have no prior contact with mental health services, making identification of other ecological factors that increase risk of suicide imperative [10, 23]. This study aims to determine factors associated with suicide/self-inflicted injury among women aged 18–65 years in the United States over 12 years, from 2003–2015.

Methods

This is a retrospective analysis of all hospitalizations with the diagnosis of self-injury or attempted suicide/ in the National Inpatient Sample (NIS) database (2003–2015). The NIS is the largest all-payer inpatient database in the United States of America and comprises a 20% stratified random sample of all U.S. hospital discharges. Each of these discharges in the NIS is de-identified. Further details on the NIS design are available at. https://www.hcup-us.ahrq.gov/. The NIS was redesigned in 2012 to improve the prediction of national estimates. To account for this, we used trend weight (TRENDWT) for 2003–2011 and the regular discharge weight (DISCWT) for 2012–2015. From 150,819,065 hospitalizations in the NIS between 2003 and September 2015, we excluded all hospitalizations in the 4th quarter of 2015. This was done to remove the impact of transitioning from the International Classification of Diseases—ninth edition (ICD-9) to the International Classification of Diseases—tenth edition (ICD- 10) codes on October 1st, 2015. We also excluded hospitalizations with ages < 18 or > 65yrs and all hospitalizations with missing variables.

Patient’s age was stratified as 18-30yrs, 31-45yrs and 46-65yrs; race/ethnicity as White, Black, Hispanics, and Others; and insurance status as Private, Medicare, Medicaid, Uninsured, and Others. We utilized the NIS annual median income generated from the zip codes and subsequently grouped them into quartiles each year by Healthcare Cost and Utilization Project (HCUP). This was stratified into four quartiles, with Quartile 1 corresponding to the lowest median income quartile and quartile 4, the highest. Patients’ smoking habits were classified as non-smokers, previous smokers, and current smokers. Intimate partner violence was defined using the International Classification of Diseases, Clinical Modification (ICD-CM) codes and the ICD-CM Supplementary Classification of External Causes of Injury and Poisoning Codes (E-codes) 995.80–995.85, V7181 and E967.3).

Main outcome

The study’s primary outcome was the occurrence of suicide or self-inflicted injury. We identified the ICD-CM supplementary classification of external causes of injury and poisoning codes (E codes) for suicide or self-inflicted injury with E950-E959 diagnostic codes. These codes have a positive predictive value of 83–100% in the literature [32].

Statistical analysis

Descriptive statistics such as frequencies and percentages describe patients’ baseline characteristics and risk factor variables. Our bivariate analysis utilized Pearson chi-square tests to evaluate the relationship between studied variables and the occurrence of suicide or self-inflicted injury. We included statistically significant variables in the final multivariate regression analyses and estimated risk of suicide or self-inflicted injury as adjusted odds ratios and 95% confidence intervals. The multivariate regression analyses also explored the interaction between race/ethnicity and median income by creating an interaction term, race × median income. A 2-tailed p-value <0.05 was considered statistically significant. All statistical analyses were performed using the STATA 14 (Stata Corp College Station, TX).

Ethics

The study was conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Institutional Review Board approval was waived because the study was carried out on a national database that contained de-identified data and did not require informed consent or direct participation of patients.

Results

We identified 1,031,693 hospitalizations of adult women with a primary diagnosis of suicide or self-inflicted injury between January 2003 and September 2015. Table 1 shows the demographic distribution of these patients by race. Among the study population, more White women (31.1%) were aged 46–65 years, compared to Blacks (22.6%), Hispanics (22.2%), and women identifying as Others (23.3%). Regarding income, more Black women (49.1%) were in the lowest income quartile compared to Hispanics (40.3%), Others (28.9%), and White (24.8%). Women identifying as Hispanics (19.0%) had the highest uninsured rate compared to Blacks (17.2%), and Whites (16.2%). Smoking habits also differed by race, with 28.8% of Whites being current smokers compared to 22.7% of Blacks and 17.6% of Hispanics (p<0.001). There was no racial/ethnic difference in the experience of intimate partner violence.

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Table 1. Sociodemographic characteristics of women aged 18–65 years with suicide/self-inflicted injury between 2003–2015.

https://doi.org/10.1371/journal.pone.0287141.t001

In the bivariate analysis (Table 2), suicide/self-inflicted injury was more common among women aged 31–45 years (p<0.001), Whites (p<0.001), and those with private insurance (p<0.001). In the multivariate analysis (Table 3), the independent predictors of suicide/self-inflicted injury were: age, race, intimate partner violence, smoking, and insurance type.

thumbnail
Table 2. Correlates of suicide/self-inflicted injury among women aged 18–65 years between 2003–2015.

https://doi.org/10.1371/journal.pone.0287141.t002

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Table 3. Predictors of suicide/self-inflicted injury among women ages 18-65yrs (NIS 2003–2015).

https://doi.org/10.1371/journal.pone.0287141.t003

Compared to women aged 18–30 years, women aged 31–45 years had 1.23 times the odds of suicide/self-inflicted injury (OR = 1.23, p<0.0001, CI = 1.19–1.27) while women aged 46–65 years had 40% fewer odds of suicide/self-inflicted injury (OR = 0.61, p<0.001, CI = 0.59–0.63). Compared to Whites, Blacks (OR = 0.36, p<0.001, CI = 0.33–0.38) and Hispanics (OR = 0.34, p<0.001, CI = 0.30–0.39) had lower odds of suicide/self-inflicted injury. However, when we examined the interaction between race/ethnicity and income, Blacks in the highest income quartile had 20% increased odds of suicide/self-inflicted injury than Whites in the lowest income group (OR = 1.20, p = 0.01, CI = 1.05–1.37).

Other factors that predicted an increase in suicide/self-inflicted injury risk in the study were current smokers (OR = 2.33, p<0.001, CI = 2.24–2.43); intimate partner violence (OR = 5.77, p<0.001, CI = 5.01–6.65). With regards to insurance, participants with Medicare (OR = 1.94, p<0.001, CI = 1.88–2.01); Medicaid (OR = 1.51, p<0.001, CI = 1.45–1.57); and those who were uninsured (OR = 3.63, p<0.0001, CI = 3.46–3.80) had increased risk of self-inflicted injury compared to those with private insurance.

Discussion

The study aimed to determine the factors associated with suicide/self-inflicted injury among females aged 18–65 years in the United States over thirteen years. Significant findings from the study are the association between age, race/ethnicity, smoking status, intimate partner violence, insurance type, and suicide/self-inflicted injury.

In this study, women aged 31–45 years had the highest suicide/self-inflicted injury prevalence. A previous study [33] reported that women aged 35–64 years had the highest suicide/self-inflicted injury prevalence, with a peak between 45 and 65 years. In this study, however, women aged 46–65 years had about 40% reduced odds of suicide/self-inflicted injury compared to women aged 18–30 years, like findings from other studies [34, 35]. Other studies have suggested that women’s suicide rate peaks at 35–44 years [36]. Changes in societal roles and mental health challenges could account for the increased risk for suicide/self-inflicted injury in this age group [35]. Among females aged 15–24 years, suicide is the leading cause of death globally [37], and the third leading cause of death in the U.S.; among those aged 25–34 years, suicide is the second leading cause of death [33]. Similarly, in this study, women ages 18–30 years had the second-highest proportion of suicide/self-inflicted injury. This finding implies that although suicide/self-inflicted injury prevention should be a universal intervention, younger women (women aged less than 45 years) are at higher risk of suicide/self-inflicted injury and should have more indicated suicide prevention interventions.

Blacks and Hispanics had a lower risk of suicide/self-inflicted injury in this study compared to Whites, like previous report [8]. Between 1999 and 2017, there has been an increase in suicide/self-inflicted injury rates across all racial-ethnic groups in the U.S., with the most significant increase seen among American Indians or Alaska Native [8]. Compared to Whites, all other racial/ethnic groups had a lower risk of suicide/self-inflicted injury in this study. Although studies have suggested a higher likelihood of suicide/self-inflicted injury misclassification among racial/ethnic minority individuals, an upward correction reduces the gap in suicide/self-inflicted injury rates between Blacks and Whites [3840]. There is usually a more strongly negative connotation to suicide among racial/ethnic minorities. Therefore, the lower rates and risk of suicide may relate to the quality of ascertainment of death as suicide [41, 42]. It is highly like that an individual belonging to a racial/ethnic minority may be less likely to make the death easily recognized as suicide because of the impact of such determination on the family left behind. Other plausible explanations for less risk of suicide/self-inflicted injury among racial/ethnic minorities despite an increased risk include the influence of religion and a negative attitude towards suicide/self-inflicted injury [43, 44]. However, given that some studies have reported more suicide/self-inflicted injury attempts among African Americans than those in Whites [45], it is more likely that underreporting and misclassification of this condition account for the lower rates seen among African Americans and other racial/ethnic minorities [4648].

In a sub-analysis, we explored the association between race/ethnicity, median income, and suicide/self-inflicted injury. Blacks in the highest income strata have a 20% increase in suicide/self-inflicted injury compared to Whites in the lowest income strata suggesting that the risk of suicide/self-inflicted injury among African-Americans is related to socioeconomic status, with higher income increases the risk. This finding is interesting because income as a variable is not an independent predictor of suicide/self-inflicted injury risk in the final regression model. In a previous study [49], being unfairly fired from work, being discouraged from moving into a neighborhood, being discouraged from education, and police abuse were associated with increased risk of suicidal ideation and suicide attempts. It is possible that Black women in the highest income strata are more likely to experience these forms of discriminations as they are more likely to interact with institutions that predominantly endorse a White-centric monocultural framework [50]. In addition, Blacks in the highest income bracket are likely to move into a different neighborhood that may be predominantly White, less connected to their communities, and less religious. These factors may increase their vulnerability to suicidal behaviors. Previous studies have shown that among Blacks, community belonginess and religion are protective factors against suicide [51, 52]. The feeling of ostracization, and repeated exposure to painful and fear-inducing situations increase vulnerability to suicidal ideation and suicidal behavior [50, 53]. Also, it is possible that there are racial differences in the associations between socioeconomic status and suicide [54, 55].

In this study, intimate partner violence increased the risk of suicide/self-inflicted injury 5-folds; other studies have reported similar associations [5658]. In addition, studies have reported that posttraumatic stress disorder and depressive symptoms mediate the relationship between intimate partner violence and suicidal behavior [59]. Therefore, it is vital to assess for depressive symptoms and suicidal thoughts and behaviors among women who have experienced intimate partner violence.

Other risk factors for suicide/self-inflicted injury identified in this study include being a current smoker and uninsured or utilizing public insurance. A meta-analysis identified an increased risk of suicide, suicidal ideation among smokers compared to non-smokers [60]. Therefore, smoking cessation and smoking prevention programs directly impact suicide prevention and should be incorporated into suicide prevention programs. Having no insurance has also been shown to be a risk factor for suicide in another study [61].

Limitation

There are several limitations to this study which needs to be taken into account in interpreting the results. First, the cross-sectional nature of the study design does not allow for causal inference, and assumes that many of the risk factors associated with suicidal behaviors are static. Secondly, using the ICD E-codes although has 83–100% positive predictive value, but a sensitivity of 2–19% [32], therefore, there is high possibility that the number of cases identified vastly underestimates the true number of cases of suicide and self-inflicted injuries. In addition to undercoding, some cases of self-inflicted injuries are accidental and not suicidal; their inclusion in the analysis may have overstated the estimate of suicidal behaviors in this study. However, non-suicidal self-inflicted injuries cannot be said to be entirely non-suicidal: studies have found co-existing suicidal ideation and behaviors in people with accidental (non-suicidal) self-inflicted injuries, subsequent suicidal thoughts and behaviors are higher among these individual, and accidental self-inflicted injuries longitudinally predicts subsequent suicidal behaviors [6264]. Thirdly, there is a general under-utilization of code modifiers for intimate partner violence which may affect the estimate of the relationship between intimate partner violence and suicide found in this study [65, 66]. Fourthly, we did not include mental health disorders and substance use disorders in our analysis. Several studies have reported association between depression, anxiety, personality disorders, substance use disorders and suicide, with a much higher relative risk of suicide in women with substance use disorders [13, 6770]. However, majority of people who die by suicide have never seen a mental health provider or ever had a diagnosis of mental health disorder [71, 72]. While it is important to identify women with mental illness and substance use disorder as these individuals represent high risk individuals, suicide prevention efforts need to focus on identifying other universal risk factors for suicidal behaviors [23]. Early intervention to prevent suicide attempts and suicidal behaviors may warrant shifting the focus from individual factors to ecological factors such as social, economic, and cultural factors, including prevention of intimate partner violence [10, 73].

Conclusions

This study showed that among adult women in the United States, the highest risk of suicide/self-inflicted injury is among women aged 31–45 years, higher earning Black women, women who have experienced intimate partner violence, uninsured, and current smokers. In addition to universal suicide prevention strategies such as universal screening and suicide hotlines, interventions and policies that reduce smoking, prevents intimate partner violence, addresses racial discrimination and bias, and provides universal health coverage are needed to prevent excess mortality from suicide deaths.

Acknowledgments

We thank the Department of surgery outcome research center of the Howard University College of Medicine for providing access to the HCUP datasets utilized in this research.

References

  1. 1. Peterson C, Sussell A, Li J, Schumacher PK, Yeoman K, Stone DM. Suicide Rates by Industry and Occupation—National Violent Death Reporting System, 32 States, 2016. MMWR Morbidity and Mortality Weekly Report. 2020;69(3):57–62. pmid:31971929
  2. 2. Bostwick J. M., Pabbati C., Geske J. R., & McKean A. J. (2016). Suicide attempt as a risk factor for completed suicide: even more lethal than we knew. American journal of psychiatry, 173(11), 1094–1100. pmid:27523496
  3. 3. Fedyszyn I. E., Erlangsen A., Hjorthøj C., Madsen T., & Nordentoft M. (2016). Repeated suicide attempts and suicide among individuals with a first emergency department contact for attempted suicide: a prospective, nationwide, Danish register-based study. The Journal of clinical psychiatry, 77(6), 20457. pmid:27232826
  4. 4. Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/external.icon
  5. 5. Crosby AE, Ortega L, Melanson C. Self-directed Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2011.
  6. 6. Stone DM, Simon TR, Fowler KA, et al. Vital Signs: Trends in State Suicide Rates—United States, 1999–2016 and Circumstances Contributing to Suicide—27 States, 2015. MMWR Morbidity and Mortality Weekly Report. 2018;67(22):617–624. pmid:29879094
  7. 7. Tsirigotis K., Gruszczynski W., & Tsirigotis M. (2011). Gender differentiation in methods of suicide attempts. Medical science monitor: international medical journal of experimental and clinical research, 17(8), PH65. pmid:21804473
  8. 8. Curtin SC, Hedegaard H. Suicide Rates for Females and Males by Race and Ethnicity:United States, 1999–2017. NCHS Health E-Stat. 2019;2017(3):10–15.
  9. 9. Hedegaard M.D. H, Curtin M.A. SC, Warner Ph.D M. Suicide Mortality in the United States, 1999–2017. NCHS Data Brief. 2018;(330):1–8. https://www.cdc.gov/nchs/data/databriefs/db330-h.pdf. pmid:30500324
  10. 10. Vijayakumar L. Suicide in women. Indian Journal of Psychiatry. 2015;57(Suppl 2):233–238. pmid:26330640
  11. 11. Beautrais AL. Women and suicidal behavior. Crisis. 2006;27(4):153–156. pmid:17219746
  12. 12. Murphy GE. Why women are less likely than men to commit suicide. Comprehensive Psychiatry. 1998;39(4):165–175. pmid:9675500
  13. 13. Olfson M., Blanco C., Wall M., Liu S. M., Saha T. D., Pickering R. P., et al. (2017). National trends in suicide attempts among adults in the United States. JAMA psychiatry, 74(11), 1095–1103. pmid:28903161
  14. 14. Kessler R. C., Berglund P., Borges G., Nock M., & Wang P. S. (2005). Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. Jama, 293(20), 2487–2495. pmid:15914749
  15. 15. Hoertel N., Franco S., Wall M. M., Oquendo M. A., Kerridge B. T., Limosin F., et al. (2015). Mental disorders and risk of suicide attempt: a national prospective study. Molecular psychiatry, 20(6), 718–726. pmid:25980346
  16. 16. Franko D. L., & Keel P. K. (2006). Suicidality in eating disorders: occurrence, correlates, and clinical implications. Clinical psychology review, 26(6), 769–782. pmid:16875766
  17. 17. Cougle J. R., Resnick H., & Kilpatrick D. G. (2009). PTSD, depression, and their comorbidity in relation to suicidality: cross‐sectional and prospective analyses of a national probability sample of women. Depression and Anxiety, 26(12), 1151–1157. pmid:19842171
  18. 18. Bjerkeset O., Romundstad P., & Gunnell D. (2008). Gender differences in the association of mixed anxiety and depression with suicide. The British Journal of Psychiatry, 192(6), 474–475. pmid:18515904
  19. 19. de Raykeer R. P., Hoertel N., Blanco C., Olfson M., Wall M., Seigneurie A. S., et al. (2018). Effects of psychiatric disorders on suicide attempt: similarities and differences between older and younger adults in a national cohort study. The Journal of clinical psychiatry, 79(6), 653.
  20. 20. Ditlevsen D. N., & Elklit A. (2012). Gender, trauma type, and PTSD prevalence: a re-analysis of 18 nordic convenience samples. Annals of general psychiatry, 11(1), 1–6.
  21. 21. Seedat S., Scott K. M., Angermeyer M. C., Berglund P., Bromet E. J., Brugha T. S., et al. (2009). Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. Archives of general psychiatry, 66(7), 785–795. pmid:19581570
  22. 22. Boyd A., Van de Velde S., Vilagut G., De Graaf R., Florescu S., Alonso J., et al. (2015). Gender differences in mental disorders and suicidality in Europe: results from a large cross-sectional population-based study. Journal of affective disorders, 173, 245–254. pmid:25462424
  23. 23. de la Garza Á. G., Blanco C., Olfson M., & Wall M. M. (2021). Identification of suicide attempt risk factors in a national US survey using machine learning. JAMA psychiatry, 78(4), 398–406. pmid:33404590
  24. 24. Chau K., Kabuth B., & Chau N. (2014). Gender and family disparities in suicide attempt and role of socioeconomic, school, and health-related difficulties in early adolescence. BioMed research international, 2014. pmid:25136577
  25. 25. Maselko J., & Patel V. (2008). Why women attempt suicide: the role of mental illness and social disadvantage in a community cohort study in India. Journal of epidemiology and community health, 62(9), 817–822. pmid:18701733
  26. 26. Fins A. (2020). National snapshot: Poverty among women & families, 2020. National Women’s Law Center. Retrieved August 2022. PovertySnapshot2020.pdf (nwlc.org)
  27. 27. Ahmadabadi Z., Najman J. M., Williams G. M., Clavarino A. M., & d’Abbs P. (2021). Gender Differences in Intimate Partner Violence in Current and Prior Relationships. Journal of interpersonal violence, 36(1–2), 915–937. pmid:29294920
  28. 28. Wodon Q., & De La Briere B. (2018). Unrealized potential: the high cost of gender inequality in earnings.
  29. 29. Vijayakumar L., John S., Pirkis J., & Whiteford H. (2005). Suicide in developing countries (2): risk factors. Crisis, 26(3), 112–119. pmid:16276753
  30. 30. Kessler R. C. (2019). Clinical epidemiological research on suicide-related behaviors—where we are and where we need to go. JAMA psychiatry, 76(8), 777–778. pmid:31188420
  31. 31. Gordon J. A., Avenevoli S., & Pearson J. L. (2020). Suicide prevention research priorities in health care. JAMA psychiatry, 77(9), 885–886. pmid:32432690
  32. 32. Swain RS, Taylor LG, Braver ER, Liu W, Pinheiro SP, Mosholder AD. A systematic review of validated suicide outcome classification in observational studies. International Journal of Epidemiology. 2019;48(5):1636–1649. pmid:30907424
  33. 33. Karch DL, Logan J, McDaniel D, Parks S, Patel N. Surveillance for violent deaths—national violent death reporting system, 16 states, 2009. Morbidity and Mortality Weekly Report: Surveillance Summaries. 2012;61(6):1–43. pmid:22971797
  34. 34. Canetto SS, Sakinofsky I. The gender paradox in suicide. Suicide and LifeThreatening Behavior. 1998;28(1):1–23. pmid:9560163
  35. 35. Mendez-Bustos P, Lopez-Castroman J, Baca-García E, Ceverino A. Life cycle and suicidal behavior among women. The Scientific World Journal. 2013;2013. pmid:23533350
  36. 36. White A, Holmes M. Patterns of mortality across 44 countries among men and women aged 15–44 years. Journal of Men’s Health and Gender. 2006;3(2):139–151.
  37. 37. Patton GC, Coffey C, Sawyer SM, et al. Global patterns of mortality in young people: a systematic analysis of population health data. The Lancet. 2009;374(9693):881–892. pmid:19748397
  38. 38. Rockett IRH, Wang S, Stack S, et al. Race/ethnicity and potential suicide misclassification: Window on a minority suicide paradox? BMC Psychiatry.2010;10(1):35. pmid:20482844
  39. 39. Huguet N, Kaplan MS, McFarland BH. Rates and correlates of undetermined deaths among African Americans: Results from the national violent death reporting system. Suicide and Life-Threatening Behavior. 2012;42(2):185–196. pmid:22486604
  40. 40. Mohler B, Earls F. Trends in adolescent suicide: misclassification bias? American Journal of Public Health. 2001;91(1):150. pmid:11189813
  41. 41. Walker RL, Lester D, Joe S. Lay theories of suicide: An examination of culturally relevant suicide beliefs and attributions among African Americans and European Americans. Journal of Black Psychology. 2006;32(3):320–334. pmid:19672479
  42. 42. Givens JL, Katz IR, Bellamy S, Holmes WC. Stigma and the acceptability of depression treatments among African Americans and whites. Journal of General Internal Medicine. 2007;22(9):1292–1297. pmid:17610120
  43. 43. Stack S. The Relationship between Culture and Suicide: AN Analysis of African Americans. Transcultural Psychiatry. 1998;35(2):253–269.
  44. 44. Thompson VLS, Bazile A, Akbar M. African Americans’ Perceptions of Psychotherapy and Psychotherapists. Professional Psychology: Research and Practice. 2004;35(1):19–26.
  45. 45. Grunbaum JA, Kann L, Kinchen S, et al. Youth risk behavior surveillance—United States, 2003. Morbidity and mortality weekly report Surveillance summaries (Washington, DC: 2002). 2004;53(2):1–96.
  46. 46. Rockett I. R. H. (2017). The Gender Suicide Gap and Differential Misclassification: A Research Autobiography. International Review of Modern Sociology, 43(1), 5–32. http://www.jstor.org/stable/44510052
  47. 47. Ali B., Rockett I., Miller T. R., & Leonardo J. B. (2022). Racial/Ethnic Differences in Preceding Circumstances of Suicide and Potential Suicide Misclassification Among US Adolescents. Journal of racial and ethnic health disparities, 9(1), 296–304. pmid:33415703
  48. 48. Rahman N., Mozer R., McHugh R. K., Rockett I., Chow C. M., & Vaughan G. (2022). Using natural language processing to improve suicide classification requires consideration of race. Suicide & life-threatening behavior, 52(4), 782–791. pmid:35384040
  49. 49. Oh H., Waldman K., Koyanagi A., Anderson R., & DeVylder J. (2020). Major discriminatory events and suicidal thoughts and behaviors amongst Black Americans: Findings from the National Survey of American Life. Journal of affective disorders, 263, 47–53. pmid:31818795
  50. 50. Klibert J., Barefoot K. N., Langhinrichsen-Rohling J., Warren J. C., & Smalley K. B. (2015). Cross-cultural and cognitive-affective models of suicide risk. Journal of Black Psychology, 41(3), 272–295.
  51. 51. Fanegan B., Berry A. M., Combs J., Osborn A., Decker R., Hemphill R., et al. (2022). Systematic Review of Religiosity’s Relationship with Suicidality, Suicide Related Stigma, and Formal Mental Health Service Utilization among Black Americans. The Psychiatric quarterly, 10.1007/s11126-022-09985-4. Advance online publication. pmid:35699905
  52. 52. Dorsey Holliman B. A., Monteith L. L., Spitzer E. G., & Brenner L. A. (2018). Resilience, cultural beliefs, and practices that mitigate suicide risk among African American women veterans. Sage open, 8(1), 2158244017753506.
  53. 53. Van Orden K. A., Witte T. K., Cukrowicz K. C., Braithwaite S. R., Selby E. A., & Joiner T. E. Jr (2010). The interpersonal theory of suicide. Psychological review, 117(2), 575–600. pmid:20438238
  54. 54. Lester D. (1991). Mortality from suicide and homicide for African Americans in the USA: A regional analysis. OMEGA-Journal of Death and Dying, 22(3), 219–226.
  55. 55. Purselle D. C., Heninger M., Hanzlick R., & Garlow S. J. (2009). Differential association of socioeconomic status in ethnic and age-defined suicides. Psychiatry research, 167(3), 258–265. pmid:19395050
  56. 56. Brown S, Seals J. Intimate partner problems and suicide: are we missing the violence? Journal of Injury and Violence Research. 2019;11(1):53–64. pmid:30636256
  57. 57. Iovine-Wong PE, Nichols-Hadeed C, Thompson Stone J, et al. Intimate partner violence, suicide, and their overlapping risk in women veterans: A review of the literature. Military Medicine. 2019;184(5–6):e201–e210. pmid:30690471
  58. 58. Tabb KM, Huang H, Valdovinos M, et al. Intimate Partner Violence Is Associated with Suicidality among Low-Income Postpartum Women. Journal of Women’s Health. 2018;27(2):171–178. pmid:28537476
  59. 59. Weaver TL, Allen JA, Hopper E, et al. Mediators of suicidal ideation within a sheltered sample of raped and battered women. Health Care for Women International. 2007;28(5):478–489. pmid:17469001
  60. 60. Poorolajal J, Darvishi N. Smoking and suicide: a meta-analysis. PloS one. 2016;11(7):e0156348. pmid:27391330
  61. 61. Xu H, Zhang W, Wang X, et al. Prevalence and influence factors of suicidal ideation among females and males in Northwestern urban China: A population-based epidemiological study. BMC Public Health. 2015;15(1):1–13.
  62. 62. Hamza C. A., Stewart S. L., & Willoughby T. (2012). Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model. Clinical psychology review, 32(6), 482–495. pmid:22717336
  63. 63. Ribeiro J. D., Franklin J. C., Fox K. R., Bentley K. H., Kleiman E. M., Chang B. P., et al. (2016). Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies. Psychological medicine, 46(2), 225–236. pmid:26370729
  64. 64. Fox K. R., Millner A. J., & Franklin J. C. (2016). Classifying nonsuicidal overdoses: Nonsuicidal self-injury, suicide attempts, or neither?. Psychiatry research, 244, 235–242. pmid:27498057
  65. 65. Rudman W. J., & Davey D. (2000). Identifying domestic violence within inpatient hospital admissions using medical records. Women & Health, 30(4), 1–13. pmid:10983606
  66. 66. Btoush R., Campbell J. C., & Gebbie K. M. (2009). Care provided in visits coded for intimate partner violence in a national survey of emergency departments. Women’s health issues, 19(4), 253–262. pmid:19589474
  67. 67. Pompili M., Girardi P., Ruberto A., & Tatarelli R. (2005). Suicide in borderline personality disorder: a meta-analysis. Nordic journal of psychiatry, 59(5), 319–324. pmid:16757458
  68. 68. Verona E., Sachs-Ericsson N., & Joiner T. E. Jr(2004). Suicide attempts associated with externalizing psychopathology in an epidemiological sample. The American journal of psychiatry, 161(3), 444–451. pmid:14992969
  69. 69. Lynch F. L., Peterson E. L., Lu C. Y., Hu Y., Rossom R. C., Waitzfelder B. E., et al. (2020). Substance use disorders and risk of suicide in a general US population: a case control study. Addiction science & clinical practice, 15(1), 14. https://doi.org/10.1186/s13722-020-0181-1
  70. 70. Esang M., & Ahmed S. (2018). A closer look at substance use and suicide. American Journal of Psychiatry Residents’ Journal.
  71. 71. Tang S., Reily N. M., Arena A. F., Batterham P. J., Calear A. L., Carter G. L., et al. (2022). People Who Die by Suicide Without Receiving Mental Health Services: A Systematic Review. Frontiers in public health, 9, 736948. pmid:35118036
  72. 72. Johnston A. K., Pirkis J. E., & Burgess P. M. (2009). Suicidal thoughts and behaviours among Australian adults: findings from the 2007 National Survey of Mental Health and Wellbeing. The Australian and New Zealand journal of psychiatry, 43(7), 635–643. pmid:19530020
  73. 73. Bebbington P. E., Cooper C., Minot S., Brugha T. S., Jenkins R., Meltzer H., et al. (2009). Suicide attempts, gender, and sexual abuse: data from the 2000 British Psychiatric Morbidity Survey. The American journal of psychiatry, 166(10), 1135–1140. pmid:19723788