Precipitating Circumstances of Suicide among Women of Reproductive Age in 16 U.S. States,2003–2007

Introduction

Suicide is the fourth leading cause of death for women between the ages of 15 and 44 years, exceeding the number of deaths due to homicide, HIV, cerebrovascular disease (CVD), and diabetes. ¹ Although women have lower rates of mortality from suicide than men, the fatality rates have not decreased in recent years. In 1999, the suicide rate among women aged 15–44 was 4.8 deaths per 100,000 population; in 2006, it was 5.0 deaths per 100,000 population. ¹ Furthermore, almost half of the suicide deaths in women occur during the reproductive age.

Very few studies have examined the determinants of suicide in young adult and middle-age women, and the vast majority of studies have been conducted outside the United States and focus on perinatal and postnatal suicide risk and protection and neurochemical and biological determinants of depression and suicidal behavior in reproductive-age women. ^{2 –6} Although depression and other mental health conditions are known risk factors for suicide, suicide is a complex behavior associated with various contributing factors. Adverse life events have been independently linked to suicide after controlling for mental health problems. ^{5 –9} There is a need to better understand the circumstances of suicide deaths in reproductive-age women to inform comprehensive prevention programs in this population. This study seeks to identify and describe the circumstances contributing to suicide deaths of women between the ages of 15 and 44 years in 16 U.S. states.

Materials and Methods

Data from the National Violent Death Reporting System (NVDRS) were analyzed to identify the proportion of suicide deaths (ICD 10 classification: X60–X84 and Y87.0) among women aged 15–44 years and to describe the leading circumstances associated with these deaths. NVDRS is an active state-based surveillance system collecting statewide data in 16 U.S. states. Data from 2003 were collected from Alaska, Massachusetts, Maryland, New Jersey, Oregon, South Carolina, and Virginia. In 2004 Colorado, Georgia, North Carolina, Oklahoma, Rhode Island, and Wisconsin were added, and in 2005, Kentucky, New Mexico, and Utah joined NVDRS.

States are required to collect data from multiple complementary data sources, including death certificates, coroner/medical examiner (CME) records, and law enforcement reports. In addition, states have the option of collecting data from other sources, such as hospital records, crime laboratory reports, Bureau of Alcohol, Tobacco, and Firearms and Explosives tracing, and in the case of child deaths, child fatality review records. Information from the data sources are either manually entered by trained abstractors or electronically imported into source-specific computerized data entry screens (e.g., death certificate data are entered into a death certificate screen, police report data are entered into a police report screen).

Suicide is defined by NVDRS as a death resulting from the use of force against oneself when the preponderance of evidence indicates that the use of force was intentional. This includes deaths of persons who intended to injure rather than kill themselves, deaths associated with a high risk for death without clear intent to inflict fatal injury (e.g., Russian roulette), and suicides involving only passive assistance to the decedent (e.g., supplying the means or information needed to complete the act. ¹⁰ Circumstances preceding death are coded from all available data sources when there is sufficient indication that the event contributed to the suicide. Circumstances are often reported by family members or friends during CME or law enforcement interviews, and as a result, more than one circumstance often are coded for each decedent.

Results

Nearly half (46%) of all suicide deaths among females occurred in women between 15 and 44 years of age. From 2003 to 2007, there were 4203 suicide deaths among women in this age group. Circumstances precipitating and contributing to the suicide event were known in 3784 cases. Among those, the most frequently cited circumstances were current mental health problem (60%), having ever been treated for a mental health problem (54%), and current depressed mood (44%). Of those decedents who had a mental health problem at the time of their death, 80% were currently receiving mental health treatment. Thirty-seven percent of decedents left a suicide note, and 37% were cited as having a history of suicide attempt(s). Thirty-one percent of decedents were noted to have a crisis in the 2 weeks before their death or having a crisis that was imminent within 2 weeks of the suicide. Thirty-six percent of decedents had a problem with a current or former intimate partner, such as a divorce, breakup, argument, jealousy, or discord.

Twenty-eight percent of decedents disclosed their intent to die by suicide to another person, with enough time for someone to have intervened, and 22% percent had a substance abuse problem other than alcohol. Alcohol dependence was indicated as a contributing factor in 16% of deaths. Physical health problem was cited in 14% of deaths, and 14% of decedents were cited to have a problem with a family member, friend, or associate (other than an intimate partner) that appears to have contributed to the suicide. Financial problems were cited in 9% of the suicides, a job problem was cited in 8%, death of a friend or family member was cited as a contributing factor in 6% of decedents, a recent criminal legal problem was cited in 6%, and other legal problems were cited in 5% of decedents. Two percent of decedents were cited as perpetrators or victims of intimate partner violence (IPV) within the past month, and 2% had a school problem.

Discussion

Mental health problems (namely, depression, anxiety disorder, and schizophrenia), alcohol abuse and dependence, and other substance abuse are risk factors for suicide. ¹¹ In the study cohort, having a current mental health problem was the most frequently cited contributing circumstance. Furthermore, a large percentage of those with a diagnosed mental health problem were currently receiving some form of mental health treatment, that is, either having a current prescription for a psychiatric medication or seeing a mental health professional within 2 months before their death or both. In addition to mental health problems and treatment, adverse life events were commonly reported for these decedents. Previous studies outside the United States have shown associations between adverse life events, such as interpersonal conflicts, personal loss, legal and work-related problems, and suicide. ^{5,9 –14} Intimate partner problems and other relationship problems were often present. It has been suggested that for many women, a sense of meaning and value is derived from a mutuality of care and responsibility in relationships. ¹¹ A woman's vulnerability to suicide, therefore, increases when her opportunity for growth within relationships is perceived as blocked or distorted. ¹¹ Another possible explanation is the lack of social connectedness and increased social isolation that can result when relational ties are severed. ¹⁵

Finally, family members or friends often noticed that the decedent was experiencing a depressed mood before her death, had disclosed her intent to die by suicide, or had a known previous suicide attempt. All these are indicators of suicide risk and common elements of suicide risk assessments in both clinical and community settings. MacDonald ¹⁶ examined suicide intervention trainees' awareness of warning signs of suicide and found that trainees, while acknowledging that warning signs for suicide are usually evident, also acknowledged that there might be a deficiency in family members' awareness of the signs of suicide. ¹⁶

This study is subject to a few limitations. First, precipitating circumstances are based on the content of law enforcement and CME reports, which are most often obtained from family and friends and may be subject to lack of relevant knowledge, response bias, and recall bias. Second, circumstance data were not available for 816 (15%) of decedents. In addition, data are from only 16 states and, therefore, may not be nationally representative. Nonetheless, the information gleaned from this descriptive study can provide useful information for further research and prevention.

Conclusions

Adverse life events can play a significant role in women's sense of well-being. To prevent suicide in women of reproductive age, multiple approaches should be taken, including but not limited to appropriate and effective mental health and substance abuse treatment; referrals to support systems for women experiencing adverse life events, such as relationship and job losses and physical illness; and building awareness of the problem and potential prevention strategies among those who provide services to this population. Furthermore, such strategies as building skills in recognizing the signs of suicide and understanding the options available to get help for someone at risk may be beneficial. Further research is needed to understand the elements of effective primary suicide prevention strategies for young adult and middle-age women that may lower exposure to or reduce the negative effects of adverse events in women of reproductive age.