Characteristics of and Circumstances Associated With Female Intimate Partner Problem-Included Suicides: Analysis of Data From the National Violent Death Reporting System (2003

Abstract

Intimate partner problems (IPP)—which include divorce, breakups, arguments, jealousy, conflict, discord, and violence—have been robust precipitating factors associated with an increased risk for suicidal thoughts and behaviors. Although research on suicide related to IPP is growing, efforts to explore the circumstances surrounding suicidality among female victims struggling with IPP remain insufficient. To address this gap, this exploratory study sought to understand the circumstances surrounding female IPP-related suicide in the United States. We conducted a secondary analysis of data from the U.S. National Violent Death Reporting System (NVDRS, 2003–2019) which includes 43 states, the District of Columbia, and Puerto Rico. Of the final analytical sample of 58,545 female suicide cases in the United States, we delineated IPP-included suicide cases (13,496, 23.1%) and non-IPP-included suicide cases (45,049, 76.9%). Two-sided Pearson chi-square tests and standardized difference (SD) tests identified significant differences in the surrounding circumstances between IPP-included suicide and non-IPP-included suicide. IPP-included female suicide was more common among younger women, those involved in an intimate relationship, and women who were pregnant or postpartum (p < .001; SD > .10). IPP-included suicide victims were more likely to have experienced depression, substance abuse, and previous interpersonal trauma than non-IPP-included suicide victims (p < .001; SD > .10). Compared to non-IPP-included suicide, IPP-included suicide was more likely to occur at the victim’s house or apartment during evening and nighttime by firearm or hanging (p < .001; SD > .10). Our findings also showed that IPP-included suicide victims had previous suicidal thoughts and were more likely to have disclosed their suicidal ideation with others before committing suicide than non-IPP-included suicide victims (p < .001; SD > .10). Findings identified unique circumstances and characteristics possibly associated with IPP-included female suicide. Our understanding of suicide may be enhanced by exploring the causal pathway behind these relationships.

Keywords

intimate partner violence intimate partner problems suicide NVDRS

Among 10- to 64-year-olds in the United States, suicide ranks as the leading cause of violent death, followed by homicide (Ertl et al., 2019). Intimate partner problems (IPP)—including divorce, breakups, arguments, jealousy, conflict, discord, and violence—are robust precipitating factors associated with an increased risk for suicidal thoughts and behaviors (Comiford et al., 2016; Kazan et al., 2016; Stack & Scourfield, 2015). Based on the National Violence Death Reporting System (NVDRS), about 25% of suicides in the United States are related to issues involving the suicide decedent’s intimate partner (Ertl et al., 2019). Although suicide triggered by IPP is prevalent among both men and women, research has found that there may be significant differences in suicide risk factors, methods, and outcomes between men and women (Freeman et al., 2017; Vijayakumar, 2015). Notably, given that IPP can include power imbalances between couples, women might face unique risk factors for and circumstances surrounding their suicidal thoughts and behaviors (Vijayakumar, 2015). However, little is known about the unique circumstances related to suicides involving IPP among U.S. women. Accordingly, this study aimed to explore the circumstances surrounding IPP-related suicide among a large-scale sample of women in the United States.

Suicide Theories and Female Suicide Related to IPP

Theories on suicide can be applied to better understand the risk of suicide among women struggling with IPP. The interpersonal theory of suicide (Joiner et al., 2009) suggests that thwarted belongingness and perceived burdensomeness might lead to suicidal ideation (Van Orden et al., 2010). IPP—which can include a relational crisis (e.g., divorce and separation) and/or violence—can impair women’s emotional, social, and financial status, thereby increasing isolation, loneliness, and hopelessness (Wolford-Clevenger et al., 2019). Such psychosocial vulnerability might lead to thwarted belongingness and perceived burdensomeness, and in turn, to suicidal thoughts. Recent suicide theories, including the interpersonal theory of suicide and the three-step model, also emphasize that suicidal ideation does not result in death by suicide unless the individual has acquired suicidal capability, such as fearlessness about death and access to suicide methods (Joiner et al., 2009; Klonsky et al., 2016; Van Orden et al., 2010). Pain inflicted by IPP may lead to a decreased fear of death, which ultimately moves women to use lethal methods to attempt and carry out a suicide (Wolford-Clevenger et al., 2019).

Risk Factors and Circumstances of Female Suicide Related to IPP

Although little research has examined the risk circumstances surrounding IPP-included suicide more broadly, some research has focused on understanding suicide among women experiencing intimate partner violence more specifically. Existing research has identified that mental health problems such as depression, posttraumatic stress disorder, substance abuse, and hopelessness might be robust mechanisms leading to abused women’s suicidality (Cavanaugh et al., 2011, 2015;Devries et al., 2013; Kafka et al., 2022; Wolford-Clevenger & Smith, 2015; Wolford-Clevenger et al., 2019). Research has also found that women’s unique individual, relational, and sociocultural characteristics and circumstances can intensify their mental health problems and suicidality. For example, socioeconomic vulnerability, a previous history of trauma, financial problems, stressful life events, chronic or disabling illness, low social support, a lack of resources, and cultural barriers have been identified as risk factors that intensify abused women’s suicidality (Guillén et al., 2015; McLaughlin et al., 2012; Munro & Aitken, 2020; Tabb et al., 2018). Notably, although a meta-analysis found that there is no one risk factor category more strongly associated with suicide than others (Franklin et al., 2017), cumulative risk factors likely have greater impacts, leading to a greatly increased risk of suicidality. For example, Thompson and colleagues found that abused women with four to five risk factors were 107 times more likely to attempt suicide than those women with no risk factors (Thompson et al., 2002).

Beyond psychosocial risk factors on suicidality, suicide research has examined the situational characteristics surrounding incidents of suicide, such as methods and time. Given that suicide theory has emphasized suicide capability as a critical factor leading to suicide completion (Joiner et al., 2009; Klonsky et al., 2016), an understanding of suicide methods, place, and time could provide critical information allowing the identification and prevention of future suicides. Research has identified that the choice of suicide method differs based on suicide victims’ characteristics, accessibility of suicide methods, and cultural acceptability (Florentine & Crane, 2010). For example, female victims tended to use methods with lower lethality (e.g., poisoning) whereas male victims tended to use highly lethal methods (e.g., firearms) (Callanan & Davis, 2012; Fisher et al., 2015). Additionally, some research has identified peak periods for suicide deaths. For example, generally, morning to early afternoon hours have been found as significant peak time for suicide risk (Gallerani et al., 1996; Tian et al., 2019). Although such situational circumstances surrounding suicide provide significant evidence for prevention points, there is a lack of evidence exploring suicide situations that specifically includes IPP.

The moment of disclosure of suicidal ideation is another critical point at which to intervene and provide necessary help and resources (Calear & Batterham, 2019). Prior suicide research has focused on examining factors associated with suicidal ideation disclosure. Although study findings have been mixed, previous studies have generally shown that older males as well as individuals with lower education levels and poor social connectedness are less likely to disclose suicidal ideation (Husky et al., 2016; Mérelle et al., 2018). On the other hand, individuals with poor health, previous suicidal ideation, and severe psychological distress are more likely to share their suicidal ideation with others (Calear & Batterham, 2019; Husky et al., 2016; Mérelle et al., 2018). Depending on the reaction received, disclosers may either feel supported or more isolated and rejected, which can potentially reinforce suicidal ideation (Love et al., 2021). The patterns of suicidal ideation disclosure have never been specifically examined in a population of women dealing with IPP.

Current Study

Understanding the risk factors associated with suicidal thoughts and behaviors is a key component of any effective suicide prevention strategy (Stone et al., 2017). Although research on IPP-included suicide is growing, efforts to explore the risk circumstances surrounding suicidality among female victims struggling with IPP remain insufficient. To date, existing studies have largely tried to understand IPP—and more specifically intimate partner violence-related suicide—using small-scale, community samples of people with a history of suicide attempts or suicidal ideation (Devries et al., 2013; Thompson et al., 2002). Only a few studies have tried to understand IPP-included suicide using population datasets like the NVDRS. However, these studies have tended to either focus only on one particular state (Brown & Seals, 2019; Kafka et al., 2022), or have only used past-year datasets (Adu et al., 2019; Gold et al., 2012). Additionally, many of these studies explored IPP-included suicide using gender-aggregated analyses that did not focus specifically on female suicide victims (Kafka et al., 2021).

Building on these efforts, this exploratory study sought to understand the circumstances surrounding female IPP-included suicide through secondary data analysis of the NVDRS, which is the most comprehensive dataset on suicide mortality. To examine unique circumstances related to female IPP-included suicide, we compared female IPP-included suicide with female non-IPP-included suicide. The study was guided by the following three research questions:

Research Question 1: What are the life circumstances surrounding completed IPP-included suicides (e.g., mental health problems, substance use problems, and stressful life events)? Are there significant differences in the circumstances surrounding IPP-included suicides and non-IPP-included suicides?

Research Question 2: What are the incident characteristics (e.g., suicide methods, place, and time) of IPP-included suicides? Are there significant differences in the incident characteristics of IPP-included and non-IPP-included suicides?

Research Question 3: What are suicide victims’ disclosure patterns? Are there significant differences between IPP-included and non-IPP-included suicide victims?

Methods

Data Sources

We used secondary data from the NVDRS, 2013 to 2019, which is a state-based reporting system funded and maintained by the U.S. Centers for Disease Control and Prevention (CDC). The NVDRS records all violent deaths including homicides, suicides, and legal intervention deaths and their relevant circumstances. This database began collecting data on every violent death from six states in 2002. Then, in 2018, the NVDRS was expanded to include data from all 50 states (Wilson, 2022). For data abstraction, trained data coders in each state reviewed law enforcement reports, toxicology reports, medical examiner reports, and death certificates, then combined these multiple sources into the NVDRS online data entry system (Rizo et al., 2019). The NVDRS captures victim characteristics (e.g., gender, age, and race), incident characteristics (e.g., location and death methods), and the diverse circumstances precipitating violence.

Case Selection

Using data from 2003 to 2019, we selected the 267,804 records for which the data coders determined that the manner of death was suicide. Thus, the data represented aggregated yearly data and observations were analyzed without regard for the year in which the suicide occurred. Given the focus on females, we then removed all cases involving males (n = 208,589, 77.9%), cases in which the sex of the victim was unknown (n = 5), and missing cases regarding the sex of the victim (n = 2). Of the remaining 59,208 cases, we further excluded those involving single/multiple homicides followed by suicides and multiple suicides (n = 665, 1.1%) to avoid confounding with our core focus on suicides

Of the final analytical sample of 58,543 female suicide cases, we identified mutually exclusive sub-groups of (a) “IPP-included” female suicide cases where IPP was potentially contributive to the suicide (n = 13,496, 23.1%) and (b) “non-IPP-included” female suicide cases where there was no indication of any IPP (n = 45,047, 76.9%). NVDRS defines IPP as “problems with a current or former intimate partner, such as a divorce, breakup, argument, jealousy, conflict, or discord, and this appears to have contributed to the death” (CDC, 2021, p. 90). Although the IPP definition does not clearly indicate intimate partner violence as one type of IPP, previous research providing narrative analysis on NVDRS IPP cases reported that about 30% to 40% of IPP cases involve intimate partner violence (e.g., Brown & Seals, 2019; Kafka et al., 2021). Accordingly, we consider IPP to broadly include relational problems that encompass relational conflict, crisis, and intimate partner violence. Based on information included in the law enforcement reports, toxicology reports, medical examiner reports, and death certificates, the data coders coded as “Yes” in the IPP variable if IPP “appears to have contributed to the death” (CDC, 2021, p. 91).

Measures

Sociodemographic variables included age, race/ethnicity, educational level, marital status, foreign-born status, pregnancy status, and homeless status. These variables were selected based on our past work in related analyses, as well as that of other researchers, as being potentially informative of female-included violence victimization (e.g., Kim & Macy, 2021). In the analysis, race was combined into two categories, White and non-White, because preliminary analysis showed that there were no significant differences across six racial and ethnic groups (e.g., White non-Hispanic, Black non-Hispanic, Hispanic, American Indian/Alaskan Native, Asian non-Hispanic). Regarding foreign-born status, foreign born included those who were not U.S. citizens by birth. The U.S.-born included anyone born in the United States, Puerto Rico, or U.S. Island areas (American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, or the U.S. Virgin Islands).

Intimate partner problems (yes = 1; no/unknown/not applicable = 0) are coded as yes if suicide victims had experienced problems with a current or former intimate partner which appeared to have contributed to the suicide. Based on the NVDRS’s coding manual, state abstractors apply this code when data sources suggest that the suicide may have been related to relational problems with a current or former intimate partner, including divorce, breakups, arguments, jealousy, conflict, or discord, or in some cases, intimate partner violence (e.g., Brown & Seals, 2019; Kafka et al., 2021).

Life circumstances (yes = 1; no/unknown/not applicable = 0) include 15 variables under the three categories of mental health and substance abuse, life stressors, and trauma experiences. Mental health and substance problems included mental illness (i.e., any disorder or syndrome listed in the DSM-IV, except alcohol and other substance use disorders); recent depressed mood (i.e., depressed mood at the time of injury, without the need for a clinical diagnosis); current mental health treatment (e.g., had a current prescription for a psychiatric medication or had visited a mental health professional within the past 2 months, including a psychiatrist, psychologist, medical doctor, therapist, and/or religious counselors); previous mental health treatment; problems with alcohol (i.e., perceived by self or others to be addicted to alcohol); and other substance abuse (e.g., using illicit drugs, such as heroin or cocaine). Life stressors included physical health problem (e.g., terminal illness, debilitating condition, chronic pain); job-related issues (e.g., problem at work, joblessness); financial problems (e.g., bankruptcy, overwhelming debts, or foreclosure of a home or business); and relationship problems with family and friends or non-family members. Trauma experiences include childhood trauma history (e.g., history of abuse or neglect as a child), perpetration of violence (i.e., committed some kind of violence such as robbing a stranger or assaulting someone in a bar in the past month), and victimization of violence (i.e., experienced some kind of violence such as being the victim of a robbery or an assault in a bar in the past month).

Incident characteristics (yes = 1; no/unknown/not applicable = 0) of suicide included situational contexts such as the location, methods used, timing, and alcohol use. Suicide locations were identified as the types of location in which injury occurred. We categorized the responses into seven total response categories (e.g., house, outdoor, residential facility, motor vehicle, street). Suicide means captured the major methods of committing suicide or the weapons used to commit suicide. We reviewed a list of all means used and categorized the responses into a total of eight response categories (e.g., poisoning, firearm, hanging, fall, sharp instrument). Suicide times were identified by the time zone when suicide occurred. We recoded the 24 time zones into four total categories: morning (6 am–11:59 am), afternoon (12 pm–5:59 pm), evening (6 pm–11:59 pm), and night (12 pm–5:59 am). Alcohol use was coded as “Yes” if it was suspected that the suicide victim had consumed alcohol in the hours leading up to their suicide.

History of suicidal ideation/suicide attempts/self-harm (yes = 1; no/unknown/not applicable = 0) refers to the suicide victims’ recent (within the past month) or prior history of suicidal thoughts or plans (verbal, handwritten, or electronic) or attempting suicide or engaging in deliberate self-harm or self-mutilating behaviors without the intent to die by suicide.

The disclosure of suicidal ideation (yes = 1; no/unknown/not applicable = 0) is coded as present if the suicide victim was known to have disclosed their thoughts and/or plans around suicide to others including their family, friends, partners, and/or healthcare providers in the month prior to their death.

Analysis

Prior to analysis, researchers thoroughly checked data for missingness and out-of-range errors/typos. In the process of creating an analytical sample for female suicide cases, we detected missing data regarding sex (n = 7), which were removed, resulting in a finalized analytical sample of n = 58,543 as described above. During the analysis of descriptive statistics, we excluded cases where sociodemographic information was unknown, non-applicable, or missing. Consequently, the response frequencies ranged from 18,857 to 58,543 across demographic characteristics (see Tables 1 and 3). It is worth noting that, besides demographic factors, most variables in NVDRS offered response categories of either “yes” or “no/unknown/non-applicable,” and they did not have any missing data since they already included missing cases in the response category.

Table 1.

Characteristics of Female Suicide Victims From 2003 to 2019, by Inclusion of IPP.

Characteristics	Female Suicide Victims, n (%)
	AllN = 58,543	IPP-Includedn = 13,496	Non-IPP-Includedn = 45,047	Difference
	AllN = 58,543	IPP-Includedn = 13,496	Non-IPP-Includedn = 45,047	SD	p
Age (years)
11–17	8,893 (15.2)	2,743 (20.3)	6,150 (13.7)
18–24	6,081 (10.4)	2,207 (16.4)	3,874 (8.6)	0.60	<.001
25–44	24,118 (41.2)	6,525 (48.4)	17,593 (39.1)
45–64	16,454 (28.1)	1,947 (14.4)	14,507 (32.2)
65+	2,997 (5.1)	74 (0.6)	2,923 (6.5)
Race/ethnicity
White, non-Hispanic	48,299 (83.4)	10,921 (81.5)	37,378 (84.0)	0.06	<.001
Non-White	9,592 (16.6)	2,473 (18.5)	7,119 (16.0)
Educational level
Less than high school	6,849 (15.0)	1,470 (14.1)	5,379 (15.2)
High school degree only	22,868 (45.0)	5,176 (49.6)	17,692 (50.1)	0.04	.002
Greater than high school	16,060 (35.1)	3,782 (36.3)	12,278 (34.7)
Marital status
Never married/widowed	22,330 (38.5)	4,330 (32.3)	18,000 (40.4)
Married/domestic partnership	20,212 (34.9)	6,188 (46.1)	14,024 (31.5)	0.30	<.001
Divorced	15,398 (26.6)	2,909 (21.7)	12,489 (28.1)
Foreign-born status
U.S. born	52,512 (93.8)	12,285 (94.2)	40,227 (93.7)	0.02	.032
Non-U.S.-born	3,459 (6.2)	754 (5.8)	2,705 (6.3)
Pregnancy status
Non-pregnant	23,522 (96.9)	4,860 (93.8)	18,662 (97.7)
Postpartum within last year	433 (1.8)	184 (3.55)	249 (1.3)	0.19	<.001
Pregnant	330 (1.4)	139 (2.7)	191 (1.0)
Homeless status
Yes	494 (0.9)	105 (0.8)	389 (0.9)	0.01	.22
No	55,741 (99.1)	13,171 (99.2)	42,570 (99.1)

Note. Unknown or non-applicable responses were removed from each category; due to missing data on demographic variables, and/or unknown or non-applicable responses, response frequencies range from 24,285 to 58,543 across characteristics. p Values compare “non-IPP-included suicides” versus “IPP-included suicides” using two-sided chi-squared tests. IPP = intimate partner problems; SD = standardized difference in percentages divided by standard error; imbalance defined as SD > 0.10.

Table 2.

Life Circumstances Preceding or Related to Suicide Incidents From 2003 to 2019, by Inclusion of IPP.

	Female Suicide Victims, n (%)
Characteristics	AllN = 58,543	IPP Includedn = 13,496	Non-IPP Includedn = 45,047	Difference
Characteristics	AllN = 58,543	IPP Includedn = 13,496	Non-IPP Includedn = 45,047	SD	p
Mental health and substance abuse
Diagnosed mental illness (yes)	34,523 (59.0)	8,066 (59.8)	26,457 (58.7)	0.02	.032
Recent depressed mood (yes)	20,907 (35.7)	6,035 (44.7)	14,872 (33.0)	0.24	<.001
Current mental illness treatment (yes)	23,822 (40.7)	5,580 (41.4)	18,242 (40.5)	0.01	.077
Previous mental illness treatment (yes)	28,399 (48.5)	6,888 (51.0)	21,511 (47.8)	0.06	<.001
Alcohol abuse problem (yes)	8,347 (14.3)	2,903 (21.5)	5,444 (12.1)	0.25	<.001
Other substance abuse problem (yes)	9,869 (16.9)	2,900 (21.5)	6,969 (15.5)	0.15	<.001
Life stressors
Physical health problem (yes)	11,655 (19.9)	1,648 (12.2)	10,007 (22.2)	0.26	<.001
Job problem (yes)	3,937 (6.7)	1,191 (8.8)	2,746 (6.1)	0.10	<.001
Financial problem (yes)	4,391 (7.5)	1,511 (11.2)	2,880 (6.4)	0.17	<.001
Relationship problem with family (yes)	5,179 (8.9)	1,538 (11.4)	3,641 (8.1)	0.11	<.001
Relationship problem with others (yes)	2,816 (4.8)	857 (6.4)	1,959 (4.4)	0.08	<.001
Trauma experiences
Childhood trauma history (yes)	962 (1.6)	344 (2.6)	618 (1.4)	0.08	<.001
Interpersonal violence perpetration (yes)	405 (0.7)	290 (2.2)	115 (0.3)	0.17	<.001
Interpersonal violence victimization (yes)	586 (1.0)	434 (3.2)	152 (0.3)	0.21	<.001

Note. p Values compare “non-IPP-included suicides” versus “IPP-included suicides” using two-sided chi-squared tests. IPP = intimate partner problems; SD = standardized difference in percentages divided by standard error; imbalance defined as SD > 0.10

Table 3.

Situational Characteristics of Suicide Incidents From 2003 to 2019, by Inclusion of IPP.

	Female Suicide Victims, n (%)
Characteristics	AllN = 58,543	IPP Includedn = 13,496	Non-IPP Includedn = 45,047	Difference
Characteristics	AllN = 58,543	IPP Includedn = 13,496	Non-IPP Includedn = 45,047	SD	p
Suicide time
6:00–11:59 am (morning)	4,837 (25.7)	970 (20.8)	3,867 (27.2)
12:00–5:59 pm (afternoon)	5,996 (31.8)	1,343 (28.8)	4,653 (32.8)	0.21	<.001
6:00–11:59 pm (evening)	4,796 (25.4)	1,419 (30.5)	3,377 (23.8)
12:00–5:59 am (night)	3,228 (17.1)	925 (19.9)	2,303 (16.2)
Incident location
House/apartment	46,524 (81.3)	11,082 (82.7)	35,442 (80.9)
Outdoors (e.g., park, bridge)	2,856 (5.0)	612 (4.6)	2,244 (5.1)
Residential/medical facility/jail	2,737 (4.8)	468 (3.5)	2,269 (5.2)
Motor vehicle	1,966 (3.4)	572 (4.3)	1,394 (3.2)	0.11	<.001
Street/road, alley, and parking lot	1,557 (2.7)	350 (2.6)	1,207 (2.8)
Other	1,588 (2.8)	323 (2.4)	1,265 (2.9)
Suicide means
Poisoning	19,942 (34.3)	3,742 (27.8)	16,200 (36.3)
Firearm	17,646 (30.4)	4,708 (34.9)	12,938 (29.0)
Hanging/strangulation	15,604 (26.9)	4,296 (31.9)	11,308 (25.3)	0.27	<.001
Fall/jump/drowning	2,553 (4.4)	367 (2.7)	2,186 (4.9)
Sharp/blunt instrument	995 (1.7)	121 (0.9)	874 (2.0)
Other	1,379 (2.4)	252 (1.9)	1,127 (2.5)
Alcohol use (yes)	11,164 (22.9)	4,039 (33.6)	7,125 (19.4)	0.33	<.001

Note. Unknown or non-applicable responses were removed from each category; due to missing data on demographic variables, and/or unknown or non-applicable responses, response frequencies range from 18,857 to 58,119 across characteristics. p Values compare “non-IPP-included suicides” versus “IPP-included suicides” using two-sided chi-squared tests. IPP = intimate partner problems; SD = standardized difference in percentages divided by standard error; imbalance defined as SD > 0.10.

Because all variables were categorical, univariate statistics (i.e., frequencies and percentages) were calculated for all suicide victim characteristics, life circumstances, incident characteristics, histories of previous suicide attempts, and disclosure for each of the following groups: (a) all suicide cases, (b) IPP-included suicide cases, and (c) non-IPP-included suicide cases. Next, as the primary analytic step to explore differences in suicides among women, we used two-sided Pearson chi-squared tests and standardized differences (SDs) to identify whether there were differences in the characteristics and circumstances surrounding IPP-included suicide cases and non-IPP-included suicide cases. SDs, which are preferable for large sample sizes, were calculated using STATA package “stddiff.” The stddiff program is applicable to produce SD in both continuous and categorical data (Bayoumi, 2016). Although there is no accepted threshold to determine a significant difference between two groups, the research team used the standards of previous researchers (e.g., Austin, 2009) to designate an absolute SD of above 0.10 as an indicator of a likely meaningful imbalance between groups. As a note, based on the data use agreement with the CDC, the research team suppressed results if the frequency count for any group was found to be below a minimum threshold of <10 observations. All p values were two-sided, and p values <.05 were considered indicative of significance. STATA/SE 16.0 software (STATA Corp.) was used to perform all the statistical analyses.

Results

Table 1 presents the demographic characteristics of female suicide victims. We identified 58,545 female suicides that occurred between 2003 and 2019. Of the 58,545 female suicides, 13,496 cases were related to IPP, indicating that about 23.1% of female suicide victims struggled with IPP. Overall, compared to non-IPP-included suicide, IPP-included suicide was identified at a higher rate in groups that were (a) younger, (b) non-White, (c) had higher education, (d) were U.S.-born, (e) were married or in a domestic partnership, and (f) were pregnant or postpartum (p < .05). Also, meaningful differences (SD > 0.10) were observed by age, marital status, and pregnancy status. Specifically, IPP-included suicides were more frequently identified in women younger than 45 years of age (p < .001; SD = 0.60), those who were married or in a domestic partnership (p < .001; SD = 0.30), and those who were pregnant or postpartum (p < .001; SD = 0.20).

Table 2 describes the life circumstances surrounding female suicide. With regard to mental health and substance abuse issues, IPP-included suicide victims were more likely than non-IPP-included suicide victims to have experienced a depressed mood (IPP included = 44.7%, non-IPP = 33.0%; p < .001; SD = 0.24), alcohol abuse problem (21.5% vs. 12.1%; p < .001; SD = 0.25), and substance abuse problem (21% vs. 15%; p < .001; SD = 0.155). Regarding life stressors, in both non-IPP-included suicide and IPP-included suicide victims, physical health problems were the most common stressors among female suicide victims. However, this proportion was much higher for non-IPP-included suicides than IPP-included suicides (IPP included = 12.2%, non-IPP = 22.2%; p < .001; SD = 0.24). Notably, compared to non-IPP-included suicide victims, IPP-included suicide victims tended to face more life stressors in the areas of financial stability (IPP included = 11.2%, non-IPP = 6.4%; p < .001; SD = 0.17) and relational problems with family (11.4% vs. 8.1%; p < .001; SD = 0.11). Regarding previous trauma history, although the overall reported proportion of trauma experiences was low, IPP-included suicide victims tended to have experienced more (a) childhood trauma, (b) interpersonal violence perpetration, and (c) interpersonal violence victimization (p < .001).

Table 3 describes the situational context surrounding incidents of female suicide. The meaningful differences were observed across all examined contextual factors including suicide (a) incident time, (b) location, (c) means, and (d) associated alcohol use. Compared to non-IPP-included suicides, IPP-included suicides largely occurred in the evening and at night between 6 pm and 6 am (IPP-included = 50.2%, non-IPP = 40.0%; p < .001; SD = 0.21). Most suicides occurred at a home or private residence for both non-IPP-included and IPP-included suicides, although this proportion was slightly higher for IPP-included suicides (IPP-included = 82.7%, non-IPP = 80.9%; p < .001; SD = 0.11). While poisoning was the most common method of female suicide (34.3%), IPP-included suicide victims tended to use firearms (34.9%) as the most common method and hanging and strangulation (31.9%) as the second most common method (p < .001; SD = 0.27). Compared to non-IPP-included suicides, IPP-included suicides occurred with more alcohol use in the hours preceding the incident (IPP-included = 33.6%, non-IPP = 19.4%; p < .001; SD = 0.33).

Table 4 shows previous suicidal intent history and suicide disclosure patterns. IPP-included suicide victims were significantly different across all examined variables with results finding, for example, that they demonstrated more previous overall suicidal intent, including (a) suicidal ideation, (b) suicide attempt, and (c) self-harm history, than non-IPP-included suicide victims did (p < .001). Also, about one-third of IPP-included suicide victims shared their suicidal ideation with others, a much higher proportion than non-IPP-included suicide victims (IPP-included = 32.6%, non-IPP = 20.5%; p < .001; SD = 0.27). IPP-included suicide victims tended to share their suicidal ideations with their partner (11.8%; p < .001; SD = 0.32) more than other groups, such as family, friends, and healthcare worker.

Table 4.

Suicide Intent History and Disclosed Suicidal Thought From 2003 to 2019, by Inclusion of IPP.

	Female Suicide Victims, n (%)
Characteristics	AllN = 58,543	IPP Includedn = 13,496	Non-IPP Includedn = 45,047	Difference
Characteristics	AllN = 58,543	IPP Includedn = 13,496	Non-IPP Includedn = 45,047	SD	p
Suicide intent history
Suicide attempt history (yes)	18,009 (30.8)	4,911 (36.4)	13,098 (29.1)	0.15	<.001
Suicide ideation history (yes)	14,472 (24.7)	4,194 (31.1)	10,278 (22.8)	0.18	<.001
Self-harm history (yes)	228 (0.4)	79 (0.60)	149 (0.3)	0.03	<.001
Suicide disclosure (yes)	13,650 (23.3)	4,396 (32.6)	9,254 (20.5)	0.27	<.001
Disclosed suicidal thought to
Intimate partner (yes)	3,157 (5.4)	1,595 (11.8)	1,562 (3.5)	0.32	<.001
Family members (yes)	2,994 (5.1)	641 (4.8)	2,353 (5.2)	0.02	<.05
Friends (yes)	1,310 (2.2)	427 (3.2)	883 (2.0)	0.07	<.001
Healthcare workers (yes)	551 (0.9)	83 (0.6)	468 (1.0)	0.04	<.001

Discussion

The aim of the exploratory secondary data analysis was to investigate the circumstances surrounding female IPP-included suicide. Study findings indicate numerous, significant, and likely meaningful differences in the circumstances surrounding female IPP-included suicide compared to female non-IPP-included suicide.

Sociodemographic Characteristics and IPP-Included Suicides

Study findings show that certain sociodemographic characteristics may play a role in increasing suicidal vulnerability in women struggling with IPP. Female suicide victims struggling with IPP are more likely to be younger, non-White, more highly educated, in an intimate partner relationship, U.S.-born, and pregnant or postpartum. Although our findings are descriptive, this finding is consistent with previous studies demonstrating that age and pregnancy or postpartum status are critical factors affecting suicide. For example, interpersonal conflict with a romantic partner (e.g., a breakup or dating violence) is a significant risk factor for adolescents (Steele et al., 2018) and young adults (Wolford-Clevenger et al., 2015). This might be related to a lack of coping and communication skills in relational problems and conflicts, which may develop with more age and maturity (Baiden et al., 2021). Additionally, previous studies reported that pregnant and postpartum women who experienced IPP, including partner violence, are at high risk for suicidality (Martin et al., 2007; Tabb et al., 2018). IPP and mental health problems (e.g., depression), which often occurred during pregnancy and the postpartum period, may significantly increase these suicidal tendencies (Campbell et al., 2021). Accordingly, researchers and practitioners need to pay attention to the risk factors related to women’s sociodemographic vulnerabilities to provide better tailored suicide prevention services.

Life Circumstances and IPP-Included Suicides

Our findings indicate that multiple circumstances which increase risk for suicide, including mental health problems, substance abuse problems, and previous trauma history, were more common among IPP-included women suicide victims than their non-IPP-included counterparts. This finding shows that women with IPP not only struggle with the IPP itself, but also with additional psychosocial challenges. It is still unclear whether IPP led to these mental health problems or whether these mental health issues are an additional set of factors affecting IPP and suicidality. However, given that IPP, trauma, and relevant behavioral and mental health problems may be bidirectional and co-occurring (Kim & Macy, 2021; Van Deinse et al., 2019), a comprehensive approach is needed to address suicidal women’s trauma, as well as the multiple psychosocial risk factors and the substance abuse, that can contribute to suicidality.

We also found that IPP-included suicide victims were more likely to face financial problems and relational problems with family and friends than non-IPP-included suicide victims. Previous research found that economic challenges were one of the most serious issues faced by women who were recently divorced or separated from their partners (Stack & Scourfield, 2015). Considering women’s vulnerability to lower incomes and gender discrimination in the job market, financial and professional difficulties might put women in even more difficult situations, leading to hopelessness and frustration. Additionally, social support is a critical protective factor preventing suicidal thoughts and behaviors. Compounding the effects of IPP, women’s relational problems with other family and friends might increase isolation, cutting off the possibility of seeking help from loved ones (Love et al., 2021; Wolford-Clevenger et al., 2019). This finding suggests that intervention efforts aimed at increasing women’s economic efficacy and social networks, which alleviate women’s financial problems and social isolation, may in turn be a form of suicide prevention.

Incident Characteristics and IPP-Included Suicides

Study findings provide preliminary information regarding when, where, and how females struggling with IPP committed suicide. IPP-included suicide victims were slightly more likely to commit suicide at their house or apartment during evening and nighttime than non-IPP-included suicide victims. Compared to previous studies, which found early afternoon as the peak time for suicide in the general population (Gallerani et al., 1996; Galvão et al., 2018), our study identified a different peak time. Although there is no clear explanation for the difference, our findings suggest that it is important to monitor suicidal women struggling with IPP in the evening and at night.

Additionally, we found that many women struggling with IPP chose to use a firearm or hanging as their suicide methods, while non-IPP-included suicide victims chose poisoning as their primary method. Suicide research has shown that some suicide methods tend to have low lethality, such as a drug or chemical overdose or use of a sharp object, while other suicide methods have high lethality, including the use of a firearm, hanging, drowning, and jumping from a height (Fisher et al., 2015; Wang et al., 2020). Our findings show that IPP-included suicide victims choose more highly lethal suicide methods than non-IPP-included victims. Suicide theories suggest that IPP might give women stronger motivation to commit suicide and escape the IPP (Van Orden et al., 2010). Although these are preliminary and descriptive findings, they may provide meaningful information on when, where, and how IPP-included suicides tend to take place, so that we can better monitor potential victims and more effectively prevent suicides among females struggling with IPP.

Disclosure Patterns Among IPP-Included Suicide Victims

Lastly, our findings show that more than one-third of suicide victims dealing with IPP had previous suicidal thoughts, as well as a history of attempted suicide. Additionally, about one-third of IPP-included suicide victims shared their suicidal ideation with others before committing suicide. This number indicates that suicide prevention opportunities exist. Notably, women struggling with IPP mostly tend to share their suicidal ideations with their partners. While this study was not designed to determine how intimate partners responded to such disclosures among these suicide victims, studies have found that invalidating responses toward suicide disclosure, including dismissing the suicidal partner’s emotional experiences, downplaying the severity of their suicidality, or devaluing of the suicidal partner or the relationship, lead to worse outcomes (Love et al., 2021). These types of partner responses have the potential to intensify suicidal partners’ feelings of thwarted belongingness and perceived burdensomeness (Van Orden et al., 2010), increasing the risk of suicide. Taken together, the previous and current findings demonstrate the importance of studying how intimate partners respond to disclosures and how those responses are perceived by individuals struggling with IPP and suicidality.

Additionally, we identified that only 0.6% of IPP-included suicide victims disclosed their suicidal thoughts to healthcare professionals. Considering that about 40% of IPP-included suicide victims were receiving generalized mental health treatment and/or related counseling (e.g., had a medication prescription or met with a mental health professional and/or religious counselor within the 2 months prior to their death), there might be a possibility for service providers to miss identifying suicidal risk. This finding indicates that more research is needed to explore suicidal women’s barriers to disclosing suicidal intentions to service providers like mental health professionals, marriage counselors, domestic violence advocates, or religious leaders who may be particularly well-placed to offer them support and help prevent their suicide. Notably, it is necessary to better understand the differences in disclosure and disclosure barriers to different types of mental health professionals and understand the variations in these service providers’ responses.

Limitations and Future Research

This exploratory secondary data analysis provided preliminary information about the context in which IPP-included female suicides take place in the United States. However, the findings should be understood in light of the study’s limitations. NVDRS data were compiled by local death investigations by coroners or medical examiners and law enforcement agencies using information provided by suicide victims’ families, friends, and other acquaintances. Accordingly, this might lead to underreporting of IPP and other relevant circumstances due to a lack of relevant knowledge and recall bias. Indeed, the relatively low rate of reported trauma experiences, including information on childhood trauma, leaves open the possibility of significant underreporting (Chen & Roberts, 2021). Additionally, NVDRS consists of mostly binary variables with two response categories (e.g., yes or no/unknown/non-applicable). The variable type might impede a full measurement of IPP and other suicide circumstances. For example, IPP is measured by asking whether the suicide victim dealt with IPP or not. Accordingly, we are not able to understand the frequency or intensity of the IPP that the suicide victim faced.

Further research is necessary for a more in-depth understanding of IPP-included female suicides. For example, this study found that IPP-included suicides were more common among women with certain sociodemographic characteristics (e.g., women who were younger, in intimate partner relationships, and either pregnant or postpartum). Research is needed to further explore the suicidality and other relevant circumstances for these particularly high-risk groups. Given that NVDRS provides narrative data for each suicide victim, researchers might use the narrative data to further explore IPP-included female suicide, based on their categorization in a high-risk group. Additionally, we identified life and situational circumstances associated with IPP-included female suicide. However, our descriptive findings cannot confer causality definitively to state that IPP were the main contributors to the recorded suicides. Accordingly, future research is needed to examine whether risk circumstances and characteristics are factors that truly precipitate IPP-included female suicides. Lastly, our findings identified that more IPP-included suicide victims disclosed their suicidal intentions to an intimate partner (informal relationship) than to a service provider (formal relationship). Further studies are needed to explore suicide victims’ decisions to disclose their suicidal intent. These studies will provide significant information as to how service providers and informal supporters can identify and help individuals who are struggling with IPP and suicide risk.

Conclusion

This study is one of the first exploratory studies to use a robust national dataset to better understand IPP-included female suicide. Results identified unique circumstances and characteristics possibly associated with IPP-included female suicide. Study findings can be used as preliminary data to inform the development of target-based suicide prevention services and programs for females who are struggling with IPP. Given the increased attention on the intersection between IPP and suicide, further studies exploring the role of IPP in female suicide are needed to help advance practice and research knowledge in this area.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: This study was supported by the L. Richardson Preyer Distinguished Chair for Strengthening Families Fund of the School of Social Work at the University of North Carolina at Chapel Hill.

ORCID iDs

Jeongsuk Kim

Christopher J. Wretman

Spenser R. Radtke

Cynthia Fraga Rizo

Rebecca J. Macy

Author Biographies

Jeongsuk Kim, PhD, is an assistant professor at the University of South Florida School of Social Work. Her work focuses on understanding violence and associated health outcomes among socially underprivileged populations and finding effective ways to prevent and respond to violence victimization and adverse health outcomes.

Christopher J. Wretman, PhD, is a data analyst previously at The University of North Carolina at Chapel Hill. His work focuses on the quantitative analysis of health and well-being outcomes to inform services for vulnerable populations.

Spenser R. Radtke, MSW, LCSW is a doctoral research assistant at the School of Social Work at the University of North Carolina at Chapel Hill. Her research focuses broadly on improving mental and physical health outcomes for youth impacted by family and intimate partner violence, human trafficking, and poly-victimization.

Cynthia Fraga Rizo, PhD, is an associate professor and a John A. Tate Early Career Scholar at the School of Social Work at the University of North Carolina at Chapel Hill. Her research focuses on the development and evaluation of interventions and services for addressing intimate partner violence, sexual violence, and human trafficking.

Rebecca J. Macy, PhD, MSW, is a professor, an associate dean for research and faculty development, and the L. Richardson Preyer Distinguished Chair for Strengthening Families at the School of Social Work at the University of North Carolina at Chapel Hill. Her work features community-based studies on intimate partner violence, sexual violence, and human trafficking and improving services for survivors.

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Characteristics of and Circumstances Associated With Female Intimate Partner Problem-Included Suicides: Analysis of Data From the National Violent Death Reporting System (2003–2019)

Abstract

Keywords

Suicide Theories and Female Suicide Related to IPP

Risk Factors and Circumstances of Female Suicide Related to IPP

Current Study

Methods

Data Sources

Case Selection

Measures

Analysis

Results

Discussion

Sociodemographic Characteristics and IPP-Included Suicides

Life Circumstances and IPP-Included Suicides

Incident Characteristics and IPP-Included Suicides

Disclosure Patterns Among IPP-Included Suicide Victims

Limitations and Future Research

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iDs

Author Biographies

References