Financial Strain and Suicide Attempts in a Nationally Representative Sample of US Adults

Eric B. Elbogen; Megan Lanier; Ann Elizabeth Montgomery; Susan Strickland; H. Ryan Wagner; Jack Tsai

Disclosures

Am J Epidemiol. 2020;189(11):1266-1274. 

In This Article

Abstract and Introduction

Abstract

Although research has identified many suicide risk factors, the relationship between financial strain and suicide has received less attention. Using data representative of the US adult population (n = 34,653) from wave 1 (2001–2002) and wave 2 (2004–2005) of the National Epidemiologic Survey on Alcohol and Related Conditions, we investigated the association between financial strain—financial debt/crisis, unemployment, past homelessness, and lower income—and subsequent suicide attempts and suicidal ideation. Multivariable logistic regression controlling for demographic and clinical covariates showed that cumulative financial strain was predictive of suicide attempts between waves 1 and 2 (odds ratio (OR) = 1.53, 95% confidence interval (CI): 1.32, 1.77). Wave 1 financial debt/crisis (OR = 1.58, 95% CI: 1.06, 2.34), unemployment (OR = 1.52, 95% CI: 1.10, 2.10), past homelessness (OR = 1.50, 95% CI: 1.03, 2.17), and lower income (OR = 1.51, 95% CI: 1.01, 2.25) were each associated with subsequent suicide attempts. Respondents endorsing these 4 financial-strain variables had 20 times higher predicted probability of attempting suicide compared with respondents endorsing none of these variables. Analyses yielded similar results examining suicidal ideation. Financial strain accumulated from multiple sources (debt, housing instability, unemployment, and low income) should be considered for optimal assessment, management, and prevention of suicide.

Introduction

Suicide is a growing problem and leading cause of death throughout the world.[1–5] The US Centers for Disease Control and Prevention reported increased rates of suicide across all demographic and age ranges over 1999–2016.[3] Research has identified clinical risk factors for suicide including mental illness, particularly major depression,[5,6] with the goal of identifying dynamic variables to be targeted by health-care providers to prevent suicide.[1,5]

Less research has examined financial strain, defined as lack of economic support and related perceived economic stress.[7–9] Studies suggest that financial debt/crises,[10–13] unemployment,[14–16] homelessness,[15,17,18] and lower income[19–21] elevate suicide risk. Multiple studies show that suicides tend to decline during times of economic prosperity and increase during times of economic hardship.[22,23] Higher suicide rates were recorded during widespread unemployment in the Great Depression and home foreclosures in the recent Great Recession.[16,24] Correspondingly, a time-series analysis using data on monthly suicide counts in New York City from 1990 through 2006 revealed that suicide rates were lower when economic conditions were stronger.[25]

These studies point to a potential link between financial strain and suicide, suggesting that financial well-being should play a role in the context of suicide prevention. Public policy targeting upstream socioeconomic factors such as financial education, vocational rehabilitation, job retraining, increasing the minimum wage, and improving homelessness services could reduce suicide rates.[4,19,22,26,27]

Within the literature, empirical studies on the association between financial strain and suicide risk have been largely cross-sectional.[11,28] Research has also been limited by nonrepresentative sampling, focus on single rather than multiple sources of financial strain, and lack of statistical control for clinical variables like major depression, substance abuse, or past suicide attempts or suicidal ideation.[14,15] Including clinical variables is important for distinguishing whether financial strain predicts suicide attempts independent of psychiatric history or whether financial strain instead serves as a proxy for underlying mental health issues related to suicide.[5,6] There is growing recognition of the need to clarify the intricate links between financial strain and mental illness particularly with respect to suicide.[22,25,29]

The purpose of the present study is to address these gaps in the literature by using a nationally representative longitudinal data set to examine whether financial strain—financial debt/crisis, past homelessness, unemployment, and lower income—predicts subsequent suicide attempts and suicidal ideation, controlling for demographic and clinical covariates.

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