key: cord-0714610-z4gfwmth authors: Rossom, Rebecca C.; Penfold, Robert B.; Owen-Smith, Ashli A.; Simon, Greg E.; Ahmedani, Brian K. title: Suicide Deaths Before and During the Coronavirus Disease 2019 Pandemic: An Interrupted Time-series Study date: 2022-03-01 journal: Med Care DOI: 10.1097/mlr.0000000000001700 sha: 2bce0688f8e72f8d33f6004bd02256d2786328c1 doc_id: 714610 cord_uid: z4gfwmth INTRODUCTION: With stressors that are often associated with suicide increasing during the coronavirus disease 2019 (COVID-19) pandemic, there has been concern that suicide mortality rates may also be increasing. Our objective was to determine whether suicide mortality rates increased during the COVID-19 pandemic. METHODS: We conducted an interrupted time-series study using data from January 2019 through December 2020 from 2 large integrated health care systems. The population at risk included all patients or individuals enrolled in a health plan at HealthPartners in Minnesota or Henry Ford Health System in Michigan. The primary outcome was change in suicide mortality rates, expressed as annualized crude rates of suicide death per 100,000 people in 10 months following the start of the pandemic in March 2020 compared with the 14 months prior. RESULTS: There were 6,434,675 people at risk in the sample, with 55% women and a diverse sample across ages, race/ethnicity, and insurance type. From January 2019 through February 2020, there was a slow increase in the suicide mortality rate, with rates then decreasing by 0.45 per 100,000 people per month from March 2020 through December 2020 (SE=0.19, P=0.03). CONCLUSIONS: Overall suicide mortality rates did not increase with the pandemic, and in fact slightly declined from March to December 2020. Our findings should be confirmed across other settings and, when available, using final adjudicated state mortality data. G iven increases in risk factors for suicide with the onset of the coronavirus disease 2019 (COVID-19) pandemic, including increases in social isolation, economic privation, bereavement, domestic violence, firearm and alcohol purchases, and prevalence of depression and anxiety, as well as reduced access to health care and services that support families experiencing or at risk for violence, there have been concerns that suicide rates would increase during the pandemic. [1] [2] [3] Suicide attempt data are often more timely than suicide death data, but suicide attempts may be greatly underreported during periods when health care access and utilization decrease, which they did during the pandemic. Suicide death data are recorded by state medical examiners and are not underreported when health care utilization declines, but lags in final reporting of state mortality data can make timely assessment of trends in suicide mortality challenge. To address the gap in understanding of the effects of the pandemic on suicide deaths, this interrupted time-series study utilized interim mortality data from patients in Michigan and Minnesota to examine changes in suicide mortality rates before and after March 2020, when the World Health Organization officially declared a pandemic and many changes in employment, school and public health policy related to the pandemic were first implemented in the United States. 4 The population at risk in this sample included all patients and insurance members of HealthPartners in Minneapolis and Henry Ford Health System in Detroit, and study activities were reviewed and approved by Institutional Review Boards at each site. Neighborhoods were defined using census block data. Income and education were estimated using publicly available Federal Information Processing System (FIPS) values set by the National Institute of Standards & Technology. 5 We measured suicide deaths and not suicide attempts because changes in suicide attempts are likely confounded by changes in care-seeking that present fewer opportunities for documentation of the occurrence of suicide attempts. Decreases in care-seeking have been similarly observed for other life-threatening disorders that had previously been considered to be obligatory conditions for emergent care, including myocardial infarction or stroke. 6 In contrast, suicide death rates are collected and reported by state medical examiners, and the assessment of suicide deaths is not influenced by likelihood to seek care during the pandemic. We chose a static denominator based on enrollment and utilization in January 2019 to avoid inflating the suicide mortality rate as an artifact of disenrollment related to job loss or lack of careseeking; that is, allowing reductions in the denominator would have likely inflated suicide death rates. Monthly state reported of preliminary cause of death were obtained from state vital statistics records and stored in each health care system's virtual data warehouse. Deaths were considered to be suicide deaths if they were categorized as such by the state. Preliminary cause of death was used because the adjudicated state mortality data are not typically available until 9-12 months after the end of the previous calendar year. Each state's preliminary cause of death data were obtained monthly, with a lag of 1-2 months; data for calendar years 2019 and 2020 were harvested in March 2021. Deaths were available for all people included in our denominators regardless of whether they were still enrolled in the health plan at the time of their death. We employed an interrupted time-series design 7 and used segmented regression 8 to evaluate the change in annualized crude rates of suicide death per 100,000 people in 14 months before March 2020 (when COVID-19 was declared a pandemic by the World Health Organization 4 ) and first 10 months of the pandemic. Consistent with standard specifications, 8 the model included a term indexing the secular trend in time, a term for immediate change in level (intercept), and a term for the change in slope. We evaluated the presence of autocorrelation via the Durbin-Watson statistic at lags up to 12 months. All analyses were performed in SAS 9.4. 9 Demographic characteristics of the 6,434,675 people at risk are summarized in Table 1 and were generally consistent with US population as a whole, 10 with our sample having slightly more women and slightly fewer people who selfidentify as Asian, Hawaiian/Pacific Islander, or Native American/Alaskan Native than the US general population. Overall, 54% of patients in our sample were women, and 22% were ages 0-19, 25% ages 20-39, 36% ages 40-64, and 16% over the age of 65. Fifty-seven percent of people were insured by commercial insurance, 18% by Medicaid, and 13% by Medicare. Forty-two percent of people lived in neighborhoods where <25% of residents had at least some college education. Three percent of patients were Asian, 14% Black, 54% White, and 2% Hispanic. From January 2019 through February 2020, overall suicide mortality rates slowly increased to 14.6 per 100,000. These rates were generally consistent with national data reporting a 2019 suicide death rate of 13.9 per 100,000. 11 Suicide mortality rates then slowly decreased from 13.4 in March 2020 to 10.8 in December 2020 (a decrease of 0.45 per 100,000 people per month, SE = 0.19, P = 0.03; Fig. 1 ). The Durbin-Watson statistic was 2.49 (Pr