Estimating the Association Between Mental Health Disorders and Suicide: a Review of Common Sources of Bias and Challenge
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INJURY EPIDEMIOLOGY (S MARSHALL, SECTION EDITOR)
Estimating the Association Between Mental Health Disorders and Suicide: a Review of Common Sources of Bias and Challenges and Opportunities for US-Based Research Josie J. Caves Sivaraman 1,2
&
Rebecca B. Naumann 1
Accepted: 21 September 2020 # Springer Nature Switzerland AG 2020
Abstract Purpose of Review The purpose of this review is to (1) illuminate prevalent methodological approaches and estimates of association between mental health diagnoses and suicide from the meta-analytic literature; (2) discuss key internal and external validity concerns with these estimates; and (3) highlight some of the unique attributes and challenges in US-based suicide research and opportunities to move the evidence base forward. Recent Findings Globally, there is considerable variability in measures of association between mental health disorders and suicide and a growing debate over methodological approaches to this research. A high suicide incidence makes the US an outlier, and the decentralized nature of US administrative data poses a unique challenge to data linkage that could otherwise advance this research. Summary We offer methodological considerations for future research and discuss opportunities made possible by the recent expansion of the US National Violent Death Reporting System to a nationwide registry. Keywords Suicide . Mental health disorder . Validity . Generalizability
Introduction Suicide is a leading cause of death internationally and within the United States (US). While global suicide mortality trends have declined over the last several years, [1] the US suicide rate increased 35% between 1999 and 2018, from 10.5 to 14.2 deaths per 100,000 population. [2] Suicide is now the 10th leading cause of death in the US, accounting for 48,344 deaths in 2018. [3] Acknowledging this concerning trend, in 2012, the US Surgeon General released a National Strategy for Suicide Prevention Plan, which advocated for a comprehensive approach to suicide prevention involving both community and clinical action. [4] The Plan highlighted the widespread This article is part of the Topical Collection on Injury Epidemiology * Josie J. Caves Sivaraman
1
Department of Epidemiology and Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
2
Carrboro, USA
consensus that mental health disorders (MHDs), including mood disorders, anxiety disorders, borderline personality disorder, schizophrenia, and substance use disorders (SUD), are leading risk factors for suicide and suicidal behavior. [4] The MHD-suicide association is widely assumed to be established and strong. Perhaps as a result, many publications in this area adopt a seemingly relaxed approach to the methods used to estimate the MHD-suicide association in the literature, with little attention to study specifics (e.g., populations studied, exposure definitions) and variability in magnitudes of associations. For example, it is quite common to find an introductory paragraph in suicide-
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