Window on the Minority Suicide Paradox: A Multiple Cause-of-Death Study
Meta-analyses and national multiple cause of death (MCOD) analyses have affirmed that comorbid psychopathology and physical disease are suicide determinants. MCOD and psychological autopsy studies indicate that reporting of comorbidity on death certificates of suicides may be more deficient for some demographic groups than others. This study examines that question for US whites, blacks, and Hispanics in order to shed light on a paradox. Contrary to the typical direction of health disparities, the two minorities register suicide rates half those of whites. MCOD public use files for 1999-2003 from the National Center for Health Statistics were accessed to estimate the prevalence of medical conditions among white and minority suicides, and to identify suicide-associated comorbidities through logistic regression analyses. Registered psychopathology among white male suicides is over twice as prevalent as for their two minority counterparts. It is also substantially higher among white female suicides than among minority opposites. With less racial-ethnic divergence, comorbid physical disease patterns follow the same direction as those for psychopathology. Suicide is associated with schizophrenia and mood disorders/ depression in all three groups, and cancer in whites and blacks only. While consistent with less access to health care for blacks and Hispanics than for whites, racial-ethnic gaps in the observed prevalence of comorbidity among suicides are incongruent with self-reported health status. Suicide in the United States is highly prone to underenumeration by medicolegal authorities. However, differential knowledge of actual comorbidity among true suicides could variously influence the respective tipping points where these authorities might misclassify white, black, and Hispanic suicides as nonsuicides. Findings induce skepticism about the magnitude, if not the validity, of the racial-ethnic divide in official suicide rates, and harbor adverse implications for suicide surveillance, etiology, policy, and prevention.
Keywords: Suicide, Validity, Comorbidity, Gender, Race, Ethnicity
Dr Ian R.H. Rockett
Professor of Epidemiology, Department of Community Medicine