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Original Investigation
November 18, 2020

Trends in Suicidality 1 Year Before and After Birth Among Commercially Insured Childbearing Individuals in the United States, 2006-2017

Author Affiliations
  • 1Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 3Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, University of California, Los Angeles
  • 4Department of Health Policy and Management, Fielding UCLA School of Public Health, University of California, Los Angeles
  • 5Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
  • 6RAND Corporation, Boston, Massachusetts
  • 7Department of Psychiatry, University of Michigan, Ann Arbor
  • 8University of Illinois at Urbana-Champaign School of Social Work, Urbana
  • 9VA Ann Arbor Healthcare System, Ann Arbor, Michigan
JAMA Psychiatry. 2021;78(2):171-176. doi:10.1001/jamapsychiatry.2020.3550
Key Points

Question  What are the trends in suicidal ideation and intentional self-harm in a large national cohort of commercially insured childbearing individuals?

Findings  In this serial cross-sectional analysis of 595 237 childbearing individuals 1 year before and after giving birth, suicidal ideation and intentional self-harm increased significantly between 2006 and 2017. Non-Hispanic Black individuals, those with low-income, and younger individuals as well as those with comorbid anxiety, depression, or other serious mental illness had larger escalations.

Meaning  Clinical and policy interventions for addressing this health crisis should be tailored to meet the unique needs of childbearing individuals in the year before and following birth, particularly among high-risk groups.

Abstract

Importance  Suicide deaths are a leading cause of maternal mortality in the US, yet the prevalence and trends in suicidality (suicidal ideation and/or intentional self-harm) among childbearing individuals remain poorly described.

Objective  To characterize trends in suicidality among childbearing individuals.

Design, Setting, and Participants  This serial cross-sectional study analyzed data from a medical claims database for a large commercially insured population in the US from January 2006 to December 2017. There were 2714 diagnoses of suicidality 1 year before or after 698 239 deliveries among 595 237 individuals aged 15 to 44 years who were continuously enrolled in a single commercial health insurance plan. Data were analyzed from October 2019 to September 2020.

Main Outcomes and Measures  The primary outcome was diagnosis of suicidality in childbearing individuals 1 year before or after birth based on the identification of relevant International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis codes during at least 1 inpatient or 2 outpatient visits.

Results  Of 595 237 included childbearing individuals, the mean (SD) age at delivery was 31.9 (6.4) years. A total of 40 568 individuals (6.8%) were Asian, 52 613 (8.6%) were Black, 73 172 (12.1%) were Hispanic, 369 501 (63.1%) were White, and 59 383 (9.5%) had unknown or missing race/ethnicity data. A total of 2683 individuals were diagnosed with suicidality 1 year before or after giving birth for a total of 2714 diagnoses. The prevalence of suicidal ideation increased from 0.1% per 100 individuals in 2006 to 0.5% per 100 individuals in 2017 (difference, 0.4%; SE, 0.03; P < .001). Intentional self-harm prevalence increased from 0.1% per 100 individuals in 2006 to 0.2% per 100 individuals in 2017 (difference, 0.1%; SE, 0.02; P < .001). Suicidality prevalence increased from 0.2% per 100 individuals in 2006 to 0.6% per 100 individuals in 2017 (difference, 0.4%; SE, 0.04; P < .001). Diagnoses of suicidality with comorbid depression or anxiety increased from 1.2% per 100 individuals in 2006 to 2.6% per 100 individuals in 2017 (difference, 1.4%; SE, 0.2; P < .001). Diagnoses of suicidality with comorbid bipolar or psychotic disorders increased from 6.9% per 100 individuals in 2006 to 16.9% per 100 individuals in 2017 (difference, 10.1%; SE, 0.2; P < .001). Non-Hispanic Black individuals, individuals with lower income, and younger individuals experienced larger increases in suicidality over the study period.

Conclusions and Relevance  In this cross-sectional study of US childbearing individuals, the prevalence of suicidal ideation and intentional self-harm occurring in the year preceding or following birth increased substantially over a 12-year period. Policy makers, health plans, and clinicians should ensure access to universal suicidality screening and appropriate treatment for pregnant and postpartum individuals and seek health system and policy avenues to mitigate this growing public health crisis, particularly for high-risk groups.

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    1 Comment for this article
    EXPAND ALL
    Suicide after pregnancy in contrast to after abortion.
    Gail Robinson, MD, FRCPC, Professor | University of Toronto
    In the United States, the debate over abortion rages, and its fate in our Supreme Court hangs in the balance. In this context, the study by Admon, Dalton, Kolenic et al.1 in JAMA Psychiatry online November 18, 2020, in addition to its importance in peripartum care, affords a critical perspective on abortion. Too often we forget that miscarriage aside, ongoing pregnancy and birth is the only alternative to abortion. There is no credible evidence that abortion, unlike that sole alternative, is causally linked to suicide2,3. This study offers two lessons: we must improve peripartum care and support, and we must consider the benefits and risks of both alternatives when we make public policy and when we counsel our patients.
    Nada L Stotland, MD, MPH
    Rush University, Chicago
    Gail Erlick Robinson MD, FRCPC, CM, OOnt.
    Professor of Psychiatry
    University of Toronto
    Toronto, Canada
    Gisele Apter
    Professor of Psychiatry
    University of Rouen
    Normandy, France
    Gisele.apter@gmail.com
    1 Admon LK, Dalton VK, Kolenic GE, et al. Trends in Suicidality 1 Year Before and After Birth Among Commercially Insured Childbearing Individuals in the United States, 2006-2017. JAMA Psychiatry. Published online November 18, 2020. doi:10.1001/jamapsychiatry.2020.3550
    2 Robinson, Gail Erlick, Stotland, Nada L., Russo, Nancy Felipe, Lang, Joan A. and Occhiogrosso, Mallay (2009) Is There an “Abortion Trauma Syndrome”? Critiquing the Evidence. Harvard Review of Psychiatry,17:4,268 — 290
    3 Steinberg J, et al "The association between first abortion and first-time non-fatal suicide attempt: A longitudinal cohort study of Danish population registries" Lancet Psychiatry 2019; DOI: 10.1016/S2215-0366(19)30400-6.
    CONFLICT OF INTEREST: None Reported
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