Changes in suicide in California from 2017 to 2021: a population-based study

Injury Epidemiology (2023) 10:19 Lund et al. Injury Epidemiology https://doi.org/10.1186/s40621-023-00429-6 Open Access ORIGINAL CONTRIBUTION Changes in suicide in California from 2017 to 2021: a population‑based study Julia J. Lund* , Elizabeth Tomsich, Julia P. Schleimer and Veronica A. Pear Abstract Background Suicide is a major public health problem with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of suicide in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years. Methods We used California-wide death data to summarize suicide and firearm suicide across race/ethnicity, age, education, gender, and urbanicity. We compared case counts and rates in 2020 and 2021 with 2017–2019 averages. Results Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10 to 19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20 to 29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. The proportion of suicides that involved a firearm in 2020 and 2021 decreased in rural areas compared to prior years, while there were modest increases in urban areas. Conclusions The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of suicide across the California population. Marginalized racial groups and younger people experienced increased risk for suicide, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal self-harm injuries and reduce related inequities. Keywords Self-harm, Suicide, Health disparities, COVID-19, Gun violence, Firearms *Correspondence: Julia J. Lund Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, USA Background Suicide is significant public health problem and a leading cause of death in the United States (USA). From 2010 to 2020, more than 480,000 people nationally died by suicide, the majority by firearm suicide. Recent social, economic, and environmental stressors may have affected the burden of and disparities in suicide. On March 19, 2020, California went under a stay-athome order in response to the COVID-19 pandemic (Office of Governor Gavin Newsom 2020). Non-essential © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Lund et al. Injury Epidemiology (2023) 10:19 businesses, such as bars, fitness clubs, and some stores, were ordered to close, and residents were asked to “shelter-in-place” at home. Many people lost employment or had to leave jobs to caretake for children or family members. A high percentage of adults had trouble paying bills or rent due to the pandemic (Pew Research Center 2020), and most became more socially isolated (Abelson 2021). At the same time, hundreds of thousands experienced loss of a loved one to COVID-19 (Verdery et al. 2020). Compounded with the pandemic and its repercussions were a variety of other co-occurring stressors in 2020 and 2021, including the widely publicized murder of George Floyd, subsequent protests and incidents of police brutality, political turmoil surrounding the 2020 presidential election, climate-change-fueled megafires, and collective grief and trauma resulting from these events (Silver et al. 2021; Bühler et al. 2022). Notably, not all groups were equally impacted. Marginalized communities and racialized groups bore the disproportionate burden of the social, health, and economic consequences of 2020 and 2021 (Wilson 2020) as a result of the ongoing legacy of structural racism in the USA, which has concentrated disadvantages (including poverty, under-funded schools, unemployment, over-policing and police violence, mass incarceration, and limited access to affordable healthcare, housing, and green spaces) among Black, Indigenous, and Hispanic communities (Bailey et al. 2017). Financial difficulties, unemployment, social isolation, and trauma have all been linked to suicide and related risk factors (e.g., suicidality, depression) (Batty et al. 2018; Elbogen et al. 2020). One analysis found that in the years following the economic downturn from 2007 to 2009, an estimated 4750 more Americans died by suicide than projected (Reeves et al. 2012). A study of quarantined people during the severe acute respiratory syndrome (SARS) outbreak in 2003 found that approximately onethird of individuals experienced symptoms of depression and posttraumatic stress disorder (PTSD), with higher rates of PTSD symptoms associated with longer durations of quarantine (Hawryluck et al. 2004). Prior pandemics have also been linked to suicide: some research suggests that deaths by suicide increased overall during the 1918–1919 influenza pandemic in the USA (Wasserman 1992) and among older people aged 65 and above in Hong Kong during the SARS epidemic (Cheung et al. 2008). Several studies have examined the link between the COVID-19 pandemic and suicide, but findings are mixed. One 2021 survey of adults in the USA found an association between COVID-19-related experiences (i.e., general distress, fe (...truncated)