Suicides Among American Indian or Alaska Native Persons — National Violent Death Reporting System, United States, 2015–2020

Compared with the general U.S. population, American Indian or Alaska Native (AI/AN) persons, particularly those who are not Hispanic or Latino (Hispanic) AI/AN, are disproportionately affected by suicide; rates among this group consistently surpass those among all other racial and ethnic groups (1). Suicide rates among non-Hispanic AI/AN persons increased nearly 20% from 2015 (20.0 per 100,000) to 2020 (23.9), compared with a <1% increase among the overall U.S. population (13.3 and 13.5, respectively) (1). Understanding characteristics of suicide among AI/AN persons is critical to developing and implementing effective prevention strategies. A 2018 report described suicides in 18 states among non-Hispanic AI/AN persons only (2). The current study used 2015–2020 National Violent Death Reporting System (NVDRS) data among 49 states, Puerto Rico, and the District of Columbia to examine differences in suicide characteristics and contributing circumstances among Hispanic and non-Hispanic AI/AN populations, including multiracial AI/AN. Results indicated higher odds across a range of circumstances, including 10 of 14 relationship problems (adjusted odds ratio [aOR] range = 1.2–3.8; 95% CI range = 1.0–5.3) and six of seven substance use problems (aOR range = 1.2–2.3; 95% CI range = 1.1–2.5), compared with non-AI/AN persons. Conversely, AI/AN decedents had reduced odds of having any current known mental health condition, any history of mental health or substance use treatment, and other common risk factors (aOR range = 0.6–0.8; 95% CI = 0.2–0.9). Suicide is preventable. Communities can implement a comprehensive public health approach to suicide prevention that addresses long-standing inequities affecting AI/AN populations (3).

NVDRS is a state-based surveillance system that collects information from death certificates, coroner or medical examiner reports, and law enforcement reports on the characteristics and circumstances of violent deaths, including suicides (4). Data in this report are from the District of Columbia, Puerto Rico, and 49 U.S. states participating in NVDRS during 2015–2020*; some jurisdictions did not participate for the entire period because they were not yet funded or because they did not achieve data completion thresholds (Supplementary Table, https://stacks.cdc.gov/view/cdc/121071) (4). Analyses were limited to decedents aged ≥10 years, because determining suicide intent in young children can be difficult (5). AI/AN persons are defined in NVDRS as persons with origins among any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition (Alaska Natives are included among this group) (6). For this study, characteristics and circumstances of suicide were compared among decedents with any AI/AN identification, similar to a recent analysis of homicides among AI/AN persons (7). Rural-urban commuting area codes were used to determine nonmetropolitan and metropolitan geographic areas. All comparisons between AI/AN and non-AI/AN persons were examined using Pearson’s chi-square tests (with p<0.05 considered statistically significant) and logistic regression analyses, controlling for age and sex to estimate aORs with 95% CIs. Analyses were conducted using SAS (version 9.4; SAS Institute). This analysis was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^†

During 2015–2020, a total of 3,397 suicides among AI/AN persons and 179,850 suicides among non-AI/AN persons were recorded in NVDRS (Table 1). Approximately three quarters (74.6%) of AI/AN suicide decedents were aged ≤44 years, compared with less than one half (46.5%) of non-AI/AN decedents. The highest percentage of AI/AN suicides (46.9%) occurred among persons aged 25–44 years, whereas among non-AI/AN persons, the largest percentage (35%) occurred among persons aged 45–64 years. Nearly 45% of AI/AN suicide decedents (compared with 18.7% of non-AI/AN suicide decedents) lived in nonmetropolitan areas. AI/AN suicide decedents had higher odds of dying by hanging, strangulation, or suffocation (aOR = 1.8) and lower odds of dying from a firearm injury (aOR = 0.7) compared with non-AI/AN decedents. AI/AN suicide decedents also had higher odds of dying in a natural area (e.g., field; aOR = 1.4) or supervised facility (e.g., prison; aOR = 2.0) compared with non-AI/AN suicide decedents.

The circumstances of suicide were known for 86% of AI/AN and 89% of non-AI/AN decedents (Table 2). AI/AN decedents were more likely than were non-AI/AN decedents to disclose suicidal intent before death (aOR = 1.2) and to have had previous suicidal thoughts or plans (aOR = 1.1), but they were less likely to leave a note (aOR = 0.7). Nearly 55% of AI/AN suicide decedents experienced any relationship problems or losses before their death, compared with 42.2% of non-AI/AN decedents (aOR = 1.4). AI/AN decedents had increased odds of an additional nine of 14 relationship problems, including higher odds of intimate partner problems (aOR = 1.4), family relationship problems (aOR = 1.2), other relationship problems (aOR=1.4), interpersonal violence victimization (aOR = 2.7) and perpetration (aOR = 1.6) within the preceding month, suicide of a friend or family member (aOR = 1.6), and arguments or conflicts preceding death (aOR = 1.6). Conversely, AI/AN suicide decedents had decreased odds of physical health, job, and financial problems than did non-AI/AN decedents (aOR range = 0.6–0.8).

Approximately one third of AI/AN (31.8%) and non-AI/AN suicide decedents (29.7%) had experienced a crisis within the preceding 2 weeks or anticipated a crisis in the upcoming 2 weeks; AI/AN decedents had higher odds of having experienced crises involving intimate partners and recent suicide of friends or family members as well as crises involving criminal legal problems than did non-AI/AN decedents (aOR range = 1.2–3.8). In addition, AI/AN decedents had higher odds of six of seven alcohol or substance use problems including any current substance use problem (aOR = 2.0), a current alcohol (aOR = 2.3) or other substance use problem (aOR = 1.6), reported alcohol use hours before death (aOR = 1.9), and crises involving alcohol (aOR = 1.6). Among persons released from an institution within the month preceding death (196), 9.2% of AI/AN decedents had been in residential substance use treatment, compared with 5.5% of non-AI/AN decedents. The prevalences of known mental health diagnoses (41.5%; [aOR = 0.7]) and history of mental health or substance use treatment (29.5%; [aOR = 0.7]) were lower among AI/AN decedents than among non-AI/AN decedents (49.2% and 35.1%, respectively).

Toxicology testing was performed for 66.6% of AI/AN suicide decedents and 61.1% of non-AI/AN decedents (Table 3). Overall, AI/AN decedents had higher odds than did non-AI/AN decedents of receiving a positive test result for at least one substance (aOR = 1.2), blood alcohol concentration of ≥0.08 g/dL (aOR = 2.3), amphetamines (aOR = 1.5), and marijuana (aOR = 1.5). Conversely, AI/AN decedents had lower odds than did non-AI/AN decedents of receiving a positive test result for opioids (aOR = 0.5), benzodiazepines (aOR = 0.4), cocaine (aOR = 0.5), antidepressants (aOR = 0.6), antipsychotics (aOR = 0.7), and barbiturates (aOR = 0.3).

Acknowledgments

Carter Betz, Division of Violence Prevention, National Center for Injury Prevention and Control, CDC; Mark Stevens, Division of Injury Prevention, National Center for Injury Prevention and Control, CDC.

Corresponding author: Deborah Stone, zaf9@cdc.gov, 770-488-3942.

¹Division of Injury Prevention, National Center for Injury Prevention and Control, CDC; ²Indian Health Service, Rockville, Maryland; ³Division of Violence Prevention, National Center for Injury Prevention and Control, CDC.

References

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Abbreviations: AI/AN = American Indian or Alaska Native; aOR = adjusted odds ratio; RUCA = rural-urban commuting area.
* Denominator includes all suicide decedents.
^† Pearson’s chi-square test p-value for difference between AI/AN and non-AI/AN populations.
^§ aORs measure the association between the decedent having the demographic or incident characteristic and the race of the decedent being AI/AN. Each aOR used non-AI/AN as the referent group and controlled for age group and sex. Therefore, aORs for age groups and sex are not presented.
^¶ p<0.05 for aOR significance test.
** Zip code RUCA codes (2010) were used to determine whether a decedent lived in a nonmetropolitan versus a metropolitan area. Decedent residential zip codes were dichotomized as metropolitan (RUCA codes 1–3) and nonmetropolitan (RUCA codes 4–10). https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/documentation/
^†† Includes suicides that occurred in a motor vehicle, street, highway, parking lot or garage, public transport, railroad tracks, or bridge.
^§§ Includes suicides that occurred on a beach or in a river, field, or woods.
^¶¶ Includes suicides that occurred in jail, prison, or supervised residential facility.
*** Includes suicides that occurred in industrial or construction sites or an abandoned house, building, or warehouse.

Abbreviations: AI/AN = American Indian or Alaska Native; aOR = adjusted odds ratio.
* Denominator includes all suicide decedents.
^† Pearson’s chi-square test result for difference between AI/AN and non-AI/AN populations; Fisher’s exact test when one or more of the cell counts in a 2×2 table is <5.
^§ aORs measure the association between the decedent having the precipitating circumstance present and the race of the decedent being AI/AN. Each aOR used Non-AI/AN as the referent group and controlled for age group and sex.
^¶ Denominator includes only suicides with one or more precipitating circumstance, unless otherwise noted. Sum of percentages in columns might exceed 100% because a suicide could have more than one precipitating circumstance.
** p<0.05 for aOR significance test.
^†† Denominator includes only those suicides in which argument or conflict preceded death.
^§§ Denominator includes only those decedents released from an institution within the previous month.
^¶¶ Supervised residential facilities not related to alcohol or substance use treatment, and other or unknown type of institution.
*** Denominator includes only decedents aged ≥18 years with at least one known circumstance.
^††† Denominator includes only decedents aged 10–17 years with at least one known circumstance.
^§§§ Denominator includes only those suicide decedents with any crisis within the past or upcoming 2 weeks.

Abbreviations: AI/AN = American Indian or Alaska Native; aOR = adjusted odds ratio.
* Denominator includes all suicide decedents.
^† Pearson’s chi-square test result for difference between AI/AN and non-AI/AN populations.
^§ aORs measure the association between the decedent receiving a positive test result for the substance and the race of the decedent being AI/AN. The denominator was the number of decedents who were tested for each substance. Each aOR used non-AI/AN as the referent group and controlled for age group and sex.
^¶ p<0.05 for aOR significance test.
** Denominator is decedents with any toxicology testing.
^†† Blood alcohol concentration of ≥0.08 g/dL is higher than the legal limit in all states and the District of Columbia and is used as the standard for intoxication.
^§§ Denominator for each positive result group is the number tested for the substance in that group.