Asthma and suicide behaviors: Results from the Third National Health and Nutrition Examination Survey (NHANES III)☆
Introduction
Each year approximately 1,000,000 people die by suicide worldwide, accounting for nearly 3% of all deaths and 56% of all violent deaths in the world (Krug et al., 2002). Among 15–24 year olds, for every suicide death there are an estimated 100–200 attempts (Goldsmith et al., 2002), contributing to significant global morbidity, in addition to mortality. In the United States (US), suicide is the 11th leading cause of death overall and the 5th leading cause of death among US adults (Fields et al., 2001).
There is no single cause of suicidal behavior; suicide results from an interaction of multiple factors (Fields et al., 2001). The strongest and most common known risk factors for suicidal behavior are untreated mental disorders, including mood disorders (Bruce et al., 2004), substance use disorders (Sher, 2005, Wilcox and Anthony, 2004), schizophrenia (Murphy, 2000), history of suicide attempts (Brown et al., 2000, Goldstein et al., 1991), physical disease (Goodwin et al., 2003a) and poor coping skills (Catanzaro, 2000). Suicide attempts are strongly linked to death by suicide and are a significant predictor of further suicidal behavior (Larkin et al., 2008).
Asthma is a common chronic condition affecting an enormous number of adults in the US. Estimates show that the condition affects approximately 17.5 million adults (2010) and accounts for 1.6 million visits to the Emergency Department each year (Schappert and Rechtsteiner, 2008). Evidence increasingly suggests a link between asthma morbidity and depression (Bartlett et al., 2004, Fritz et al., 1996, Shalowitz et al., 2001, Weil et al., 1999).
A number of studies have found statistically significant links between asthma and suicide ideation (Druss and Pincus, 2000, Goodwin and Marusic, 2004) and suicide attempts (SA). One longitudinal (Goodwin and Eaton, 2005) and two cross-sectional (Clarke et al., 2008, Goodwin and Marusic, 2004) studies have shown links between asthma and suicide attempt in community-based samples of youth and adults in the US. A number of studies (Goodwin et al., 2003c) have also shown that, relative to other common, chronic physical conditions, the association between asthma or other respiratory disease and suicide behavior is much stronger, for reasons that remain unclear (Goodwin et al., 2002).
Methodological shortcomings of previous studies have resulted in a limited understanding of the association between asthma and suicidal ideation and suicide attempts among adults, due in part to limited measurement of potential confounders of these relationships. Specifically, measurement of cigarette smoking, which is associated with both asthma and suicide behavior, has been measured with lifetime retrospective recall, which is vulnerable to self-report bias. Numerous studies have linked smoking with increased rates of adult asthma and asthma morbidity (McLeish and Zvolensky, 2010). Findings also suggest a strong relationship between smoking and risk of suicide behavior (Boden et al., 2008, Hughes, 2008, Riala et al., 2009, Schneider et al., 2005). Therefore, it is conceivable that the relationship between asthma and suicide behavior is due to confounding by cigarette smoking. In addition, previous studies have not examined the potential role of poverty in the link between asthma and suicide behavior. Asthma is disproportionately common among youth and adults living in poverty in the United States; depression and suicide behavior are also significantly more common among lower socioeconomic segments of the population. Therefore it is possible that lack of inclusion of poverty in previous studies has led to results that can be explained by confounding (Akinbami et al., Ferretti and Coluccia, 2009, Nikiema et al., Rojas and Stenberg).
Against this background, the proposed study aims to begin to fill these gaps. First, we will investigate the relationship between asthma and suicidal ideation among adults in the United States. Second, we will examine the relationship between asthma and suicide behaviors. Third, we will adjust for cigarette smoking, measured via blood cotinine level, and poverty, as well as other potential demographic confounders.
Section snippets
Sample
The Third National Health and Nutrition Examination Survey (NHANES) III used complex, multi-stage, stratified, clustered samples of civilian, noninstitutionalized populations to obtain a representative sample of the US population ages 2 months and older (1994). In addition, to ensure the representativeness of both ethnicity and age, African Americans, Mexican Americans, infants, children, and those over sixty years old were oversampled. The proposed study included data from adults ages 18 and
General characteristics
The current report is based on 6584 participants who participated in the MEC examination, were administered the DIS and also had complete covariable data collection. Participants were mean age ± SD 29 ± 5 years and 55% were female. The prevalence of current or former asthma was 4% and 2% respectively, and 5% of participants reported an attempted suicide while 16% reported suicidal ideation. Only 1% of participants were determined to have had a non-severe or severe manic episode while a DSM-III
Discussion
Our results add to extant knowledge in three ways. First, our results show that current asthma, but not former asthma, is associated with suicidal ideation and suicide attempt. This is relevant for several reasons. From a clinical perspective, these data suggest that adults with current asthma may be at increased risk for suicide behavior, independent of mood disorders. Because a substantial percentage of individuals “outgrow” childhood asthma in early adulthood, this information is important
Contributors
Dr. Goodwin conceived of the study, planned original analyses and wrote the first draft of the manuscript; Drs Demmer, Galea, Lemeshow, Ortega, and Beautrais contributed to writing the manuscript and each made important contributions to the study design and interpretation of results; Dr. Demmer analyzed the data. Dr. Goodwin is the guarantor of the paper.
Funding
Work was supported by grant #DA20892 from NIDA to Dr. Goodwin.
Conflicts of interest
None.
Acknowledgments
We thank Jamie Chiel, who assisted with the preparation of the manuscript.
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