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Social, Cultural, and Economic Determinants Related to Suicide, Panel 1

The first panel of speakers was introduced by moderator Debra Houry, who noted that the session’s overview of the evidence on social, cultural and economic determinants of suicide “will help us form the basis for much of what we’re doing.” Houry continued, “During today’s session our panels will share some of the risk and protective factors for suicide, and the factors related to suicide among the general population and veterans, as well as the implications for preventing suicide through interventions.” The panel included three panelists: Eric Elbogen (Duke University) presented on financial factors as significant social determinants of health, including risk of suicide morbidity (i.e., suicidal ideation, suicide attempt, and mortality linked with suicide); Sandro Galea (Boston University School of Public Health) provided an overview of social determinants of health and how they might be used in developing more effective interventions; and Irma Elo (University of Pennsylvania) provided an overview of trends in suicide mortality in the report High and Rising Mortality Rates Among Working-Age Adults (NASEM, 2021).

FINANCIAL WELLBEING AS A SOCIAL DETERMINANT OF SUICIDE RISK IN VETERANS

Elbogen began his discussion of financial wellbeing as one of multiple factors that form social determinants of health in relation to suicide risk among veterans by emphasizing the financial challenges that service members face at the point of separation from the military, often, becoming financially independent for the first time at a later age than their civilian counterparts. Veterans are more likely to incur debt and be delinquent on debt payments, he noted. Elbogen continued, these financial struggles occur alongside challenges in employability that veterans encounter as they transition out of the service; these might include the need to retrain to transfer work skills to the civilian sector, and physical and mental health injuries that might affect employability.

Such challenges are consequential, contributing to financial wellbeing as a social determinant of risk for suicide morbidity, Elbogen said. He cited a study whose “an extensive analysis [of VA medical records] confirmed that for veterans . . ., financial problems increased odds of suicidal ideation and suicide attempts significantly, even controlling for other risk factors” (Blosnich et al., 2019). This mirrors the link between financial strain and suicide evident in the general population, he noted (Richardson et al., 2013).

Elbogen stressed that financial wellbeing “doesn’t occur in a vacuum” but is part of a constellation of risk and protective factors. He pointed to findings in the National Post-Deployment Adjustment Survey (2020), a survey he led which investigated whether protective factors, including financial wellbeing, predicted suicidal ideation. The survey looked at eight psychosocial protective factors, some of which related to financial wellbeing, like employment and having money for basic needs. The study found having more of these eight psychosocial protective factors, including financial wellbeing, was associated with a significant drop in suicidal ideation one year later (from 60% for those having zero protective factors to 3% for those having all eight protective factors), Elbogen reported.

This was similar to findings within the general population, Elbogen said. His team looked at the National Epidemiologic Survey on Alcohol

and Related Conditions (NESARC), a survey of more than 34,000 people in the United States, conducted by the National Institutes of Health. This dataset showed that individuals with financial debt and crisis, a history of homelessness, and a history of unemployment, and were below median income were 20 times more likely to attempt suicide in the next three years compared with those who did not have any financial risk factors, Elbogen said. “The cumulative financial strain was significant even when controlling for depression, substance use, and history of suicide attempts and ideation.” Examination of this same NESARC dataset using machine learning by researchers at Columbia University identified the top 20 predictors of suicide attempts out of the 2,500 variables included in the dataset (de la Garza et al., 2021), said Elbogen. He observed that within the top 20 predictors, 4 had to do with financial strain, “showing that there is a link between financial strain and suicide risk” in the general population.

Elbogen then turned to financial strategies and money management interventions that have been used to address financial strain that, as a result, have the potential to decrease the risk of suicide. He cited a meta-analysis of 29 studies that showed that financial strategies do have a medium effect size in terms of reducing spending and increasing saving (Davydenko et al., 2021). Elbogen noted that this and other research shows the importance of establishing a specific reason for financial goals: “I’m saving up for X because I value Y.” This includes techniques like using technology to create an avatar of the user as an older person to concretize the idea of saving for the future, he said. $teps for Achieving Financial Empowerment ($AFE) is an intervention program developed by Elbogen and his team, funded by the Department of Education, to help veterans learn strategies that promote financial wellbeing. $AFE uses this same strategy of associating a financial goal with a psychosocial SMART goal. Elbogen emphasized that the importance here lies in the fact that these psychosocial goals add a sense of self-determination. He briefly listed other ways to help relieve financial strain for veterans, including helping veterans attain work, avoid scams, and access veteran-specific discounts (including awareness of a page on the VA website that lists available discounts).

Elbogen closed his presentation by reiterating that financial stability is one of many protective factors, and that “developing financial stability and other psychosocial protective factors can be viewed especially from the lens of social determinants of suicide as a critical part of community success.” He noted that things service members have when they are in the military—including stable housing, a job, social support, basic needs met, a sense of mission—may no longer be present when they transition into civilian life. Supporting the financial wellbeing of veterans (by connecting them to financial tools, financial resources, and financial education) “can provide an upstream approach to ultimately help prevent and reduce risk of suicide.”

SETTING THE STAGE: THE SIGNIFICANCE OF SOCIAL DETERMINANTS OF HEALTH

More attention needs to be paid to social determinants of health because they contribute “substantially more to health than does health care and medicine,” said Galea in his overview of the social determinants of health. He noted that in terms of the “production of health,” “health care is maybe 10 to 20 percent of health” while “most of our health actually comes from” socioeconomic factors, physical environment, and health behaviors (i.e., social determinants of health). However, in the United States, funding and support are focused primarily on health care, resulting in a mismatch between health determinants and health expenditures, with 90 percent of national health expenditures devoted to health care services and 9 percent to healthy behaviors, Galea said. This in turn results in “sicker and shorter lives,” where the United States lagged behind other countries in life expectancy (Roser, 2017). He called out the importance of this symposium’s focus on social determinants of health within the “array of factors that are relevant.”

Galea illustrated the importance of attending to social determinants of health by recounting the life of Blind Willie Johnson, a blues musician from Texas, born at the turn of the 20th century. Galea described a host of injuries and challenges Johnson encountered over the course of his life before dying at age 40 of malaria, after having been denied care when taken to a hospital. Galea observes that “it’s very clear that it wasn’t just malaria that killed Blind Willie Johnson;” social determinants of health—including domestic violence, homelessness, poverty, racism, poor access to health care—played a significant role. Focusing only on the prevention and treatment of malaria would not have given him a “healthier, longer life,” Galea argued, and noted that similarly, in the United States today,

focusing medicine and treatment alone will not lead to “longer, healthier lives. Ultimately, the social determinants are a nondiscretionary part of the determinants of health,” Galea summarized.

Galea presented a conceptual framework for thinking about “a full set of social determinants of health” and how different level forces interact with and influence one another (see Figure 2-1). Using this framework, Galea discussed four points about social determinants of health as they relate to suicide risk and prevention for veterans. The first point is that social determinants manifest over the life course. “We tend to think of veterans’ health or military health as indexed to military experience, and we tend to forget that the military experience actually is part of a full continuum of lifetime experiences.” To illustrate this, Galea pointed to a study that connected onset of depression with adverse childhood events within a National Guard cohort; though assessment might focus on military experiences, in fact “it is adverse events during childhood that matter” in this case.

Galea’s second point is that social support can be a protective factor in maintaining health in general. This can be seen in a study that looked at factors associated with deployment-related posttraumatic stress; this study

found an association between low levels of preparedness and support with high prevalence of posttraumatic stress disorder (PTSD). Galea also pointed to a study showing that low social support “is substantially associated with greater risk of suicidal ideation.”

The third of these four points Galea makes is that when investigating the social determinants of suicide, one must also attend to the determinants of other mental health disorders that are themselves determinants of risk—that is, “the full range of mental health factors that are coincident with, and some antecedent to, suicidal ideation.” For example, one study shows that those with PTSD are four times more likely to report suicidality than those without, said Galea, while those with PTSD and two or more other disorders are eight times more likely to report suicidality than those without.

Galea’s fourth and final point had to do with “ubiquity” which he defined as “forces that are present everywhere.” Ubiquity, he said, describes social determinants that are “all around us” and sometimes, because of this, “very hard to think of them.” He gave the example of loneliness and isolation as contributing factors in the increase in drug overdose deaths in the past year. Ubiquity describes “something that has deep impact that we actually don’t think about,” he explained.

Galea closed with a reiteration of the importance of social determinants and the problems with basing public health solutions primarily on medical treatments. He illustrated this through a brief recounting of an ongoing argument about the causes of starvation among children that unfolded between two public health advocates in 19th-century England, Edwin Chadwick and William Farr. Farr showed that poverty was a significant contributor to childhood death in England; Chadwick focused on micronutrient deficiency as the cause of death. Galea noted that both are right, but that interventions centered primarily on correcting a micronutrient deficiency would not actually address the problem in a complete way. Similarly, “we as a society tend to privilege thinking about and talking about our biomedical approach, a pillable approach, and tend to under-privilege conversation about all these other forces.” Noting that this is not an “either/or argument” between a biomedical approach and engagement with social determinants, Galea urged the development of “comprehensive approaches” that bring to bear “this full range of determinants.”

OVERVIEW OF TRENDS IN SUICIDE IN HIGH AND RISING MORTALITY RATES AMONG WORKING-AGE ADULTS

Elo presented findings on trends in suicide mortality in High and Rising Mortality Rates Among Working-Age Adults (NASEM, 2021), a consensus study report by the National Academies of Sciences, Engineering, and Medicine, in the third panel of this session. This study was guided by a framework of social determinants of health and provides insight into increasing mortality rates among middle-aged Americans, “particularly from causes referred to as “deaths of despair” that included suicide, alcohol-related causes, and drug overdose.” While it did not focus on veterans’ suicide, many of the factors visible in this big-picture view pertain to veterans as well, Elo said.

The study was designed to investigate possible causes behind “big increases” in mortality rates and a decline in U.S. life expectancy from 2014 to 2018, Elo explained. She set the stage by reviewing these data, which show that deaths from substance abuse and mental health (including drug poisoning, alcohol-induced death, mental and behavioral causes, and suicide) “were the main reasons” for decline in U.S. life expectancy during this time. Changes in mortality as seen in standardized death rates between 1990 and 2017 show widespread increases across three age groups spanning 25 to 64: non-Hispanic White males, non-Hispanic Black males, and Hispanic males; data for females is similar. Elo called out the particularly big increase in death by drug poisoning, which included suicide by drug poisoning, for women ages 25–44. Turning to suicide mortality particularly, she noted that rates increased in almost all states with some variation across the country, particularly for ages 25–65, and especially in rural areas.

Elo said that the committee’s approach to analysis relied on a “comprehensive framework” of social determinants of health. This included attending to upstream factors (e.g., social, political, and cultural contexts that included such things as federal, state, and local policies; corporate and business practices; social and economic inequality; and culture) and “meso-

level structural factors” (e.g., family context, social networks, work environments, health care, physical and built environment), and their effects on individual and proximate determinants of health. The committee similarly took a big-picture approach in considering experiences and factors across the life course, including early life.

Elo reports that the committee found that explanations for suicide centered on four factors:

1. Mental and emotional health
2. Economic factors
3. Social engagement, religious participation, and social support
4. Access to lethal means

Elo elaborated briefly on each of these areas. She noted that in the area of mental and emotional health, the committee “witnessed [a] rise in hopelessness, stress, and poor mental health,” including an increase in stressful life events, in the United States during this period of time. She listed other factors that increase individuals’ risk of suicide, including psychiatric disorders, impulsivity, prior suicide attempts, and family history of suicide. These factors also interact with broader cultural, social, and economic contexts, she noted.

Of economic factors, Elo said, “very few studies looked at causal processes; however, there is ample evidence that there is a strong association between economic disruptions, financial strain, and suicide.” Within this area, she said, the committee identified factors related to employment, such as loss of manufacturing and mining jobs in rural areas and wage stagnation or decline, as well as housing foreclosure rates and changes to social safety net programs. Many of these factors had a stronger association with individuals with lower levels of schooling, she said.

Trends in various forms of social engagement, religious participation, and social support were also offered as possible explanations for rising suicide rates during the period of study, Elo said. These included loss of social networks concomitant with job loss, a decline in civic participation, decreases in religious affiliation and church attendance, and, at the family level, increasing divorce rates and increases in single-parent families. In general, “much of the social and cultural trends have diminished access to social support” that would be a protective factor against suicide.

Access to lethal means is a major factor in suicide rates, said Elo. She noted the strong association between firearm availability and suicide rates, pointing to data that show that states with looser gun regulations also tend to have higher firearm-related rates of suicide. Firearm-related suicides are much higher in rural areas, and more prevalent among men, she continued. Elo also noted increases in the use of other modalities that contribute to the

overall increase in rates of suicide. These include higher rates for suicide by drug poisoning, especially by women.

Elo closed her presentation by mentioning that data from 2019 and 2020 “suggest suicide mortality has not increased during the pandemic, perhaps contrary to our expectations.”

DISCUSSION

The discussion began with a question from committee member Rajeev Ramchand, who brought up the interplay between financial stress and mental health and, within that, the role of mental health workers in helping veterans navigate financial stressors as part of mental health care. Elbogen noted that psychologists might be involved “to the extent that financial stressors begin to interact with mental health problems.” But he emphasized the importance of knowing the limits of psychological treatment and making referrals to financial experts in cases where the area of need extends beyond the realm of mental health.

Strauman noted the huge range of social determinants mentioned in the three presentations and wondered about raising awareness around the fact that there is such a big range of factors and broadening the general understanding of what these many factors are. He added that if the “word already is out,” what could be done to help systematize and support this message. Galea responded by emphasizing how difficult it can be to communicate about that health “inextricable” from socially determined factors, but that the present social movements and social context may be a turning point, with “disgust” about racial and economic inequities around COVID-19 acting as a catalyst for including social determinants in conversations about health. It is, he argued, “our collective responsibility” to include social determinants in discussions about health so as to create “political pressure . . . to act on the social determinants.” Elo concurred, remarking “I do think that a lot of it depends on political will to do something about it.” She voiced some skepticism over whether recent attention to social determinants of health “will translate into real action given the biomedical community’s bigger presence in the political discussions,” but noted that “I think it does take all of us to make that happen.” And she reiterated the statement that “until social determinants of health are better addressed, the United States continues to fall behind” in life expectancy. Elbogen referenced fundamental attribution errors (i.e., focusing on individual characteristics at the expense of broader contextual determinants) as one possible reason for the tendency to ignore social determinants. Evelyn Lewis added that awareness around the importance of social determinants—in all their various forms—has been raised again and again over the years in piecemeal ways that rarely impact “upstream” issues such as

medical training; she remarked that this perspective needs to be “integrated into the full spectrum of what [medical personnel, all members of the medical team] needs to be considered during their patient interactions” if any lasting downstream results are to be expected. Galea reinforced this, noting, “in the broader conversation, we keep thinking that if we just act good enough downstream, it’s going to be good enough.” Blosnich pointed to the importance of social workers within the medical infrastructure as those trained in connecting people to resources.

Subsequent discussion points included the existence of financial education offered to veterans by the military through the Office of Financial Readiness; the research potential of a question that asks, are there “sets of social circumstances,” including adverse child experiences, that then contribute to putting people in harm’s way—that is, making them “more at risk for other adverse social circumstances,” said Galea; and the importance of support, connectedness, and belonging in combatting adverse circumstances but also—with the creation of an in-group, or clique—exacerbating them. The final point of discussion Houry raised for this panel was the future of veteran suicide prevention. Galea emphasized bridging the VA and community efforts, and making sure that veterans return to supportive community. Elbogen emphasized the interrelationship of protective factors, and pointed to the importance of encouraging “that underlying sense of self determination, control, and hope in the future.” Elo mentioned the potential of targeted interventions for individuals; such interventions would be built on knowledge of specific risk factors associated with a higher risk of suicide.

Strauman closed the panel by pointing to the potential of interdisciplinary collaboration; “extending suicide prevention to include (from an academic perspective) disciplines like sociology, anthropology, nursing, economics” has the potential to “include a really broad base of community stakeholders.”