Xiao Jun (John) Wen, MD; Chaoyang Li, MD, PhD; Guixiang Zhao, MD, PhD; Alexander E. Crosby, MD, Matthew M. Zack, MD, MPH; Lina Balluz, Sc.D. MPH

Centers for Disease Control and Prevention

Presented on June 11, 2013, CSTE Annual Conference 2013, Pasadena, CA

Socioeconomic status and anxiety/stress/depression are associated with suicidal thoughts among adults

who served in the U.S. military: A latent class analysis

Office of Surveillance, Epidemiology, and Laboratory Services

Public Health Surveillance Program Office

BackgroundSuicide mortality among veterans and active military in the U.S has been a national concern in recent years

Data source: VA http://www.va.gov/opa/docs/Suicide-Data-Report-2012-final.pdf. Death per 100,000

BackgroundPredictors for suicide death among veterans and active military in the U.S:

- Being male, white, single, unemployed, and depressed - Risk factor assessments are usually done by multivariate

logistic regression models

BackgroundLimitations of single-indicator modeling:

- It does not fully account for the correlation and overlap among individual suicide risk factors

- Examples - Social economic status: employment and annual

income level - Mental health status: depressive disorders, depression,

anxiety, post-traumatic stress disorder- A risk factor may include multiple indicators, or it is a class

of multiple factors in the same domain. Such risk factor can be very difficulty to handle by a single-indicator modeling approach

BackgroundTo identify class variables in the domains of socioeconomic status and mental health status as potential correlates of suicidal thoughts

MethodsData source

Behavioral Risk Factor Surveillance System (BRFSS) 2011 dataOptional model Sample used in the analysis

-6,884 adult respondents who had served in the U.S. military (did not include those in training for the Reserves or National Guard and also excluded those who refused or answered “do not know” to the question about suicide thoughts)-Both landline and cell phone-Nine states participations (Alaska, Kansas, Louisiana, Maine, Nebraska, Nevada, New Jersey, North Carolina, and Tennessee)

MethodsOutcome variable: suicidal thoughts

Question asked about it: “Has there been a time in the past 12 months when you thought of taking your own life?”

MethodsQuestions asked about the economic status:

Employment: “Are you currently…? (multiple choices on employment)”Annual income: “(How much) is your annual household income from all sources?”Home ownership: “Do you own or rent your home?”

MethodsQuestions about mental health and treatment:

“(Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?” (core questionnaire)“Has a doctor or other health professional ever told you that you have depression, anxiety, or post traumatic stress disorder (PTSD)?”“In the past 12 months, did you receive any psychological or psychiatric counseling or treatment?”

MethodsModeling of the Latent class variables

Indicators Domains Outcome Covariates

Social economic

Mental health

• Employment• Annual income• Home ownership

• Depression/anxiety• Depression/

anxiety/• PTSD• Received

counseling treatment

Suicidal thoughts

• Age

• Sex

• Marital status

• Health insurance coverage

• Smoking

• Physical activities

• Self-rated health

• Disability

• Traumatic brain injury

Latent class variables

Methods • Probabilities of being at the low socioeconomic class by

latent class analysis

Unmployed or unable to work Household annual income <$25,000

non-home owner0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Non-low social class - 86.4% of the sampleLow social class - 13.6% of the sample

Member of latent class in socioeconomic domain

Prob

abili

ties

MethodsProbabilities of high risk of mental health by latent class analysis

Depression Anxiety/depression/PTSD Received counseling/treatment0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Mentally healthy class - 88.0% of the sample

Member of latent class in mental health domain

Prob

abilt

ies

MethodsTable 1 Fit of latent class models using Bayesian information criterion (BIC) and quality of models for health-related domains, Behavioral Risk Factor Surveillance System (BRFSS), 2011

No. of classes in the model

Health-related Domain

Socioeconomic class Mental health

  BIC Entropy BIC Entropy

1 19070.31 n/a 15823.40 n/a

2 18136.74 0.70 12154.23 0.92

3 18172.13 0.50 12189.62 0.83

4 18207.53 0.54 12225.02 0.95

ResultsTable 2 Prevalence of self-reported suicidal thoughts by demographics, socioeconomic and mental health status, and risk factors among adults who served in the military, from nine states in U.S., 2011

Variable Unweighted sample No. * (%)Overall 6884 (100.0) 18-34 years old 258 (12.6) 35-54 years old 1183 (27.5) 55+ years old 5443 (60.0) Men 6342 (92.6) women 542 (7.4) Non-Hispanic white 5950 (79.3) Non-white 934 (20.7) Married 4486 (68.1) Previously married 1981 (22.2) Never married 417 ( 9.7) Employed 2458 (44.6) Unemployed 268 (6.3) Homemaker/student 93 (2.9) Retired 3617 (39.2) Unable to work 432 ( 7.2) education attainment 12 yrs or less 2445 (41.9) Some college or higher 4423 (58.1) Not covered by health plan 418 ( 8.8) Covered by health plan 6458 (91.2) Self-rated fair/Poor Health 1572 (21.4) Self-rated good/Excellent Health 5279 (78.6) With disability 2563 (33.3) No disability 4289 (66.7) Smoker 1090 (20.0) Former smoker/Never smoked 5766 (80.0)

ResultsTable 2 Prevalence of self-reported suicidal thoughts by demographics, socioeconomic and mental health status, and risk factors among adults who served in the military, from nine states in U.S., 2011

Non-binge drinker 6019 (87.4)Binge drinker 732 (12.6)non-heavy drinker 6397 (94.7)Heavy drinker 345 (5.3)Physically active in leisure time 4933 (71.6)Not physically active in leisure time 1938 (28.4)Served in combat/war zone 2751 (41.8)Not served in combat/war zone 4133 (58.2)Had traumatic brain injury 225 (3.7)No traumatic brain injury 6640 (96.3)Socioeconomic class latent variable ┼   Non-low socioeconomic class 6126 (86.4) Low socioeconomic class 758 (13.6) Unemployed or unable to work 700 (13.4) Employed/retired/students/home maker 6168 (86.6) Household annual income <$25,000 1541 (24.4) Household annual income $25,000 +/unknown 4561 (75.6) Not own a home 990 (18.7) Own a home 5894 (81.3)Mental health latent variable ╫   Mentally healthy class 6150 (88.0) Mentally unhealthy class 734 (12.0)Had anxiety/depressive disorder 981 (15.0)No anxiety/depressive disorder 5872 (85.0)Had depression/anxiety/PTSD 895 (14.3)No depression/anxiety/PTSD 5955 (85.7)Received counseling in past 12 months 502 (9.2)Not received counseling in past 12 months 6368 (90.8)

ResultsTable 2 Sample descriptive statistics by demographics, socioeconomic and mental health status, and risk factors among adults who served in the military, from nine states in U.S., 2011

Variable Prevalence % (95% CI) p-value PR % (95% CI)Overall 4.8 (3.9─5.8)   n/a 18-34 years old 9.2 (5.1─16.0) 0.0393 2.58 (1.38─4.82) 35-54 years old 5.3 (3.8─7.3) 0.075 1.49 (1.00─2.24) 55+ years old 3.6 (2.8─4.5) Reference Reference Men 4.7 (3.8─5.8)  >0.05 0.81 (0.47─1.39) women 5.8 (3.5─9.3) Reference Reference Non-Hispanic white 4.6 (3.6─5.7) Reference Reference Non-white 5.4 (3.4─8.5) 0.4831 1.19 (0.71─1.98) Married 3.6 (2.7─4.7) Reference   Previously married 6.8 (5.0─ 9.2) 0.006 1.89 (1.26─2.85) Never married 8.4 (4.3─15.6) 0.0863 2.35 (1.16─4.73) Employed 2.9 (1.9─4.5) Reference Reference Unemployed 16.0 (9.5─25.7) 0.0016 5.49 (2.83─10.64) Homemaker/student 5.2 (1.3─ 17.9) 0.5275 1.76 (0.44─7.07) Retired 3.2 (2.2─4.5) 0.7639 1.09 (0.62─1.90) Unable to work 14.8 (10.3─20.8) <0.0001 5.05 (2.89─8.80) education attainment 12 yrs or less 5.2 (3.7─7.3) 0.3791 1.21 (0.80─1.84) Some college or higher 4.3 (3.3─5.5) Reference Reference Not covered by health plan 14.5 (9.3─21.9) 0.0009 3.80 (2.34─ 6.19) Covered by health plan 3.8 (3.0─4.8) Reference Reference Self-rated fair/Poor Health 10.0 (7.5─13.3) <0.0001 2.99 (1.99─4.48) Self-rated good/Excellent Health 3.4 (2.5─4.4) Reference Reference With disability 8.7 (6.9─10.9) <0.0001 3.39 (2.19─5.24) No disability 2.6 (1.8─ 3.7) Reference Reference Smoker 8.3 (5.8─ 11.7) 0.0055 2.11 (1.37─3.25) Former smoker/Never smoked 3.9 (3.0─5.0) Reference Reference

ResultsTable 2 Prevalence of self-reported suicidal thoughts by demographics, socioeconomic and mental health status, and risk factors among adults who served in the military, from nine states in U.S., 2011

Non-binge drinker 4.2 (3.4─ 5.3) Reference ReferenceBinge drinker 7.9 (4.8─ 12.8) 0.0708 1.88 (1.09─3.24)non-heavy drinker 4.7 (3.8─5.7) Reference ReferenceHeavy drinker 7.5 (3.2─16.7) 0.3769 1.61 (0.68─3.82)Physically active in leisure time 3.7 (2.8─4.9) Reference ReferenceNot physically active in leisure time 7.4 (5.5─9.8) 0.0033 1.97 (1.31─2.96)Served in combat/war zone 4.8 (3.5─6.6) 0.9359 1.02 (0.67─1.54)Not served in combat/war zone 4.7 (3.6─6.1) Reference ReferenceHad traumatic brain injury 12.9 (7.1─22.3) 0.0261 2.90 (1.57─5.36)No traumatic brain injury 4.4 (3.6─5.5) Reference ReferenceSocioeconomic class latent variable ┼       Non-low socioeconomic class 3.3 (2.6─4.2) Reference Reference Low socioeconomic class 13.9 (9.8─19.4) <0.0001 4.21 (2.76─6.40) Unemployed or unable to work 15.4 (11.3─20.6) Reference Reference Employed/retired/students/home maker 3.1 (2.4─4.1) <0.0001 4.93 (3.28─ 7.42) Household annual income <$25,000 9.1 (6.7─12.3) 0.0001 2.92 (1.92─4.43) Household annual income $25,000 +/unknown

3.1 (2.4─4.1) Reference Reference

Not own a home 9.0 (6.2─12.9) 0.0032 2.38 (1.53─3.70) Own a home 3.8 (3.0─4.8) Reference ReferenceMental health latent variable ╫       Mentally healthy class 2.4 (1.8─3.2) Reference Reference Mentally unhealthy class 22.1 (17.0─28.1) <0.0001 9.21 (6.23─13.62)Had anxiety/depressive disorder 20.6 (16.2─25.9) <0.0001 10.61 (7.06─ 15.94)No anxiety/depressive disorder 1.9 (1.4─2.7) Reference ReferenceHad depression/anxiety/PTSD 18.9 (14.6─24.2) <0.0001 7.93 (5.32─11.82)No depression/anxiety/PTSD 2.4 (1.8─ 3.2) Reference ReferenceReceived counseling in past 12 months 22.3 (16.4─29.5) <0.0001 7.75 (5.22─11.50)Not received counseling in past 12 months 2.9 (2.2─3.7) Reference Reference

ResultsTable 3 Adjusted Prevalence ratios of self-reported suicidal thoughts by latent classes of

socioeconomic and mental health determinants among adults served in the military, from nine states in U.S., 2011

Variable Model 1 Model 2 Model 3Socioeconomic class latent variable ┼       Non-low socioeconomic class Reference n/a Reference Low socioeconomic class 1.60 (1.04─2.45) n/a 1.23 (0.83─1.81)Mental health latent variable ╫       Mentally healthy class n/a Reference Reference Mentally unhealthy class n/a 5.89 (3.69─9.38) 5.73 (3.59─9.15) Aged 18-34 yrs 2.22 (1.10─4.49) 1.79 (0.96─3.36) 1.79 (0.95─3.35) Aged 35-54 yrs 1.54 (1.01─2.35) 1.39 (0.90─2.12) 1.36 (0.89─2.08) Aged 55+ Reference Reference Reference Men 1.31 (0.71─2.43) 1.78 (0.95─3.34) 1.74 (0.94─3.23) women Reference Reference Reference Married Reference Reference Reference Previously married 1.56 (1.03─2.35) 1.69 (1.14─2.49) 1.60 (1.06─2.43) Never married 1.58 (0.81─3.07) 1.64 (0.86─3.14) 1.54 (0.78─3.04) Not covered by health plan 2.31 (1.44─3.71) 3.09 (1.94─4.92) 2.89 (1.88─4.45) Covered by health plan Reference Reference Reference Self-rated fair/Poor Health 1.76 (1.09─2.83) 1.50 (0.93─2.40) 1.46 (0.91─2.36) Self-rated good/Excellent Health Reference Reference Reference With disability 2.54 (1.47─4.41) 1.76 (1.03─3.01) 1.74 (1.02─2.99) Without disability Reference Reference Reference Smoker 1.28 (0.82─1.99) 1.15 (0.76─1.76) 1.14 (0.76─1.73) Former smoker/Never smoked Reference Reference Reference Physically active in leisure time Reference Reference Reference Physically inactive in leisure time 1.32 (0.89─1.94) 1.47 (1.03─2.11) 1.44 (1.00─2.07) Had dramatic brain injury 1.66 (0.84─3.28) 1.12 (0.57─2.19) 1.10 (0.55─2.16) No dramatic brain injury Reference Reference Reference

DiscussionsWe identified two latent class variables that are associated with suicidal thoughts

- Being a member of lower socioeconomic class

- Being a member of mentally unhealthy class

Discussions

We also identified several individual risk factors that are associated with suicidal thoughts:– No healthcare coverage– Self-rated poor/fair health statusBased on our knowledge, they have not been reported in the literature.

Discussions• Strength of the analysis:- Examined the likelihood of being a member

of lower socioeconomic class and mentally unhealthy class

- Using these valid latent class variables as independent variables to identify potential indicators of the suicidal thoughts

- Modeling results indicate that being a member of lower socioeconomic class or of mentally unhealthy class is more likely to report suicidal thoughts

Discussions• Strength of the analysis:– Latent class variable modeling approach

counted for the correlation and overlap among individual suicide risk factors

– Overcame some of the limitations from the single-indicator modeling approaches

– Filled some information gaps about suicidal thoughts among old-aged veterans and active military: • Majority of the respondents (60%) in this analysis

were aged 55 years old or above and recent publications only focused on younger veterans and active military

DiscussionsLimitations of the analysis:– selection bias:

-Those with no phone were not included-Those who were institutionalized due to very poor mental health status

– Recall bias:-Self-reported data

– Social desirability bias -Very sensitive question was asked– Cross sectional analysis:

- Cause-effects relationship should not be inferred

Conclusions• Our latent-class modeling approach has

identified that socioeconomic and mentally unhealthy status among adults are strongly associated with suicidal thoughts. Suicide prevention programs should focus on adults in this group.

• It may also be useful in identifying other potential risk factors that are difficult to do so by the conventional single-indicator modeling approaches.

Thanks• To your attention• To all of my coauthors:

– Chaoyang Li, MD, PhD – Guixiang Zhao, MD, PhD – Alexander E. Crosby, MD – Matthew M. Zack, MD, MPH – Lina Balluz, Sc.D. MPH

Contact Information

John WenEnvironmental Health Tracking

BranchDivision of Hazards and Health

EffectsNational Center for Environment

HealthCenters for Disease Control and

Prevention770-488-3984tzw4@cdc.gov