Study Suggests Unique Link between Homelessness and Suicide

BACKGROUND:
Over the past 20 years, suicide has consistently been one of the top 10 leading causes of death in the United States. While a large body of literature has identified several risk factors for suicide (i.e., mental illness, low-socioeconomic status, family history of suicide), suicide remains a major clinical challenge. Recognizing important sub-populations at risk is one area that needs further attention. Surprisingly, there have been few studies conducted on suicide among homeless populations, although evidence suggests suicide rates are much higher among those who are homeless or have been homeless. This study sought to replicate these previous findings with a larger, national population cohort. Using data on 36,155 adults (3,101 Veterans and 33,024 non-Veterans) who took part in the National Epidemiological Survey of Alcohol and Related Conditions-III (conducted between April 2012 and June 2013), investigators examined the association between lifetime homelessness and suicide. Other measures, in addition to medical and mental health comorbidities, included demographics, military history, geographic region, immigration status, public benefits, and health insurance.

FINDINGS:

• After controlling for common risk factors, results suggest a unique link between homelessness and suicide. Veterans with a history of homelessness were 8.8 times more likely to have attempted suicide than Veterans with no history of homelessness (25% vs. 3%).
• Among only non-Veterans, 23% of survey respondents with any lifetime homelessness reported lifetime suicide attempts compared to 5% of respondents without any lifetime homelessness.
• In the total study cohort, lifetime homelessness was significantly and independently associated with lifetime suicide attempts. The association between homelessness and suicide was stronger among Veterans than non-Veterans. Major depressive disorder, bipolar disorder, and borderline personality disorder were also strongly associated with lifetime suicide attempts.

IMPLICATIONS:

• VA and other healthcare systems may benefit from synergies developed between homeless and suicide prevention services in this era of integrated care.

LIMITATIONS:

• Lifetime homelessness since the age of 15 was assessed, but there is a body of literature showing childhood adverse effects including childhood homelessness are predictive of adult homelessness.
• Medical problems were based on self-report and so their validity is unknown.

AUTHOR/FUNDING INFORMATION:
Dr. Tsai is Director of Research for VA's National Center on Homelessness among Veterans. A former HSR&D Career Development Awardee, Dr. Tsai also is a core investigator with HSR&D's Pain Research, Informatics, Multi-Morbidities, and Education Center (PRIME), part of the VA Connecticut Health Care System.

Tsai J and Cao X. Association between Suicide Attempts and Homelessness in a Population-based Sample of US Veterans and Non-Veterans. Journal of Epidemiology and Community Health. January 2, 2019; Epub ahead of print.