Discussion

In this nationally representative sample of US adults from 2009 to 2020, Black and Hispanic individuals were significantly less likely than White individuals to report past-year SI but among individuals with past-year SI, were significantly more likely to report a past-year SA, a result that was essentially unchanged after controlling for a large number of potentially confounding sociodemographic and clinical factors. Stated differently, Black and Hispanic individuals report less frequent thoughts of suicide than White individuals but when they do, they are more likely to report active attempts. Stark differences were also found in use of mental health services with less use by Black and Hispanic individuals. However, interaction analyses suggested no significant relationship between service use and racial/ethnic differences in SI or SA. There were few significant differences between racial/ethnic groups who did not use mental health services in the reasons for not using such services. Black and Hispanic individuals were more likely to report not knowing where to go for treatment and Hispanic individuals were more likely to report concerns about stigma.

While much attention has been focused on the recent increase in SAs and suicide deaths among Black adolescents (Congressional Black Caucus, 2019; Xiao, Cerel, & Mann, Reference Xiao, Cerel and Mann2021), very little attention has been paid to racial/ethnic differences in suicidal behavior among adults, despite the observed increase in suicide rates among Black and Hispanic adults in data from the National Center for Health Statistics (Curtin, Reference Curtin2022; Garnett et al., Reference Garnett, Curtin and Stone2022). Our results provide updated epidemiologic estimates of racial and ethnic differences in past-year SI and SAs and are believed to be the first study in adults to show that among individuals with past-year SI, Black adults may be more likely than Whites to report a past-year SA. These findings are consistent with several recent studies of adolescents showing that Black and Hispanic adolescents are less likely to report past-year SI but may be more likely to report SAs (Lindsey, Sheftall, Xiao, & Joe, Reference Lindsey, Sheftall, Xiao and Joe2019; Romanelli, Xiao, & Lindsey, Reference Romanelli, Xiao and Lindsey2020; Xiao, Romanelli, & Lindsey, Reference Xiao, Romanelli and Lindsey2019). Data from older epidemiologic surveys of adults, including the ECA, NCS, and NCS-R, either found no significant racial/ethnic difference or greater rates of SAs among White adults (Baca-Garcia et al., Reference Baca-Garcia, Perez-Rodriguez, Keyes, Oquendo, Hasin, Grant and Blanco2010; Kessler et al., Reference Kessler, Berglund, Borges, Nock and Wang2005; Moscicki et al., Reference Moscicki, O'Carroll, Rae, Locke, Roy and Regier1988; Olfson et al., Reference Olfson, Blanco, Wall, Liu, Saha, Pickering and Grant2017). In addition, data from the NSAL and NLAAS examined lifetime SI and SAs but did not directly compare suicidal thoughts/behavior across racial/ethnic groups (Cheng et al., Reference Cheng, Fancher, Ratanasen, Conner, Duberstein, Sue and Takeuchi2010; Joe et al., Reference Joe, Baser, Breeden, Neighbors and Jackson2006, Reference Joe, Baser, Neighbors, Caldwell and Jackson2009). It is important to note that our findings on SAs do not generalize to the general population as past-year SAs were only assessed among individuals who reported past-year SI, not among the entire survey sample. Another potential explanation for our diverging results include the possibility that SAs among Black individuals may have disproportionately increased in recent years compared to other racial groups, although we did not find evidence supporting this possibility. This explanation may find support from the finding of a recent study that past-year SAs among Black adults with MDE have nearly doubled and increased more than any other demographic subgroup (Bommersbach, Rosenheck, & Rhee, Reference Bommersbach, Rosenheck and Rhee2022b) [under review]. It is also possible that, even in the absence of a differential temporal trend, our use of a larger sample size resulted in greater power to detect differences between racial/ethnic groups.

Our results demonstrating that when Black and Hispanic individuals report suicidality, they are much more likely to report more severe suicidal behavior and less likely to report SI, and it is alarming given the recent rise in suicide deaths among Black and Hispanic individuals (Curtin, Reference Curtin2022). An often-cited explanation for this rise in suicide is that minoritized populations may be less likely to receive mental health care when experiencing suicidality, either due to reduced help-seeking behavior (Taylor & Kuo, Reference Taylor and Kuo2019), concerns about stigma (Nadeem et al., Reference Nadeem, Lange, Edge, Fongwa, Belin and Miranda2007), greater comfort with alternative treatment options, or structural barriers (Lillie-Blanton & Hoffman, Reference Lillie-Blanton and Hoffman2005). While our results demonstrate that Black and Hispanic individuals are less likely to receive mental health services, this did not account for the greater frequency of SA. Thus, other explanations are likely contributing to these findings.

Reporting styles may partially explain these results. Black and Hispanic individuals may be less likely to report suicidal thoughts or behavior until they reach a more severe threshold, either due to differences in socio-cultural norms for the expression of distress, perhaps reflecting greater mental health stigma. Our study clearly found Hispanic individuals experiencing suicidality were particularly concerned about stigma. Second, it is possible that disparities in aspects of service use not measured in this study may contribute to the findings. For example, Black and Hispanic individuals may be less likely to receive evidenced-based treatment or timely treatment in proximity to need, either due to possible provider bias and structural racism or less frequent expression of suicidality, as our study may suggest (Wang et al., Reference Wang, Lane, Olfson, Pincus, Wells and Kessler2005). Prior studies have demonstrated that Black patients are more likely to experience mental health treatment delays, less likely to receive prescription medication for depression, and report less satisfaction with services (Alegria et al., Reference Alegria, Chatterji, Wells, Cao, Chen, Takeuchi and Meng2008; Bommersbach, Jegede, Stefanovics, Rhee, & Rosenheck, Reference Bommersbach, Jegede, Stefanovics, Rhee and Rosenheck2022a; Cook et al., Reference Cook, Zuvekas, Carson, Wayne, Vesper and McGuire2014, Reference Cook, Hou, Lee-Tauler, Progovac, Samson and Sanchez2019; Maura & Weisman de Mamani, Reference Maura and Weisman de Mamani2017; McFarland & Klein, Reference McFarland and Klein2005; Olfson, Cherry, & Lewis-Fernandez, Reference Olfson, Cherry and Lewis-Fernandez2009; Remmert, Guzman, Mavandadi, & Oslin, Reference Remmert, Guzman, Mavandadi and Oslin2022; Wang et al., Reference Wang, Lane, Olfson, Pincus, Wells and Kessler2005; Wells, Klap, Koike, & Sherbourne, Reference Wells, Klap, Koike and Sherbourne2001). Additionally, our results suggest that Black and Hispanic individuals with SI are less likely to know where to go for treatment, suggesting a failure of the mental health system to ensure services are known and approachable for these populations. A better understanding of how these well-documented disparities impact outcomes among minoritized populations with suicidal thoughts or behavior are needed (Washington, 2006).

These results have a number of potential implications for suicide prevention. First, providers should be aware of increasing rates of suicide and higher rates of SAs among Black and Hispanic individuals. Training on suicide risk assessment should avoid propagating generalized beliefs that White males are most impacted by suicidality. Such teaching may result in under-recognition of suicidality among Black and Hispanic individuals. In addition, the results of our study raise the question of whether Black and Hispanic individuals are more likely to under-report SI. Such a finding may have impeded accurate clinical assessment of suicidality, but requires replication in clinical samples.

Additionally, as research continues to shed light on potential racial/ethnic differences in suicidal behavior, suicide prevention programs would do well to recognize differential risks for suicide across race/ethnicity, including the interpersonal and structural impacts of racism, adverse childhood experiences, and socioeconomic disparities (Washington, 2006; Xiao et al., Reference Xiao, Cerel and Mann2021). Continued efforts to dismantle structural racism in healthcare settings is critical to ensuring that Black and Hispanic individuals experiencing suicidality feel comfortable seeking professional care and receive timely, evidence-based care. In addition, interventions outside the healthcare system to improve identification of high-risk individuals are needed, including training in suicide risk assessment for clergy, religious leaders, and school personnel; public health promotion campaigns that target mental health stigma, especially among Hispanic populations; and continued expansion of community-based crisis services.

Several potential limitations deserve mention. Most notably, the retrospective, self-report nature of the data introduces the possibility of recall and reporting bias. Future research could consider examining medically-verifiable SAs to mitigate this limitation. In addition, SAs were only assessed among individuals reporting past-year SI so, as stated previously, our findings on SAs are only applicable to individuals with SI. In addition, SAs were assessed with a single question that may have mis-classified non-suicidal self-injury. Third, NSDUH does not survey individuals who are currently incarcerated. Given that racial minorities are over-represented in prisons and jails, rates of SI and SAs may have been underestimated in this study. Finally, the broad racial and ethnic categories available in NSDUH did not allow for more nuanced understanding of racial and ethnic subgroups (Jegede, Na, Rhee, Stefanovics, & Rosenheck, Reference Jegede, Na, Rhee, Stefanovics and Rosenheck2021).

In spite of these limitations, this nationally representative study suggests that Black and Hispanic individuals are less likely than White individuals to report SI but when they do, they are more likely to report attempts. While they are less likely to report receiving mental health treatment, less service use does not underlie the difference in suicidal behavior across racial/ethnic groups. Thus, it is likely that other factors, including differences in reporting styles, socio-culturally acceptable forms of distress, and possible structural racism in the mental health system, may differentially impact racial/ethnic subgroups and risk of both suicide precursors and suicide mortality. Further study of these phenomena is needed.