Racial and Ethnic Disparities in Suicide
By David Nerenz, Ph.D., MSSIC Associate Director
In most areas of health care, significant racial and ethnic disparities in access to care, processes of care, and outcomes of care can be found. The typical pattern is African American or Hispanic patients having poorer access, lower likelihood of receiving guideline-recommended care, and poorer treatment outcomes. Some of the effects seen may be due to social or other demographic factors like income, education, employment type, and insurance coverage. However, in studies where these factors are taken into account, there still may be independent effects of race or ethnicity.
In suicide, these typical patterns are reversed. Non-Hispanic Whites have higher suicide rates than either African Americans or Hispanics. Native Americans have suicide rates even higher than Whites, though.
The trends are shifting somewhat in the past few years, with suicide rates for African American and Hispanic populations rising and suicide rates for Whites declining somewhat. Still, there are significant gaps in rates between Native Americans (highest), non-Hispanic Whites (high), and African Americans. Asians, and Hispanics (lowest).
What do these differences and trends mean for a quality improvement collaborative focusing on reducing rates of suicide? In the spine surgery collaborative (MSSIC), there has been a focused effort on reducing racial disparities in surgical outcomes since 2023. In MSSIC, African American patients have worse outcomes than Whites (both clinical and patient-reported outcomes), even when a variety of related clinical and demographic factors are controlled for statistically. Once or twice a year, each participating hospital receives a “dashboard” showing its outcomes stratified by race (and also by a neighborhood SES index), along with an analysis of possible underlying factors amenable to QI intervention.
For example, one can see in the MSSIC data that African American patients are more likely to receive surgery on an emergency basis and therefore less likely to receive all the pre-surgical education and “optimization” (smoking cessation, HbA1c control among diabetics) that elective cases receive. Black patients are also more likely to be single and living alone, so that they often don’t have the same level of support for post-surgical care that White patients might have. QI interventions aimed at filling these “gaps” (e.g., more frequent follow-up phone calls, more frequent home health care, more intensive on-line education during and immediately after hospitalization) are being rolled out to try to reduce the observed outcome disparities. Interventions are not targeted specifically at African American patients, but interventions targeted at the underlying risk factor(s) (emergency surgery, living alone) will inevitably affect proportionately more Black than White patients, thereby reducing disparities.
For suicide, the path forward to trying to reduce racial or ethnic disparities seems more challenging, as it is less clear what key underlying factors that lead to suicide, and that differ by race or ethnicity, are amenable to QI intervention. It has been suggested, for example, that higher degrees of religiosity in African American and Hispanic communities, and higher levels of stigma associated with suicide, are both protective factors that lead to lower rates in those groups vs. Whites. One study found that Black college students were able to identify more reasons for living rather than attempting suicide than White students similarly situated. Higher degrees of family and societal integration have been identified as potential protective factors against suicide among African Americans and Hispanics. Resilience or coping ability or “toughness” has also been suggested as an underlying reason for lower suicide rates among racial or ethnic groups subject to discrimination.
Even if all of this is true and the effects are significant, what can hospitals or practices in a QI collaborative do about broad societal/cultural factors like these? In MSSIC, a decision was made not to try to address broad societal factors; instead, the philosophy has been to use data in the registry to try to identify personal, local, specific factors associated with poor outcomes and then design QI interventions to address them. A “disparity lens” has led to a search for tangible, actionable factors leading to racial/ethnic disparities thar are amenable to QI intervention.
Would a “disparity lens” on suicide prevention yield any different insights from those already informing work in the collaborative? Possibly, although the direction of analysis might be reversed ̶ identify protective factors found among Black or Hispanic communities that might be brought forward in some way to White patients at risk for suicide rather than to identify risk factors for poor outcomes among racial/ethnic minority groups as has been the case in MSSIC.
In MSSIC, being single is a risk factor. We can’t ask people to get married as a QI intervention, but we can do something about living alone, which seems to be the real risk factor rather than marital status per se. In the context of MI Mind and suicide, it wouldn’t be possible to convert White patients at risk for suicide to religion as a way to prevent suicide, but perhaps some of the emotional or cognitive elements of religiosity can be included or strengthened in suicide prevention programs. Similarly, it’s not possible to replicate all aspects of familial or community cohesion for White patients at risk for suicide, but perhaps similar mechanisms can be created by structures like online or in-person support groups.
Reducing disparities in suicide for the group(s) with the highest rates means a focus on Native Americans or Whites at risk for suicide. QI efforts can’t lose track, though, of the very recent trends of increasing suicide rates among African Americans and Hispanics. Rising rates in those groups to get closer to White rates is not the way to reduce disparities! The same kind of search for underlying causes amenable to intervention that would lead to efforts to reduce White or Asian suicide rates would and should be applied to African Americans and Hispanics as well.
None of this is simple or easy, but reducing racial disparities in outcomes, however defined in each collaborative, is part of the work of improving outcomes overall.