Supplementary appendix

This appendix formed part of the original submission and has been peer reviewed.
We post it as supplied by the authors.
Supplement to: Reeves A, Stuckler D, McKee M, Gunnell D, Chang S-S, Basu S. Increase in
state suicide rates in the USA during economic recession. Lancet 2012; published online
Nov 5. http://dx.doi.org/10.1016/S0140-6736(12)61910-2.

Appendix
Data and Methods
Suicide Data
Age-standardized suicide rates were taken from the Centre for Disease Controls Underlying Cause
of Death database which covers the years 1999-2009.10 Data for 2010 are available from the detailed
tables for the National Vital Statistics Report Deaths: Final Data for 2010.11 Causes of death are
processed following the International Classification of Diseases, Tenth Revision (ICD-10).12 Deaths
that were coded as Intentional self-harm (X60-X84) under the ICD-10 are included in the analysis.
These data are available for each state plus the District of Columbia but not by age and gender.
Population data for 2010 (totaling 308,745,538) were taken from the United States Census Bureau and
used to weight each state.13
Data on unemployment were taken from the Bureau of Labor Statistics Local Area Unemployment
Statistics.14 We used statewide and seasonally unadjusted annual rates of unemployment between
1999-2010.

Statistical Models
The statistical analysis proceeded in two steps. In the first step we estimated a time trend regression
of the number of suicide deaths nationally for those years between 1999-2007, i.e. prior to the 20082010 recession. This time trend model included a dummy variable identifying those recession years
(2008-2010) to estimate the change in suicide rates associated with the recession. Similar estimates of
the excess deaths were obtained when comparing the actual number of deaths with a forecast derived
from the 1999-2007 trend. The year 2007 was chosen as the cut-point because, although the
unemployment rate across the US fluctuated prior to 2007 between 4% and 6%, between 2007 and
2010 the unemployment rate rose 5% (see figure below). Consistent with these data, the National
Bureau of Economic Research also dates the year 2007 as the start of the recession in the U.S.15

In the second step of the analysis we assessed the state-level association between unemployment rates
and age-standardised suicide rates. To correct for potential unobserved confounding factors such as
varying surveillance systems, we adjusted for a set of state level dummy variables (so-called fixed
effects models). We also adjusted for each states time-trends in suicide rates. Including these
dummy variables provides conservative estimates.16 Reflecting the fact that populations were not
sampled independently we used robust standard errors which were clustered by state.17 This also
enabled us to estimate confidence intervals that were robust to serial correlation. All models were
analysed using Stata version 12.

Disaggregation by regions
a. Geographic region

b. Governors political affiliation

c. States with strong associations

References

10 National Center for Health Statistics. Underlying cause of death 19992009.

http://wonder.cdc.gov/wonder/help/ucd.html (accessed Nov 1, 2012).
11 National Center for Health Statistics. Detailed tables for the national vital statistics report (nvsr)
deaths: final data for 2010. Hyattsville, MD: Centers for Disease Control and Prevention, 2012.
12 WHO. International statistical classification of diseases and related health problems, 10th revision.
Geneva: World Health Organization, 2010.
13 United States Census Bureau. United States census, 2010. Washington, DC: US Department of
Commerce, 2011.
14 US Bureau of Labor Statistics. Local area unemployment statistics. Washington, DC: Bureau of
Labor Statistics, 2012.
15 NBER Business Cycle Dating Committee. Determination of the December 2007 peak in economic
activity. http://www.nber.org/cycles/dec2008.html (accessed Oct 31, 2012).
16 Jones A. Health econometrics. In: Cuyler A, Newhouse J, eds. Handbook of health economics.
London: Elsevier Science, 2000: 265344.
17

Newey WK, West KD. A simple, positive semi-definite, heteroskedasticity and

autocorrelation consistent covariance matrix. Econometrica 1987; 55: 70308.