The influence of state mental health perceptions and spending on an individual’s use of mental health services

Purpose

To explore the possible contextual effects of state-level mental health perceptions and public spending for mental health treatment on an individual’s use of mental health services, independent of the individual’s own perceptions.

Methods

Cross-sectional data from the 2007 Behavioral Risk Factor Surveillance System were used. A total of 216,514 participants from 35 states and the District of Columbia were included in the study. Logistic regression and multilevel modeling were used to estimate the effects of individual-level characteristics and three state-level factors—per capita spending on community mental health services, aggregated perceptions of the effectiveness of mental health treatment and the stigma of mental illness—on the individual’s current use of mental health services.

Results

Adjusting for the individual’s perceptions and characteristics, state-level perception of treatment effectiveness was positively associated with the use of mental health services [odds ratio (OR) for 5 % increase in the percentage perceiving effectiveness = 1.08; 95 % confidence interval (CI): 1.01, 1.16]. This association was strongest for individuals who experienced 1–4 days of mental distress in the past 30 days (OR = 1.17; 95 % CI 1.06, 1.29). State-level public spending on community mental health services was also positively associated with an individual’s use of mental health services (OR for a $40 increase in spending = 1.09; 95 % CI 1.01, 1.17); however, state-level perceptions of mental-illness stigma was not.

Conclusions

Our findings suggest there may be contextual effects of state-level perceptions of treatment effectiveness and state spending on community mental health services on the use of mental health services.     

Antenatal maternal mental health as determinant of postpartum depression in a population based mother–child cohort (Rhea Study) in Crete,Greece

Purpose

Antenatal maternal mental health has been identified as an important determinant of postpartum depression (PPD). We investigated the occurrence of depression both antenatally and postnatally and examined whether maternal trait anxiety and depression during pregnancy were associated with PPD at 8 weeks postpartum in a prospective mother–child cohort (Rhea Study) in Crete, Greece.

Methods

438 women completed the Edinburgh Postnatal Depression Scale (EPDS) and the Trait subscale of the State-Trait Anxiety Inventory (STAI-Trait) questionnaires assessing antenatal depression and anxiety, respectively, during the third trimester of pregnancy as well as the EPDS at 8 weeks postpartum.

Results

The prevalence of women with probable depression (EPDS score ≥13) was 16.7 % at 28–32 weeks of pregnancy and 13.0 % at 8 weeks postpartum. A per 5 unit increase in the STAI-Trait subscale increased the odds for PPD by 70 % (OR = 1.70, 95 % CI 1.41, 2.05), whereas a per unit increase in EPDS during pregnancy increased the odds for PPD by 27 % (OR = 1.27, 95 % CI 1.19, 1.36).

Conclusions

Our findings suggest that antenatal maternal psychological well-being has a significant effect on PPD, which might have important implications for early detection during pregnancy of women at risk for postpartum depression.     

Nonsuicidal self-harm and suicide attempts in adolescents: differences in kind or in degree?

Purpose

The purpose of the present study was to measure the prevalence of self-harm (SH) behaviours and examine potential differences in characteristics among adolescents reporting on self-harm (SH), depending on whether they had attempted suicide (SA), performed nonsuicidal self-harm (NSSH), or both.

Methods

Cross-sectional survey of 11,440 adolescents aged 14–17 years in the city of Oslo, Norway. Responses regarding measures of lifetime SH and risk factors were collected. The response rate was 92.7 %. Data were analysed by segregating SH responses into the categories of NSSH, SA, and NSSH + SA.

Results

Among all respondents, 4.3 % reported NSSH, 4.5 % reported SA, 5.0 % reported both NSSH and SA, and 86.2 % reported no SH. The group reporting to have engaged in both behaviours comprised more girls and reported more suicidal ideation, problematic lifestyles, poorer subjective health, and more psychological problems compared with the other groups. The four groups could be distinguished by one discriminant function that accounted for most of the explained variance.

Conclusions

Our findings suggest that NSSH and SA are parts of the same dimensional construct in which suicidal ideation carries much of the weight in adolescents from a school-based sample. They also indicate the group of adolescents who seems to alternate between NSSH and SA is more burdened with mental ill-health and behavioural problems compared with others. These adolescents should therefore be targeted by clinicians and school health personnel for identification and provision of adequate help and services.     

Ethnicity,socioeconomic position and severity of problems as predictors of mental health care use in 5- to 8-year-old children with problem behaviour

Background

Empirical research on mental health care use and its determinants in young school-aged children is still scarce. In this study, we investigated the role of ethnicity, socioeconomic position (SEP) and perceived severity by both parents and teachers on mental health care use in 5- to 8-year-old children with emotional and/or behavioural problems.

Methods

Data from 1,269 children with a high score (>P90) on the Strengths and Difficulties Questionnaire (SDQ) in the school year 2008–2009 were linked to psychiatric case register data over the years 2010–2011. Cox proportional hazards models were used to predict mental health care use from ethnicity, SEP and perceived severity of the child’s problems.

Results

During the follow-up period, 117 children with high SDQ scores (9.2 %) had used mental health care for the first time. Ethnic minority children were less likely to receive care than Dutch children (HR Moroccan/Turkish: 0.26; 95 % CI 0.13–0.54, HR other ethnicity: 0.26; 95 % CI 0.12–0.58). No socioeconomic differences were found. After correction for previous care use, ethnicity and parental perceived severity, impact score as reported by teachers was significantly associated with mental health care use (HR 1.58; 95 % CI 1.01–2.46).

Conclusions

Ethnicity is an important predictor of mental health care use in young children. Already in the youngest school-aged children, ethnic differences in the use of mental health care are present. A distinct predictor of care use in this age group is severity of emotional and behavioural problems as perceived by teachers. Therefore, teachers may be especially helpful in the process of identifying young children who need specialist mental health care.     

Mental health of children who work on the streets in Brazil after enrollment in a psychosocial program

Purpose

To evaluate the mental health status of children working on the streets in Sao Paulo City, Brazil, two years after their participation in a psychosocial program, and to identify factors associated with their mental health status.

Methods

From a total sample of 126 children working on the streets, 107 (85%) were re-evaluated two years after the initiation of a psychosocial program which aimed to cease their work on the streets. The focus was the presence of mental health problems, defined based on a screening instrument (Strengths and Difficulties Questionnaire). Logistic regression models tested factors related to the probability that a child would not present mental health problems at follow-up.

Results

The likelihood of a child presenting mental health problems was higher at baseline compared to the two-year follow-up (67.5 and 56.1%, respectively). Absence of mental health problems two years after a psychosocial intervention was significantly correlated with the following baseline factors: lower level of caregiver’s psychiatric symptoms as measured by the SRQ (Self-Report Questionnaire) (AOR = 0.84, p = 0.0065), absence of child physical neglect (AOR = 0.38, p = 0.0705) and parental Protestant religion affiliation, compared to other religions (AOR = 4.06; p = 0.0107).

Conclusions

Different factors are related to the absence of mental health problems of children working on the streets after enrollment in a two-year psychosocial program. Our findings suggest that interventions that aim to improve child mental health should consider the detection of psychiatric symptoms in caregivers, provide treatment when it is needed, and also assess other problems such as neglect in the family setting.

     

How equitable are psychological therapy services in South East London now? A comparison of referrals to a new psychological therapy service with participants in a psychiatric morbidity survey in the same London borough

Purpose

Psychological therapy services are sometimes characterised as being small and inequitable, with an over-representation of white middle class women. The ‘Improving Access to Psychological Therapies (IAPT)’ initiative is a programme in England that attempts to make evidence-based therapies accessible to more people more equitably. The aim of this study is to assess whether an IAPT service is delivering an equitable service a London borough. Patients using services at the Southwark IAPT service (n = 4,781) were compared with a sub-group of participants in the South East London Community Health study (SELCOH) with diagnosable mental health problems and who were also resident in Southwark (n = 196).

Methods

We compared Southwark IAPT patients and SELCOH participants on equity criteria of age, gender, ethnicity, occupational status and benefits status. To investigate if referral pathways influenced equity, patients referred by their general practitioner (GP pathway) (n = 3,738) or who self-referred (self-referral pathway) (n = 482) were compared with SELCOH participants.

Results

Southwark IAPT patients significantly differed from SELCOH participants on all our equity criteria and similar differences were found with GP pathway patients. However, self-referrals did not differ from the SELCOH group on age, gender, ethnicity and benefit status.

Conclusions

When compared to a community sample with diagnosable mental disorders, health disparities were found with the overall Southwark IAPT service and with GP pathway patients. Although unemployed people did access IAPT, fewer disparities were found with the self-referral pathway patients, suggesting that the IAPT self-referral pathway may be important in reducing inequitable access to services.     

Risk factors of mental illness among adult survivors after the Wenchuan earthquake

Purpose

This study was to analyze the mental health status of the adults from the areas struck by the Wenchuan earthquake, to understand the factors that may have impact on their mental health after they were exposed to the earthquake, to obtain information specifically relevant to further research and future preventive measures.

Methods

We used multistage stratified random sampling methods in three areas that were severely damaged in the Wenchuan earthquake, Sichuan Province, China. For this study, 14,798 individuals were identified with simple random selection methods at the sampling sites, 14,207 were screened with the 12-item General Health Questionnaire (GHQ-12), and 3,692 individuals were administered a Chinese version of the Structured Clinical Interview for Diagnostic and Statistical Manual (DSM)-IV axis I disorders by 180 investigators.

Results

The risk factors for post-traumatic stress disorder included old age, female gender, low school education and witness someone die in the earthquake (P < 0.05, 95 % CI). The risk factors for anxiety disorder included old age, female gender, low school education, living alone and witness someone die in the earthquake (P < 0.05, 95 % CI). The risk factors for depression included old age, female gender, low school education and living alone (P < 0.05, 95 % CI).

Conclusions

Given inadequate knowledge and practices concerning the mental health of disaster victims in China, the information provided by this study is useful for directing, strengthening, and evaluating disaster-related mental health needs and interventions after the earthquake.     

Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis

Purpose

To evaluate the effectiveness of peer-delivered interventions in improving clinical and psychosocial outcomes among individuals with severe mental illness (SMI) or depression.

Methods

Systematic review and meta-analysis of randomised controlled trials comparing a peer-delivered intervention to treatment as usual or treatment delivered by a health professional. Random effect meta-analyses were performed separately for SMI and depression interventions.

Results

Fourteen studies (10 SMI studies, 4 depression studies), all from high-income countries, met the inclusion criteria. For SMI, evidence from three high-quality superiority trials showed small positive effects favouring peer-delivered interventions for quality of life (SMD 0.24, 95 % CI 0.08–0.40, p = 0.003, I ² = 0 %, n = 639) and hope (SMD 0.24, 95 % CI 0.02–0.46, p = 0.03, I ² = 65 %, n = 967). Results of two SMI equivalence trials indicated that peers may be equivalent to health professionals in improving clinical symptoms (SMD ?0.14, 95 % CI ?0.57 to 0.29, p = 0.51, I ² = 0 %, n = 84) and quality of life (SMD ?0.11, 95 % CI ?0.42 to 0.20, p = 0.56, I ² = 0 %, n = 164). No effect of peer-delivered interventions for depression was observed on any outcome.

Conclusions

The limited evidence base suggests that peers may have a small additional impact on patient’s outcomes, in comparison to standard psychiatric care in high-income settings. Future research should explore the use and applicability of peer-delivered interventions in resource poor settings where standard care is likely to be of lower quality and coverage. The positive findings of equivalence trials demand further research in this area to consolidate the relative value of peer-delivered vs. professional-delivered interventions.     

The distribution of self-reported psychotic-like experiences in non-psychotic help-seeking mental health patients in the general population; a factor mixture analysis

Purpose

Factor mixture analysis (FMA) and item response mixture models in the general population have shown that the psychosis phenotype has four classes. This study attempted to replicate this finding in help-seeking people accessing mental health services for symptoms of non-psychotic mental disorders.

Methods

All patients (18–35 years old) referred for non-psychotic mental health problems to the secondary mental healthcare service in The Hague between February 2008 to February 2010 (N = 3,694), were included. Patients completed the Prodromal Questionnaire (PQ). Hybrid latent class analysis was applied to explore the number, size and symptom profiles of the classes.

Results

The FMA resulted in four classes. Class 1 (N = 1,039, 28.1 %) scored high on conceptual disorganization, inattention and mood disorder. Patients in Class 2 (N = 619, 16.8 %) endorsed almost all PQ-items, were more often screened as being psychotic or at high risk of developing psychosis, without care takers noticing. In Class 3 (N = 1,747, 47.3 %) perplexity, paranoia and negative symptoms were more prevalent. Patients were more often at high risk of developing psychosis. Class 4 (N = 286, 7.7 %) represented the ‘normative’ group with low probabilities for all items.

Discussion

The results support the hypothesis that a representation in four classes of psychotic-like experiences can also be applied in a help-seeking population.     

The effect of migration on social capital and depression among older adults in China

Purpose

An estimated 9 million elderly people accompanied their adult children to urban areas in China, raising concerns about their social capital and mental health following re-location. The aim of this study was to examine the effect of migration on social capital and depression among this population.

Methods

Multistage stratified cluster sampling was applied to recruit the migrant and urban elderly in Hangzhou from May to August, 2013. Data were collected from face-to-face interviews by trained college students using a standardized questionnaire. Social capital measurements included cognitive (generalized trust and reciprocity) and structure (support from individual and social contact) aspects. Depression was measured by Geriatric Depression Scale-30 (GDS-30). Chi-square tests and binary logistic regression models were used for analysis.

Results

A total of 1248 migrant elderly and 1322 urban elderly were eligible for analysis. After adjusting for a range of confounder factors, binary logistic regression models revealed that migrant elderly reported significantly lower levels of generalized trust [OR = 1.34, 95% CI (1.10–1.64)], reciprocity [OR = 1.55, 95% CI (1.29–1.87)], support from individual [OR = 1.96, 95% CI (1.61–2.38)] and social contact [OR = 3.27, 95% CI (2.70–3.97)]. In the full adjusted model, migrant elderly were more likely to be mentally unhealthy [OR = 1.85, 95% CI (1.44–2.36)] compared with urban elderly.

Conclusions

Migrant elderly suffered from a lower mental health status and social capital than their urban counterparts in the emigrating city. Attention should focus on improving the social capital and mental health of this growing population.

     

Prevalence of mental health disorders among low-income African American adolescents

Purpose

Data on the prevalence of mental health disorders for low-income, urban African American adolescents are scarce. This study presents data about the burden of mental disorders for this understudied population.

Methods

Mental disorders were assessed using the Diagnostic Interview Schedule for Children (C-DISC), Youth Self-Report (YSR), and Child Behavior Checklist (CBCL) among a sample of adolescents and their caregivers from very impoverished neighborhoods in a Southern city.

Results

Based on the C-DISC, 3.8, 5.1 and 7.7 % of adolescents met diagnostic criteria for major depression, post-traumatic stress disorder, and conduct disorder, respectively. There were significant differences among some of the mental health disorders based on adolescent and caregiver characteristics such as sex, school status, caregiver work status, and income level. We found a low prevalence of alcohol, marijuana, and substance abuse and dependence disorders.

Conclusions

Information about the prevalence of mental health disorders in specific communities and populations can assist in addressing unmet needs, planning for services and treatment, and reducing health disparities.     

A prediction model for the incidence of civil detention for crisis patients with psychiatric illnesses; the Amsterdam study of acute psychiatry VII

Objective

Given raised numbers of civil detentions in the Netherlands and other European countries, it is important to assess the patient risk profile with respect to the incidence of those far-reaching treatment decisions. The aim of the ASAP study is to develop a comprehensive prediction model that considers all possible patient-related predictors known from earlier research.

Methods

We took a random sample of 252 from the 2,682 patients coming into contact with two psychiatric emergency teams in Amsterdam between September 2004 and September 2006. We recorded socio-demographic and clinical characteristics, aspects of social support and psychiatric history. We interviewed the patients using the Verona Service Satisfaction Scale (Verona-EU) and the Birchwood Insight Scale. During a two-year follow-up period we noted their use of mental health care facilities.

Results

Stepwise logistic regression analyses with resulted in a final prediction model (P ≤ 0.001) including preceding involuntary admission (OR 9.4, 95 % CI 3.6–24.7, P ≤ 0.001), domestic situation alone (OR 4.5, 95 % CI 1.9–11.0, P = 0.001) and VSSS score satisfactory (OR 0.2, 95 % CI 0.0–0.8, P = 0.030) as predictors of civil detention during 2 years of follow-up.

Conclusion

With the presented prediction model it will be possible to identify patients at a high risk of civil detention: patients with a history of previous involuntary admissions who live alone and are not satisfied with the mental health care they got before. This suggests the possibility that timely preventive measures can be taken comprising the adjustment or intensification of the treatment plan for this specific group of patients.     

Mental health of internally displaced preschool children: a cross-sectional study conducted in Bogotá, Colombia

Purpose

Ongoing armed conflicts, like the one in Colombia, have forcibly displaced millions of people including many young children. This study aimed to assess the mental health of internally displaced preschoolers in Bogotá Colombia and to identify correlates of mental health in these children.

Methods

Cross-sectional study conducted among 279 children attending four kindergartens in a deprived neighbourhood in Bogotá. Child mental health was assessed with the Child Behaviour Checklist (CBCL) 1.5–5 years, a parent-report. Univariate analyses and multivariate logistic regressions were performed to assess the association between displacement and child mental health and to identify correlates of mental health in displaced children.

Results

Displaced children (n = 90) more often met borderline cut-off scores for the CBCL scales than non-displaced children (n = 189) (e.g. total problems 46.7 vs. 22.8 %; p < 0.001). The association between displacement and presence of CBCL total problems remained after adjustment for socio-demographic factors (Adjusted OR 3.3, 95 % CI 1.5; 6.9). Caretaker’s mental health partly explained the association. In displaced children, caretaker’s mental health (p < 0.01) and family functioning (p < 0.01) were independently associated with child mental health. Exposure to traumatic events and social support was also associated with child mental health; however, associations were not independent.

Conclusion

In this deprived neighbourhood in Bogotá, preschool children registered as internally displaced presented worse mental health than non-displaced peers. Family functioning and caretaker’s mental health were strongly and independently associated with displaced children’s mental health.     

Ambulance attendances resulting from self-harm after release from prison: a prospective data linkage study

Objective

Incarcerated adults are at high risk of self-harm and suicide and remain so after release into the community. The aims of this study were to estimate the number of ambulance attendances due to self-harm in adults following release from prison, and to identify factors predictive of such attendances.

Methods

Baseline surveys with 1309 adults within 6 weeks of expected release from prison between 2008 and 2010 were linked prospectively with state-wide correctional, ambulance, emergency department, hospital and death records in Queensland, Australia. Associations between baseline demographic, criminal justice and mental health-related factors, and subsequent ambulance attendances resulting from self-harm, were investigated using negative binomial regression.

Results

During 4691 person-years of follow-up (median 3.86 years per participant), there were 2892 ambulance attendances in the community, of which 120 (3.9%) were due to self-harm. In multivariable analyses, being Indigenous [incidence rate ratio (IRR): 2.10 (95% CI 1.14–3.86)], having previously been hospitalised for psychiatric treatment [IRR: 2.65 (95% CI 1.44–4.87)], being identified by prison staff as being at risk of self-harm whilst incarcerated [IRR: 2.12 (95% CI 1.11–4.06)] and having a prior ambulance attendance due to self-harm [IRR: 3.16 (95% CI 1.31–7.61)] were associated with self-harm attendances.

Conclusions

Ambulance attendances resulting from self-harm following release from prison are common and represent an opportunity for tertiary intervention for self-harm. The high prevalence of such attendances, in conjunction with the strong association with prior psychiatric problems, reinforces the importance of providing appropriate ambulance staff training in the assessment and management of self-harm, and mental health problems more broadly, in this vulnerable population.

     

Does good leadership buffer effects of high emotional demands at work on risk of antidepressant treatment? A prospective study from two Nordic countries

Purpose

Emotionally demanding work has been associated with increased risk of common mental disorders. Because emotional demands may not be preventable in certain occupations, the identification of workplace factors that can modify this association is vital. This article examines whether effects of emotional demands on antidepressant treatment, as an indicator of common mental disorders, are buffered by good leadership.

Methods

We used data from two nationally representative work environment studies, the Danish Work Environment Cohort Study (n = 6,096) and the Swedish Longitudinal Occupational Survey of Health (n = 3,411), which were merged with national registers on antidepressant purchases. All individuals with poor self-reported baseline mental health or antidepressant purchases within 8.7 months before baseline were excluded, and data analysed prospectively. Using Cox regression, we examined hazard ratios (HRs) for antidepressants in relation to the joint effects of emotional demands and leadership quality. Buffering was assessed with Rothman’s synergy index. Cohort-specific risk estimates were pooled by random effects meta-analysis.

Results

High emotional demands at work were associated with antidepressant treatment whether quality of leadership was poor (HR = 1.84, 95 % CI 1.32–2.57) or good (HR = 1.70, 95 % CI 1.25–2.31). The synergy index was 0.66 (95 % CI 0.34–1.28).

Conclusions

Our findings suggest that good leadership does not substantially ameliorate any effects of emotional demands at work on employee mental health. Further research is needed to identify possible preventive measures for this work environment exposure.     

Estimated rates of mental disorders in, and situational characteristics of, incidents of nonfatal use of force by police

Purpose

To examine the estimated rates of mental disorders and associated situational characteristics in people involved in nonfatal use of force incidents with police in VIC, Australia.

Methods

A random sample of 4,267 cases between 1995 and 2008 from a dedicated police Use of Force Register were linked with the state-wide public mental health database and a police contacts database. Rates of ICD 9 and ICD 10 mental disorders recorded on the public mental health database were examined, as well as rates of criminal offending and the characteristics of force used by both parties.

Results

More than a third of people on whom the police resorted to using force (n = 1,621, 38 %) had a history of mental disorder. Significant overrepresentations of the estimated prevalence of psychosis [12.5 %, OR = 9.03, 95 % CI (7.41, 11.01), p < 0.001] and schizophrenia [9.1 %, OR = 9.73, 95 % CI (7.59, 12.47) p < 0.001] were found. Those diagnosed with mental disorders were 1.52 times more likely to use or threaten to use weapons on police, even after taking into account age, sex, substances intoxication and violent behaviour [95 % CI (1.23, 1.91), p < 0.001]; however, they were no more likely to injure or be injured by police than those without a recorded history of mental disorder. There was a noted trend for police to use, or threaten to use, weapons on people with a history of psychosis (other than schizophrenia) [OR = 1.40, 95 % CI (1.11, 1.78), p = 0.005].

Conclusions

Psychoses and schizophrenia are dramatically overrepresented in cases where police resort to using force. Situational characteristics evident in the encounters are suggestive of a sub-group of people with mental disorders presenting with aggressive and otherwise problematic behaviours coupled with histories of criminal offending; this presents significant ongoing challenges for the police.     

Cancer mortality in patients with psychiatric diagnoses: a higher hazard of cancer death does not lead to a higher cumulative risk of dying from cancer

Purpose

Both increased as well as decreased cancer mortality among psychiatric patients has been reported, but competing death causes were not included in the analyses. This study aims to investigate whether observed cancer mortality in patients with psychiatric disorders might be biased by competing death causes.

Method

In this retrospective cohort study on data from the Psychiatric Case Register Middle Netherlands linked to the death register of Statistics Netherlands, the risk of cancer death among patients with schizophrenia (N = 4,590), bipolar disorder (N = 2,077), depression (N = 15,130) and their matched controls (N = 87,405) was analyzed using a competing risk model.

Results

Compared to controls, higher hazards of cancer death were found in patients with schizophrenia (HR = 1.61, 95 % CI 1.26–2.06), bipolar disorder (HR = 1.20, 95 % CI 0.81–1.79) and depression (HR = 1.26, 95 % CI 1.10–1.44). However, the HRs of death due to suicide and other death causes were more elevated. Consequently, among those who died, the 12-year cumulative risk of cancer death was significantly lower.

Conclusions

Our analysis shows that, compared to the general population, psychiatric patients are at higher risk of dying from cancer, provided that they survive the much more elevated risks of suicide and other death causes.     

Association of suicide rates, gun ownership, conservatism and individual suicide risk

Objectives

The purpose of the study was to examine the association of suicide rates, firearm ownership, political conservatism, religious integration at the state level, and individual suicide risk. Social structural and social learning and social integration theories were theoretical frameworks employed. It was hypothesized that higher suicide rates, higher state firearm availability, and state conservatism elevate individual suicide risk.

Method

Data were pooled from the Multiple Cause of Death Files. Multilevel logistic regression models were fitted to all deaths occurring in 2000 through 2004 by suicide.

Results

The state suicide rate significantly elevated individual suicide risk (AOR = 1.042, CI = 1.037, 1.046). Firearm availability at the state level was associated with significantly higher odds of individual suicide (AOR = 1.004, CI = 1.003, 1.006). State political conservatism elevated the odds of individual suicides (AOR = 1.005, CI = 1.003, 1.007), while church membership at the state level reduced individual odds of suicide (AOR = 0.995, CI = 0.993, 0.996). The results held even after controlling for socioeconomic and demographic variables at the individual level.

Conclusion

It was concluded that the observed association between individual suicide odds and national suicide rates, and firearm ownership cannot be discounted. Future research ought to focus on integrating individual level data and contextual variables when testing for the impact of firearm ownership. Support was found for social learning and social integration theories.