Economic precarity, loneliness, and suicidal ideation during the COVID-19 pandemic

Julia Raifman; Catherine K Ettman; Lorraine T Dean; Salma M Abdalla; Alexandra Skinner; Colleen L Barry; Sandro Galea

doi:10.1371/journal.pone.0275973

. 2022 Nov 16;17(11):e0275973. doi: 10.1371/journal.pone.0275973

Economic precarity, loneliness, and suicidal ideation during the COVID-19 pandemic

Julia Raifman ^1,^*, Catherine K Ettman ², Lorraine T Dean ², Salma M Abdalla ¹, Alexandra Skinner ³, Colleen L Barry ⁴, Sandro Galea ¹

Editor: Pedro Vieira da Silva Magalhaes⁵

PMCID: PMC9668199 PMID: 36383566

Abstract

The US population faced stressors associated with suicide brought on by the COVID-19 pandemic. Understanding the relationship between stressors and suicidal ideation in the context of the pandemic may inform policies and programs to prevent suicidality and suicide. We compared suicidal ideation between two cross-sectional, nationally representative surveys of adults in the United States: the 2017–2018 National Health and Nutrition Examination Survey (NHANES) and the 2020 COVID-19 and Life Stressors Impact on Mental Health and Well-being (CLIMB) study (conducted March 31 to April 13). We estimated the association between stressors and suicidal ideation in bivariable and multivariable Poisson regression models with robust variance to generate unadjusted and adjusted prevalence ratios (PR and aPR). Suicidal ideation increased from 3.4% in the 2017–2018 NHANES to 16.3% in the 2020 CLIMB survey, and from 5.8% to 26.4% among participants in low-income households. In the multivariable model, difficulty paying rent (aPR: 1.5, 95% CI: 1.2–2.1) and feeling alone (aPR: 1.9, 95% CI: 1.5–2.4) were associated with suicidal ideation but job loss was not (aPR: 0.9, 95% CI: 0.6 to 1.2). Suicidal ideation increased by 12.9 percentage points and was almost 4.8 times higher during the COVID-19 pandemic. Suicidal ideation was more prevalent among people facing difficulty paying rent (31.5%), job loss (24.1%), and loneliness (25.1%), with each stressor associated with suicidal ideation in bivariable models. Difficulty paying rent and loneliness were most associated with suicidal ideation. Policies and programs to support people experiencing economic precarity and loneliness may contribute to suicide prevention.

Introduction

At the start of the coronavirus 2019 (COVID-19) pandemic, the population of the United States (US) faced several co-occurring stressors. The pandemic led to economic downturn, creating stressors of job loss and financial distress. Black, Hispanic, and Native American people are made especially vulnerable to these economic shocks as a result of centuries of structural racism that shape inequities in wealth [1]. Additionally, physical distancing to prevent the spread of COVID-19 created stressors including social isolation and loneliness.

Economic precarity [2] and social isolation [3] are associated with mental distress and suicide. Other studies have documented increases in mental distress and suicidality [4–8] during the pandemic, but few have examined economic hardship. While there were not increases in suicide deaths in the US or many other countries in 2020 [9–11], suicide remains a leading cause of premature death in the US [12] and may continue to evolve [13]. Suicidality is an indicator of major mental distress and a risk factor for suicide [14]. Understanding the populations most at risk of suicidal ideation and the association between COVID-19 stressors and suicidal ideation can inform policies and programs to reduce suicidality and prevent suicide. This study aimed to evaluate the relationship between stressors and suicidal ideation during the start of the COVID-19 pandemic.

Methods

Sample

We used data from a nationally representative sample of US adults aged 18 or older collected through the AmeriSpeak standing panel. Panelists were invited to participate in the COVID-19 and Life Stressors Impact on Mental Health and Well-being (CLIMB) study from March 31, 2020 through April 13, 2020 and were paid a cash equivalent of $3 for completing the survey (64.3% completion rate). We created and applied post-stratification weights to align the study sample with the U.S. adult population according to the U.S. Current Population Survey [15]. Previously published work further describes details on the AmeriSpeak sampling frame and the CLIMB study [5,16]. As a pre-pandemic comparison, we used data from the 2017–2018 National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of noninstitutionalized civilian US adults aged 18 years or older collected by the US government. The CLIMB and NHANES samples are comparable in that both are nationally representative groups of US adults residing in all 50 states and the District of Columbia. The AmeriSpeak sampling frame covers approximately 97% of all US households, and NHANES sampling units similarly cover all US counties. We excluded participants who did not respond to questions about suicidal ideation in NHANES and participants who did not respond to any analysis variables in CLIMB data.

Exposures

We evaluated three COVID-19 stressors reflecting economic precarity and loneliness, each measured as binary variables reported in response to a question, “Have any of the following affected your life as a result of the coronavirus or COVID-19 outbreak?” Our exposure variables were based on whether participants checked boxes for “losing a job,” “having difficulty paying rent,” and “feeling alone”.

Outcome

Both surveys assessed suicidal ideation based on Patient Health Questionnaire-9 (PHQ-9) item 9, which asks participants whether they have had “Thoughts that you would be better off dead or of hurting yourself in some way” over the past two weeks. Response options are “Not at all,” “several days,” “more than half the days,” or “nearly every day”. We created a binary variable for reporting these feelings with any frequency. Prior research indicates responses to this question were correlated with future suicide attempts and deaths [14,17,18].

Analysis

First, we described the demographic characteristics of participants in the 2020 CLIMB data and in the 2017–2018 NHANES data. Second, we estimated the prevalence of suicidal ideation by demographic characteristics and calculated the share with suicidal ideation within subgroups in 2020 relative to 2017–2018. Third, we used CLIMB data to estimate unadjusted and adjusted prevalence ratios (PR and aPR) of the association between COVID-19 related stressors and suicidal ideation using a Poisson regression model with robust variance to approximate a log-binomial regression model, with α = 0.05 [19]. In the multivariable model, to reduce bias, we adjusted for age group, education level, sex, race and ethnicity, household income, savings, marital status, COVID-19 illness, and COVID-19 bereavement. We ran a multivariate sensitivity analysis without the stressor variable for “having difficulty paying rent” in the same regression model as the “losing a job” exposure because difficulty paying rent may lie on the causal pathway in the association between job loss and suicidal ideation.

Results

A total of 1,415 (96.3%) of 1,470 CLIMB participants responded to all questions relevant to the analysis and 5,085 (86.8%) of 5,856 NHANES participants responded to suicidal ideation questions and were included in the samples (Table 1). The NHANES sample was younger, less likely to be married, more likely to have high school or less education, and less likely to be low-income relative to the CLIMB sample.

Table 1. Participant demographic characteristics.

	Sample characteristics
	NHANES, 2017–2018		CLIMB, 2020		p-value
	n	%	n	%
Total	5,085	100	1,415	100	N/A
Difficulty paying rent
No	N/A	N/A	1,199	84.7	N/A
Yes	N/A	N/A	216	15.3	N/A
Lost job
No	N/A	N/A	1,253	88.5	N/A
Yes	N/A	N/A	162	11.5	N/A
Feeling alone
No	N/A	N/A	952	67.3	N/A
Yes	N/A	N/A	463	32.7	N/A
Mean age (avg, std)	49.6	18.5	46.0	16.5	N/A
Age group
18–29	965	21.3	238	16.8	<0.001
30–44	1,106	24.2	493	34.8	<0.001
45–59	1,183	26.5	337	23.8	0,040
60+	1,831	28.1	347	24.5	<0.001
Sex
Male	2,489	48.7	708	50.0	0.387
Female	2,596	51.3	707	50.0	0.387
Race/ethnicity
Non-Hispanic White	1,801	63.0	922	65.2	0.129
Non-Hispanic Black	1,178	11.1	137	9.7	0.133
Non-Hispanic another race or multiracial	947	10.1	105	7.4	0.002
Hispanic	1,159	15.8	251	17.7	0.086
Education level
High school graduate or less	2,262	39.4	327	23.1	<0.001
Some college	1,640	30.4	631	44.5	<0.001
College grad or more	1,177	30.2	457	32.3	0.130
Not reported	6	<0.1	0	N/A	N/A
Marital status
Unmarried or separated	2,424	45.1	716	50.6	<0.001
Married	2,412	51.5	699	49.4	0.162
Not reported	249	3.4	0	N/A	<0.001
Household income
$0-$19,999	875	11.5	220	15.6	<0.001
$20,000-$39,999^a	1,322	21.4	321	22.7	0.294
$40,000-$74,999^a	891	17.7	410	29.0	<0.001
≥$75,000	1,356	38.7	464	32.8	<0.001
Not reported	641	10.7	0	N/A	<0.001
Savings
<$5,000	N/A	N/A	720	50.9	N/A
≥$5,000	N/A	N/A	695	49.1	N/A
COVID-19 illness
No	N/A	N/A	1,403	99.1	N/A
Yes	N/A	N/A	12	0.9	N/A
Death of someone close due to COVID-19					,
No	N/A	N/A	1,390	98.2	N/A
Yes	N/A	N/A	25	1.8	N/A

Open in a new tab

Notes: Percents are weighted. Data on suicidal ideation among those with COVID-19 illness and bereavement are based on small sample sizes.

^a Income categories for NHANES participants were $20,000 to $44,999 and $45,000 to $74,999 based on different cut points for income questions.

The prevalence of suicidal ideation was 3.4% in the 2017–2018 NHANES sample and 16.3% in the 2020 CLIMB survey (Table 2). The greatest absolute increases in suicidal ideation and 2020 prevalence of suicidal ideation were among participants earning less than $20,000 (5.8% to 26.4%), participants aged 18 to 29 (4.1% to 23.5%), and participants who were Hispanic (3.7% to 23.1%). In 2020, suicidal ideation was high among those who faced difficulty paying rent (31.5%, Fig 1) and job loss (24.1%), as well as loneliness (25.1%).

Table 2. COVID-19 stressors, demographic characteristics, and suicidality.

	Suicidal ideation				Absolute difference 2020 - (2017–2018)	Ratio, 2020: 2017–2018	Z score p-value
	NHANES, 2017–2018, Suicidal ideation		CLIMB, 2020
	n	%	n	%	Percentage points
Total	192	3.4	231	16.3	12.9	4.8	<0.001
Difficulty paying rent
No	N/A	N/A	163	13.6	N/A	N/A	N/A
Yes	N/A	N/A	68	31.5	N/A	N/A	N/A
Lost job
No	N/A	N/A	192	15.3	N/A	N/A	N/A
Yes	N/A	N/A	39	24.1	N/A	N/A	N/A
Feeling alone
No	N/A	N/A	115	12.1	N/A	N/A	N/A
Yes	N/A	N/A	116	25.1	N/A	N/A	N/A
Age group
18–29	38	4.1	56	23.5	19.1	5.7	<0.001
30–44	38	3.1	92	18.7	15.4	6.0	<0.001
45–59	48	3.0	47	14.0	11	4.7	<0.001
60+	68	3.5	36	10.4	6.8	2.9	<0.001
Sex
Male	102	4.0	109	15.4	11.5	3.9	<0.001
Female	90	2.9	122	17.3	13.9	5.8	<0.001
Race/ethnicity
Non-Hispanic White	71	3.3	124	13.5	10.2	4.1	<0.001
Non-Hispanic Black	33	3.1	22	16.1	12.1	4.9	<0.001
Non-Hispanic another race or multiracial	34	4.0	27	25.7	20.1	6.0	<0.001
Hispanic	54	3.7	58	23.1	19.1	6.2	<0.001
Education level
High school graduate or less	112	4.2	68	20.8	16.1	4.8	<0.001
Some college	60	4.3	101	16	11.8	3.7	<0.001
College grad or more	20	1.4	62	13.6	11.7	9.4	<0.001
Not reported	N/A	N/A	N/A	N/A	N/A	N/A
Marital status
Unmarried or separated	127	4.6	152	21.2	16.4	4.6	<0.001
Married	54	2.2	79	11.3	8.9	5.0	<0.001
Not reported	11	5.2	N/A	N/A	N/A	N/A	N/A
Household income
$0-$19,999	50	5.8	58	26.4	19.8	4.4	<0.001
$20,000-$39,999^a	63	5.0	56	17.5	12.1	3.4	<0.001
$40,000-$74,999^a	32	3.3	59	14.4	11.1	4.4	<0.001
≥$75,000	25	2.1	58	12.5	10.5	6.0	<0.001
Not reported	22	2.7	N/A	N/A	N/A	N/A	N/A
Savings
<$5,000	N/A	N/A	155	21.5	N/A	N/A	N/A
≥$5,000	N/A	N/A	76	10.9	N/A	N/A	N/A
COVID-19 illness
No	N/A	N/A	223	15.9	N/A	N/A	N/A
Yes	N/A	N/A	8	66.7	N/A	N/A	N/A
Death of someone close due to COVID-19
No	N/A	N/A	222	16	N/A	N/A	N/A
Yes	N/A	N/A	9	36	N/A	N/A	N/A

Open in a new tab

Notes: Percents are weighted. Data on suicidal ideation among those with COVID-19 illness and bereavement are based on small sample sizes. P-values depict Z-score differences for two sample tests of proportions.

^a Income categories for NHANES participants were $20,000 to $44,999 and $45,000 to $74,999 based on different cut points for income questions.

Fig 1 — The figure depicts the percentages with 95% confidence intervals of participants who reported suicidal ideation among those who did or did not report COVID-19-related stressors, including difficulty paying rent, losing a job, and feeling alone. Data used to create the figure comes from the COVID-19 and Life Stressors Impact on Mental Health and Well-being (CLIMB) study conducted from March 31, 2020 through April 13, 2020.

Each of the stressors we evaluated were associated with suicidal ideation in the bivariable model (Table 3; Difficulty paying rent PR: 2.3, 95% CI: 1.8 to 3.1; feeling alone PR: 2.1, 95% CI: 1.6 to 2.6; job loss PR: 1.6, 95% CI: 1.1 to 2.2). In the multivariable model, difficulty paying rent was associated with suicidal ideation (aPR: 1.5, 95% CI: 1.2 to 2.1), while losing a job was not (aPR: 0.9, 95% CI: 0.6 to 1.2). The sensitivity analysis with job loss as the exposure without difficulty paying rent in the model did not change the effect estimate. Feeling alone was also associated with suicidal ideation (aPR: 1.9, 95% CI: 1.5 to 2.4). Although the sample size for persons with COVID-19 illness (n = 12) or bereavement (n = 25) is small, the results (66.7% and 36.0%, respectively) are suggestive that COVID-19 illness or bereavement may be associated with increased suicidal ideation.

Table 3. COVID-19 related stressors and suicidal ideation over the past two weeks (N = 1415).

Variables	PR	95% CI	p-value	aPR	95% CI	p-value
COVID-19 related stressors
Lost job	1.6	1.1–2.2	0.004	0.9	0.6–1.2	0.525
Difficulty paying rent	2.3	1.8–3.1	<0.001	1.5	1.2–2.1	0.003
Feeling alone	2.1	1.6–2.6	<0.001	1.9	1.5–2.4	<0.001
Age group
18 to 29	2.3	1.5–3.3	<0.001	1.3	0.9–2.0	0.217
30 to 44	1.8	1.3–2.6	0.001	1.3	0.9–1.9	0.147
45 to 59	1.3	0.9–2.0	0.155	1.1	0.7–1.7	0.627
≥60	Reference group			Reference group
Sex
Male	Reference group			Reference group
Female	1.1	0.9–1.4	0.345	0.9	0.7–1.1	0.414
Race/ethnicity
Non-Hispanic White	Reference group			Reference group
Non-Hispanic Black	1.2	0.8–1.8	0.404	0.8	0.5–1.2	0.288
Non-Hispanic and another race or multiracial	1.9	1.3–2.8	0.001	1.8	1.2–2.6	0.002
Hispanic	1.7	1.3–2.3	<0.001	1.4	1.0–1.8	0.032
Income group
$0-$19,999	2.1	1.5–2.9	<0.001	1.2	0.8–1.8	0.317
$20,000-$39,999	1.4	1.0–2.0	0.054	1.0	0.7–1.4	0.859
$40,000-$74,999	1.2	0.8–1.6	0.414	1.0	0.7–1.4	0.872
≥$75,000	Reference group			Reference group
Education level
High school graduate or less	1.5	1.1–2.1	0.008	1.2	0.9–1.7	0.271
Some college	1.2	0.9–1.6	0.268	1.0	0.7–1.4	0.965
College graduate or above	Reference group			Reference group
Marital status
Unmarried or separated	1.9	1.5–2.4	<0.001	1.3	1.0–1.8	0.036
Married	Reference group			Reference group
Savings
<$5,000	2.0	1.5–2.5	<0.001	1.4	1.1–1.9	0.021
≥$5,000	Reference group			Reference group
COVID-19 illness
No	Reference group			Reference group
Yes	4.2	2.8–6.4		3.5	1.9–6.4	<0.001
Death of someone close due to COVID-19
No	Reference group			Reference group
Yes	2.3	1.3–3.9		1.7	0.9–3.0	0.109

Open in a new tab

Notes: Estimates are prevalence ratios (PR) and adjusted prevalence ratios (aPR) based on Poisson regression analyses with robust variance. The PR is based on a bivariable analyses of each variable and suicidal ideation. The aPR is adjusted for all variables listed in the table. There were small samples of participants with COVID-19 illness (n = 12) and bereavement (n = 25).

Discussion

We found that suicidal ideation was 4.8 times higher during the COVID-19 pandemic; 16.1% of people reported suicidal ideation in 2020, relative to 3.4% in 2017–2018. In keeping with prior studies, we found that people living in low-income households are particularly at risk of mental distress during the COVID-19 pandemic [5,6,16].

Reporting difficulty paying rent was associated with suicidal ideation. Prior research indicates that financial distress, such as that which became widespread during the COVID-19 pandemic, is associated with suicide² and that eviction in particular is associated with suicide [20]. Policies such as the Centers for Disease Control and Prevention’s federal eviction moratorium, state eviction moratoriums, and federal and state unemployment insurance policies [21] and federal stimulus payments may help prevent suicide. While job loss was not associated with suicidal ideation during the CLIMB study period of late March and early April in the adjusted analysis, it is important to study job loss and mental health over a longer term period as high unemployment was prolonged for several months, especially for people in low-income households and who are Black and Hispanic [22]. It is also possible that the suicidality impacts of job loss differed by wealth and whether people who lost work faced imminent economic hardship, and further studies among subgroups are needed.

People who reported feeling alone were 1.9 times as likely to report suicidal ideation, highlighting the need for programs and policies to provide social support, such as through social connections in environments with lower COVID-19 risk (e.g. outdoors) or via computer or phone. There is a need for further research on loneliness among subgroups such as older populations.

This study was conducted early in the course of COVID-19 spread across the US; we did not have a large enough sample of persons experiencing COVID-19 illness or bereavement to study the association between COVID-19 illness or bereavement with suicidal ideation. The results suggest a potential association between these exposures and suicidal ideation that warrants further study.

Finally, prior studies indicate that means restriction [23], particularly of firearms [24], is associated with reductions in suicide. Suicide by firearm is the predominant means of suicide death in the United States. As such, and in light of previous evidence that links suicidality to suicide death, policies or programs to reduce household firearm ownership could play an important role in suicide prevention in the COVID-19 context of elevated stressors.

Limitations include that the characteristics of participants in CLIMB and NHANES differed, although both were nationally representative surveys and should be generalizable to the broader population. The NHANES sample was younger and less likely to be low-income. We were further limited by the questions asked in the surveys as indicators of economic precarity and loneliness and the possibility that participants interpreted these questions in different ways. These questions were not included in the NHANES survey, so it was not possible to compare these exposures before and after the pandemic. Furthermore, the CLIMB study was conducted early in the pandemic, and the relationship between stressors and suicidal ideation may have changed as the pandemic and associated stressors continue to affect the US population. There is a need for further research on exposures and suicidality over time and among subgroups, especially those affected by structural racism and inequities.

Conclusion

Suicidal ideation increased substantially during the COVID-19 pandemic. Those facing difficulty paying rent and feeling alone may be at particular risk of suicide. Policies and programs to support people experiencing economic precarity and difficulty paying rent may contribute to suicide prevention, as may programs to support individuals facing prolonged social isolation.

Supporting information

S1 Checklist. STROBE statement—checklist of items that should be included in reports of cross-sectional studies.

(DOCX)

Click here for additional data file.^{(32.4KB, docx)}

Data Availability

The CLIMB dataset is publicly available here: https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/R2BWJL.

Funding Statement

This study was funded in part through support from the Rockefeller Foundation Boston University 3-D Commission (https://3dcommission.health). JR and AS worked on this project while funded by K01 MH116817 from the National Institutes of Health (https://www.nih.gov) and grant No. 77922 from the Robert Wood Johnson Foundation Evidence for Action Program (https://www.rwjf.org). CE worked on this project while funded by grant No. T32 AG 23482 15 from the National Institutes of Health (https://www.nih.gov). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

References

1.Hamilton D, Darity W. Can ‘baby bonds’ eliminate the racial wealth gap in putative post-racial America? Rev Black Polit Econ. 2010;37(3–4): 207–216. [Google Scholar]
2.Elbogen EB, Lanier M, Montgomery AE, Strickland S, Wagner HR, Tsai J. Financial strain and suicide attempts in a nationally representative sample of US adults. Am J Epidemiol. 2020;189(11): 1266–1274. doi: 10.1093/aje/kwaa146 [DOI] [PubMed] [Google Scholar]
3.Calati R, Ferrari C, Brittner M, Oasi O, Olié E, Carvalho A, et al. Suicidal thoughts and behaviors and social isolation: A narrative review of the literature. J Affect Disord. 2019;245: 653–667. doi: 10.1016/j.jad.2018.11.022 [DOI] [PubMed] [Google Scholar]
4.Riehm KE, Holingue C, Smail EJ, Kapteyn A, Bennett D, Thrul J, et al. Trajectories of mental distress among US adults during the COVID-19 pandemic. Ann Behav Med. 2021;55(2): 93–102. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA Netw Open. 2020;3(9): e2019686. doi: 10.1001/jamanetworkopen.2020.19686 [DOI] [PMC free article] [PubMed] [Google Scholar]
6.McGinty EE, Presskreischer R, Han H, Barry CL. Psychological distress and loneliness reported by US adults in 2018 and April 2020. JAMA. 2020;324(1): 93–94. doi: 10.1001/jama.2020.9740 [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Farooq S, Tunmore J, Ali MW, Ayub M. Suicide, self-harm and suicidal ideation during COVID-19: A systematic review. Psychiatry Res. 2021;306:114228. doi: 10.1016/j.psychres.2021.114228 [DOI] [PMC free article] [PubMed] [Google Scholar]
8.John A, Eyles E, Webb RT, Okolie C, Schmidt L, Arensman E, et al. The impact of the COVID-19 pandemic on self-harm and suicidal behavior: Update of living systematic review. F1000Res. 2020;9:1097. [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Curtin SC, Hedegaard H, Ahmad FB. Provisional numbers and rates of suicide by month and demographic characteristics: United States, 2020. National Vital Statistics System. 2021; 16. [Google Scholar]
10.Pirkis J, John A, Shin S, DelPozo-Banos M, Arya V, Analuisa-Aguilar P, et al. Suicide trends in the early months of the COVID-19 pandemic: An interrupted time-series analysis of preliminary data from 21 countries. Lancet Psychiat. 2021;8(7):579–588. doi: 10.1016/S2215-0366(21)00091-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Knipe D, John A, Padmanathan P, Eyles E, Dekel D, Higgins JPT, et al. Suicide and self- harm in low- and middle-income countries during the COVID-19 pandemic. A systematic review. medRxiv. 2021. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.National Vital Statistics System. 10 leading causes of death by age group, United States—2018. Available at https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2018-508.pdf. Accessibility verified April 27, 2022.
13.Tanaka T, Okamoto S. Increase in suicide following an initial decline during the COVID-19 pandemic in Japan. Nat Hum Behav. 2021;5: 229–238. doi: 10.1038/s41562-020-01042-z [DOI] [PubMed] [Google Scholar]
14.Simon GE, Rutter CM, Peterson D, Oliver M, Whiteside U, Operskalski B, et al. Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? Psychiatr Serv. 2013;64(12): 1195–1202. doi: 10.1176/appi.ps.201200587 [DOI] [PMC free article] [PubMed] [Google Scholar]
15.Technical overview of the AmeriSpeak panel: NORC’s probability-based household panel. NORC at the University of Chicago. 2021. Available at https://amerispeak.norc.org/Documents/Research/AmeriSpeak%20Technical%20Overview%202019%2002%2018.pdf. Accessibility verified November 17, 2021.
16.Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Low assets and financial stressors associated with higher depression during COVID-19 in a nationally representative sample of US adults. J Epidemiol Community Health. 2021;75: 501–508. [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Simon GE, Coleman KJ, Rossom RC, Beck A, Oliver M, Johnson E, et al. Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice. J Clin Psychiatry. 2016;77(2):221–227. doi: 10.4088/JCP.15m09776 [DOI] [PMC free article] [PubMed] [Google Scholar]
18.Louzon SA, Bossarte R, McCarthy JF, Katz IR. Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? Psychiatr Serv. 2016;67(5): 517–522. doi: 10.1176/appi.ps.201500149 [DOI] [PubMed] [Google Scholar]
19.Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;59(7): 702–706. doi: 10.1093/aje/kwh090 [DOI] [PubMed] [Google Scholar]
20.Fowler KA, Gladden RM, Vagi KJ, Barnes J, Frazier L. Increase in suicides associated with home eviction and foreclosure during the US housing crisis: findings from 16 national violent death reporting system states, 2005–2010. Am J Public Health. 2015;105(2): 311–316. doi: 10.2105/AJPH.2014.301945 [DOI] [PMC free article] [PubMed] [Google Scholar]
21.Cylus J, Glymour MM, Avendano M. Do generous unemployment benefit programs reduce suicide rates? A state fixed-effect analysis covering 1968–2008. Am J Epidemiol. 2014;80(1): 45–52. [DOI] [PMC free article] [PubMed] [Google Scholar]
22.Bureau of Labor Statistics. The employment situation—September 2020. Available at https://www.bls.gov/news.release/empsit.nr0.htm. Accessibility verified October 4, 2020.
23.Ishimo M, Sampasa-Kanyinga H, Olibris B, et al. Universal interventions for suicide prevention in high-income Organisation for Economic Co-operation and Development (OECD) member countries: a systematic review. Inj. 2021;27: 184–193. doi: 10.1136/injuryprev-2020-043975 [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Santaella-Tenorio J, Cerdá M, Villaveces A, Galea S. What do we know about the association between firearm legislation and firearm-related injuries? Epidemiol Rev. 2016;38(1): 140–157. doi: 10.1093/epirev/mxv012 [DOI] [PMC free article] [PubMed] [Google Scholar]

PLoS One. doi: 10.1371/journal.pone.0275973.r001

Decision Letter 0

Michelle Torok

2 Nov 2021

PONE-D-21-30553Economic precarity, social isolation, and suicidal ideation during the COVID-19 pandemicPLOS ONE

Dear Dr. Raifman,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. There is consensus across the Reviewer's that this manuscript would make a welcome contribution to the literature on the impacts of COVID-19, however, there are concerns as to how well the literature reviewed as part of the Introduction aligns to the aims and outcomes of this study, as well as insufficient detail in the Methodology. Many of the issues raised are quite minor, however, I strongly encourage you to address all feedback, point-by-point, to strengthen the manuscript. In particular, please make sure to complete and attach the STROBE statement as part of your re-submission, as per Reviewer 1's request.

Please submit your revised manuscript by Dec 13 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Michelle Torok, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

2. Thank you for stating the following in the Competing Interests section:

[We have read the journal's policy and the authors of this manuscript have the following competing interests: SG reports serving as a consultant for Sharecare and Tivity Health. All other authors declare that no competing interests exist.]

Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

Additional Editor Comments:

In addition to the comments provided by Reviewer's 1 and 2, the following minor issues need to be addressed:

1. The authors should revise the Introduction to focus on the suicidal ideation literature rather than the mortality literature, consistent with the outcomes measured in their study.

2. In the exposures section (Methods) the authors state that social isolation is measured by the question "feeling alone" - yet refer to to this exposure as loneliness in the Results. Loneliness is more accurate given that feeling alone does not capture whether the person is actually alone. Please change social isolation to loneliness in the Methods.

3. This paper would benefit from more description of where the two samples were drawn from (geographically), the recruitment methods (were similar methods used?), and the response rates for each survey to help the reader understand how comparable the two samples are. Could authors please also include the mean age for the two samples in Table 1, as it looks like the CLIMB sample could be overall younger than the NHANES sample.

4. In the results, the authors make a statement about the increase in suicidal ideation between the two surveys ["Overall, suicidal ideation increased more

107 than fourfold, from 3.4% in the 2017-2018 NHANES to 16.3% in the 2020 CLIMB survey"] however I'm not sure it's appropriate to use 'increase' here given that two samples are not from the same population (and we do not know if the CLIMB sample would have had a higher prevalence of ideation outside of COVID]; re-writing as something more objective would be beneficial, like "the prevalence of suicidal ideation was 3.4% in the NHANES study and 16.3% in the CLIMB sample".

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I thank the authors for the interesting and important study that has further novelty and importance by stratifying analyses by key demographic groups likely disproportionately affected by the pandemic. The authors’ findings confirm this disproportionate impact is the case. My comments are all minor I think, with the most major probably pertaining to ensuring the manuscript is reported per the STROBE Statement and the RECORD Statement (if it’s routinely collected data - NHANES is arguably but unsure about AmeriSpeak) and these reporting guidelines are populated and uploaded.

Page 2, line 30: ‘analyzed April 28 to September 30, 2020’ – the authors may not need to report the dates they analysed the CLIMB data in the abstract, unless this is in here for some specific reason?

Page 2, line 39 ‘Suicidal ideation increased more than fourfold during the COVID-19 pandemic.’ – could say ‘increased by 12.9% and was almost 4.8 times higher.’ It’s definitely closer to five than four.

Page 2, line 41 ‘support people experiencing economic precarity’ – Although ‘precarity’ is a simpler version of precarious and precariousness I imagine, I hard not heard of it before. Is ‘uncertainty’ a more common word in your context, or ‘difficulties’ or ‘challenges’ even? It’s not a big issue so I will leave it to the authors to decide.

Page 3, line 55: ‘Increases in suicide have occurred with prior pandemics [4]’ – Here, it would be best to instead cite these two reviews:

Rogers, J. P., Chesney, E., Oliver, D., Begum, N., Saini, A., Wang, S., ... & David, A. S. (2021). Suicide, self-harm and thoughts of suicide or self-harm in infectious disease epidemics: a systematic review and meta-analysis. Epidemiology and psychiatric sciences, 30.

Zortea, T. C., Brenna, C. T., Joyce, M., McClelland, H., Tippett, M., Tran, M. M., ... & Platt, S. (2020). The impact of infectious disease-related public health emergencies on suicide, suicidal behavior, and suicidal thoughts. Crisis.

Page 3, line 57: ‘While suicide mortality data are typically not publicly available for several months after the end of each year, understanding the populations most at risk of suicidal ideation and the association between COVID-19 stressors and suicidal ideation can inform policies and programs to prevent suicide.’ – I think you will need to change this statement to incorporate the following papers:

Pirkis, J., John, A., Shin, S., DelPozo-Banos, M., Arya, V., Analuisa-Aguilar, P., ... & Spittal, M. J. (2021). Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries. The Lancet Psychiatry, 8(7), 579-588.

Knipe, D., John, A., Padmanathan, P., Eyles, E., Dekel, D., Higgins, J. P., ... & Gunnell, D. (2021). Suicide and self-harm in low-and middle-income countries during the COVID-19 pandemic: A systematic review. medRxiv.

Farooq, S., Tunmore, J., Ali, W., & Ayub, M. (2021). Suicide, self-harm and suicidal ideation during COVID-19: a

systematic review. Psychiatry Research, 114228.

John, A., Eyles, E., Webb, R. T., Okolie, C., Schmidt, L., Arensman, E., ... & Gunnell, D. (2021). The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: update of living systematic review. F1000Research, 9(1097), 1097.

Although many of these papers are about suicide mortality data, I think this is perhaps less relevant for the authors, as most indices of mental health seem to have changed except suicide mortality data (I only know of increases in suicide mortality data in Vienna, Puerto Rico and Japan at the moment). Therefore, it’d probably be good to cite this in your introduction too:

Farooq, S., Tunmore, J., Ali, W., & Ayub, M. (2021). Suicide, self-harm and suicidal ideation during COVID-19: a systematic review. Psychiatry Research, 114228.

People will make arguments that those who think, attempt and die by suicide are distinct, and that these populations are distinct from people experiencing mental health symptoms or conditions too, so I think it’d be good to focus on the relevant literature regarding ideation specifically.

Page 3, line 66: ‘AmeriSpeak standing panel’ – can the authors provide some more information on this? While NHANES is well-known internationally, I have never heard of this. Doing a quick Google Search, some further elaboration would alleviate any reader concerns about the rigor of this survey. A recent paper in the Lancet Americas spent some more time describing it: https://www.thelancet.com/journals/lanam/article/PIIS2667-193X%2821%2900087-9/fulltext

You might even just paraphrase what they said, which is: ‘Details on the AmeriSpeak sampling frame and on the CLIMB study can be found in previous writing. [[1],[17]]’

Page 3, line 68: ‘(64% completed)’ – Do you mean a 64% response rate? Was the survey considered nationally representative before non-response? It seems paraphrasing a statement like this might help: ‘Post-stratification weights were created; once applied, the survey weights aligned the study sample with the U.S. adult population based on the U.S. Current Population Survey. [[19]]’ https://www.thelancet.com/journals/lanam/article/PIIS2667-193X%2821%2900087-9/fulltext Could also add the decimal place: 64.3

Page 3, line 73: We excluded participants who did not respond to questions about suicidal ideation in NHANES and participants who did not respond to any analysis variables in CLIMB data.’ – I presume the results section will mention how many people were excluded?

Page 4, line 77: ‘We evaluated three COVID-19 stressors reflecting economic precarity and social isolation, each measured as binary variables reported in response to a question, “Have any of the following affected your life as a result of the coronavirus or COVID-19 outbreak?” First, we measured job loss based on checking “losing a job.” Second, we measured difficulty paying rent based on checking “having difficulty paying rent.” Third, we measured social isolation as checking “feeling alone.”’

– I think the authors’ findings are really interesting and important as it is nice to see a focus on inequity with these outcomes. So, could the authors clarify that these were the only available stressors for economic precarity and social isolation, and if there were reasons for not looking at other aspects (e.g., outside the scope of the paper)?

Also, it may be odd to say ‘we measured’ if you did not select the measures or collect the data. You could say “The three checkboxes we used asked about ‘losing a job,’ ‘having difficulty paying rent,’ and “feeling alone.”

Page 4, line 85: ‘We measured suicidal ideation’ – could say that ‘both surveys assessed suicidal ideation.’

Page 4, line 89: ‘Prior research indicates responses to this question were correlated with future suicide attempts and deaths [7-9].’ – if they are future suicide attempts and deaths, do you need to say ‘predict’ instead of ‘were correlated with’, and say how well they predict, as any one risk factor by itself is likely a poor predictor of attempts and deaths – see https://pubmed.ncbi.nlm.nih.gov/27841450/

Page 4, line 96: It is great the authors have opted with PRs and Poisson rather than ORs and log reg. Is it easy for the authors to supply their code for the analysis in case other researchers may wish to repeat their study with similar data?

Page 5, line 106: ‘Overall, suicidal ideation increased more than fourfold, from 3.4% in the 2017-2018 NHANES to 16.3% in the 2020 CLIMB survey.’ – As it’s closer to fivefold the authors could say ‘4.79’ or ‘4.8,’ perhaps one decimal place is best.

Page 6, line 116 and page 8, line 147. Can the authors please have columns reporting precise rather than thresholded p-values? This will avoid Type I and Type II errors

(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2850991/), align with the ASA Statement on p-values (https://www.tandfonline.com/doi/full/10.1080/00031305.2016.1154108) and guidelines from other influential papers on p-values (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4877414/).

Page 9, line 156: ‘more than fourfold’ – 4.8 times higher? Or nearly fivefold.

Page 9, line 164: ‘Center for Disease Control and Prevention’ – ‘Centers’

Page 9, line 166: ‘may play help’ – typo?

Page 9, line 172: ‘People who reported feeling lonely were nearly twice as likely to report suicidal ideation’ – 1.9 times as likely? Also, there is some inconsistency in terminology here. The question AmeriSpeak asked was about feeling alone, which you’ve termed social isolation, but it’s referred to as ‘feeling lonely’ in the discussion. Maybe for consistency and brevity you can say ‘feeling alone’ throughout, as it depends on how people interpreted this question (were they actually socially isolated, or perceiving being socially isolated and feeling alone and lonely).

Page 10, line 167: ‘While job loss was not associated with suicidal ideation during the CLIMB study period of late March and early April,’ – do you need to suffix with ‘in the adjusted analysis’?

Page 10, line 183: ‘particularly of firearms [15], is associated with reductions in suicide.’

- A lot of the means restriction interventions were recently summarised in: Ishimo, M. C., Sampasa-Kanyinga, H., Olibris, B., Chawla, M., Berfeld, N., Prince, S. A., ... & Lang, J. J. (2021). Universal interventions for suicide prevention in high-income Organisation for Economic Co-operation and Development (OECD) member countries: a systematic review. Injury prevention, 27(2), 184-193. I suggest citing it.

For firearms specifically, I think the latest systematic review is this, but I suggest the authors citation search it: https://academic.oup.com/epirev/article/38/1/140/2754868?login=true Also better to cite though than the currently cited study.

You might also need to say here that firearms is the predominant suicide method in the US (as it might be hanging elsewhere) so that international readers know why firearms warrant mentioning here.

Page 10, line 188 ‘Limitations include that suicidal ideation was based on self-report’ – yes, any self-reported measure has limitations but how else do we measure ideation? If there is not viable alternative way to measure ideation, I suggest the authors omit this as it’s not something that can be improved upon and it’s a universal limitation of studies on ideation.

Page 10, line 188 ‘that the characteristics of participants in CLIMB and NHANES differed.’ – But both were nationally representative surveys? Additionally, you should probably note here that suicidal ideation was still higher in 2020 (I don’t mean ‘statistical significance,’ just higher) across all strata, compared to 2017 to 2018.

Page 10, line 189 ‘Those who responded to surveys may have differed from those who did not, particularly if stressors affected survey participation.’ – I’m not a survey expert, but as I understand, post-stratification weighting should cancel this out by adjusting for non-response?

Page 10, lines 188-193 – It would perhaps be good to include something about the limitations or exposure measurement if you think there are some. 1-item measures are sometimes criticised. ‘having difficulty paying rent’ is fairly straightforward, although it does not account for people’s income levels. ‘Losing a job’ could mean different things to different people – what about a contractor who has lots of small jobs and loses one job. ‘Feeling alone’ seems a little open to interpretation. These are only minor limitations, but may just warrant mentioning.

Page 10, line 186: Those facing difficulty paying rent and loneliness may be at particular risk of suicide.’ – maybe ‘feeling alone’ instead of ‘loneliness’ for consistency?

Page 14, Fig 1: I’m not sure the data labels add to the figure as they are already in the tables, so they could be removed. As they are above the upper limit, they might be misinterpreted as the upper limit.

Page 14, Fig 1: Red is sometimes considered a colour to avoid in the suicide sector due to the links to blood. The authors could instead choose from these colorblind-friendly colors: https://jfly.uni-koeln.de/color/#pallet

As this is an observational study, per PLOS One requirements the authors need to report according to, populate and submit the STROBE Statement. If the authors consider that NHANES and AmeriSpeak are routinely collected health data, the RECORD Statement (considered supplementary to STROBE and submitted alongside it) can be populated and submitted as well.

Overall, I think this is a really good manuscript. As the literature on suicide is moving so quickly during COVID-19 I’d encourage the authors to check the literature for new studies and reviews just prior to submission if invited to resubmit, be as outcome-specific as possible (ideation, not attempts and deaths), and emphasise slightly more the novelty of this paper (have many other papers done this?) focusing on inequities and people disproportionately bearing the impacts of COVID-19.

Reviewer #2: This is an interesting study on the increase in the prevalence of suicidal ideation during the COVID-19 pandemic.

However, I do not recommend this article for publication in its current form as several limitations have to be highlighted:

1. "The CLIMB and NHANES samples are comparable in that both are nationally representative": in my opinion, this statement is one of the major limitations of the study and should be more clearly analyzed and discussed. The Table 2 should try to depict more precisely the comparability of the two samples. Notably, the percentage of people with high school graduate or less is higher in the NHANES compared to the CLIMBS.

2. The prevalence of "feeling alone", "difficulty paying a rent" or "lost job" were not assessed in the NHANES study so that it is not possible to know if the prevalence of these social conditions were similar or not in the two samples. Moreover, economic precarity and loneliness are already identified as robust risk factors for suicidal ideation and behaviors so that this result does not add much value to the existing evidence regarding suicide prevention.

3. It is not clear if the prevalence ratios were measured with the data issued from the two samples or only for the CLIMB study? As some variables were measured in the two samples and other only in the CLIMB sample, the statistic analyses should be more precisely described and explained.

4. Figure 1: the p should be given for a better understanding of the results depicted in this figure. Are the observed differences statistically significant?

5. The discussion does not fit with the results of the study. For example, the authors discuss the role of means restrictions to prevent suicide, while their study is focused on suicidal ideation with no assessment of access to suicide means.

6. "We found that people living in low-income households and young people are particularly at risk of mental distress during the COVID-19 pandemic": this statement is not supported by the multivariate analysis showing no differences in reported suicidal ideation according to the age of participants

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Stuart Leske

Reviewer #2: Yes: Edouard Leaune

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2022 Nov 16;17(11):e0275973. doi: 10.1371/journal.pone.0275973.r002

Author response to Decision Letter 0

27 May 2022

Thank you for the opportunity to revise and respond to the reviewers’ comments on our manuscript, entitled “Economic precarity, social isolation, and suicidal ideation during the COVID-19 pandemic”. We appreciate the comments and the editor’s and reviewers’ thoughtful feedback that has improved the quality of this manuscript. We have provided detailed responses below and tracked changes to the manuscript.

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

The manuscript has been edited to fit specific journal requirements.

2. Thank you for stating the following in the Competing Interests section:

Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

We added the following Competing Interests statement to the cover letter: “We have read the journal’s policy and the authors of this manuscript have the following competing interests: SG reports serving as a consultant for Sharecare and Tivity Health. This does not alter our adherence to PLOS ONE policies on sharing data and materials. All other authors declare that no competing interests exist.”

In your revised cover letter, please address the following prompts:

We will update your Data Availability statement on your behalf to reflect the information you provide.

Thank you for this clarification. There are no ethical or legal restrictions to sharing the CLIMB dataset, so we uploaded the minimal anonymized dataset as a Supporting Information file. The full dataset may be available upon reasonable request of the authors and will be considered on a case-by-case basis by CE and SG. NHANES is a publicly available dataset made available online by the CDC: https://wwwn.cdc.gov/nchs/nhanes/continuousnhanes/default.aspx?BeginYear=2017. We updated the cover letter to reflect these changes to our Data Availability statement.

Additional Editor Comments:

In addition to the comments provided by Reviewers 1 and 2, the following minor issues need to be addressed:

1. The authors should revise the Introduction to focus on the suicidal ideation literature rather than the mortality literature, consistent with the outcomes measured in their study.

Thank you for this feedback. We revised the introduction to focus more specifically on suicidal ideation with references to recent literature in the context of the COVID-19 pandemic. The introduction now includes the following text: “Economic precarity [2] and social isolation [3] are associated with mental distress and suicide. Other studies have documented increases in mental distress and suicidality [4-8] during the pandemic, but few have examined economic hardship. While there were not increases in suicide deaths in the US or many other countries in 2020 [9-11], suicide remains a leading cause of premature death in the US [12] and may continue to evolve [13]. Suicidality is an indicator of major mental distress and a risk factor for suicide [14]. Understanding the populations most at risk of suicidal ideation and the association between COVID-19 stressors and suicidal ideation can inform policies and programs to reduce suicidality and prevent suicide.”

2. In the exposures section (Methods) the authors state that social isolation is measured by the question "feeling alone" - yet refer to this exposure as loneliness in the Results. Loneliness is more accurate given that feeling alone does not capture whether the person is actually alone. Please change social isolation to loneliness in the Methods.

Thank you for this comment. We changed “social isolation” to “loneliness” in the Methods as suggested and in the title of the manuscript.

Thank you for this suggestion. Based on your feedback and comments from Reviewer 1, we added the following sentences about the CLIMB sample: “We created and applied post-stratification weights to align the study sample with the U.S. adult population according to the U.S. Current Population Survey [15]. Previously published work further describes details on the AmeriSpeak sampling frame and the CLIMB study [5,16].” We also described that CLIMB has a 64.3% completion rate. To further describe the comparability between the two samples, we added the following sentences: “The CLIMB and NHANES samples are comparable in that both are nationally representative groups of US adults residing in all 50 states and the District of Columbia. The AmeriSpeak sampling frame covers approximately 97% of all US households, and NHANES sampling units similarly cover all US counties.” We revised Table 1 to include the mean age for the two samples, and we added the following sentence to the Results section to describe differences: “The NHANES sample was younger, less likely to be married, more likely to have high school or less education, and less likely to be low-income relative to the CLIMB sample.”

4. In the results, the authors make a statement about the increase in suicidal ideation between the two surveys ["Overall, suicidal ideation increased more

Thank you for this suggestion. We replaced the sentence you cited with the following: “The prevalence of suicidal ideation was 3.4% in the 2017-2018 NHANES sample and 16.3% in the 2020 CLIMB survey.”

R1 Comment 1

R1 Response 1

Thank you for this comment. We deleted the following phrase from the abstract: “analyzed April 28 to September 30, 2020.”

R1 Comment 2

R1 Response 2

Thank you for this suggestion. We replaced “more than fourfold” with “increased by 12.9 percentage points and was almost 4.8 times higher”.

R1 Comment 3

Page 2, line 41 ‘support people experiencing economic precarity’ – Although ‘precarity’ is a simpler version of precarious and precariousness I imagine, I had not heard of it before. Is ‘uncertainty’ a more common word in your context, or ‘difficulties’ or ‘challenges’ even? It’s not a big issue so I will leave it to the authors to decide.

R1 Response 3

Thank you for this comment. We appreciate your perspective, but we think “precarity” best captures this experience. We have seen authors use the term previously in several contexts including the following:

Perry BL, Aronson B, Pescosolido BA. Pandemic precarity: COVID-19 is exposing and exacerbating inequalities in the American Heartland. PNAS. 2021;118(8):e2020685118.

Bozarth K, Western G, Jones J. Black women best: The framework we need for an equitable economy. Roosevelt Institute. 2020. Available from: https://rooseveltinstitute.org/wp-content/uploads/2020/09/RI_Black-Women-Best_IssueBrief-202009.pdf.

R1 Comment 4

Page 3, line 55: ‘Increases in suicide have occurred with prior pandemics [4]’ – Here, it would be best to instead cite these two reviews:

R1 Response 4

Thank you for sharing these reviews. We added citations to both articles.

R1 Comment 5

Farooq, S., Tunmore, J., Ali, W., & Ayub, M. (2021). Suicide, self-harm and suicidal ideation during COVID-19: a systematic review. Psychiatry Research, 114228.

R1 Response 5

Thank you for these suggestions. We removed the phrase about suicide mortality data not typically being publicly available for several months after the end of each year. Based on your thoughts and comments from the editor, we also revised the introduction section to focus more specifically on suicidal ideation rather than suicide mortality. We greatly appreciate the recent literature you recommended and we cited these sources. The introduction now includes the following text: “Economic precarity [2] and social isolation [3] are associated with mental distress and suicide. Other studies have documented increases in mental distress and suicidality [4-8] during the pandemic, but few have examined economic hardship. While there were not increases in suicide deaths in the US or many other countries in 2020 [9-11], suicide remains a leading cause of premature death in the US [12] and may continue to evolve [13]. Suicidality is an indicator of major mental distress and a risk factor for suicide [14]. Understanding the populations most at risk of suicidal ideation and the association between COVID-19 stressors and suicidal ideation can inform policies and programs to reduce suicidality and prevent suicide.”

R1 Comment 6

You might even just paraphrase what they said, which is: ‘Details on the AmeriSpeak sampling frame and on the CLIMB study can be found in previous writing. [[1],[17]]’

R1 Response 6

Thank you for this suggestion. We cited these papers and added a clarifying sentence: “Previously published work further describes details on the AmeriSpeak sampling frame and the CLIMB study [5,16].”

R1 Comment 7

R1 Response 7

Thank you for these suggestions. We replaced “64% completed” with “64.3% completion rate”. We also added the following clarifying sentence: “We created and applied post-stratification weights to align the study sample with the U.S. adult population according to the U.S. Current Population Survey [15].”

R1 Comment 8

R1 Response 8

Thank you for this comment. We included the following sentence in the results section that describes the total number of survey respondents as well as the number of participants included in the analytic sample: “A total of 1,415 (96.3%) of 1,470 CLIMB participants responded to all questions relevant to the analysis and 5,085 (86.8%) of 5,856 NHANES participants responded to suicidal ideation questions and were included in the samples.”

R1 Comment 9

R1 Response 9

Thank you for this comment. Although the survey measured additional stressors including travel restrictions and not being able to get food due to shortages, we chose to focus on economic precarity and loneliness in particular. We inserted the following sentence in place of describing the exposure variables as ones we “measured”: “Our exposure variables were based on whether participants checked boxes for “losing a job,” “having difficulty paying rent,” and “feeling alone”.

R1 Comment 10

Page 4, line 85: ‘We measured suicidal ideation’ – could say that ‘both surveys assessed suicidal ideation.’

R1 Response 10

Thank you for this suggestion. The sentence now begins with the following: “Both surveys assessed suicidal ideation…”.

R1 Comment 11

R1 Response 11

Thank you for this comment. As you highlight, any one risk factor is a poor predictor of suicide attempts and deaths. Because of this, we chose to use language that describes an association to avoid implying that a non-RCT is causal.

R1 Comment 12

R1 Response 12

Thank you so much for this suggestion. We are happy to supply our code for the analysis.

R1 Comment 13

R1 Response 13

Thank you for this suggestion. Based on feedback from the editor, we replaced this sentence with the following: “The prevalence of suicidal ideation was 3.4% in the 2017-2018 NHANES sample and 16.3% in the 2020 CLIMB survey.”

R1 Comment 14

Page 6, line 116 and page 8, line 147. Can the authors please have columns reporting precise rather than thresholded p-values? This will avoid Type I and Type II errors

R1 Response 14

Thank you for this comment. We divided table 2 into two tables (tables 2 and 3) and added columns to each of the tables that report precise p-values.

R1 Comment 15

Page 9, line 156: ‘more than fourfold’ – 4.8 times higher? Or nearly fivefold.

R1 Response 15

Thank you for this suggestion. We replaced “more than fourfold increase” with “4.8 times higher”.

R1 Comment 16

Page 9, line 164: ‘Center for Disease Control and Prevention’ – ‘Centers’

R1 Response 16

Thank you for catching this error. We have made the correction.

R1 Comment 17

Page 9, line 166: ‘may play help’ – typo?

R1 Response 17

Thank you for pointing this out. We corrected the typo and it now reads “may help”.

R1 Comment 18

R1 Response 18

Thank you for this comment. We replaced “nearly twice” with “1.9 times.” We also replaced “feeling lonely” with “feeling alone”. Throughout the manuscript, we adjusted the language we used to say “feeling alone” or “loneliness” instead of “social isolation”.

R1 Comment 19

R1 Response 19

Thank you for this suggestion. We added the following phrase: “in the adjusted analysis”.

R1 Comment 20

Page 10, line 183: ‘particularly of firearms [15], is associated with reductions in suicide.’

You might also need to say here that firearms is the predominant suicide method in the US (as it might be hanging elsewhere) so that international readers know why firearms warrant mentioning here.

R1 Response 20

Thank you for these suggestions. We cited both reviews you recommended in place of the previously cited studies. We also added clarification that firearms is the predominant suicide method in the US.

R1 Comment 21

R1 Response 21

Thank you for this suggestion. We removed this limitation as you recommended.

R1 Comment 22

R1 Response 22

Thank you for this comment. We added a clarifying phrase to the limitations that both surveys were nationally representative. We also added the following sentence to describe how the characteristics of participants differed between the two surveys: “The NHANES sample was younger and less likely to be low-income.”

R1 Comment 23

R1 Response 23

Thank you for this comment. We removed this sentence from the manuscript.

R1 Comment 24

R1 Response 24

Thank you for this suggestion. We added the following sentence to the discussion section: “We were further limited by the questions asked in the surveys as indicators of economic precarity and loneliness and the possibility that participants interpreted these questions in different ways.”

R1 Comment 25

Page 10, line 186: Those facing difficulty paying rent and loneliness may be at particular risk of suicide.’ – maybe ‘feeling alone’ instead of ‘loneliness’ for consistency?

R1 Response 25

Thank you for this suggestion. We changed “loneliness” to “feeling alone”.

R1 Comment 26

R1 Response 26

Thank you for this comment. We removed the data labels from the figure.

R1 Comment 27

R1 Response 27

Thank you for this suggestion and for sharing the colorblind-friendly resource. We changed the color scheme of the figure.

R1 Comment 28

R1 Response 28

Thank you for this comment. We completed and submitted the STROBE Statement with the resubmission.

R1 Comment 29

R1 Response 29

Thank you so much for your helpful and thoughtful feedback. We revised the introduction to focus more specifically on suicidal ideation with references to recent literature in the context of the COVID-19 pandemic. We highlighted how our paper is unique in that it explores a relationship between economic precarity and suicidality and complements other work related to suicidal ideation during the pandemic. We also added the following sentence to the introduction to describe how historical and modern-day policies shaped inequities in COVID-19 and economic outcomes: “Black, Hispanic, and Native American people are made especially vulnerable to these economic shocks as a result of centuries of structural racism that shape inequities in wealth.”

Reviewer #2: This is an interesting study on the increase in the prevalence of suicidal ideation during the COVID-19 pandemic.

However, I do not recommend this article for publication in its current form as several limitations have to be highlighted:

R2 Comment 1

"The CLIMB and NHANES samples are comparable in that both are nationally representative": in my opinion, this statement is one of the major limitations of the study and should be more clearly analyzed and discussed. The Table 2 should try to depict more precisely the comparability of the two samples. Notably, the percentage of people with high school graduate or less is higher in the NHANES compared to the CLIMBS.

R2 Response 1

Thank you for your comment. We appreciate the encouragement to more formally compare the samples. We separated Table 2 into two tables to fully describe the sample and we calculated p-values for differences in proportions. We described differences between the samples: “The NHANES sample was younger, less likely to be married, more likely to have high school or less education, and less likely to be low-income relative to the CLIMB sample.”

R2 Comment 2

The prevalence of "feeling alone", "difficulty paying a rent" or "lost job" were not assessed in the NHANES study so that it is not possible to know if the prevalence of these social conditions were similar or not in the two samples. Moreover, economic precarity and loneliness are already identified as robust risk factors for suicidal ideation and behaviors so that this result does not add much value to the existing evidence regarding suicide prevention.

R2 Response 2

Thank you for your comment. We thought it was important to evaluate economic hardship and loneliness as risk factors during the COVID-19 pandemic, given that they rose in prevalence. We also added discussion of the limitation in measurement in NHANES prior to the pandemic to the discussion section: “We were further limited by the questions asked in the surveys as indicators of economic precarity and loneliness and the possibility that participants interpreted these questions in different ways. These questions were not included in the NHANES survey, so it was not possible to compare these exposures before and after the pandemic.”

R2 Comment 3

It is not clear if the prevalence ratios were measured with the data issued from the two samples or only for the CLIMB study? As some variables were measured in the two samples and other only in the CLIMB sample, the statistic analyses should be more precisely described and explained.

R2 Response 3

Thank you for this comment. We added clarification to the analysis subsection of the Methods to describe that the prevalence ratios were measured with data from the CLIMB study only.

R2 Comment 4

Figure 1: the p should be given for a better understanding of the results depicted in this figure. Are the observed differences statistically significant?

R2 Response 4

Thank you for this suggestion. We added p-values to the figure to demonstrate that the observed differences are statistically significant.

R2 Comment 5

The discussion does not fit with the results of the study. For example, the authors discuss the role of means restrictions to prevent suicide, while their study is focused on suicidal ideation with no assessment of access to suicide means.

R2 Response 5

Thank you for this comment. We appreciate your point and agree that the focus of this manuscript is on suicidal ideation. However, knowing that suicidality is related to suicide, we think it is important to additionally speak to strategies for suicide prevention. We considered your thoughts and the comments from Reviewer 1 and we added the following sentences to the discussion section: “Suicide by firearm is the predominant means of suicide death in the United States. As such, and in light of previous evidence that links suicidality to suicide death, policies or programs to reduce household firearm ownership could play an important role in suicide prevention in the COVID-19 context of elevated stressors.”

R2 Comment 6

"We found that people living in low-income households and young people are particularly at risk of mental distress during the COVID-19 pandemic": this statement is not supported by the multivariate analysis showing no differences in reported suicidal ideation according to the age of participants

R2 Response 6

Thank you for this comment. We removed the phrase “and young people” from this sentence.

PLoS One. doi: 10.1371/journal.pone.0275973.r003

Decision Letter 1

Pedro Vieira da Silva Magalhaes

28 Jun 2022

PONE-D-21-30553R1Economic precarity, loneliness, and suicidal ideation during the COVID-19 pandemicPLOS ONE

Dear Dr. Raifman,

There are a few minor issues still pending and raised by reviewer #1, which need some attention.

Please submit your revised manuscript by Aug 12 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Pedro Vieira da Silva Magalhaes, M.D., Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: Thank you to the authors for making these revisions, and I accept their rebuttals on some points. I have no further comments on how they addressed the revisions. Some minor points:

Page 2, line 33: after ‘robust variance’, just add ‘to generate unadjusted and adjusted prevalence ratios (PR and aPR).’ – only aPR is mentioned in the abstract, so can omit ‘PR and’ if space is tight.

Page 2, line 38: for balance eporting null and non-null findings and completeness in the abstract, you could add to the end of this sentence: ‘but job loss was not (aPR: 0.9, 95% CI: 0.6 to 1.2)’

Page 2, lines 39-40: Should move this sentence to line 35, after ‘households.’ as it’s the total sample.

Page 13, lines 185-189: Job loss may also be a crude marker as someone might obtain another job relatively quickly while others may not, and I think people more disadvantaged would find it more difficult to get another job? Also, as you have shown, there is a lower prevalence of suicidal ideation in those with more savings, so job loss will affect people differently (some people may not have liked their job and liked their new job better, too, if they found one). The number losing their job in CLIMB 2020 is perhaps too small to stratify by those variables, so perhaps that’s a subsequent study you can suggest to understand this more. Initial relationships (or absence - near parity in the PR) might look different down the track when you can stratify this by other important variables.

Page 13, lines 191-194: ‘Feeling alone’ is in the literature and my experience, more frequently associated with the suicides of elderly people, and we know they likely use technology less. This is perhaps an area for future study – a stratified analysis by age group to see if these recommendations are broad-based or apply to specific groups.

Page 15, lines 220-221: Could add ‘there is a need for further research to determine if job loss affects suicidal ideation differently in different population subgroups’, or something to that effect.

Thank you for the opportunity to review this manuscript again.

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Stuart Leske

Reviewer #2: Yes: Edouard Leaune

**********

PLoS One. 2022 Nov 16;17(11):e0275973. doi: 10.1371/journal.pone.0275973.r004

Author response to Decision Letter 1

26 Sep 2022

Thank you for the opportunity to revise and respond to the reviewers’ comments on our manuscript, entitled “Economic precarity, social isolation, and suicidal ideation during the COVID-19 pandemic.” We appreciate the comments and the editor’s and reviewers’ thoughtful feedback that has improved the quality of this manuscript. We have provided detailed responses below and tracked changes to the manuscript.

Reviewer #1: Thank you to the authors for making these revisions, and I accept their rebuttals on some points. I have no further comments on how they addressed the revisions. Some minor points:

Thank you again for your thoughtful reviews and for your additional suggestions.

Thank you for the suggestion. We made this change.

Page 2, line 38: for balance eporting null and non-null findings and completeness in the abstract, you could add to the end of this sentence: ‘but job loss was not (aPR: 0.9, 95% CI: 0.6 to 1.2)’

Thank you for the suggestion. We made this change.

Page 2, lines 39-40: Should move this sentence to line 35, after ‘households.’ as it’s the total sample.

Thank you for the suggestion. We made this change.

Thank you for this suggestion. We added a sentence about this caveat and the suggestion for further study.

“It is also possible that the suicidality impacts of job loss differed by wealth and whether people who lost work faced imminent economic hardship, and further studies among subgroups are needed.”

Thank you for this suggestion. We added the following sentence to the discussion of feeling alone.

“There is a need for further research on loneliness among subgroups such as older populations.”

Thank you for this suggestion. We added the following sentence to the discussion section.

“There is a need for further research on exposures and suicidality over time and among subgroups, especially those affected by structural racism and inequities.”

PLoS One. doi: 10.1371/journal.pone.0275973.r005

Decision Letter 2

Pedro Vieira da Silva Magalhaes

27 Sep 2022

Economic precarity, loneliness, and suicidal ideation during the COVID-19 pandemic

PONE-D-21-30553R2

Dear Dr. Raifman,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Pedro Vieira da Silva Magalhaes, M.D., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0275973.r006

Acceptance letter

Pedro Vieira da Silva Magalhaes

8 Nov 2022

PONE-D-21-30553R2

Economic precarity, loneliness, and suicidal ideation during the COVID-19 pandemic

Dear Dr. Raifman:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Pedro Vieira da Silva Magalhaes

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. STROBE statement—checklist of items that should be included in reports of cross-sectional studies.

(DOCX)

Click here for additional data file.^{(32.4KB, docx)}

Data Availability Statement

The CLIMB dataset is publicly available here: https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/R2BWJL.

[pone.0275973.ref001] 1.Hamilton D, Darity W. Can ‘baby bonds’ eliminate the racial wealth gap in putative post-racial America? Rev Black Polit Econ. 2010;37(3–4): 207–216. [Google Scholar]

[pone.0275973.ref002] 2.Elbogen EB, Lanier M, Montgomery AE, Strickland S, Wagner HR, Tsai J. Financial strain and suicide attempts in a nationally representative sample of US adults. Am J Epidemiol. 2020;189(11): 1266–1274. doi: 10.1093/aje/kwaa146 [DOI] [PubMed] [Google Scholar]

[pone.0275973.ref003] 3.Calati R, Ferrari C, Brittner M, Oasi O, Olié E, Carvalho A, et al. Suicidal thoughts and behaviors and social isolation: A narrative review of the literature. J Affect Disord. 2019;245: 653–667. doi: 10.1016/j.jad.2018.11.022 [DOI] [PubMed] [Google Scholar]

[pone.0275973.ref004] 4.Riehm KE, Holingue C, Smail EJ, Kapteyn A, Bennett D, Thrul J, et al. Trajectories of mental distress among US adults during the COVID-19 pandemic. Ann Behav Med. 2021;55(2): 93–102. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref005] 5.Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA Netw Open. 2020;3(9): e2019686. doi: 10.1001/jamanetworkopen.2020.19686 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref006] 6.McGinty EE, Presskreischer R, Han H, Barry CL. Psychological distress and loneliness reported by US adults in 2018 and April 2020. JAMA. 2020;324(1): 93–94. doi: 10.1001/jama.2020.9740 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref007] 7.Farooq S, Tunmore J, Ali MW, Ayub M. Suicide, self-harm and suicidal ideation during COVID-19: A systematic review. Psychiatry Res. 2021;306:114228. doi: 10.1016/j.psychres.2021.114228 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref008] 8.John A, Eyles E, Webb RT, Okolie C, Schmidt L, Arensman E, et al. The impact of the COVID-19 pandemic on self-harm and suicidal behavior: Update of living systematic review. F1000Res. 2020;9:1097. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref009] 9.Curtin SC, Hedegaard H, Ahmad FB. Provisional numbers and rates of suicide by month and demographic characteristics: United States, 2020. National Vital Statistics System. 2021; 16. [Google Scholar]

[pone.0275973.ref010] 10.Pirkis J, John A, Shin S, DelPozo-Banos M, Arya V, Analuisa-Aguilar P, et al. Suicide trends in the early months of the COVID-19 pandemic: An interrupted time-series analysis of preliminary data from 21 countries. Lancet Psychiat. 2021;8(7):579–588. doi: 10.1016/S2215-0366(21)00091-2 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref011] 11.Knipe D, John A, Padmanathan P, Eyles E, Dekel D, Higgins JPT, et al. Suicide and self- harm in low- and middle-income countries during the COVID-19 pandemic. A systematic review. medRxiv. 2021. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref012] 12.National Vital Statistics System. 10 leading causes of death by age group, United States—2018. Available at https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2018-508.pdf. Accessibility verified April 27, 2022.

[pone.0275973.ref013] 13.Tanaka T, Okamoto S. Increase in suicide following an initial decline during the COVID-19 pandemic in Japan. Nat Hum Behav. 2021;5: 229–238. doi: 10.1038/s41562-020-01042-z [DOI] [PubMed] [Google Scholar]

[pone.0275973.ref014] 14.Simon GE, Rutter CM, Peterson D, Oliver M, Whiteside U, Operskalski B, et al. Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? Psychiatr Serv. 2013;64(12): 1195–1202. doi: 10.1176/appi.ps.201200587 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref015] 15.Technical overview of the AmeriSpeak panel: NORC’s probability-based household panel. NORC at the University of Chicago. 2021. Available at https://amerispeak.norc.org/Documents/Research/AmeriSpeak%20Technical%20Overview%202019%2002%2018.pdf. Accessibility verified November 17, 2021.

[pone.0275973.ref016] 16.Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Low assets and financial stressors associated with higher depression during COVID-19 in a nationally representative sample of US adults. J Epidemiol Community Health. 2021;75: 501–508. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref017] 17.Simon GE, Coleman KJ, Rossom RC, Beck A, Oliver M, Johnson E, et al. Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice. J Clin Psychiatry. 2016;77(2):221–227. doi: 10.4088/JCP.15m09776 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref018] 18.Louzon SA, Bossarte R, McCarthy JF, Katz IR. Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? Psychiatr Serv. 2016;67(5): 517–522. doi: 10.1176/appi.ps.201500149 [DOI] [PubMed] [Google Scholar]

[pone.0275973.ref019] 19.Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;59(7): 702–706. doi: 10.1093/aje/kwh090 [DOI] [PubMed] [Google Scholar]

[pone.0275973.ref020] 20.Fowler KA, Gladden RM, Vagi KJ, Barnes J, Frazier L. Increase in suicides associated with home eviction and foreclosure during the US housing crisis: findings from 16 national violent death reporting system states, 2005–2010. Am J Public Health. 2015;105(2): 311–316. doi: 10.2105/AJPH.2014.301945 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref021] 21.Cylus J, Glymour MM, Avendano M. Do generous unemployment benefit programs reduce suicide rates? A state fixed-effect analysis covering 1968–2008. Am J Epidemiol. 2014;80(1): 45–52. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref022] 22.Bureau of Labor Statistics. The employment situation—September 2020. Available at https://www.bls.gov/news.release/empsit.nr0.htm. Accessibility verified October 4, 2020.

[pone.0275973.ref023] 23.Ishimo M, Sampasa-Kanyinga H, Olibris B, et al. Universal interventions for suicide prevention in high-income Organisation for Economic Co-operation and Development (OECD) member countries: a systematic review. Inj. 2021;27: 184–193. doi: 10.1136/injuryprev-2020-043975 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0275973.ref024] 24.Santaella-Tenorio J, Cerdá M, Villaveces A, Galea S. What do we know about the association between firearm legislation and firearm-related injuries? Epidemiol Rev. 2016;38(1): 140–157. doi: 10.1093/epirev/mxv012 [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Economic precarity, loneliness, and suicidal ideation during the COVID-19 pandemic

Julia Raifman

Catherine K Ettman

Lorraine T Dean

Salma M Abdalla

Alexandra Skinner

Colleen L Barry

Sandro Galea

Roles

Abstract

Introduction

Methods

Sample

Exposures

Outcome

Analysis

Results

Table 1. Participant demographic characteristics.

Table 2. COVID-19 stressors, demographic characteristics, and suicidality.

Fig 1. COVID-19 stressors and suicidal ideation.

Table 3. COVID-19 related stressors and suicidal ideation over the past two weeks (N = 1415).

Discussion

Conclusion

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Michelle Torok

Roles

Author response to Decision Letter 0

Decision Letter 1

Pedro Vieira da Silva Magalhaes

Roles

Author response to Decision Letter 1

Decision Letter 2

Pedro Vieira da Silva Magalhaes

Roles

Acceptance letter

Pedro Vieira da Silva Magalhaes

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases