The Cost of Suicide Mortality in New Brunswick, 1996

Dale Clayton and Alberto Barceló

Introduction

Suicide touches the lives of many Canadians. In 1996, suicide was the leading cause of death among those aged 25-29 years in New Brunswick.¹ Previous studies have shown that suicide rates in New Brunswick increased from 1987 to 1995,² from 9.5 per 100,000 (95% confidence interval [CI] = 7.46-12.07) to 16.17 per 100,000 (95% CI = 13.48-19.36). Suicide deaths accounted for 1.4% of all deaths occurring in New Brunswick in 1987,³ and this figure rose to 2.0% of all deaths in 1995,⁴ although the increase was not statistically significant. This provincial ranking compares with national statistics in which suicide deaths remained at 1.9% of all deaths in both 1987³ and 1995.⁴ An awareness of rising suicide rates has led to questions about the economic impact of suicide in New Brunswick.

Although many Canadian cost-of-illness studies have been completed,^5-11 no Canadian cost-of-suicide studies have been reported that include both direct and indirect costs. Earlier Canadian cost-of-suicide studies have focused on only one category of costs (direct or indirect), but not both. Hanvelt et al. estimated the indirect cost per suicide death of men aged 25S64 in Canada from 1987 to 1991 at $516,800 (1990 US$).¹¹ Using the conversion rate to 1990 Canadian dollars cited by Hanvelt et al. of $1.167 (CAN) = $1 (US) and adjusting to 1996 Canadian dollars using the consumer price index,¹² the estimate by Hanvelt et al. becomes $684,524.86 per suicide death. Hanvelt et al. further reported that for men of this age group, suicide deaths resulted in the third greatest loss in productivity, behind HIV/AIDS deaths and motor vehicle fatalities.¹¹ Similarly, Miller estimated suicide deaths by gunshot in Canada in 1991 to cost $1,036,494 per suicide death (1993 CAN$);⁶ this does not include Miller's estimate of lost quality of life. Adjusting to 1996 dollars, this estimate translates to $1,078,238.85 per suicide death.

Several US studies have examined the economic burden of suicide deaths in association with specific mental disorders^13-15 or within specific age groups.¹⁶ Although these studies have been useful in quantifying the cost of suicide within these groups, the appropriateness of extrapolating from these studies to a broader Canadian population remains questionable. Issues that arise when making these US-Canadian comparisons include differences in health care costs, given the different health care systems in the two countries, and the socio-economic representativeness of suicides occurring within specific age or mental illness categories with respect to all suicides occurring in Canada. Table 1 summarizes the results of previous cost-of-illness studies as they relate to suicide deaths.

This study used an incidence-based human capital approach to estimate the total economic burden of suicide deaths in New Brunswick in 1996.

Methods

Identifying Completed Suicide Cases

Suicide deaths that occurred in New Brunswick in 1996 were identified from the New Brunswick Vital Statistics database. Name, address, Medicare number, date of birth and date of death were collected for each case, and each case was cross-referenced with the suicide database of the New Brunswick Coroner's Office to ensure that all reported suicide deaths in the province had been identified.

Cost Estimates

Costs were conceptually categorized into two groups: actual dollar expenditures related to the suicide death (direct costs) and estimates of the value of future productivity losses (indirect costs). It should be noted that this classification into direct and indirect categories is arbitrary and does not affect the resulting economic value estimates.

Direct Costs

Ambulance services

The use of ambulance services in association with each suicide case was determined by cross-referencing Medicare numbers with the New Brunswick Ambulance Services database. The average cost per ambulance service in 1996 was then applied to the identified cases. This cost was estimated by dividing the total cost of operating ambulance services in the province during the 1996/97 fiscal year by the number of service calls answered during that period.

Hospital services

The Hospital Financial Utilization Management System (HFUMS) of the Department of Health and Community Services was cross-referenced with Medicare numbers of completed suicide cases. Hospital services that were shown to be associated with a suicide attempt and subsequent death were included. For each case identified, the records department of the associated hospital was contacted and asked for the Resource Intensity Weight (RIW) assigned to each case by the Canadian Institute for Health Information.¹⁷ Using the most recent dollar value equivalent (1994/95) calculated for HFUMS adjusted to 1996 values according to the consumer price index¹⁸ (1 RIW = $2,829.62), actual cost estimates for each case were made by multiplying the RIW by the equivalent dollar value.

Physician services

Costs for physician services were identified by cross-referencing Medicare numbers of completed suicides cases with the New Brunswick Medicare payment database. Physician services provided one day before a successful suicide attempt and up to and including the day of death were included in our cost estimate.

Autopsy services

Data relating to costs of autopsy services were obtained directly from the New Brunswick Coroner's Office. These data reflected costs associated with performing a post-mortem examination but did not include such services as transporting the body to a regional morgue facility.

Funeral/cremation services

A provincial average cost for funeral and cremation services provided in 1996 was calculated from information obtained from all funeral/cremation service providers in the province. All service providers were asked to report the number of funeral/cremation services provided by their establishment in 1996 as well as the average cost for those services. A provincial average was then calculated by weighting the information supplied by each provider to the total number of services that were reported.

Police investigations

Costs incurred for the police investigation of suicide deaths in New Brunswick in 1996 were obtained directly from all police forces in the province. Each of the 16 regional police forces as well as the New Brunswick Division of the Royal Canadian Mounted Police were asked to supply the number of suicide cases investigated in their jurisdiction during the 1996 calendar year. Each police force provided estimates of the total cost incurred for their suicide investigations based on personnel costs.

Indirect Costs

Potential years of life lost (PYLL)

PYLL calculations provide a quantifiable estimate of the number of years of potential or productive life lost as a result of premature death. PYLL before age 75 were calculated and expressed as a ratio to the mean population under age 75 in 1996, as described by the Canadian Institute for Health Information.¹⁹

Discounted future earnings (DFE)

Lost future earnings as a result of suicide death were calculated using the model developed by Vodden et al. for the Ontario Ministry of Transportation.¹⁰ The model estimates total future earnings lost as a result of premature death for both labour force work and unpaid labour (see Appendix). Future earnings were discounted by an appropriate rate to convert them to present day values. A rate of 4% was used for calculations based on recommendations made by Miller et al.²⁰ and the experiences of other cost-of-suicide reports.¹³ All calculations of discounted future earnings were carried out using the S-Plus version 4.5 software package.²¹

Survival probabilities, P_y,s(n), were collected from the New Brunswick Statistics Agency based on published reports from Statistics Canada.²² Mean annual employment earnings by age and sex in New Brunswick, Y_s(n), were obtained from the 1996 Statistics Canada Labour Force Survey.²³

Information relating to the value of homemaking services was taken from the Statistics Canada publication Households' Unpaid Work: Measurement and Valuation.²⁴ Data drawn from this publication were based on the results of the 1992 national General Social Survey (GSS) using a generalist approach for estimating replacement costs (see reference for a detailed description of methodology). Replacement cost data by demographic group were converted to annual dollars per person using census population estimates.²⁴ The value of homemaking services by age and sex, Y^h_s(n), was then entered into the DFE model similarly to mean annual employment earnings, Y_s(n) (see Appendix).

Labour productivity data are reported annually by the Centre for the Study of Living Standards.²⁵ A rate of increase in labour productivity of 0.04 $GDP/hour/employed worker was estimated by calculating the mean of the three-year moving averages of the annual change in labour productivity from 1984 to 1995.

Results

Ninety-three suicide deaths were identified in both the Vital Statistics and Coroner's Office databases. One additional case was found in the Coroner's Office database that did not appear in the Vital Statistics data. Information from both sources was combined, and a total of 94 deaths was used in all calculations. Table 2 summarizes the total cost estimates associated with suicide deaths in New Brunswick in 1996. The total cost of suicide deaths was calculated to be $79,888,513.17.

Discounted future earnings

Total discounted future earnings were calculated for each case in 1996 using a discount rate of 4% (see Appendix). Estimated discounted future earnings for the 94 suicide deaths in 1996 were calculated to be $79,353,354.56, providing the largest contributing factor (99%) of the overall cost of suicide deaths. A sensitivity analysis of the 4% discount rate was performed to assess the variability of discounted future earnings at 2%, 4%, 6%, 8% and 10% discount rates. The results of this analysis are presented in Figure 1.

Method of Suicide

Since average costs were used in the estimation of ambulance, autopsy and funeral services, and police investigation costs were not available by suicide method, accurate comparison of total costs by suicide method is not possible. However, including only cost estimates for hospital and physician services provides a relative ranking of suicide method by health care costs (Table 4). Using this comparison, suicide by firearm was the most costly method ($13,920.32), followed by jump/fall ($12,531.13) and strangulation ($10,541.85).

The greatest cost of suicide deaths occurred in those age groups with the greatest number of suicide deaths. This was found to be the 35-49 age group for both men ($31,805,592.92; n = 37) and women ($4,418,836.70; n = 6) (Table 5). Of the 94 suicide deaths occurring in 1996, 85.1% were male, accounting for 84.4% of the total provincial cost of suicide.

Discussion

The results of the present study indicate that suicide deaths have a significant impact on the New Brunswick economy. Total average cost per suicide death in 1996 was estimated to be $849,877.80. The per capita cost of suicide deaths for the population of New Brunswick was $104.84. This does not include the emotional and psychological burden experienced by the friends and family members of suicide victims. Nor does it encompass the value of that part of a person's life that cannot be estimated simply by a loss in productivity (e.g. the value of being someone's friend, the value of being aware of one's existence, the value of emotional experiences, etc.).

This study made use of the human capital approach to estimate the value of lost productivity due to premature death. This approach estimates loss by approximating current market values for lost productivity in the future.^4,9,27 This estimate is made for both paid (e.g. employment) and unpaid labour (e.g. homemaking). Lost productivity can be quite easily summed using widely accepted numerical values; employment earnings by age and sex are easily reproducible and measurable numbers. Using a discounted future earnings model,¹⁰ the age- and sex-specific values of both paid and unpaid labour can be summed over the years of life lost to premature death, and adjusted by labour productivity and discount rates.

Another method of approximating the value of life lost is the "willingness-to-pay" approach.^4,9,27 Unlike the human capital approach, which estimates the market value of human productivity, willingness-to-pay reflects the societal value of life by estimating the amount of money people would be willing to pay to avoid a suicide death. The willingness-to-pay approach is believed to assign a greater economic value to lost life than the human capital approach, as it encompasses the psychological and physical burden of pain, suffering and lost quality of life. The decision to use the human capital approach in this study was made on the basis of the availability of relevant data sources and the reproducibility of the study's results.

This study provides a reference point from which subsequent cost-of-suicide studies may be compared. These results are similar to those reported by Hanvelt et al.¹¹ and Miller,⁶ given their focus on either partial cost or specific method. Indirect costs per suicide death of males aged 25-64 estimated by Hanvelt et al. were $684,524.86 (adjusted to 1996$). As expected, this was less than our estimate of both indirect and direct costs for both sexes and all age groups, of $849,877.80. Miller estimated total costs per suicide death by gunshot to be $1,078,238.85 (adjusted to 1996$). This does not include Miller's estimate of "lost quality of life", which was not included in the present study. Miller's estimate was greater than that for the gunshot suicides included in our study ($816,849.51 per death). This difference is likely due to estimates of discounted future earnings in the two studies. The age and sex of the cases sampled heavily influence discounted future earnings estimates. As may have occurred in Miller's study, a sample of younger cases with a higher proportion of males would result in a higher estimate.

This report provides an overall cost estimate of nearly $80 million for suicide deaths occurring in New Brunswick in 1996, which translates to an average cost of $849,877.80 per suicide death. With greater refinement of data sources, future studies should include the cost of mental health services for friends and family members of suicide victims and an estimation of lost productivity values for those grieving a suicide death.

It would also be possible to broaden the scope of future cost-of-suicide studies to include all forms of suicidal behaviour. This would include not only costs following a suicide death, but costs incurred for each suicidal person before their successful attempt. A further step would be to then include costs associated with suicide attempts that never result in suicide death. Such a study would provide a complete profile of the economic impact of suicidal behaviour in society. Nevertheless, the present study provides the groundwork for further research.

Summary

In summary, this report describes the costs associated with suicide deaths occurring in New Brunswick in 1996. The model used to assess these costs involved an incidence-based human capital approach involving both direct and indirect costs. A total cost of $79,888,513.17 was reported for the 94 suicide deaths in 1996, resulting in a mean cost of $849,877.80 per suicide death. An itemized breakdown of costs was presented by age, sex and method of suicide. Comparisons with other Canadian cost-of-fatal illness studies are discussed, and suggestions for further research are given.

Acknowledgements

The authors wish to thank Varsha Chhatre, biostatistician with the New Brunswick Provincial Epidemiology Service, for her technical assistance in the calculation of discounted future earnings.

References

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Dale Clayton, New Brunswick Department of Health and Community Services, PO Box 5100, Fredericton, New Brunswick E3B 5G8; E-mail: dale.clayton@gov.nb.ca

Alberto Barceló, Pan-American Health Organization, Regional Office of the World Health Organization, Washington, DC, USA

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