The U.S. age-adjusted suicide rate is over 35% higher than 2 decades ago—during which time many other high income countries instead had suicide rate declines—and the COVID-19 pandemic highlighted the urgent need to address nonfatal self-harm injuries, particularly among youth.^1–3 This study aimed to report the estimated annual economic cost of U.S. suicide and nonfatal self-harm.

This cross-sectional retrospective cost analysis of the U.S. population followed STROBE reporting guidelines for observational studies and applicable elements of the CHEERS reporting guidelines for economic evaluations.⁴ This study used publicly available data and did not require institutional review. In July 2023 CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS) Cost of Injury provided the number of suicides and nonfatal self-harm injury emergency department (ED) visits by sex (male/female) and age group (10–24, 25–44, 45–64, and 65+ years) and the annual economic cost of associated medical spending, lost work productivity, reduced quality of life from injury morbidity, and avoidable mortality (using the value of statistical life, VSL) during 2015–2020.¹ The data source uses the societal perspective, including tangible and intangible costs, and a 1-year time horizon (period over which costs are assessed) for nonfatal injuries.⁵ Costs are 2020 U.S. dollars. Outcome measures were the number, age-adjusted rate, and annual economic cost of suicides and self-harm injuries by sex, age group, and cost element (e.g., medical spending).

WISQARS data and methods are comprehensively described elsewhere.⁵ Suicide deaths were from the National Center for Health Statistics.⁶ ED visits were from the National Electronic Injury Surveillance System-All Injury Program, a nationally representative probability sample of hospitals.⁷ One-year follow-up medical spending (e.g., repeat nonfatal self-harm) and lost work unit costs due to nonfatal injuries were from the National Inpatient Sample and National Emergency Department Sample (which can produce survey-weighted national estimates of community hospital encounters) and Market-Scan Commercial Claims and Encounters Databases (which demonstrate medical payments to providers from approximately 350 health insurance payers—large employers, health plans, and government and public organizations).^8–11 The monetary value of injury morbidity and mortality in the data source used quality of life loss estimates for injuries and recommended methods for VSL, a monetary estimate of the collective value placed on mortality risk reduction as derived in research studies through revealed preferences (e.g., observed wage differences for dangerous occupations) or stated preferences from surveys of individual persons’ willingness to pay for mortality risk reduction.^12–14 Data source VSL varied by decedent age (0–17 years, $18.0 million; 18–65 years, $11.4 million and values descending from $6.5 million (aged 66 years) to US$440,000 (aged ≥100 years), adjusted for older adults’ decreasing general life expectancy, baseline quality of life and discounted 3% to present value⁵) and each quality-adjusted life year loss was valued at $580,000.^5,14

The economic cost of suicide and ED-treated nonfatal self-harm injuries averaged $510 billion annually during 2015–2020 (range: $488B to $532B) (Table 1). The annual economic cost of suicides alone averaged $484 billion (95% of the total) due to the high cost of lost life years ($484B), followed by medical spending ($13B for fatal and nonfatal injuries combined), injury morbidity reduced quality of life ($10B), and work loss due to non-fatal injuries ($3B) (Table 1).

Working-aged adults (aged 25–64 years) comprised nearly 75% of the economic cost of suicide (annual average: $356B) whereas children and younger adults (aged 10–44 years) comprised nearly 75% of the economic cost of nonfatal self-harm injuries ($19B) (Figure). ED visits for nonfatal self-harm were more common for females (60% of visits annually overall and 70% among aged 10–24 years). The number of ED visits for females and males aged 10–24 years was higher at the end of the study period, generating a higher economic cost (females: 151,448 visits [$7.2B] in 2020 versus 131,309 [$5.8B] in 2015—a 15% visit increase and a 17% age-adjusted visit rate increase; males: and 61,606 visits [$4.0B] versus 58,335 visits [$3.6B]—a 6% visit increase and a 9% age-adjusted visit rate]) compared to decreases among older age groups; the exception was an increase in visits among males aged 65+ years old (8,396 visits [$771M] in 2020 versus 6,814 [$698M] in 2015—a 23% visit increase and a 1% visit rate increase) (Table 1). Males comprised the majority (nearly 80% annually) of suicides. The number of suicides and associated economic cost were higher at the end of the study period for both males and females aged 10–24, 25–44 and 65+ years but lower among adults aged 45–64 years.

The average annual economic cost of medical spending, lost work, lower quality of life, and avoidable deaths from U.S. suicide and nonfatal self-harm using national data sources was $510B. This estimate is higher than a previous similar estimate of $94B based on an older version of the same data source.¹⁵ The present study used more recent and comprehensive estimates of attributable medical spending, lost work costs, and measured economic costs during a period of higher incidence. However, the higher estimate presented here is primarily due to a change in CDC WISQARS Cost of Injury to value premature mortality and morbidity using VSL instead of lost labor market productivity; VSL is approximately 10 times more than foregone employment compensation.⁵ Higher or lower total annual VSL in this study’s results reflects the age distribution among individuals who died by suicide because VSL varies by age in the data source. Like previous reporting, this study’s results highlight that suicides declined for the older working age population (45–64 year old) during the COVID-19 pandemic year of 2020.¹⁶ This study identifies that nonfatal self-harm costs also decreased for both that age group and younger working ages (25–44 year old) that year.

The estimated economic cost of suicide and self-harm, in terms of direct costs such as medical spending or more expansively evaluated in terms of societal cost, can be used in decision-making on the present value of investment in prevention strategies. Suicide is preventable through a comprehensive public health approach inclusive of multisectoral partnerships, using data to drive prevention decision-making and implementation and evaluation of multiple culturally relevant prevention strategies to address the many factors associated with suicide.²¹

For persons in crisis, help is available 24/7 through the Suicide & Crisis Lifeline (https://www.988lifeline.org or by texting or calling 988).