Suicide is a major public health problem that can have devastating effects on families, friends, and communities. Bereavement among family and friends of suicide decedents has been associated with mental and physical health problems, such as depression and hypertension.^1–3 Furthermore, exposure to suicide can lead to psychiatric and psychosocial morbidities for anyone who knows or identifies with the suicide decedent.⁴ The impact of suicide extends beyond close kin and friends, with possibly tragic consequences on the well-being of community members.⁴ Given the detrimental effects of suicide and its significant increase in the past decades,⁵ there is an urgent need to identify factors influencing suicidal behavior. Understanding co-occurring precipitating factors can help identify issues that may contribute to suicidal ideation prior to the progression to suicide attempt or death.^6,7

Several factors can increase the risk of suicide.⁷ Mental health problems (which is the most commonly reported precipitating factor of suicides), physical health problems, job and financial challenges, severe injury or assault, bereavement, substance abuse, legal problems, and intimate partner problems are among the most frequent precipitating factors of suicides.^8–12 Suicide risk varies by socio-demographic characteristics, such as sex, age, race/ethnicity, education, and marital and military status.¹³ The suicide rate for males is four times that of females; suicide rates among non-Hispanic White persons is twice that of Black and Asian Americans.¹⁴ Suicide rates among veterans and other military personnel have been estimated to be almost twice that of civilians.^12,15,16 A 2015 study using NVDRS data of circumstances preceding suicide in 27 states found that intimate partner problems (IPP) contributed to over one-quarter of suicides. It was more common among suicide decedents with no known mental health problem than those with known mental health difficulties.¹⁷ Further, a study of Kentucky Violent Death Reporting System suicides between 2005 and 2015 identified IPP as a precipitating circumstance in 26% of all suicide cases.¹⁸ Research also suggests that divorce, separation, child custody conflicts, and anticipated IPP-related crises are common contributors to suicide.¹⁷

The prevalence of IPP as a contributing factor to suicide seems to be related to the specific sample studied. For instance, IPP appears to be more common among active-duty military personnel who die by suicide and suicide decedents who perpetrate homicide before dying by suicide than among the general population.^19–22 Additionally, much IPP-related suicide research focuses primarily on one component of IPP – Intimate Partner Violence (IPV).^23–28 While IPV can be a severe result of relationship discord, more studies need to investigate partner problems beyond partner violence to understand the complex association between suicide and IPP. Although the association between IPP and suicide is well established,^29–31 few studies have explicitly examined differences in circumstances that preceded suicide between suicide decedents who reportedly experienced IPP versus those who did not. Current studies are typically narrow in terms of the geographic distribution of their sample⁹ or the population examined,^19–22 thus limiting their generalizability. Because there is a need to further elucidate the circumstances of IPP-related suicides among a broader population, the purpose of this study is to use national data to identify the differences in precipitating circumstances associated with IPP-related suicides and non-IPP-related suicides.

From 2003 to 2020, there were 402,391 suicide deaths of adults (18 years +) from the 48 participating states in NVDRS; of them, 20% were IPP-related suicides. Among the IPP-related suicides, 25- to 44-year-old persons comprised almost half (49.0%) of decedents, and a majority were White (80.2%), male (78.7%), and had at least a high school education (85.3%). Additionally, there were proportionally more veterans among the IPP suicide decedents than non-IPP suicide decedents (14.4% vs. 13.8%) (Table 3).

A few demographic differences emerged between IPP-related suicide decedents and those without a documented history of IPP. Non-IPP suicide decedents were more likely to be older, with an average age of 45.4 (SD=18.0) years compared to 40.9 (SD=13.9) years for IPP decedents. Further, significantly more non-IPP suicide decedents were 65 years or older (15.6%) than IPP decedents (5.6%). Significantly more non-IPP than IPP suicide decedents were Black (19.7% vs. 7.0%), female (23.6% vs. 21.3%), with less than high school education (15.4% vs. 11.6%), and unmarried (51.2% vs. 31.7%) (Table 3).

After controlling for socio-demographic variables, mental health problems emerged as a significant difference, with a significantly higher proportion of IPP-related suicides than non-IPP suicides involving mental health problems (Table 4). Other precipitating factors commonly identified among IPP-related suicides included depressed mood, history of suicidal thoughts, history of suicide attempts, and alcohol problems (Table 4). The strongest significant differences between the two groups were a history of suicidal thoughts (aOR=2.7) and depressed mood (aOR=2.1). With an aOR=0.8, there was not a significant difference between the two groups regarding problematic substance use. More non-IPP suicide decedents (18.1%) than IPP decedents (10.1%) experienced a physical health problem.

After controlling for socio-demographic variables, suicide decedents who experienced IPP were at greater odds than their non-IPP counterparts for experiencing most life stressors examined, including problems with family, friends or associates, suicide of a family member or friend, other deaths of family and friends, financial and job-related problems, and interpersonal violence perpetration and victimization. The most pronounced differences in life stressors experienced by IPP decedents were perpetration of interpersonal violence (aOR = 6.5), arguments (aOR = 4.1), interpersonal violence victimization (aOR = 2.2), and financial problems (aOR = 2.0).

After controlling for socio-demographic variables, the odds of recent legal problems were significantly higher among IPP decedents (aOR = 1.6) than non-IPP-related suicides. Another significant difference was whether the suicide was precipitated by a crime, with more non-IPP suicide decedents (10.7%) than IPP decedents (5.5%) experiencing criminal problems.

The purpose of this study was to advance the scientific understanding of common precipitating factors of IPP-related suicides and to examine how they differ from non-IPP-related suicides. Of the 402,391 suicides reported to NVDRS from 48 states and two territories from 2003 to 2020, one in five suicides was IPP-related. All examined precipitating factors were observed in both IPP and non-IPP-related suicides; however, the groups differed in the frequency with which these factors contributed to suicides. This study advances the scientific understanding of suicides involving IPP and informs possible prevention strategies in several ways.

Regarding health problems, IPP-related suicides were strongly associated with a history of suicidal thoughts and mental health problems (depressed mood, alcohol problem, mental health diagnosis, mental health problems, and depressed mood). While mental health problems increase suicide risk,^11,35 the present study underlines the increased association of mental health problems among suicide decedents specifically experiencing IPP compared to those who did not.³⁶ A partner relationship marked by interpersonal conflict and violence may contribute to or exacerbate mental health problems. Conversely, mental health problems may also contribute to difficulties experienced within an intimate partner relationship.^37,38

Problematic alcohol use was also a more commonly experienced precipitating factor for IPP-related suicides than non-IPP, but problematic substance use (apart from alcohol) did not differ between the two groups. Still, substance use was a contributing factor among one-fifth of both IPP and non-IPP-related suicides. Researchers have found associations between suicide attempts and drug and/or alcohol use among battered women.^27,28,39,40 However, those studies included only women in violent relationships and did not differentiate between drug and alcohol use. Problematic alcohol and substance use is related to unstable mood, mental health problems, poor problem-solving and coping skills, and a number of other factors that can exacerbate the risk for suicide as well as the likelihood of experiencing intimate partner problems.^41,42

Not surprisingly, multiple life stressors were associated with IPP-related suicides. Perpetrating interpersonal violence, being the victim of such violence, and having arguments were particularly strong. Suicide can be the culmination of these stressors.³⁶ Additionally, experiencing an acute adverse life event (like deciding to divorce or experiencing intimate partner violence) could contribute to an impulsive suicide attempt among individuals who did not previously have a suicide plan.³⁶ Thus, monitoring by clinicians, mental health providers, and the helpful connectedness of family and friends of non-suicidal individuals encountering severe adverse life events is paramount.³⁶

Multiple forms of violence tend to be interrelated.⁴³ For instance, one study suggested IPV perpetration increases the risk of suicide. Kafka and colleagues, in a qualitative review of NVDRS abstracts, concluded that suicide was often an impulsive response to acute strain or conflict in an already abusive relationship.³⁷ Further, IPP-related homicide-suicides tend to occur among those with violent outbreaks, a history of intimate partner violence, and homicidal threats to victims. In addition, some intimate partner homicide-suicide perpetrators had previous interactions with the courts.⁴⁴ These court encounters provide an opportunity for the criminal justice system to intervene in potentially harmful scenarios following arrests and adjudication. While arrests for IPV alone may help protect women from violence,⁴⁵ stronger mandates to enter mental health treatment or IPV prevention programs following arrests may also be useful.⁴⁴ Also, using more holistic and trauma-informed approaches for IPV intervention programs that integrate suicide prevention efforts could help improve the effectiveness of these interventions while also engaging IPV perpetrators in services.³⁷

Problems with family members or friends, as well as the recent suicide of a family member or a friend, could be indicators of thwarted belongingness and social isolation.^46,47 Social isolation is a risk factor for IPV and suicide, which aligns with the findings from the current study.^35,48 Promoting social connectedness can reduce social isolation and suicide. Gatekeepers can help identify people experiencing suicidal ideation and IPP and help individuals find social groups where they can become an integral part and enhance connectedness.^46,49

IPP suicide decedents also had greater odds of having financial, job-related, and recent legal problems, possibly related to divorce, separation of assets, and child custody or mental health problems. Unemployment—one indicator of job problems—is a predictor of IPP-related suicides.^23,50 Programs that strengthen economic support can potentially reduce the risk of IPP-related suicides. Strengthening household financial security by providing unemployment benefits, temporary assistance, livable wages, medical benefits, and retirement and disability insurance to help cover the cost of necessities or to offset expenses in the event of disability could both reduce tension in an intimate partner relationship and buffer the risk of suicide.¹² Additionally, housing stabilization policies aim to keep people in their homes and provide housing options during financial insecurity, which could reduce suicide risk.¹²

Three factors were salient in non-IPP-related suicides compared to IPP suicides: the sample was more likely to be older, have more physical health conditions, and have more criminal problems. Research exploring the association between criminal problems and IPP-related suicides is scarce. Comiford et al. concluded that IPP-related suicides were four times more likely to be precipitated by a crime than non-IPP-related suicides.⁹ Because this study was conducted in one state, cultural or geographical factors may explain the differences in outcomes between studies. This study found that non-IPP-related suicide decedents were older than IPP suicide decedents. A possible explanation is that violence towards older adults might be labeled as elder abuse, not IPV.⁵¹ Also, older adult deaths associated with intimate partners might result from homicide, not suicide. One study that included seven US states found 31% of homicides among women 65 years and older were IPV related.⁵¹

Results from prior studies on the impact of physical health problems on suicide are inconsistent. For instance, Kaplan and colleagues⁵² concluded that individuals with functional limitations were at higher risk for suicide than those without such constraints; however, chronic conditions did not predict death by suicide. In contrast, other studies have found an association between chronic disease and suicide attempts. For instance, Cavanaugh et al. found that female IPV victims who reported having a chronic disease were more likely to attempt suicide during their lifetime.⁵⁰ Physical health problems can, in some cases, potentially bring couples together. In a study of breast cancer patients and their partners, some couples indicated that the cancer diagnosis brought them closer together. Patients reported more affection from their spouses 3 months post-diagnosis.⁵³ Perhaps, physical health problems can decrease the risk of IPP-related suicides because the disease can lead to more empathy, stronger appreciation, and fewer intimate partner problems.

The present study adds to the limited literature on precipitating factors associated with IPP-related suicides. To the authors’ knowledge, this is the first study to use data from this large multistate surveillance system to identify differences in precipitating factors associated with IPP-related suicides compared to suicides that did not involve IPP. Prior studies have used state-level data and or focused on intimate partner violence.^9,18,37 Understanding the precipitating factors associated with IPP-related suicides is essential for suicide prevention efforts. CDC has a compilation of resources that provide best practices for preventing suicide and intimate partner violence: Suicide Prevention Resource for Action¹² and Preventing Intimate Partner Violence Across the Lifespan: A Technical Package of Programs, Policies, and Practices.⁵⁴ Both resources describe the best available evidence supporting policies, programs, and practices that can reduce the risk for both IPP and suicide at multiple levels of the social ecology.