INSPIRED: INtegrating Social determinants and Policy In REducing Disparities

Grant Details:

Funder: NIMH (MHRN III Feasibility Pilot Program)

Grant Number: U19MH121738

Project Period: 7/1/2023 – 6/30/2024


Background:  US children experienced up to 200% increases in stress, depression, 130% in suicidal ideation and suicide attempts (SI/SA); and the highest pediatric suicide rates, compared to the pre-COVID period. Black and Hispanic youth, females, and low-income families are especially at risk. Our research, along with others’ found that food insecurity, as a vital social determinant of health (SDoH), can worsen child mental health. In response, the federal, state, and local governments have expanded and added flexibility to ongoing public policies (e.g., food assistance, unemployment) and initiated new pandemic-related policies. Addressing SDoH, especially by leveraging policies, is key to reducing mental health disparities. However, most research focused on individual SDoH (e.g., negative life events) and cross-sectional design, ignoring structural SDoH at the population level and in the long term. We propose INSPIRED: INtegrating Social determinants and Policy In REducing Disparities in youth suicide, to fill the gap and bring a richly linked external database on multilevel SDoH and policies (by local, county, and state) to electronic health records (EHR) in MHRN.

Research Questions:

1.    What are the relationships between population-level SDoH and youth suicide (SI/SA)?

2.    How do pandemic-era policies (containment, health, economy, food, housing) affect youth suicide?

3.    Whether the associations between SDoH, policy, and youth suicide vary by race, ethnicity, and sex?


To address these research questions, we will:

●     Study Cohort: Youth ages 10-25 years old on the day of visiting INSIGHTS (n>11 million), before Dec 2023. We have geocoded data by 5-digit, 9-digit, city/state, NYC patients > borough & neighborhood tracking since 2010 and moving forward. This cohort has geographic heterogeneity (figure on the right) across the NY State to allow linkages and feasibilities. Demographically, it is also diverse (11% 0-19 yrs old, 34% 20-44 yrs old, 37% White, 13% Black, 14% Hispanic). In NYC, 28% are from Bronx and 26% from Manhattan.

●     Measures: Outcomes SI/SA (diagnoses codes); Exposures 1) SDoH (AHRQ SDoH databases, primary data collection tailored to climate change [from the Environmental Protection Agency]), to food insecurity [from Feeding American]), to childcare [from Child Opportunity Index]), 2) COVID-19 policy (e.g., U.S. COVID-19 County Policy Database, OxCGRT/USA COVID-19 policy database), 3) Pre-COVID policy (e.g., Supplemental Nutrition Assistance Program [SNAP]), 4) demographic characteristics (sex, race, ethnicity).

●     Statistical Analysis: 1) Link SDoH and policy data to MHRN-INSIGHTS Cohorts, 2) Examine associations between population-level SDoH, policies, and SI/SA, adjusting for covariates, 3) Use causal models (e.g., instrumental variables, differences-in-difference) to assess the impact of policies on youth suicide, 4) For each step, we will address health disparities by conducting subgroup analysis to examine differences by sex, race, ethnicity, age, and site characteristics. 5) We will conduct several sensitivity analyses, including specifying youth with multiple suicide-related visits, applying false-discovery rates to adjust multiple group comparisons, and different methods of dealing with missing data (e.g., listwise, multiple imputations).

Connections to Previous MHRN Projects: Our proposed research builds on previous MHRN projects, such as addressing social risks and studies on individual-level SDoH.13 We will leverage the expertise and data resources from these projects to enhance the rigor and impact of our study. In conclusion, our INSPIRED project will contribute valuable insights into the complex relationships between SDoH, policy, and youth suicide, with a focus on reducing disparities. Our findings will inform policy interventions and improve mental health care delivery for youth populations at risk for suicidal behaviors. Our prior studies on SDoH, Policy, and mental health (see References) further enhance the feasibility of achieving the goals in 1 year.

Planned Products: 1) A comprehensive SDoH and policy database will be developed and prepared to be linked to MHRN, serving as a valuable resource for future researchers. 2) two papers, one for the associations between SDoH and suicidal behaviors, another for causal evidence on the impact of state-level pandemic-era policies on youth suicide, 3) A policy brief, offering actionable recommendations for policymakers to mitigate suicide disparities among vulnerable youth groups, with the goal to inform effective policy, 4) use results as preliminary data to submit >1 R01 NIMH application in the project period.

Lead Site: Cornell(PI Yunyu Xiao)

Participating Sites: INSIGHTS (future use of MHRN VDM).

Current Status:

Summary of Findings: