Can Suicide Risk Be Significantly Influenced by Underwriting?
Suicide often leaves the bereaved with more questions than answers. Many will find it difficult to ever understand why such a drastic step was taken. The risk factors for suicide traditionally considered by life insurance underwriters are highly influenced by routine clinical assessments, often undertaken in acute situations following an episode of self-directed violence.
Clinical factors in assessing suicide risk are:
- Diagnosis of mental health co-morbidity
- Use of a violent not a passive method (e.g. hanging vs. poisoning)
- Being male
- Social hardship
- A history of previous attempts
The presence of these variables is sensitive in identifying those who complete suicide, but they are also highly non-specific in their ability to predict a rare, if tragic, event. One 2017 study (Large et al.) concluded, “We need to acknowledge our powerlessness to usefully classify individuals or groups of patients according to future suicide risk”.1
The underwriter is required to assess risk over a much longer arc than the clinician. Once a mental disorder has been disclosed at application, questions about self-injurious thoughts and behaviour inevitably follow. Despite the heavy reliance upon them, these questions have statistically weak associations with later suicide attempts, or death by suicide, and very poor sensitivity.2
This finding has been replicated among psychiatric in-patients and for most mental health diagnoses, except schizophrenia. In a review of recent evidence looking to identify individuals who try suicide (attempters), as distinct from those who merely contemplate it (ideators), another 2017 study (Klonsky et al.) found that “The majority of traditionally cited risk factors for suicide - including depression, hopelessness, most psychiatric disorders, and even impulsivity - predict suicidal ideation but do not distinguish suicide attempters from suicide ideators”.3
Identifying those with traditional risks factors as a high-risk group, a meta-analysis found 95% of cases in that group would not complete suicide. Over a five-year follow-up of patients, 5.5% of high-risk patients died by suicide in contrast to 1% of low-risk patients. Overall, just over half of suicides occurred in the high-risk group. In insurance terms, this equates to potentially heavy ratings for a group of people who would be unlikely to claim.4
Ribeiro et al. (2016) took a similar approach, concluding that “The likelihood of death by suicide in the U.S. in a given year is 12.5/100,000 (i.e., 0.000125); attempts are estimated to be 25 times more likely (i.e., 0.0031). The strongest predictor in this meta-analysis was Non-Suicidal Self-Injury (NSSI) [weighted mean OR 4.27] predicting future suicide attempts. Based on this estimate, the presence of NSSI [non-suicidal self-injury] would still only increase the odds of an attempt to 0.013 - a figure still nearly zero.”5
The lifetime prevalence of suicide has been estimated at 8.6% in those who have ever been hospitalized for affective disorders because of perceived suicide risk (suicidality); 4.0% in those ever hospitalized without specification of suicidality; 2.2% in all psychiatric patients and less than 0.5% in non-affective population.6 Despite this, clinical practice does not offer a great deal of help to the underwriter in most cases when mental health disclosures are made. The greatest risk is in those with severe and enduring mental health problems who are relatively unlikely to be within the insured population. Given this association, it is notable that only 11% of suicide claims in one insured series had mental health problems identified at underwriting.7
The underwriter is limited to looking at the characteristics of the individual but can make no allowance for changes in society that may have a profound impact upon the suicide rate. To cite one of many examples, Corcoran et al. (2015) looked at the impact of the 2008 economic recession in Ireland.8 Prior to the recession, the study found, incidence of suicide was falling but by the end of 2012 the male rate was 57% higher than it would have been if the rate had continued its downward trend. Female rates were almost unchanged. Men 25 to 44 years of age were most affected by the recession. There were 476 more male and 85 more female deaths in the five years.
The changes associated with the economic recession bucked the trend for a declining suicide rate in many countries because of prevention and alcohol strategies, improvement in recognition and treatment.9 In Japan a high rate of suicide occurred following economic crashes, although the social meaning of suicide in Japan is different from many other countries, and has more to do with culture than rates of mental illness per se.10 The U.S. remains a significant exception, where the unforeseen effects of over-prescribing opioids and the economic recession have proved particularly toxic, and ready access to firearms means 60% of gun deaths each year are suicides with a fatality rate of 85%.11
In cultures where mental illness carries a significant stigma, it may be less likely to appear on application forms or within medical evidence, prompting no action on the part of the underwriter. Apart from identifying the very few high-risk applicants (i.e. those with severe mental health problems, drug and alcohol problems, or who have recently been admitted to hospital following a suicide attempt by violent means) the underwriter will have little impact on suicide claims. The drivers for differing suicide rates in different markets are probably less related to the individual risk factors identifiable by the standard underwriting process than the influence of social and economic factors.
- Large et al., BJPsych Bulletin (2017) 41, 160-163, DOI: 10.1192/pb.bp.116.054940.
- Riberio et al., Psychol Med. 2016 January; 46(2): 225–236. DOI:10.1017/S0033291715001804.
- Klonsky et al., Current Opinions in Psychiatry 2017, 30:15–20. DOI:10.1097/YCO.0000000000000294
- Psychology Medicine 2016 January; 46(2): 225–236. DOI:10.1017/S0033291715001804.
- Bostwick & Pankratz (2000) Affective disorders and suicide risk: a reexamination. Am J Psychiatry.157.1925-32. DOI:10.1176/appi.ajp.157.12.1925.
- Goodwin, J. Suicide Analysis: A closer look at a concerning trend. https://www.insurancegateway.co.za/download/10145.
- Corcoran et al. (2015). Impact of the economic recession and subsequent austerity on suicide and self-harm in Ireland: an interrupted time series analysis. International Journal of Epidemiology, 2015, 969–977. DOI: 10.1093/ije/dyv058.
- Fond et al. (2016). Disparities in suicide mortality trends between United States of America and 25 European Countries. Nature. Scientific Reports, 6:20256, DOI: 10.1038/srep20256.
- Koo and Cox (2008). An economic interpretation of suicide cycles in Japan. Federal Reserve Bank of Dallas. Research department working paper 0603. https://core.ac.uk/download/pdf/6275417.pdf.