The burden of suicidal ideation across Europe: a cross-sectional survey in five countries

Figures & data

Table 1 Demographic and clinical characteristics among SI, nSI, and general population groups^a

	(a) SI (n=905)		(b) nSI (n=2,403)		(c) General population (n=48,752)		p-value
	%	n	%	n	%	n	a vs b	a vs c	b vs c
Gender
Male	32.0	290	35.5	852	47.4	23,095	0.066	<0.001	<0.001
Female	68.0	615	64.5	1551	52.6	25,657
Age (years)
18–29	17.1	155	12.7	304	16.7	8,140	<0.001	<0.001	<0.001
30–39	14.9	135	13.9	334	15.7	7,652
40–49	28.1	254	21.7	521	17.3	8,449
50–59	25.3	229	25.7	617	16.3	7,926
≥60	14.6	132	26.1	627	34.0	16,585
Country
France	15.2	138	15.6	375	26.5	12,910	0.024	<0.001	<0.001
Germany	22.9	207	25.7	617	24.1	11,728
Italy	46.7	423	41.5	997	20.8	10,153
Spain	6.9	62	9.4	225	17.3	8,410
UK	8.3	75	7.9	189	11.4	5,551
Marital status (married or living with partner)^b	47.2	427	52.0	1249	62.7	30,561	0.025	<0.001	<0.001
Education (completed university)^c	26.1	236	29.3	704	38.3	18,673	0.040	<0.001	<0.001
Household income							0.043	<0.001	<0.001
Low (<20,000 € or £)	40.7	368	36.1	868	23.1	11,257
Medium (≥20,000 to <40,000 € or £)	33.0	299	33.7	810	37.5	18,281
High (≥40,000 € or £)	20.1	182	22.0	529	29.1	14,180
Declined to answer	6.2	56	8.2	196	10.3	5,034
Employed	44.8	405	48.8	1173	55.3	26,951
CCI (mean, SD)	0.72	1.22	0.56	1.02	0.29	0.77	0.037	<0.001	<0.001
BMI							0.018	<0.001	<0.001
Underweight (<18.5 kg/m^2)	4.4	40	3.1	75	3.3	1,617	0.001	<0.001	<0.001
Normal weight (≥18.5 to <25.0 kg/m^2)	27.8	252	31.4	754	43.7	21,328
Overweight (≥25.0 to <30.0 kg/m^2)	27.6	250	30.3	728	31.4	15,293
Obese (≥30.0 kg/m^2)	30.1	272	26.0	625	14.9	7,243
Declined to answer	10.1	91	9.2	221	6.7	3,271
Exercised	41.5	376	51.6	1239	62.2	30,342	<0.001	<0.001	<0.001
Alcohol use (daily)	6.3	57	5.5	132	8.0	3,881	0.102	<0.001	<0.001
Current smoker	36.7	332	30.3	728	22.4	10,900	0.714	<0.001	<0.001
Comorbidities
Hypertension	27.0	244	26.7	641	19.1	39,450	0.868	<0.001	<0.001
Diabetes (type 1 or 2)	12.4	112	11.7	281	7.3	3,579	0.589	<0.001	<0.001
Anemia	9.1	82	6.0	144	2.5	1,202	0.002	<0.001	<0.001
Rheumatoid arthritis	7.8	71	4.5	107	2.2	1,050	<0.001	<0.001	<0.001
Cancer	5.7	52	6.6	158	5.2	2,552	0.383	0.494	0.004
Arrhythmia	2.9	26	3.5	84	2.3	1,107	0.373	0.229	<0.001
Chronic kidney disease	1.8	16	1.2	29	0.7	347	0.214	<0.001	0.006
Hepatitis A	1.1	10	1.0	24	0.9	421	0.787	0.438	0.486
HIV/AIDS	0.8	7	0.2	4	0.2	100	0.007	<0.001	0.681

Notes: ^aData are shown as % and n, except for CCI values (mean, SD); ^b<0.3% had missing values; ^capproximately 1% declined to answer.

Abbreviations: BMI, body mass index; CCI, Charlson Comorbidity Index; nSI, non-suicidal ideation; SI, suicidal ideation.

Table 2 Depression-related characteristics among respondents with SI or nSI

	SI (n=905)		nSI (n=2403)		p-value
	%	n	%	n
Family history of depression	44.1	399	38.5	924	0.003
Length of diagnosis					0.266
<1 year	4.7	41	6.1	139
1–3 years	16.3	143	17.7	403
3–5 years	10.3	91	10.3	234
≥5 years	68.8	605	65.9	1,497
Participation in talking therapy	30.6	277	22.7	546	<0.001
Prescription medication use for depression
SSRI/SNRI/SARI/NaSSA	90.2	816	90.6	2,177	0.708
TeCA/TCA	13.4	121	11.5	276	0.137
Benzodiazepine	3.9	35	2.8	67	0.109
Antipsychotic	2.7	24	2.2	52	0.404
NDRI/NRI	1.3	12	1.3	31	0.935
MAOI/RIMA	0.4	4	0.1	3	–^a
Lithium	0.2	1	0.3	3	–^a

Notes: ^aValid comparison not applicable.

Abbreviations: MAOI, monoamine oxidase inhibitor; NaSSA, noradrenergic and specific serotonergic antidepressant; NDRI, norepinephrine–dopamine reuptake inhibitor; NRI, norepinephrine reuptake inhibitor; nSI, non-suicidal ideation; RIMA, reversible inhibitor of monoamine oxidase A; SI, suicidal ideation; SNRI, serotonin–norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant; TeCA, tetracyclic antidepressant.

Figure 1 Study flowchart: cohort identification.

Abbreviations: MDD, major depressive disorder; NHWS, National Health and Wellness Survey; nSI, non-suicidal ideation; SI, suicidal ideation; FR, France; GE, Germany; IT, Italy; SP, Spain.

Table 3 Adjusted differences for health-related quality of life among respondents with SI or nSI compared to general population controls

	General population controls versus
	SI^a	nSI^a
	Adjusted difference (LCL to UCL)	Adjusted difference (LCL to UCL)
EQ-5D Index	−0.34 (−0.35 to −0.33)	−0.15 (−0.16 to −0.14)
Health status, EQ-VAS	−29.44 (−30.73 to −28.16)	−14.75 (−15.56 to −13.95)
MCS	−20.02 (−20.57 to −19.47)	−10.77 (−11.12 to −10.43)
PCS	−4.49 (−5.00 to −3.98)	−2.50 (−2.82 to −2.18)
SF-12 Bodily Pain	−8.70 (−9.30 to −8.08)	−4.75 (−5.13 to −4.37)
SF-12 General Health	−11.00 (−11.50 to −10.44)	−6.28 (−6.61 to −5.94)
SF-12 Mental Health	−17.40 (−17.95 to −16.85)	−9.27 (−9.61 to −8.92)
SF-12 Physical Functioning	−6.68 (−7.21 to −6.15)	−3.53 (−3.87 to −3.20)
SF-12 Role Emotional	−18.94 (−19.60 to −18.28)	−10.14 (−10.55 to −9.73)
SF-12 Role Physical	−9.74 (−10.30 to −9.18)	−5.09 (−5.44 to −4.74)
SF-12 Social Functioning	−16.20 (−16.76 to −15.64)	−8.45 (−8.80 to −8.10)
SF-12 Vitality	−11.68 (−12.26 to −11.11)	−6.78 (−7.14 to −6.42)

Notes: ^aGeneralized linear models were adjusted for sociodemographic and health status variables. Comparisons versus the general population were statistically significant at p≤0.001.

Abbreviations: EQ-5D, EuroQol-5 Dimensions; EQ-VAS, EuroQol visual analogue scale; LCL, lower confidence level; MCS, mental component summary score; nSI, non-suicidal ideation; PCS, physical component summary score; SF-12, 12-item Short Form Health Survey; SI, suicidal ideation; UCL, upper confidence level.

Figure 2 Adjusted risk for (A) WPAI and (B) HRU among respondents with SI or nSI compared to the general population controls.^a

Note: ^aGeneralized linear models adjusted for socio-demographic and health status variables were used. *p<0.001.
Abbreviations: ER, emergency room; HCP, healthcare professional; HRU, healthcare resource use; nSI, non-suicidal ideation; SI, suicidal ideation; WPAI, work productivity and activity impairment.

Figure S1 Percentage of patients with major depressive disorder at risk for suicidal ideation.

Table S1 Adjusted means for health-related quality of life among respondents with SI and nSI compared to general population controls

Parameter	Adjusted means (SE)^a
	France	Germany	Italy	Spain	UK	Europe
EQ-5D Index
SI	0.479 (0.017)	0.639 (0.011)	0.734 (0.013)	0.520 (0.018)	0.367 (0.011)	0.504 (0.006)
nSI	0.601 (0.011)	0.768 (0.007)	0.813 (0.007)	0.738 (0.012)	0.599 (0.008)	0.691 (0.004)
General population	0.787 (0.004)	0.879 (0.003)	0.896 (0.003)	0.889 (0.004)	0.778 (0.004)	0.843 (0.002)
EQ-VAS
SI	50.515 (1.718)	46.996 (1.357)	48.897 (2.359)	44.761 (2.303)	42.417 (1.036)	45.659 (0.666)
nSI	60.385 (1.073)	59.657 (0.853)	63.661 (1.278)	62.807 (1.518)	58.765 (0.734)	60.349 (0.432)
General population	73.109 (0.383)	76.390 (0.421)	76.666 (0.452)	77.524 (0.543)	72.770 (0.437)	75.102 (0.194)
MCS score
SI	28.961 (0.746)	29.714 (0.591)	29.255 (1.071)	33.047 (0.946)	27.751 (0.430)	28.374 (0.287)
nSI	36.384 (0.466)	38.815 (0.372)	37.705 (0.580)	40.501 (0.624)	37.981 (0.305)	37.625 (0.186)
General population	46.659 (0.166)	50.277 (0.183)	46.736 (0.205)	49.443 (0.223)	49.235 (0.182)	48.395 (0.084)
PCS score
SI	47.171 (0.639)	45.123 (0.570)	45.905 (0.895)	43.338 (0.823)	44.176 (0.460)	45.223 (0.267)
nSI	47.916 (0.399)	45.874 (0.359)	48.697 (0.485)	47.130 (0.542)	46.514 (0.326)	47.213 (0.173)
General population	49.563 (0.143)	49.145 (0.177)	50.592 (0.171)	51.288 (0.194)	48.389 (0.194)	49.711 (0.078)
SF-12 Bodily Pain
SI	40.723 (0.779)	40.657 (0.683)	39.983 (1.102)	38.602 (1.016)	39.764 (0.514)	40.152 (0.317)
nSI	43.648 (0.487)	43.027 (0.429)	44.565 (0.597)	44.805 (0.670)	44.242 (0.364)	44.097 (0.206)
General population	47.802 (0.174)	48.863 (0.212)	48.864 (0.211)	51.027 (0.240)	48.182 (0.217)	48.848 (0.092)
SF-12 General Health
SI	41.419 (0.620)	36.974 (0.560)	38.398 (1.041)	37.819 (0.894)	37.298 (0.483)	37.693 (0.277)
nSI	43.777 (0.387)	42.219 (0.352)	43.112 (0.564)	43.268 (0.589)	41.840 (0.343)	42.392 (0.180)
General population	48.912 (0.138)	48.534 (0.174)	48.323 (0.199)	49.513 (0.211)	48.309 (0.204)	48.664 (0.081)
SF-12 Mental Health
SI	31.351 (0.733)	34.418 (0.569)	32.598 (1.069)	35.723 (0.933)	30.727 (0.447)	32.099 (0.285)
nSI	38.475 (0.458)	41.848 (0.358)	40.660 (0.579)	42.307 (0.616)	39.720 (0.317)	40.232 (0.185)
General population	48.105 (0.164)	50.724 (0.177)	48.720 (0.205)	50.851 (0.220)	49.405 (0.189)	49.499 (0.083)
SF-12 Physical Functioning
SI	45.016 (0.680)	45.636 (0.563)	44.852 (0.947)	43.297 (0.893)	41.747 (0.475)	44.009 (0.277)
nSI	47.020 (0.425)	46.661 (0.354)	49.639 (0.513)	47.183 (0.589)	45.798 (0.337)	47.156 (0.180)
General population	50.184 (0.152)	50.940 (0.174)	51.789 (0.181)	51.895 (0.211)	48.964 (0.201)	50.689 (0.081)
SF-12 Role Emotional
SI	30.462 (0.868)	27.902 (0.688)	29.146 (1.232)	30.691 (1.144)	27.742 (0.539)	27.904 (0.341)
nSI	36.755 (0.542)	36.173 (0.432)	36.878 (0.667)	38.227 (0.754)	37.979 (0.382)	36.700 (0.221)
General population	45.834 (0.194)	48.497 (0.213)	45.586 (0.236)	46.971 (0.270)	47.759 (0.228)	46.843 (0.099)
SF-12 Role Physical
SI	40.630 (0.721)	37.732 (0.600)	39.969 (0.992)	38.812 (0.937)	37.897 (0.497)	38.418 (0.292)
nSI	43.670 (0.450)	41.639 (0.377)	43.622 (0.537)	43.395 (0.618)	43.488 (0.352)	43.066 (0.190)
General population	47.858 (0.161)	47.942 (0.186)	48.329 (0.190)	49.330 (0.221)	47.881 (0.210)	48.156 (0.085)
SF-12 Social Functioning
SI	34.422 (0.734)	34.119 (0.598)	33.335 (1.029)	34.549 (0.929)	30.876 (0.473)	32.030 (0.291)
nSI	39.404 (0.459)	40.243 (0.376)	40.372 (0.557)	41.410 (0.613)	40.320 (0.335)	39.773 (0.188)
General population	47.075 (0.164)	49.594 (0.185)	46.313 (0.197)	49.403 (0.219)	49.140 (0.200)	48.226 (0.085)
SF-12 Vitality
SI	38.740 (0.753)	39.440 (0.606)	40.066 (1.041)	42.761 (0.981)	38.651 (0.495)	39.524 (0.299)
nSI	43.195 (0.471)	44.904 (0.381)	45.835 (0.564)	48.235 (0.647)	42.936 (0.351)	44.431 (0.194)
General population	48.818 (0.168)	52.191 (0.188)	51.419 (0.200)	54.038 (0.231)	50.103 (0.209)	51.208 (0.087)

Notes: ^aGeneralized linear models were adjusted for sociodemographic and health status variables. All comparisons were p<0.05 with the exception of the following cases, where SI and nSI patients were not statistically different: France, PCS; Germany, PCS and Physical Functioning.

Abbreviations: EQ-5D, EuroQol-5 Dimensions; EQ-VAS, EuroQol visual analogue scale; MCS, mental component summary; nSI, non-suicidal ideation; PCS, physical component summary; SF-12, 12-Item Short Form Health Survey; SI, suicidal ideation.

Table S2 Adjusted mean percentage work productivity and activity impairment among respondents with SI and nSI compared to general population controls

Parameter	Adjusted means (SE)^a
	France	Germany	Italy	Spain	UK	Europe
Absenteeism (%)
SI	31.040 (3.976)*^#	35.910 (4.212)*^#	15.227 (2.924)^#	13.508 (2.541)^#	45.584 (4.131)*^#	29.190 (1.633)*#
nSI	18.910 (1.621)^#	20.992 (1.520)^#	9.497 (1.046)^#	12.727 (1.562)^#	20.944 (1.347)^#	15.851 (0.578)#
General population	5.978 (0.242)	7.602 (0.288)	4.194 (0.185)	3.929 (0.204)	6.589 (0.253)	5.765 (0.105)
Presenteeism (%)
SI	37.499 (5.428)^#	47.136 (6.061)*^#	44.847 (8.477)^#	37.712 (7.055)^#	47.954 (4.673)*^#	44.022 (2.653)*#
nSI	29.545 (2.680)^#	30.356 (2.237)^#	36.337 (3.783)^#	34.869 (4.157)^#	33.062 (2.021)^#	31.882 (1.155)#
General population	15.393 (0.604)	14.756 (0.558)	18.221 (0.749)	14.486 (0.696)	17.848 (0.648)	16.481 (0.288)
Total work productivity impairment (%)
SI	53.909 (6.778)^#	61.813 (7.152)*^#	51.024 (9.623)^#	45.214 (8.198)^#	67.340 (5.922)*^#	57.951 (3.177)*^#
nSI	40.443 (3.401)^#	41.555 (2.929)^#	40.734 (4.222)^#	40.950 (4.807)^#	42.293 (2.540)^#	40.282 (1.411)^#
General population	19.396 (0.741)	19.801 (0.726)	20.719 (0.844)	17.101 (0.808)	20.977 (0.752)	19.915 (0.342)
Activity impairment (%)
SI	52.687 (4.637)*^#	55.451 (4.071)*^#	55.452 (7.236)^#	47.248 (5.628)^#	63.252 (3.398)*^#	56.703 (1.986)*^#
nSI	41.747 (2.301)^#	42.920 (1.985)^#	41.181 (2.931)^#	38.059 (3.010)^#	45.508 (1.761)^#	42.522 (0.973)^#
General population	22.976 (0.454)	21.907 (0.504)	22.649 (0.577)	18.144 (0.517)	23.886 (0.548)	22.380 (0.231)

Notes: ^aGeneralized linear models were used adjusted for sociodemographic and health status variables.*Compared to the nSI population, values for SI patients differed at p<0.05. ^#Compared to the general population, values for SI and nSI patients differed at p<0.05.

Abbreviations: nSI, non-suicidal ideation; SI, suicidal ideation.

Table S3 Adjusted means for healthcare resource use among respondents with SI and nSI compared to general population controls

Parameter	Adjusted means (SE)^a
	France	Germany	Italy	Spain	UK	Europe
HCP visits
SI	14.524 (1.311)*^#	15.338 (1.159)*^#	11.517 (1.558)^#	14.276 (1.753)*^#	7.669 (0.443)*^#	12.209 (0.445)*^#
nSI	10.013 (0.575)^#	10.626 (0.514)^#	9.371 (0.698)^#	8.175 (0.683)^#	5.826 (0.246)^#	8.678 (0.210)^#
General population	4.046 (0.088)	4.406 (0.110)	4.092 (0.114)	3.693 (0.116)	2.654 (0.069)	3.764 (0.043)
General/family practitioner
SI	3.773 (0.373)^#	4.010 (0.328)*^#	4.065 (0.587)*^#	4.382 (0.576)*^#	3.311 (0.209)*^#	4.303 (0.171)*^#
nSI	3.203 (0.202)^#	2.732 (0.147)^#	2.734 (0.226)^#	2.876 (0.263)^#	2.480 (0.117)^#	3.051 (0.082)^#
General population	1.658 (0.040)	1.609 (0.046)	1.814 (0.055)	1.472 (0.053)	0.988 (0.030)	1.504 (0.019)
Hospitalized
SI	0.307 (0.052)^#	0.227 (0.036)*^#	0.224 (0.061)^#	0.314 (0.077)^#	0.257 (0.036)^#	0.235 (0.019)*^#
nSI	0.206 (0.026)^#	0.152 (0.018)^#	0.109 (0.023)^#	0.195 (0.043)^#	0.201 (0.022)^#	0.164 (0.010)^#
General population	0.107 (0.006)	0.101 (0.007)	0.058 (0.006)	0.067 (0.007)	0.160 (0.009)	0.106 (0.003)
ER visits
SI	0.331 (0.057)^#	0.288 (0.043)*^#	0.747 (0.149)*^#	1.415 (0.220)*^#	0.361 (0.041)^#	0.463 (0.029)*^#
nSI	0.230 (0.030)^#	0.185 (0.021)^#	0.168 (0.028)^#	0.728 (0.091)^#	0.404 (0.033)^#	0.313 (0.015)^#
General population	0.120 (0.007)	0.110 (0.008)	0.106 (0.008)	0.288 (0.017)	0.196 (0.010)	0.162 (0.004)

Notes: ^aGeneralized linear models were adjusted for sociodemographic and health status variables. *Compared to the nSI population, values for SI patients differed at p<0.05. ^#Compared to the general population, values for SI and nSI patients differed at p<0.05.

Abbreviations: ER, emergency room; HCP, healthcare professional; nSI, non-suicidal ideation; SI, suicidal ideation.