Patterns of Health Care Usage in the Year Before Suicide: A Population-Based Case-Control Study

Healthcare resource utilization prior to suicide death or suicide attempt in patients with major depressive disorder-A Danish registry-based cohort study

INTRODUCTION

Major depressive disorder (MDD) is associated with suicide events and with increased healthcare resource utilization (HRU). The aim was to analyze the pattern of HRU prior to death by suicide or suicide attempt in patients with MDD using national registries.

METHODS

Danish adults with MDD, who died by suicide or had a first-time suicide attempt, were matched with MDD controls on age, sex, and MDD severity and analyzed for psychiatric and non-psychiatric hospital and private practitioner contacts, and prescriptions 1 year prior to the event. For individuals having a second suicide attempt, HRU prior to first and second suicide attempt was analyzed.

RESULTS

Among 1061 individuals dying by suicide and 3759 individuals with suicide attempt, compared with their controls, the proportion with psychiatric hospitalization was more than 50% increased, mainly accounted for by acute contacts. The difference to the matched controls decreased with increasing MDD severity. Non-psychiatric HRU was increased as well. The proportion with psychiatric hospitalizations or ED visits was reduced prior to the second attempt compared with first attempt.

CONCLUSION

Among individuals with MDD, psychiatric and non-psychiatric HRU was increased 1 year prior to suicide event. The proportion of individuals who had psychiatric HRU decreased from first to second suicide attempt.

Assessing the Healthcare Utilization of Youth Who Died by Suicide: A Case-Control Study

OBJECTIVE

Suicide is the second leading cause of death in youth ten years old or older. Healthcare utilization prior to death by suicide is high in adults, but there is conflicting evidence in youth. The objective of this study was to compare healthcare utilization in youth who died by suicide to youth who died in a motor vehicle accident (MVC) to determine whether healthcare utilization is associated with death by suicide in youth.

METHODS

This retrospective case-control study used death records from Coroners/Medical Examiners (C/MEs) for children 11-17 years old who died by suicide (case) and MVC (control) between October 2013 and October 2018 were obtained. Data from the electronic medical record (EMR) at a healthcare system was reviewed. The primary outcome was healthcare utilization. Secondary outcomes included mental health diagnosis. Data was analyzed using Fisher's Exact Test and considered significant if p < 0.05.

RESULTS

The analysis included 60 youth who died by suicide and 14 youth who died by MVC. Most decedents were male (68%) and white (80%). Mean age at death was 16 years old. Only 25 decedents had a corresponding record in the EMR, with no significant difference based on manner of death (35% suicide vs 29% MVC, p = 0.8). Fourteen decedents had a known mental health diagnosis in their EMR with no difference based on manner of death (p = 0.5).

CONCLUSIONS

There was no difference in healthcare utilization or mental health diagnosis in youth who died by suicide compared to youth who died by MVC. Strict reliance on both of these factors when considering youth who may be at risk of suicide is inadequate. Expanding universal suicide screening to other settings, including schools or primary care, can help identify youth at risk for suicide and may prevent unnecessary deaths.HIGHLIGHTSLittle is known regarding the healthcare utilization of youth who died by suicide prior to their death.This study uses a case-control design to investigation healthcare utilization of youth who died by suicide versus youth who died in a motor vehicle crash.We did not find a significant difference in healthcare utilization between cases and controls. These findings suggest that non-clinical interventions would be useful in detecting suicide risk.

Mental Health Among People Presenting for Care of Physical Symptoms: The Factors Associated with Suicidality and Symptoms of Depression and Anxiety are Similar Across Specialties

Background

To identify differences in thoughts of suicide and symptoms of depression and anxiety by specialty among people presenting for care of physical symptoms, we analyzed data from routine mental health measurement in a small multispecialty practice and asked: 1. Are there any differences in suicidality (analyzed as an answer of 1 or greater or 2 or greater on the Patient Health Questionnaire [PHQ] question 9) in non-specialty and various types of specialty care? 2. Are there any factors-including specialty-associated with symptoms of depression (mean PHQ score), PHQ thresholds (greater than 0, 3 or greater, 10 or greater), Generalized Anxiety Disorder instrument [GAD] score of 3 or greater, and either GAD score 3 or greater or PHQ score 3 or greater? and 3. What factors are associated with referral to a social worker?

Methods

As part of routine specialty and non-specialty care, 13,211 adult patients completed a measure of symptoms of depression (PHQ) that included a question about suicidality and a measure of symptoms of anxiety (GAD). Factors associated with suicidality and symptoms of depression and anxiety at various thresholds, and visit with a social worker, were sought in multivariable models.

Results

Accounting for potential confounding in multivariable analyses, a score higher than 0 on the suicidality question (present in 18% of people) was associated with men, younger age, English-speakers, and neurodegenerative specialty care. Symptoms of depression on their continuum and using various thresholds (28% of people had a PHQ score greater than 2) were associated with non-Spanish-speakers, younger age, women, and county insurance or Medicaid insurance. Care from the social worker was associated with PHQ score of 3 or greater and having any suicidal thoughts (score of 1 or greater on question 9) but was less common with Medicare or Commercial Insurance and less common in the unit treating cognitive decline.

Conclusion

The notable prevalence of symptoms of depression and suicidality among people presenting for care of physical symptoms across specialties and the relatively similar factors associated with suicidality, symptoms of depression, and symptoms of anxiety at various thresholds suggests that both non-specialty and specialty clinicians can be vigilant for opportunities for improved mental health. Increased recognition that people seeking care for physical symptoms often have mental health priorities has the potential to improve comprehensive care strategies, alleviate distress, and reduce suicide.

Predisposing, enabling and need factors associated with past-year health service use for mental health reasons in adults with suicidal ideation in France

BACKGROUND

We aimed to determine the prevalence of past-year health service use for mental health reasons in a French representative sample of adults overall and in those reporting suicidal ideation in the past year and assess the factors associated with health service use according Andersen's model of healthcare seeking behaviors.

METHODS

Data were drawn from the 2017 Health Barometer survey a large computer-assisted telephone survey on a representative sample of the general population aged 18-75 years living in France (n = 25,319). Logistic regression analyses were used to study past-year health service use for mental health reasons as a function of predisposing, enabling and need factors. Analyses were stratified according to suicidal ideation and sex.

RESULTS

Among individuals with suicidal ideation, 45.1 % of adults, 50.4 % of females and 37.6 % of males, reported past-year health service use for a mental health reason. Increased odds of health service use were observed regarding predisposing (female sex, younger age, higher education), enabling (income level), and need factors (prior suicide attempts, role impairment and major depression). Among males, the only significant factors included age 65-75 (aOR = 0.16, 95%CI = 0.03-0.84) and major depression (aOR = 2.79, 95%CI = 1.79-4.36).

LIMITATIONS

Self-reported service utilization. Cross-sectional survey.

CONCLUSIONS

In a country with a high level of medical coverage, further research is needed to identify sex-specific socio-demographic, economic and clinical differences in the use of different types of health services as well as perceived need for care, structural and attitudinal barriers to treatment.

Health care utilisation two years prior to suicide in Sweden: a retrospective explorative study based on medical records

OBJECTIVE

Previous literature has suggested that identifying putative differences in health care seeking patterns before death by suicide depending on age and gender may facilitate more targeted suicide preventive approaches. The aim of this study is to map health care utilisation among individuals in the two years prior to suicide in Sweden in 2015 and to examine possible age and gender differences.

METHODS

Design: A retrospective explorative study with a medical record review covering the two years preceding suicide.

SETTING

All health care units located in 20 of Sweden's 21 regions.

PARTICIPANTS

All individuals residing in participating regions who died by suicide during 2015 (n = 949).

RESULTS

Almost 74% were in contact with a health care provider during the 3 months prior to suicide, and 60% within 4 weeks. Overall health care utilisation during the last month of life did not differ between age groups. However, a higher proportion of younger individuals (< 65 years) were in contact with psychiatric services, and a higher proportion of older individuals (≥ 65 years) were in contact with primary and specialised somatic health care. The proportion of women with any type of health care contact during the observation period was larger than the corresponding proportion of men, although no gender difference was found among primary and specialised somatic health care users within four weeks and three months respectively prior to suicide.

CONCLUSION

Care utilisation before suicide varied by gender and age. Female suicide decedents seem to utilise health care to a larger extent than male decedents in the two years preceding death, except for the non-psychiatric services in closer proximity to death. Older adults seem to predominantly use non-psychiatric services, while younger individuals seek psychiatric services to a larger extent.

Contact with the health care system prior to suicide: A nationwide population-based analysis using linkage national death certificates and national health insurance data

This study aimed to discover the proportion of people dying by suicide who had non-psychiatric medical contact alone or any mental health contact in the year, month, and week prior to suicide. Data on suicide deaths (n = 74,741) of all South Koreans from 2009 to 2013 were linked with National Health Insurance (NHI) data by social security number to identify health care contact during the 12 months prior to suicide. The NHI data includes records on inpatient or outpatient service and type of health care institutes which the decedents have contacted. Among the 74,741 individuals who died by suicide, the proportion of individuals who contacted non-psychiatric health care alone was 60.1%, 46.1%, and 35.5%; and the proportion of those who had any mental health contact was 27.9%, 18.0%, and 7.9% in the year, four weeks, and week before death, respectively. Psychiatric care visits in the year, four weeks and weeks prior to death occurred most frequently in psychiatric local clinics. Non-psychiatric care visits in the year and four weeks prior to death were most common in local clinics at the primary care level, but in the one week before death, non-psychiatric care visits were common in tertiary hospital departments. This study indicates that the majority of suicide cases are not diagnosed and managed preceding death despite high general medical contact rates. It implies that suicide prevention strategy should be applied to non-psychiatric medical settings in countries with high suicide rates like South Korea.

Resampling to address inequities in predictive modeling of suicide deaths

Objective

Improve methodology for equitable suicide death prediction when using sensitive predictors, such as race/ethnicity, for machine learning and statistical methods.

Methods

Train predictive models, logistic regression, naive Bayes, gradient boosting (XGBoost) and random forests, using three resampling techniques (Blind, Separate, Equity) on emergency department (ED) administrative patient records. The Blind method resamples without considering racial/ethnic group. Comparatively, the Separate method trains disjoint models for each group and the Equity method builds a training set that is balanced both by racial/ethnic group and by class.

Results

Using the Blind method, performance range of the models’ sensitivity for predicting suicide death between racial/ethnic groups (a measure of prediction inequity) was 0.47 for logistic regression, 0.37 for naive Bayes, 0.56 for XGBoost and 0.58 for random forest. By building separate models for different racial/ethnic groups or using the equity method on the training set, we decreased the range in performance to 0.16, 0.13, 0.19, 0.20 with Separate method, and 0.14, 0.12, 0.24, 0.13 for Equity method, respectively. XGBoost had the highest overall area under the curve (AUC), ranging from 0.69 to 0.79.

Discussion

We increased performance equity between different racial/ethnic groups and show that imbalanced training sets lead to models with poor predictive equity. These methods have comparable AUC scores to other work in the field, using only single ED administrative record data.

Conclusion

We propose two methods to improve equity of suicide death prediction among different racial/ethnic groups. These methods may be applied to other sensitive characteristics to improve equity in machine learning with healthcare applications.

Hospital visit histories of suicide decedents: a study in Utah

The study aims to describe the 3-year hospital visit histories of suicide decedents in Utah grouped by the suicide method they used. Hospital visit histories from the Utah Office of Health Care Statistics were linked to a census of suicide mortality data from the National Violent Death Reporting System in 2014 and 2015. Overall, 14% of suicide decedents had visited a hospital for deliberate self-harm (DSH) and 49% for a behavioural health issue (BHI), including DSH, suicidal ideation, mental health and substance abuse, prior to their death. Firearms suicide decedents made up over half of all suicides but were the least likely to have a history of DSH or BHI prior to their death (8% and 41%, respectively). Few suicide decedents visited a hospital for DSH prior to their death, although half had visits for BHI. Hospital-based interventions that aim to prevent suicide should not be limited to visits for DSH.

National Trends of Mental Health Care Among US Adults Who Attempted Suicide in the Past 12 Months

IMPORTANCE

Although suicide attempts remain the strongest risk factor for future suicide, little is known about recent trends in the prevalence of and risk factors for suicide attempts and past-year use of services among adults who attempted suicide.

OBJECTIVE

To estimate annual rates of suicide attempts and use of mental health services among US adults from 2008 to 2019.

DESIGN, SETTING, AND PARTICIPANTS

This US nationally representative cross-sectional study used the National Survey of Drug Use and Health (NSDUH) from 2008 through 2019. Participants included noninstitutionalized US civilians 18 years or older (n = 484 732). The overall annual rates of suicide attempts per 100 000 adults in the general population and national trends from 2008 to 2019 were estimated, with suicide attempts defined as self-reported efforts to kill one's self in the past 12 months. Subgroup analyses were also performed by demographic characteristics and clinical conditions. The trends in past-year use of mental health services among those who reported past-year suicide attempts were then examined. Data were analyzed from October to December 2021.

MAIN OUTCOMES AND MEASURES

Rate of suicide attempts from 2008 to 2019. Multivariate-adjusted logistic regression analyses were used to determine whether adjusting for sociodemographic and clinical factors associated with past-year suicide attempts could account for the change within the study period.

RESULTS

Of 484 732 survey participants, most were 35 years or younger (69.8%), women (51.8%), and non-Hispanic White individuals (65.7%). From 2008 to 2019, the weighted unadjusted suicide attempt rate per 100 000 population increased from 481.2 to 563.9 (odds ratio [OR], 1.17 [95% CI, 1.01-1.36]; P = .04) and remained significant after controlling for sociodemographic characteristics (adjusted OR [aOR], 1.23 [95% CI, 1.05-1.44]; P = .01). Rates of suicide attempt increased particularly among young adults aged 18 to 25 years (aOR, 1.81 [95% CI, 1.52-2.16]; P < .001), women (aOR, 1.33 [95% CI, 1.09-1.62]; P = .005), those who were unemployed (aOR, 2.22 [95% CI, 1.58-3.12]; P < .001) or never married (aOR, 1.60 [95% CI, 1.31-1.96]; P < .001), and individuals who used substances (aOR, 1.44 [95% CI, 1.19-1.75]; P < .001). In multivariate analyses, the temporal trend of increasing suicide attempts remained significant even after controlling for other significant sociodemographic and clinical factors (aOR, 1.36 [95% CI, 1.16-1.60]; P < .001). Several sociodemographic and clinical subgroups remained independently associated with suicide attempts, especially those with serious psychological distress (aOR, 7.51 [95% CI, 6.49-8.68]; P < .001), major depressive episodes (aOR, 2.90 [95% CI, 2.57-3.27]; P < .001), and alcohol use disorder (aOR, 1.81 [95%CI, 1.61-2.04]; P< .001) as well as individuals who reported being divorced or separated (aOR, 1.65 [95% CI, 1.35-2.02]; P < .001) or being unemployed (aOR, 1.47 [95% CI, 1.27-1.70]; P< .001) and those who identified as Black (aOR, 1.41 [95% CI, 1.24-1.60]; P < .001) or American Indian or Alaska Native, Asian, or Native Hawaiian or Other Pacific Islander (aOR, 1.56 [95% CI, 1.26-1.93]; P < .001). Among adults with a suicide attempt, there was no significant change in the likelihood of receiving past-year mental health or substance-related services. During the study period, 34.8% to 45.5% reported needing services but did not receive them, with no significant change from 2008 to 2019.

CONCLUSIONS AND RELEVANCE

Although suicide attempts appear to be increasing, use of services among those who attempted suicide has not increased, suggesting a need to expand service accessibility and/or acceptability, as well as population-wide prevention efforts.

Suicide among those who use mental health services: Suicide risk factors as evidenced from contact-based characteristics in Victoria

OBJECTIVE

The majority of suicide decedents have had contact with health services in the months before their death. Contacts for mental health services present potential suicide prevention opportunities. This study aims to compare contact-based characteristics among suicide decedents and living controls in the year subsequent to clinical mental health contact with the public health system in Victoria, Australia.

METHODS

A population-based nested case-control study of those who had mental health-related hospital and community contacts with the public health system was conducted. Cases (suicide decedents) were age and gender-matched to living controls (suicide non-decedents). These records were linked to records of suicides that occurred in the 12 months following the health service contact, between January 1, 2011, and December 31, 2016. Victorian residents aged 10 years and above were selected at the time of contact (483,933 clients). In the study population, conditional logistic regression models were used to assess the relationship between contact-based characteristics and suicide. Socio-demographics and mental health-related hospital and community contact data was retrieved from the Victorian Admitted Episodes Dataset, the Victorian Emergency Minimum Dataset and the Public Clinical Mental Health database and suicide data from the Victorian Suicide Register.

RESULTS

During a six-year period, 1,091 suicide decedents had at least one mental health contact with the public health system in the 12 months preceding the suicide. Overall, controls used more mental health services than cases; however, cases used more mental health services near the event. The relationship between the type of service and suicide differed by service type: hospital admissions and emergency department presentations had a significant positive association with suicide with an OR of 2.09 (95% CI 1.82-2.40) and OR of 1.13 (95% CI 1.05-1.22), and the effect size increased as the event approached, whereas community contacts had a significant negative association with an OR of 0.93 (95% CI 0.92-0.94), this negative association diminished in magnitude as the event approached (OR∼1).

CONCLUSION

Suicide decedents had less contact with mental health services than non-decedents; however, evidence suggests suicide decedents reach out to mental health services proximal to suicide. An increase in mental health service contact by an individual could be an indication of suicide risk and therefore an opportunity for intervention. Further, community level contact should be further explored as a possible prevention mechanism considering the majority of suicide decedents do not access the public clinical mental health services.

Comparing the predictive value of screening to the use of electronic health record data for detecting future suicidal thoughts and behavior in an urban pediatric emergency department: A preliminary analysis

AIM

Brief screening and predictive modeling have garnered attention for utility at identifying individuals at risk of suicide. Although previous research has investigated these methods, little is known about how these methods compare against each other or work in combination in the pediatric population.

METHODS

Patients were aged 8-18 years old who presented from January 1, 2017, to June 30, 2019, to a Pediatric Emergency Department (PED). All patients were screened with the Ask Suicide Questionnaire (ASQ) as part of a universal screening approach. For all models, we used 5-fold cross-validation. We compared four models: Model 1 only included the ASQ; Model 2 included the ASQ and EHR data gathered at the time of ED visit (EHR data); Model 3 only included EHR data; and Model 4 included EHR data and a single item from the ASQ that asked about a lifetime history of suicide attempt. The main outcome was subsequent PED visit with suicide-related presenting problem within a 3-month follow-up period.

RESULTS

Of the N = 13,420 individuals, n = 141 had a subsequent suicide-related PED visit. Approximately 63% identified as Black. Results showed that a model based only on EHR data (Model 3) had an area under the curve (AUC) of 0.775 compared to the ASQ alone (Model 1), which had an AUC of 0.754. Combining screening and EHR data (Model 4) resulted in a 17.4% (absolute difference = 3.6%) improvement in sensitivity and 13.4% increase in AUC (absolute difference = 6.6%) compared to screening alone (Model 1).

CONCLUSION

Our findings show that predictive modeling based on EHR data is helpful either in the absence or as an addition to brief suicide screening. This is the first study to compare brief suicide screening to EHR-based predictive modeling and adds to our understanding of how best to identify youth at risk of suicidal thoughts and behaviors in clinical care settings.

Risk Assessment of Self-Injurious Behavior and Suicide Presentation in the Emergency Department: An Integrative Review

INTRODUCTION

Globally, there is a lack of clarity regarding the best practice to distinguish patients at the highest risk of suicide. This review explores the use of risk assessment tools in emergency departments to identify patients at high risk of repeat self-harm, suicide attempts, or death by suicide.

METHODS

The review question ("Does the use of risk assessment tools in emergency departments identify patients at high risk of repeat self-harm, suicide attempts, or death by suicide?") focused on exposure and outcome. Studies of any design were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used. Study characteristics and concepts were extracted, compared, and verified. An integrative approach was used for reporting through narrative synthesis.

RESULTS

Nine studies were identified for inclusion. Two risk assessment tools were found to have good predictive ability for suicide ideation and self-harm. Three had modest prediction of patient disposition, but in one study, the clinical impression of nurses had higher predictive ability. One tool showed modest predictive ability for patients requiring admission.

DISCUSSION

This review found no strong evidence to indicate that any particular risk tool has a superior predictive ability to identify repeat self-harm, suicide attempts, or death by suicide. Best practice lacks clarity to determine patients at highest risk of suicide, but the use of risk assessment tools has been recommended. Nevertheless, such tools should not be used in isolation from clinical judgment and experience to evaluate patients at risk. Education and training to augment risk assessment within the emergency department are recommended.

Suicide Prevention Programs Across U.S. Outpatient Mental Health Care Settings: Differences by Facility Ownership

OBJECTIVE

This study aimed to examine whether facility ownership (public, private nonprofit, private for-profit ownership) was associated with provision of suicide prevention programs.

METHODS

A retrospective cross-sectional study identified self-reported suicide prevention program status across 7,597 mental health facilities with outpatient settings by using data from the 2019 Substance Abuse and Mental Health Services Administration Behavioral Health Treatment Services Locator. Multivariable logistic regression models examined whether facility ownership was associated with availability of these programs.

RESULTS

In 2019, only 61.2% of facilities provided outpatient suicide prevention programs. Higher odds of program provision were associated with public ownership (adjusted odds ratio [AOR]=1.64, 95% confidence interval [CI]=1.37-1.97, p<0.001), facilities serving young adults (AOR=2.16, 95% CI=1.66-2.82, p<0.001) or serving seniors (AOR=1.44, 95% CI=1.27-1.63, p<0.001), and facilities accepting Medicare (AOR=1.34, 95% CI=1.16-1.53, p<0.001), compared with their counterparts, with significant differences across facility ownership types by rurality of locations. Facilities accepting uninsured patients (AOR=0.81, 95% CI=0.68-0.98, p=0.027) or Medicaid patients (AOR=0.76, 95% CI=0.62-0.92, p=0.006) had lower odds of providing these programs.

CONCLUSIONS

Facility ownership contributed to significantly different decisions on provision of outpatient suicide prevention programs. Maldistribution of these services should raise concerns, given nationwide efforts to prevent suicide and weak ownership regulations for mental health facilities. Understanding barriers and facilitators for deployment of these programs may improve access to suicide prevention services for all, especially for eligible patients in rural areas.

Assessing Suicidal Ideation Using a Brief Self-Report Measure

Accurate assessment of suicidal thoughts is a challenge for researchers and clinicians. There is evidence that self-report and clinical interview assessment methods can result in different endorsement numbers when used to assess suicidal ideation. This study investigates endorsement rates and psychometric properties of a two-item self-report measure of suicidal ideation that distinguishes active from passive suicidal ideation, when compared with a clinical interview. Individuals presenting at an outpatient psychiatry clinic completed a measure of depression severity containing two items assessing passive and active suicidal ideation before undergoing a structured clinical interview. Self-report and clinical interview items demonstrated a low level of agreement. Self-report items were more strongly correlated with same-domain clinical interviewer ratings than different-domain ratings. These items demonstrated high negative predictive value and moderate-to-low positive predictive value for interviewer ratings. A two-item measure of suicidal ideation did not highly align with corresponding interviewer ratings, though such a measure may be useful in determining the absence of suicidal ideation, as well as distinguishing between passive and active suicidal ideation.

The impact of suicide prevention education programmes for nursing students: A systematic review

The purpose of this systematic review was to locate and synthesize peer-reviewed evidence regarding the effectiveness of providing suicide prevention education to nursing students. Systematic searches were conducted in seven databases (EMBASE, EmCare, Joanna Briggs, MEDLINE, PsycINFO, Scopus, and Web of Science). Results were screened in duplicate at two stages: title and abstract, and full text. Critical appraisal and data extraction were also completed in duplicate. Initial database searching yielded 303 results. Following the addition of seven records from relevant reference lists, and the removal of duplicates, a total of 118 results were included for screening. Eight articles were deemed eligible for inclusion in this review; most (n = 5) were quantitative. While all were conducted within university settings, half were stand-alone education sessions, while the remaining were integrated with existing programmes/courses. The types of education programmes varied considerably across studies, with only three being established, evidence-based programmes. The studies explore a range of outcomes, which have been narratively categorized as enhanced skills, abilities, and self-confidence; development of positive attitudes and beliefs; acquisition of knowledge; and programme experience and evaluation. While there is a small body of evidence indicating that suicide prevention education programmes contribute to improvements in skills, abilities, self-confidence, and attitudes among nursing students, the variability in educational interventions and outcomes, coupled with short-term evaluation time frames, makes it difficult to fully understand the impact of this important suicide prevention strategy.

Contacts with Health Services During the Year Prior to Suicide Death and Prevalent Conditions A Nationwide Study

BACKGROUND

This study was designed to describe contacts with health services during the year before suicide death in France, and prevalent mental and physical conditions.

METHODS

Data were extracted from the French National Health Data System (SNDS), which comprises comprehensive claims data for inpatient and outpatient care linked to the national causes-of-death registry. Individuals aged ≥15 years who died from suicide in France in 2013-2015 were included. Medical consultations, emergency room visits, and hospitalisations during the year preceding death were collected. Conditions were identified, and standardised prevalence ratios (SPRs) were estimated to compare prevalence rates in suicide decedents with those of the general population.

RESULTS

The study included 19,144 individuals. Overall, 8.5% of suicide decedents consulted a physician or attended an emergency room on the day of death, 34.1% during the week before death, 60.9% during the month before death. Most contacts involved a general practitioner or an emergency room. During the month preceding suicide, 24.4% of individuals were hospitalised at least once. Mental conditions (36.8% of cases) were 7.9-fold more prevalent in suicide decedents than in the general population. The highest SPRs among physical conditions were for liver/pancreatic diseases (SPR=3.3) and epilepsy (SPR=2.7).

LIMITATIONS

The study population was restricted to national health insurance general scheme beneficiaries (76% of the population living in France).

CONCLUSIONS

Suicide decedents have frequent contacts with general practitioners and emergency departments during the last weeks before death. Improving suicide risk identification and prevention in these somatic healthcare settings is needed.

The quantification of the psychiatric revolution: a quasi-natural experiment of the suicide impact of the Basaglia Law

BACKGROUND

The Italian 180/1978 reform abolishing asylums is one of the most contested mental health programs ever implemented. It aimed to shift care of mental illness into the community improving outcomes and reducing expenditure. It was a model for successive deinstitutionalization initiatives across Europe and North America. However, there were longstanding concerns that, without expansion of community care, it may have deprived patients with mental illness access to support, placing them at increased risk of suicide.

METHODS

Regression discontinuity models were used to quantify the association between the number of suicides and the introduction of the Basaglia Law, disaggregated by age-group and gender, covering 20 Italian regions during the period 1975-84. Models were adjusted for potential socio-demographic confounding factors, region-specific fixed effects and pre-existing time-trends.

RESULTS

Italian regions implemented the Basaglia Law to varying degrees over time. We observed that, after adjusting for pre-existing time trends, the implementation was associated with a consistent increase in the number of suicides for all the age-groups [incidence rate ratio, age 15-44: 1.29, 95% confidence interval (CI) 1.18-1.41; age 45-74: 1.45, 95% CI 1.37-1.54] and for both genders (males: 1.47, 95% CI 1.41-1.53; females: 1.36, 95% CI 1.25-1.47). Hospital closure appeared to be an important mediating mechanism.

CONCLUSIONS

The Basaglia Law was associated with a significant increase in the number of suicides, with evidence of an association with closures of facilities, leaving those with mental illness with nowhere to go, as the envisioned community care structures failed to be developed as originally planned.

Healthcare utilization, psychiatric medication and risk of rehospitalization in suicide-attempting patients with common mental disorders

OBJECTIVE

Common mental disorders are strong risk factors for suicide attempt. We compared common mental disorder patients with and without suicide attempt regarding health care utilization and psychiatric medication, assessed gender differences and identified how psychotropic medication of attempters is associated with subsequent rehospitalization.

METHODS

We used administrative claims data of 22,276 common mental disorder patients with inpatient care in Lower Austria between 1 January 2006 and 31 December 2011. Suicide attempters (cases, n = 615) and non-attempters (controls, n = 21,661) were compared regarding specific healthcare utilization by calculating mean differences of time-dependent contact probabilities and psychiatric medication (i.e. prescribed defined daily doses) ± 0.5 years around their suicide attempt (cases)/common mental disorder diagnosis (controls). Cluster analysis was used to group suicide attempters according to their psychiatric medication. The risk of rehospitalization 0.5-3 years after the attempt was calculated with regression analysis controlling for sex, age and morbidity-related factors.

RESULTS

Contacts with general practitioners were lower for attempters than non-attempters (mean difference of contact probabilities over observation period, males = -0.05, 95% confidence interval = [-0.07, -0.03]; females: mean difference = -0.04, 95% confidence interval = [-0.05, -0.03]). Regarding psychiatrists, female attempters had markedly higher contact probabilities after the attempt compared to female non-attempters (mean difference = 0.02, 95% confidence interval = [0.007, 0.04]); male attempters had lower contact probabilities before the attempt compared to male non-attempters (mean difference = -0.01, 95% confidence interval = [-0.004, -0.02]). Attempters had higher dosages of psychiatric medication across the entire period. Antidepressant and antipsychotic medication peaked at the time of common mental disorder diagnosis/attempt. Benzodiazepine prescriptions were considerably higher for male attempters than their female counterparts and were constantly elevated for male attempters across the observation period. A cluster of attempters with long-term benzodiazepine prescriptions had an increased risk of rehospitalization (adjusted odds ratio = 2.4, 95% confidence interval = [1.1, 5.5]).

CONCLUSION

Despite lower contact probabilities, common mental disorder patients with suicide attempt are prescribed more psychiatric medication, particularly benzodiazepines, with an elevated risk of rehospitalization. Strong sex differences were found.

Differences in Health Care Utilization in the Year Before Suicide Death: A Population-Based Case-Control Study

OBJECTIVE

To compare health care usage between suicide decedents and living controls in the year before suicide in a large representative US population.

PATIENTS AND METHODS

Cases (n=1221) and controls (n=3663) belonged to an integrated health care system from January 1, 2009, through December 31, 2014. Cases and controls were matched for age and sex in a 1:3 ratio, with diagnostic and/or billing codes used to enumerate and classify health care visits in the year before the index suicide. Matched analysis via conditional logistic regression related odds of suicide to visit type. A generalized estimating equation model was used to compare timing and frequency of visits between cases and controls.

RESULTS

In the year before death, cases had an increased odds of both inpatient hospitalizations and emergency department nonmental health visits (odds ratio [OR], 1.55; 95% CI, 1.27-1.88; P<.001 and OR, 1.42; 95% CI, 1.26-1.60; P<.001) but not outpatient nonmental health visits (OR, 1.00; 95% CI, 0.99-1.01; P=.63). Decedents increased health care utilization closer to suicide death and had significantly more health care visits than did controls 3 months before suicide (6 vs 2; P=.01) but not 9 to 12 months before suicide (4 vs 2; P=.07). At all time points, cases used more mental health care services than did controls.

CONCLUSION

Compared with controls, suicide decedents had emergency department visits and more inpatient hospitalizations, both mental health and nonmental health related. As death approached, cases' frequency of health care usage increased. The only category in which cases and controls did not differ was in the frequency of outpatient nonmental health visits.

Variation in patterns of health care before suicide: A population case-control study

BACKGROUND

The United States has experienced a significant rise in suicide. As decision makers identify how to address this national concern, healthcare systems have been identified as an optimal location for prevention.

OBJECTIVE

To compare variation in patterns of healthcare use, by health setting, between individuals who died by suicide and the general population.

DESIGN

Case-Control Study.

SETTING

Eight healthcare systems across the United States.

PARTICIPANTS

2674 individuals who died by suicide between 2000 and 2013 along with 267,400 individuals matched on time-period of health plan membership and health system affiliation.

MEASUREMENTS

Healthcare use in the emergency room, inpatient hospital, primary care, and outpatient specialty setting measured using electronic health record data during the 7-, 30-, 60-, 90-, 180-, and 365-day time periods before suicide and matched index date for controls.

RESULTS

Healthcare use was more common across all healthcare settings for individuals who died by suicide. Nearly 30% of individuals had a healthcare visit in the 7-days before suicide (6.5% emergency, 16.3% outpatient specialty, and 9.5% primary care), over half within 30 days, and >90% within 365 days. Those who died by suicide averaged 16.7 healthcare visits during the year. The relative risk of suicide was greatest for individuals who received care in the inpatient setting (aOR = 6.23). There was both a large relative risk (aOR = 3.08) and absolute utilization rate (43.8%) in the emergency room before suicide.

LIMITATIONS

Participant race/ethnicity was not available. The sample did not include uninsured individuals.

CONCLUSIONS

This study provides important data about how care utilization differs for those who die by suicide compared to the general population and can inform decision makers on targeting of suicide prevention activities within health systems.

Emergency Department Presentations and Youth Suicide: A Case-Control Study

OBJECTIVE

We estimate associations between emergency department (ED) diagnoses and suicide among youth to guide ED care.

METHOD

This ED-based case-control study used data from the Office of the Chief Coroner and all EDs in Ontario, Canada. Cases ( n = 697 males and n = 327 females) were aged 10 to 25 years who died by suicide in Ontario between April 2003 and March 2014, with an ED contact in the year before their death. Same-aged ED-based controls were selected during this time frame. Crude and adjusted odds ratios (aORs) and 95% confidence intervals were calculated.

RESULTS

Among youth diagnosed with a mental health problem at their most recent ED contact (41.9% cases, 5% controls), suicide was elevated among nonfatal self-inflicted: 'other' injuries, including hanging, strangulation, and suffocation in both sexes (aORs > 14); cut/pierce injuries in males (aOR > 5); poisonings in both sexes (aORs > 2.2); and mood and psychotic disorders in males (aORs > 1.7). Among those remaining, 'undetermined' injuries and poisonings in both sexes (aORs > 5), 'unintentional' poisonings in males (aOR = 2.1), and assault in both sexes (aORs > 1.8) were significant. At least half of cases had ED contact within 106 days.

CONCLUSIONS

The results highlight the need for timely identification and treatment of mental health problems. Among those with an identified mental health problem, important targets for suicide prevention efforts are youth with self-harm and males with mood and psychotic disorders. Among others, youth with unintentional poisonings, undetermined events, and assaults should raise concern.

Increased Risk of Suicide Attempts and Unintended Death Among Those Transitioning From Prison to Community in Later Life

OBJECTIVE

The number of individuals transitioning from correctional facilities to community in later life (age ≥50 ) is increasing. We sought to determine if later-life prison release is a risk factor for suicidal behavior and death by accidental injury, including drug overdose.

DESIGN

Retrospective cohort study.

SETTING

U.S. Department of Veterans Affairs and Medicare healthcare systems, 2012-2014.

PARTICIPANTS

Veterans age ≥50 released from correctional facilities (N = 7,671 re-entry veterans) and those never incarcerated (N = 7,671).

METHODS

Dates of suicide attempt and cause-specific mortality defined using the National Suicide Prevention Applications Network and the National Suicide Data Repository, respectively.

RESULTS

Later-life prison release was associated with increased risk of suicide attempt (599.7 versus 134.7 per 100,000 per year; adjusted hazard ratio [HR] 3.45; 95% confidence interval [CI] 2.24-5.32; p < 0.001, Wald χ² = 31.58, degrees of freedom [df] = 1), death by drug overdose (121.7 versus 43.5; adjusted HR 3.45; 95% CI 1.37-8.73; p = 0.009, Wald χ² = 6.86, df = 1), and other accidental injury (126.0 versus 39.1; adjusted HR 3.13; 95% CI 1.28-7.69; p = 0.013, Wald χ² = 6.25, df = 1), adjusting for homelessness, traumatic brain injury, medical and psychiatric conditions, and accounting for competing risk of other deaths. Suicide mortality rates were observed as nonsignificant between re-entry veterans and those never incarcerated (30.4 versus 17.4, respectively; adjusted HR 2.40; 95% CI 0.51-11.24; p = 0.266, Wald χ² = 1.23, df = 1).

CONCLUSION

Older re-entry veterans are at considerable risk of attempting suicide and dying by drug overdose or other accidental injury. This study highlights importance of prevention and intervention efforts targeting later-life prison-to-community care transitions.

Weren't Asked, Didn't Tell: Prevalence of Communication of Suicidal Ideation in Suicide Decedents During the Last Year of Life

OBJECTIVE

To explore what percentage of suicide decedents (SDs) vs controls were assessed for suicidality at medical appointments in the year before death.

PATIENTS AND METHODS

Using the Rochester Epidemiology Project, 66 SDs dying in Olmsted County, Minnesota, between January 1, 2000, and December 31, 2009, were identified and matched with 141 age- and sex-matched controls. Blinded chart review determined how often providers screened and subjects endorsed suicidal ideation (SI). Positive indicators included chart notes recording SI and/or Patient Health Questionnaire-9 scored more than 0 on question 9.

RESULTS

We found that only 29 of 66 (43.9%) SDs and 14 of 141 (9.9%) controls had been screened at any point by any means (P < .001). Only 25.8% (17 of 66) of SDs expressed SI, whereas 58.6% of screened SDs (17 of 29) did so, though none at final appointments before death. No control ever expressed SI. While the majority of both cases and controls went unscreened, providers were more likely to screen SDs (P < .001; odds ratio [OR], 9.0; 95% CI, 3.6-22.0), even with controlling for mental health diagnoses (P = .02; OR, 3.6; 95% CI, 1.2-10.6).

CONCLUSIONS

With providers screening less than half of SDs at any point in the year before death, and less than 60% of SDs ever endorsing SI, including none at final appointments, the findings of this naturalistic study bring into question both current screening practices and screening effectiveness. Nonetheless, when SDs were screened, they were significantly more likely to endorse SI than were controls, not 1 of whom ever expressed SI. Taken together, these data suggest that patients expressing SI at any point are at elevated risk for eventual suicide.

Screening pregnant women for suicidal behavior in electronic medical records: diagnostic codes vs. clinical notes processed by natural language processing

BACKGROUND

We examined the comparative performance of structured, diagnostic codes vs. natural language processing (NLP) of unstructured text for screening suicidal behavior among pregnant women in electronic medical records (EMRs).

METHODS

Women aged 10-64 years with at least one diagnostic code related to pregnancy or delivery (N = 275,843) from Partners HealthCare were included as our "datamart." Diagnostic codes related to suicidal behavior were applied to the datamart to screen women for suicidal behavior. Among women without any diagnostic codes related to suicidal behavior (n = 273,410), 5880 women were randomly sampled, of whom 1120 had at least one mention of terms related to suicidal behavior in clinical notes. NLP was then used to process clinical notes for the 1120 women. Chart reviews were performed for subsamples of women.

RESULTS

Using diagnostic codes, 196 pregnant women were screened positive for suicidal behavior, among whom 149 (76%) had confirmed suicidal behavior by chart review. Using NLP among those without diagnostic codes, 486 pregnant women were screened positive for suicidal behavior, among whom 146 (30%) had confirmed suicidal behavior by chart review.

CONCLUSIONS

The use of NLP substantially improves the sensitivity of screening suicidal behavior in EMRs. However, the prevalence of confirmed suicidal behavior was lower among women who did not have diagnostic codes for suicidal behavior but screened positive by NLP. NLP should be used together with diagnostic codes for future EMR-based phenotyping studies for suicidal behavior.

The PHQ-9 Item 9 based screening for suicide risk: a validation study of the Patient Health Questionnaire (PHQ)-9 Item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS)

BACKGROUND

Item 9 of the Patient Health Questionnaire (PHQ) evaluates passive thoughts of death or self-injury within the last two weeks, and is often used to screen depressed patients for suicide risk. We aimed to validate the PHQ-9 item 9 with a brief electronic version of the Columbia Suicide Severity Rating Scale (eC-SSRS).

METHODS

We analyzed data from 841 patients enrolled in the National Network of Depression Centers Clinical Care Registry. We performed a validation analysis of PHQ-9 item 9 for suicide risk and ideation, using the eC-SSRS as a gold standard (defined as positive response to suicidal ideation with intent to act or recent suicidal behavior).

RESULTS

Of the 841 patients, 13.4% and 41.1% were assessed as being positive for suicide risk by the eC-SSRS and PHQ-9 item 9, respectively. For the overall cohort, sensitivity was 87.6% (95%CI 80.2-92.5%), specificity was 66.1% (95%CI 62.6-69.4%), PPV was 28.6% (95%CI 24.1-33.6%), and NPV was 97.2% (95%CI 95.3-98.3%) for the PHQ-9 suicide item. These performance measures varied within subgroups defined by demographic and clinical characteristics. In addition, the validity of PHQ-9 item 9 (cutoff score of 1) with eC-SSRS-defined suicide ideation showed overall poor results.

LIMITATIONS

The gold standard used in our study was a surrogate measure of suicidality based on eC-SSRS scores.

CONCLUSIONS

The results of our study suggest that item 9 of the PHQ-9 is an insufficient assessment tool for suicide risk and suicide ideation, with limited utility in certain demographic and clinical subgroups that requires further investigation.

Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017

Aim: To examine rates of contact with primary and mental health care prior to suicide in men and women and across a range of age categories. Method: The authors performed a systematic review of 44 studies from 2000 to 2017 of which 36 reported rates on contact with primary health care and 14 reported on contact with mental health care prior to suicide. Results: Contact with primary health care was highest in the year prior to suicide with an average contact rate of 80%. At one month, the average rate was 44%. The lifetime contact rate for mental health care was 57%, and 31% in the final 12 months. In general, women and those over 50 years of age had the highest rates of contact with health care prior to suicide. Conclusions: Contact with primary health care prior to suicide is common even in the final month before death. The findings presented in this study highlight the importance of placing suicide prevention strategies and interventions within the primary health care setting.

Psychiatric Emergencies: Assessing and Managing Suicidal Ideation

The assessment of suicide risk is a daunting, but increasingly frequent task for outpatient practitioners. Guidelines for depression screening identify more individuals at risk for treatment and mental health resources are not always easily accessible. For those patients identified as in need of a formal suicide risk assessment, this article reviews established risk and protective factors for suicide and provides a framework for the assessment and management of individuals at risk of suicide. The assessment should be explicitly documented with a summary of the most relevant risk/protective factors for that individual with a focus on interventions that may mitigate risk.