Association Between Medical Diagnoses and Suicide in a Medicaid Beneficiary Population, North Carolina 2014-2017

Employee attitudes toward suicide prevention and Counseling on Access to Lethal Means: initial findings from an academic medical center implementing the Zero Suicide framework

Introduction

Zero Suicide is a strategic framework designed to transform a healthcare system's suicide prevention activities. In 2020, University of Utah Health launched a Zero Suicide program and Counseling on Access to Lethal Means (CALM) training for its employees. In 2022, the healthcare system surveyed its workforce's attitudes toward suicide prevention and CALM. We sought to evaluate employees' attitudes and behaviors toward suicide prevention and CALM training following the launch of the Zero Suicide program.

Methods

A Zero Suicide Workforce Survey was administered online through REDCap to all University of Utah Health employees. The analytic sample included 3,345 respondents. We used two-portion z-tests to compare the proportions of respondents who (1) completed CALM training and (2) did not yet complete the CALM training because they felt it was irrelevant to their position by different employee characteristics.

Results

More than half of the respondents in the analytic sample were directly interacting with patients who may be at risk for suicide (57.6%). About 8.4% of the respondents had completed CALM training. Among those who had not yet completed CALM training, 9.5% indicated they did not think CALM was relevant to their job. Respondents knowledgeable about warning signs for suicide and respondents who were confident in their ability to respond when suspecting elevated suicide risk were significantly more likely to complete CALM training.

Discussion

This evaluation provides important insights from the workforce of a large academic medical center implementing a Zero Suicide program, including insights on opportunities for improving program implementation and evaluation.

Critical gaps in understanding firearm suicide in Hispanic communities: demographics, mental health, and access to care

Suicide rates increased by 26.7% among Hispanics from 2015 to 2020, driven at least in part by highly lethal firearm suicide deaths. However, there are critical gaps in characterizing firearm suicide risks and prevention opportunities in Hispanic communities. We examined Hispanic adult firearm suicide decedents reported through the National Violent Death Reporting System from 2013-2019, focusing on demographic characteristics, firearm choices, suicidal thoughts/behaviors, mental health, and mental health treatment, compared with non-Hispanic adult firearm suicide decedents. Only 13.8% of Hispanic firearm suicide decedents were known to be undergoing treatment for a mental health or substance use problem prior to death, compared to 18.8% of non-Hispanic firearm suicide decedents. On average, Hispanic firearm suicide decedents were significantly less likely than non-Hispanic firearm suicide decedents known to have been treated for a mental health or substance use problem. These results may underscore the critical need for public health agencies and policymakers to promote initiatives integrating mental health screening into medical care, reducing mental health stigma among Hispanics, and expanding mental health treatment capacity in Hispanic communities.

Association of medical conditions and firearm suicide among legal handgun purchasers in California: a case-control study

BACKGROUND

Suicide is a pressing public health problem, and firearm owners are at especially elevated risk. Certain health conditions are markers of suicide risk, but more research is needed on clinical risk markers for suicide among firearm owners specifically. Our goal was to examine associations of emergency department and inpatient hospital visits for behavioral and physical health conditions with firearm suicide among handgun purchasers.

METHODS

This was a case-control study of 5415 legal handgun purchasers in California who died between January 1, 2008, and December 31, 2013. Cases were firearm suicide decedents; controls were motor vehicle crash decedents. Exposures were emergency department and hospital visits for six categories of health diagnoses in the 3 years prior to death. To account for selection bias due to deceased controls, we used probabilistic quantitative bias analysis to generate bias-adjusted estimates.

RESULTS

There were 3862 firearm suicide decedents and 1553 motor vehicle crash decedents. In multivariable models, suicidal ideation/attempt (OR 4.92; 95% CI 3.27-7.40), mental illness (OR 1.97; 95% CI 1.60-2.43), drug use disorder (OR 1.40; 95% CI 1.05-1.88), pain (OR 1.34; 95% CI 1.07-1.69), and alcohol use disorder (OR 1.29; 95% CI 1.01-1.65) were associated with higher odds of firearm suicide. When adjusting for all conditions simultaneously, only the associations for suicidal ideation/attempt and mental illness remained significant. Quantitative bias analysis indicated that observed associations were generally biased downward. For example, the bias-adjusted OR for suicidal ideation/attempt was 8.39 (95% simulation interval 5.46-13.04), almost twice that of the observed OR.

CONCLUSIONS

Diagnoses for behavioral health conditions were markers for firearm suicide risk among handgun purchasers, even for conservative estimates that did not adjust for selection bias. Encounters with the healthcare system may provide opportunities to identify firearm owners at high risk of suicide.

Living Alone and Suicide Risk in the United States, 2008‒2019

Objectives. To evaluate the association between living alone and suicide and how it varies across sociodemographic characteristics. Methods. A nationally representative sample of adults from the 2008 American Community Survey (n = 3 310 000) was followed through 2019 for mortality. Cox models estimated hazard ratios of suicide across living arrangements (living alone or with others) at the time of the survey. Total and sociodemographically stratified models compared hazards of suicide of people living alone to people living with others. Results. Annual suicide rates per 100 000 person-years were 23.0 among adults living alone and 13.2 among adults living with others. The age-, sex-, and race/ethnicity-adjusted hazard ratio of suicide for living alone was 1.75 (95% confidence interval = 1.64, 1.87). Adjusted hazards of suicide associated with living alone varied across sociodemographic groups and were highest for adults with 4-year college degrees and annual incomes greater than $125 000 and lowest for Black individuals. Conclusions. Living alone is a risk marker for suicide with the strongest associations for adults with the highest levels of income and education. Because these associations were not controlled for psychiatric disorders, they should be interpreted as noncausal. (Am J Public Health. 2022;112(12):1774-1782. https://doi.org/10.2105/AJPH.2022.307080).

Innovations in suicide prevention research (INSPIRE): a protocol for a population-based case-control study

BACKGROUND

Suicide deaths have been increasing for the past 20 years in the USA resulting in 45 979 deaths in 2020, a 29% increase since 1999. Lack of data linkage between entities with potential to implement large suicide prevention initiatives (health insurers, health institutions and corrections) is a barrier to developing an integrated framework for suicide prevention.

OBJECTIVES

Data linkage between death records and several large administrative datasets to (1) estimate associations between risk factors and suicide outcomes, (2) develop predictive algorithms and (3) establish long-term data linkage workflow to ensure ongoing suicide surveillance.

METHODS

We will combine six data sources from North Carolina, the 10th most populous state in the USA, from 2006 onward, including death certificate records, violent deaths reporting system, large private health insurance claims data, Medicaid claims data, University of North Carolina electronic health records and data on justice involved individuals released from incarceration. We will determine the incidence of death from suicide, suicide attempts and ideation in the four subpopulations to establish benchmarks. We will use a nested case-control design with incidence density-matched population-based controls to (1) identify short-term and long-term risk factors associated with suicide attempts and mortality and (2) develop machine learning-based predictive algorithms to identify individuals at risk of suicide deaths.

DISCUSSION

We will address gaps from prior studies by establishing an in-depth linked suicide surveillance system integrating multiple large, comprehensive databases that permit establishment of benchmarks, identification of predictors, evaluation of prevention efforts and establishment of long-term surveillance workflow protocols.

Suicide typologies among Medicaid beneficiaries, North Carolina 2014-2017

BACKGROUND

There is a well-established need for population-based screening strategies to identify people at risk of suicide. Because only about half of suicide decedents are ever diagnosed with a behavioral health condition, it may be necessary for providers to consider life circumstances that may also put individuals at risk. This study described the alignment of medical diagnoses with life circumstances by identifying suicide typologies among decedents. Demographics, stressful life events, suicidal behavior, perceived and diagnosed health problems, and suicide method contributed to the typologies.

METHODS

This study linked North Carolina Medicaid and North Carolina Violent Death Reporting System (NC-VDRS) data for analysis in 2020. For suicide decedents from 2014 to 2017 aged 25-54 years, we analyzed 12 indicators of life circumstances from NC-VDRS and 6 indicators from Medicaid claims, using a latent class model. Separate models were developed for men and women.

RESULTS

Most decedents were White (88.3%), with a median age of 41, and over 70% had a health care visit in the 90 days prior to suicide. Two typologies were identified in both males (n = 175) and females (n = 153). Both typologies had similar profiles of life circumstances, but one had high probabilities of diagnosed behavioral health conditions (45% of men, 71% of women), compared to low probabilities in the other (55% of men, 29% of women). Black beneficiaries and men who died by firearm were over-represented in the less-diagnosed class, though estimates were imprecise (odds ratio for Black men: 3.1, 95% confidence interval: 0.8, 12.4; odds ratio for Black women: 5.0, 95% confidence interval: 0.9, 31.2; odds ratio for male firearm decedents: 1.6, 95% confidence interval: 0.7, 3.4).

CONCLUSIONS

Nearly half of suicide decedents have a typology characterized by low probability of diagnosis of behavioral health conditions. Suicide screening could likely be enhanced using improved indicators of lived experience and behavioral health.