Number of visits to the emergency department and risk of suicide: a population-based case-control study

Clusters of substance use and mental health variables with emergency room visits in U.S. adults: The 2020 National Survey on Drug Use and Health

BACKGROUND

This study evaluated the prevalence of emergency room (ER) visits, given numerous substance use and mental health variables in the past year.

METHODS

Data from 5206 emergency room visits out of 27,170 adults were extracted from the 2020 National Survey on Drug Use and Health. Oblique principal component cluster analysis was used to classify 39 substance use and mental health variables into disjoint clusters.

RESULTS

In 2020, the overall prevalence of ER visits was 21.9 %. Being female, age above 65 years, with insurance, low income and low education levels, and being African American increased the risk of ER visit. Nine clusters were made out of 39 substance use and mental health variables. Multivariate stepwise logistic regression analysis showed 15 substance use and mental health variables were significantly associated with ER visits including heavy alcohol use past 30 days in cluster 3, nicotine dependence and cigarettes use in cluster 4, major depressive episode, serious psychological distress, and suicidal plans in past year in cluster 5, any psychotherapeutics use in cluster 7, tranquilizers use and lorazepam products use in cluster 8, and any pain reliever, pain reliever misuse, hydrocodone products use, oxycodone products use, tramadol products use, and codeine products use in cluster 9.

CONCLUSIONS

Several substance use and mental health problems, including nicotine dependence, illicit drugs, and serious mental health problems were among the common reasons for ER visits. These findings suggest the effective use of ER as the venue to implement interventions for substance use and mental health.

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.

Predictive factors for recurrent suicide attempts: Evidence from the ACTION-J study

Aim

Risk factors for attempted suicide have been widely studied. However, there is limited evidence on predictive factors for suicide reattempts. We aimed to identify these in suicide attempters admitted to emergency departments.

Methods

This is the second analysis from a randomized controlled multicenter trial, ACTION-J. Patient characteristics were extracted from baseline demographic data and clinical data of participants. Predictive factors for a recurrent suicide attempt in each gender were examined using Cox proportional hazards regression analysis. Dependent variables were months from trial entry to the first reattempt. Independent variables were characteristics regarded as potential predictive factors.

Results

The study included 914 adults (400 men and 514 women). A visit to a psychiatrist within a month of the suicide attempt was significantly associated with reattempts in men (hazard ratio [HR] 2.49, 95% confidence interval [CI] 1.21-5.25). Substance-related disorders (HR 3.65, 95% CI 1.16-7.9.60), drinking alcohol less than once per month (HR 0.42, 95% CI 0.17-0.88), previous suicide attempts (HR 2.28, 95% CI 1.40-3.87), and taking a drug overdose for the first suicide attempt (HR 1.82, 95% CI 1.14-3.01) were significantly associated with reattempts in women.

Conclusion

Our data highlight the importance of visits to a psychiatrist a short time before the first suicide attempt in men and substance-related disorder, previous suicide attempts, and drug overdose in the first suicide attempt in women as predictive factors for future suicide reattempts.

Psychiatric emergency visit trends and characteristics in a mental health epicenter in Istanbul during COVID-19 lockdown

BACKGROUND

We aimed to explore the impact of the preventive measures and partial lockdown to the psychiatric emergency department (PED) visits during COVID-19 pandemic in a mental health epicenter in Istanbul.

METHODS

A total of 5839 patients admitted to PED during the lockdown period (LP) between March 30 and May 31, 2020, were enrolled in this retrospective cohort study. Data of these patients were compared to those of patients in the same period in 2019 between April 1 and June 2, 2019 (non-LP). We also investigated the monthly number of PED visits and hospitalizations between March 1 and December 31, 2020, and compared it to the same period in 2019.

RESULTS

The volume of PED visits and hospitalizations in LP decreased by 12% and 41.6%, respectively. The rates of patients presenting anxiety and depressive disorders and bipolar disorders were found to significantly increase in LP than non-LP (p < 0.001; p < 0.001; p < 0.01, respectively). Depressive disorders, prior history of mental illness, and aggressive behavior were found to predict frequent PED visits while decrease in age and male gender found to predict hospitalizations. Regarding suicide attempt, younger patients and those with new-onset mental disorders were found to be at high risk in LP. Patients diagnosed with COVID-19 in PED visits were mostly with psychotic and bipolar disorders.

CONCLUSION

Policy-makers should focus on studies on mental health services to reorganize and enhance such services, which are crucial to prevent and manage adverse mental health consequences of the pandemic and congestion in PEDs.

Suicide and suicide attempts in adults: exploring suicide risk 24 months after a psychiatric emergency room visit

Objective:

Suicide risk (including attempted and completed suicide) should be measured over short periods of time after contacting health services. The objective of this study was to identify the patterns of attempted and completed suicides within 24-months of a psychiatric emergency department visit, as well as to investigate predictive risk factors, including sociodemographic and clinical variables, previous suicidal behavior, and service utilization.

Method:

A convenience sample (n=147), recruited at a general hospital’s psychiatric emergency room, included patients with suicidal ideation, suicidal plans or previous suicide attempts. These patients were followed for 24 months, focusing on two main outcomes: attempted and completed suicides.

Results:

After six months there were no completed suicides and 36 suicide attempts, while after 24 months there were seven completed suicides and 69 suicide attempts. A final logistic regression model for suicide attempts at 24 months identified somatic pathology and the number of previous psychiatric hospitalizations as predictive factors, with a good area under the receiver operating characteristic curve.

Conclusions:

The findings showed distinct patterns of attempted and completed suicides over time, indicating the importance of a systematic multidisciplinary suicide risk evaluation in psychiatric emergency rooms.

Outcome of pediatric emergency mental health visits: incidence and timing of suicide

OBJECTIVES

To determine the incidence, risk, and timing of mortality (unnatural and natural causes) among youth seen in a pediatric emergency department (ED) for mental health concerns, compared with matched non-mental health ED controls.

METHODS

This was a retrospective cohort study conducted at a quaternary pediatric ED in British Columbia. All visits for a mental health related condition between July 1st, 2005, and June 30th, 2015, were matched on age, sex, triage acuity, socioeconomic status, and year of visit to a non-mental health control visit. Mortality outcomes were obtained from vital statistics data through December 31st, 2016 (cumulative follow-up 74,390 person-years).

RESULTS

Among all cases in our study, including 6,210 youth seen for mental health concerns and 6,210 matched controls, a total of 13 died of suicide (7.5/100,000 person-years) and 33 died of suicide or indeterminate causes (44/100,000 person-years). All-cause mortality was significantly lower among mental health presentations (121.3/100,000 v. 214.5/100,000 person-years; hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.37-0.78). The median time from initial emergency visit to suicide was 5.2 years (interquartile range, 4.2-7.3). Among mental health related visits, risk of death by suicide or indeterminate cause was three-fold that of matched controls (HR, 3.05 95%CI, 1.37-6.77).

CONCLUSIONS

While youth seeking emergency mental health care are at increased risk of death by unnatural causes, their overall mortality risk is lower than non-mental health controls. The protracted duration from initial presentation to suicide highlights the need for long-term surveillance and preventative care for youth seen in the ED for all mental health concerns.

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.

Suicide prevention by emergency nurses: perceived self-efficacy in assessment, management and referral at Kenyatta National Hospital in Kenya

BACKGROUND

Emergency Departments are underutilized settings for suicide prevention and management as patients with occult (camouflaged) suicides and suicidal ideation are rarely screened by nurses and other health workers in these sites. The under-detection rates could be a result of lack of suicide assessment and management confidence among the hospital staff. The aim of the study was to find out the perceived self-efficacy in suicide risk assessment, management and referral among nurses working in an emergency department within a lower income country.

METHOD

The Risk Assessment and Management Self-Efficacy Scale (RAMSES) was administered among nurses in an emergency department (ED) within an urban region in a descriptive study. The risk assessment, management and referral domains among 64 respondents were evaluated using mean and standard deviation calculations in SPSS v 21.

RESULTS

The total RAMSES composite score in risk assessment, management and referral was 6.19 (SD 2.107) with risk assessment having the lowest mean score of 6.09 (SD 2.08), while risk referral process mean score was the highest at 6.55 (SD 2.36). The nurses had the least confidence in developing a written risk management plan 5.68 (SD 2.51) as well as using screening instruments to assess risk 5.90 (SD 2.15).

FINDINGS

Nurses in emergency department have below average self-efficacy in suicide assessment and management necessitating training as well as integration of protocols that could enhance effective utilization of emergency departments as suicide prevention and management settings.

Emergency department and hospital care prior to suicide: A population based case control study

BACKGROUND

High proportions of those who die by suicide in Northern Ireland (NI) are not known to mental health services, making it important to understand contact with the wider health services. Previous research has not examined the patterns of emergency department (ED) attendance and hospital admissions amongst those who have died by suicide in NI.

OBJECTIVES

The study objectives are to examine the relationships between ED attendances, hospital admissions, and death by suicide.

METHODS

A case control methodology was used, drawing on routinely collected administrative data on all deaths by suicide in Northern Ireland between 1/1/2012 and 31/12/2015. Each death was matched to 5 live controls, based on age and gender (n = 6630).

RESULTS

Death by suicide is associated with a recent ED attendance, with the highest odds for those who attended within the past three months (odds = 3.2, 95% CI = 2.5-4.2). Death by suicide is also associated with recent hospital admission, with the highest odds of death for admission within the past three months (odds = 6.6, 95% CI = 5.2-8.3). The odds of suicide are also higher for those living in a more deprived or urban area.

LIMITATIONS

The study is limited to administrative data.

CONCLUSIONS

Staff in EDs and hospitals may have a role in suicide prevention. These findings again support the importance of addressing economic deprivation and other area level factors, such as contagion in suicide prevention strategies.

Self-Directed Violence After Medical Emergency Department Visits Among Youth

INTRODUCTION

Identifying medical encounters that precede self-directed violence may allow for important prevention opportunities. This study examined the risk of self-directed violence after visiting the emergency department for a range of physical health conditions among youth.

METHODS

This retrospective cohort study used 2012-2013 statewide emergency department data from six states. Among patients aged 15-29 years, the exposure group included 2,192,322 emergency department visits for 16 selected conditions, coded by whether visits for those conditions were the first, second, or third or later visit for that condition. Emergency department visits for a minor infection served as the reference group (n=149,163). A Cox proportional hazard model was used to assess the risk of a self-directed violence event within 6 months for each condition. Analyses were conducted in 2017.

RESULTS

Overall, 8,489 (0.4%) of all patients visited the emergency department for self-directed violence over a 6-month period. Initial visits for epilepsy or seizures conveyed a markedly elevated hazard ratio for subsequent self-directed violence at 6.0 and 5.7, respectively (p<0.001). Initial visits for other conditions showed moderately elevated risk with hazard ratios primarily <2. Second visits for various pain symptoms, syncope, vomiting, or non-self-directed violence injury also had a 3- to 5-fold increase in hazard ratios for subsequent self-directed violence. Hazard ratios for third or later visit increased to 8.8 for back pain, 6.9 for headache, about 5 for abdominal pain, dental complaints, and non-self-directed violence injury (p<0.001).

CONCLUSIONS

Young people presenting to the emergency department for certain medical conditions are at an increased risk of subsequent self-directed violence. An awareness of these patterns may help guide screening efforts for suicide prevention in clinical settings.

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.

LETHAL MEANS ACCESS AND ASSESSMENT AMONG SUICIDAL EMERGENCY DEPARTMENT PATIENTS

BACKGROUND

Reducing access to lethal means (especially firearms) might prevent suicide, but counseling of at-risk individuals about this strategy may not be routine. Among emergency department (ED) patients with suicidal ideation or attempts (SI/SA), we sought to describe home firearm access and examine ED provider assessment of access to lethal means.

METHODS

This secondary analysis used data from the Emergency Department Safety Assessment and Follow-up Evaluation, a three-phase, eight-center study of adult ED patients with SI/SA (2010-2013). Research staff surveyed participants about suicide-related factors (including home firearms) and later reviewed the ED chart (including documented assessment of lethal means access).

RESULTS

Among 1,358 patients with SI/SA, 11% (95% CI: 10-13%) reported ≥1 firearm at home; rates varied across sites (range: 6-26%) but not over time. On chart review, 50% (95% CI: 47-52%) of patients had documentation of lethal means access assessment. Frequency of documented assessment increased over study phases (40-60%, P < .001) but was not associated with state firearm ownership rates. Among the 337 (25%, 95% CI: 23-27%) patients discharged to home, 55% (95% CI: 49-60%) had no documentation of lethal means assessment; of these, 13% (95% CI: 8-19%; n = 24) actually had ≥1 firearm at home. Among all those reporting ≥1 home firearm to study staff, only half (50%, 95% CI: 42-59%) had provider documentation of assessment of lethal means access.

CONCLUSIONS

Among these ED patients with SI/SA, many did not have documented assessment of home access to lethal means, including patients who were discharged home and had ≥1 firearm at home.

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

OBJECTIVE

To compare the type and frequency of health care visits in the year before suicide between decedents and controls.

PATIENTS AND METHODS

Cases (n=86) were Olmsted County, Minnesota, residents whose death certificates listed "suicide" as the cause of death from January 1, 2000, through December 31, 2009. Each case had 3 age- and sex-matched controls (n=258). Demographic, diagnostic, and health care usage data were abstracted from medical records. Conditional logistic regression was used to analyze differences in the likelihood of having had psychiatric and nonpsychiatric visits in the year before death, as well as in visit types and frequencies 12 months, 6 months, and 4 weeks before death.

RESULTS

Cases and controls did not significantly differ in having had any health care exposure (P=.18). Suicide decedents, however, had a significantly higher number of total visits in the 12 months, 6 months, and 4 weeks before death (all P<.001), were more likely to have carried psychiatric diagnoses in the previous year (odds ratio [OR], 8.08; 95% CI, 4.31-15.17; P<.001), and were more likely to have had outpatient and inpatient mental health visits (OR, 1.24; 95% CI, 1.05-1.47; P=.01 and OR 6.76; 95% CI, 1.39-32.96; P=.02, respectively). Only cases had had emergency department mental health visits; no control did.

CONCLUSION

Given that suicide decedents did not differ from controls in having had any health care exposure in the year before death, the fact alone that decedents saw a doctor provides no useful information about risk. Compared with controls, however, decedents had more visits of all types including psychiatric ones. Higher frequencies of health care contacts were associated with elevated suicide risk.