Suicide Risk Among Adults With Mental Health Emergency Department Visits With and Without Suicidal Symptoms

Psychosocial Risks and Adolescent Mental Health: The Moderating Role of Objective Neighborhood Characteristics

PURPOSE

Although previous studies have examined the association between youth psychosocial risks and their perceptions of their neighborhood, it is unclear how objective neighborhood characteristics are associated with psychosocial risks and mental health symptoms among adolescents. We investigated how neighborhood characteristics moderate the relationship between youth psychosocial characteristics and mental health symptoms.

METHODS

This cross-sectional study examined 13,837 emergency department visits by 14-18-year-olds who completed a standardized Behavioral Health Screening in a tertiary pediatric hospital in Philadelphia from 2013 to 2020. Psychosocial risk factors and mental health symptoms were assessed based on self-reported survey responses. We characterized neighborhoods as low-, moderate-, and high-stress based on gun violence incidence from 2013 to 2020 and the census tract-level Child Opportunity Index. Mixed effects logistic regression and Poisson models were used to examine moderation effects.

RESULTS

The 9,814 included patients were 64% female and 64% non-Hispanic Black. The following psychosocial risk factors were associated with two to eight times higher odds of depressive symptoms and suicide risk: exposure to trauma, bullying at school, at-risk substance use, fighting, and retaliation. Adolescents living in high-stress neighborhoods were twice as likely to report fighting and retaliation and reported more psychosocial risk factors than those in low-stress neighborhoods. Odds of mental health symptoms increased with the number of psychosocial risk factors, particularly in youth from low-stress neighborhoods.

DISCUSSION

Objective neighborhood characteristics had a significant interaction effect on the relationship between psychosocial risks and depression and suicide risk among adolescents seeking care in a pediatric emergency department.

Predicting suicide death after emergency department visits with mental health or self-harm diagnoses

OBJECTIVE

Use health records data to predict suicide death following emergency department visits.

METHODS

Electronic health records and insurance claims from seven health systems were used to: identify emergency department visits with mental health or self-harm diagnoses by members aged 11 or older; extract approximately 2500 potential predictors including demographic, historical, and baseline clinical characteristics; and ascertain subsequent deaths by self-harm. Logistic regression with lasso and random forest models predicted self-harm death over 90 days after each visit.

RESULTS

Records identified 2,069,170 eligible visits, 899 followed by suicide death within 90 days. The best-fitting logistic regression with lasso model yielded an area under the receiver operating curve of 0.823 (95% CI 0.810-0.836). Visits above the 95th percentile of predicted risk included 34.8% (95% CI 31.1-38.7) of subsequent suicide deaths and had a 0.303% (95% CI 0.261-0.346) suicide death rate over the following 90 days. Model performance was similar across subgroups defined by age, sex, race, and ethnicity.

CONCLUSIONS

Machine learning models using coded data from health records have moderate performance in predicting suicide death following emergency department visits for mental health or self-harm diagnosis and could be used to identify patients needing more systematic follow-up.

Longitudinal risk of suicide outcomes in people with severe mental illness following an emergency department visit and the effects of suicide prevention treatment

BACKGROUND

Individuals with severe mental illness (SMI), including bipolar disorder (BD) and schizophrenia-spectrum disorders (SSD), are at high risk for suicide. However, suicide research often excludes individuals with SMI. The current research examined differences in suicide outcomes (i.e., suicide attempt or death) for adults with and without BD and SSD diagnoses following an emergency department (ED) visit and investigated the efficacy of the Coping Long Term with Active Suicide Program (CLASP) intervention in reducing suicide outcomes among people with SMI.

METHODS

1235 adults presenting with recent suicidality were recruited from 8 different EDs across the United States. Using a quasi-experimental, stepped wedge series design, participants were followed for 52-weeks with or without subsequent provision of CLASP.

RESULTS

Participants in the SSD group and the BD group had significantly shorter time to and higher rate of suicide outcomes than participants with other psychiatric diagnoses in all study phases and in non-CLASP phases, respectively. Participants with BD receiving the CLASP intervention had significantly longer time to suicide outcomes than those not receiving CLASP; these differences were not observed among those with SSD.

LIMITATIONS

Study limitations include self-reported psychiatric diagnosis, exclusion of homeless participants, and small sample size of participants with SSD.

CONCLUSIONS

Participants with SMI were at higher risk for suicide outcomes than participants with other psychiatric diagnoses. CLASP was efficacious among those participants with BD. Psychiatric diagnosis may be a key indicator of prospective suicide risk. More intensive and specialized follow-up mental health treatment may be necessary for those with SSD.

Emergency Department Care of the Patient with Suicidal or Homicidal Symptoms

Patients frequently present to the emergency department (ED) with acute suicidal and homicidal thoughts. These patients require timely evaluation, with determination of disposition by either voluntary or involuntary hospitalization or discharge with appropriate outpatient follow-up. Safety concerns should be prioritized for patients as well as ED staff. Patient dignity and autonomy should be respected throughout the process.

Intramuscular ketamine vs. midazolam for rapid risk-reduction in suicidal, depressed emergency patients: Clinical trial design and rationale

Emergency department (ED) visits for suicidal ideation or behavior have been increasing in all age groups, particularly younger adults. A rapid-acting treatment to reduce suicidal thinking, adapted for ED use, is needed. Previous studies have shown a single dose of ketamine can improve depression and suicidal ideation within hours. However, most studies used 40 min intravenous infusions which can be impractical in a psychiatric ED. The ER-Ketamine study we describe here is a randomized midazolam-controlled clinical trial (RCT; NCT04640636) testing intramuscular (IM) ketamine's feasibility, safety, and effectiveness to rapidly reduce suicidal ideation and depression in a psychiatric ED. A pre-injection phase involves screening, informed consent, eligibility confirmation, and baseline assessment of suicidal ideation, depression, and comorbidities. The randomized double-blind IM injection is administered in the ED under research staff supervision, vital sign monitoring, pharmacokinetic blood sampling, and clinical assessments. The post-injection phase occurs on a psychiatric inpatient unit with follow-up research assessments through four weeks post-discharge. Outcome measures are feasibility, safety, and effects on suicidal ideation and depression at 24 h post-injection, and through follow-up. The target sample is N = 90 adults in a major depressive episode, assessed by ED clinicians as warranting hospitalization for suicide risk. Here we report design, rationale, and preliminary feasibility and safety for this ongoing study. Demographics of the 53 participants (ages 18 to 65 years) randomized to date suggest a diverse sample tending towards younger adults.

Sleep deprivation and suicide risk among minoritized US adolescents

OBJECTIVES

To assess (1) the prevalence of suicide ideation/behavior among adolescents with short sleep by race/ethnicity and (2) the association between sleep duration and suicidal ideation and behavior among American youth by race/ethnicity from 2007 to 2019.

METHODS

Data were drawn from the Youth Risk Behavior Surveillance System (YRBSS). Logistic regression analyses were used to assess the relationship between sleep duration and suicidal ideation/behavior.

RESULTS

Overall, suicide ideation/behavior increased among U.S. adolescents of all racial groups from 2007 to 2019. Adjusting for race/ethnicity, sexual identity, age, sex, substance use, trauma, and bullying, those with short sleep had approximately twice the odds [OR: 1.92 (95% CI: 1.65, 2.23)] of suicide ideation/consideration compared to those with long sleep. Stratified analyses indicated that Black students with short sleep had higher odds of making a suicide plan (OR = 1.51, 95% C.I.: 1.27, 1.79) compared with Black students with long sleep. A similar pattern was observed across other racial/ethnic groups (e.g., Hispanic: (OR = 1.74, 95% C.I.: 1.53, 1.97).

CONCLUSION

Emphasis on suicide interventions is of the essence, especially with increasing rates. Sleep duration significantly predicts suicide risk among all adolescents. Additional research is needed to assess factors that predict suicide among minoritized adolescents, specifically Black and Hispanic adolescents.

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.

Trends in patient suicide rate after psychiatric discharge in Korea from 2010 to 2018: A nationwide population-based study

BACKGROUND

There is limited quantitative evidence to investigate short-term suicide rates although the risk of suicide in psychiatric patients is exceptionally high in the early post-discharge period. This study aimed to explore the trends of the 30 days suicide rate after discharge using population-based data from Korea.

METHODS

This study was conducted on psychiatric patients aged 15 years or older discharged between 2010 and 2018. Patients were extracted from the National Health Insurance Claim Database (NHICD) and information on suicide was obtained from the National Statistical Office. Age-standardized suicide rate (ASR) and Standardized Mortality Ratio (SMR) within 30 days after discharge was estimated and tested using joinpoint regression.

RESULTS

Of the 1,576,028 patients discharged from hospitals from 2010 to 2018, 53.9 % were male and 47.9 % were aged between 40 and 59 years. The 30 days ASRs for psychiatric patients after discharge varied from 174.9 to 218.0 per 100,000 patients with no clear trend excluding patients with schizophrenia and anxiety disorder. The SMR for suicide within 30 days after discharge was 66.8 in 2016-2018, and patients aged 20 to 39, female, and patients with depression had high SMRs compared to other groups.

LIMITATIONS

Factors that may impact the suicide were not considered in this study. Since the NHICD data is collected for payment of medical expenses, there may be scope for inaccuracies.

CONCLUSIONS

The 30 days suicide rate after psychiatric discharge has failed to decrease between 2010 and 2018. This study recommends early interventions after discharge and intensive interventions for patient groups who may be vulnerable to suicide.

Hospital inpatient suicides: A retrospective comparison between psychiatric and non-psychiatric inpatients in Milan healthcare facilities

INTRODUCTION

Inpatient suicide in hospitals is a worrying phenomenon that has received little attention. This study retrospectively explored the socio-demographic, clinical, and suicide-related characteristics of hospital inpatient suicides in Milan, Italy, which were collected at the Institute of Forensic Medicine during a twenty-eight-year period (1993-2020). In particular, this study compared the features of hospital inpatient suicides in patients with and without psychiatric diagnoses.

METHODS

Data were collected through the historical archive, annual registers, and autopsy reports, in certified copies of the originals deposited with the prosecutors of the courts.

RESULTS

Considering the global sample, inpatients were mainly men (N = 128; 64.6%), with a mean age of 56.7 years (SD ± 19.8), of Italian nationality (N = 176; 88.9%), admitted to non-psychiatric wards (N = 132; 66.7%), with a single illness (N = 111; 56.1%), treated with psychotropic medications (N = 101; 51%), who used violent suicide methods (N = 177; 89.4%), died of organic injuries (N = 156; 78.8%), and outside the buildings (N = 114; 72.7%). Comparing psychiatric and non-psychiatric inpatients, suicide cases with a non-psychiatric diagnosis were predominantly men (N = 48; 76.2%), hospitalized in non-psychiatric wards (N = 62; 98.4%), assuming non-psychotropic drugs (N = 37; 58.7%), and died in outside hospital spaces (N = 54; 85.7%).

CONCLUSIONS

A fuller characterization of suicide among hospitalized inpatients requires systematic and computerized data gathering that provides for specific information. Indeed, this could be valuable for inpatient suicide prevention strategies as well as institutional policies.

Insurance and inpatient admission of emergency department patients with depression in the United States

OBJECTIVE

To estimate the contribution of insurance on rates of inpatient admission for emergency department visits with depression diagnoses.

METHODS

We identified 3,681,581 visits for depression in the National Emergency Department Sample (2007-2018). We classified them by concurrent injury, suicidal ideation, or neither. Payer categories were defined, non-exclusively, as Medicare, Medicaid, private insurance, and no insurance. Logistic regression models, adjusted for age, year, and comorbidities, were used to describe differences in rates of inpatient admission by payer type, stratified by visit features.

RESULTS

Rates of inpatient admission for visits with neither injury nor suicidal ideation (31.9%; 95%CI, 30.8-33.0) were lower than for visits with injury (37.9%; 95%CI, 36.7-39.1) or with suicidal ideation (39.7%; 95%CI, 37.3-42.1). Rates of admission were significantly lower for those without insurance (26.6%; 95%CI, 25.5-27.8) than for those with insurance (37.1%; 95%CI, 36.1-38.1). In adjusted models, insurance was associated with increased likelihood (OR = 1.81, 95%CI, 1.69-1.94) of admission. Insurance continued to be a significant predictor of admission among ED visits for depression with concurrent injury (OR = 1.39; 95%CI, 1.29-1.51).

CONCLUSION

After controlling for demographic characteristics and medical comorbidities, patients with depression who have insurance are significantly more likely to be admitted to the hospital compared to those without insurance.