Health care utilization as a marker for suicidal behavior on an American Indian Reservation

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.

Association between suicidal ideation and suicide: meta-analyses of odds ratios, sensitivity, specificity and positive predictive value

BACKGROUND

The expression of suicidal ideation is considered to be an important warning sign for suicide. However, the predictive properties of suicidal ideation as a test of later suicide are unclear.AimsTo assess the strength of the association between suicidal ideation and later suicide measured by odds ratio (OR), sensitivity, specificity and positive predictive value (PPV).

METHOD

We located English-language studies indexed in PubMed that reported the expression or non-expression of suicidal ideation among people who later died by suicide or did not. A random effects meta-analysis was used to assess the pooled OR, sensitivity, specificity and PPV of suicidal ideation for later suicide among groups of people from psychiatric and non-psychiatric settings.

RESULTS

There was a moderately strong but highly heterogeneous association between suicidal ideation and later suicide (n = 71, OR = 3.41, 95% CI 2.59-4.49, 95% prediction interval 0.42-28.1, I2 = 89.4, Q-value = 661, d.f.(Q) = 70, P ≤0.001). Studies conducted in primary care and other non-psychiatric settings had similar pooled odds to studies of current and former psychiatric patients (OR = 3.86 v. OR = 3.23, P = 0.7). The pooled sensitivity of suicidal ideation for later suicide was 41% (95% CI 35-48) and the pooled specificity was 86% (95% CI 76-92), with high between-study heterogeneity. Studies of suicidal ideation expressed by current and former psychiatric patients had a significantly higher pooled sensitivity (46% v. 22%) and lower pooled specificity (81% v. 96%) than studies conducted in non-psychiatric settings. The PPV among non-psychiatric cohorts (0.3%, 95% CI 0.1%-0.5%) was significantly lower (Q-value = 35.6, P < 0.001) than among psychiatric samples (3.9%, 95% CI 2.2-6.6).

CONCLUSIONS

Estimates of the extent of the association between suicidal ideation and later suicide are limited by unexplained between-study heterogeneity. The utility of suicidal ideation as a test for later suicide is limited by a modest sensitivity and low PPV.Declaration interestM.M.L. and C.J.R. have provided expert evidence in civil, criminal and coronial matters. I.B.H. has been a Commissioner in Australia's National Mental Health Commission since 2012. He is the Co-Director, Health and Policy at the Brain and Mind Centre (BMC) University of Sydney. The BMC operates an early-intervention youth services at Camperdown under contract to Headspace. I.B.H. has previously led community-based and pharmaceutical industry-supported (Wyeth, Eli Lily, Servier, Pfizer, AstraZeneca) projects focused on the identification and better management of anxiety and depression. He is a Board Member of Psychosis Australia Trust and a member of Veterans Mental Health Clinical Reference group. He was a member of the Medical Advisory Panel for Medibank Private until October 2017. He is the Chief Scientific Advisor to, and an equity shareholder in, InnoWell. InnoWell has been formed by the University of Sydney and PricewaterhouseCoopers to administer the $30 M Australian Government Funded Project Synergy. Project Synergy is a 3-year programme for the transformation of mental health services through the use of innovative technologies.

Suicidal ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: a meta-analysis

AIMS

Several authors claimed that expression of suicidal ideation is one of the most important predictors of completed suicide. However, the strength of the association between suicidal ideation and subsequent completed suicide has not been firmly established in different populations. Furthermore, the absolute suicide risk after expression of suicidal ideation is unknown. In this meta-analysis, we examined whether the expression of suicidal ideation predicted subsequent completed suicide in various populations, including both psychiatric and non-psychiatric populations.

METHODS

A meta-analysis of cohort and case-control studies that assessed suicidal ideation as determinant for completed suicide in adults. Two independent reviewers screened 5726 articles for eligibility and extracted data of the 81 included studies. Pooled risk ratios were estimated in a random effects model stratified for different populations. Meta-regression analysis was used to determine suicide risk during the first year of follow-up.

RESULTS

The risk for completed suicide was clearly higher in people who had expressed suicidal ideation compared with people who had not, with substantial variation between the different populations: risk ratio ranging from 2.35 (95% confidence interval (CI) 1.43-3.87) in affective disorder populations to 8.00 (95% CI 5.46-11.7) in non-psychiatric populations. In contrast, the suicide risk after expression of suicidal ideation in the first year of follow-up was higher in psychiatric patients (risk 1.40%, 95% CI 0.74-2.64) than in non-psychiatric participants (risk 0.23%, 95% CI 0.10-0.54). Past suicide attempt-adjusted risk ratios were not pooled due to large underreporting.

CONCLUSIONS

Assessment of suicidal ideation is of priority in psychiatric patients. Expression of suicidal ideation in psychiatric patients should prompt secondary prevention strategies to reduce their substantial increased risk of suicide.

Demographic, Clinical, and Service Utilization Factors Associated with Suicide-Related Visits among Alaska Native and American Indian Adults

Alaska Native and American Indian people (AN/AIs) are disproportionately affected by suicide. Within a large AN/AI health service organization, demographic, clinical, and service utilization factors were compared between those with a suicide-related health visit and those without. Cases had higher odds of a behavioral health diagnosis, treatment for an injury, behavioral health specialty care visits, and opioid medication dispensation in the year prior to a suicide-related visit compared to gender-, age-, and residence- (urban versus rural) matched controls. Odds of a suicide-related visit were lower among those with private insurance and those with non-primary care ambulatory clinic visits.

“They Might Think I Was Crazy”: Young American Indians’ Reasons for Not Seeking Help When Suicidal

It is well known that many suicidal young people avoid asking for help; however, the reasons why are less understood. A sample of 101 American Indians (age 15-21 years) who had thought about or attempted suicide was asked open-ended questions about barriers to seeking formal and informal help while suicidal. The 74 participants who avoided at least one type of help most commonly reported internal factors, such as embarrassment, lack of problem recognition, a belief that nobody could help, and self-reliance. Structural barriers, such as lack of money or service availability, were only rarely cited. Findings indicate that efforts to increase help seeking among young, suicidal American Indians should target beliefs about emotional problems and help seeking.

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.

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

BACKGROUND

The aim was to study whether number of visits to emergency department (ED) is associated with suicide, taking into consideration known risk factors.

METHODS

This is a population-based case-control study nested in a cohort. Computerized database on attendees to ED (during 2002-2008) was record linked to nation-wide death registry to identify 152 cases, and randomly selected 1520 controls. The study was confined to patients attending the ED, who were subsequently discharged, and not admitted to hospital ward. Odds ratio (OR) and 95% confidence intervals (CI) of suicide risk according to number of visits (logistic regression) adjusted for age, gender, mental and behavioral disorders, non-causative diagnosis, and drug poisonings.

RESULTS

Suicide cases had on average attended the ED four times, while controls attended twice. The OR for attendance due to mental and behavioral disorders was 3.08 (95% CI 1.61-5.88), 1.60 (95% CI 1.06-2.43) for non-causative diagnosis, and 5.08 (95% CI 1.69-15.25) for poisoning. The ORs increased gradually with increasing number of visits. Adjusted for age, gender, and the above mentioned diagnoses, the OR for three attendances was 2.17, for five attendances 2.60, for seven attendances 5.97, and for nine attendances 12.18 compared with those who had one visit.

CONCLUSIONS

Number of visits to the ED is an independent risk factor for suicide adjusted for other known and important risk factors. The prevalence of four or more visits was 40% among cases compared with 10% among controls. This new risk factor may open new venues for suicide prevention.

Correlates of Alaska Native fatal and nonfatal suicidal behaviors 1990-2001

Factors correlated with suicidal behavior in a predominately Alaska Native region of Alaska are described, and the correlates relating to fatal and nonfatal suicide behaviors in this indigenous population are distinguished. Suicide data from the region (1990-2001) were aggregated and compared to 2000 U.S. Census Data using chi-squared tests. Multivariable logistic regression was used to identify predictors of suicide behaviors. Suicidal behaviors were significantly more common among single, unemployed Alaska Natives who had not completed high school. In multivariable analysis, male sex, age > or = 25 years, firearms, and substance abuse history were each associated with suicide death.

Racial and ethnic differences in the mental health problems and use of mental health care

OBJECTIVES

We compared rates of mental health problems and use of mental health care across multiple racial and ethnic groups using secondary data from a large, nationally representative survey.

METHODS

We pooled cross-sectional data from the 2001-2003 National Surveys on Drug Use and Health. Our sample included 134,875 adults classified as white, African American, American Indian/Alaskan Native, Asian, Mexican, Central and South American, Puerto Rican, other Hispanic-Latino, or those with multiple race and ethnicities. For each group, we estimate the past year probability of: (1) having 1 or more mental health symptoms in the past year, (2) having serious mental illness in the past year, (3) using mental health care, (4) using mental health care conditional on having mental health problems, (5) reporting unmet need for mental health care, and (6) reporting unmet need for mental health care conditional on having mental health problems.

RESULTS

We found significantly higher rates of mental health problems and higher self-reported unmet need relative to whites among American Indian/Alaskan Natives and lower rates of mental health problems and use of mental health care among African American, Asian, Mexican, Central and South American, and other Hispanic-Latino groups. These differences generally were robust to the inclusion of clinical and socio demographic covariates.

CONCLUSIONS

Overall, our study shows wide variation in mental health morbidity and use of mental health care across racial and ethnic groups in the United States. These results can help to focus efforts aimed at understanding the underlying causes of the differences we observe.

Strengthening the prevention and care of injuries worldwide

The global burden of injuries is enormous, but has often been overlooked in attempts to improve health. We review measures that would strengthen existing efforts to prevent and treat injuries worldwide. Scientifically-based efforts to understand risk factors for the occurrence of injury are needed and they must be translated into prevention programmes that are well designed and assessed. Areas for potential intervention include environmental modification, improved engineering features of motor vehicle and other products, and promotion of safe behaviours through social marketing, legislation, and law enforcement. Treatment efforts need to better define the most high-yield services and to promote these in the form of essential health services. To achieve these changes, there is a need to strengthen the capacity of national institutions to do research on injury control; to design and implement countermeasures that address injury risk factors and deficiencies in injury treatment; and to assess the effectiveness of such countermeasures. Although much work remains to be done in high-income countries, even greater attention is needed in less-developed countries, where injury rates are higher, few injury control activities have been undertaken, and where most of the world's population lives. In almost all areas, injury rates are especially high in the most vulnerable sections of the community, including those of low socioeconomic status. Injury control activities should, therefore, be undertaken in a context of attention to human rights and other broad social issues.

Suicidal ideation and suicide attempts as predictors of mental health service use

OBJECTIVE

To examine the extent to which suicidal ideation and suicide attempts are predictive of service use.

DESIGN AND SETTING

The National Survey of Mental Health and Wellbeing considered service utilisation in relation to self-reported mental health problems. Service utilisation was inquired of in relation to hospital-based care (including both specialist mental health and general care settings), as well as consultations with a range of health professionals (both specialist and non-specialist mental health professionals, including psychiatrists, psychologists and general practitioners) on an outpatient basis.

PARTICIPANTS

Secondary analysis of self-report data from 10,641 randomly selected Australian adults who participated in the National Survey of Mental Health and Wellbeing in 1997. The key predictor variables were reported suicidal ideation and suicide attempts over the past 12 months.

MAIN OUTCOME MEASURES

Use of services for mental health problems (past 12 months).

RESULTS

When considered in isolation, individuals reporting suicidal ideation were more likely to make use of at least one type of service for mental health problems than non-suicidal individuals (OR, 17.3; 95% CI, 13.2-22.6), and individuals reporting suicide attempts were even more likely to do so (OR, 32.3; 95% CI, 9.0-115.4). In the case of suicidal ideation, this effect remained significant after controlling for a range of potential confounders. For suicide attempts, the effect of mental health service use was no longer significant after other variables were taken into account.

CONCLUSIONS

Suicidal individuals are likely to make use of services, and a high proportion of suicides may be preventable through appropriate healthcare system responses.

Suicide and recency of health care contacts. A systematic review

BACKGROUND

Many countries have set targets for suicide reduction, and suggested that mental health care providers and general practitioners have a key role to play.

METHOD

A systematic review of the literature.

RESULTS

Among those in the general population who commit suicide, up to 41% may have contact with psychiatric inpatient care in the year prior to death and up to 9% may commit suicide within one day of discharge. The corresponding figures are 11 and 4% for community-based psychiatric care and 83 and 20% for general practitioners.

CONCLUSIONS

Among those who die by suicide, contact with health services is common before death. This is a necessary but not sufficient condition for clinicians to intervene. More work is needed to determine whether these people show characteristic patterns of care and/or particular risk factors which would enable a targeted approach to be developed to assist clinicians in detecting and managing high-risk patients.

Health-related quality of life for rural American Indians in New Mexico

OBJECTIVES

To determine health-related quality of life for rural American Indians using an economical telephone surveillance system.

DESIGN

We interviewed 618 American Indians by telephone about health-related quality of life using an adaptation of the Behavioral Risk Factor Surveillance System questionnaire.

RESULTS

A smaller proportion of rural New Mexico American Indians (50.7%) reported their general health as 'excellent' or 'very good' compared to the overall New Mexico (58.2%) and US populations (57.9%). American Indians reported a mental health limitation more frequently than the New Mexico and the US populations. However, 13% fewer rural New Mexico American Indians reported a limitation in usual activities. Most limitations were due to musculoskeletal conditions or diabetes mellitus. Survey respondents were found to be representative of the rural American Indian population as reported by the 1990 US Census Bureau by tribal group affiliation and age, but were not representative by income, education, and gender.

CONCLUSIONS

Health-related quality of life for rural American Indians differs little from that of other New Mexicans and the general US population; however, when physical and mental health was rated as poor, fewer American Indians reported a limitation in usual activities. A telephone survey focusing on New Mexico American Indians is an efficient method by which to conduct surveillance of health-related quality of life.