Syndromic Surveillance of Suicidal Ideation and Self-Directed Violence - United States, January 2017-December 2018

Sexual and Gender Minority Status and Suicide Mortality: An Explainable Artificial Intelligence Analysis

Objectives: Suicide risk is elevated in lesbian, gay, bisexual, and transgender (LGBT) individuals. Limited data on LGBT status in healthcare systems hinder our understanding of this risk. This study used natural language processing to extract LGBT status and a deep neural network (DNN) to examine suicidal death risk factors among US Veterans. Methods: Data on 8.8 million veterans with visits between 2010 and 2017 was used. A case-control study was performed, and suicide death risk was analyzed by a DNN. Feature impacts and interactions on the outcome were evaluated. Results: The crude suicide mortality rate was higher in LGBT patients. However, after adjusting for over 200 risk and protective factors, known LGBT status was associated with reduced risk compared to LGBT-Unknown status. Among LGBT patients, black, female, married, and older Veterans have a higher risk, while Veterans of various religions have a lower risk. Conclusion: Our results suggest that disclosed LGBT status is not directly associated with an increase suicide death risk, however, other factors (e.g., depression and anxiety caused by stigma) are associated with suicide death risks.

Cognitive behavioral therapy following esketamine for major depression and suicidal ideation for relapse prevention: The CBT-ENDURE randomized clinical trial study protocol

In 2020, esketamine received a supplemental indication as a therapy for major depression with suicidal ideation (MDSI), based on protocols enrolling hospitalized patients. Given the high risk of suicide following hospital discharge and the high relapse rates following discontinuation of esketamine, the optimal long-term treatment approach remains unclear. Cognitive behavioral therapy (CBT) is highly effective in relapse prevention and has been shown to prevent suicide attempts in high-risk populations. Here we describe the study protocol for the CBT-ENDURE trial: Cognitive Behavioral Therapy Following Esketamine for Major Depression and SUicidal Ideation for RElapse Prevention. Patients with depression (N = 100) who are admitted to hospital or are outpatients with clinically significant suicidal ideation will be enrolled in the study. All patients will receive esketamine (twice weekly for four weeks) and will be randomly assigned (1:1 ratio) to receive a 16-week course of CBT plus treatment as usual (CBT group) or treatment as usual only (TAU only group). Patients are followed for a total of 6 months. Supported under a funding announcement from NIMH to conduct safety and feasibility trials for patients at high risk for suicide, the primary outcome of the CBT-ENDURE study is feasibility (as measured by recruitment and retention), with a key secondary outcome being relapse among those who experience substantial benefit following two weeks of esketamine.

Trends and Seasonality of Emergency Department Visits and Hospitalizations for Suicidality Among Children and Adolescents in the US from 2016 to 2021

Importance

The detection of seasonal patterns in suicidality should be of interest to clinicians and US public health officials, as intervention efforts can benefit by targeting periods of heightened risk.

Objectives

To examine recent trends in suicidality rates, quantify the seasonality in suicidality, and demonstrate the disrupted seasonality patterns during the spring 2020 COVID-19-related school closures among US children and adolescents.

Design, Setting, and Participants

This population-based, descriptive cross-sectional study used administrative claims data from Optum's deidentifed Clinformatics Data Mart Database. Participants included children aged 10 to 12 years and adolescents aged 13 to 18 years who were commercially insured from January 1, 2016, to December 31, 2021. Statistical analysis was conducted between April and November 2022.

Exposures

Month of the year and COVID-19 pandemic.

Main Outcomes and Measures

Rates and seasonal patterns of emergency department (ED) visits and hospitalizations for suicidality.

Results

The analysis included 73 123 ED visits and hospitalizations for suicidality reported between 2016 and 2021. Among these events, 66.1% were reported for females, and the mean (SD) age at the time of the event was 15.4 (2.0) years. The mean annual incidence of ED visits and hospitalizations for suicidality was 964 per 100 000 children and adolescents (95% CI, 956-972 per 100 000), which increased from 760 per 100 000 (95% CI, 745-775 per 100 000) in 2016 to 1006 per 100 000 (95% CI, 988-10 024 per 100 000) in 2019, with a temporary decrease to 942 per 100 000 (95% CI, 924-960 per 100 000) in 2020 and a subsequent increase to 1160 per 100 000 (95% CI, 1140-1181 per 100 000) in 2021. Compared with January, seasonal patterns showed peaks in April (incidence rate ratio [IRR], 1.15 [95% CI, 1.11-1.19]) and October (IRR, 1.24 [95% CI, 1.19-1.29]) and a nadir in July (IRR, 0.63 [95% CI, 0.61-0.66]) during pre-COVID-19 years and 2021. However, during the spring of 2020, which coincided with school closures, seasonal patterns were disrupted and April and May exhibited the lowest rates.

Conclusions and Relevance

The findings of this study indicated the presence of seasonal patterns and an observed unexpected decrease in suicidality among children and adolescents after COVID-19-related school closures in March 2020, which suggest a potential association between suicidality and the school calendar.

Views on increased federal access to state and local National Syndromic Surveillance Program data: a nominal group technique study with state and local epidemiologists

BACKGROUND

US public health authorities use syndromic surveillance to monitor and detect public health threats, conditions, and trends in near real-time. Nearly all US jurisdictions that conduct syndromic surveillance send their data to the National Syndromic Surveillance Program (NSSP), operated by the US. Centers for Disease Control and Prevention. However, current data sharing agreements limit federal access to state and local NSSP data to only multi-state regional aggregations. This limitation was a significant challenge for the national response to COVID-19. This study seeks to understand state and local epidemiologists' views on increased federal access to state NSSP data and identify policy opportunities for public health data modernization.

METHODS

In September 2021, we used a virtual, modified nominal group technique with twenty regionally diverse epidemiologists in leadership positions and three individuals representing national public health organizations. Participants individually generated ideas on benefits, concerns, and policy opportunities relating to increased federal access to state and local NSSP data. In small groups, participants clarified and grouped the ideas into broader themes with the assistance of the research team. An web-based survey was used to evaluate and rank the themes using five-point Likert importance questions, top-3 ranking questions, and open-ended response questions.

RESULTS

Participants identified five benefit themes for increased federal access to jurisdictional NSSP data, with the most important being improved cross-jurisdiction collaboration (mean Likert = 4.53) and surveillance practice (4.07). Participants identified nine concern themes, with the most important concerns being federal actors using jurisdictional data without notice (4.60) and misinterpretation of data (4.53). Participants identified eleven policy opportunities, with the most important being involving state and local partners in analysis (4.93) and developing communication protocols (4.53).

CONCLUSION

These findings identify barriers and opportunities to federal-state-local collaboration critical to current data modernization efforts. Syndromic surveillance considerations warrant data-sharing caution. However, identified policy opportunities share congruence with existing legal agreements, suggesting that syndromic partners are closer to agreement than they might realize. Moreover, several policy opportunities (i.e., including state and local partners in data analysis and developing communication protocols) received consensus support and provide a promising path forward.

The role of mental health and substance use disorders on the relation of migraine with self-directed violence among women in the United States

OBJECTIVES

Migraine disproportionately affects women of reproductive age, and is associated with self-directed violence (SDV) which confers substantial risk for suicides. Mental health disorders (MHD) and substance use disorders (SUD) are higher among persons with migraines. However, there's limited information on the influence of these conditions on SDV among women. We evaluated the interplay of MHD and SUD on the relation of migraine with SDV among US women.

METHODS

We analyzed data from 96 million hospitalizations among women aged 15-49 years from the National Inpatient Sample (2004-2015). International Classification of Disease codes were used to identify hospitalizations for migraine and other health conditions. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

From 2004 to 2015 the prevalence (per 1000 hospitalizations) of migraine increased from 17.5 to 33.5, while SDV prevalence also increased from 10.5 to 38.9. A greater proportion of women hospitalized with migraine had epilepsy, suicidal ideations, SUD and MHD than women without migraine. In models adjusted for demographic and behavioral/lifestyle factors, menstrual disorders, pregnancy, health conditions and violent assault, hospitalization with migraine was positively associated with SDV (OR = 1.15, CI: 1.12-1.18). Women with migraine and either SUD (OR = 5.17, CI: 4.46-5.97) or MHD (OR = 14.13; CI: 12.1-16.47) had elevated odds of SDV, with the odds varying by type of MHD and SUD.

CONCLUSIONS

A significant relation between hospitalization with migraine and SDV was observed especially among reproductive-age women with SUD and MHD. Clinicians should consider monitoring women with these characteristics for suicide risk.

Prevalence of suicide ideation, self-harm, and suicide among Chinese patients with schizophrenia: a systematic review and meta-analysis

Aims

Suicide ideation, self-harm, and suicide are common in patients with schizophrenia, but the reported prevalence vary largely across studies. Improved prevalence estimates and identification of moderators of the above self-directed violence are needed to enhance recognition and care, and to guide future management and research. This systematic review aims to estimate the pooled prevalence and identify moderators of suicide ideation, self-harm, and suicide among patients diagnosed with schizophrenia in China.

Methods

Relevant articles published until September 23, 2021, were searched using PubMed, EBSCO, Web of Science, Embase, Science Direct, CNKI, CBM, VIP, and Wanfang databases. Eligible studies published in English or Chinese which reported the prevalence of suicide ideation, self-harm, or suicide among Chinese patients with schizophrenia were collected. All studies passed a quality evaluation. This systematic review was registered with PROSPERO (registration number CRD42020222338). PRISMA guidelines were used in extracting and reporting data. Random-effects meta-analyses were generated using the meta package in R.

Results

A total of 40 studies were identified, 20 of which were evaluated as high-quality studies. Based on these studies, the prevalence of lifetime suicide ideation was 19.22% (95% CI: 7.57-34.50%), prevalence of suicide ideation at the time of investigation was 18.06% (95% CI: 6.49-33.67%), prevalence of lifetime self-harm was 15.77% (95% CI: 12.51-19.33%), and prevalence of suicide was 1.49% (95% CI: 0.00-7.95%). Multivariate meta-regression analysis revealed that age (β = - 0.1517, p = 0.0006) and dependency ratio (β = 0.0113, p < 0.0001) were associated with the lifetime prevalence of self-harm. Study assessment score (β = 0.2668, p < 0.0001) and dependency ratio (β = 0.0050, p = 0.0145) were associated with the lifetime prevalence of suicide ideation. Results of the spatial analysis showed that the prevalence of self-directed violence varied greatly across different provinces.

Conclusion

This systematic review provides estimates of the prevalence of self-directed violence among Chinese patients with schizophrenia and explores its moderators and spatial patterns. Findings also have important implications for allocating prevention and intervention resources to targeted high-risk populations in high prevalence areas.

Association between clinically recognized suicidality and subsequent initiation or continuation of medications for opioid use disorder

BACKGROUND

Among individuals with opioid use disorder (OUD), medications for OUD (MOUD) may lower suicide risk. Therefore, it is important that individuals with OUD and suicidality receive MOUD. This study examined associations between clinically recognized suicidality and subsequent initiation or continuation of MOUD among patients with OUD in the national Veterans Health Administration (VA).

METHODS

Electronic health record data were extracted for outpatients with OUD who received VA care 10/1/2016-7/31/2017. Suicidality was measured using diagnostic codes for suicidal ideation/attempt and patient record flags. Analyses were conducted separately among patients without prior-year MOUD receipt to examine MOUD initiation, and with prior-year MOUD receipt to examine MOUD continuation. Poisson regression models estimated likelihood of MOUD receipt in the following year for patients with prior-year suicidality relative to those without. Models were adjusted for sociodemographic and clinical characteristics.

RESULTS

Among 20,085 patients with no prior-year MOUD, 12% had suicidality and 12% received MOUD in the following year. Suicidality was positively associated with MOUD initiation (adjusted incidence rate ratio [aIRR]: 1.15, 95% confidence interval [CI]: 1.04-1.28). Among 10,162 patients with prior-year MOUD, 9% had suicidality and 84% received MOUD in the following year. Suicidality was negatively associated with MOUD continuation (aIRR: 0.95, 95% CI 0.91-0.98).

CONCLUSIONS

Among VA patients with OUD, clinically recognized suicidality may increase likelihood of MOUD initiation but decrease likelihood of continuation. Efforts to increase initiation overall and to support retention for patients with suicidality are needed.

Design, development, and evaluation of a surveillance system for suicidal behaviors in Iran

BACKGROUND

Suicide is a serious cause of morbidity and mortality in Iran and worldwide. Although several organizations gather information on suicide and suicide attempts, there is substantial misperception regarding the description of the phenomenon. This study proposes the minimum data set (MDS) for suicidal behaviors surveillance.

METHODS

A literature review was first conducted to achieve a thorough overview of suicide-related items and map the existing evidence supporting the development of the MDS. The data items included in the literature review were then analyzed using a two-round Delphi technique with content validation by an expert panel. The suicidal behaviors surveillance system was then established based on the confirmed MDS, and ultimately, its performance was assessed by involving the end-users.

RESULTS

The panel of experts consisted of 50 experts who participated in the Delphi phase and validity content review. Of these, 46% were men, and their mean age and average work experience were (36.4, SD ± 6.4) and (12.32, SD ± 5.2) years, respectively. The final MDS platform of our study contained 108 items classified into eight main categories. A web-based system with a modular and layered architecture was developed based on the derived MDS.

CONCLUSION

The developed system provides a framework for recording suicidal behaviors' data. The integration of multiple suicide-related information systems at the regional and national levels makes it possible to assess the long-term outcomes and evolutions of suicide prevention interventions.

The Psychoanalytic Study of Suicide, Part I: An Integration of Contemporary Theory and Research

Psychodynamic psychotherapy has an important role in suicide prevention. The psychoanalytic study of suicide has taught us a great deal about the human experience and the process of suicidality. There is also much to be learned from other fields of study and from empirical research that can be integrated into psychoanalytic therapies. Central to the psychoanalytic approach to suicide has been understanding the patient's internal subjective experience of unbearable emotional or psychic pain and the urgent need for relief. Emotional pain can include intense affects such as shame, humiliation, self-hate, and rage. Factors that can increase vulnerability to suicidal states include problems with early attunement, dissociation and deficits in bodily love and protection, conscious and unconscious fantasy, and certain character traits and dynamics. Empirical research has confirmed many basic psychoanalytic concepts about suicide, including escape from unbearable pain as the primary driver of suicidal behavior, the role of dissociation in increasing risk of bodily attack, and the importance of unconscious processes. Further research into implicit processes and their role in the suicidal process holds potential to improve suicide risk assessment and to enhance psychotherapy by bringing otherwise inaccessible material into the treatment.

Predicting Sex-Specific Nonfatal Suicide Attempt Risk Using Machine Learning and Data From Danish National Registries

Suicide attempts are a leading cause of injury globally. Accurate prediction of suicide attempts might offer opportunities for prevention. This case-cohort study used machine learning to examine sex-specific risk profiles for suicide attempts in Danish nationwide registry data. Cases were all persons who made a nonfatal suicide attempt between 1995 and 2015 (n = 22,974); the subcohort was a 5% random sample of the population at risk on January 1, 1995 (n = 265,183). We developed sex-stratified classification trees and random forests using 1,458 predictors, including demographic factors, family histories, psychiatric and physical health diagnoses, surgery, and prescribed medications. We found that substance use disorders/treatment, prescribed psychiatric medications, previous poisoning diagnoses, and stress disorders were important factors for predicting suicide attempts among men and women. Individuals in the top 5% of predicted risk accounted for 44.7% of all suicide attempts among men and 43.2% of all attempts among women. Our findings illuminate novel risk factors and interactions that are most predictive of nonfatal suicide attempts, while consistency between our findings and previous work in this area adds to the call to move machine learning suicide research toward the examination of high-risk subpopulations.

Incidence of suicide mortality among childhood cancer survivors: A population-based retrospective study

The aim of our study was to investigate the suicide rates among childhood cancer survivors and assess factors associated with higher suicide risk. A review of data from Surveillance, Epidemiology, and End Results (SEER) program from 1975 to 2016 was performed for this study. This program is based on the US population and is supported by the US National Cancer Institute (NCI). Survivors diagnosed with childhood cancer were recorded. There were 40 suicides among 567,233 person-years, giving a suicide rate of 7.1 per 100,000 person-years. Compared with cancer diagnosed between 10 and 14 years old, survivors with cancer diagnosed between 0 and 4 years old had lower suicide risk. Females had a lower risk of suicide than males. Compared with survivors of thyroid cancer, the aHRs were 0.16 for acute lymphocytic leukemia, 0.15 for nodal Hodgkin's lymphoma, 0.14 for brain cancers and 0.09 for kidney cancers. Most suicides occurred after 15 years old. Suicide was a problem for survivors, especially those with thyroid cancer. Beside treating patients holistically, early psychological interventions such as communicating effectively, providing social support and follow-up care related to psychological health are needed.

Association of Online Risk Factors With Subsequent Youth Suicide-Related Behaviors in the US

IMPORTANCE

The association between online activities and youth suicide is an important issue for parents, clinicians, and policy makers. However, most information exploring potential associations is drawn from survey data and mainly focuses on risk related to overall screen time.

OBJECTIVE

To evaluate the association between a variety of online risk factors and youth suicide-related behavior using real-world online activity data.

DESIGN, SETTING, AND PARTICIPANTS

A matched case-control study was conducted from July 27, 2019, to May 26, 2020, with the sample drawn from more than 2600 US schools participating in an online safety monitoring program via the Bark online safety tool. For 227 youths having a severe suicide/self-harm alert requiring notification of school administrators, cases were matched 1:5 to 1135 controls on location, the amount of follow-up time, and general volume of online activity.

EXPOSURES

Eight potential online risk factors (cyberbullying, violence, drug-related, hate speech, profanity, sexual content, depression, and low-severity self-harm) through assessment of text, image, and video data.

MAIN OUTCOMES AND MEASURES

Severe suicide/self-harm alert requiring notification of school administrators; severe suicide alerts are statements by youths indicating imminent or recent suicide attempts and/or self-harm.

RESULTS

The 1362 participants had a mean (SD) age of 13.3 (2.41) years; 699 (51.3%) were male. All 8 online risk factors studied exhibited differences between case and control populations and were significantly associated with subsequent severe suicide/self-harm alerts when examining total direct and indirect pathways. These associations ranged from an adjusted odds ratio (aOR) of 1.17 (95% CI, 1.09-1.26) for drug-related content to an aOR of 1.82 (95% CI, 1.63-2.03) for depression-related content. When considering the total number of different types of online risk factors among the 8 measured, there was an exponentially larger risk of severe suicide/self-harm alerts; youths with 5 or more of the 8 risk factors present in their online activity had a more than 70-fold increased odds of subsequently having a severe suicide/self-harm alert (aOR, 78.64; 95% CI, 34.39-179.84).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that many discrete types of risk factors are identifiable from online data and associated with subsequent youth suicide-related behavior. Although each risk factor carries a specific association with suicide-related behavior, the greatest risk is evident for youths demonstrating multiple types of online risk factors.

Perceptions of Alerts Issued by Social Media Platforms in Response to Self-injury Posts Among Latinx Adolescents: Qualitative Analysis

BACKGROUND

There is growing interest in using social media data to detect and address nonsuicidal self-injury (NSSI) among adolescents. Adolescents often do not seek clinical help for NSSI and may adopt strategies to obscure detection; therefore, social media platforms may be able to facilitate early detection and treatment by using machine learning models to screen posts for harmful content and subsequently alert adults. However, such efforts have raised privacy and ethical concerns among health researchers. Little is currently known about how adolescents perceive these efforts.

OBJECTIVE

The aim of this study is to examine perceptions of automated alerts for NSSI posts on social media among Latinx adolescents, who are at risk for NSSI yet are underrepresented in both NSSI and health informatics research. In addition, we considered their perspectives on preferred recipients of automated alerts.

METHODS

We conducted semistructured, qualitative interviews with 42 Latinx adolescents between the ages of 13 and 17 years who were recruited from a nonprofit organization serving the Latinx community in Milwaukee, Wisconsin. The Latinx population in Milwaukee is largely of Mexican descent. All interviews were conducted between June and July 2019. Transcripts were analyzed using framework analysis to discern their perceptions of automated alerts sent by social media platforms and potential alert recipients.

RESULTS

Participants felt that automated alerts would make adolescents safer and expedite aid before the situation escalated. However, some worried that hyperbolic statements would generate false alerts and instigate conflicts. Interviews revealed strong opinions about ideal alert recipients. Parents were most commonly endorsed, but support was conditional on perceptions that the parent would respond appropriately. Emergency services were judged as safer but inappropriate for situations considered lower risk. Alerts sent to school staff generated the strongest privacy concerns. Altogether, the preferred alert recipients varied by individual adolescents and perceived risks in the situation. None raised ethical concerns about the collection, analysis, or storage of personal information regarding their mental health status.

CONCLUSIONS

Overall, Latinx adolescents expressed broad support for automated alerts for NSSI on social media, which indicates opportunities to address NSSI. However, these efforts should be co-constructed with adolescents to ensure that preferences and needs are met, as well as embedded within broader approaches for addressing structural and cultural barriers to care.

Treating Pediatric and Geriatric Patients at Risk of Suicide in General Emergency Departments: Perspectives From Emergency Department Clinical Leaders

STUDY OBJECTIVE

We explored emergency department clinical leaders' views on providing emergency mental health services to pediatric and geriatric patients with suicidal ideation and suicide attempts.

METHODS

We conducted semistructured interviews with a total of 34 nursing directors, medical directors, and behavioral health managers at 17 general hospital EDs across the United States, using purposive sampling to ensure variation among hospitals. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using Atlas.ti and a directed content analysis approach.

RESULTS

Respondents from across a range of ED types expressed concerns regarding the capacity of their EDs to meet mental health needs of children and older adults. They experienced emotional distress over the increasing number of pediatric patients presenting to EDs with suicidal ideation/suicide attempt and described EDs as inappropriate environments for young patients with suicidal ideation/suicide attempt. Similarly, leaders expressed feeling ill-equipped to diagnose and treat geriatric patients with suicidal ideation/suicide attempt, who often had medical comorbidities that complicated treatment planning. Respondents noted that pediatric and geriatric patients frequently boarded in the ED. Some felt compelled to use creative solutions to provide safe spaces for pediatric and geriatric patients. Respondents voiced frustration over the lack of outpatient and inpatient mental health services for these patients.

CONCLUSION

Clinical leaders in EDs across the nation expressed distress at feeling they were not adequately equipped to meet the needs of pediatric and geriatric patients with suicidal ideation/suicide attempt. Future innovations to provide ED care for children and older adults with suicidal ideation/suicide attempt might include training for ED teams, access to specialist mental health clinicians through telehealth, and adaptations of physical spaces.

Childhood adversity, suicidality, and non-suicidal self-injury among children and adolescents admitted to emergency departments

PURPOSE

This population-based study explored the associations between childhood adversity and admission to emergency departments (EDs) with non-suicidal self-injury (NSSI) and with a suicide attempt.

METHODS

A nationally representative cross-sectional sample of 5-17-year-olds admitted to EDs (N = 143,113,677) from 2006 to 2015 was utilized to assess the associations between childhood adversities, NSSIs, and suicide attempts.

RESULTS

ED admissions with NSSI and admissions with a suicide attempt were associated with greater odds of exposure to individual childhood adversities (aORs: 1.34 to 5.86; aORs: 2.37 to 15.69, respectively). ED admissions with a suicide attempt were associated with greater odds of exposure to childhood adversities that might be perceived as less extreme or harmful (separation or divorce aOR: 15.69) than other adversities (death of a family member aOR: 13.38; history of physical abuse aOR: 9.56) as well as greater odds of exposure to three or more childhood adversities (aOR: 20.98).

CONCLUSION

Early detection of childhood adversities is important for identifying potential risk factors for self-harm. ED admission data can provide population-level surveillance to aid in these efforts and lead to more targeted and effective interventions aimed at reducing the negative effects of toxic stress that can result from exposure to childhood adversities.

Development of a Machine Learning Model Using Multiple, Heterogeneous Data Sources to Estimate Weekly US Suicide Fatalities

Importance

Suicide is a leading cause of death in the US. However, official national statistics on suicide rates are delayed by 1 to 2 years, hampering evidence-based public health planning and decision-making.

Objective

To estimate weekly suicide fatalities in the US in near real time.

Design, Setting, and Participants

This cross-sectional national study used a machine learning pipeline to combine signals from several streams of real-time information to estimate weekly suicide fatalities in the US in near real time. This 2-phase approach first fits optimal machine learning models to each individual data stream and subsequently combines predictions made from each data stream via an artificial neural network. National-level US administrative data on suicide deaths, health services, and economic, meteorological, and online data were variously obtained from 2014 to 2017. Data were analyzed from January 1, 2014, to December 31, 2017.

Exposures

Longitudinal data on suicide-related exposures were obtained from multiple, heterogeneous streams: emergency department visits for suicide ideation and attempts collected via the National Syndromic Surveillance Program (2015-2017); calls to the National Suicide Prevention Lifeline (2014-2017); calls to US poison control centers for intentional self-harm (2014-2017); consumer price index and seasonality-adjusted unemployment rate, hourly earnings, home price index, and 3-month and 10-year yield curves from the Federal Reserve Economic Data (2014-2017); weekly daylight hours (2014-2017); Google and YouTube search trends related to suicide (2014-2017); and public posts on suicide on Reddit (2 314 533 posts), Twitter (9 327 472 tweets; 2015-2017), and Tumblr (1 670 378 posts; 2014-2017).

Main Outcomes and Measures

Weekly estimates of suicide fatalities in the US were obtained through a machine learning pipeline that integrated the above data sources. Estimates were compared statistically with actual fatalities recorded by the National Vital Statistics System.

Results

Combining information from multiple data streams, the machine learning method yielded estimates of weekly suicide deaths with high correlation to actual counts and trends (Pearson correlation, 0.811; P < .001), while estimating annual suicide rates with low error (0.55%).

Conclusions and Relevance

The proposed ensemble machine learning framework reduces the error for annual suicide rate estimation to less than one-tenth of that of current forecasting approaches that use only historical information on suicide deaths. These findings establish a novel approach for tracking suicide fatalities in near real time and provide the potential for an effective public health response such as supporting budgetary decisions or deploying interventions.

An Observational Study of Telemental Care Delivery and the Context for Involuntary Commitment for Mental Health Patients in a Group of Rural Emergency Departments

Background: Rates for all-cause U.S. emergency department (ED) visits to rural critical access hospitals (CAHs) have increased by 50% since 2005. During the same time period, total number of U.S. hospital admissions for a mental health (MH) crisis has increased by 12.2%, with rural counties demonstrating the largest suicide rate increases overall. Introduction: Increasing number of rural patients are reporting need for MH care in the region's four rural EDs. Characteristics of ED telemental health services were evaluated, including MH diagnostic category, voluntary vs. involuntary commitment (IC), forensic vs. nonforensic presentation, ED throughput, disposition, and payor reimbursement. Materials and Methods: Observational 2.5-year program evaluation of telemental health care delivery for children (n = 114) and adults (n = 417) who were evaluated by a rural ED physician and received an MH diagnosis. Participants (N = 531) were treated by a licensed psychiatrist through telemental care delivery from September 2017 to April 2020. Results: Noncommitted ED MH patients (86%; n = 455) were distributed across three major diagnostic groups: (1) depression, anxiety, or other mental illness (35%); (2) substance abuse (33%); or (3) suicide risk (32%), with 47% admitted inpatients (IPs), 47% referred outpatient (OPs), and 6% admitted to CAH. Fourteen percent (n = 76/531) of ED MH patients were subsequently IC, with 67% of those assessed as needing IP care. Forty-nine percent (n = 37) of IC patients presented in police custody. Most common diagnosis for IC patients was suicidal ideation/attempt (χ² [2, N = 452] = 12.884, p = 0.002). Admitted patients experienced significantly longer length of stay than those with OP referral (p = 0.001). Mean total payor reimbursements for ED MH care were significantly lower than actual ED costs (p < 0.001). Discussion: Innovative approaches to telemental care for IC and non-IC patients need to be piloted and comparatively evaluated in rural CAHs. Conclusion: As the gateway to critically needed MH care, rural CAHs and public services pivotal to care access (e.g., law enforcement) need additional resources and support.

Adherence to suicide reporting guidelines by news shared on a social networking platform

Rates of suicide in the United States are at a more than 20-y high. Suicide contagion, or spread of suicide-related thoughts and behaviors through exposure to sensationalized and harmful content is a well-recognized phenomenon. Health authorities have published guidelines for news media reporting on suicide to help prevent contagion; however, uptake of recommendations remains limited. A key barrier to widespread voluntary uptake of suicide-reporting guidelines is that more sensational content is perceived to be more engaging to readers and thus enhances publisher visibility and engagement; however, no empirical information exists on the actual influence of adherence to safe-reporting practices on reader engagement. Hence, we conducted a study to analyze adherence to suicide-reporting guidelines on news shared on social media and to assess how adherence affects reader engagement. Our analysis of Facebook data revealed that harmful elements were prevalent in news articles about suicide shared on social media while the presence of protective elements was generally rare. Contrary to popular perception, closer adherence to safe-reporting practices was associated with a greater likelihood of an article being reshared (adjusted odds ratio [AOR] = 1.19, 95% confidence interval [CI] = 1.10 to 1.27) and receiving positive engagement ("love" reactions) (AOR = 1.20, 95% CI = 1.13 to 1.26). Mean safe-reporting scores were lower in the US than other English-speaking nations and variation existed by publisher characteristics. Our results provide empirical evidence that improved adherence to suicide-reporting guidelines may benefit not only the health of individuals, but also support publisher goals of reach and engagement.

Advancing injury and violence prevention through data science

INTRODUCTION

The volume of new data that is created each year relevant to injury and violence prevention continues to grow. Furthermore, the variety and complexity of the types of useful data has also progressed beyond traditional, structured data. In order to more effectively advance injury research and prevention efforts, the adoption of data science tools, methods, and techniques, such as natural language processing and machine learning, by the field of injury and violence prevention is imperative.

METHOD

The Centers for Disease Control and Prevention's (CDC) National Center for Injury Prevention and Control has conducted numerous data science pilot projects and recently developed a Data Science Strategy. This strategy includes goals on expanding the availability of more timely data systems, improving rapid identification of health threats and responses, increasing access to accurate health information and preventing misinformation, improving data linkages, expanding data visualization efforts, and increasing efficiency of analytic and scientific processes for injury and violence, among others.

RESULTS

To achieve these goals, CDC is expanding its data science capacity in the areas of internal workforce, partnerships, and information technology infrastructure. Practical Application: These efforts will expand the use of data science approaches to improve how CDC and the field address ongoing injury and violence priorities and challenges.