Suicide More Likely Among Self-Harm ED Patients

January 03, 2020
Sidra Goldman-Meller, MPH, PhD

Sidra Goldman-Meller, MPH, PhD

Suicide mortality was significantly more likely among patients who presented in the emergency department with deliberate self-harm, according to new research.

Sidra Goldman-Mellor, MPH, PhD, an associate professor in the Department of Public Health at University of California, Merced, and colleagues sought to learn if there is an association between emergency department presentation and one-year incidence of suicide or other mortality.

The investigators found that, along with an increase in mortality for patients with self-harm, there was also a significant increase in suicide mortality for patients who presented to the emergency department with suicidal ideation, and a slight association among those who presented with any other chief concern.

Implementation of suicide risk screening and intervention is needed in the emergency department, the findings suggest.

Goldman-Mellor and the team of investigators used statewide, all-payer, longitudinally linked emergency department patient records and mortality data from California residents who presented to a California-licensed emergency department at least once from January 2009–December 2011. The patients arrived at the emergency department with either deliberate self-harm, suicidal ideation but not self-harm, or neither.

The primary outcome of the study was suicide within 1 year of the index date. Secondary outcomes included deaths by unintentional injury and other causes.

The investigators were interested in patient demographics including sex and age group, race/ethnicity, and insurance status. Clinical factors of interest to the team included comorbid diagnoses at the index emergency department visit and the method of self-harm injury for those with deliberate self-harm.

There was also a focus on psychiatric diagnoses associated with suicide risk: depression, bipolar disorder, anxiety disorder, psychotic disorder, alcohol-related disorder, and drug-related disorder.

The team calculated crude mortality rates per 100,000 person-years of follow-up for suicide or causes of death the year after the first emergency department visit for self-harm, suicidal ideation, and reference groups.

The study population included 648,646 patients (mean age, 43.8 years; 350,687 women). Among the patients, 83,507 presented with deliberate self-harm (mean age, 35.3 years; 49,120 women), 67,379 presented with suicidal ideation (mean age, 40.4 years; 32,825), and 497,760 were reference patients (mean age, 45.7 years; 268,742 women).

Patients who presented at the emergency department with self-harm or suicidal ideation were more likely to be of non-Hispanic white race/ethnicity (deliberate self-harm: 48,558 patients; suicidal ideation: 38,292 patients; reference 247,087 patients).

The suicide rate the following year for patients who deliberately self-harmed was 693.4 deaths per 100,000 person-years, and the standardized mortality ratio was 56.8 (95% CI, 52.1–61.4). Including patients who presented with deliberate self-harm and died by suicide on their index date, the suicide rate would be 709.2 deaths per 100,000 person-years.  

Among those in the self-harm cohort, men (1011.1 deaths per 100,000 person-years) and patients at least 65 years old (1919.5 deaths per 100,000 person-years) had significantly higher suicide rates than women (473.5 deaths per 100,000 person-years) and patients 10–24 years old (221.3 deaths per 100,000 person-years).

Several comorbid clinical diagnoses—depression, bipolar, anxiety, psychotic, and drug use disorders—were associated with increased risk of suicide in patients with self-harm. Patients with a comorbid diagnosis of bipolar disorder (adjusted RR, 1.45; 95% CI, 1.16–1.81), anxiety disorder (adjusted RR, 1.44; 95% CI, 1.15–1.81), or psychotic disorder (adjusted RR, 1.36; 95% CI, 1.02–1.82) were statistically significantly more likely to die by suicide than those without any of the diagnoses.

For patients in the suicidal ideation group, suicide rate in the year after the initial emergency department visit was 384.5 deaths per 100,000 person-years and the standardized mortality ratio was 31.4 (95% CI, 27.5–35.2).

In the reference group, the suicide rate in the following year of an emergency department visit was 23.4 deaths per 100,00 person-years.

Patients who presented at the emergency department with self-harm or suicidal ideation were more likely to be of non-Hispanic white race/ethnicity (deliberate self-harm: 48,558 patients; suicidal ideation: 38,292 patients; reference 247,087 patients).

Rates of nonsuicide external-cause mortality were disproportionately high for patients with self-harm (SMR, 14.2.; 95% CI, 12.9–15.5), patients with suicidal ideation (SMR, 11.8; 95% CI, 10.6–13.0), and reference patients (SMR, 2.2; 95% CI, 2.0–2.3). Overdoses made up 72% of unintentional deaths in the self-harm group and 61% in the suicidal ideation group.

The findings underscore the need for clinicians to ensure that patients who present at the emergency department receive follow-up mental healthcare, the study authors noted.

Interventions include universal screening, safety planning, and telephone follow-up and support. Public health surveillance of patterns and associations of suicide and mortality among the population could improve healthcare quality and address the parity between mental and physical healthcare, the investigators concluded.

The study, “Association of Suicide and Other Mortality With Emergency Department Presentation,” was published online in JAMA Network Open.
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