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.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Preventive MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Health, United States, 2016: With Chartbook on Long-Term Trends in Health.National Center for Health Statistics, Hyattsville, MD2017
- Increase in suicide in the United States, 1999–2014.NCHS Data Brief. 2016; 241: 1-8
CDC, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). www.cdc.gov/ncipc/wisqars. Accessed October 1, 2017.
- 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action.2012 (Washington, DC; 2012)
- Preventing Suicide: A Technical Package of Policies, Programs, and Practices.National Center for Injury Prevention and Control, CDC, Atlanta, GA2017
- Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the U.S. Air Force: cohort study.BMJ. 2003; 327: 1376
- Suicide prevention strategies revisited: 10-year systematic review.Lancet Psychiatry. 2016; 3: 646-659
- Suicide prevention strategies: a systematic review.JAMA. 2005; 294: 2064-2074
- Emergency department contact prior to suicide in mental health patients.Emerg Med J. 2011; 28: 467-471
- Health care contacts in the year before suicide death.J Gen Intern Med. 2014; 29: 870-877
- Attendance at the accident and emergency department in the year before suicide: retrospective study.Br J Psychiatry. 2003; 183: 28-33
- Substance Abuse and Suicide Prevention: Evidence and Implications—A White Paper.Substance Abuse and Mental Health Services Administration, Rockville, MD2008 (DHHS Pub. No. SMA-08-4352)
- Factors that influence emergency department doctors’ assessment of suicide risk in deliberate self-harm patients.Eur J Emerg Med. 2003; 10: 283-287
- Adolescent suicide risk screening in the emergency department.Acad Emerg Med. 2009; 16: 1234-1241
- Non-psychiatric inpatient care preceding admission for self-harm in young people.J Psychosom Res. 2016; 88: 8-13
- Number of visits to the emergency department and risk of suicide: a population- based case-control study.BMC Public Health. 2015; 15: 227
- Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients.Arch Gen Psychiatry. 1988; 45: 581-588
- Current perspective on the role of psychological factors in adolescent suicide.Psychiatr Ann. 1990; 20: 122-127
- Adolescent suicide: endpoint of long-term difficulties.J Am Acad Child Adolesc Psychiatry. 1992; 31: 649-654
- Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 1.0.CDC, National Center for Injury Prevention and Control, Atlanta, GA2011
- Adolescent suicide and suicidal behavior.J Child Psychol Psychiatry. 2006; 47: 372-394
- Longitudinal association between self-injurious thoughts and behaviors and suicidal behavior in adolescents and young adults: a systematic review with meta-analysis.J Affect Disord. 2017; 215: 37-48
- Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital.Br J Psychiatry. 2003; 182: 537-542
- Suicide following self-harm: findings from the Multicentre Study of self-harm in England, 2000–2012.J Affect Disord. 2015; 175: 147-151
- Suicide attempt in young people: a signal for long-term health care and social needs.JAMA Psychiatry. 2014; 71: 119-127
- Mental illness and suicide after self-harm among young adults: long-term follow-up of self-harm patients, admitted to hospital care, in a national cohort.Psychol Med. 2016; 46: 3397-3405
- Global burden of diseases, injuries, and risk factors for young people's health during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2016; 387: 2383-2401
- Trends in U.S. emergency department visits for attempted suicide and self-inflicted injury, 1993–2008.Gen Hosp Psychiatry. 2012; 34: 557-565
- Healthcare Cost and Utilization Project (HCUP).Agency for Healthcare Research and Quality, Rockville, MD2017
- Healthcare Cost and Utilization Project (HCUP).Agency for Healthcare Research and Quality, Rockville, MD2017
- Identification of hospitalizations for intentional self-harm when E-codes are incompletely recorded.Pharmacoepidemiol Drug Saf. 2010; 19: 1263-1275
- Tutorial: survival estimation for Cox regression models with time-varying coefficients using SAS and R.J Stat Softw. 2014; 61 (Code Snippet 1.)
- Model building in Proc PHREG with automatic variable selection and information criteria.SAS Users Global Forum. 2005; (Paper 206-30)
- Predictive modeling and concentration of the risk of suicide: implications for preventive interventions in the U.S. Department of Veterans Affairs.Am J Public Health. 2015; 105: 1935-1942
- Predicting suicides after psychiatric hospitalization in U.S. Army soldiers: the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).JAMA Psychiatry. 2015; 72: 49-57
- Suicide in people with epilepsy: how great is the risk.Epilepsia. 2009; 50: 1933-1942
- Epilepsy and risk of suicide: a population-based case-control study.Lancet Neurol. 2007; 6: 693-698
- Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors.American Psychiatric Association, Arlington, VA2003
- Prognostic significance of functional somatic symptoms in adolescence: a 15-year community-based follow-up study of adolescents with depression compared with healthy peers.BMC Psychiatry. 2012; 12: 90
- Migraine suicidal ideation, and suicide attempts.Neurology. 1992; 42: 392
- The impact of physical pain on suicidal thoughts and behaviors: meta-analyses.J Psychiatr Res. 2015; 71: 16-32
- The association of self-injurious behaviour and suicide attempts with recurrent idiopathic pain in adolescents: evidence from a population-based study.Child Adolesc Psychiatry Ment Health. 2015; 9: 32
- Low back pain: risk factors for suicide should be elicited.BMJ. 2006; 333: 201
- Suicidality in chronic abdominal pain: an analysis of the Hispanic Health and Nutrition Examination Survey (HHANES).Pain. 1998; 76: 137-144
- Back pain and risk of suicide among Finnish farmers.Am J Public Health. 1995; 85: 1452-1453
- Risk factors for suicidal thoughts in adolescence-a prospective cohort study: the Young-HUNT study.BMJ Open. 2014; 4e005867
- Chronic pain in adolescents is associated with suicidal thoughts and behaviors.J Pain. 2011; 12: 1032-1039
- The association between pain and suicidal behavior in an English national sample: the role of psychopathology.J Psychiatr Res. 2018; 98: 39-46
- Chronic pain and suicide: understanding the association.Curr Pain Headache Rep. 2014; 18: 435
- Chronic pain in the emergency department: a pilot mixed-methods cross-sectional study examining patient characteristics and reasons for presentations.Pain Res Manag. 2016; 20163092391
- Dental complaints in emergency departments: a national perspective.Ann Emerg Med. 2015; 42: 93-99
- Visits to U.S. emergency departments by 20 to 29 year-olds with chief complaint of toothache during 2001–2010.J Am Dent Assoc. 2015; 146: 295-302
- The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic non-cancer pain: the role of opioid prescription.Clin J Pain. 2014; 30: 557-564
- CDC guideline for prescribing opioids for chronic pain—United States, 2016.MMWR Recomm Rep. 2016; 65: 1-49
- Incidence of suicidal ideation and behavior in the United States, 1994.Suicide Life Threat Behav. 1999; 29: 140
- Care of Adults With Mental Health and Substance Abuse Disorders in U.S. Community Hospitals, 2004.Agency for Healthcare Research and Quality, Rockville, MD2007
Article Info
Publication History
Published online: December 17, 2018
Identification
Copyright
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine.
