Self-Directed Violence After Medical Emergency Department Visits Among Youth

Published:December 17, 2018DOI:


      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.


      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.


      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).


      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 access
      One-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 to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • National Center for Health Statistics
        Health, United States, 2016: With Chartbook on Long-Term Trends in Health.
        National Center for Health Statistics, Hyattsville, MD2017
        • Curtin SC
        • Warner M
        • Hedegaard H
        Increase in suicide in the United States, 1999–2014.
        NCHS Data Brief. 2016; 241: 1-8
      1. CDC, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Accessed October 1, 2017.

        • HHS, Office of the Surgeon General, National Action Alliance for Suicide Prevention
        2012 National Strategy for Suicide Prevention: Goals and Objectives for Action.
        2012 (Washington, DC; 2012)
        • Stone DM
        • Holland KM
        • Bartholow B
        • Crosby AE
        • Davis S
        • Wilkins N
        Preventing Suicide: A Technical Package of Policies, Programs, and Practices.
        National Center for Injury Prevention and Control, CDC, Atlanta, GA2017
        • Knox KL
        • Litts DA
        • Talcott GW
        • Feig JC
        • Caine ED
        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
        • Zalsman G
        • Hawton K
        • Wasserman D
        • et al.
        Suicide prevention strategies revisited: 10-year systematic review.
        Lancet Psychiatry. 2016; 3: 646-659
        • Mann J
        • Apter A
        • Bertolote J
        Suicide prevention strategies: a systematic review.
        JAMA. 2005; 294: 2064-2074
        • Da Cruz D
        • Pearson A
        • Saini P
        • et al.
        Emergency department contact prior to suicide in mental health patients.
        Emerg Med J. 2011; 28: 467-471
        • Ahmedani BK
        • Simon GE
        • Stewart C
        • et al.
        Health care contacts in the year before suicide death.
        J Gen Intern Med. 2014; 29: 870-877
        • Gairin I
        • House A
        • Owens D
        Attendance at the accident and emergency department in the year before suicide: retrospective study.
        Br J Psychiatry. 2003; 183: 28-33
        • Center for Substance Abuse Treatment
        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)
        • Cooper JB
        • Lawlor MP
        • Hiroeh U
        • Kapur N
        • Appleby L
        Factors that influence emergency department doctors’ assessment of suicide risk in deliberate self-harm patients.
        Eur J Emerg Med. 2003; 10: 283-287
        • King CA
        • O'Mara RM
        • Hayward CN
        • Cunningham RM
        Adolescent suicide risk screening in the emergency department.
        Acad Emerg Med. 2009; 16: 1234-1241
        • Idenfors H
        • Stromsten LM
        • Renberg ES
        Non-psychiatric inpatient care preceding admission for self-harm in young people.
        J Psychosom Res. 2016; 88: 8-13
        • Kvaran RB
        • Gunnarsdottir OS
        • Kristbjornsdottir A
        • Valdimarsdottir UA
        • Rafnsson V
        Number of visits to the emergency department and risk of suicide: a population- based case-control study.
        BMC Public Health. 2015; 15: 227
        • Brent DA
        • Perper JA
        • Goldstein CE
        Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients.
        Arch Gen Psychiatry. 1988; 45: 581-588
        • Husain SA
        Current perspective on the role of psychological factors in adolescent suicide.
        Psychiatr Ann. 1990; 20: 122-127
        • Marttunen MJ
        • Aro HM
        • Lonnqvist JK
        Adolescent suicide: endpoint of long-term difficulties.
        J Am Acad Child Adolesc Psychiatry. 1992; 31: 649-654
        • Crosby AE
        • Ortega L
        • Melanson C
        Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 1.0.
        CDC, National Center for Injury Prevention and Control, Atlanta, GA2011
        • Bridge JA
        • Goldstein TR
        • Brent DA
        Adolescent suicide and suicidal behavior.
        J Child Psychol Psychiatry. 2006; 47: 372-394
        • Castellvi P
        • Lucas-Romero E
        • Miranda-Mendizabal A
        • et al.
        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
        • Hawton K
        • Zahl D
        Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital.
        Br J Psychiatry. 2003; 182: 537-542
        • Hawton K
        • Bergen H
        • Cooper J
        • et al.
        Suicide following self-harm: findings from the Multicentre Study of self-harm in England, 2000–2012.
        J Affect Disord. 2015; 175: 147-151
        • Goldman-Mellor SJ
        • Caspi A
        • Harrington H
        Suicide attempt in young people: a signal for long-term health care and social needs.
        JAMA Psychiatry. 2014; 71: 119-127
        • Beckman K
        • Mittendorfer-Rutz E
        • Lichtenstein P
        • et al.
        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
        • Mokdad AH
        • Forouzanfar MH
        • Daoud F
        • et al.
        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
        • Ting SA
        • Sullivan AF
        • Boudreaux ED
        • Miller I
        • Camargo CA
        Trends in U.S. emergency department visits for attempted suicide and self-inflicted injury, 1993–2008.
        Gen Hosp Psychiatry. 2012; 34: 557-565
        • State Inpatient Database Documentation
        Healthcare Cost and Utilization Project (HCUP).
        Agency for Healthcare Research and Quality, Rockville, MD2017
        • State Emergency Department Database Documentation
        Healthcare Cost and Utilization Project (HCUP).
        Agency for Healthcare Research and Quality, Rockville, MD2017
        • Patrick AR
        • Miller M
        • Barber CW
        • Wang PS
        • Canning CF
        • Schneeweiss S
        Identification of hospitalizations for intentional self-harm when E-codes are incompletely recorded.
        Pharmacoepidemiol Drug Saf. 2010; 19: 1263-1275
        • Thomas L
        • Reyes EM
        Tutorial: survival estimation for Cox regression models with time-varying coefficients using SAS and R.
        J Stat Softw. 2014; 61 (Code Snippet 1.)
        • Shtatland ES
        • Kleinman K
        • Cain EM
        Model building in Proc PHREG with automatic variable selection and information criteria.
        SAS Users Global Forum. 2005; (Paper 206-30)
        • McCarthy JF
        • Bossarte RM
        • Katz IR
        • et al.
        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
        • Kessler RC
        • Warner CH
        • Ivany C
        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
        • Bell GS
        • Gaitatzis A
        • Bell CL
        • Johnson AL
        • Sander JW
        Suicide in people with epilepsy: how great is the risk.
        Epilepsia. 2009; 50: 1933-1942
        • Christensen J
        • Vestergaard M
        • Mortensen PB
        • Sidenius P
        • Agerbo E
        Epilepsy and risk of suicide: a population-based case-control study.
        Lancet Neurol. 2007; 6: 693-698
        • American Psychiatric Association
        Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors.
        American Psychiatric Association, Arlington, VA2003
        • Bohman H
        • Jonsson U
        • Päären A
        • von Knorring L
        • Olsson G
        • von Knorring AL
        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
        • Breslau N
        Migraine suicidal ideation, and suicide attempts.
        Neurology. 1992; 42: 392
        • Calati R
        • Laglaoui Bakhiyi C
        • Artero S
        • Ilgen M
        • Courtet P
        The impact of physical pain on suicidal thoughts and behaviors: meta-analyses.
        J Psychiatr Res. 2015; 71: 16-32
        • Koenig J
        • Oelkers-Ax R
        • Parzer P
        • et al.
        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
        • Linsley KR
        • Martin J
        Low back pain: risk factors for suicide should be elicited.
        BMJ. 2006; 333: 201
        • Magni G
        • Rigatti-Luchini S
        • Fracca F
        • Merskey H
        Suicidality in chronic abdominal pain: an analysis of the Hispanic Health and Nutrition Examination Survey (HHANES).
        Pain. 1998; 76: 137-144
        • Penttinen J
        Back pain and risk of suicide among Finnish farmers.
        Am J Public Health. 1995; 85: 1452-1453
        • Strandheim A
        • Bjerkeset O
        • Gunnell D
        • Bjørnelv S
        • Holmen TL
        • Bentzen N
        Risk factors for suicidal thoughts in adolescence-a prospective cohort study: the Young-HUNT study.
        BMJ Open. 2014; 4e005867
        • Tilburg MA
        • Spence NJ
        • Whitehead WE
        • Bangdiwala S
        • Goldston DB
        Chronic pain in adolescents is associated with suicidal thoughts and behaviors.
        J Pain. 2011; 12: 1032-1039
        • Jacob L
        • Haro JM
        • Koyanagi A
        The association between pain and suicidal behavior in an English national sample: the role of psychopathology.
        J Psychiatr Res. 2018; 98: 39-46
        • Hooley JM
        • Franklin JC
        • Nock MK
        Chronic pain and suicide: understanding the association.
        Curr Pain Headache Rep. 2014; 18: 435
        • Poulin PA
        • Nelli J
        • Tremblay S
        • et al.
        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
        • Lewis C
        • Lynch H
        • Johnston B
        Dental complaints in emergency departments: a national perspective.
        Ann Emerg Med. 2015; 42: 93-99
        • Lewis CW
        • McKinney CM
        • Lee HH
        • Melbye ML
        • Rue TC
        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
        • Edlund MJ
        • Martin BC
        • Russo JE
        • Devries A
        • Braden JB
        • Sullivan MD
        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
        • Dowell D
        • Haegerich TM
        • Chou R
        CDC guideline for prescribing opioids for chronic pain—United States, 2016.
        MMWR Recomm Rep. 2016; 65: 1-49
        • Crosby AE
        • Cheltenham MP
        • Sacks JJ
        Incidence of suicidal ideation and behavior in the United States, 1994.
        Suicide Life Threat Behav. 1999; 29: 140
        • Owens P
        • Myers M
        • Elixhauser A
        • Brach C
        Care of Adults With Mental Health and Substance Abuse Disorders in U.S. Community Hospitals, 2004.
        Agency for Healthcare Research and Quality, Rockville, MD2007