Abstract
Objective
The main objective is to identify which patient characteristics have the strongest association with suicide outcomes during the 12-months after the index emergency department (ED) visit.
Methods
Data were analyzed from the first two phases of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE). The ED-SAFE study, a quasi-experimental, interrupted time series design, involved participation from eight general medical EDs across the United States. Participants included adults presenting to the ED with active suicidal ideation or an attempt in the last week. Data collection included baseline interview; 6- and 12-month chart reviews; and 6-, 12-, 24-, 36-, and 52-week telephone follow-up assessments. Regression analyses were conducted.
Results
Among 874 participants, the median age was 37 years (interquartile range 27–47) with 56% female (n=488), 74% white (n=649), and 13% Hispanic (n=113). At baseline, 577 (66%) had suicidal ideation only while 297 (34%) had a suicide attempt in the past week. Data sufficient to determine outcomes were available for 782 (90%). In the 12-months after the index ED visit, 195 (25%) had documentation of at least one suicide attempt or suicide. High school education or less, an ED visit in the preceding 6 months, prior non-suicidal self-injury (NSSI), current alcohol misuse, and intent or plan were predictive of future suicidal behavior.
Conclusions and Relevance
Continuing to build an understanding of the factors associated with future suicide behaviors for this population will help guide design and implementation of improved suicide screening and interventions in the ED and allocation of scarce resources.
Introduction
With more than an average of 420,000 individuals presenting annually to the emergency department (ED) for suicide and self-injury related visits, identifying factors associated with suicide risk for these patients is critical.1 A variety of factors are associated with suicidal behavior for adults identified as at-risk for suicide; including demographics2, psychiatric disorders2–3, substance abuse disorders, and social problems (e.g., poor maternal relationship3). However, there is limited research on risk factors associated with the ED population, specifically if and how these factors change in the year following the initial ED visit.
The present study adds to the existing literature by confirming or establishing associations of psychiatric and non-psychiatric risk factors found in the patient’s medical record with future suicide outcomes for ED patients actively endorsing thoughts and a plan for suicide (active suicidal ideation) or behavior during the initial ED visit. From a clinical standpoint, this type of information is critical for determining which patients will require additional resources to mitigate risk and, ultimately, to prevent suicidal behavior.
Method
The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) was a quasi-experimental, 8-center study designed to test an approach to universal screening for suicide risk and post-visit telephone intervention among ED patients (see Boudreaux et al., 2013 for complete description).4 The ED-SAFE consisted of three phases of data collection: treatment as usual (phase 1), universal screening (phase 2), and universal screening + intervention (phase 3) and was conducted from August 2, 2010 through November 8, 2013. The current study analyzes data from the first two phases because no study-related interventions for suicidal patients were implemented in these phases, increasing the applicability of our study to general US EDs.
ED-SAFE participants were selected by first determining whether the individual’s chart had documentation of any screening for self-harm ideation or behavior. If documentation indicated positive self-harm, (i.e., self-harm ideation or behavior was documented as present), the patient was approached for further eligibility screening. If the patient confirmed either active suicidal ideation or a suicide attempt within the past week and agreed to participate, then s/he was consented for enrollment in the ED-SAFE study.
The participants completed a baseline assessment and were then followed post-discharge (from ED or inpatient, if admitted) using a multi-method approach involving telephone assessments and chart reviews. Following the index ED visit, each participant was telephoned by a trained interviewer at 6-, 12-, 24-, 36-, and 52-weeks for an outcome assessment. In addition, chart reviews were conducted by a trained chart abstractor at the site at 6- and 12-months. The first three chart reviews were independently reviewed by the site PI for accuracy. For the major predictor variables, kappas between the RA and the site PI were very strong, ranging from .96 to 1.00.
Institutional review boards at each site approved all study procedures and protocols; overall study oversight and monitoring was conducted by the NIMH Data and Safety Monitoring Board.
Measures
Socio-demographics
Patient characteristics collected during baseline interviews included general demographics such as age, sex, race, ethnicity, sexual orientation, and marital status, along with components of socioeconomic status (i.e., education, employment). Patients also were asked whether they had a primary care provider, lived alone, if a loved one had died in the past 3 months, and if s/he was a member of the armed services.
Physical health
At the index ED visit, patients responded “yes” or “no” to “In the past 12 months, have you had any of the following health problems?”: diagnosis of heart disease/heart attack, cancer, HIV, diabetes, stroke, and chronic pain. Quality of life was measured using the SF-6D, which focuses on physical functioning, role participation, social functioning, bodily pain, mental health, and vitality.5
Mental health
At the index ED visit, patients responded “yes” or “no” to “Have you ever been diagnosed by a doctor or therapist with…”: depression, bipolar disorder, alcohol abuse, drug abuse, anxiety, ADHD, eating disorder, schizophrenia, or other psychiatric problems. Mental health diagnoses were examined by ICD codes (290–319) collected during chart review and reports of interpersonal violence measured by responses of “yes” or “no” to “In the past 30 days (including today), have you been hit, kicked punched, or otherwise hurt by someone?”
The Brief Symptom Inventory-18 (BSI-18) was included for measures of somatization, depression, anxiety, and an overview of patient symptoms and intensity (Global Severity Index).6 These four scales have shown good internal consistency, test-retest reliability, validity and sensitivity.7
Healthcare utilization
Measures of healthcare utilization occurring 6-months prior to the index ED visit (yes/no) included indicators of hospitalization for psychological or emotional problems and whether the patient visited the ED.
Treatment received
Receipt of a mental health evaluation during the index ED visit (yes/no) and hospital admission (yes/no) also were analyzed.
Substance use
Drug use was defined by a “yes” to the question “Over the past 12 months, have you used drugs other than those required for medical reasons?” Current drug use also was examined by a “yes” for “intentional illegal or prescription drug misuse” or a “yes” for “any positive urine tox screen” during the index ED visit.
Alcohol misuse (past year) was assessed by calculating a score based on responses to “How often do you have a drink containing alcohol?”, “How many drinks containing alcohol do you have on a typical day when you are drinking?”, and “How often do you have four or more drinks on one occasion?” For men and women under 65 years of age, a total score of 8 or more and a score of 7 or more for men and women over 65 were considered indicators of harmful or hazardous alcohol use.8
Suicide-related indicators
To examine suicidal ideation severity, suicidal ideation intensity, and suicide attempt severity, scores were derived from responses to items from the Columbia Suicide Severity Rating Scale (C-SSRS; see Posner et al., 20089 for detailed scoring information). The C-SSRS has been validated in the context of three multisite studies including a study of adults presenting to an emergency department for psychiatric reasons.10
Additional suicide-related items (all yes/no responses) collected at baseline included lifetime preparatory acts, lifetime interrupted attempts, lifetime aborted attempts, history of non-suicidal self-injury, presence of lethal means, and history of suicide attempts.
Outcome
The primary outcome was the traditional suicide outcome – i.e., a suicide composite comprised of suicide attempts (yes/no) or suicides (yes/no). An event was labeled as a suicide attempt if it was a potentially self-injurious behavior associated with at least some intent to die as a result of the act. Documentation of these outcomes at any of the follow-up assessment time points (i.e., telephone follow-up or chart review) counted as a “yes” for the traditional outcome.
Research has identified preparatory acts, interrupted and aborted suicide attempts as significant predictors of suicide outcomes, so to generate preliminary empirical evidence for how these variables impact findings when included as part of the suicide outcome11, the traditional outcome measure was expanded to include preparatory acts (yes/no) and aborted and interrupted attempts (yes/no).
Data analysis
All analyses were conducted using STATA 13.1 (StataCorp, College Station, TX). Unadjusted analyses were conducted. All variables with an association P≤.10 (two-tailed) were included in a multivariable logistic regression. Odds ratios (ORs) were reported with 95% confidence intervals (CIs). In the final model, P<.05 was considered statistically significant. To account for commonly recognized socio-demographic differences, age, sex, race, and ethnicity were included in the multivariable model regardless of statistical significance in initial unadjusted testing.
Based on power calculations using a significance (alpha) level of .05 and the sample size for our cohort (n=874), there will be sufficient power to detect a small effect size (d=.12).
Results
Among 874 participants, the median age was 37 years (interquartile range 27–47) with 56% female (n=488), 74% white (n=649), and 13% Hispanic (n=113). At baseline, 577 (66%; 95%CI=62–70) reported suicidal ideation alone, while 297 (34%; 95%CI=29–40) reported a suicide attempt in the past week. Of the 297 with a suicide attempt in the past week, 227 (76.4%) presented to the ED as a result of a suicide attempt; the remaining presented with suicide-related complaints (n=28; 9.43%), mood disorders (n=3; 1%), substance use (n=2; 0.7%), concerns for non-suicidal self-harm (n=1; 0.34%), general medical issues (e.g., chest pain, n=8; 2.7%), or were missing data on the presenting complaint (n=28; 9.43%). There were 782 participants (90%) with data available at any of the follow-up assessment time points to determine if the participant experienced one of the constituents of the traditional outcome. Of those 782 individuals, all of them were followed through chart review, 707 (90%) completed at least one of the 5 telephone follow-up assessments; 405 (52%) completed all of the telephone follow-up assessments. Of the 782 participants, 264 (34%) screened positive for current suicidal ideation or behavior, of which 239 (91%) received a mental health evaluation at the index ED visit. In the 12-months after the index ED visit, 195 (25%) had documentation of at least one suicide attempt or suicide. (Table 1).
Table 1.
Suicide composite outcome responses by category
| n | % | |
|---|---|---|
| Total Participants | 874 | 100% |
| Participants with completed chart reviews | 874 | 100% |
| Participants completing at least one telephone follow-up | 707 | 81% |
| Participants completing all five telephone follow-ups | 405 | 46% |
| Participants with events qualifying as outcome data (from either chart review or telephone follow-up assessment) |
782 | 90% |
| Traditional outcome | 195 | 100% |
| Suicide attempt | 193 | 99% |
| Suicide | 2 | 1% |
| Expanded outcome | 430 | 55% |
| All responses (participants counted in multiple categories): |
||
| Preparatory acts | 237 | 30% |
| Aborted attempt | 311 | 40% |
| Interrupted attempt | 255 | 33% |
| Suicide attempt | 193 | 25% |
| Suicide completion | 2 | .3% |
| Overall suicide composite outcome (participants counted for only the most severe category*): |
||
| Preparatory acts | 23 | 5% |
| Aborted attempt | 71 | 17% |
| Interrupted attempt | 141 | 33% |
| Suicide attempt | 193 | 45% |
| Suicide | 2 | .5% |
Total deaths=16; 2, clearly intentional; 5, unsure if intentional, not enough information to determine; 9, clearly not intentional
Categories were ordered by suicide severity. Participants with multiple outcome responses (e.g., "yes" for preparatory act and "yes" for suicide attempt) were categorized in most severe category (in this case, suicide attempt).
Socio-demographics
Unadjusted analyses (Table 2) indicated that individuals with a high school education or less or those who were unemployed were more likely to have a suicide outcome in the 12-months following the index ED visit.
Table 2.
Unadjusted analysis results for factors associated with 12-month suicide outcomes
| Variable | OR | 95% CI | P | OR | 95% CI | P |
|---|---|---|---|---|---|---|
| Demographics | ||||||
| Age | 1.00 | .99–1.01 | .84 | 1.01 | .99–1.02 | .03 |
| Female | 1.18 | .85–1.64 | .32 | 1.47 | 1.10–1.95 | .008 |
| White | 1.02 | .70–1.50 | .90 | 1.25 | .94–1.67 | .13 |
| Hispanic | .79 | .47–1.34 | .38 | .93 | .60–1.43 | .73 |
| Gay/Lesbian/Bisexual | 1.32 | .82–2.10 | .25 | 1.34 | .87–2.07 | .19 |
| Married | .88 | .58–1.34 | .54 | .93 | .65–1.32 | .67 |
| Lives alone | 1.20 | .84–1.71 | .32 | 1.17 | .85–1.61 | .33 |
| Death of a loved one in past 3 months | .71 | .46–1.09 | .11 | .94 | .66–1.33 | .71 |
| Served in the military | 1.15 | .61–2.17 | .68 | 1.55 | .86–2.80 | .15 |
| Education; High school graduate or lower |
1.46 | 1.05–2.03 | .02 | 1.55 | 1.17–2.06 | .002 |
| Has a primary care provider | 1.23 | .86–1.75 | .26 | 1.40 | 1.03–1.89 | .03 |
| Has insurance coverage | 1.24 | .85–1.80 | .26 | 1.12 | .81–1.54 | .50 |
| Unemployed | 1.56 | 1.06–2.30 | .02 | 1.87 | 1.36–2.57 | <.001 |
| General Health | ||||||
| Diagnosed with… | ||||||
| At least one chronic health condition | 1.01 | .70–1.45 | .96 | 1.74 | 1.27–2.38 | .001 |
| Heart disease/heart attack | 1.31 | .72–2.36 | .38 | 1.45 | .83–2.53 | .19 |
| Cancer | 1.00 | .36–2.80 | .99 | 1.55 | .61–3.91 | .36 |
| HIV | .69 | .20–2.45 | .57 | 1.83 | .63–5.32 | .27 |
| Diabetes | 1.49 | .93–2.37 | .097 | 1.89 | 1.19–2.99 | .007 |
| Stroke | 1.00 | .20–5.01 | .99 | 1.38 | .33–5.80 | .66 |
| Chronic pain | .99 | .70–1.40 | .94 | 1.56 | 1.15–2.10 | .004 |
| BSI Depression | 1.02 | .98–1.06 | .28 | 1.06 | 1.03–1.10 | <.001 |
| BSI Anxiety | 1.01 | .99–1.04 | .35 | 1.02 | 1.00–1.04 | .12 |
| BSI Somatization | 1.04 | 1.01–1.07 | .009 | 1.04 | 1.01–1.07 | .002 |
| BSI Global Severity Index | 1.01 | 1.00–1.02 | .07 | 1.02 | 1.01–1.03 | .001 |
| Quality of life (SF-6D) | 1.01 | .94–1.08 | .76 | .93 | .88–.99 | .02 |
| Mental Health | ||||||
| History of… | ||||||
| Mental health problems (combined) | 4.20 | 1.79–9.82 | .001 | 2.85 | 1.72–4.73 | <.001 |
| Depression | 3.45 | 1.90–6.27 | <.001 | 3.01 | 2.02–4.50 | <.001 |
| Bipolar disorder | 1.85 | 1.33–2.56 | <.001 | 1.56 | 1.17–2.08 | .002 |
| Anxiety | 2.02 | 1.41–2.90 | <.001 | 1.90 | 1.43–2.56 | <.001 |
| ADHD | 1.18 | .81–1.71 | .39 | .99 | .71–1.39 | .97 |
| Eating disorder | 1.78 | 1.14–2.79 | .01 | 1.67 | 1.07–2.59 | .02 |
| Schizophrenia | 1.48 | .91–2.39 | .11 | 1.68 | 1.06–2.68 | .03 |
| Other psych problems | 1.62 | 1.13–2.32 | .009 | 1.45 | 1.04–2.03 | .03 |
| Interpersonal violence | .78 | .45–1.35 | .38 | .94 | .60–1.48 | .80 |
| Healthcare Utilization | ||||||
| Hospitalized for psychological or emotional problems within past 6- months |
3.02 | 2.01–4.52 | <.001 | 2.43 | 1.79–3.29 | <.001 |
| ED visit within the past 6-months | 2.49 | 1.73–3.57 | <.001 | 1.99 | 1.49–2.66 | <.001 |
| Treatment Received | ||||||
| Mental health evaluation | .65 | .41–1.05 | .08 | .69 | .44–1.08 | .11 |
| Hospital admission (any) | .98 | .94–1.03 | .42 | .99 | .96–1.03 | .62 |
| Hospital admission (psychiatric) | 1.27 | .92–1.77 | .15 | 1.23 | .93–1.63 | .16 |
| Substance Use | ||||||
| Drug abuse (past) | 1.40 | .93–2.08 | .11 | 1.59 | 1.09–2.32 | .01 |
| Drug use (current) | .99 | .72–1.37 | .97 | .93 | .70–1.23 | .59 |
| Intentional illegal or prescription drug misuse (current ED visit) |
.84 | .59–1.20 | .34 | .86 | .63–1.18 | .35 |
| Positive tox screen (current ED visit) | 1.31 | .92–1.87 | .14 | 1.36 | 1.00–1.85 | .049 |
| Alcohol abuse (past) | 1.14 | .77–1.69 | .53 | 1.30 | .91–1.85 | .14 |
| Alcohol misuse (current) | 1.40 | 1.00–1.96 | .053 | 1.13 | .84–1.53 | .43 |
| Suicide-related items | ||||||
| Columbia Suicide Severity Rating Scale (C-SSRS) |
||||||
| Suicidal ideation severity (current) | 1.39 | 1.15–1.67 | .001 | 1.44 | 1.24–1.67 | <.001 |
| Suicidal ideation severity (lifetime) | 1.12 | 1.05–1.20 | .001 | 1.12 | 1.06–1.19 | <.001 |
| Suicidal ideation intensity | 1.01 | .97–1.06 | .52 | 1.06 | 1.02–1.10 | .002 |
| Suicide attempt severity | .99 | .77–1.28 | .93 | 1.20 | .93–1.56 | .16 |
| Lethal means available | .83 | .32–2.15 | .86 | 1.23 | .52–2.89 | .64 |
| Engaged in preparatory acts (lifetime) | 1.26 | .90–1.75 | .17 | 1.52 | 1.14–2.02 | .004 |
| At least one interrupted attempt (lifetime) |
1.48 | 1.06–2.08 | .02 | 1.54 | 1.16–2.06 | .003 |
| At least one aborted attempt (lifetime) | 1.28 | .91–1.80 | .16 | 1.80 | 1.34–2.42 | <.001 |
| History of NSSI | 1.59 | 1.15–2.21 | .005 | 1.44 | 1.08–1.91 | .01 |
| History of suicide attempts | 2.44 | 1.62–3.69 | <.001 | 2.30 | 1.68–3.15 | <.001 |
Abbreviations: CI=confidence interval; NSSI=non-suicidal self-injury
Traditional outcome=suicide attempt, suicide
Expanded outcome = preparatory act, interrupted attempt, aborted attempt, suicide attempt, suicide
Physical health
Individuals diagnosed with diabetes had the strongest association with the suicide outcome.
Mental health
Reporting a history of at least one mental health problem was associated with the suicide outcome, as were specific diagnoses of depression, bipolar disorder, anxiety, and eating disorder. Suicide outcomes were associated with higher scores on the BSI somatization and global severity index scales. However, because BSI scores for global severity were strongly associated with corresponding self-reported psychiatric history and the individual psychiatric history variables had stronger associations with our outcome, the self-reported psychiatric variables were included, rather than the BSI global severity scales in the multivariable model. Mental health variables created using ICD codes were not statistically significant.
Healthcare utilization
In the 6-months prior to the index ED visit, hospitalization for psychological or emotional problems or at least one ED visit were significantly associated with future suicide behavior.
Treatment received
Receipt of a mental health evaluation at the index ED visit was significantly associated with the suicide outcome.
Drug use and alcohol misuse
Suicide outcomes were associated with documented alcohol misuse during the index ED visit.
Suicide-related indicators
C-SSRS scores for baseline suicide ideation severity indicated both current and worst ever (lifetime) scores were positively associated with future suicidal behavior. In addition, individuals reporting at least one interrupted attempt (lifetime), history of non-suicidal self-injury, or a history of suicide attempt were significantly more likely to engage in future suicide behavior.
Multivariable model
Participants were more likely to have a positive suicide composite within 12-months after the index ED visit if, at the index ED visit, they reported that their highest level of education was high school completion or less, had an ED visit within the past 6-months, had current alcohol misuse, had a high C-SSRS suicidal ideation severity score (current), or a history of non-suicidal self-injury (Table 3).
Table 3.
Multivariable regression results for factors associated with 12-month suicide outcomes (n=745)
| Traditional Outcome | Expanded Outcome | |||||
|---|---|---|---|---|---|---|
| Variable | OR | 95% CI | P | OR | 95% CI | P |
| Demographics | ||||||
| 60 or older | .78 | .53–1.16 | .21 | 1.09 | .74–1.61 | .67 |
| Female | 1.08 | .73–1.60 | .70 | 1.34 | .91–1.95 | .14 |
| White | .91 | .59–1.40 | .66 | .89 | .58–1.36 | .59 |
| Hispanic | .72 | .40–1.30 | .28 | .91 | .52–1.59 | .74 |
| High school education or less | 1.45 | 1.00–2.11 | .049 | 1.83 | 1.25–2.68 | .002 |
| Unemployed | 1.15 | .73–1.81 | .55 | 1.53 | 1.00–2.33 | .048 |
| Primary care provider | na | na | na | 1.34 | .89–2.00 | .16 |
| General Health | ||||||
| Diagnosed with… | ||||||
| At least one chronic health condition | na | na | na | 3.39 | 1.16–9.90 | .03 |
| Diabetes | 1.00 | .99–1.00 | .42 | 1.00 | .95–1.04 | .84 |
| Chronic pain | na | na | na | .37 | .13–1.06 | .06 |
| BSI Somatization | 1.03 | .99–1.06 | .11 | 1.02 | .98–1.05 | .36 |
| Quality of life (SF-6D) | na | na | na | .98 | .90–1.06 | .53 |
| Treatment Received | ||||||
| Mental health evaluation | .63 | .37–1.08 | .10 | na | na | na |
| Mental Health | ||||||
| History of… | ||||||
| Mental health problems (combined) | 1.18 | .34–4.06 | .80 | .85 | .33–2.17 | .73 |
| Depression | 1.85 | .78–4.39 | .16 | 2.00 | 1.02–3.93 | .044 |
| Bipolar disorder | 1.27 | .87–1.87 | .22 | .98 | .66–1.44 | .90 |
| Anxiety | 1.12 | .72–1.74 | .61 | 1.19 | .78–1.81 | .42 |
| Eating disorder | .92 | .65–1.32 | .66 | .83 | .56–1.23 | .35 |
| Schizophrenia | na | na | na | 1.03 | .74–1.44 | .86 |
| Other psych problems | 1.07 | .88–1.31 | .51 | .90 | .72–1.14 | .39 |
| Healthcare Utilization | ||||||
| Hospitalized for psychological or emotional problems |
1.41 | .84–2.36 | .20 | 1.33 | .83–2.13 | .23 |
| ED visit within the past 6-months | 2.06 | 1.36–3.12 | .001 | 1.51 | 1.04–2.19 | .03 |
| Substance use | ||||||
| Positive tox screen | na | na | na | 1.20 | .83–1.74 | .34 |
| Drug abuse (past) | na | na | na | 1.20 | .74–1.94 | .47 |
| Alcohol misuse (current) | 1.50 | 1.02–2.20 | .04 | na | na | na |
| Suicide-related | ||||||
| Suicidal Ideation Severity (current) | 1.43 | 1.16–1.77 | .001 | 1.52 | 1.24–1.86 | <.001 |
| Suicidal Ideation Severity (lifetime) | 1.06 | .98–1.14 | .17 | 1.06 | .98–1.14 | .19 |
| Suicidal Ideation Intensity (current) | na | na | na | 1.01 | .97–1.06 | .60 |
| Preparatory acts (lifetime) | na | na | na | .90 | .71–1.16 | .42 |
| Interrupted attempts (lifetime) | .99 | .66–1.47 | .95 | .81 | .54–1.20 | .28 |
| Aborted attempts (lifetime) | na | na | na | 1.23 | .84–1.80 | .29 |
| Non-suicidal self-injury (lifetime) | 1.51 | 1.03–2.22 | .03 | 1.35 | .92–1.98 | .13 |
| Suicide attempt(s) (lifetime) | 1.33 | .82–2.17 | .25 | 1.25 | .80–1.94 | .33 |
Abbreviations: CI=confidence interval; NSSI=non-suicidal self-injury
Traditional outcome=suicide attempt, suicide
Expanded outcome = preparatory act, interrupted attempt, aborted attempt, suicide attempt, suicide
Hosmer-Lemeshow’s goodness-of-fit test revealed that the multivariable model fit well with our data (P=.95). No values had variance inflation factors greater than 10 indicating low collinearity between the variables. The overall model accounted for 10% of the variance in the outcome.
Near term predictors
The largest proportion of suicide outcomes occurred within 6-weeks of the initial ED visit (n=77; 40%) (Table 4). Predictors of 6-week outcomes included BSI somatization (1.09, 95%CI = 1.01–1.19, P=.03), ED visit within the past 6-months (2.17, 95%CI = 1.12–4.21, P=.02), no current alcohol misuse (.43, 95%CI .20-.95, P=.04), and current suicidal ideation with a plan and intent (1.70, 95%CI 1.18–2.44, P=.004).
Table 4.
Total participants reporting an outcome during the 12-month follow-up timeframe*
| Expanded outcome | |||||
|---|---|---|---|---|---|
| Traditional outcome | |||||
| Suicide | Suicide attempt |
Interrupted attempt |
Aborted attempt |
Preparatory act |
|
| Total | |||||
| 6-week | 0 | 77 | 121 | 155 | 102 |
| 12-week | 0 | 56 | 97 | 113 | 72 |
| 24-week | 0 | 61 | 93 | 126 | 81 |
| 36-week | 0 | 46 | 62 | 94 | 65 |
| 52-week | 2 | 53 | 75 | 78 | 71 |
These values represent raw counts of participants at each study timeframe. Participants were counted at multiple timeframes.
Exploratory expanded outcome
After adding preparatory acts, interrupted and aborted attempts, we found participants were more likely to have at least one outcome if, at the index ED visit, they reported that their highest level of education was high school completion or less, were unemployed, had a history of chronic health condition(s), had a history of depression, had an ED visit within the past 6-months, or had a high C-SSRS suicidal ideation severity score (current). (Table 3). The model was a reasonable fit for the data (P=.20).
Discussion
One important goal of the ED-SAFE was to identify factors associated with future suicide risk among ED patients presenting with active suicidal ideation or behavior. In this high-risk population, outcome data were ascertained on 90% (n=782) of the cases where 195 (25%) study participants attempted suicide or died by suicide in the 12-months after the index ED visit. Participants were more likely to have suicidal behavior if, at the index ED visit, they reported their highest level of education was high school or less. From a health history standpoint, increased future suicidal behavior was associated with a history of non-suicidal self-injury, current alcohol misuse, and reports of an ED visit within the past 6-months. Finally, individuals indicating suicidal ideation with intent or intent with a plan, were more likely to engage in future suicide behavior.
A large percentage of the traditional outcome was reported within 6-weeks of the initial visit. The most notable differences between the 6-week and broader timeframe were high school education or less, alcohol misuse, and a history of non-suicidal self-injury (NSSI) were not predictive, but high scores on the BSI somatization measure became a significant predictor. This suggests that the presence of serious health issues may be important for predicting short-term suicide outcomes among ED patients. This aligns with previous literature linking chronic health conditions and functional limitations with greater suicide risk.12–13
Although there is no established universal approach, the present study found that current suicidal ideation severity, current alcohol misuse, and documentation of an ED visit within the past 6-months have a strong association with predicting suicide outcomes for ED patients presenting with suicidal ideation or behavior. However, prior suicide attempt severity and a history of mental health problems were not found to be significant predictors. As in previous research, socioeconomics appear to be important for assessing risk in the general population.14–16 One explanation may be that these individuals are hospitalized more frequently which has been identified as a risk factor for suicide.17 Our findings also align with Posner et al.18 that individuals with suicidal ideation with intent or greater had higher odds for attempting suicide within 24-weeks of the initial assessment.
Our model was based on the traditional outcomes of suicide attempts and suicides. However, it has been suggested that suicide outcomes include a broader range of variables, such as preparatory acts and interrupted and aborted suicide attempts. The current study briefly touched upon this expanded model and determined that using this outcome results in some additional predictors, including unemployment, a history of chronic health condition(s), and a history of depression. Future research on this model is needed and may benefit from comparisons to existing prediction rules, such as the ReACT self-harm rule.19
Findings such as these are useful for meeting the demands for improved screening, interventions, treatment, and follow-up with suicidal ED patients.20 Using empirically supported variables to improve guidelines targeting patients presenting with suicide risk may help clinicians choose appropriate treatment and improve long-term suicide management for these patients.
Limitations
Although several variables associated with 12-month suicide outcomes were identified, our model only accounted for 10% of the variance in the traditional outcome. Although this is lower than other studies21, our findings provide additional support for variables associated with suicide outcomes for an at-risk for suicide ED population. In addition, some of the variables included in our model are readily available in the patient’s medical record.
Another limitation was the small sample size for completed suicides (n=2). From a health standpoint, the low mortality rate is positive; however, from a statistical standpoint it does not provide enough power to draw conclusions about factors influencing completed suicides. Additional research is needed to identify risk factors for completed suicides in an ED population.
We did not directly follow patients with no suicidal ideation; however, we did conduct random chart reviews to account for times when the ED was not covered by research staff and fidelity assessments to ensure that suicide screenings were being appropriately completed. Although this did not directly track the non-suicidal patients, it did provide a means for verifying the accuracy of the ED-SAFE data.
The large number of variables examined in the current study allowed for a broad comparison of several relevant factors associated with longitudinal suicide outcomes. However, the large number of variables also limits the extent to which each variable or category of variables could be examined. The goal of the current study was to identify a comprehensive group of predictors for identifying ED patients at risk for engaging in suicide behavior. Future research may want to further delve into the individual implications for each of the findings from the larger grouping of variables.
Finally, it should be noted that some of our significant findings had odds ratios with confidence intervals close to 1.00. These findings point to clinical and statistical significance, but should be interpreted cautiously. Future research is needed to replicate and confirm these findings. However, the results do provide us with an initial framework upon which to build future studies.
Conclusion
Among participants in ED-SAFE – a unique, prospectively recruited and tracked cohort of ED patients from multiple, geographically diverse sites – both psychiatric and non-psychiatric characteristics are associated with engaging in future suicide behavior. In addition, ED-SAFE was the first study to track preparatory acts and interrupted and aborted suicide attempts over a 12-month timeframe, which allowed for initial investigation into expanding the traditional suicide outcome measure. The findings that individuals with high school completion or less, an ED visit within the past 6-months, current alcohol misuse, a high C-SSRS suicidal ideation severity score (current), or a history of non-suicidal self-injury were more likely to have a suicide attempt or suicide within 12-months after the index ED visit add to the extant research on risk factors for future suicide behavior in an adult ED population with the goal of facilitating identification of ED patients at-risk for future suicide behaviors.
Acknowledgments
FUNDING: The project described was supported by Award Number U01MH088278 from the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health.
Footnotes
Conflict of interest: The authors have no conflicts of interest to report.
None of the authors have financial conflicts of interest to disclose.
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