Journal Article Annotations
2019, 4th Quarter
Annotations by Kemuel Philbrick
December 2019
The Findings:
Patients with an index episode of deliberate but nonfatal self-harm had the highest rate of suicide in the following year and among these, men, patients 65 years and older, and those with non-Hispanic white ethnicity had the higher rates. These same three groups were also those most likely to die by suicide in the year following an index presentation with suicidal ideation. Among those who presented with self-harm, comorbid bipolar disorder, anxiety disorder or psychotic disorder had statistically significantly increased risk of death by suicide than patients without those diagnoses; other psychiatric diagnoses did not achieve statistical significance. Among those with index suicidal ideation, only comorbid depression was associated with increased suicide risk in the following year. The method of initial injury was categorized as poisoning, cutting/piercing, hanging, jumping, firearm, and all other; those whose index nonfatal self-harm event involved a firearm had a far higher suicide rate in the subsequent year (the means utilized in the subsequent suicides is not reported). Perhaps not surprisingly, mortality by non-suicide causes in the year after the index presentation was also disproportionately elevated; overdoses composed just over 70% of all unintentional deaths in the self-harm group and 61% of deaths in those who had initially presented with suicidal ideation. The study also examined other factors such as source of insurance or payer, rurality of residence, and the Elixhauser Comorbidity Index score.
Strengths and Weaknesses:
This large, population-based study proves more informative for general practice than earlier, smaller studies that were limited to selective populations, e.g., military or Medicaid patient pools. On the other hand, sociodemographic characteristics of California residents are not homogenous with all other states. Individuals who died outside of California were not available for analysis. There was no capacity to distinguish between deliberate self-harm associated with the intent to die versus those without an intent to die. There was also no information about the degree of engagement with outpatient care following dismissal from the ED in those who did, or did not, subsequently die by suicide.
Relevance:
In some institutions, the inpatient C/L service bears responsibility for assessment and disposition of emergency department (ED) patients. In all institutions, the inpatient C/L service regularly encounters patients on medical and surgical services who were admitted after presenting to the ED with either deliberate self-harm or suicidal ideation. This study underscores the substantial risk of death by suicide in the following year of such patients and encourages us to pay particular attention to securing practical and accessible post-hospital follow-up for such patients in hope of shepherding them safely through the ensuing year towards greater stability and safety.
Type of study: Cohort Study