Syndromic Surveillance of Suicidal Ideation and Self-Directed Violence — United States, January 2017–December 2018

Suicide is a growing public health problem in the United States, claiming approximately 47,000 lives in 2017 (1). However, deaths from suicide represent only a small part of a larger problem because each year millions of persons experience suicidal ideation and engage in suicidal and nonsuicidal self-directed violence, both risk factors for suicide (2). Emergency departments (EDs) are an important setting for monitoring these events in near real time (3–5). From 2001 to 2016, ED visit rates for nonfatal self-harm increased 42% among persons aged ≥10 years (1). Using data from CDC’s National Syndromic Surveillance Program (NSSP), ED visits for suicidal ideation, self-directed violence, or both among persons aged ≥10 years during January 2017–December 2018 were examined by sex, age group, and U.S. region. During the 24-month period, the rate of ED visits for suicidal ideation, self-directed violence, or both increased 25.5% overall, with an average increase of 1.2% per month. Suicide prevention requires comprehensive and multisectoral approaches to addressing risk at personal, relationship, community, and societal levels. ED syndromic surveillance data can provide timely trend information and can support more targeted and prompt public health investigation and response. CDC’s Preventing Suicide: A Technical Package of Policy, Programs, and Practices includes tailored suicide prevention strategies for health care settings (6).

CDC’s NSSP BioSense Platform,* a national public health surveillance system, was used to identify ED visits for this study. At the time of this investigation,^† NSSP included data from approximately 65% of visits at facilities categorized as EDs (i.e., urgent care and outpatient facilities were excluded) from 55 jurisdictions in 45 states.^§ The Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) tool in the BioSense Platform was used to analyze ED visits. In collaboration with CDC, the NSSP Community of Practice Syndrome Definition Committee developed a definition to identify ED visits involving suicidal ideation, self-directed violence, or both, which combines clinical presentation and Boolean operators (e.g., hanging, laceration, or overdose attempt) and diagnosis codes associated with suicidal ideation, self-directed violence, or both.^¶ The definition is designed to query patients’ chief complaint history, discharge diagnosis, and admission reason code and description fields and includes common misspellings of suicide-related terms, while excluding visits in which a patient “denies suicidal ideation” or “is not suicidal.” The syndrome definition used for this investigation does not differentiate between suicidal ideation and self-directed violence, nor the method of self-directed violence (7). The composite measure used in this investigation was the first syndrome definition ever developed by the NSSP Community of Practice Syndrome Definition Committee and CDC to capture ED visits broadly related to suicidal ideation, self-directed violence, or both. More specific syndrome definitions that separately assess ED visits related to suicidal ideation, self-directed violence, or specific mechanisms of self-directed violence are in development.

Monthly ED visits involving suicidal ideation, self-directed violence, or both per 100,000 ED visits among persons aged ≥10 years during January 2017–December 2018 were computed overall and stratified by sex, age group, and U.S. region.** Rates were calculated by dividing the number of ED visits related to suicidal ideation, self-directed violence, or both by the total number of ED visits recorded in ESSENCE each month, multiplied by 100,000. Percentage changes in the monthly rate for ED visits for suicidal ideation, self-directed violence, or both overall and for each stratum were examined. Estimates of average monthly percentage change were calculated using Joinpoint regression with Joinpoint software (version 4.7.0.0; National Cancer Institute).^†† P-values <0.05 were considered statistically significant.

During January 2017–December 2018, among approximately 163 million ED visits assessed in NSSP, a total of 2,123,614 involved suicidal ideation, self-directed violence, or both (1,300.6 per 100,000 ED visits). During the same period, the rate of ED visits involving suicidal ideation, self-directed violence, or both increased 25.5%, with an average increase of 1.2% per month (Table). Both sexes experienced significant increases during this period: the rate increased 22.7% for females and 27.6% for males (Table) (Figure 1). Among females, ED visit rates involving suicidal ideation, self-directed violence, or both significantly increased among those aged 10–19 years (33.7% increase), 40–59 years (17.6%), and ≥60 years (29.0%). Females aged 20–39 years did not experience a significant increase in ED visit rate for suicidal ideation, self-directed violence, or both. Among males, all age groups experienced significant increases in ED visit rates related to suicidal ideation, self-directed violence, or both during January 2017–December 2018, including those aged 10–19 years (62.3%), 20–39 years (29.1%), 40–59 years (20.4%), and ≥60 years (36.7%). For both females and males aged 10–19 years, a seasonal pattern in ED visits for suicidal ideation, self-directed violence, or both was observed, with the lowest proportion of visits occurring during summer months. Three of five U.S. regions experienced significant increases in these ED visit rates: the Midwest (33.8%), Northeast (16.0%), and West (13.3%) (Table) (Figure 2). Among females, rates of ED visits related to suicidal ideation, self-directed violence, or both significantly increased in the Midwest (28.7%), West (14.7%), and Northeast (13.6%). Among males, rates of ED visits related to suicidal ideation, self-directed violence, or both significantly increased in all U.S. regions except the Southwest (Midwest, 38.7%; Southeast, 33.5%; Northeast, 17.7%; and West, 11.1%). Rates were consistently highest in the West for both females and males.

Acknowledgments

Rasneet Kumar, Zachary Stein; members of the NSSP Community of Practice Syndrome Definition Committee; state and local health departments participating in CDC’s National Syndromic Surveillance Program.

Corresponding author: Marissa L. Zwald, MZwald@cdc.gov, 404-498-5774.

¹Division of Violence Prevention, National Center for Injury Prevention and Control, CDC; ²Division of Health Informatics and Surveillance, Center for Surveillance, Epidemiology, and Laboratory Services, CDC; ³Division of Overdose Prevention, National Center for Injury Prevention and Control, CDC.

References

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Abbreviations: CI = confidence interval; ED = emergency department.
* Per 100,000 visits. Calculated as number of ED visits related to suicidal ideation, self-directed violence, or both divided by the total number of ED visits for each month and multiplied by 100,000. Percentage change in rates were determined by subtracting the number during the previous month from the number during the current month, then dividing by the previous month’s number multiplied by 100%.
^† The Northeast region includes U.S. Department of Health and Human Services (HHS) Region 1 (Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont), HHS Region 2 (New Jersey and New York), and HHS Region 3 (District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia); the Southeast region includes HHS Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee); the Southwest region includes HHS Region 6 (Arkansas, Louisiana, New Mexico, and Texas); the Midwest region includes HHS Region 5 (Indiana, Illinois, Michigan, Minnesota, Ohio, and Wisconsin) and HHS Region 7 (Iowa, Kansas, Missouri, and Nebraska); and the West region includes HHS Region 8 (Colorado, Montana, North Dakota, and Utah), HHS Region 9 (Arizona, California, and Nevada), and HHS Region 10 (Alaska, Idaho, Oregon, and Washington).
^§ Data are current as of February 8, 2019.
^¶ Statistically significant (p<0.05).

FIGURE 1. Monthly rate* of emergency department (ED) visits related to suicidal ideation (SI), self-directed violence (SDV), or both, by sex and age group — National Syndromic Surveillance Program, United States, January 2017–December 2018^†

* Per 100,000 visits. Calculated as number of ED visits related to SI, SDV, or both, divided by the total number of ED visits for each month and multiplied by 100,000.

^† Data are current as of February 8, 2019.

FIGURE 2. Monthly rate* of emergency department (ED) visits related to suicidal ideation (SI), self-directed violence (SDV), or both, by sex and region^† — National Syndromic Surveillance Program, United States, January 2017–December 2018^§

* Per 100,000 visits. Calculated as number of ED visits related to SI, SDV, or both, divided by the total number of ED visits for each month and multiplied by 100,000.

^† Northeast: U.S. Department of Health and Human Services (HHS) Region 1 (Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont), HHS Region 2 (New Jersey and New York), and HHS Region 3 (District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia); Southeast: HHS Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee); Southwest: HHS Region 6 (Arkansas, Louisiana, New Mexico, and Texas); Midwest: HHS Region 5 (Indiana, Illinois, Michigan, Minnesota, Ohio, and Wisconsin) and HHS Region 7 (Iowa, Kansas, Missouri, and Nebraska); West: HHS Region 8 (Colorado, Montana, North Dakota, and Utah), HHS Region 9 (Arizona, California, and Nevada), and HHS Region 10 (Alaska, Idaho, Oregon, and Washington).

^§ Data are current as of February 8, 2019.