Emergency Department Surveillance of Nonfatal Suicide-Related Outcomes
Suicide is a leading cause of death in the United States. In 2021, 48,183 people died by suicide.1 Additionally, every year, millions of Americans seriously think about suicide, make a plan for suicide, or attempt suicide.2
CDC is using new and existing data to better understand, monitor, and prevent suicide and suicidal behavior.
CDC funded the Emergency Department Surveillance of Nonfatal Suicide-Related Outcomes (ED-SNSRO) cooperative agreement to help states increase the timeliness of surveillance of nonfatal suicide-related outcomes. Collecting near real-time data on nonfatal suicide-related outcomes—such as suicidal ideation and suicide attempts —helped states rapidly track and respond to changing patterns in suicidal behavior.
- New York
- Rhode Island
- West Virginia
States used ED-SNSRO funding to:
- Increase the timeliness of reporting nonfatal suicide-related outcomes, and
- Disseminate surveillance findings to key stakeholders working to prevent or respond to suicide and nonfatal suicidal behaviors.
What is syndromic surveillance?
Syndromic surveillance provides public health officials with a timely system for detecting, understanding, and monitoring health events. By tracking symptoms of patients in emergency departments—before a diagnosis is confirmed—public health can detect unusual levels of illness to determine whether a response is warranted.
Read more about CDC’s National Syndromic Surveillance Program (NSSP).
Visit CDC’s Suicide Prevention webpage to find out more about what CDC is doing to prevent suicide.
Near real-time emergency department (ED) data related to self-harm and suicides are now available for state and local public health use in Ohio. The Ohio Department of Health’s Violence and Injury Prevention Section used ED-SNSRO’s syndromic surveillance data to develop a comprehensive, customizable, and interactive dashboard in EpiCenter, Ohio’s syndromic surveillance system. The dashboard allows users to easily monitor and analyze ED visits for suspected suicide attempts, self-harm, and suicidal ideation in their jurisdiction. The Ohio Self-Directed Violence Dashboard became available to state and local public health EpiCenter users in May 2022.
This near real-time data came at a critical time for informing public health action to prevent suicide and suicidal behavior in Ohio. Health departments often have limited resources to analyze syndromic surveillance data. COVID-19 response efforts restricted these already limited resources, and at the same time the pandemic’s potential to increase risk factors for suicide elevated the need to monitor timely data for self-harm and suicide-related outcomes.
The dashboard includes data filters such as state- or county-level data; hour, day, or week of visit; patient facility location; and age group and sex of patients. In total, the dashboard displays 10 visuals that allow users to quickly assess trends over time and make comparisons between different demographic groups (such as sex, age, and race/ethnicity), between counties, and between county and state-level data. Data can also be displayed by percentage of all ED visits, rate per 10,000 ED visits, or rate per 10,000 or 100,000 population. Training is ongoing for local and state-level public health colleagues on how to use the new dashboard’s capabilities.
Vermont had a record high number of suicide deaths in 2021. Nonfatal suicide-related emergency department (ED) visits also significantly increased in recent years. The rate increase for these ED visits accelerated especially for Vermonters ages 10-19 between October 2020 and March 2021. Given the increasing trends, it was critically important to alert Vermont’s suicide prevention partners so they could use these timely data to inform suicide prevention efforts.
The Vermont Department of Health (VDH) used ED-SNSRO’s syndromic surveillance data to publish a data brief [PDF – 5 pages] detailing the spike in suicide-related ED visits for young people ages 10-19 during the COVID-19 pandemic. VDH brought together partners, including state mental health commissioners, suicide prevention staff, clinicians, and others, to identify action steps based on the data in the report. These organizations shared data and aligned messaging around an increase in intentional poisonings and suicide-related ED visits. Interventions included parental awareness messaging on social media and targeted messaging to pediatric, family medicine, and emergency medicine providers. VDH also collaborated with the Northern New England Poison Control (NNEPC) to present poison control and ED visit data during a statewide suicide prevention data workgroup meeting, which helped inform mental health workers, researchers, and other programming staff of the increase. In addition, VDH and NNEPC worked together to produce educational briefs and pamphlets for parents and providers on intentional poisoning among youth. NNEPC presented the ED visit data and poison control data on their monthly Poison Center Pointers, a podcast for clinicians.
ED visits for intentional poisonings remained elevated throughout 2021, but the increase plateaued. Numerous news reports and attention from community organizations raised the profile on intentional poisonings. Messaging about mental health treatment and suicide prevention programs, especially for youth, are included as important prevention strategies.
Washington State’s syndromic surveillance program, the Rapid Health Information Network (RHINO), leverages near real-time data to track trends and provide reports to local suicide prevention partners on unusual patterns or increases in suicide-related visits to emergency departments (EDs). RHINO uses syndromic surveillance data to detect clusters of suicide and suicide-related behavior. In public health, a cluster is a greater-than-expected number of cases of a disease or occurrence that takes place among a group of people close in time, typically days or weeks. These data uncovered more than 10 clusters of nonfatal suicide attempts treated in EDs between October 1, 2021, and January 31, 2022.
The RHINO team uses the platform to perform a daily check to detect clusters. This check involves examining zip code data and the timing of ED visits to identify case counts that exceed what has been observed historically for that same area and time period. Surveillance of nonfatal suicide-related outcomes, across time and location, is a new approach to identifying communities and populations at risk and can help improve and tailor prevention efforts.
Health officers throughout the state will get automatic alerts about increases in cases displaying unusual demographic patterns (such as visits by adolescent girls), patterns that involve a particular medication (such as overdoses by a specific over-the-counter drug), or case numbers that remain elevated for several days. The reports are often shared with local partners. One local health jurisdiction notified its injury and violence prevention program and another shared the cluster detection findings at a youth and family-focused task force meeting.
The RHINO team continues to work with local health jurisdictions to validate the clusters, ask for feedback on actions taken after a cluster is detected, and assist with data interpretation for suicide-related behaviors.
In May 2021, Oregon’s National Violent Death Reporting System revealed that a cluster of suicides occurred in 2020 by means of ingesting a chemical. Prior to 2020, this chemical had only been identified as the means of suicide in Oregon in one 2018 case. However, the chemical was used in 14 suicide deaths in 2020, and in two suicide deaths* in 2021. Oregon’s ED-SNSRO project provided the capacity to actively monitor morbidity and mortality data for unusual activity.
Oregon’s ED-SNSRO team reviewed medical examiner narratives for all cases, noting similarities across cases and establishing a monitoring process to identify any new cases. The Oregon Health Authority (OHA) tracked poisonings involving this chemical across data systems, developed and distributed data briefs for emergency medical services, local medical examiners, and emergency departments, and alerted suicide prevention coordinators in the affected counties. OHA also created a fact sheet to help emergency medical services and emergency departments identify and treat these poisonings and a corresponding fact sheet for medical examiners on what to look for at the scene of death and in autopsies to identify these poisonings.
OHA requested that Oregon Poison Control and state hospital systems document and report all poisonings involving this chemical in their data systems. OHA also contacted the Centers for Disease Control and Prevention (CDC), the Environmental Protection Agency (EPA), and the Food and Drug Administration (FDA) to alert them to this suicide cluster and discuss national-level action. The availability of this emerging, near real-time data and implications allowed OHA to act quickly to enact new surveillance protocols and alert systems that were put in place through ED-SNSRO support.
*At the time this story was written.
In Rhode Island, Hasbro’s Children’s Hospital Pediatric Psychiatry Emergency Services worked with the Rhode Island Department of Health (RIDOH) to investigate a suspected increase in the number of young people seen in emergency departments for suicidal ideation and attempts, particularly those involving drug overdoses. The ED-SNSRO team reviewed the data and quickly determined that there was an increase in suicide attempts involving over-the-counter (OTC) medication among girls under 18. A multi-agency team used these ED-SNSRO data to implement a campaign across Rhode Island to help prevent intentional overdoses with OTC medication. The campaign is called Over-the-Counter does not mean On-the-Counter [PDF – 1 page]. It includes social media, TV ads, and print ads (in English, Spanish, and Portuguese). The health department also provides medication lock bags and pill bottle timer caps to the public at no cost. The agencies involved in the campaign received over 1,000 requests for medication lock bags within the first few weeks of its launch. The immediate impact of this data-to-action campaign would not have been possible without ED-SNSRO. ED-SNSRO syndromic data allowed RIDOH to quickly respond to emerging local needs with a focused community response.
Multiple agencies collaborated to make these activities possible and successful, including:
- Rhode Island Department of Health
- Youth Suicide Prevention Team
- ED-SNSRO Team
- Hasbro Children’s Hospital’s Pediatric Psychiatry Emergency Services
- Rhode Island’s Executive Office of Health and Human Services
- Rhode Island Department of Education
- Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals
- South County Regional Prevention Coalition
- Kent County Prevention Coalition
Suicide is one of the leading causes of death in Utah. In 2020, Utah Department of Health’s Incident Command System (ICS)—which was in place to deal with the high number of opioid overdoses — became concerned about the impact of COVID-19 restrictions on mental health and suicide. However, most suicide-related data sources, such as death certificates and hospitalizations, were not timely enough to understand trends during and related to COVID-19. Fortunately, ED SNSRO’s syndromic surveillance can detect changes in the number of people seeking emergency medical services for suicide-related behavior and can help focus interventions once issues are identified.
ICS and the state’s COVID Suicide Surveillance Committee analyzed trends in nonfatal suicide-related syndromic surveillance data. Analysis of data from 2019, 2020, and 2021 revealed that the average number and rate of suicide attempts was higher after COVID-19 restrictions were put in place. The suicide attempt rate was highest among 10–17-year-olds.
Timely syndromic surveillance from ED-SNSRO of suicide-related outcomes provided a way to analyze current trends and answer media and partner requests about how COVID-19 impacted suicide-related outcomes in Utah. Results were shared with suicide prevention personnel in bi-weekly meetings and included in a report on social and behavioral health [PDF – 33 pages] during COVID-19 in Utah. Participation in ED-SNSRO strengthened collaboration among staff from multiple programs within the health department and external partners from behavioral health and healthcare systems.
- Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 2018-2021 on CDC WONDER Online Database, released in 2023. Data are from the Multiple Cause of Death Files, 2018-2021, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10-expanded.html on Jan 23, 2023.
- Substance Use and Mental Health Services Administration (2022). Key substance use and mental health indicators in the United States: Results from the 2021 National Survey on Drug Use and Health (HHS Publication No. PEP22-07-01-005, NSDUH Series H-57). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report