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Trends in Emergency Department Visits for Nonfatal Self-inflicted Injuries Among Youth Aged 10 to 24 Years in the United States, 2001-2015

DOI:10.1001/jama.2017.13317
Authors:
Melissa C Mercado-Crespo at Centers for Disease Control and Prevention
Melissa C Mercado-Crespo
Kristin Holland at U.S. Department of Health and Human Services
Kristin Holland
Ruth W. Leemis at Centers for Disease Control and Prevention
Ruth W. Leemis
Deborah M Stone at U.S. Department of Health and Human Services
Deborah M Stone
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Abstract

In the United States, youth have the highest burden of nonfatal self-inflicted injury (ie, deliberate physical harm against oneself, inclusive of suicidal and nonsuicidal intent) requiring medical attention.¹ One study found that emergency department (ED) visits for these injuries during the 1993 to 2008 period varied by age group, ranging from 1.1 to 9.6 per 1000 ED visits, with adolescents aged 15 to 19 years exhibiting the highest rates.¹ Self-inflicted injury is one of the strongest risk factors for suicide—the second-leading cause of death among those aged 10 to 24 years during 2015.² This study examined trends in nonfatal self-inflicted injuries treated in hospital EDs among US children, adolescents, and young adults aged 10 to 24 years (hereafter referred to as youth).
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Trends in Emergency Department Visits for Nonfatal Self-
inflicted Injuries Among Youth Aged 10 to 24 Years in the United
States, 2001–2015
Melissa C. Mercado, PhD, MSc, MA1, Kristin Holland, PhD, MPH1, Ruth W. Leemis, MPH1,
Deborah M. Stone, ScD, MSW, MPH1, and Jing Wang, MD, MPH1
1National Center for Injury Prevention and Control, Centers for Disease Control and Prevention,
Atlanta, Georgia
In the United States, youth have the highest burden of nonfatal self-inflicted injury (ie,
deliberate physical harm against oneself, inclusive of suicidal and nonsuicidal intent)
requiring medical attention.1 One study found that emergency department (ED) visits for
these injuries during the 1993 to 2008 period varied by age group, ranging from 1.1 to 9.6
per 1000 ED visits, with adolescents aged 15 to 19 years exhibiting the highest rates.1 Self-
inflicted injury is one of the strongest risk factors for suicide—the second-leading cause of
death among those aged 10 to 24 years during 2015.2 This study examined trends in nonfatal
self-inflicted injuries treated in hospital EDs among US children, adolescents, and young
adults aged 10 to 24 years (hereafter referred to as youth).
Methods
The National Electronic Injury Surveillance System—All Injury Program (NEISS-AIP)
collects data on all first-time visits for nonfatal injuries treated in 66 US hospital EDs
through stratified probability sampling, allowing for the derivation of national estimates.3
Corresponding Author: Melissa C. Mercado, PhD, MSc, MA, National Center for Injury Prevention and Control, Centers for Disease
Control and Prevention, 4770 Buford Hwy NE, Mailstop F-63, Atlanta, GA 30341-3717 cju8@cdc.gov.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of
Interest and none were reported.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the
CDC.
Author Contributions: Dr. Mercado had full access to all of the data in the study and takes responsibility for the integrity of the data
and the accuracy of the data analysis.
Concept and design:
Mercado, Holland, Leemis, Stone.
Acquisition, analysis, or interpretation of data:
Mercado, Holland, Leemis, Wang.
Drafting of the manuscript:
Mercado, Holland, Leemis, Wang.
Critical revision of the manuscript for important intellectual content:
All authors.
Statistical analysis:
Holland, Wang.
Administrative, technical, or material support:
Mercado, Holland, Leemis.
Supervision:
Mercado.
Other - subject matter expertise:
Stone.
Additional Contributions: The data used in this report originated from the National Electronic Injury Surveillance System All Injury
Program, operated by the US Consumer Product Safety Commission and whose data are made available by CDC’s web-based Injury
Statistics Query and Reporting System, supported by CDC’s National Center for Injury Prevention and Control. We thank Tadesse
Haileyesus, MS (CDC’s National Center for Injury Prevention and Control), for providing technical support. He did not receive
compensation for his contribution.
HHS Public Access
Author manuscript
JAMA
. Author manuscript; available in PMC 2018 November 21.
Published in final edited form as:
JAMA
. 2017 November 21; 318(19): 1931–1933. doi:10.1001/jama.2017.13317.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Self-inflicted injuries were identified by reviewing injury cause narratives and other coded
data within ED records. This study used publicly available secondary data and was exempted
by the CDC from institutional review board review.
Self-inflicted injury ED visit rates were calculated from 2001 through 2015 by sex, age (10–
14, 15–19, and 20–24 years), along with injury method (poisoning, sharp object, blunt
object), and 95% CIs using US Census population estimates as denominators. Rates were
weighted to obtain nationally representative estimates and age-adjusted to the 2000 US
Census population. Trends in self-inflicted injury ED visit rates were assessed using
joinpoint regression software (Surveillance Research Program, National Cancer Institute),
version 4.3.1.0. The annual percentage change described the rate of change for each linear
segment.
Results
From 2001 to 2015, NEISS-AIP captured 43 138 youth self-inflicted injury ED visits. The
overall weighted age-adjusted rate for this group showed no statistically significant trend
until 2008, increasing 5.7% (95% CI, 3.0%–8.4%) annually thereafter and reaching 303.7
per 100 000 population (95% CI, 254.1–353.3) in 2015 (Table). Age-adjusted trends for
males overall and across age groups remained stable throughout 2001–2015 (Figure, Table).
Overall age-adjusted rates for females demonstrated no statistically significant trend before
2009, yet increased 8.4% (95% CI, 5.6%–11.2%) yearly from 2009 to 2015. After 2009,
rates among females aged 10 to 14 years increased 18.8% (95% CI, 12.1%–25.8%) per year
—from 109.8 (95% CI, 69.9–149.7) in 2009 to 317.7 (95% CI, 230.3–405.1) per 100 000
population in 2015. Rates among females aged 15 to 19 years showed a 7.2% (95% CI,
3.8%–10.8%) increase per year during 2008–2015. Rates among females aged 20 to 24
years exhibited a 2.0% (95% CI, 0.8%–3.1%) increase per year throughout 2001–2015
(Figure, Table).
Trends for all self-inflicted injury methods were stable for males. Poisoning was the most
common method of self-inflicted injury for females, with rates remaining stable until 2007
and increasing 5.3% (95% CI, 0.5%–10.4%) annually thereafter. Female rates for self-
inflicted injuries by sharp object increased 7.1% (95% CI, 5.2%–8.9%) annually throughout
2001–2015; female rates for blunt object injuries were stable during 2006–2015 (Table).
Discussion
Youth self-inflicted injury ED visit rates were relatively stable before 2008. However, rates
among females significantly increased thereafter—particularly among females aged 10 to 14
years, who experienced an 18.8% annual increase from 2009 to 2015. This study only
included ED cases; thus, rates were underestimated. Also, limited statistical power could
have resulted in some trends not showing statistical significance. Findings are consistent
with previously reported upward trends in youth suicide rates during 1999–2014, in which
rates increased most notably after 2006 with females aged 10 to 14 years experiencing the
greatest increase.4 Findings also coincide with increased reports of depression among youth,
Mercado et al. Page 2
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especially young girls.5 Other potential underlying reasons for the observed increasing
trends, particularly among young females, warrant further study.
These findings underscore the need for the implementation of evidence-based,
comprehensive suicide and self-harm prevention strategies within health systems and
communities. These strategies include strengthening access to and delivery of care for
suicidal youth within health systems and creating protective environments, promoting youth
connectedness, teaching coping and problem-solving skills, and identifying and supporting
at-risk youth within communities.6
Acknowledgments
Funding/Support: This secondary data analysis study was conducted as part of the regular roles and
responsibilities of all coauthors at the Centers for Disease Control and Prevention (CDC).
Role of the Funder/Sponsor: The CDC was involved in the design and conduct of the study; management,
analysis, and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit
the manuscript for publication. Data was secondarily analyzed by the CDC, who was not involved in the data
collection process.
References
1. Ting SA, Sullivan AF, Boudreaux ED, Miller I, Camargo CA Jr. Trends in US emergency
department visits for attempted suicide and self-inflicted injury, 1993–2008. Gen Hosp Psychiatry.
2012; 34(5):557–565. [PubMed: 22554432]
2. Centers for Disease Control and Prevention. [Accessed December 22, 2016] About underlying cause
of death 1999–2015. https://wonder.cdc.gov/ucd-icd10.html
3. Schroeder, T., Ault, K. The NEISS Sample (Design and Implementation) 1997 to Present.
Washington, DC: Consumer Product Safety Commission; 2001.
4. Curtin, SC., Warner, M., Hedegaard, H. Increase in suicide in the United States, 1999–2014.
Hyattsville, MD: National Center for Health Statistics; 2016.
5. Mojtabai R, Olfson M, Han B. National trends in the prevalence and treatment of depression in
adolescents and young adults. Pediatrics. 2016; 138(6):e20161878. [PubMed: 27940701]
6. Stone, DM., Holland, KM., Bartholow, BN., Crosby, AE., Jack, SPD., Wilkins, N. Preventing
Suicide: A Technical Package of Policies, Programs, and Practices. Atlanta, GA: National Center
for Injury Prevention and Control, Centers for Disease Control and Prevention; 2017.
Mercado et al. Page 3
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Figure. Non-fatal Self-Inflicted Injury Emergency Department Visits among Youth aged 10–24
Years — United States, 2001–2015
APC=Annual Percentage Change; CI=Confidence Intervals
Dotted lines indicate observed rates and solid lines indicate modeled rates. The error bars
represent the standard errors of the observed rates. Only the significant trends were labeled
with APC.
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Mercado et al. Page 5
Table
Trends in Non-fatal Self-Inflicted Injury Emergency Department Visit Rates (per 100,000) among Youth aged 10–24 years — United States, 2001–2015
a
2001 2015 Segment 1 Segment 2 Segment 3
Unweighted
Nonfatal
Self-Inflicted
Injury ED
Visits, No.
Weighted
Rate (95%
CI)
Unweighted
Nonfatal
Self-Inflicted
Injury ED
Visits, No.
Weighted
Rate (95%
CI)
Period APC (95% CI) Period APC (95% CI) Period APC (95% CI)
Male
Age group, y
10–14 93 33.9 (21.4 to
46.4) 180 44.1 (22.9 to
65.3) 2001–2015 1.0 (−2.0 to 4.1)
15–19 387 213.7 (150.4
to 277.0) 531 256.5 (176.9
to 336.1) 2001–2015 0.5 (−0.9 to 1.8)
20–24 350 240.7 (165.6
to 315.8) 407 243.8 (181.7
to 305.9) 2001–2015 −0.1 (−1.3 to 1.2)
Injury Type
b
Poisoning 460 89.5 (69.9 to
109.1) 359 74.1 (55.2 to
93) 2001–2008 −6.3 (−10.4 to
−2.1) 2008–2011 10.6 (−19.4 to
51.9) 2011–2015 −4.3 (−14.0 to
6.4)
Sharp object 228 45.2 (33.4 to
57.1) 347 50.7 (38.5 to
62.8) 2001–2015 1.1 (−0.3 to 2.5)
Blunt object 35 6.0 (3.1 to
8.9) 101 11.8 (7.3 to
16.3) 2001–2015 1.3 (−2.5 to 5.2)
Overall Trend 830 160.8 (114.9
to 206.7) 1118 184.3 (135.1
to 233.5) 2001–2015 0.5 (−0.5 to 1.6)
Age-adjusted Overall Trend 830 160.2 (127.9
to 192.5) 1118 179.2 (144.9
to 213.5) 2001–2015 0.3 (−0.7 to 1.4)
Female
Age group, y
10–14 286 119.4 (78.4
to 160.4) 1033 317.7 (230.3
to 405.1) 2001–2004 9.7 (−8.1 to 30.9) 2004–2009 −4.3 (−13.1 to
5.4) 2009–2015 18.8 (12.1 to
25.8)
15–19 725 389.3 (271.7
to 506.9) 1356 632.5 (465.9
to 799.1) 2001–2004 11.0 (−2.8 to
26.7) 2004–2008 −4.6 (−14.1 to
5.9) 2008–2015 7.2 (3.8 to 10.8)
20–24 355 228.0 (150.4
to 305.6) 556 346.2 (253.1
to 439.3) 2001–2015 2.0 (0.8 to 3.1)
Injury Type
b
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Mercado et al. Page 6
2001 2015 Segment 1 Segment 2 Segment 3
Unweighted
Nonfatal
Self-Inflicted
Injury ED
Visits, No.
Weighted
Rate (95%
CI)
Unweighted
Nonfatal
Self-Inflicted
Injury ED
Visits, No.
Weighted
Rate (95%
CI)
Period APC (95% CI) Period APC (95% CI) Period APC (95% CI)
Poisoning 988 170.9 (135
to 206.8) 987 203.3 (167.1
to 239.5) 2001–2007 −6.4 (−13.0 to
0.8) 2007–2015 5.3 (0.5 to 10.4)
Sharp object 261 54.1 (40.5 to
67.7) 1021 136.3 (103.5
to 169) 2001–2015 7.1 (5.2 to 8.9)
Blunt object 19 2.5 (0.5 to
4.5) 104 11.2 (7.3 to
15.0) 2001–2006 36.1 (15.7 to 60.0) 2006–2015 −0.7 (−4.9 to
3.6)
Overall Trend 1366 244.3 (171.8
to 316.8) 2945 430.8 (325.5
to 536.1) 2001–2004 9.1 (0.2 to 18.8) 2004–2009 −1.6 (−5.7 to
2.8) 2009–2015 7.9 (5.0 to 10.8)
Age-adjusted Overall Trend 1366 245.5 (196.5
to 294.5) 2945 434.0 (363.2
to 504.8) 2001–2004 9.0 (0 to 18.8) 2004–2009 −1.9 (−6.2 to
2.5) 2009–2015 8.4 (5.6 to 11.2)
Overall
Age-adjusted overall trend 201.6 (163.8
to 239.4) 303.7 (254.1
to 353.3) 2001–2004 7.9 (−2.4 to 19.4) 2004–2008 −3.7 (−11.0 to
4.1) 2008–2015 5.7 (3.0 to 8.4)
Abbreviation: APC, annual percentage change.
a
Joinpoint regression was used to determine nonfatal self-inflicted injury emergency department visit rate trends overall and by sex or age-group. Trends are presented as linear segments connected at the
joinpoints (ie, at the years when the slope of each trend changed significantly). The number and location of joinpoints for each trend is determined statistically. Therefore, the time periods for each linear
segment within each trend may vary. If no joinpoint was identified for a trend, then that trend remained linear for the entire 2001–2015 period; in those instances, the APC is presented in Segment 1 only
and left blank for all other segments.
b
Insufficient sample size to analyze the trends for other types of self-inflicted injury. Blunt object-related injuries include “Injuries resulting from being struck by (hit) or crushed by a human, animal, or
inanimate object or force other than a vehicle or machinery.” This does not include falls from heights, such as buildings and bridges.
JAMA
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... Both patientlevel and visit-level analyses were conducted. results For both patient-level models, subsets that included additional records based on an expansion of selection criteria were significantly more likely to include children (model 1: OR 2.8, model 2: OR 2.9; compared with those 25-54 years), those with mental health disorders (model 1: OR 6.5, model 2: OR 4. 3) and rural residents (model 1: OR 1.2, model 2: OR 1.4). Drug-related disorder and means of self-harm were significantly different among subsets for both models. ...
... For over a decade, self-harm by poisoning has ranked among the top five leading causes of injury emergency department (ED) visits resulting in hospitalisation in the USA (all ages) and second among those aged 15-24. 1 Self-harm by other means (cutting and other specified means) has ranked among the top 20 leading causes of death. 1 Furthermore, selfharming behaviours have been increasing and are especially prevalent among youth. [1][2][3] Studies have found that those who self-harm are more likely to repeat the behaviour and are at increased risk of suicide. [4][5][6][7][8][9][10][11][12] The urgency of addressing this problem is evident as suicide is consistently a leading cause of death 13 and the suicide rate in the USA has been increasing for nearly two decades (up 34% from 1999 to 2017). 1 Wisconsin has experienced an even greater increase (40%) over this period. ...
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Background This study explores the impact of using different criteria to identify nonfatal hospitalisations with self-harm injuries using 2017–2018 Wisconsin discharge data. Methods Using International Classification of Diseases, 10th Revision, Clinical Modification codes, we classified records by three mutually exclusive selection criteria: subset A--principal diagnosis of injury, and any code for self-harm, initial encounter only; subset B--non-injury principal diagnosis, and any code for self-harm, initial encounter only; subset C--any principal diagnosis, and any code for self-harm, subsequent and sequelae encounters only. These categories were used to conduct two separate logistic regression models. Model 1 analysed the impact of surveillance limited to a principal diagnosis of injury, initial self-harm encounter (subset B compared with A). Model 2 analysed the impact if limited to initial encounters for self-harm, regardless of principal diagnosis (subset C compared with (A+B)). Both patient-level and visit-level analyses were conducted. Results For both patient-level models, subsets that included additional records based on an expansion of selection criteria were significantly more likely to include children (model 1: OR 2.8, model 2: OR 2.9; compared with those 25–54 years), those with mental health disorders (model 1: OR 6.5, model 2: OR 4.3) and rural residents (model 1: OR 1.2, model 2: OR 1.4). Drug-related disorder and means of self-harm were significantly different among subsets for both models. Visit-level analyses revealed similar results. Discussion Expanding case selection criteria would better capture the scale of hospitalisation for nonfatal self-harm. Using restrictive selection criteria may result in biased understanding of the affected populations, potentially impacting the development of policy and prevention programmes.
... Suicide is the second leading cause of death in youths aged 12 to 18 years in the US. 1 In 2019, 2090 (7.1 per 100 000) adolescents in this age group died by suicide. 2 Visits to hospital emergency departments due to suicidal ideation or attempts in youths aged 15 to 19 years are increasing, 3 with the largest increase observed in Black, Hispanic, and female adolescents between 2008 and 2015. 4,5 Monitoring the temporal trends of suicidal behaviors is important to guide development of effective suicide prevention. [6][7][8][9] In particular, detecting changes in temporal trends in subgroups and when the risk of suicide is greater in those groups can identify high-risk populations for targeted intervention and guide hypothesis generation and testing. ...
... Trends in suicidal ideation among females, particularly among non-Hispanic Black, non-Hispanic White, and Hispanic females, showed a V-shape (decreasing-increasing) change across the entire study period Our finding of the substantial increase in suicide attempts parallels the increase in emergency department visits for nonfatal self-inflicted injuries among youths and young adults. 4,5,33,34 We detected a larger increase in male adolescents attempting suicide than in their female counterparts from 1991 through 2019, which is consistent with previous studies on suicide death rates among male children and youths aged 5 to 18 years between 1991 and 2017. 14,23,35 Possible male-specific risk factors include greater access to firearms at home, 36 less predisposition to seek help, 37 and a greater tendency to adopt avoidance strategies to cope with emotional problems. ...
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Full-text available
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Importance Disparities by sex and racial/ethnic group in suicide death rates are present in US adolescents. Whether disparities in suicide death extend to groups targeted for suicide prevention efforts, namely, those with suicidal ideation or nonfatal suicide attempts, is unknown. Objective To examine differences in temporal trends between suicidal ideation and suicide attempts in US adolescents from 1991 through 2019 by sex and race/ethnicity subgroups. Design, Setting, and Participants A cross-sectional analysis of the national Youth Risk Behavior Survey, weighted to represent US adolescents from 1991 to 2019, included 183 563 US high-school students in grades 9 to 12. Data were analyzed from September 16, 2020, through April 12, 2021. Exposures Calendar year, sex, race/ethnicity, and interactions of sex and race/ethnicity. Main Outcomes and Measures Survey-weighted prevalence estimates, annual percentage changes (APCs) and average APC in the survey-weighted prevalence of suicidal ideation and nonfatal suicide attempts, constructed from self-reported suicidal ideation, plan, and attempts in each survey year, by sex, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian or Pacific Islander and Native Hawaiian, American Indian/Alaska Native), and their interactions (sex × race/ethnicity). Results In 183 563 (unweighted) included adolescents (mean [SD] age, 16.07 [1.23] years; 94 282 females [weighted percentage, 49.4%; 95% CI, 48.8%-50.1%]), the prevalence of suicidal ideation decreased from 1991 to 2019 (from 19.4% to 15.8%; 95% CI, 0.7%-0.9%), whereas the prevalence of nonfatal suicide attempts increased from 1991 to 2019 (from 7.3% to 8.9%; 95% CI, 1.0%-1.4%). Joinpoint regression indicated a −3.1% (95% CI, −3.7% to −2.6%) annual decrease in suicidal ideation between 1991 and 2009, followed by a 3.4% annual increase (95% CI, 1.9% -4.8%) between 2009 and 2019. Decreasing followed by increasing trends in suicidal ideation showed modestly different turning points in female (1991-2009, 2009-2019), White (1991-2009, 2009-2019), Hispanic (1991-2007, 2007-2019), and Black (1991-2005, 2005-2019) adolescents. Although no significant trends were observed in suicide attempts from 1991 through 2019, male (68.4% increase; 95% CI, 0.2% -1.2%) and Black (79.7% increase; 95% CI, 0.1%-1.5%) adolescents had greater increases in the prevalence of suicide attempts. Interaction of sex and race/ethnicity revealed increases in suicidal ideation in White females from 2009 to 2019 (APC, 4.3%; 95% CI, 1.5%-7.1%), Black females from 2005 to 2019 (APC, 3.4%; 95% CI, 1.4%-5.4%), and Hispanic females from 2009 to 2019 (APC, 3.3%; 95% CI, 1.0%-5.6%) and suicide attempts in White females from 2009 to 2019 (APC, 3.1%; 95% CI, 0.3%-6.0%). Conclusions and Relevance The findings of this study show apparent sex and racial/ethnic differences in trends in suicidal ideation and suicide attempts. Increases in suicidal ideation since 2009 were observed in female individuals; changes in male and Black adolescents represented the largest increase in the prevalence of suicide attempts between 1991 and 2019. Evidence-based suicide prevention programs need to be tailored by sex and race/ethnicity, calling for greater diversification of health care system, school, and community prevention approaches.
... The difference in suspected suicide attempts by sex and the increase in suspected suicide attempts among young persons, especially adolescent females, is consistent with past research: self-reported suicide attempts are consistently higher among adolescent females than among males (7), and research before the COVID-19 pandemic indicated that young females had both higher and increasing rates of ED visits for suicide attempts compared with males (8). However, the findings from this study suggest more severe distress among young females than has been identified in previous reports during the pandemic (1,2), reinforcing the need for increased attention to, and prevention for, this population. ...
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Beginning in March 2020, the COVID-19 pandemic and response, which included physical distancing and stay-at-home orders, disrupted daily life in the United States. Compared with the rate in 2019, a 31% increase in the proportion of mental health-related emergency department (ED) visits occurred among adolescents aged 12-17 years in 2020 (1). In June 2020, 25% of surveyed adults aged 18-24 years reported experiencing suicidal ideation related to the pandemic in the past 30 days (2). More recent patterns of ED visits for suspected suicide attempts among these age groups are unclear. Using data from the National Syndromic Surveillance Program (NSSP),* CDC examined trends in ED visits for suspected suicide attempts† during January 1, 2019-May 15, 2021, among persons aged 12-25 years, by sex, and at three distinct phases of the COVID-19 pandemic. Compared with the corresponding period in 2019, persons aged 12-25 years made fewer ED visits for suspected suicide attempts during March 29-April 25, 2020. However, by early May 2020, ED visit counts for suspected suicide attempts began increasing among adolescents aged 12-17 years, especially among girls. During July 26-August 22, 2020, the mean weekly number of ED visits for suspected suicide attempts among girls aged 12-17 years was 26.2% higher than during the same period a year earlier; during February 21-March 20, 2021, mean weekly ED visit counts for suspected suicide attempts were 50.6% higher among girls aged 12-17 years compared with the same period in 2019. Suicide prevention measures focused on young persons call for a comprehensive approach, that is adapted during times of infrastructure disruption, involving multisectoral partnerships (e.g., public health, mental health, schools, and families) and implementation of evidence-based strategies (3) that address the range of factors influencing suicide risk.
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Article
  • Jul 2021
Background Dialectical behaviour therapy (DBT) is an evidence-based treatment for adolescents targeting suicidal and non-suicidal self-injurious behaviours. Research supports DBT's efficacy in inpatient settings, but implementation and sustainability are understudied. Aims This study is a follow-up of a previous study by Tebbett-Mock et al and examines the efficacy and sustainability of an adolescent DBT inpatient unit within a psychiatric hospital in the Northeast. We hypothesised that adolescents who received DBT in our follow-up group (DBT Group 2) would not have statistical difference (ie, greater or fewer) of the following compared with the first group of patients who received DBT on the unit the year prior (DBT Group 1) and would have significantly fewer of the following compared with the treatment as usual (TAU) group: (1) constant observation hours for suicidal ideation, self-injury and aggression; (2) incidents of suicide attempts, self-injury and aggression; (3) restraints; (4) seclusions; (5) days hospitalised; (6) times readmitted to the unit within 30 days of discharge. Methods We conducted a retrospective chart review for adolescents receiving inpatient DBT (DBT Group 1, n=425; DBT Group 2, n=393) and a historical control group (TAU, n=376). The χ 2 tests and one-way analysis of variance were conducted as preliminary analyses to examine group differences on diagnosis, gender and age. Kruskal-Wallis H tests were conducted to examine group differences on outcomes. Mann-Whitney U tests were used as post hoc analyses. Results Patients in DBT Group 2 were comparable to DBT Group 1 for the number of constant observation hours for self-injury (U=83 432.50, p=0.901), restraints (U=82 109, p=0.171) and days hospitalised (U=83 438.5, p=0.956). Patients in DBT Group 2 had a significantly greater number of incidents of suicide attempts compared with DBT Group 1 (U=82 662.5, p=0.037) and of self-injury compared with patients in DBT Group 1 (U=71724.5, p<0.001) and TAU (U=65649.0, p<0.001). Conclusions Results provide support for adolescent inpatient DBT compared with TAU and highlight staff turnover and lack of training as potential barriers to sustainability and efficacy.
Worldwide increases in adolescent loneliness
Article
Introduction Several studies have documented increases in adolescent loneliness and depression in the U.S., UK, and Canada after 2012, but it is unknown whether these trends appear worldwide or whether they are linked to factors such as economic conditions, technology use, or changes in family size. Methods The Programme for International Student Assessment (PISA) survey of 15- and 16-year-old students around the world included a 6-item measure of school loneliness in 2000, 2003, 2012, 2015, and 2018 (n = 1,049,784, 51% female) across 37 countries. Results School loneliness increased 2012–2018 in 36 out of 37 countries. Worldwide, nearly twice as many adolescents in 2018 (vs. 2012) had elevated levels of school loneliness. Increases in loneliness were larger among girls than among boys and in countries with full measurement invariance. In multi-level modeling analyses, school loneliness was high when smartphone access and internet use were high. In contrast, higher unemployment rates predicted lower school loneliness. Income inequality, GDP, and total fertility rate (family size) were not significantly related to school loneliness when matched by year. School loneliness was positively correlated with negative affect and negatively correlated with positive affect and life satisfaction, suggesting the measure has broad implications for adolescent well-being. Conclusions The psychological well-being of adolescents around the world began to decline after 2012, in conjunction with the rise of smartphone access and increased internet use, though causation cannot be proven and more years of data will provide a more complete picture.
Treating Pediatric and Geriatric Patients at Risk of Suicide in General Emergency Departments: Perspectives From Emergency Department Clinical Leaders
Article
Study objective: We explored emergency department clinical leaders' views on providing emergency mental health services to pediatric and geriatric patients with suicidal ideation and suicide attempts. Methods: We conducted semistructured interviews with a total of 34 nursing directors, medical directors, and behavioral health managers at 17 general hospital EDs across the United States, using purposive sampling to ensure variation among hospitals. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using Atlas.ti and a directed content analysis approach. Results: Respondents from across a range of ED types expressed concerns regarding the capacity of their EDs to meet mental health needs of children and older adults. They experienced emotional distress over the increasing number of pediatric patients presenting to EDs with suicidal ideation/suicide attempt and described EDs as inappropriate environments for young patients with suicidal ideation/suicide attempt. Similarly, leaders expressed feeling ill-equipped to diagnose and treat geriatric patients with suicidal ideation/suicide attempt, who often had medical comorbidities that complicated treatment planning. Respondents noted that pediatric and geriatric patients frequently boarded in the ED. Some felt compelled to use creative solutions to provide safe spaces for pediatric and geriatric patients. Respondents voiced frustration over the lack of outpatient and inpatient mental health services for these patients. Conclusion: Clinical leaders in EDs across the nation expressed distress at feeling they were not adequately equipped to meet the needs of pediatric and geriatric patients with suicidal ideation/suicide attempt. Future innovations to provide ED care for children and older adults with suicidal ideation/suicide attempt might include training for ED teams, access to specialist mental health clinicians through telehealth, and adaptations of physical spaces.
A Critique on Psychiatric Inpatient Admissions for Suicidality in Youth
Article
For the last few decades, psychiatric inpatient admissions for the treatment of suicidality in US youth have been increasing. Nonetheless, since 2007, the national rate of completed suicides by youth has steadily and sizably increased. Therefore, a literature review was performed to evaluate the usefulness of the psychiatric inpatient admission of suicidal youths. The analysis concluded that suicidality is surprisingly common in youth, completed suicide is very uncommon in early adolescence, suicidal ideation is a major reason in early adolescence for inpatient admission, girls are admitted to psychiatric inpatient units three times more than boys even though boys complete suicide four times more than girls, inpatient stays average 6 days and are quite expensive, and repeat attempts after inpatient treatment are common. Thus, filling more beds for youth with suicidality lacks evidence of a public health, long-term benefit. Expanding the focus in psychiatry to population efforts including means reductions is recommended.
United States national trends in prevalence of major depressive episode and co-occurring suicidal ideation and treatment resistance among adults
Article
  • Jun 2021
Background Improvement in depression screening and treatment has emerged as a national priority in the US. This study examined temporal trends in prevalence of sub-populations of individuals with pastyear major depressive episode (MDE), including those with suicidal ideation (SI), a suicide plan or attempt (SP/SA), and treatment-resistant depression (TRD). Methods Using the National Survey on Drug Use and Health (NSDUH; 2009-2017), yearly prevalence and trends over time of sub-populations among US adults overall and among those with MDE were determined; prevalence estimates were stratified by sociodemographic characteristics. Results Over the 9-year period, prevalence of MDE+SI increased significantly by 29.3%, from 1.7% to 2.2% (adjusted odds ratio [aOR]=1.38, 95% CI=1.20-1.59); the increase was most prominent among young adults, women, Caucasians, and Native Americans/Alaskan Natives. Among those with MDE, prevalence of SI increased by 21.2%, from 25.6% to 31.1% (aOR=1.25, 95% CI=1.06-1.48). Among those with an MDE in 2017, 31.1% reported SI, 11.5% reported a SP/SA, 9.1% had TRD, and 4.3% experienced TRD+SI. Limitations The NSDUH is based on self-report data; rates of diagnoses and SI from objective assessments and clinical evaluations may be different. Additionally, the survey is cross-sectional rather than longitudinal. Conclusions Substantial increases in the prevalence of SI among adults and among those with MDE were observed from 2009-2017; disproportionate trends were observed among some sociodemographic groups. These findings underscore the importance of understanding the reasons for these concerning trends, as well as the need for improvements in identification and treatment for at-risk individuals.
Negative Health Review of Cell Phones and Social Media
Article
Full-text available
  • Mar 2021
Cell phone and social media usage have become intriguing topics to explore and discuss over recent years. This research aims to review correlations of negative effects in mental and physical health caused by cell phone and social media use in the past two decades. The history of cell phones and their capabilities will be introduced. The need for human connection will be emphasized. Exploration of the connection between unbalanced use and different aspects of health will be evaluated such as addiction, social influences, brain changes, and multitasking. Lastly, resources and recommendations to find balance and support for anyone being adversely affected by cell phones and social media will be provided. Current literature reveals that there is a negative correlation between increased cell phone and social media use with human connection, mental health, and physical health.
Increase in Suicide in the United States, 1999–2014
Article
Full-text available
  • Apr 2016
Key findings: Data from the National Vital Statistics System, Mortality •From 1999 through 2014, the age-adjusted suicide rate in the United States increased 24%, from 10.5 to 13.0 per 100,000 population, with the pace of increase greater after 2006. •Suicide rates increased from 1999 through 2014 for both males and females and for all ages 10-74. •The percent increase in suicide rates for females was greatest for those aged 10-14, and for males, those aged 45-64. •The most frequent suicide method in 2014 for males involved the use of firearms (55.4%), while poisoning was the most frequent method for females (34.1%). •Percentages of suicides attributable to suffocation increased for both sexes between 1999 and 2014.
National Trends in the Prevalence and Treatment of Depression in Adolescents and Young Adults
Article
Objectives: This study examined national trends in 12-month prevalence of major depressive episodes (MDEs) in adolescents and young adults overall and in different sociodemographic groups, as well as trends in depression treatment between 2005 and 2014. Methods: Data were drawn from the National Surveys on Drug Use and Health for 2005 to 2014, which are annual cross-sectional surveys of the US general population. Participants included 172 495 adolescents aged 12 to 17 and 178 755 adults aged 18 to 25. Time trends in 12-month prevalence of MDEs were examined overall and in different subgroups, as were time trends in the use of treatment services. Results: The 12-month prevalence of MDEs increased from 8.7% in 2005 to 11.3% in 2014 in adolescents and from 8.8% to 9.6% in young adults (both P < .001). The increase was larger and statistically significant only in the age range of 12 to 20 years. The trends remained significant after adjustment for substance use disorders and sociodemographic factors. Mental health care contacts overall did not change over time; however, the use of specialty mental health providers increased in adolescents and young adults, and the use of prescription medications and inpatient hospitalizations increased in adolescents. Conclusions: The prevalence of depression in adolescents and young adults has increased in recent years. In the context of little change in mental health treatments, trends in prevalence translate into a growing number of young people with untreated depression. The findings call for renewed efforts to expand service capacity to best meet the mental health care needs of this age group.
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Trends in US Emergency Department Visits for Attempted Suicide and Self-inflicted Injury, 1993–2008
Article
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Preventing Suicide: A Technical Package of Policies, Programs, and Practices
  • Jan 2017
  • D M Stone
  • K M Holland
  • B N Bartholow
  • A E Crosby
  • Spd Jack
  • N Wilkins
Stone, DM., Holland, KM., Bartholow, BN., Crosby, AE., Jack, SPD., Wilkins, N. Preventing Suicide: A Technical Package of Policies, Programs, and Practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2017.
About underlying cause of death 1999-2015
  • Dec 2016
Centers for Disease Control and Prevention. [Accessed December 22, 2016] About underlying cause of death 1999-2015. https://wonder.cdc.gov/ucd-icd10.html
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  • Jan 2001
  • T Schroeder
  • K Ault
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Schroeder, T., Ault, K. The NEISS Sample (Design and Implementation) 1997 to Present. Washington, DC: Consumer Product Safety Commission; 2001.