What happens to patients at risk for suicide after they leave the emergency department (ED)? According to a new study funded by the National Institute of Mental Health and published in JAMA Network Open , people who presented to California EDs with deliberate self-harm or suicidal ideation were not just at risk for a future suicide—they were at extreme risk.
The researchers divided patients into 3 groups: 83,507 who had deliberately self-harmed with or without co-occurring suicidal ideation; 67,379 presenting with suicidal ideation but without deliberate self-harm; and 497,760 without either self-harm or suicidal ideation.
In the first year after the ED visit, the patients who had presented with deliberate self-harm had a suicide rate almost 57 times higher than that of demographically similar Californians. Among those with suicidal ideation, the suicide rate was about 31 times higher. The suicide rate for the reference group, while the lowest of the 3 groups, was still twice the rate among Californians overall.
The researchers found certain clinical and demographic characteristics predicted subsequent suicide. Men and patients aged > 65 years had higher rates of suicide when compared with women or people aged 10 to 24 years. In all groups, suicide rates were higher for non-Hispanic, white patients.
Comorbid diagnoses were associated with suicide risk but with “striking differences” among the groups, the researchers say. Among patients presenting with deliberate self-harm, those with a comorbid diagnosis of bipolar disorder, anxiety disorder, or a psychotic disorder were more likely to die of suicide. Among reference patients, those with bipolar disorder, depression, or alcohol use disorder had a higher risk.
Of note, the researchers say, patients in the deliberate self-harm group who presented with a firearm-related injury had a subsequent suicide rate of 4.4% in the following year, a far higher rate than that in any other patient group. The researchers urge ED physicians to be aware that patients who present with self-harm who use high-lethality methods at a nonfatal event remain at highly increased risk for future suicide.
To the researchers’ knowledge, this is the first US population-based study to examine 12-month suicide rates after an index ED visit. These findings reinforce the importance of universal screening for suicide risk in EDs and the need for follow-up care, the researchers add, “an approach that has been found to increase the number of ED patients identified as warranting treatment for suicide risk by approximately 2-fold, but which is also not yet widespread.”