From the Editor
Are ED visits for suicide attempts becoming more frequent? What are the implications for care?
In the first selection from The American Journal of Psychiatry, Dr. Tanner J. Bommersbach (of the Mayo Clinic) and his co-authors attempt to answer these questions by considering US trends in ED visits for suicide attempts and intentional self-harm. Using national survey data collected over a 10-year period, they estimate that the absolute number of suicide attempts tripled to 5.3 million. “A significant national increase in emergency department visits for suicide attempts and intentional self-harm occurred from 2011 to 2020, as a proportion of total emergency department visits and as visits per capita.” We analyze this study.
In the second selection, Drs. Robert A. Kleinman (of the University of Toronto) and Brian S. Barnett (of the Cleveland Clinic) write about smoking cessation and mental illness in a Viewpoint just published in JAMA Psychiatry. They note societal progress – smoking rates are sharply down over the past five decades – yet many with mental illness still use tobacco. They argue that psychiatrists have a significant role to play in addressing this problem. “Patients who stop smoking can limit tobacco-related illness, avoid the distressing effects of nicotine withdrawal and craving, and live longer.”
Later this week, the Olympics conclude in Paris. In the third selection, former Olympian Alexi Pappas discusses her mother’s suicide and her own struggles with depression. In a deeply personal essay from The New York Times, she contemplates genes and destiny and healing. “My future – the universe where my fear lives – was never set in stone, and neither was my mom’s. I’m more than my genes, and I would not reroll the dice if given the option.”
There will be no Readings for the next two weeks.
DG
Selection 1: “National Trends in Emergency Department Visits for Suicide Attempts and Intentional Self-Harm”
Tanner J. Bommersbach, Mark Olfson, Taeho Greg Rhee
The American Journal of Psychiatry, July 2024
Suicide continues to be a major public health problem in the United States, and suicide rates have risen by 35% since 2000. Suicide attempts are the single most important risk factor for suicide and the risk factor most likely to precipitate contact with the health care system. It is estimated that 1 in 25 individuals who present to the hospital for self-harm will die by suicide within 5 years… Since many patients are treated in emergency departments after a suicide attempt, emergency departments are an important setting for determining epidemiologic trends in suicidal behavior, especially because the United States does not have a national monitoring system for suicide attempts. Over the past three decades, several studies have raised concern about rising emergency department visits for suicide attempts… Yet, there have been no nationally representative U.S. estimates of annual trends in emergency department visits for suicide attempts and intentional self-harm since 2013, including trends stratified by sociodemographic groups.
So begins a paper by Bommersbach et al.
Here’s what they did:
- They drew data from the National Hospital Ambulatory Medical Care Survey, “an annual cross-sectional national sample survey of emergency departments” with a response rate of 77%.
- “Visits for suicide attempts and intentional self-harm were identified using discharge diagnosis codes… or reason-for-visit codes.”
- “The annual proportion of emergency department visits for suicide attempts and intentional self-harm was estimated.”
Here’s what they found:
- Total number. “The estimated number of suicide attempt and intentional self-harm emergency department visits increased from 1.43 million (0.6% of total emergency department visits) in 2011–2012 to 5.37 million (2.1% of total emergency department visits) in 2019–2020 (average annual percent change: 19.5%…).”
- Per capita. “Visits per capita increased from 261 to 871 visits per 100,000 persons (average annual percent change, 18.8%…).”
- Sociodemographics. “The increase in visits was widely distributed across sociodemographic groups.”
- Age groups. “While suicide attempt and intentional self-harm visits were most common among adolescents, adults age 65 or older demonstrated the largest increase (average annual percent change, 30.2%…).”
- Diagnoses. Drug-related diagnoses were the most common co-occurring diagnosis among suicide attempt and intentional self-harm visits. See figure below.
- Evaluations. Less than 16% of these ED visits included an evaluation by a mental health professional. (!!)
A few thoughts:
1. This is an impressive study with a solid dataset – that is, survey data with an excellent response rate covering a full decade – and published in a major journal.
2. The main findings in a sentence: up and up, both as a proportion of total ED visits and ED visits per capita.
3. Ouch.
4. Does this trend reflect growing mental despair? Or are more people seeking care with declining stigma? Or both?
5. The data ends at the beginning of the pandemic. Like all great studies, the authors raise more questions than they answer. We must wonder: what do ED visits look like in the era of COVID-19?
6. In an accompanying Editorial, Annette Erlangsen (of the University of Copenhagen) and her co-authors don’t mince their words: “It is highly concerning that an almost threefold increase in the number of suicide attempts was estimated over the past decade in the United States.”
They see a need for action in the US and beyond:
“In the Bommersbach et al. study, as many as 80% of those presenting with suicide attempts were considered to have a mental disorder. Admission to a psychiatric hospital or referral to outpatient treatment hinges on insurance coverage, access, and availability of care. In a country with a universal health care system, it was reported that less than half of those who presented with a suicide attempt were referred to psychiatric treatment. These data constitute ample incentive for initiating suicide prevention efforts directly in the emergency department, and several evidence-supported interventions are suitable for this. For example, a safety planning intervention in the emergency department, which was followed by structured risk assessments over the telephone, has been associated with reductions in repeat suicidal behavior.”
The Editorial can be found here:
https://psychiatryonline.org/doi/10.1176/appi.ajp.20240524
7. Like all studies, there are limitations. The authors note several, including the reliance on ICD codes which have lower sensitivity – and thus may, in fact, underestimate the total number of suicide attempt-related visits.
The full AJP study can be found here:
https://psychiatryonline.org/doi/10.1176/appi.ajp.20230397
Selection 2: “Smoking Cessation as a Priority for Psychiatrists”
Robert A. Kleinman and Brian S. Barnett
JAMA Psychiatry, 31 July 2024
The last 50 years have seen important reductions in cigarette smoking in the United States. However, these reductions have been unevenly distributed, and rates of cigarette smoking remain elevated among individuals with psychiatric illness, including other substance use disorders (SUDs). Psychiatrists are uniquely positioned to address this disparity, having both the skills to treat tobacco use disorder and regular contact with patients more likely to smoke.
So begins a Viewpoint by Drs. Kleinman and Barnett.
They note that smoking rates remain high among those with mental disorders and summarize relevant literature:
- “Estimates from the 2019 US National Survey on Drug Use and Health indicated that 24% of individuals with a past-year major depressive episode and 36% of individuals with an SUD had past-month cigarette smoking, compared with 16% of individuals without a past-year major depressive episode or SUD.”
- “In a large psychiatric hospital system in Maryland… 62% of patients with schizophrenia smoked cigarettes.
- “Tobacco-related diseases were responsible for 53% of deaths among individuals with schizophrenia, 48% of deaths among those with bipolar disorder, and 50% of deaths among those with depression admitted to California hospitals between 1990 and 2005.” (!!)
Yet medications are rarely prescribed. “A study of smoking cessation medication use, conducted through the Medical Expenditure Panel Survey among individuals who smoke, found in 2019 that less than 2% of individuals were prescribed varenicline or nicotine replacement therapy, and 8.4% were prescribed bupropion.”
They argue that psychiatrists are uniquely positioned to help patients quit. “Many paradigms of smoking cessation counseling (eg, the 5 As: ask, advise, assess, assist, and arrange; problem-solving; and coping skills) use techniques familiar to psychiatrists. Helping patients to identify high-risk situations, anticipate internal and external triggers for smoking, and navigate cravings has similarities to strategies used in several types of psychotherapy. An understanding of patients’ other psychiatric symptoms can assist psychiatrists in tailoring smoking cessation counseling to the challenges faced by patients with other psychiatric disorders.”
Why then the hesitancy? They mention several things, including that “psychiatrists may feel as though smoking cessation falls under the purview of other health professionals, especially given the physical health sequelae of tobacco use and tobacco use disorder historically being addressed in primary care settings.” They disagree: “many patients with mental illness have more regular contact with psychiatrists than with other physicians.” Psychiatrists may also feel that patients are uninterested in change. However, they note: “Studies of motivation and readiness to change have found similar or higher levels of motivation to stop smoking among individuals with mental illness compared with other individuals.”
They close with practical suggestions. “We recommend psychiatrists screen for tobacco use, as well as for other types of nicotine consumption, such as electronic cigarettes, as a core part of psychiatric assessments. If the screening is positive, psychiatrists should evaluate the contribution of smoking and nicotine withdrawal to the symptoms driving presentation for psychiatric assessment. Psychiatrists should then offer patients smoking cessation pharmacotherapies and appropriate counseling and/or motivational interviewing.”
A few thoughts:
1. This is an excellent Viewpoint.
2. The recommendations are reasonable and practical.
3. While other substances are clearly problematic, the mortality and morbidity of tobacco use overshadow everything else. That’s not an argument to ignore, say, the opioid crisis. Rather, Drs. Kleinman and Barnett are right to remind us of the burden of cigarettes.
4. Want to hear more about motivational interviewing? This Quick Takes interview with Dr. Leslie Buckley (of the University of Toronto) may be of interest:
The full JAMA Psych Viewpoint can be found here:
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2821945
Selection 3: “Chasing Five Rings to Escape Destiny”
Alexi Pappas
The New York Times, 19 June 2024
‘Your mommy was just so sad that she had to go.’
I’ve been told this all my life. I suppose that this framing is meant to comfort me, as if my mom’s suicide was as natural, unavoidable and unfortunate as a sand castle facing its eventual collapse. I have never found this explanation reassuring, though, because she contributed to half of my DNA. I have no control over how much of my mom’s mental illness is inside of me. If her suicide was inevitable, would I face the same outcome as her? Would I one day ‘have to go,’ too?
My mom had bipolar disorder… After developing an addiction to pain pills that were originally prescribed to treat a back injury due to pregnancy complications, she became suicidal and died in 1994, when I was 4 years old.
So begins an essay by Pappas.
She writes about her mother. “She was an accomplished athlete and singer, class valedictorian and one of the first female software consultants at her company.” Pappas comments on genes. “Explain to me how, apart from genes, my mom could have so many successes … and still ‘have to go’? Especially since my mom’s only brother ‘had to go’ several years later, too.”
“So to say that I fear my genes is an understatement.”
She discusses her fears and her running. “[F]or the longest time, the only way I could think of to avoid my mom’s fate was to rely on another, more undeniably positive aspect of my genetic makeup – my athletic ability.” And so, she pushed herself, eventually competing at the Olympics. “Because forever an Olympian, forever happy, right?”
After the Games, she was low. “I felt blindsided that becoming an Olympian didn’t provide me with the satisfaction I so craved. Instead of viewing the Olympics as proof that I could overcome obstacles or adapt to adversity, I mistook the accolades as a cure for my intrinsic discomfort. So, when I became overwhelmed with sadness after the Games, I rejected my depression for as long as I could, afraid that if I acknowledged it, I would finally have to confront the destiny I assumed for myself and ‘have to go.’”
She talks about getting care. “My dad sensed red flags and eventually made me get help. When he told me that ‘we aren’t going to lose this time,’ I knew exactly what he meant. Sometimes you get help for yourself; sometimes it takes thinking about the people you love. I got help because of my dad.” Her psychiatrist made a comment that was particularly helped. “He compared mental illness to falling and scraping your knee, except the cut is on your brain. And, just like your knee, your brain can be treated, too.”
“While depression may be an invisible injury, treating your mental health like your physical health is not only possible, but necessary. I now understand that even though I can’t control what my genes have in store for me, there are steps I can take to manage their influence.”
She closes by pushing past genes and destiny. “I’m creating my self, not just discovering it. I have visible and invisible muscles both inside and out that I can strengthen and use to push myself across great distances. I have agency and potential until the day I die. I’m grateful for who I am and what I was born with and without. And while I have no way of regaining what’s been lost, there’s nothing that says I ‘have to leave.’ I prefer the mystery of life, with all its beauty and pain, over the certainty of death.”
A few thoughts:
1. This is a beautiful essay.
2. We should be grateful that she is so willing to talk about her journey.
3. A runner who uses her athleticism to cope with her loss and pain – raw and relatable.
4. In 2020, Pappas did a video about her depression which was considered in a past Reading. Her comments about her mother are particularly moving. “I’ve had such misunderstanding for my own mom, and such resentment towards her. I thought she just didn’t love me enough to stay. That’s not true. She was sick… She didn’t have to die. And that’s so sad because we would have been really good friends, I think.” That Reading can be found here:
The full NYT essay can be found here:
https://www.nytimes.com/2024/06/19/special-series/alexi-pappas-fear-depression-olympics.html
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
Recent Comments