The association between alcohol use disorder and suicidal ideation in a New Zealand birth cohort.

BACKGROUND: Alcohol use disorder is associated with increased suicide risk; however, both alcohol use disorder and suicide share risk factors which must be accounted for in order to understand this relationship. This study aimed to explore the longitudinal relationship between alcohol use disorder and suicidal ideation in adulthood, while accounting for both child background and adult covariate factors. METHOD: Data were collected from the Christchurch Health and Development Study, a birth cohort of 1265 children born in Christchurch (New Zealand) in mid-1977. Alcohol use disorder (operationalised as alcohol abuse and alcohol dependence) was quantified between age 18 and 40 in five data waves. The outcome measure suicidal ideation was reported over the same time periods. Childhood confounding variables were controlled for, as well as time-dynamic covariates collected in adulthood, including internalising disorders, distress due to relationship dissolutions and other substance use disorders. RESULTS: The association between alcohol abuse and suicidal ideation was not statistically significant before or after adjusting for childhood confounding and adulthood covariate factors, when compared to no alcohol disorder. However, the association between alcohol dependence and suicidal ideation was significant both before and after adjustment (unadjusted odds ratio = 2.89, 95% confidence interval = [2.09, 3.99]; adjusted odds ratio = 1.52, 95% confidence interval = [1.04, 2.23]), when compared to no alcohol disorder. Furthermore, alcohol dependence remained significant when compared to alcohol abuse (unadjusted odds ratio = 2.33, 95% confidence interval = [1.61, 3.37]; adjusted odds ratio = 1.54, 95% confidence interval = [1.00, 2.37]). CONCLUSION: This analysis found an association between alcohol dependence and suicidal ideation within a New Zealand birth cohort, which persists even after adjustment for childhood confounding and adulthood covariate factors. Given the high rates of suicide and heavy drinking within the New Zealand population, any comprehensive national or regional suicide prevention plan should seek to reduce risky alcohol consumption at an individual and population level, as this represents a modifiable risk factor for suicide.

Farm suicides in New Zealand, 2007-2015: A review of coroners' records.

OBJECTIVE: Economic recessions and severe weather events are often associated with increased suicide rates. The Global Dairy Crisis 2015/2016 led to an economic downturn in the New Zealand dairy farming industry and, coupled with droughts in some regions and floods in others, raised fears about increased suicide rates among farmers. However, little was known about suicides in the farming sector. This study reviews characteristics of recent farm-related suicides in New Zealand and assesses the extent to which financial stresses contributed to the deaths. METHODS: Data were abstracted from coroners' records for a consecutive series of 185 people in farm- and agriculture-related occupations who died by suicide between 2007 and 2015 and for whom coronial inquiries had been completed. RESULTS: Farm suicides were heterogeneous: six distinct risk profiles were identified. Financial stresses made negligible contributions to farm suicides. Overall, risk factors for farm suicides differed little from risk factors for suicide in the general population. However, suicide risk in farmers was exacerbated by ready access to firearms: almost 40% of farm suicides involved firearms, compared to 8% in the general population over the same time. Among farm suicides, young male farm labourers predominated, rather than farm owners or managers. For many young men, relationship losses, acute alcohol intoxication and ready access to a firearm formed a common constellation of risk factors. CONCLUSIONS: While coroners' records are variable and do not record specific information about financial stresses and weather events, it was clear that these issues made a negligible contribution to farm suicides. A range of rural suicide prevention initiatives are needed to address various farm suicide risk profiles. In particular, young male labourers often had no contact with health services prior to death, suggesting that rural suicide prevention efforts need to be positioned within community, farming and sports organisations, as well as health and social service providers.

An examination of suicide research and funding in New Zealand 2006-16: implications for new research and policies.

Objective Suicide is a significant public health problem in New Zealand, with the youth suicide rate being one of the highest among developed countries. Increased suicide rates in recent years suggest that the evidence base and research priorities for New Zealand suicide prevention need to be reassessed. To inform policy development, the aim of the present study was to evaluate all peer-reviewed New Zealand published suicide research and major grant allocations from 2006 to 2016. Methods The methodology duplicated a recent Australian review of suicide prevention research and funding. Publications and grant funding allocations were assessed independently. Key research databases were searched in April 2016 for all suicide-related publications. Identified papers were then classified by research type, population focus and type of self-injurious behaviour. Citation indices were obtained for each publication. Annual reports, newsletters and summary data from four major New Zealand funding bodies (the Health Research Council of New Zealand, Marsden Fund, Lottery Health Research and the Ministry of Health) were reviewed for funding allocations. Identified grants were coded for type of project, type of self-injurious behaviour and target population. Descriptive analyses were performed. Results In all, 104 published articles and 27 grants met review criteria. Total funding was NZ$12677261.62. Most published articles were epidemiological in nature and the most common type of grant was for an intervention. Conclusions In the past decade, a substantial number of articles has been published and significant funding was invested in New Zealand's suicide research. The present review suggests that future research investments should focus on effective translation of research findings into suicide prevention programs. Several pragmatic recommendations are proposed to help improve the evidence base and reduce New Zealand's suicide rates. What is known about the topic? Suicide prevention continues to be a national public health priority for New Zealand. Although much is known about the prevalence of suicidal behaviours in New Zealand, less is known about how well suicide research has addressed prevention priorities and specific target populations. Australian research found that research funding and publications were dominated by epidemiological studies rather than evaluation or intervention studies. It is yet to be determined whether these research and funding trends also apply for New Zealand. What does this paper add? This study examined all peer-reviewed and published suicide research and all major suicide prevention projects that have been funded in New Zealand between 2006 and 2016. The purpose of the review was to summarise the evidence base, evaluate funding and determine the ability of the evidence base to inform policy development. The findings demonstrate that the New Zealand research trends are similar to those found in Australia, with most studies being epidemiological and few representative of interventions. What are the implications for practitioners? This review highlights that there were few intervention and evaluation studies. Partnerships between practitioners and/or community organisations implementing interventions and researchers to systematically evaluate existing interventions and develop new evidence-based interventions would help improve the evidence base for New Zealand suicide prevention.

International Society for Bipolar Disorders Task Force on Suicide: meta-analyses and meta-regression of correlates of suicide attempts and suicide deaths in bipolar disorder.

OBJECTIVES: Bipolar disorder is associated with a high risk of suicide attempts and suicide death. The main objective of the present study was to identify and quantify the demographic and clinical correlates of attempted and completed suicide in people with bipolar disorder. METHODS: Within the framework of the International Society for Bipolar Disorders Task Force on Suicide, a systematic review of articles published since 1980, characterized by the key terms bipolar disorder and 'suicide attempts' or 'suicide', was conducted, and data extracted for analysis from all eligible articles. Demographic and clinical variables for which ≥ 3 studies with usable data were available were meta-analyzed using fixed or random-effects models for association with suicide attempts and suicide deaths. There was considerable heterogeneity in the methods employed by the included studies. RESULTS: Variables significantly associated with suicide attempts were: female gender, younger age at illness onset, depressive polarity of first illness episode, depressive polarity of current or most recent episode, comorbid anxiety disorder, any comorbid substance use disorder, alcohol use disorder, any illicit substance use, comorbid cluster B/borderline personality disorder, and first-degree family history of suicide. Suicide deaths were significantly associated with male gender and first-degree family history of suicide. CONCLUSIONS: This paper reports on the presence and magnitude of the correlates of suicide attempts and suicide deaths in bipolar disorder. These findings do not address causation, and the heterogeneity of data sources should limit the direct clinical ranking of correlates. Our results nonetheless support the notion of incorporating diagnosis-specific data in the development of models of understanding suicide in bipolar disorder.

A review of factors associated with greater likelihood of suicide attempts and suicide deaths in bipolar disorder: Part II of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder.

OBJECTIVES: Many factors influence the likelihood of suicide attempts or deaths in persons with bipolar disorder. One key aim of the International Society for Bipolar Disorders Task Force on Suicide was to summarize the available literature on the presence and magnitude of effect of these factors. METHODS: A systematic review of studies published from 1 January 1980 to 30 May 2014 identified using keywords 'bipolar disorder' and 'suicide attempts or suicide'. This specific paper examined all reports on factors putatively associated with suicide attempts or suicide deaths in bipolar disorder samples. Factors were subcategorized into: (1) sociodemographics, (2) clinical characteristics of bipolar disorder, (3) comorbidities, and (4) other clinical variables. RESULTS: We identified 141 studies that examined how 20 specific factors influenced the likelihood of suicide attempts or deaths. While the level of evidence and degree of confluence varied across factors, there was at least one study that found an effect for each of the following factors: sex, age, race, marital status, religious affiliation, age of illness onset, duration of illness, bipolar disorder subtype, polarity of first episode, polarity of current/recent episode, predominant polarity, mood episode characteristics, psychosis, psychiatric comorbidity, personality characteristics, sexual dysfunction, first-degree family history of suicide or mood disorders, past suicide attempts, early life trauma, and psychosocial precipitants. CONCLUSION: There is a wealth of data on factors that influence the likelihood of suicide attempts and suicide deaths in people with bipolar disorder. Given the heterogeneity of study samples and designs, further research is needed to replicate and determine the magnitude of effect of most of these factors. This approach can ultimately lead to enhanced risk stratification for patients with bipolar disorder.

Epidemiology, neurobiology and pharmacological interventions related to suicide deaths and suicide attempts in bipolar disorder: Part I of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder.

OBJECTIVES: Bipolar disorder is associated with elevated risk of suicide attempts and deaths. Key aims of the International Society for Bipolar Disorders Task Force on Suicide included examining the extant literature on epidemiology, neurobiology and pharmacotherapy related to suicide attempts and deaths in bipolar disorder. METHODS: Systematic review of studies from 1 January 1980 to 30 May 2014 examining suicide attempts or deaths in bipolar disorder, with a specific focus on the incidence and characterization of suicide attempts and deaths, genetic and non-genetic biological studies and pharmacotherapy studies specific to bipolar disorder. We conducted pooled, weighted analyses of suicide rates. RESULTS: The pooled suicide rate in bipolar disorder is 164 per 100,000 person-years (95% confidence interval = [5, 324]). Sex-specific data on suicide rates identified a 1.7:1 ratio in men compared to women. People with bipolar disorder account for 3.4-14% of all suicide deaths, with self-poisoning and hanging being the most common methods. Epidemiological studies report that 23-26% of people with bipolar disorder attempt suicide, with higher rates in clinical samples. There are numerous genetic associations with suicide attempts and deaths in bipolar disorder, but few replication studies. Data on treatment with lithium or anticonvulsants are strongly suggestive for prevention of suicide attempts and deaths, but additional data are required before relative anti-suicide effects can be confirmed. There were limited data on potential anti-suicide effects of treatment with antipsychotics or antidepressants. CONCLUSION: This analysis identified a lower estimated suicide rate in bipolar disorder than what was previously published. Understanding the overall risk of suicide deaths and attempts, and the most common methods, are important building blocks to greater awareness and improved interventions for suicide prevention in bipolar disorder. Replication of genetic findings and stronger prospective data on treatment options are required before more decisive conclusions can be made regarding the neurobiology and specific treatment of suicide risk in bipolar disorder.

Suicides by jumping from a height in Hong Kong: a review of coroner court files.

PURPOSE: Jumping from a height is the most common method for suicide in Hong Kong and other urban cities, but it remains understudied locally and internationally. We used Coroner records in exploring the ecological factors associated with these deaths and the personal characteristics of persons who jumped to their death (hereafter, "jumping suicides"). We compared suicides by jumping with all other suicides and examined the suicides that occurred at ten different jumping sites. METHODS: The Coroner's files of all suicides in Hong Kong from 2002 to 2007 included 6,125 documented deaths. RESULTS: 2,964 (48.4%) involved jumping during the study period. Eighty-three percent (83%) of suicide jumps occurred in residential buildings, and of these, 61% occurred from the decedent's own home. Jumping suicides differed from non-jumping suicides in terms of their socio-demographic characteristics (e.g., for male: 60.8 vs. 67.3% of jumping suicide and non-jumping suicides, p < 0.0001) and the presence of physical illness (44.4 vs. 42.7% for jumping and non-jumping suicides, p < 0.0001). While statistically significant, these differences are relatively modest. In contrast, 40.7 documented illnesses vs. 23.1% for jumping and non-jumping suicides (p < 0.0001). CONCLUSIONS: Means restriction is a key strategy for suicide prevention. Installation of physical barriers, one of the mean restriction strategies, at common places for suicide has strong evidence to avert suicides without substitution effects. There seems to be challenges to implement physical barriers to prevent residential jumping suicides. Simply applying physical barriers to preclude jumping in Hong Kong appears to be difficult given its ubiquitous "high-rise" residential dwellings. Hence, we also need to develop alternative strategies aimed at preventing people from becoming suicidal.

Acute alcohol use and suicide deaths: an analysis of New Zealand coronial data from 2007-2020.

AIMS: Acute alcohol use is a proximal risk factor for suicide. However, the proportion of suicide deaths involving acute alcohol use has not been quantified in New Zealand. We sought to quantify and characterise the association between acute alcohol use and suicide. METHODS: Data for all suicides (≥15 years) between July 2007 and December 2020 were drawn from the National Coronial Information System. Acute alcohol use was defined as blood alcohol concentration (BAC) >50mg/100mL. Logistic regression was used to compare characteristics between suicide deaths with and without acute alcohol use. RESULTS: Twenty-six point six percent of suicide deaths involved acute alcohol use. No difference in the association was found by sex (male AOR: 0.87 (95%CI: 0.74,1.02)). Ethnicity differences were identified (Maori AOR: 1.20 (95%CI: 1.01,1.42), Pacific AOR: 1.46 (95%CI: 1.10,2.00)). Those aged 15-54 years had similar risks of suicide involving acute alcohol use, with a lower association in older age groups. CONCLUSIONS: Acute alcohol use was identified in approximately one quarter of suicides, with stronger associations in those of Maori and Pasifika ethnicity, and those aged <55 years. Acute alcohol use is a significant but modifiable risk factor for suicide in New Zealand.

A preliminary naturalistic study of low-dose ketamine for depression and suicide ideation in the emergency department.

We examined the preliminary feasibility, tolerability and efficacy of single-dose, intravenous (i.v.) ketamine in depressed emergency department (ED) patients with suicide ideation (SI). Fourteen depressed ED patients with SI received a single i.v. bolus of ketamine (0.2 mg/kg) over 1-2 min. Patients were monitored for 4 h, then re-contacted daily for 10 d. Treatment response and time to remission were evaluated using the Montgomery-Asberg Depression Rating Scale (MADRS) and Kaplan-Meier survival analysis, respectively. Mean MADRS scores fell significantly from 40.4 (s.e.m.=1.8) at baseline to 11.5 (s.e.m.=2.2) at 240 min. Median time to MADRS score ≤10 was 80 min (interquartile range 0.67-24 h). SI scores (MADRS item 10) decreased significantly from 3.9 (s.e.m.=0.4) at baseline to 0.6 (s.e.m. =0.2) after 40 min post-administration; SI improvements were sustained over 10 d. These data provide preliminary, open-label support for the feasibility and efficacy of ketamine as a rapid-onset antidepressant in the ED.

Multiple aspects of sexual orientation: prevalence and sociodemographic correlates in a New Zealand national survey.

Sexual orientation consists of multiple components. This study investigated both sexual identity and same-sex sexual behavior. Data came from the New Zealand Mental Health Survey, a nationally representative community sample of New Zealanders aged 16 years or older, interviewed face-to-face (N = 12,992, 48% male). The response rate was 73.3%. Self-reported sexual identity was 98.0% heterosexual, 0.6% bisexual, 0.8% homosexual, 0.3% "Something else," and 0.1% "Not sure." Same-sex sexual behavior with a partner was more common: 3.2% reported same-sex sexual experience only and 1.9% reported both experience and a relationship. For analysis of childhood and lifecourse, five sexuality groups were investigated: homosexual, bisexual, and heterosexual divided into those with no same-sex sexual experience, experience only, and experience and relationship. The non-exclusively heterosexual groups were more likely to have experienced adverse events in childhood. Educational achievement and current equivalized household income did not differ systematically across the sexuality groups. Only 9.4% of the exclusively heterosexual lived alone, compared with 16.7% of bisexuals and 19.0% of homosexuals. Heterosexuals were more likely than bisexuals or homosexuals to have ever married or had biological children, with differences more marked for males than for females. Heterosexuals with no same-sex sexual experience were more likely to be currently married than the other two heterosexual groups. Restricting comparisons to heterosexual, bisexual, and homosexual identification ignores the diversity within heterosexuals. Differences between the bisexual and homosexual groups were small compared with the differences between these groups and the exclusively heterosexual group, except for sex (80.8% of bisexuals were female).

Introducing the Psychological Autopsy Methodology Checklist.

OBJECTIVE: Case-control psychological autopsy studies are the research standard for the postmortem, quantitative study of ongoing or recent risk factors for suicide. We aimed to develop a reliable checklist of methodological quality of these studies. METHOD: We adapted items from a validated checklist to address general methodological elements and created novel items to address the unique aspects of psychological autopsy research to generate a 16-item checklist assessing reporting, external validity, internal validity, and power. We used percent agreement and kappa to evaluate inter-rater reliability of the items and overall checklist based on independent ratings of 26 case-control psychological autopsy studies conducted internationally. We also summed the items to generate overall quality ratings, assessing internal consistency with coefficient alpha (α). RESULTS: Inter-rater reliability for the overall checklist was high (percent agreement, 86.5%) and that based conservatively on kappa was substantial (κ .71) whereas internal consistency was low (α = 0.56). The inter-rater reliability of the individual items showed acceptable to high agreement. CONCLUSION: A novel checklist provides a reliable means to assess the methodological quality of specific elements of quantitative case-control psychological autopsy studies, providing detailed guidance in planning such studies. Lower internal consistency may limit its utility as a summary measure of study quality.

Chronic physical conditions and their association with first onset of suicidal behavior in the world mental health surveys.

OBJECTIVE: To investigate the association of a range of temporally prior physical conditions with the subsequent first onset of suicidal ideation, plans, and attempts in large, general population, cross-national sample. The associations between physical conditions and suicidal behavior remain unclear due to sparse data and varied methodology. METHODS: Predictive associations between 13 temporally prior physical conditions and first onset of suicidal ideation, plans, and attempts were examined in a 14-country sample (n = 37,915) after controlling for demographic, socioeconomic, and psychosocial covariates, with and without adjustment for mental disorders. RESULTS: Most physical conditions were associated with suicidal ideation in the total sample; high blood pressure, heart attack/stroke, arthritis, chronic headache, other chronic pain, and respiratory conditions were associated with attempts in the total sample; epilepsy, cancer, and heart attack/stroke were associated with planned attempts. Epilepsy was the physical condition most strongly associated with the suicidal outcomes. Physical conditions were especially predictive of suicidality if they occurred early in life. As the number of physical conditions increased, the risk of suicidal outcomes also increased, however the added risk conferred was generally smaller with each additional condition. Adjustment for mental disorders made little substantive difference to these results. Physical conditions were equally predictive of suicidality in higher and lower income countries. CONCLUSIONS: The presence of physical conditions is a risk factor for suicidal behavior even in the absence of mental disorder.

Postcard intervention for repeat self-harm: randomised controlled trial.

BACKGROUND: Self-harm and suicidal behaviour are common reasons for emergency department presentation. Those who present with self-harm have an elevated risk of further suicidal behaviour and death. AIMS: To examine whether a postcard intervention reduces self-harm re-presentations in individuals presenting to the emergency department. METHOD: Randomised controlled trial conducted in Christchurch, New Zealand. The intervention consisted of six postcards mailed during the 12 months following an index emergency department attendance for self-harm. Outcome measures were the proportion of participants re-presenting with self-harm and the number of re-presentations for self-harm in the 12 months following the initial presentation. RESULTS: After adjustment for prior self-harm, there were no significant differences between the control and intervention groups in the proportion of participants re-presenting with self-harm or in the total number of re-presentations for self-harm. CONCLUSIONS: The postcard intervention did not reduce further self-harm. Together with previous results this finding suggests that the postcard intervention may be effective only for selected subgroups.

Health-care staff attitudes towards self-harm patients.

OBJECTIVE: To examine attitudes towards self-harm patients and need for training about self-harm amongst health-care staff in Christchurch, New Zealand. METHODS: Health-care staff from a general and a psychiatric hospital completed a questionnaire about their attitudes towards self-harm patients and their need for training about self-harm. RESULTS: A total of 195 staff members completed the questionnaire (response rate 64.4%). Overall, health-care staff had both positive and negative attitudes towards self-harm patients. Staff believed that their contact was helpful to self-harm patients, that they were patient and understanding, and were optimistic about patients' outcomes. However, staff did not feel confident working with self-harm patients and believed that their training in this area was inadequate. Attitudes were not significantly associated with age, gender, or experience. However, more negative attitudes were significantly associated with higher levels of burnout (through high emotional exhaustion (p <0.0002) and low personal accomplishment (p <0.003)). Staff comments indicated that their greatest difficulties working with self-harm patients included repetitive self-harm, frustrating and difficult patient behaviour, communication difficulties, and time pressure. Staff suggestions for improvement included more training, provision of a handbook or guidelines, and greater flexibility with patient allocations. CONCLUSIONS: Overall, health-care staff had positive attitudes towards self-harm patients, and a strong desire to help such patients. However, staff did not feel confident working with self-harm patients and had a strong desire for additional training in this area. Additional staff training in working with self-harm patients could have the potential to increase staff confidence and attitudes and enhance patient care.

Suicide Prevention in the Western Pacific Region.

This chapter draws on internationally available data to describe the epidemiology of suicide and self-harm in the World Health Organization (WHO) Western Pacific Region. It then describes the suicide prevention activities in the region, using in-depth case studies to highlight some key suicide prevention activities in certain countries/areas and the Global Survey on Suicide Prevention conducted in 2013 by the International Association for Suicide Prevention (IASP) and WHO. It demonstrates that there is considerable variability both between and within low and middle income countries and high income countries, both in terms of rates of suicide and self-harm and in terms of the preventive efforts that have been mobilised to address them. Adequate funding for suicide prevention efforts in the region should be a priority, as should the delivery of a range of suicide prevention approaches. Evaluation and monitoring efforts are also crucial.

Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO World Mental Health Surveys.

BACKGROUND: Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts. METHODS AND FINDINGS: Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9-8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5-5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies. CONCLUSIONS: This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.

Epidemiological trends in psychosis-related Emergency Department visits in the United States, 1992-2001.

Mental health visits represented an increasing fraction of all Emergency Department (ED) visits in the U.S. between 1992 and 2001. This study used the National Hospital Ambulatory Medical Care Survey, a 4-staged probability sample of ED visits from geographically diverse hospitals around the U.S., to assess the contribution of all psychosis-related visits to this overall trend. Unlike other mental-health-related ED visits, the rate of psychosis-related visits did not increase. This lack of change is notable in the context of dramatic changes in both healthcare financing and antipsychotic prescribing practices during this period. There was an unexpected decrease in Medicare-funded psychosis-related ED visits at a time of increasing Medicare enrollment overall. An important demographic trend over this decade was the increasing urbanization of psychosis-related ED visits coincident with a relative decrement in such visits within rural areas.