Identifying Subgroups of Youth Suicide Decedents Based on Clinical Profiles of Psychiatric and Medical Diagnoses: A Latent Class Analysis.

PURPOSE: To identify risk subgroups of youth suicide decedents using demographic and clinical psychiatric and medical diagnostic profiles to inform tailored youth suicide prevention efforts. METHODS: This study linked Ohio Medicaid and death certificate data for Medicaid enrolled youth aged 8-25 years who died by suicide between January 1, 2010, and December 31, 2020 (N = 511). Latent class analysis was used to identify distinct clinical risk subgroups. RESULTS: Three latent classes were identified. Internalizing problems were common across all classes, but especially prevalent in class 1, the High Internalizing + Multiple Comorbidities group (n = 152, 30%). A prior history of suicidal behavior was confined to class 1 decedents, who were otherwise characterized by substance misuse, and multiple psychiatric and medical comorbidities. Class 2 decedents, the Internalizing + Externalizing group (n = 176, 34%), were more often younger, male, Black, and unlikely to have a history of substance misuse. Decedents in class 3, the Internalizing + Substance Misuse group (n = 183, 36%), were more often older and likely to have a history of substance misuse, but unlikely to exhibit other externalizing problems. DISCUSSION: Internalizing psychopathology is particularly common among youth who die by suicide, with comorbid externalizing psychopathology, substance misuse, and medical problems contributing to youth suicide risk. Because less than a third of youth who die by suicide have a prior history of recognized suicidal thinking or behavior, universal screening for youth suicide risk should be considered, particularly in younger children, and efforts to integrate suicide prevention in traditional health care settings should be prioritized.

Association Between Marijuana Laws and Suicide Among 12- to 25-Year-Olds in the United States From 2000 to 2019.

OBJECTIVE: Cannabis use is associated with suicide-related outcomes in both adolescents and adults, and may be increasing amid shifting cannabis policies. However, little is known about the impact of medical marijuana legalization (MML) and recreational marijuana legalization (RML) policies on youth suicide. Using 20 years of national data, we examined associations between MML, RML, and suicide-related mortality among US individuals aged 12 to 25 years, and assessed whether they varied based on age and sex. METHOD: Suicide deaths (N = 113,512) from the 2000-2019 National Vital Statistics System Multiple Cause of Death files for age groups 12 to 13, 14 to 16, 17 to 19, 20 to 22, and 23 to 25 years were examined in relation to time-varying cannabis law status using a staggered adoption difference-in-difference (DiD) approach with a negative binomial regression to determine associations between MML, RML, and suicide rates, controlling for individual- and state-level covariates and accounting for the varying effective dates of MML and RML by state. RESULTS: The overall unadjusted annual suicide rate was 10.93/100,000, varying from 9.76 (states without marijuana laws (ML)) to 12.78 (MML states) to 16.68 (RML states). In multivariable analysis, both MML (incidence rate ratio [IRR] = 1.10, 95% CI: 1.05-1.15) and RML (IRR = 1.16, 95% CI: 1.06-1.27) were associated with higher suicide rates among female youth compared to those in states without ML. Youth aged 14 to 16 years had higher rates of suicide in states with RML compared to states with MML (IRR = 1.14, 95% CI: 1.00-1.30) and states without ML (IRR = 1.09, 95% CI: 1.00-1.20). Findings were consistent across sensitivity analyses. CONCLUSION: MML and RML were associated with increased suicide-related mortality in female youth and 14- to- 16-year-old individuals of both sexes. Mechanisms through which cannabis policies are related to increased youth suicide warrant further study and should inform legislative reform.

Child Welfare System-Level Factors Associated with All-Cause Mortality Among Children in Foster Care in the United States, 2009-2018.

Little is known about the impact of child welfare system-level factors on child mortality as an outcome within foster care. Using data from the Adoption and Foster Care Analysis and Reporting System, 2009-2018, we examined the associations between county-level sociodemographic, foster care performance, and judicial reform characteristics with all-cause mortality rates. Results of random effects negative binomial regression analyses showed that higher proportions of younger children (<1 year: IRR = 1.06, 95% CI [1.02, 1.11]; 5-9 years: IRR = 1.05, 95% CI [1.01, 1.09]); children of color (i.e., non-Hispanic Asian: IRR = 1.07, 95% CI [1.01, 1.13]; multiracial: IRR = 1.03, 95% CI [1.01, 1.04]; non-Hispanic Black: IRR = 1.02, 95% CI [1.01, 1.02]; Hispanic: IRR = 1.01, 95% CI [1.01, 1.02]); and male children (IRR = 1.10, 95% CI [1.05, 1.15]) were associated with higher mortality risks at the county level. Current class action lawsuits (IRR = 0.79, 95% CI [0.63, 0.99]) and active consent decrees (IRR = 0.77, 95% CI [0.63, 0.94]) were associated with lower mortality risks. None of the foster care performance characteristics (e.g., foster care entry, placement stability, permanency) were associated with mortality risks. These findings have implications for addressing health disparities and reforming foster care systems through programmatic and policy efforts.

Spatiotemporal Patterns of Deaths of Despair Across the U.S., 2000-2019.

INTRODUCTION: Deaths of despair (i.e., suicide, drug/alcohol overdose, and chronic liver disease and cirrhosis) have been increasing over the past 2 decades. However, no large-scale studies have examined geographic patterns of deaths of despair in the U.S. This ecologic study identifies geographic and temporal patterns of individual and co-occurring clusters of deaths of despair. METHODS: All individuals aged ≥10 years who died in the U.S. between 2000 and 2019 and resided within the 48 contiguous states and Washington, District of Columbia were included (N=2,171,105). Causes of death were limited to deaths of despair, namely suicide, drug/alcohol overdose, and chronic liver disease and cirrhosis. Univariate and multivariate space-time scan statistics were used to identify individual and co-occurring clusters with excess risk of deaths of despair. County-level RRs account for heterogeneity within each cluster. Analyses were conducted from late 2021 to early 2022. RESULTS: Six suicide clusters, four overdose clusters, nine liver disease clusters, and three co-occurring clusters of all three types of deaths were identified. A large portion of the western U.S., southeastern U.S., and Appalachia/rust belt were contained within the co-occurring clusters. The co-occurring clusters had average county RRs ranging from 1.17 (p<0.001) in the southeastern U.S. to 4.90 (p<0.001) in the western U.S. CONCLUSIONS: Findings support identifying and targeting risk factors common to all types of deaths of despair when planning public health interventions. Resources and policies that address all deaths of despair simultaneously may be beneficial for the areas contained within the co-occurring high-risk clusters.

Association Between Social Determinants of Health and Deliberate Self-Harm Among Youths With Psychiatric Diagnoses.

OBJECTIVE: The authors sought to examine the association between adverse social determinants of health (SDoHs) and risk for self-harm among youths. METHODS: The authors performed a retrospective longitudinal analysis of Ohio Medicaid claims data (April 1, 2016-December 31, 2018) of 244,958 youths (ages 10-17 years) with a primary psychiatric diagnosis. SDoHs were identified from ICD-10 codes and classified into 14 categories, encompassing abuse and neglect, child welfare placement, educational problems, financial problems, exposure to violence, housing instability, legal issues, disappearance or death of a family member, family disruption by separation or divorce, family alcohol or drug use, parent-child conflict, other family problems, social and environmental problems, and nonspecific psychosocial needs. Cox proportional hazards analysis was used to examine the association between SDoHs and self-harm (i.e., nonsuicidal self-injury or suicide attempt). Analyses controlled for demographic characteristics and comorbid psychiatric and general medical conditions. RESULTS: During follow-up after an index claim event, 51,796 youths (21.1%) had at least one adverse SDoH indicator, and 3,262 (1.3%) had at least one self-harm event. Abuse and neglect (hazard ratio [HR]=1.90, 99% CI=1.70-2.12), child welfare placement (HR=1.32, 99% CI=1.04-1.67), parent-child conflict (HR=1.52, 99% CI=1.23-1.87), other family problems (HR=1.25, 99% CI=1.01-1.54), and nonspecific psychosocial needs (HR=1.41, 99% CI=1.06-1.89) were associated with significantly increased hazard of self-harm. CONCLUSIONS: Adverse SDoHs were significantly associated with self-harm, even after controlling for demographic and clinical characteristics, underscoring the need for capturing SDoH information in medical records to identify youths at elevated suicide risk and to inform targeted interventions.

Predictors of substance use disorder treatment initiation and engagement among adolescents enrolled in Medicaid.

Background: Adolescents with substance use disorders (SUD) should receive timely access to treatment to improve lifelong outcomes. The Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement in treatment (IET) performance measure was intended to promote quality improvement for patients with SUD. Yet, few studies have assessed predictors of measure performance among adolescents or other engagement in mental health services, which is critical to understanding disparities in treatment quality or opportunities for targeted improvement strategies. The present study reports the rates and predictors of IET among adolescents with SUD, as well as receipt of any mental health services. Methods: The sample included adolescents enrolled in Medicaid in 14 states who had a qualifying diagnosis for SUD (2009-2013) and met HEDIS IET performance measure eligibility criteria. Three outcomes were assessed, including initiation of SUD treatment within 14 days of qualifying diagnosis, engagement in SUD treatment (2 or more encounters) within 30 days of initiation, and receipt of any mental health services (1 or more encounters) within 30 days of initiation. Logistic regression was used to identify demographic and clinical characteristics associated with outcomes. Results: Among 20,602 adolescents who met eligibility criteria, 49.5% initiated SUD treatment, 48.5% engaged in SUD treatment, and 70% received any mental health service. Adolescents with higher levels of clinical need (e.g., medical complexity, mental health comorbidity, and multiple SUD diagnoses) had significantly higher odds of initiating, but lower odds of engaging in treatment or receiving any mental health service. Conclusions: To increase the delivery of SUD treatment, efforts should target adolescents with co-occurring mental health needs, many of whom are receiving mental health services after SUD diagnosis. Integrating addiction and mental health services could address these missed opportunities.

Correlates of deliberate self-harm among youth with bipolar disorder.

OBJECTIVE: Youth with bipolar disorder (BD) are at high risk for deliberate self-harm (DSH) and suicide. However, research regarding factors associated with DSH, a key suicide risk factor, among youth with BD is limited. In a population-based sample of youth with BD, we therefore investigated associations between demographic, clinical, and service utilization factors and DSH incidence and compared suicide, unintentional injury, and all-cause mortality to the general population. METHOD: We analyzed a retrospective cohort of youth aged 5 to 19 years with a new BD episode between 2010 and 2017 (n = 25,244) using Ohio Medicaid claims and death certificate data. Cox proportional hazards models examined associations between different factors and DSH. Mortality rates were compared to the general population using standardized mortality ratios. RESULTS: During follow-up, 1,517 (6.0%) youth had at least one DSH event. Older index age, female sex, comorbid psychiatric/medical conditions, prior DSH/suicidal ideation, and prior ER mental healthcare were associated with increased DSH risk. Prior DSH was most strongly associated with increased DSH risk for 3 months after a new BD episode. Being non-Hispanic Black (vs. White, non-Hispanic) and prior psychiatric hospitalization were associated with decreased DSH hazard. DSH risk was highest for 3 months after a new BD episode. Suicide, unintentional injury, and all-cause mortality rates were elevated in youth with BD. LIMITATIONS: May not generalize to other states or non-Medicaid populations; claims data cannot distinguish suicidal intent of self-harm CONCLUSION: Early intervention following a new BD episode, particularly among high-risk groups, is key to prevent DSH.

Mental Health Service Utilization Among Medical Students with a Perceived Need for Care.

OBJECTIVE: The authors investigated levels of perceived need for help, patterns of mental health service utilization, and barriers to care among US medical students with a focus on students who perceived a need for help but did not report service use in the past 12 months. METHODS: The authors administered an online survey to 2,868 medical students at three schools in Ohio between January and February 2020 including validated scales for psychological distress, self-stigma, and an exploration of mental health treatment. The authors used multivariable logistic regression to identify factors associated with treatment and qualitative analysis to identify common barriers to care. RESULTS: Twenty-eight percent (N = 800) of 2,868 students responded to the survey. Fifty-six percent (n = 439) of students reported a perceived need for help, while 34.6% of these respondents (n = 152) did not receive treatment. Among those with perceived need who completed the survey (n = 388), Asian students compared to non-Hispanic white students (adjusted odds ratio [aOR] = 0.45, 95% confidence interval [CI] 0.25-0.82) and those with higher self-stigma (aOR = 0.90, 95% CI 0.87-0.94) had lower odds of service use. Students told by others to seek help (aOR = 2.82, 95% CI 1.71-4.64) were the only group with higher odds of service use. The most common barriers to care were lack of time, difficulty accessing services, and stigma. CONCLUSIONS: Despite a perceived need for help, many students do not seek care and experience treatment barriers. Schools can encourage help-seeking by identifying students in need, using targeted messaging, fostering a low-stigma environment, and removing barriers.

Risk Factors for Deliberate Self-harm and Suicide Among Adolescents and Young Adults With First-Episode Psychosis.

Little is known about the risk factors for deliberate self-harm (DSH) and suicide among adolescents and young adults with first episode psychosis (FEP) and the longitudinal course of DSH following the initial onset of illness. This study identifies risk factors for DSH and suicide death among Medicaid-covered adolescents and young adults with FEP along with the periods of greatest risk for DSH after diagnosis. A retrospective longitudinal cohort analysis was performed using Medicaid claims data merged with death certificate data for 19 422 adolescents and young adults (aged 15-24 years) diagnosed with the onset of FEP between 2010 and 2017. DSH per 1000 person-years and standardized mortality rates for suicide were determined. Hazard ratios of DSH and suicide were estimated by Cox proportional hazard models. During follow-up, 2148 (11.1%) individuals had at least one self-harm event and 22 (0.1%) died by suicide. The hazards of DSH were significantly higher for those with a previous DSH, suicidal ideation, child abuse and neglect, comorbid medical and psychiatric diagnoses, and prior mental health care. The median follow-up time for those who had DSH was 208.0 days (SD: 526.5 days) in adolescents and 108.0 days (SD: 340.0 days) in young adults. Risk of DSH was highest in the first 3 months following FEP. Individuals with FEP are at high risk for self-harm and suicidal behavior, and recognition of who among these individuals and when following illness onset they are at greatest risk may guide more precise clinical recognition and intervention.

Mortality and Cause of Death Among Youths Previously Incarcerated in the Juvenile Legal System.

Importance: More than 50 000 youths are incarcerated in the United States on any given day, and youth incarceration has been linked to lasting adverse outcomes, including early mortality. Improving our understanding of the factors associated with early mortality among incarcerated youths can inform appropriate prevention strategies. Objective: To examine mortality rates and causes of death among youths previously incarcerated in the juvenile legal system. Design, Setting, and Participants: This retrospective longitudinal population-based cohort study compared mortality rates between youths aged 11 to 21 years incarcerated from 2010 to 2017 with same-aged nonincarcerated Medicaid-enrolled youths in the state of Ohio. Data from January 2017 to December 2019 were collected from juvenile incarceration, Medicaid, and death certificate information in Ohio. Exposure: Incarceration in the state of Ohio's juvenile legal system. Main Outcomes and Measures: Number, characteristics, and causes of deaths. Poisson regression incidence rate ratios (IRRs) compared mortality rates between previously incarcerated and Medicaid-enrolled youths. Results: Among 3645 incarcerated youths, 3398 (93.2%) were male, 2155 (59.1%) Black, 1307 (35.9%) White, and 183 (5.0%) other race and ethnicity. Overall, 113 youths (3.1%) died during the study period. Homicide was the leading cause of death in formerly incarcerated youths (homicide: 63 [55.8%]; legal intervention [ie, death due to injuries inflicted by law enforcement]: 3 [2.7%]). All-cause mortality rates were significantly higher among previously incarcerated youths than Medicaid-enrolled youths (adjusted IRR [aIRR], 5.91; 95% CI, 4.90-7.13) in every demographic subgroup. Compared with Medicaid-enrolled youths, mortality rates for previously incarcerated youths were highest for homicide (aIRR, 11.02; 95% CI, 8.54-14.22), overdose (aIRR, 4.32; 95% CI, 2.59-7.20), and suicide (aIRR, 4.30; 95% CI, 2.22-8.33). Formerly incarcerated Black youths had a significantly higher risk of homicide (aIRR, 14.24; 95% CI, 4.45-45.63) but a lower risk of suicide (aIRR, 0.18; 95% CI, 0.04-0.89) and overdose (aIRR, 0.31; 95% CI, 0.10-0.99) than White youths who were incarcerated. Previously incarcerated youths aged 15 to 21 years were significantly more likely to die than youths aged 22 to 29 years, irrespective of cause of death (aIRR for youths aged 22-29 years, 0.09; 95% CI, 0.06-0.14). Conclusions and Relevance: In this study, youths with a history of incarceration were significantly more likely to experience early mortality compared with nonincarcerated Medicaid-enrolled youths. Delinquency and violence prevention strategies that incorporate a culturally informed approach and consider sex and developmental level are critical.

Health Services Use by Children in the Welfare System Who Died by Suicide.

OBJECTIVES: To examine characteristics and health service use patterns of suicide decedents with a history of child welfare system involvement to inform prevention strategies and reduce suicide in this vulnerable population. METHODS: A retrospective matched case-control design (120 suicide decedents and 1200 matched controls) was implemented. Suicide decedents included youth aged 5 to 21 who died by suicide and had an open case in Ohio's Statewide Automated Child Welfare Information System between 2010 and 2017. Controls were matched to suicide decedents on sex, race, and ethnicity. Comparisons were analyzed by using conditional logistic regressions to control for matching between the suicide and control groups. RESULTS: Youth in the child welfare system who died by suicide were significantly more likely to experience out-of-home placements and be diagnosed with mental and physical health conditions compared with controls. Suicide decedents were twice as likely to access mental health services in the 1 and 6 months before death, regardless of the health care setting. A significantly higher percentage of suicide decedents used physical health services 6 months before their death or index date. Emergency department visits for both physical and mental health conditions were significantly more likely to occur among suicide decedents. CONCLUSIONS: Suicide decedents involved in the child welfare system were more likely to use both mental and physical health care services in the months before their death or index date. Findings suggest that youth involved in the child welfare system may benefit from suicide prevention strategies in health care settings.

Association of Cannabis Use With Self-harm and Mortality Risk Among Youths With Mood Disorders.

Importance: Cannabis use and cannabis use disorder (CUD) are common among youths and young adults with mood disorders, but the association of CUD with self-harm, suicide, and overall mortality risk is poorly understood in this already vulnerable population. Objective: To examine associations of CUD with self-harm, suicide, and overall mortality risk in youths with mood disorders. Design, Setting, and Participants: A population-based retrospective cohort study was performed using Ohio Medicaid claims data linked with death certificate data. The analysis included 204 780 youths (aged 10-24 years) with a diagnosis of mood disorders between July 1, 2010, and December 31, 2017, who were followed up to 365 days from the index diagnostic claim until the end of enrollment, the self-harm event, or death. Statistical analysis was performed from April 4 to July 17, 2020. Exposure: Physician-diagnosed CUD defined using outpatient and inpatient claims from 180 days prior to the index mood disorder diagnostic claim through the 365-day follow-up period. Main Outcomes and Measures: Nonfatal self-harm, all-cause mortality, and deaths by suicide, unintentional overdose, motor vehicle crashes, and homicide. Marginal structural models using inverse probability weights examined associations between CUD and outcomes. Results: This study included 204 780 youths (133 081 female participants [65.0%]; mean [SD] age at the time of mood disorder diagnosis, 17.2 [4.10] years). Cannabis use disorder was documented for 10.3% of youths with mood disorders (n = 21 040) and was significantly associated with older age (14-18 years vs 10-13 years: adjusted risk ratio [ARR], 9.35; 95% CI, 8.57-10.19; and 19-24 years vs 10-13 years: ARR, 11.22; 95% CI, 10.27-12.26), male sex (ARR, 1.79; 95% CI, 1.74-1.84), Black race (ARR, 1.39; 95% CI, 1.35-1.44), bipolar or other mood disorders (bipolar disorders: ARR, 1.24; 95% CI, 1.21-1.29; other mood disorders: ARR, 1.20; 95% CI, 1.15-1.25), prior history of self-harm (ARR, 1.66; 95% CI, 1.52-1.82), previous mental health outpatient visits (ARR, 1.26; 95% CI, 1.22-1.30), psychiatric hospitalizations (ARR, 1.66; 95% CI, 1.57-1.76), and mental health emergency department visits (ARR, 1.54; 95% CI, 1.47-1.61). Cannabis use disorder was significantly associated with nonfatal self-harm (adjusted hazard ratio [AHR], 3.28; 95% CI, 2.55-4.22) and all-cause mortality (AHR, 1.59; 95% CI, 1.13-2.24), including death by unintentional overdose (AHR, 2.40; 95% CI, 1.39-4.16) and homicide (AHR, 3.23; 95% CI, 1.22-8.59). Although CUD was associated with suicide in the unadjusted model, it was not significantly associated in adjusted models. Conclusions and Relevance: Cannabis use disorder is a common comorbidity and risk marker for self-harm, all-cause mortality, and death by unintentional overdose and homicide among youths with mood disorders. These findings should be considered as states contemplate legalizing medical and recreational marijuana, both of which are associated with increased CUD.

Association of Timely Outpatient Mental Health Services for Youths After Psychiatric Hospitalization With Risk of Death by Suicide.

Importance: Timely outpatient follow-up care after psychiatric hospitalization is an established mental health quality indicator and considered an important component of suicide prevention, yet little is known about whether follow-up care is associated with a reduced risk of suicide soon after hospital discharge. Objective: To evaluate whether receipt of outpatient care within 7 days of psychiatric hospital discharge is associated with a reduced risk of subsequent suicide among child and adolescent inpatients and examine factors associated with timely follow-up care. Design, Setting, and Participants: This population-based, retrospective, longitudinal cohort study used Medicaid data from 33 states linked with National Death Index data. The study population included all youths aged 10 to 18 years who were admitted to a psychiatric hospital from January 1, 2009, to December 31, 2013. Data analysis was completed from October 9, 2019, through May 15, 2020. Exposure: Mental health follow-up visits received within 7 days of hospital discharge. Main Outcomes and Measures: Suicides occurring in the 8 to 180 days after hospital discharge. Logistic regression modeled the association between demographic, clinical, and mental health service history factors and receipt of an outpatient visit within 7 days after discharge. Poisson regression estimated the association between suicide risk and outpatient visits within 7 days after discharge, adjusting for confounding using inverse probability of treatment weights from the logistic model. Results: Of the total 139 694 youths admitted to a psychiatric hospital, 51.9% were female, 31.1% were aged 10 to 13 years, and 68.9% were aged 14 to 18 years. A total of 56.5% of the youths received a mental health follow-up visit within 7 days of discharge, and this was associated with a significantly lower odds of suicide (adjusted relative risk, 0.44; 95% CI, 0.23-0.83; P = .01) during the 8 to 180 days postdischarge period. Youths with longer lengths of stay (4-5 days: adjusted odds ratio [AOR], 1.20 [95% CI, 1.17-1.24]; 6-7 days: AOR, 1.47 [95% CI, 1.43-1.52]; 8-12 days AOR, 1.75 [95% CI, 1.69-1.81]; 13-30 days: AOR, 1.71 [95% CI, 1.63-1.78]), prior outpatient mental health care (AOR, 1.58; 95% CI, 1.51-1.65), and foster care placement (AOR, 1.32; 95% CI, 1.28-1.37) were more likely to receive 7-day follow-up, whereas those who were non-Hispanic Black (AOR, 0.82; 95% CI, 0.79-0.84), were older (AOR, 0.82; 95% CI, 0.80-0.84), were medically ill (AOR, 0.77; 95% CI, 0.74-0.81), and had managed care insurance (AOR, 0.88; 95% CI, 0.87-0.91) were less likely to receive follow-up visits. Conclusions and Relevance: In this cohort study, risk of suicide during the 6 months after psychiatric hospitalization was decreased among youth who had an outpatient mental health visit within 7 days after discharge. Addressing disparities in timely continuity of care may help advance health equity agendas.

Suicide in Older Adults in Ohio: Characteristics, Precipitants, and Mental Health Service Utilization.

The objective of the research is to examine characteristics of Ohio suicide decedents ages 65 + (N = 1273) and factors associated with behavioral health (BH) services utilization. The Ohio Violent Death Reporting System, 2012-2015, was the data source. Logistic regression analyses were used to examine the association among characteristics, suicide means, and BH service utilization. Of the study subjects, 96.0% were non-Hispanic white; 84.6%, male; and 63.0% living in urban areas. About 75.1% used firearms; 27.6% reported recent BH treatment. Those who were never married, depressed, and had a prior suicide attempt were more likely to have BH treatment within two months of death. Findings suggest a need for training of primary and BH providers to improve screening and assessment, treatment, and follow up care for older adults, especially those with histories of suicide attempts, depression, and firearm access. Suggested interventions include annual BH screenings and lethal means restriction at the individual and community levels.

Factors Associated With Multiple Psychiatric Readmissions for Youth With Mood Disorders.

OBJECTIVE: Inpatient psychiatric readmission rates are increasingly considered indicators of quality of care. This study builds upon prior research by examining patient-, hospital-, and community-level factors associated with single and multiple readmissions for youth. METHOD: A retrospective cohort study was conducted using Medicaid claims data from four states supplemented with the American Hospital Association survey, the Area Resource File, and the National Survey of Mental Health Treatment Services. Multinomial logistic regression examined patient-, hospital-, and community-level factors that were associated with inpatient psychiatric readmission for 6,797 Medicaid-eligible youth with a primary diagnosis of mood disorder using a three-level nominal dependent variable coded as no readmission, one readmission, and two or more readmissions within 6 months after discharge. RESULTS: Six months after initial discharge, 941 youth (13.8%) were readmitted once and 471 (6.9%) were readmitted two or more times. The odds of single or multiple readmissions were significantly higher (p < .05) for youth classified as disabled or in foster care, those with multiple psychiatric comorbidities, medical comorbidity, and prior psychiatric hospitalization. Treatment in hospitals with high percentage of Medicaid discharges and a high number of beds was associated with lower odds of readmission. There was a significant interaction between length of stay and outpatient mental health follow-up within 7 days of discharge. CONCLUSION: Patient- and hospital-level factors are associated with likelihood of both single and multiple youth inpatient psychiatric readmissions, suggesting potential risk markers for psychiatric readmission.

Contextual Factors Associated With County-Level Suicide Rates in the United States, 1999 to 2016.

Importance: Understanding geographic and community-level factors associated with suicide can inform targeted suicide prevention efforts. Objectives: To estimate suicide rates and trajectories, assess associated county-level contextual factors, and explore variation across the rural-urban continuum. Design, Setting, and Participants: This cross-sectional study included all individuals aged 25 to 64 years who died by suicide from January 1, 1999, to December 31, 2016, in the United States. Spatial analysis was used to map excess risk of suicide, and longitudinal random-effects models using negative binomial regression tested associations of contextual variables with suicide rates as well as interactions among county-level contextual variables. Data analyses were conducted between January 2019 and July 2019. Exposure: County of residence. Main Outcomes and Measures: Three-year county suicide rates during an 18-year period stratified by rural-urban location. Results: Between 1999 and 2016, 453 577 individuals aged 25 to 64 years died by suicide in the United States. Decedents were primarily male (349 082 [77.0%]) with 101 312 (22.3%) aged 25 to 34 years, 120 157 (26.5%) aged 35 to 44 years, 136 377 (30.1%) aged 45 to 54 years, and 95 771 (21.1%) aged 55 to 64 years. Suicide rates were higher and increased more rapidly in rural than in large metropolitan counties. The highest deprivation quartile was associated with higher suicide rates compared with the lowest deprivation quartile, especially in rural areas, although this association declined during the period studied (rural, 1999-2001: incidence rate ratio [IRR], 1.438; 95% CI, 1.319-1.568; P < .001; large metropolitan, 1999-2001: 1.208; 95% CI, 1.149-1.270; P < .001; rural, 2014-2016: IRR, 1.121; 95% CI, 1.032-1.219; P = .01; large metropolitan, 2014-2016: IRR, 0.942; 95% CI, 0.887-1.001; P = .06). The presence of more gun shops was associated with an increase in county-level suicide rates in all county types except the most rural (rural: IRR, 1.001; 95% CI, 0.999-1.004; P = .40; micropolitan: IRR, 1.005; 95% CI, 1.002-1.007; P < .001; small metropolitan: IRR, 1.010; 95% CI, 1.006-1.014; P < .001; large metropolitan: IRR, 1.012; 95% CI, 1.006-1.018; P < .001). High social capital was associated with lower suicide rates than low social capital (IRR, 0.917; 95% CI, 0.891-0.943; P < .001). High social fragmentation, an increasing percentage of the population without health insurance, and an increasing percentage of veterans in a county were associated with higher suicide rates (high social fragmentation: IRR, 1.077; 95% CI, 1.050-1.103; P < .001; percentage of population without health insurance: IRR, 1.005; 95% CI, 1.004-1.006; P < .001; percentage of veterans: IRR, 1.025; 95% CI, 1.021-1.028; P < .001). Conclusions and Relevance: This study found that suicide rates have increased across the nation and most rapidly in rural counties, which may be more sensitive to the impact of social deprivation than more metropolitan counties. Improving social connectedness, civic opportunities, and health insurance coverage as well as limiting access to lethal means have the potential to reduce suicide rates across the rural-urban continuum.

A National Comparison of Suicide Among Medicaid and Non-Medicaid Youth.

INTRODUCTION: In the U.S., youth enrolled in Medicaid experience more risk factors for suicide, such as mental illness, than youth not enrolled in Medicaid. To inform a national suicide prevention strategy, this study presents suicide rates in a sample of youth enrolled in Medicaid and compares them with rates in the non-Medicaid population. METHODS: Data sources were death certificate data matched with Medicaid data from 16 states, and the Web-based Injury Statistics Query and Reporting System. Deaths by suicide that occurred between 2009 and 2013 by youth aged 10 to 18 years were identified for Medicaid and non-Medicaid groups. Age-, gender-, and cause-specific mortality rates were calculated separately for both groups. Standardized mortality ratios were calculated to compare rates, and standardized mortality ratio 95% CIs were estimated with Poisson regressions. The data were analyzed in 2018. RESULTS: A substantial proportion (39%) of the total number of deaths by suicide (N=4,045) in youth occurred among those enrolled in Medicaid. The overall suicide rate did not significantly differ between groups (standardized mortality ratio=0.96, 95% CI=0.90, 1.03). However, compared with the non-Medicaid group, the suicide rate in the Medicaid group was significantly higher among youth aged 10 to 14 years (standardized mortality ratio=1.28, 95% CI=1.11, 1.47), females (regardless of age; standardized mortality ratio=1.14, 95% CI=1.01, 1.29), and those who died by hanging (standardized mortality ratio=1.26, 95% CI=1.16, 1.38). CONCLUSIONS: The population-based profile of suicide among youth enrolled in Medicaid differs from the profile of youth not enrolled in Medicaid, confirming the importance of Medicaid as a "boundaried" suicide prevention setting.

Trends in and Predictors of Long-Term Antipsychotic Polypharmacy Use Among Ohio Medicaid Patients with Schizophrenia, 2008-2014.

OBJECTIVE: The study examined trends and patterns in long-term antipsychotic polypharmacy among Ohio Medicaid patients with schizophrenia and predictors of use. METHODS: A study using a retrospective cohort design and Medicaid claims data was conducted for a cohort of 25,062 adults with a schizophrenic disorder receiving antipsychotic medication between 2008 and 2014. Long-term antipsychotic polypharmacy was defined as simultaneous treatment with two or more antipsychotic medications for ≥90 days. Annual trends in antipsychotic polypharmacy were estimated. Multivariate logistic regression was used to identify patient demographic, clinical, and treatment characteristics associated with antipsychotic polypharmacy. RESULTS: The prevalence of antipsychotic polypharmacy decreased significantly from 29.5% in 2008 (2,715 of 9,211) to 24.9% in 2014 (2,866 of 11,500) (adjusted odds ratio=.98, 99% confidence interval=.97-.99, p<.001). Factors significantly associated with antipsychotic polypharmacy included younger age, male sex, disabled status, rural residence, a schizophrenic disorder other than schizoaffective disorder, a greater number of general medical comorbidities, treatment with more psychotropic medication classes, and more outpatient mental health treatment and emergency department visits. Antipsychotic polypharmacy was significantly less likely for African Americans or those from other racial minority groups compared with whites, for those with substance use disorders compared with others, and for those with a greater number of inpatient psychiatric hospitalizations. CONCLUSIONS: Antipsychotic polypharmacy declined for pharmacologically treated individuals with schizophrenia in Ohio Medicaid between 2008 and 2014, but it remained inordinately prevalent given existing treatment guidelines that recommend antipsychotic monotherapy as the standard of care for patients with schizophrenia.

Mapping suicide mortality in Ohio: A spatial epidemiological analysis of suicide clusters and area level correlates.

Previous studies have investigated spatial patterning and associations of area characteristics with suicide rates in Western and Asian countries, but few have been conducted in the United States. This ecological study aims to identify high-risk clusters of suicide in Ohio and assess area level correlates of these clusters. We estimated spatially smoothed standardized mortality ratios (SMR) using Bayesian conditional autoregressive models (CAR) for the period 2004 to 2013. Spatial and spatio-temporal scan statistics were used to detect high-risk clusters of suicide at the census tract level (N=2952). Logistic regression models were used to examine the association between area level correlates and suicide clusters. Nine statistically significant (p<0.05) high-risk spatial clusters and two space-time clusters were identified. We also identified several significant spatial clusters by method of suicide. The risk of suicide was up to 2.1 times higher in high-risk clusters than in areas outside of the clusters (relative risks ranged from 1.22 to 2.14 (p<0.01)). In the multivariate model, factors strongly associated with area suicide rates were socio-economic deprivation and lower provider densities. Efforts to reduce poverty and improve access to health and mental health medical services on the community level represent potentially important suicide prevention strategies.