Economic evaluations of adult critical care pharmacy services: a scoping review.

OBJECTIVES: To summarise the extent and type of evidence available regarding economic evaluations of adult critical care pharmacy services in the context of UK practice. METHODS: A literature search was conducted in eight electronic databases and hand searching of full-text reference lists. Of 2409 journal articles initially identified, 38 were included in the final review. Independent literature review was undertaken by two investigators in a two-step process against the inclusion and exclusion criteria; title and abstract screening were followed by full-text screening. Included studies were taken from high-income economy countries that contained economic data evaluating any key aspect of adult critical care pharmacy services. Grey literature and studies that could not be translated into the English language were excluded. RESULTS: The majority were before-and-after studies (18, 47%) or other observational studies (17, 45%), and conducted in North America (25, 66%). None of the included studies were undertaken in the UK. Seven studies (18%) included cost-benefit analysis; all demonstrated positive cost-benefit values for clinical pharmacist activities. CONCLUSIONS: Further high-quality primary research focussing on the economic evaluation of UK adult critical care pharmacy services is needed, before undertaking a future systematic review. There is an indication of a cost-benefit value for critical care pharmacist activities. The lack of UK-based economic evaluations is a limitation to further development and standardisation of critical care pharmacy services nationally.

Preventing Suicidal Behavior Among American Indian and Alaska Native Adolescents and Young Adults.

From 2009 to 2018, overall suicide rates in the United States increased by 20.3% and increased by 43.5% among non-Hispanic American Indian and Alaska Native (AI/AN) communities. Combining years 2009 through 2018, suicide rates per 100 000 population among non-Hispanic AI/AN adolescents and young adults aged 15 to 34 years were 2 to 4 times higher than those of adolescents and young adults of other races and ethnicities. An estimated 14% to 27% of non-Hispanic AI/AN adolescents attempted suicide during that time. The elevated rates of suicidal behavior among non-Hispanic AI/AN adolescents and young adults reflect inequities in the conditions that create health. In this topical review, we describe school-based educational efforts that are driven by local AI/AN communities, such as the American Indian Life Skills curriculum, that teach stress and coping skills and show promise in reducing suicidal ideation attempts and fatalities among AI/AN adolescents. Using a social-determinants-of-health lens, we review the availability and quality of employment as an important influencer of suicidal behavior, as well as the role of the workplace as an environment for suicide prevention in AI/AN communities. Working with tribal, state, local, and federal colleagues, the public health community can implement programs known to be effective and create additional comprehensive strategies to reduce inequities and ultimately reduce suicide rates.

Psychiatric Treatment and Repeat Suicide Attempts Among Adults With Substance Use, by HIV Status, United States, 2014-2020.

OBJECTIVES: The association among psychiatric treatment history, HIV, and suicide reattempts among people starting treatment for substance use is not well understood. The objective of this study was to describe, by HIV status, the risk and protective factors associated with suicide reattempts among adults seeking treatment for substance use. METHODS: The study included 340 390 US adult residents aged ≥18 years in the Addiction Severity Index-Multimedia Version network from January 1, 2014, through December 31, 2020. We used adjusted logistic regression models to estimate strength of association between prior psychiatric treatment, HIV status, and sociodemographic factors and suicide reattempts within 30 days of treatment evaluation. RESULTS: Adults who had been prescribed psychiatric medication were less likely to have a recent suicide reattempt (adjusted odds ratio [aOR] = 0.8; 95% CI, 0.7-0.8) than adults with no prescription history. Adjusted models found similar protective effects between psychiatric treatment and suicide reattempts among adults reporting abuse, mental illness, injection drug use, and limited activity because of a medical condition. Conversely, the following were associated with recent suicide reattempts: being male (aOR = 1.4; 95% CI, 1.3-1.5), having a high school education/GED (General Educational Development) or less (aOR = 1.2; 95% CI, 1.1-1.2), being single (aOR = 1.2; 95% CI, 1.1-1.3), experiencing a pain problem (aOR = 1.2; 95% CI, 1.2-1.3), and not being referred to substance use treatment by court (aOR = 3.4; 95% CI, 3.2-3.7). CONCLUSIONS: A history of prescribed psychiatric medication is significantly associated with a reduced risk for suicide reattempts among adults seeking substance use treatment. Clinicians should consider incorporating mental health and suicide assessments into substance use treatment plans.

Mental Health Surveillance Among Children - United States, 2013-2019.

Mental health encompasses a range of mental, emotional, social, and behavioral functioning and occurs along a continuum from good to poor. Previous research has documented that mental health among children and adolescents is associated with immediate and long-term physical health and chronic disease, health risk behaviors, social relationships, education, and employment. Public health surveillance of children's mental health can be used to monitor trends in prevalence across populations, increase knowledge about demographic and geographic differences, and support decision-making about prevention and intervention. Numerous federal data systems collect data on various indicators of children's mental health, particularly mental disorders. The 2013-2019 data from these data systems show that mental disorders begin in early childhood and affect children with a range of sociodemographic characteristics. During this period, the most prevalent disorders diagnosed among U.S. children and adolescents aged 3-17 years were attention-deficit/hyperactivity disorder and anxiety, each affecting approximately one in 11 (9.4%-9.8%) children. Among children and adolescents aged 12-17 years, one fifth (20.9%) had ever experienced a major depressive episode. Among high school students in 2019, 36.7% reported persistently feeling sad or hopeless in the past year, and 18.8% had seriously considered attempting suicide. Approximately seven in 100,000 persons aged 10-19 years died by suicide in 2018 and 2019. Among children and adolescents aged 3-17 years, 9.6%-10.1% had received mental health services, and 7.8% of all children and adolescents aged 3-17 years had taken medication for mental health problems during the past year, based on parent report. Approximately one in four children and adolescents aged 12-17 years reported having received mental health services during the past year. In federal data systems, data on positive indicators of mental health (e.g., resilience) are limited. Although no comprehensive surveillance system for children's mental health exists and no single indicator can be used to define the mental health of children or to identify the overall number of children with mental disorders, these data confirm that mental disorders among children continue to be a substantial public health concern. These findings can be used by public health professionals, health care providers, state health officials, policymakers, and educators to understand the prevalence of specific mental disorders and other indicators of mental health and the challenges related to mental health surveillance.

Suicidal Thoughts and Behaviors Among Adults Aged ≥18 Years - United States, 2015-2019.

PROBLEM/CONDITION: Suicidal thoughts and behaviors are important public health concerns in the United States. In 2019, suicide was the 10th leading cause of death among persons aged ≥18 years (adults); in that year, 45,861 adults died as a result of suicide, and an estimated 381,295 adults visited hospital emergency departments for nonfatal, self-inflicted injuries. Regional- and state-level data on self-inflicted injuries are needed to help localities establish priorities and evaluate the effectiveness of suicide prevention strategies. PERIOD COVERED: 2015-2019. DESCRIPTION OF SYSTEM: The National Survey on Drug Use and Health (NSDUH) is an annual survey of a representative sample of the civilian, noninstitutionalized U.S. population aged ≥12 years. NSDUH collects data on the use of illicit drugs, alcohol, and tobacco; initiation of substance use; substance use disorders and treatment; health care; and mental health. This report summarizes data on responses to questions concerning suicidal thoughts and behaviors contained in the mental health section among sampled persons aged ≥18 years in all 50 states and the District of Columbia. This report summarizes 2015-2019 NSDUH data collected from 254,767 respondents regarding national-, regional-, and state-level prevalence of suicidal thoughts, planning, and attempts by age group, sex, race and ethnicity, region, state, education, marital status, poverty level, and health insurance status. RESULTS: Prevalence estimates of suicidal thoughts and behaviors varied by sociodemographic factors, region, and state. During 2015-2019, an estimated 10.6 million (annual average) adults in the United States (4.3% of the adult population) reported having had suicidal thoughts during the preceding year. The prevalence of having had suicidal thoughts ranged from 4.0% in the Northeast and South to 4.8% in the West and from 3.3% in New Jersey to 6.9% in Utah. An estimated 3.1 million adults (1.3% of the adult population) had made a suicide plan in the past year. The prevalence of having made suicide plans ranged from 1.0% in the Northeast to 1.4% in the Midwest and West and from 0.8% in Connecticut and New Jersey to 2.4% in Alaska. An estimated 1.4 million adults (0.6% of the adult population) had made a suicide attempt in the past year. The prevalence of suicide attempts ranged from 0.5% in the Northeast to 0.6% in the Midwest, South, and West and from 0.3% in Connecticut to 0.9% in West Virginia. Past-year prevalence of suicidal thoughts, suicide planning, and suicide attempts was higher among females than among males, higher among adults aged 18-39 years than among those aged ≥40 years, higher among noncollege graduates than college graduates, and higher among adults who had never been married than among those who were married, separated, divorced, or widowed. Prevalence was also higher among those living in poverty than among those with a family income at or above the federal poverty threshold and higher among those covered by Medicaid or the Children's Health Insurance Program than among those with other types of health insurance or no health insurance coverage. INTERPRETATION: The findings in this report highlight differences in the adult prevalence of suicidal thoughts, plans to attempt suicide, and attempted suicide during the 12 months preceding the survey at the national, regional, and state levels during 2015-2019. Geographic differences in suicidal thoughts and behavior varied by sociodemographic characteristics and might be attributable to sociodemographic composition of the population, selective migration, or the local cultural milieu. These findings underscore the importance of ongoing surveillance to collect locally relevant data on which to base prevention and intervention strategies. PUBLIC HEALTH ACTION: Understanding the patterns of and risk factors for suicide is essential for designing, implementing, and evaluating public health programs for suicide prevention and policies that reduce morbidity and mortality related to suicidal thoughts and behaviors. State health departments and federal agencies can use the results from this report to assess progress toward achieving national and state health objectives in suicide prevention. Strategies might include identifying and supporting persons at risk, promoting connectedness, and creating protective environments.

Implementing the national suicide prevention strategy: Time for action to flatten the curve.

Since 1999, the Office of the United States Surgeon General has identified suicide prevention as a national public health priority. The National Strategy on Suicide Prevention, coordinated by the public-private Action Alliance, was most recently updated in 2012. In early 2021, the Surgeon General's office released a Call to Action to fully implement the national strategy. Six core types of actions to prevent suicide include adopting a broad public health approach, addressing upstream factors including social determinants of health, reducing access to multiple forms of lethal means, adopting evidence-based care for persons at risk, enhancing crisis care and care transitions, and improving the quality and use of suicide-related data. From 1999 through 2018, suicide rates in the U.S. increased by approximately one-third, and suicide had become the tenth leading cause of death. While most recent national data indicate a small reduction in the suicide rate, decreases were not seen across all demographic groups. Population groups which may require special emphasis or outreach efforts include adolescents, working age adults, military veterans, and American Indians/Alaskan Natives. Increases in social isolation, mental distress, and economic hardship during the COVID-19 pandemic indicate clear needs to address the full spectrum of suicidal behavior. This will require a multisector and whole of government approach, using contemporary evidence-informed approaches and best practices as well as innovative methods including those based on predictive analytics.

Circumstances Associated With Suicides Among Females-16 States, United States, 2005-2016.

BACKGROUND: Suicide rates in the United States have been consistently increasing since 2005 and increasing faster among females than among males. Understanding circumstances related to the changes in suicide may help inform prevention programs. This study describes the circumstances associated with suicides among females in the United States using the National Violent Death Reporting System. METHODS: We analyzed the circumstances of suicides occurring from 2005 to 2016 in 16 states (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin) among females aged 10 years and above. We compared the percentages of circumstances reported for the entire sample, by age group, and by race/ethnicity. Trends in changes in the leading circumstances were analyzed using Joinpoint regression. RESULTS: From 2005 to 2016, there were 27,809 suicides among females 10 years and older in the 16 states. Overall, the 2 leading precipitating circumstances were current mental health problem and ever treated for mental health problem. The leading circumstances differed by demographics. Joinpoint analysis showed inflection points in reports of job problems, financial problems, and non-intimate partner relationship problems during 2005-2009. During 2010-2016, downward inflections were seen in reports of job problems and financial problems and upward inflections in substance abuse problems and a recent or impending crisis. CONCLUSIONS: These findings show changes by age group and race/ethnicity in the circumstances associated with suicides among females in the 16 states have occurred. Studying these shifts and identifying the most salient circumstances among female suicide decedents may help prevention programs adapt to different needs.

Youth Suicide: An Opportunity for Prevention.

In the United States, youth suicide is a large and growing public health problem that contributes to health care costs, lost productivity, morbidity, and premature death. In 2017, an estimated 199,877 youths aged 10 to 24 years were treated in emergency departments in the United States for self-harm,1 and 7.4% of high school students reported that they attempted suicide one or more times in the past year.2 Suicide was the second leading cause of death among youths aged 10 to 24 years in 2017,1 and the suicide rate increased significantly for both male and female youths from 1999 to 2017.3.

Trends in the Incidence and Lethality of Suicidal Acts in the United States, 2006 to 2015.

Importance: Understanding changes in the incidence rates and lethality of suicidal acts may explain increasing suicide rates. Objective: To examine trends in the incidence rates and lethality of suicidal acts from 2006 to 2015 among persons aged 10 to 74 years. Design, Setting, and Participants: This cross-sectional study was conducted from May 2, 2018, to January 30, 2019. Medically treated nonfatal suicide attempts were identified from the 2006 to 2015 Nationwide Inpatient Sample and Nationwide Emergency Department Sample databases. Suicides were identified from the 2006 to 2015 mortality files of the National Vital Statistics System. Main Outcomes and Measures: The incidence rate of suicidal acts was calculated by dividing the number of total suicidal acts by the US population. Lethality was measured through the case fatality rates (CFRs) of suicidal acts by dividing the number of suicides by the total number of suicidal acts. Results: A total of 1 222 419 (unweighted) suicidal acts, which included both suicides and nonfatal suicide attempts, were identified from 2006 to 2015. Overall, the incidence rates of total suicidal acts increased 10% from 2006 to 2015 (annual percentage change [APC], 0.8%; 95% CI, 0.3%-1.3%), and the CFRs of suicidal acts increased 13% during the 2006 to 2015 period (APC, 2.3%; 95% CI, 1.3%-3.3%). In subgroup analyses, incidence rates increased by 1.1% (95% CI, 0.6%-1.6%) per year for female individuals during the 2006 to 2015 period but remained stable for male individuals. The CFRs increased for both sexes (APC, 5.0% [95% CI, 3.1%-6.9%] since 2010 for female individuals; 1.6% [95% CI, 0.6%-2.5%] since 2009 for male individuals). Incidence rates increased among adolescents from 2011 to 2015 and among older adults aged 65 to 74 years throughout the 2006 to 2015 period. Conversely, the CFRs increased since 2009 among persons aged 20 to 44 years (APC, 3.7%; 95% CI, 2.5%-5.0%) and since 2012 for those aged 45 to 64 years (APC, 2.7%; 95% CI, 0.0%-5.4%). Persons aged 20 to 44 years and 45 to 64 years experienced increases in suicidal acts by more lethal means, whereas adolescents and older adults aged 65 to 74 years showed increased incidence by all means. Conclusions and Relevance: This study found increased suicidal acts among female persons, adolescents, and older adults aged 65 to 74 years, implying the need to address emerging or exacerbating suicide risk factors for these populations. The findings on the increased lethality particularly among persons aged 20 to 64 years highlighted the need to reduce access to materials that could be used as lethal means among persons at risk of suicide. These findings on population-level epidemiologic patterns can be used to guide the development of comprehensive suicide prevention strategies.

National Trends in hospitalizations for self-directed violence related to opioids and/or depression - United States, 2000-2015.

This study examined national trends in self-directed violence in the context of changes in opioid use and depression to better inform prevention measures. Using 2000-2015 National Inpatient Sample (NIS) data, we identified 625,064 hospitalizations for self-directed violence among persons aged ≥10 years in the United States. Based on whether co-listing opioid related diagnosis and depression, we categorized hospitalizations for self-directed violence into four comorbid categories as 1) related to opioids alone; 2) related to depression alone; 3) related to both opioids and depression; and 4) related to neither opioids nor depression. Census population estimates served as the denominator for calculating hospitalization rates for self-directed violence. Hospitalization rates for self-directed violence related to opioids doubled from 5.1 per 100,000 persons in 2000 to 11.0 in 2015. The rate of increase was highest for self-directed violence related to both opioids and depression, which increased 9.4% annually during 2000-2011 and then decreased 4.3% annually during 2011-2015. Hospitalizations for self-directed violence related to depression alone remained the predominant category, accounting for approximately 60% of hospitalizations for self-directed violence; the rates among females aged 10-24 years were the highest among all subgroups, and rose 7.8% annually since 2011 reaching 93.2 per 100,000 persons in 2015. These findings highlight the importance of assessing the risk for self-directed violence among patients misusing opioids and the importance of treating opioid use disorder and depression, particularly when they co-occur. Prevention and treatment of depression is especially important for young females.

Syndromic Surveillance of Suicidal Ideation and Self-Directed Violence - United States, January 2017-December 2018.

Suicide is a growing public health problem in the United States, claiming approximately 47,000 lives in 2017 (1). However, deaths from suicide represent only a small part of a larger problem because each year millions of persons experience suicidal ideation and engage in suicidal and nonsuicidal self-directed violence, both risk factors for suicide (2). Emergency departments (EDs) are an important setting for monitoring these events in near real time (3-5). From 2001 to 2016, ED visit rates for nonfatal self-harm increased 42% among persons aged ≥10 years (1). Using data from CDC's National Syndromic Surveillance Program (NSSP), ED visits for suicidal ideation, self-directed violence, or both among persons aged ≥10 years during January 2017-December 2018 were examined by sex, age group, and U.S. region. During the 24-month period, the rate of ED visits for suicidal ideation, self-directed violence, or both increased 25.5% overall, with an average increase of 1.2% per month. Suicide prevention requires comprehensive and multisectoral approaches to addressing risk at personal, relationship, community, and societal levels. ED syndromic surveillance data can provide timely trend information and can support more targeted and prompt public health investigation and response. CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices includes tailored suicide prevention strategies for health care settings (6).

Suicide among veterinarians in the United States from 1979 through 2015.

OBJECTIVE To assess proportionate mortality ratios (PMRs) for suicide among male and female US veterinarians from 1979 through 2015. DESIGN PMR study. SAMPLE Death records for 11,620 veterinarians. PROCEDURES Information for veterinarians who died during 1979 through 2015 was obtained from AVMA obituary and life insurance databases and submitted to a centralized database of US death records to obtain underlying causes of death. Decedent data that met records-matching criteria were imported into a software program for calculation of PMRs for suicide stratified by sex and indirectly standardized for age, race, and 5-year calendar period with 95% confidence intervals. RESULTS 398 deaths resulted from suicide; 326 (82%) decedents were male, 72 (18%) were female, and most (298 [75%]) were ≤ 65 years of age. The PMRs for suicide for all veterinarian decedents (2.1 and 3.5 for males and females, respectively), those in clinical positions (2.2 and 3.4 for males and females, respectively), and those in nonclinical positions (1.8 and 5.0 for males and females, respectively) were significantly higher than for the general US population. Among female veterinarians, the percentage of deaths by suicide was stable from 2000 until the end of the study, but the number of such deaths subjectively increased with each 5-year period. CONCLUSIONS AND CLINICAL RELEVANCE Results of the study indicated that PMRs for suicide of female as well as male veterinarians were higher than for the general population. These data may help to inform stakeholders in the creation and implementation of suicide prevention strategies designed for veterinarians.

RISING SUN: Prioritized Outcomes for Suicide Prevention in the Arctic.

The Arctic Council, a collaborative forum among governments and Arctic communities, has highlighted the problem of suicide and potential solutions. The mental health initiative during the United States chairmanship, Reducing the Incidence of Suicide in Indigenous Groups: Strengths United Through Networks (RISING SUN), used a Delphi methodology complemented by face-to-face stakeholder discussions to identify outcomes to evaluate suicide prevention interventions. RISING SUN underscored that multilevel suicide prevention initiatives require mobilizing resources and enacting policies that promote the capacity for wellness, for example, by reducing adverse childhood experiences, increasing social equity, and mitigating the effects of colonization and poverty.

Efforts and Opportunities to Understand Women's Mortality Due to Suicide and Homicide Using the National Violent Death Reporting System.

Women's mortality due to violent deaths is a public health issue that has received national attention. Many data systems only collect death certificate data, which provide very limited information about the circumstances surrounding a violent death. The Centers for Disease Control and Prevention's (CDC's) National Violent Death Reporting System (NVDRS) is the first and only surveillance system to capture data from death certificates, coroner/medical examiner reports, and law enforcement reports allowing for a more comprehensive picture and targeted prevention efforts. The system currently operates in 40 states, the District of Columbia, and Puerto Rico; however, with additional funding from the Consolidated Appropriations Act of 2018, this surveillance system will fully expand to cover all 50 states. A number of analyses have been conducted using NVDRS data to compare suicide and homicide among women with men; however, only a handful of studies have been conducted among subgroups of women. The present study provides an overview of NVDRS while highlighting a few key analytic studies with implications for suicide and homicide prevention/intervention among women. Data from the 2014 NVDRS Surveillance Summary are also presented to emphasize the unique opportunity to use NVDRS data to study the characteristics of suicide and homicide among women. The summary includes data from 18 states that were collected statewide. This information can provide state and local public health experts with essential data on female suicide and homicide, not provided in other surveillance systems, to help shape prevention and intervention efforts.

Violence-Related Disparities Experienced by Black Youth and Young Adults: Opportunities for Prevention.

INTRODUCTION: The purpose of this study is to characterize violence-related disparities experienced by young blacks in the U.S. Reducing violence experienced by blacks, particularly youth, who are at substantially higher risk, is essential to improving the health of blacks in the U.S. METHODS: Data from four independent data sets for youth and adults were analyzed to examine rates of homicide, assault, injury from a physical fight, bullying victimization, and missing school because of safety concerns for non-Hispanic blacks and whites aged 10-34 years between 2010 and 2015. Disparities in adverse childhood experiences (e.g., exposure to violence and household challenges) and physical/mental health outcomes in adulthood were examined. Data were analyzed in 2017. RESULTS: Black adolescents and young adults are at higher risk for the most physically harmful forms of violence (e.g., homicides, fights with injuries, aggravated assaults) compared with whites. In addition, black adults reported exposure to a higher number of adverse childhood experiences than whites. These adverse childhood experiences were positively associated with increased odds of self-reported coronary heart disease, fair or poor physical health, experiencing frequent mental distress, heavy drinking, and current smoking. CONCLUSIONS: Disproportionate exposure to violence for blacks may contribute to disparities in physical injury and long-term mental and physical health. Understanding the violence experiences of this age group and the social contexts surrounding these experiences can help improve health for blacks in the U.S. Communities can benefit from the existing evidence about policies and programs that effectively reduce violence and its health and social consequences.

Vital Signs: Trends in State Suicide Rates - United States, 1999-2016 and Circumstances Contributing to Suicide - 27 States, 2015.

INTRODUCTION: Suicide rates in the United States have risen nearly 30% since 1999, and mental health conditions are one of several factors contributing to suicide. Examining state-level trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. METHODS: Trends in age-adjusted suicide rates among persons aged ≥10 years, by state and sex, across six consecutive 3-year periods (1999-2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to examine contributing circumstances among decedents with and without known mental health conditions. RESULTS: During 1999-2016, suicide rates increased significantly in 44 states, with 25 states experiencing increases >30%. Rates increased significantly among males and females in 34 and 43 states, respectively. Fifty-four percent of decedents in 27 states in 2015 did not have a known mental health condition. Among decedents with available information, several circumstances were significantly more likely among those without known mental health conditions than among those with mental health conditions, including relationship problems/loss (45.1% versus 39.6%), life stressors (50.5% versus 47.2%), and recent/impending crises (32.9% versus 26.0%), but these circumstances were common across groups. CONCLUSIONS: Suicide rates increased significantly across most states during 1999-2016. Various circumstances contributed to suicides among persons with and without known mental health conditions. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: States can use a comprehensive evidence-based public health approach to prevent suicide risk before it occurs, identify and support persons at risk, prevent reattempts, and help friends and family members in the aftermath of a suicide.

Issues in Developing a Surveillance Case Definition for Nonfatal Suicide Attempt and Intentional Self-harm Using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Coded Data.

Suicide and intentional self-harm are among the leading causes of death in the United States. To study this public health issue, epidemiologists and researchers often analyze data coded using the International Classification of Diseases (ICD). Prior to October 1, 2015, health care organizations and providers used the clinical modification of the Ninth Revision of ICD (ICD-9-CM) to report medical information in electronic claims data. The transition in October 2015 to use of the clinical modification of the Tenth Revision of ICD (ICD-10-CM) resulted in the need to update methods and selection criteria previously developed for ICD-9-CM coded data. This report provides guidance on the use of ICD-10-CM codes to identify cases of nonfatal suicide attempts and intentional self-harm in ICD-10-CM coded data sets. ICD-10-CM codes for nonfatal suicide attempts and intentional self-harm include: X71-X83, intentional self-harm due to drowning and submersion, firearms, explosive or thermal material, sharp or blunt objects, jumping from a high place, jumping or lying in front of a moving object, crashing of motor vehicle, and other specified means; T36-T50 with a 6th character of 2 (except for T36.9, T37.9, T39.9, T41.4, T42.7, T43.9, T45.9, T47.9, and T49.9, which are included if the 5th character is 2), intentional self-harm due to drug poisoning (overdose); T51-T65 with a 6th character of 2 (except for T51.9, T52.9, T53.9, T54.9, T56.9, T57.9, T58.0, T58.1, T58.9, T59.9, T60.9, T61.0, T61.1, T61.9, T62.9, T63.9, T64.0, T64.8, and T65.9, which are included if the 5th character is 2), intentional self-harm due to toxic effects of nonmedicinal substances; T71 with a 6th character of 2, intentional self-harm due to asphyxiation, suffocation, strangulation; and T14.91, Suicide attempt. Issues to consider when selecting records for nonfatal suicide attempts and intentional self-harm from ICD-10-CM coded administrative data sets are also discussed.

Methods and Findings from the National Violent Death Reporting System for Identifying Gang-Like Homicides, 2005-2008.

BACKGROUND: The National Violent Death Reporting System (NVDRS) captures homicides that law enforcement or coroner/medical examiners deem as gang-related but the criteria used may vary across locations. Also, the existing gang-related variable likely underestimates the number of homicides that are associated with gang activity. This study utilizes NVDRS data to identify "gang-like" homicides which are not currently captured as "gang-related." METHODS: A set of criteria recommended by a panel of experts in gang violence, was applied to homicides collected in the NVDRS. These criteria, termed "gang-like" characteristics, were developed in order to better identify homicides consistent with gang activity. The narratives of the identified cases were then reviewed to refine the operational standard. After the reviews were complete, the typology was modified to finalize the operationalization of "gang-like" homicides. RESULTS: A total of 481 gang-like homicides were identified using the "gang-like" criteria. This represents an increase of almost 69% over the 696 gang-related homicides captured in NVDRS dataset. Gang-like and gang-related homicides combined represented 6.6% of homicides that occurred from 2005 to 2008. Among the 16 states included in this analysis, Colorado (15.5%) and Oklahoma (14%) had the highest percentage of homicides that were either gang-related or gang-like. Maryland had the greatest relative increase (227.3%) between gang related and gang-like homicides. CONCLUSION: The new "gang-like" variable complements the existing "gang-related" variable by providing an automated, standardized way to identify homicides that have circumstances consistent with gang activity. This new variable might be useful to states and localities seeking an efficient way to monitor homicides potentially resulting from gang activity. Additional efforts are needed to standardize the reporting of homicides associated with gang activity.

Suicide Trends Among and Within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanism of Death - United States, 2001-2015.

PROBLEM/CONDITION: Suicide is a public health problem and one of the top 10 leading causes of death in the United States. Substantial geographic variations in suicide rates exist, with suicides in rural areas occurring at much higher rates than those occurring in more urban areas. Understanding demographic trends and mechanisms of death among and within urbanization levels is important to developing and targeting future prevention efforts. REPORTING PERIOD: 2001-2015. DESCRIPTION OF SYSTEM: Mortality data from the National Vital Statistics System (NVSS) include demographic, geographic, and cause of death information derived from death certificates filed in the 50 states and the District of Columbia. NVSS was used to identify suicide deaths, defined by International Classification of Diseases, 10th Revision (ICD-10) underlying cause of death codes X60-X84, Y87.0, and U03. This report examines annual county level trends in suicide rates during 2001-2015 among and within urbanization levels by select demographics and mechanisms of death. Counties were collapsed into three urbanization levels using the 2006 National Center for Health Statistics classification scheme. RESULTS: Suicide rates increased across the three urbanization levels, with higher rates in nonmetropolitan/rural counties than in medium/small or large metropolitan counties. Each urbanization level experienced substantial annual rate changes at different times during the study period. Across urbanization levels, suicide rates were consistently highest for men and non-Hispanic American Indian/Alaska Natives compared with rates for women and other racial/ethnic groups; however, rates were highest for non-Hispanic whites in more metropolitan counties. Trends indicate that suicide rates for non-Hispanic blacks were lowest in nonmetropolitan/rural counties and highest in more urban counties. Increases in suicide rates occurred for all age groups across urbanization levels, with the highest rates for persons aged 35-64 years. For mechanism of death, greater increases in rates of suicide by firearms and hanging/suffocation occurred across all urbanization levels; rates of suicide by firearms in nonmetropolitan/rural counties were almost two times that of rates in larger metropolitan counties. INTERPRETATION: Suicide rates in nonmetropolitan/rural counties are consistently higher than suicide rates in metropolitan counties. These trends also are observed by sex, race/ethnicity, age group, and mechanism of death. PUBLIC HEALTH ACTION: Interventions to prevent suicides should be ongoing, particularly in rural areas. Comprehensive suicide prevention efforts might include leveraging protective factors and providing innovative prevention strategies that increase access to health care and mental health care in rural communities. In addition, distribution of socioeconomic factors varies in different communities and needs to be better understood in the context of suicide prevention.