May 13, 2010

Emergency Department Visits for Drug-related Suicide Attempts by Adolescents: 2008

Suicide is a major public health problem and a tragedy for all involved—family, friends, neighbors, colleagues, and communities. With about 1,000 completed suicides per year among persons aged 12 to 17, suicide ranks as the third leading cause of death among youths in this age range.¹ Behind the statistics on completed suicides are still more troubling numbers on suicide ideation and attempts. The 2007 Youth Risk Behavior Surveillance System (YRBSS) indicated that 14.5 percent of all high school students (grades 9 through 12) seriously considered attempting suicide in the past year, 11.3 percent made a suicide plan, 6.9 percent attempted suicide, and 2.0 percent had their suicide attempt treated by a doctor or nurse.²

The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related emergency department (ED) visits in the United States.^3,4 To be a DAWN case, the ED visit must have involved a drug, either as the direct cause of the visit or as a contributing factor. DAWN data can be used to examine ED visits for drug-related suicide attempts. Although DAWN includes only suicide attempts that involve drugs, these attempts are not limited to drug overdoses. If there is drug involvement in a suicide attempt by other means (e.g., cut wrists while drinking alcohol), the case is included as drug related. Excluded are suicide attempts with no drug involvement and suicide-related behaviors other than actual attempts (e.g., suicidal ideation or suicidal thoughts). This issue of The DAWN Report focuses on drug-related ED visits involving suicide attempts among adolescents aged 12 to 17; subsequent reports will focus on visits involving suicide attempts among other age groups.

During 2008, an estimated 263,871 drug-related ED visits were made by adolescents. Nearly one tenth of these (8.8 percent, or 23,124 visits) involved a suicide attempt. Many of the ED visits involved multiple drugs, with an overall average of 1.8 drugs (including alcohol) per ED visit (2.0 for males; 1.7 for females). Females accounted for nearly three fourths (72.3 percent) of the ED visits for drug-related suicide attempts among adolescents.

Pharmaceuticals were involved in 95.4 percent of ED visits for drug-related suicide attempts among adolescents (Table 1). Alcohol, sometimes combined with other drugs, was involved in about 1 in 10 (11.4 percent) of these visits, while illicit drugs were involved in 8.8 percent of ED visits.⁵ Anti-anxiety drugs were involved in 26.2 percent of the visits, and almost half of those visits were accounted for by benzodiazepines (12.6 percent). Antidepressants were involved in 23.0 percent of visits, and more than half of those visits were accounted for by selective serotonin reuptake inhibitors (e.g., fluoxetine). A smaller percentage of visits involved narcotic painkillers (e.g., oxycodone) and attention-deficit/hyperactivity disorder (ADHD) stimulants (e.g., methylphenidate) (5.1 and 1.5 percent of visits, respectively). Pain medications containing acetaminophen, ibuprofen, or aspirin as their main ingredient were involved in 25.4, 14.9, and 4.2 percent of ED visits for drug-related suicide attempts, respectively. Other prescription and over-the-counter (OTC) pharmaceuticals involved in suicide attempts were all found at levels less than 5 percent, and usually less than 1 percent (data not shown).

The drugs involved in ED visits for drug-related suicide attempts varied by gender (Figure 1). For example, antipsychotic drugs (e.g., quetiapine) were indicated in 14.3 percent of visits by males compared with 4.8 percent of visits by females, whereas acetaminophen products were indicated in 28.5 percent of ED visits by females compared with 17.1 percent of visits by males.

Figure 1. Selected Substances Involved in Emergency Department (ED) Visits for Drug-related Suicide Attempts among Adolescents, by Gender: 2008

Overall, more than three fourths (77.0 percent) of the ED visits for drug-related suicide attempts among adolescents ended with evidence of follow-up care. The likelihood of follow-up varied by the types of drugs involved, ranging from a high of 90.2 percent for visits involving prescription antidepressants to a low of 52.4 percent for visits involving ibuprofen products (Figure 2). Follow-up care is defined broadly to include admission to an inpatient unit in the hospital, transfer to another health care facility, or referral to detoxification.

Figure 2. Disposition of Emergency Department (ED) Visits Involving Drug-related Suicide Attempts among Adolescents, by Selected Type of Drug Involved*: 2008

Teen suicide is a major public health problem. One predictor of a future suicide attempt is a previous suicide attempt, and any adolescent who is in an ED because of a suicide attempt should be considered at higher risk for another, possibly fatal, attempt. Thus, EDs afford a unique opportunity to identify at-risk youth and their families and to provide immediate intervention. The findings reported here point to several considerations that may help policymakers, health care professionals, educators, and parents to take advantage of this intervention opportunity.

First, a greater proportion of the ED visits for drug-related suicide attempts were made by adolescent females than males, and the types of drugs involved in the visits varied by gender. Therefore, it may be important to consider these gender differences in managing crises, developing and using brief interventions, and planning aftercare.

Second, an ED visit for a suicide attempt is an opportunity to intervene with the parents/caretakers to educate them about the importance of monitoring the medicines to which the child has access.

Third, it is clear from the findings on ED follow-up that visits entailing less dangerous drugs (e.g., ibuprofen products) receive less follow-up than visits involving prescription drugs such as antidepressants. This may indicate a need to promote awareness among ED professionals and to develop more therapeutic interventions.