Fatal self-injury in the United States, 1999–2018: Unmasking a national mental health crisis

Abstract

Background: Suicides by any method, plus 'nonsuicide' fatalities from drug self-intoxication (estimated from selected forensically undetermined and 'accidental' deaths), together represent self-injury mortality (SIM)fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999À2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification. Methods: For this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the 'nonsuicide' SIM component. Findings: The national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p<0.001) versus 1.8% (95% CI: 1.6%, 2.0%; p<0.001) for the suicide rate.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States

“…We used deidentified manner and underlying cause-of-death data for the 50 US states and the District of Columbia at 4 observation points : 1999-2000, 2007-2008, 2013-2014, and 2018-2019; rationale for these points has been previously documented. 1 Our source was CDC's Wide-ranging Online Data for Epidemiologic Research (WONDER) database. 22 Deaths had been precoded in accordance with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10).…”

“…The proportions for the undetermined and unintentional drug deaths were applied directly to the aggregated data to estimate the active behavior component of SIM. [1][2][3] We assumed these deaths were deaths from drug self-intoxication, 6 as potentially verifiable by singular or cumulative evidence of pharmacy or physician shopping in a prescription drug monitoring database, high concentration of drugs in the stomach or small intestine of the corpse detected through autopsy, illicit drug positivity in toxicologic testing, and documentation of drug paraphernalia at the death scene. 3 This active behavior component reflects common patterned, premorbid behaviors associated with increased risk for premature death.…”

“…Social and Environmental Factors and Rates of Self-injury Mortality and Suicide century US, which manifested as a nationwide phenomenon when fatal self-injury was represented by SIM rather than suicide, its conventional indicator. 1 This crisis is intensifying further, given provisional CDC data showing a transformation in the geography of opioid-related fatalities through the westward spread of fentanyl distribution. 32 Based on our data, which largely preceded the widespread national distribution of fentanyl and its congeners, Western mountain states, adjacent Midwestern states, and Arkansas had the least evidence of misclassifying suicide counts, as they had relatively fewer deaths attributed to fentanylrelated and other drug poisoning deaths than Eastern states prior to 2019.…”

“…The United States has endured an evolving crisis of self-injury mortality (SIM) during the opening decades of the 21st century due to suicide and drug misuse. 1 SIM augments registered suicides with most opioid or other drug overdose fatalities caused by individuals' instrumental actions on the day of death-ultimately with the goal of improving injury surveillance, enhancing etiologic understanding, and establishing the foundation for effective, scalable programs of prevention and clinical intervention. 2,3 We have applied the broader construct of SIM to characterize drug fatalities arising from persons' instrumental behaviors, given well-documented uncertainty of where to draw demarcating lines between deaths arising from an intention to die (ie, suicides), intentional behaviors that lead to fatalities (ie, drug-related deaths now called accidents, later relabeled unintentional by the Centers for Disease Control and Prevention) as diagnosed by medical examiners or ruled by coroners , as well as truly accidental or unintentional injuries that occur without preceding probability-altering risk factors.…”

Geographic Disparities in Readmissions for Peripheral Artery Disease in South Carolina

“…To adjust for correlated and uncorrelated spatial heterogeneity and generate stable and reliable prevalence rates, we applied the conditional autoregressive Besag-York-Mollie (BYM) model [ 37 ]. More information about this model, including mathematical specifications, can be found elsewhere [ 38 , 39 , 40 ]. In short, this model includes a spatial random effect, which accounts for ZCTA level spatial dependence (e.g., clustering) of readmission prevalence and a non-spatial random effect, which accounts for any residual ZCTA level variation that is not spatially structured.…”