Dr. Valuck is associate professor in the Department of Clinical Pharmacy and Dr. Libby is assistant professor in the Department of Psychiatry, both at the University of Colorado School of Pharmacy in Denver. Dr. Benton is assistant professor in the Department of Psychiatry at the University of Pennsylvania Medical School in Philadelphia and an adult, child, and adolescent psychiatrist at The Children’s Hospital of Philadelphia. Dr. Evans is the Ruth Meltzer professor and chairman of the Department of Psychiatry and professor of Psychiatry, Medicine, and Neuroscience at the University of Pennsylvania School of Medicine.
Disclosures: Dr. Valuck receives grant support from the Agency for Healthcare Research and Quality, the American Foundation for Suicide Prevention, Eli Lilly, Forest, Janssen, and Pfizer. Dr. Libby receives grant support from Eli Lilly. Dr. Benton receives grant support from the National Institute of Mental Health (NIMH). Dr. Evans is consultant to Abbott, AstraZeneca, Bristol-Myers Squibb/Otsuka, Eli Lilly, Forest, Johnson & Johnson Pharmaceutical Research and Development, Neuronetics, Pamlab, and Wyeth; and receives grant support from the NIMH.
Please direct all correspondence to: Robert J. Valuck, PhD, RPh, Associate Professor, Department of Clinical Pharmacy, University of Colorado at Denver and Health Sciences Center, 4200 E Ninth Ave, C-238, Denver, CO 80262-0238; Tel: 303-315-3841; Fax: 303-315-1797; E-mail: Robert.Valuck@UCHSC.EDU.
• A retrospective study examined the annual rates of suicide attempts among managed care enrollees.
• The study found that 50% of suicide attempters were adults 25–64 of age, 38% were youths 10–19 years of age, and 55% had a psychiatric diagnosis 90 days prior to the attempt.
Introduction: Depression is a risk factor for suicide and is prevalent among adult and pediatric populations. Associations between antidepressant use and suicidal behaviors have resulted in a black box warning about antidepressant use. This study examines annual rates of suicide attempts among managed-care enrollees and describes their demographics, diagnoses, and prior treatments.
Methods: A retrospective case series was compiled from the PharMetrics Integrated Outcomes Database, representing 47 million covered lives from 1998–2005. Suicide attempts were identified from paid claims data using the International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision diagnostic codes. Numbers of suicide attempters and population-based rates were measured annually. Demographic data, chronic disease, psychiatric diagnoses, and antidepressant use were described.
Results: Among 10,914 attempters, subjects with one suicide attempt increased from .04% in 1998 to .13% in 2005. Most were female (72%), adult (63%), and lived in the Midwest (57%). The most frequent (38%) age group was 10–19 years of age. Over 50% had a diagnosis of depression (38%), anxiety (14%), or substance abuse (14%). Fifty-three percent were receiving antidepressants.
Discussion: The findings in this study support the large body of evidence reporting higher risks of suicide attempts or completion among children and adolescents. The findings are also consistent with reports of lack of recognition and undertreatment of psychiatric illness, since 47% of suicide attempters in the present study were not receiving antidepressants at the time of the attempt.
Conclusion: While suicide attempters varied significantly in their demographic characteristics, psychiatric diagnosis and antidepressant use were similar in the majority of cases. Further studies should identify shared risk factors for suicide among those treated with antidepressants.
Major depressive disorder (MDD) has been shown to be a prevalent disorder in both adult and pediatric populations. The most recent estimate based on the National Comorbidity Study Replication for the adult United States population is 16.2% for lifetime prevalence of MDD.1 Estimates of 1-year prevalence are as high as 2.5% in childhood and 8.3% in adolescence.2,3 Important from a public health perspective and for this study, a four-fold increased likelihood of suicide attempt associated with pediatric depression has been reported,4,5 and those with MDD are at especially high risk compared to those with other emotional disorders.6 Studies report higher risk for suicide attempts among adolescents, particularly among those with depression.7,8
Concern over a possible link between antidepressant use and “suicidality” (a term that encompasses a large range of behaviors, including completed suicide, suicide attempt, planning or other preparatory action, suicidal ideation, and self-injury with lethal intent)9 has led the US Food and Drug Administration to take regulatory action in the form of a black box warning for this class of drugs for children and adolescents (up to 18 years of age) in 2004,10 and for young adults (ages 19–24 years) in 2007,11 despite the existence of very few cases of suicide attempt and no reports of completed suicide(s) in antidepressant clinical trials.12 Given the rarity of reported suicidal behaviors in clinical trials and the difficulty in accurately classifying such behaviors from case report forms9 little is known about the demographic or clinical characteristics of subjects who attempt suicide or how often such attempts occur in large, “real-world” populations.
The purpose of this study is to quantify the crude incidence rate of suicide attempt in US managed healthcare plans and to provide descriptive information on demographic and clinical characteristics of suicide attempt cases. Such information will lay the groundwork for further, comparative studies of suicide attempters and other subjects to further our understanding of the possible link between patient factors, prescribed medication use, and suicide attempt.
Data for this study come from a commercially available claims database provided by PharMetrics, Inc., a unit of Intercontinental Marketing Services (presently known as IMS), the largest national patient-centric database of longitudinal, integrated medical, facility, and pharmacy claims data. These integrated data include paid claims from 85 managed-care plans nationally, representing 47 million covered lives from 1998 to 2005. The majority of subjects in this database (92%) were covered by commercial insurance plans, and 8% were insured by Medicaid. Descriptive statistics suggest that these integrated data describe a population that is regionally representative and comparable to US Census distributions on age and gender. In fact, the 0–65 years age distribution within the database is not statistically different than the 2000 US Census distribution.13
Information on the number of managed-care enrollees covered by participating health plans and stratified by age, gender, and in total, was provided by PharMetrics for the purpose of calculating crude incidence rates of suicide attempt. Blinded, individual patient-level medical claims data (consisting of all paid physician, facility, and pharmacy claims records) were obtained for those subjects with at least one suicide attempt, as defined below, and with at least 360 days of prior enrollment and claims history. This restriction was employed to enable accurate description of demographic and clinical characteristics of identified case subjects in the year prior to as well as at the time of the suicide attempt.
Suicide Attempt Cases
Suicide attempt cases were identified from insurance claims coded for a suicide attempt associated with any visit to a medical provider or facility. The National Center on Health Statistics reports that most states use the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)14 to code injuries resulting from suicide attempts; ICD-10 codes are also in use and all states use these codes for suicide deaths.15 These external cause codes describe manner and mechanism of injury, but do not differentiate suicide attempt from self-inflicted injury, ie, an injury not intended to cause death. We followed the Centers for Disease Control and Prevention guidelines in defining suicide attempts as claims with ICD-9-CM codes E950-E959 and ICD-10 codes X60-X84 and Y87.0.16 For each suicide attempt case, the date of the attempt was labeled the “index date” (in the case of multiple attempts per subject, the date of the first attempt was labeled the “index date” and subsequent descriptive analyses focused only on the initial attempt).
Several measures were determined or calculated for each suicide attempt case. For all measures, descriptive statistics were used where appropriate (Statistical Analysis System v9.0, Cary, North Carolina). No inferential statistical tests were performed. The study received exemption from institutional review board-approval by the Colorado Multiple Institutional Review Board (Aurora, Colorado).
Suicide Attempt Rate
The crude annual incidence rate of suicide attempt in the base population was calculated as the percent of enrolled subjects with at least one attempt in a given calendar year (1998–2005). The number of attempts per subject as well as the minimum, maximum, mean, median, and modal number of attempts per subject were also determined to fully characterize the distribution of attempts in the population.
For each suicide attempt case, the authors of this article determined subject age in years at time of first attempt (mean, standard deviation, median, and interquartile range), and broken down further by age groupings (pediatric, <18 years of age; young adult, 18–24 years of age; adult, 25–64 years of age; or elderly, ≥65 years of age) and age decades (0–9, 10–19, etc., up to 90–99). The authors also determined subject gender (male or female), region (East, Midwest, South, or West), and payer type (commercial insurance, Medicaid, Medicare Risk, Self-insured, or Medicare Gap).
For each suicide attempt case, the presence of numerous diagnoses of interest were identified using ICD-9-CM codes, both at the time of initial suicide attempt (within 90 days of, or on, the “index” date) or previous diagnoses (>90 days prior to the initial attempt). Mental health disorders of interest included: MDD, anxiety, schizophrenia, substance use disorder, bipolar disorder, any other mental health disorder (not previously listed), the presence of multiple mental health disorders, and the presence of any mental health disorder. Terminal disorders of interest included: HIV/AIDS, or malignant neoplasm. The 10 most frequently occurring “other” (ie, non-mental health, non-terminal) diagnoses among suicide attempt cases were identified as well. The level of chronic medical comorbidity and healthcare service utilization for each suicide attempt case at the time of initial suicide attempt were measured using the Chronic Disease Indicator (CDI) score, which indicates the total number of chronic diseases a subject has according to medical and pharmacy claims data,17 and the subject’s prior year total healthcare costs (paid by their managed health plan; expressed as mean, standard deviation, median, and interquartile range). Also noted for each case subject was the location at which the suicide attempt was coded (ie, the type of medical facility where the suicide attempt diagnosis was made).
For each suicide attempt case, several parameters indicative of prior medical treatment were determined. Antidepressant use prior to the first suicide attempt was identified using pharmacy claims data and was classified as any use of an antidepressant (yes/no); class of antidepressant used (ie, selective serotonin reuptake inhibitor [SSRI] monotherapy, serotonin norepinephrine reuptake inhibitor [SNRI] monotherapy, tricyclic antidepressant monotherapy, other antidepressant monotherapy, or multiple antidepressant use—either consecutively or concurrently); recent use (within 90 days or not); and use at the time of the suicide attempt (overlapping the “index date” or not). Use of other psychotropic medications of interest was measured as “yes” (indicative of any use in the 360 days prior to first suicide attempt) or “no” (no recorded use) for the following classes of drugs: conventional antipsychotics, atypical antipsychotics, anxiolytics, mood stabilizers, or other psychotropic medications (not previously listed). Lastly, prior receipt of psychotherapy services was also determined, using the Current Procedural Terminology, 4th Edition.18 Psychotherapy service use was classified as any prior psychotherapy claim(s) (yes/no); if yes, number of psychotherapy visits prior to first suicide attempt (one or >1); and the mean, standard deviation, median, mode, and range of number of psychotherapy visits per case were determined.
Suicide attempt cases from a national managed-care population were identified and rates of attempt were measured annually for the years 1998–2005 (Table 1). The percent of subjects with at least one attempt out of all managed-care enrollees increased from .04% (4 cases per 10,000 enrollees) in 1998 to .13% (13 cases per 10,000 enrollees) in 2005. Although the number of attempts per case ranged from 1–17, the average number of attempts per case was 1.1 and the median and modal number of attempts per case was one.
Demographic characteristics of suicide attempts subjects are described in Table 2. The average age at first suicide attempt was 29 years, with a median age of 25 years. Half of attempters were adults 25–64 years of age; older adults accounted for <1% of all attempts. Youths <18 years of age accounted for 28%, and young adults 18–24 years of age accounted for 22% of attempts. The most frequent age group (in decades) were youths 10–19 years of age at 38% of all attempts. Most attempters were female (72%). Suicide attempt cases were prominent in the Midwestern health plans (57%) and health plans in the West (28%). A majority of cases came from commercial insurance plans (64%). Cases from Medicaid plans (22% of suicide attempts) were proportionally higher than overall representation in the manage care patient population (9% of all enrollees).
Diagnostic history is reported for time periods within 90 days prior to the first suicide attempt (if there is more than one) and >90 days (91–360 days, at least as long as the 1 year minimum window preceding the attempt, and possibly longer than 1 year; Table 3). In the 90 days prior to the attempt, 50% of cases had either a diagnosis of depression (38%) or anxiety (12%). Fourteen percent had a diagnosis of substance abuse disorders. Thirty percent of cases had multiple mental health or substance abuse disorders. In the period >90 days prior to the attempt, 75% of attempters had been given a diagnosis of depression (52%) or anxiety (23%). Approximately 24% were assigned a substance abuse diagnosis on a medical claim. Forty-seven percent of attempters had multiple mental health or substance abuse diagnoses. Overall, 70% of cases had some type of psychiatric diagnosis on a paid claim >90 days prior to the suicide attempt.
Terminal diagnoses were uncommon. The most common non-psychiatric diagnoses in the 90 days prior to the attempt were headache (6%), abdominal pain (6%), pharyngitis (6%), lumbago (5%), and poisoning (5%). Chronic disease indicator CDI scores ranged from 0–20, with a median of two and mode of zero, indicating that these attempters did not represent complex severely chronically medically ill patients. Nearly 40% of attempts were reported in hospital emergency rooms, followed by inpatient settings (21%).
Psychiatric treatment history is described for any period in 360 days prior to the first suicide attempt (Table 4). Among cases, 60% had some record of filled antidepressant prescriptions. Among those, 35% of cases used SSRIs and >50% used multiple antidepressants of any class. Among antidepressant users, 72% was within 90 days prior to the suicide attempt and 53% was at the time of the attempt. A history of other mental health medications was reported for cases in the 360-day period prior to the attempt and included atypical antipsychotics (17%), anxiolytics (14%), mood stabilizers (4%) and other psychotropic drugs (37%).
Prior to the suicide attempt, 56% had at least one record coded for psychotherapy from any type of healthcare provider. Only 10% had only one claim for psychotherapy. The average number of psychotherapy visits was 17, with a median of 9, ranging from 1–274; the modal number of psychotherapy visits was one.
This study provides crude incidence rates as well as demographic and clinical characteristics of suicide attempters in a large representative sample of US managed-healthcare plans.
The authors of this article found trends toward increasing rates of the total number of suicide attempts per 10,000 enrollees from 1998 (0.04%) to 2005 (0.13%). Significant differences between the demographic characteristics of suicide attempters were also found. In this sample, females were the majority of first-time suicide attempters (71.8%), consistent with findings from epidemiologic surveys suggesting increased rates of suicide attempts among females.19,20 First suicide attempts spanned a wide age range but occurred with much greater frequencies among individuals <20 years of age.
The finding that the highest rates for first-time suicide attempts were among the 10–19-year-old age group (38%) is similar to the findings of other large epidemiologic surveys of suicide attempts.19,20 These surveys suggest that higher risks for initial suicidal ideation, plans, and attempts occur during the late teen years and early twenties and the median ages of onset for all of these outcomes occur during the mid-twenties. Consistent with these findings, this study described found a mean age at first suicide attempt of 29 years with a median of 25 years. Young adults 18–24 years of age accounted for 22% of all attempts and youths <18 years of age accounted for 28% of all attempts. The other 50% were accounted for by adults 25–64 years of age.
The findings in this study support the large body of evidence reporting higher risks for suicide attempts or suicide completion among children and adolescents. This increased risk among youths has recently received a great deal of attention in the psychiatric literature and public media. The FDA’s black box warning in 2004, suggesting that this population may be more vulnerable to increased suicidality when SSRIs or SNRIs are prescribed, has resulted in substantial declines in prescription rates for these agents in this age group and some decreased prescribing in adults up to 60 years of age as well. A study by Gibbons and colleagues21 assessed whether these warnings led to changes in prescription patterns and changes in suicide rates. They noted a 22% decrease in prescriptions for young people in 2003 and 2004 in the US and Netherlands and a subsequent increase in the rate of completed suicide in the US (14%) and the Netherlands (49%). The largest decreases in prescriptions were observed in the population <20 years of age, one group most vulnerable to suicide. An inverse relationship was noted between the SSRI prescription rates and the rates of completed suicides for the period 1998–2005. The trend toward increased prescription rates and decreased suicide rates for children and adolescents observed between 1998–2003 has been reversed with increased suicide rates noted in 2004. These data raise questions about current trends for treatments of psychiatric disorders associated with suicide. The decline in prescriptions may suggest trends toward undertreatment or underrecognition of depression. Evidence from the pediatric and adult populations suggests that diagnoses for depression and treatments have declined since 2004.22,23
The most recent population-based estimates of the 1-year prevalence of trends for suicide attempts describe rates of .6% from 2001–2003. These studies also show higher rates of psychiatric symptoms meeting criteria for a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),24 disorder among suicide attempters. In the National Comorbidity Survey–Replication (NCS-R) studies, MDD (51%) was the most common individual disorder among people with suicide-related behaviors, and anxiety disorders (81%) were the most common class of disorders.19 Similar to the attempters, >90% of completed suicides in the US are associated with psychiatric illness, most commonly mood disorders (60%).25-29 Another result of the study was that most attempters had a psychiatric or substance use diagnosis at 90 days prior to the attempt and at >90 days prior to their attempt, and many had more than one diagnosis in the time period 90 days prior to an attempt or >90 days prior to attempt. Most attempters in the sample were diagnosed with an MDD (38% to 52%), anxiety disorder (12% to 23%), or substance use disorder (55% to 70%) prior to their suicide attempt. Higher rates of attempted suicide were associated with the presence of MDD, anxiety disorder, or substance use disorders within the 90 days prior to an attempt, and the highest rates occurred at >90 days prior to the attempt. Any mental health or substance use disorder was associated with higher rates of attempted suicide (55.3%) when compared to no psychiatric diagnosis (16.8%).
An important finding in the described study is that nearly 50% of the attempters in this population were not receiving antidepressants for any psychiatric disorder. Among those receiving medication treatment for depression, only 53% were using medications at the time of the attempt. Of those attempters receiving antidepressants, 38% were receiving SSRI or SNRI monotherapy and 51% were receiving multiple antidepressants. In addition, slightly more than 50% of the population had received some form of psychotherapy. Recent data for antidepressant prescribing patterns suggest that of 9,911,743 antidepressant prescriptions written for the population <20 years of age, 65% of those prescriptions were SSRIs and 20% were for non-serotonin–specific agents.21 The 51% rate of multiple antidepressant prescribing in the present study might be related to the severity of depression among attempters and/or prior poor response to antidepressants, suggesting treatment refractory disorders.
The evidence suggests that the majority of depressed individuals who die from suicide seek professional help within the month prior to their deaths.30 Nonetheless, the majority of these individuals are not being treated with antidepressants at the time of their suicide.31-33 These findings are consistent with the lack of recognition and undertreatment of psychiatric illness in general34 and mood disorder in particular.35 The data from the present study of suicide attempters also suggest underrecognition and lack of treatment since approximately 47% of suicide attempters were not receiving antidepressants at the time of the attempt. The trend toward increasing incidence rates for suicide attempts between 1998 and 2005 in the authors’ preliminary data cannot fully be explained. While suicide attempts are a risk factor for completed suicides, there is not a direct correlation between rates of attempts and rates of completion, making it difficult to provide correlations between data from the authors of this study and data on completed suicides.
Advances in the evidence-based treatments for depressive disorders should predict decreased suicide attempts in this population. Findings in this study, suggesting increased rates of first-time attempts, are in line with some epidemiologic studies that suggest that suicide-related behaviors have not changed over time, although evidence-based treatments have increased significantly.19,20 Epidemiologic data examining trends for suicidal behaviors from the 1990–1992 NCS and the follow up 2001–2003 NCS-R survey showed significant increases in treatment for depression and decreases in completed suicide rates, but no decrease in suicidal behaviors over time, suggesting potential clinical differences between attempters and completers.
These results have several limitations. ICD-9-CM codes as proxies for DSM-IV-TR psychiatric diagnoses for this study limit the ability to assess methods of diagnostic ascertainment, intent of self-injury, and severity of depression, which could impact suicidal behavior. Additionally, use of claims data to assess treatments provides limited information about adherence to treatment prior to or at the time of attempt or appropriateness, sufficient intensity, or continuity of treatment. Even with sufficient treatment, medication, and psychotherapies, recent evidence suggests that there is a phase during the treatment process during which the incidence of suicide attempts remains high. Simon and Savarino36 studied the incidence of suicide attempts among depressed patients starting psychotherapy or medications prescribed by a psychiatrist or primary care provider. While differences were found in the overall incidence of suicide attempts between these three treatment conditions, the pattern of suicide attempts did not vary. They found the highest incidence rates during the month before initiation, the second highest 1 month after initiation of medication or psychotherapy, and declines thereafter. Even with the appropriate management of these disorders, suicide attempts remain common. This is also important given the knowledge that adherence to antidepressant treatment is not great, with data suggesting that ≥33% of patients beginning antidepressants discontinue treatment within a few weeks.37 Additionally, ethnic background, SES data, and marital status, all identified risk factors for suicide attempts, were not included in this analysis. Despite the above limitations, the demographics and clinical characteristics of our population appear to be similar to available population-based estimates.
Preliminary findings from this large data set representing US managed healthcare plans provide crude incidence rates for suicide attempts and descriptive demographic and clinical data that do not differ substantially from those predicted by current epidemiologic data regarding suicide attempts. Additionally, the study presented provides preliminary descriptive data about the clinical presentations and psychiatric diagnoses and some descriptive data about antidepressant treatments and suicide attempts. These data suggest that managed-care databases could be used to further describe and understand the demographic and clinical characteristics of suicide attempters and those who will attempt suicide as well as the associations between antidepressant use and suicide attempts.
The findings that slightly <50% of the attempters had received antidepressant treatment and that slightly >50% received psychotherapy lend support to existing data that psychiatric illness remains underrecognized, untreated, or inadequately treated despite significant advances in detection and treatment.34,35 In light of these data, the black box warnings issued by the FDA could increase risks for undertreatment of depressed children, adolescents, and young adults who are very high-risk groups and should be the focus of further investigation. Future study is also needed to better understand the demographic and clinical characteristics that predispose individuals to suicidal behaviors.
Future efforts should focus on using patient-level data to further describe and characterize the population of suicide attempters. Although most of the attempters in the study provided had significant psychopathology, some attempters had no recorded psychiatric diagnosis. In addition, the frequency of suicide attempts far exceeds the number of deaths from suicide, suggesting that perhaps attempters and completers are not the same population. Comparative studies examining these two populations are needed. Finally, sufficient numbers of cases exist in the PharMetrics database for continued epidemiologic investigation into possible relationships between depression, antidepressant medication use, and suicide attempts. PP
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