Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12–25 Years Before and During the COVID-19 Pandemic

United States, January 2019-May 2021

Ellen Yard, PhD; Lakshmi Radhakrishnan, MPH; Michael F. Ballesteros, PhD; Michael Sheppard, MS; Abigail Gates, MSPH; Zachary Stein, MPH; Kathleen Hartnett, PhD; Aaron Kite-Powell, MS; Loren Rodgers, PhD; Jennifer Adjemian, PhD; Daniel C. Ehlman, ScD; Kristin Holland, PhD; Nimi Idaikkadar, MPH; Asha Ivey-Stephenson, PhD; Pedro Martinez, MPH; Royal Law, PhD; Deborah M. Stone ScD

Disclosures

Morbidity and Mortality Weekly Report. 2021;70(24):888-894. 

In This Article

Abstract and Introduction

Introduction

Beginning in March 2020, the COVID-19 pandemic and response, which included physical distancing and stay-at-home orders, disrupted daily life in the United States. Compared with the rate in 2019, a 31% increase in the proportion of mental health–related emergency department (ED) visits occurred among adolescents aged 12–17 years in 2020.[1] In June 2020, 25% of surveyed adults aged 18–24 years reported experiencing suicidal ideation related to the pandemic in the past 30 days.[2] More recent patterns of ED visits for suspected suicide attempts among these age groups are unclear. Using data from the National Syndromic Surveillance Program (NSSP),* CDC examined trends in ED visits for suspected suicide attempts during January 1, 2019–May 15, 2021, among persons aged 12–25 years, by sex, and at three distinct phases of the COVID-19 pandemic. Compared with the corresponding period in 2019, persons aged 12–25 years made fewer ED visits for suspected suicide attempts during March 29–April 25, 2020. However, by early May 2020, ED visit counts for suspected suicide attempts began increasing among adolescents aged 12–17 years, especially among girls. During July 26–August 22, 2020, the mean weekly number of ED visits for suspected suicide attempts among girls aged 12–17 years was 26.2% higher than during the same period a year earlier; during February 21–March 20, 2021, mean weekly ED visit counts for suspected suicide attempts were 50.6% higher among girls aged 12–17 years compared with the same period in 2019. Suicide prevention measures focused on young persons call for a comprehensive approach, that is adapted during times of infrastructure disruption, involving multisectoral partnerships (e.g., public health, mental health, schools, and families) and implementation of evidence-based strategies[3] that address the range of factors influencing suicide risk.

CDC examined NSSP ED visit data, which include approximately 71% of the nation's EDs in 49 states (all except Hawaii) and the District of Columbia. ED visits for suspected suicide attempts were identified by using a combination of chief complaint terms and administrative discharge diagnosis codes. ED visits for suspected suicide attempts include visits for suicide attempts, as well as some nonsuicidal self-harm visits.[4] Suspected suicide attempts were identified by querying an NSSP syndrome definition developed by CDC in partnership with state and local health departments (Supplementary Table, https://stacks.cdc.gov/view/cdc/106694). All analyses were restricted to EDs that reported consistently throughout the study period (January 1, 2019–May 15, 2021) and had at least one visit for suspected suicide attempts; 41% of those that reported consistently had one or more visits for suspected suicide attempts.§ Weekly counts and rates (mean number of ED visits for suspected suicide attempts/mean total number of ED visits) x 100,000) analyzed by age group (12–17 and 18–25 years) and sex were plotted across the entire study period, and analyzed for three distinct periods: spring 2020 (March 29–April 25, 2020; calendar year weeks 14–17); summer 2020 (July 26–August 22, 2020; weeks 31–34); and winter 2021 (February 21–March 20, 2021; weeks 8–11) and compared with their corresponding reference periods in 2019. These time frames were selected as representative of distinct periods throughout the pandemic. Percent change and visit ratios (rate of ED visits for suspected suicide attempts during surveillance period/rate of ED visits for suspected suicide attempts during reference period) with 95% confidence intervals (CIs) were calculated to compare suspected suicide attempt ED visit rates by pandemic period and sex; CIs that excluded 1.0 were considered statistically significant. NSSP race and ethnicity data were not available at the national level for this analysis at the time it was conducted. All analyses were conducted using R software (version 4.0.5; R Foundation). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.**

Among adolescents aged 12–17 years, the number of weekly ED visits for suspected suicide attempts decreased during spring 2020 compared with that during 2019 (Figure 1) (Table). ED visits for suspected suicide attempts subsequently increased for both sexes. Among adolescents aged 12–17 years, mean weekly number of ED visits for suspected suicide attempts were 22.3% higher during summer 2020 and 39.1% higher during winter 2021 than during the corresponding periods in 2019, with a more pronounced increase among females. During winter 2021, ED visits for suspected suicide attempts were 50.6% higher among females compared with the same period in 2019; among males, such ED visits increased 3.7%. Among adolescents aged 12–17 years, the rate of ED visits for suspected suicide attempts also increased as the pandemic progressed (Supplementary Figure 1, https://stacks.cdc.gov/view/cdc/106695). Compared with the rate during the corresponding period in 2019, the rate of ED visits for suspected suicide attempts was 2.4 times as high during spring 2020, 1.7 times as high during summer 2020, and 2.1 times as high during winter 2021 (Table). This increase was driven largely by suspected suicide attempt visits among females.

Figure 1.

Numbers of weekly emergency department visits* for suspected suicide attempts among adolescents aged 12–17 years, by sex — National Syndromic Surveillance Program, United States, January 1, 2019–May 15, 2021
Abbreviations: ED = emergency department; NSSP = National Syndromic Surveillance Program.
*ED visits for suspected suicide attempts were identified by querying an NSSP syndrome definition developed by CDC in partnership with state and local health departments (https://stacks.cdc.gov/view/cdc/106694). NSSP ED visit data include approximately 71% of the nation's EDs in 49 states (all except Hawaii) and the District of Columbia.
Visits for suspected suicide attempts include visits for suicide attempts, as well as nonsuicidal self-harm.

Among men and women aged 18–25 years, a 16.8% drop in the number of ED visits for suspected suicide attempts occurred during spring 2020 compared with the 2019 reference period (Figure 2) (Table). Although ED visits for suspected suicide attempts subsequently increased, they remained consistent with 2019 counts (Figure 2). However, the ED visit rate for suspected suicide attempts among adults aged 18–25 years was higher throughout the pandemic compared with that during 2019 (Supplementary Figure 2, https://stacks.cdc.gov/view/cdc/106696). Compared with the rate in 2019, the rate was 1.6 times as high during spring 2020, 1.1 times as high during summer 2020, and 1.3 times as high during winter 2021 (Table).

Figure 2.

Numbers of weekly emergency department visits* for suspected suicide attempts among adults aged 18–25 years, by sex — National Syndromic Surveillance Program, United States, January 1, 2019–May 15, 2021
Abbreviations: ED = emergency department; NSSP = National Syndromic Surveillance Program.
*ED visits for suspected suicide attempts were identified by querying an NSSP syndrome definition developed by CDC in partnership with state and local health departments (https://stacks.cdc.gov/view/cdc/106694). NSSP ED visit data include approximately 71% of the nation's EDs in 49 states (all except Hawaii) and the District of Columbia.
Visits for suspected suicide attempts include visits for suicide attempts, as well as nonsuicidal self-harm.

*NSSP is a collaborative program among CDC, federal partners, local and state health departments, and academic and private sector partners to support the collection and analysis of electronic health data from EDs, urgent and ambulatory care centers, inpatient health care facilities, and laboratories.
Analysis was limited to ED encounters. As of March 31, 2021, a total of 3,722 EDs covering 49 states (all except Hawaii) and the District of Columbia contributed data to the platform daily, including data from 71% of all nonfederal EDs in the United States.
§To limit the impact of data quality on trends, all analyses were restricted to facilities with a coefficient of variation <30 throughout the analysis period January 2019–May 2021 so that only consistently reporting facilities were included. Of all the EDs that met the data quality criteria, 41% had visits and thus were included in the analysis.
Percent change in visits per week during each surveillance period was calculated as the difference in total visits between the surveillance period and the reference period, divided by the total visits during the reference period, times 100%. ([ED visits for suspected suicide attempts during surveillance period–ED visits for suspected suicide attempts during reference period]/ED visits for suspected suicide attempts during reference period*100%).
**45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

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