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Background: Suicide is a public health concern, but little is known about the patterns of health care visits made before a suicide attempt, and whether those patterns differ by race/ethnicity., Objectives: To examine racial/ethnic variation in the types of health care visits made before a suicide attempt, when those visits occur, and whether mental health or substance use diagnoses were documented., Research Design: Retrospective, longitudinal study, 2009-2011., Participants: 22,387 individuals who attempted suicide and were enrolled in the health plan across 10 health systems in the Mental Health Research Network., Measures: Cumulative percentage of different types of health care visits made in the 52 weeks before a suicide attempt, by self-reported racial/ethnicity and diagnosis. Data were from the Virtual Data Warehouse at each site., Results: Over 38% of the individuals made any health care visit within the week before their suicide attempt and ∼95% within the preceding year; these percentages varied across racial/ethnic groups (P<0.001). White individuals had the highest percentage of visits (>41%) within 1 week of suicide attempt. Asian Americans were the least likely to make visits within 52 weeks. Hawaiian/Pacific Islanders had proportionally the most inpatient and emergency visits before an attempt, but were least likely to have a recorded mental health or substance use diagnosis. Overall, visits were most common in primary care and outpatient general medical settings., Conclusions: This study provides temporal evidence of racial/ethnic differences in health care visits made before suicide attempt. Health care systems can use this information to help focus the design and implementation of their suicide prevention initiatives.

Objective: To investigate if the widely publicized warnings in 2003 from the US Food and Drug Administration about a possible increased risk of suicidality with antidepressant use in young people were associated with changes in antidepressant use, suicide attempts, and completed suicides among young people., Design: Quasi-experimental study assessing changes in outcomes after the warnings, controlling for pre-existing trends., Setting: Automated healthcare claims data (2000-10) derived from the virtual data warehouse of 11 health plans in the US Mental Health Research Network., Participants: Study cohorts included adolescents (around 1.1 million), young adults (around 1.4 million), and adults (around 5 million)., Main Outcome Measures: Rates of antidepressant dispensings, psychotropic drug poisonings (a validated proxy for suicide attempts), and completed suicides., Results: Trends in antidepressant use and poisonings changed abruptly after the warnings. In the second year after the warnings, relative changes in antidepressant use were -31.0% (95% confidence interval -33.0% to -29.0%) among adolescents, -24.3% (-25.4% to -23.2%) among young adults, and -14.5% (-16.0% to -12.9%) among adults. These reflected absolute reductions of 696, 1216, and 1621 dispensings per 100,000 people among adolescents, young adults, and adults, respectively. Simultaneously, there were significant, relative increases in psychotropic drug poisonings in adolescents (21.7%, 95% confidence interval 4.9% to 38.5%) and young adults (33.7%, 26.9% to 40.4%) but not among adults (5.2%, -6.5% to 16.9%). These reflected absolute increases of 2 and 4 poisonings per 100,000 people among adolescents and young adults, respectively (approximately 77 additional poisonings in our cohort of 2.5 million young people). Completed suicides did not change for any age group., Conclusions: Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people. It is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting., (© Lu et al 2014.)

Background: Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples., Objective: To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed., Design: Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states., Participants: In all, 5,894 individuals who died by suicide, and were health plan members in the year before death., Main Measures: Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site., Key Results: Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p < 0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means., Conclusions: This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.

Context: Several studies have suggested that lithium treatment reduces risk of suicide in bipolar disorder, but no research has examined suicide risk during treatment with divalproex, the most commonly prescribed mood-stabilizing drug in the United States., Objective: To compare risk of suicide attempt and suicide death during treatment with lithium with that during treatment with divalproex., Design and Setting: Retrospective cohort study conducted at 2 large integrated health plans in California and Washington., Patients: Population-based sample of 20 638 health plan members aged 14 years or older who had at least 1 outpatient diagnosis of bipolar disorder and at least 1 filled prescription for lithium, divalproex, or carbamazepine between January 1, 1994, and December 31, 2001. Follow-up for each individual began with first qualifying prescription and ended with death, disenrollment from the health plan, or end of the study period., Main Outcome Measures: Suicide attempt, recorded as a hospital discharge diagnosis or an emergency department diagnosis; suicide death, recorded on death certificate., Results: In both health plans, unadjusted rates were greater during treatment with divalproex than during treatment with lithium for emergency department suicide attempt (31.3 vs 10.8 per 1000 person-years; P<.001), suicide attempt resulting in hospitalization (10.5 vs 4.2 per 1000 person-years; P<.001), and suicide death (1.7 vs 0.7 per 1000 person-years; P =.04). After adjustment for age, sex, health plan, year of diagnosis, comorbid medical and psychiatric conditions, and concomitant use of other psychotropic drugs, risk of suicide death was 2.7 times higher (95% confidence interval [CI], 1.1-6.3; P =.03) during treatment with divalproex than during treatment with lithium. Corresponding hazard ratios for nonfatal attempts were 1.7 (95% CI, 1.2-2.3; P =.002) for attempts resulting in hospitalization and 1.8 (95% CI, 1.4-2.2; P<.001) for attempts diagnosed in the emergency department., Conclusion: Among patients treated for bipolar disorder, risk of suicide attempt and suicide death is lower during treatment with lithium than during treatment with divalproex.