Categorizing self-injury mortality (SIM) help to understand national trends for today’s epidemics of suicide

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A recent study published in Injury Prevention described a method for categorizing self-injury mortality (SIM) to help us better examine national trends for today’s epidemics of suicide and drug-related deaths.

This SIM study compared trends among non-Hispanic blacks and Hispanics with those of whites. SIM included all suicides, regardless of method.

The study also viewed most drug overdoses as self-injury, even where evidence did not meet the standard for a suicide classification.

This approach is due to the observed pattern of intentionally repeated self-injury behaviors found in most drug deaths.

The SIM investigation, according to the researchers, underscores the need to view suicides and drug deaths as two fatal outcomes associated with common risk factors.

In some cases, these outcomes also share symptoms of hopelessness and loss of behavioral control that may be amenable to targeted prevention efforts.

The researchers also said that their findings highlight the need for the US health care system to address data surveillance and health care delivery disparities that have important implications for innovative strategies to reduce “deaths of despair.”

The study was led by West Virginia University’s Ian Rockett, PhD, MPH, MA. McLean Hospital’s Hilary S. Connery, MD, PhD, was a co-investigator.

According to Rockett, SIM is important for several reasons. “SIM recognizes that suicides are not accurately accounted for,” he said.

“It allows most drug deaths to belong in the suicide category because they are not true accidents, providing a perspective on total death burden.

This lens is important for revealing more granular data trends that may guide the allocation of prevention and treatment resources.

Examining SIM helps us better see the trends of the current mental health crisis for women and minorities as well as for white men.”

While the SIM rate for whites rose by 55% between 2008 and 2017, it increased by 109% for blacks and 69% for Hispanics. Women in all three groups were more likely to die from drug overdoses than men.

Although Hispanics had the lowest rates of SIM, they died at a younger age. Hispanics dying from self-injury in 2017 were projected to have lost 43 years of life verses 37 and 32 for whites and blacks, respectively.

The SIM study finds that suicide is likely underreported for females because women tend to use methods that are less violent and less obvious than those of men.

Women who take their own lives are more likely to do so with drugs than by hanging or with guns.

The study also indicates that evidence of suicide is rarer for blacks and Hispanics than for whites because of unequal access to health care or because of different use of health care, when accessible. Black and Hispanic people who died by suicide had fewer previously documented mental health conditions than their white counterparts.

Connery provided more treatment context.

The researchers also said that their findings highlight the need for the US health care system to address data surveillance and health care delivery disparities that have important implications for innovative strategies to reduce “deaths of despair.”

“The health care system has a long history of separating people coming for mental health disorders care from those coming for substance use disorders care,” she said.

“Considering today’s concurrent epidemics, this system doesn’t work well at a population level because of the high rates of co-occurrence of substance use disorders and other mental health disorders.

It’s extremely common for a depressed person to be misusing substances but asking only for help for depression.

Likewise, a person asking for help with opioid use disorder may seek medical treatment but not report suicidal thoughts and planning. In both cases, screening for suicide risk factors and overdose risk factors will improve early detection, which may then allow targeted, integrated treatments to prevent SIM deaths.”

The other major barrier to understanding and preventing self-injury deaths, according to Connery, is that they are portrayed as either “intentional” or “unintentional.”

“This false dichotomy leads to depictions of self-injury deaths as either intentional suicide or accidental substance poisoning,” she said.

“The desire to die prior to self-injury deaths occurs along a spectrum of low to high desire to die, which may influence risk-taking behaviors even if a person’s conscious intentions are not fully suicidal.”

The study shows how the nation, as well as states and local communities, could improve prevention programs.

Strategies would include a greater emphasis on screening for common risk factors and consistently asking patients about their substance use and suicidal thoughts and behaviors.

“Too often, academic publications and mass media show suicides and drug deaths in the 21st century as separate problems,” said Rockett.

“To the contrary, these issues are intertwined, and constitute a mental health catastrophe.”


Global development goals increasingly rely on country-specific estimates for benchmarking a nation’s progress. To meet this need, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 estimated global, regional, national, and, for selected locations, subnational cause-specific mortality beginning in the year 1980. Here we report an update to that study, making use of newly available data and improved methods. GBD 2017 provides a comprehensive assessment of cause-specific mortality for 282 causes in 195 countries and territories from 1980 to 2017.

Methods

The causes of death database is composed of vital registration (VR), verbal autopsy (VA), registry, survey, police, and surveillance data. GBD 2017 added ten VA studies, 127 country-years of VR data, 502 cancer-registry country-years, and an additional surveillance country-year. Expansions of the GBD cause of death hierarchy resulted in 18 additional causes estimated for GBD 2017.

Newly available data led to subnational estimates for five additional countries—Ethiopia, Iran, New Zealand, Norway, and Russia.

Deaths assigned International Classification of Diseases (ICD) codes for non-specific, implausible, or intermediate causes of death were reassigned to underlying causes by redistribution algorithms that were incorporated into uncertainty estimation. We used statistical modelling tools developed for GBD, including the Cause of Death Ensemble model (CODEm), to generate cause fractions and cause-specific death rates for each location, year, age, and sex.

Instead of using UN estimates as in previous versions, GBD 2017 independently estimated population size and fertility rate for all locations. Years of life lost (YLLs) were then calculated as the sum of each death multiplied by the standard life expectancy at each age. All rates reported here are age-standardised.

Findings

At the broadest grouping of causes of death (Level 1), non-communicable diseases (NCDs) comprised the greatest fraction of deaths, contributing to 73·4% (95% uncertainty interval [UI] 72·5–74·1) of total deaths in 2017, while communicable, maternal, neonatal, and nutritional (CMNN) causes accounted for 18·6% (17·9–19·6), and injuries 8·0% (7·7–8·2). Total numbers of deaths from NCD causes increased from 2007 to 2017 by 22·7% (21·5–23·9), representing an additional 7·61 million (7·20–8·01) deaths estimated in 2017 versus 2007.

The death rate from NCDs decreased globally by 7·9% (7·0–8·8). The number of deaths for CMNN causes decreased by 22·2% (20·0–24·0) and the death rate by 31·8% (30·1–33·3).

Total deaths from injuries increased by 2·3% (0·5–4·0) between 2007 and 2017, and the death rate from injuries decreased by 13·7% (12·2–15·1) to 57·9 deaths (55·9–59·2) per 100 000 in 2017.

Deaths from substance use disorders also increased, rising from 284 000 deaths (268 000–289 000) globally in 2007 to 352 000 (334 000–363 000) in 2017. Between 2007 and 2017, total deaths from conflict and terrorism increased by 118·0% (88·8–148·6).

A greater reduction in total deaths and death rates was observed for some CMNN causes among children younger than 5 years than for older adults, such as a 36·4% (32·2–40·6) reduction in deaths from lower respiratory infections for children younger than 5 years compared with a 33·6% (31·2–36·1) increase in adults older than 70 years. Globally, the number of deaths was greater for men than for women at most ages in 2017, except at ages older than 85 years.

Trends in global YLLs reflect an epidemiological transition, with decreases in total YLLs from enteric infections, respiratory infections and tuberculosis, and maternal and neonatal disorders between 1990 and 2017; these were generally greater in magnitude at the lowest levels of the Socio-demographic Index (SDI).

At the same time, there were large increases in YLLs from neoplasms and cardiovascular diseases. YLL rates decreased across the five leading Level 2 causes in all SDI quintiles. The leading causes of YLLs in 1990—neonatal disorders, lower respiratory infections, and diarrhoeal diseases—were ranked second, fourth, and fifth, in 2017.

Meanwhile, estimated YLLs increased for ischaemic heart disease (ranked first in 2017) and stroke (ranked third), even though YLL rates decreased. Population growth contributed to increased total deaths across the 20 leading Level 2 causes of mortality between 2007 and 2017. Decreases in the cause-specific mortality rate reduced the effect of population growth for all but three causes: substance use disorders, neurological disorders, and skin and subcutaneous diseases.

Interpretation

Improvements in global health have been unevenly distributed among populations. Deaths due to injuries, substance use disorders, armed conflict and terrorism, neoplasms, and cardiovascular disease are expanding threats to global health.

For causes of death such as lower respiratory and enteric infections, more rapid progress occurred for children than for the oldest adults, and there is continuing disparity in mortality rates by sex across age groups.

Reductions in the death rate of some common diseases are themselves slowing or have ceased, primarily for NCDs, and the death rate for selected causes has increased in the past decade.


Source:
McLean Hospital
Media Contacts:
Laura Neves – McLean Hospital
Image Source:
The image is in the public domain.

Original Research: Open access
“Unrecognised self-injury mortality (SIM) trends among racial/ethnic minorities and women in the USA”. Ian Rockett et al.
Injury Prevention doi:10.1136/injuryprev-2019-043371.

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