Risk Factors for Suicidal Behaviors Among Los Alamos Youth Presented for the LAPS Healthy Schools Initiative and the United Way of Northern New Mexico’s Behavioral Health Initiative January 19, 2017

Objectives Examine trends of fatal and non-fatal suicidal behaviors January 1999 - September 2016 Youth 10-19 years of age Los Alamos County Investigate behaviors among youth 10-19 years to help inform prevention strategies Make recommendations to LAPS to reduce the risk of youth suicide.

Methods Trends in fatal and non-fatal suicidal behaviors among youth ages 10 - 19 years, using the following data sources Descriptive epidemiology findings & statistical tests of significance Data Source NM Death Certificate Database Bureau of Vital Records and Health Statistics, NMDOH NM Hospital Emergency Department Data Health Systems Epidemiology Program, NMDOH Youth Risk and Resiliency Survey (YRRS) Injury & Behavioral Epidemiology Bureau, NMDOH Suicide attempt and suicidal ideation Emergency Department (ED) visits Los Alamos Medical Center Syndromic Surveillance System NMDOH used multiple data sources to identify fatal and non-fatal suicidal behaviors and to examine trends in suicidal behaviors and associated risk and protective factors; including NM Death Certificate Database NM Hospital Emergency Department Data NMDOH staff also conducted Los Alamos Medical Center (LAMC) medical chart reviews to identify factors that may have contributed to suicidal behaviors among this group.

Medical Chart Abstraction: Los Alamos Medical Center ED Case Definition January 01, 2014 – May 2016 Ages 10 – 19 years ICD-9/10 codes - external cause of injury code/diagnosis code Suicide attempt, or any mention of intentional self-injury with expressed intent to cause injury or die Data from LAMC ED visits were abstracted from medical charts We created a case definition as any ED visit from January 01 2014 – May 2016 among youth ages 10-19 years With an ICD-9/10 CM external cause of injury code or diagnosis code for suicide attempt in any field or any mention of intentional self-injury wit expressed intent to cause injury or die. In 2014 we identified 3 visits that met case definition, 2015 11, amd 2016 2 cases through may.

Medical Chart Abstraction: Suicide Attempt 16 visits met case definition from 2014-2016 3 11 2 Data from LAMC ED visits were abstracted from medical charts We created a case definition as any ED visit from January 01 2014 – May 2016 among youth ages 10-19 years With an ICD-9/10 CM external cause of injury code or diagnosis code for suicide attempt in any field or any mention of intentional self-injury wit expressed intent to cause injury or die. In 2014 we identified 3 visits that met case definition, 2015 11, amd 2016 2 cases through may. Visits in 2014 Visits in 2015 Visits in 2016

Suicide Deaths among Youth

Suicide Deaths Among Youth 10-19 Years, Los Alamos, Rio Arriba, and Santa Fe Counties, 1999-2016* There were 4 suicide deaths from 1999-2015 among youth age 10-199 years in LA County *2016 death data are preliminary; 2016 deaths include deaths registered at the NMBVRHS through 3/16/2016

Suicide Rate among Youth, 10-19 years, Los Alamos, Rio Arriba, Santa Fe, and Statewide, 1999-2015 During this 17 year period from 1999-2015 the suicide rate among 10 to 19 year olds in Los Alamos County (9.1 per 100,000) was lower than the rate in Rio Arriba County (26.6 per 100,000), and similar to the rates in Santa Fe County (10.0 per 100,000), and statewide (10.6 per 100,000) The youth suicide rate in Los Alamos County was not statistically significantly different than the surrounding counties or statewide rates (Figure 1). It should be noted that some of these rates were calculated with fewer than 20 cases; therefore, the rates in Figure 1 are unstable and should be interpreted with caution Source: New Mexico Death Certificate Database, Bureau of Vital Records and Health Statistics, New Mexico Department of Health. Retrieved November 28, 2016 from New Mexico Department of Health, Indicator-Based Information System for Public Health website: http://ibis.health.state.nm.us/.

Non-Fatal Intentional Self-Injury (Suicide Attempt)

Non-Fatal Intentional Self-Injury ED Visit Rates among Youth Aged 10-19 Years by Geographic Region, 2010 -2015 From 2010 – 2015, there were 65 visits to an emergency department for non-fatal intentional self-injury among youth 10-19 years of age who were residents of Los Alamos County The rate of ED visits in Los Alamos County was higher than the surrounding counties of Santa Fe (376.2 per 100,000), Rio Arriba (268.0 per 100,000), and New Mexico statewide (283.1 per 100,000) among youth 10 - 19 years of age The rate for Los Alamos was statistically significantly higher than the rate for Rio Arriba and statewide, but was not statistically significantly different than the rate for Santa Fe County (Figure 2). Sources: NMDOH, Health Systems Epidemiology Program (HSEP), 2010-2014 Statewide Emergency Department Data and 2015 Preliminary Statewide Emergency Department Data, September 23, 2016.

Non-Fatal Intentional Self-Injury ED Visit Rates Among Youth Aged 10-19 Years Los Alamos County, 2010-2015 Sources: NMDOH, HSEP, 2010-2014 Statewide Emergency Department Data and 2015 Preliminary Statewide Emergency Department Data, September 23, 2016.

Suicidal Ideation

Suicidal Ideation Emergency Department Visit Rates Among Youth Aged 10-19 Years by Geographic Region, 2010-2015 From 2010 – 2015, there were 95 visits to an emergency department with any diagnosis of suicidal ideation among youth 10-19 years of age who were residents of Los Alamos County The ED suicidal ideation visit rate in Los Alamos County was higher than that for the surrounding counties of Rio Arriba (367.7 per 100,000) Santa Fe (598.4 per 100,000), and New Mexico statewide (529.1 per 100,0000) among youth 10 - 19 years of age The rate for Los Alamos County was not statistically significantly higher than Santa Fe County or statewide, but was statistically significantly higher than the rate for Rio Arriba County. Sources: NMDOH, HSEP, 2010-2014 Statewide Emergency Department Data and 2015 Preliminary Statewide Emergency Department Data, September 23, 2016.

Suicidal Ideation Emergency Department Visit Rates Among Youth Aged 10-19 Years by Year, Los Alamos County, 2010-2015 By year, the number of ED visits for suicidal ideation fluctuated, with a low of 8 in 2010 to a high of 22 in 2015. But a recent trends suggest suicidal ideation is increasing Sources: NMDOH, HSEP, 2010-2014 Statewide Emergency Department Data and 2015 Preliminary Statewide Emergency Department Data, September 23, 2016.

LAMC Medical Chart Abstraction

LAMC ED Visits with any Complaint of Suicide Attempt among Youth Aged 10-19 Years, January 2014 – September 2016 (n=16) We identified 25 ED visits between January 2014 and April 2016 among youth age 10 – 19 years that had at least one non-fatal intentional self-injury (suicide attempt) ICD-CM code. Of the 25 visits identified, 16 (64%) met the inclusion criteria. This graph illustrates the distribution of visits over time and identifies two months (May and August 2015) during which the number of visits increased substantially. Sources: NMDOH, HSEP, 2014 Statewide Emergency Department Data, 2015 Preliminary Statewide Emergency Department Data, and 2016 Syndromic Surveillance Data, May 10, 2016. Medical record abstraction, LAMC Medical Records Department, May 9 and 11, 2016.

Characteristic Number (percent) (n=16) Gender Male 3 (19%) Female 13 (81%) Age (years) Median 15.5 yrs Mean 15.4 yrs Range 12 – 19 yrs Race/ethnicity White 100% Hispanic 0% Among the 16 youth who were treated in the LAMC emergency department for non-fatal intentional self-harm, 13 (81%) were female, with median age of 15.5 years (mean 15.4, range 12 – 19 years). And 100% were White

Self-Inflicted Injury ED Visits Among Youth 10-19 Years Los Alamos County, 2010-2016

Seven (44%) had a history of one prior suicide attempt, 1 (6%) had a history of more than one prior suicide attempt, 4 (25%) had no history of prior suicide attempt, and 4 (25%) were missing this information in the medical chart.

Of the 16 youth who were treated in the ED, a majority (13; 81%) used a medication/drug (i.e. prescription, over-the-counter, or illicit drug) overdose as the primary method of injury, while 3 (19%) had self-inflicted cutting/lacerations.

Alcohol was involved in 2 (12%) of non-fatal intentional self-injury events, while 14 (88%) did not have any alcohol involvement

Almost all youth (14; 88%) had a previous diagnosis of a mental disorder. Of those with a previous mental disorder diagnosis, the majority (12; 75%) had a depressive disorder.

Further, among the 16 youth, 6 (38%) had received mental health treatment in the 30 days prior to the emergency department visit, 3 (19%) had not received mental health treatment, and half (8; 50%) had an unknown history of receiving mental health treatment in the past 30 days

While the majority of youth had an unknown treatment history in the past month, 12 (75%) had an antidepressant listed in the medical chart as a current medication.

A majority (12; 75%) of those who were seen in the LAMC emergency department were transferred to a mental health treatment facility, while 4 (25%) were discharged home

LAMC Suicidal Ideation ED Visits Among Youth Aged 10-19 Years January 2014 – September 2016 (n=57) Between January 2014 and September 2016, there were 57 visits to the LAMC ED for suicidal ideation. Peak visits occurred during April (6, 11%) and January (5; 9%) of 2016 (Figure 7). Sources: NMDOH, HSEP, 2014-2015 Statewide Emergency Department Data and 2016 Syndromic Surveillance Data, October 19, 2016.

16 LAMC Suicidal Ideation ED Visits Youth Characteristics (n=57) Mean and median age Among the 57 youth who were treated in the LAMC ED for suicidal ideation, the majority (53%) were female and the mean and median ages were 16 years, (range 12 – 19 years).

LAMC ED Surveillance June – September 2016 Based on an increase in suicide attempts during the summer months in 2015 (identified through medical chart abstraction), the NMDOH increased surveillance for fatal and non-fatal suicide behaviors at Los Alamos Medical Center Emergency Department from June 1 – September 12, 2016. During this time, there were three visits to the emergency department for suicide attempt. Of the three visits, two were male, the median age was 14 years, all visits were due to drug overdose, and all three patients were transferred to an inpatient treatment facility for follow up care. Source: LAMC Emergency Department Adolescent Suicide Attempts reporting log.

Protective Factors for Suicidal Behaviors Among High School Students, Los Alamos County and New Mexico, 2015 Of the 14 resiliency indicators, percentages for 11 resiliency indicators were higher for Los Alamos County high school students compared to high school students statewide (Figure 10).

Conclusions 1999-2015, 4 suicides among Los Alamos County youth 10-19 years Not different from suicide rates compared to surrounding counties/statewide 2010-2015 65 ED visits for suicide attempt 95 ED visits for suicidal ideation LA County youth suicide attempt rate higher than for Rio Arriba & statewide, but not Santa Fe County LA County youth suicidal ideation rate higher for Rio Arriba, but not Santa Fe County or statewide From 1999 to 2015, there were four youth suicides among Los Alamos County residents During 1999 – 2015, suicide rates among Los Alamos youth were not significantly different from suicide rates among youth in surrounding counties and statewide. From 2010 – 2015, there were 65 emergency department visits for non-fatal intentional self-injury and 95 emergency department visits for suicidal ideation among Los Alamos County youth 10 – 19 years. The Los Alamos County youth suicide attempt rate was statistically significantly higher than for Rio Arriba County and statewide but not significantly higher than Santa Fe County. The Los Alamos County youth suicide ideation rate was statistically significantly higher than for Rio Arriba County, but not statistically higher than for Santa Fe County and statewide.

Conclusions Peak in ED visits for suicide attempt during May and August, 2015 Majority of suicide attempts Female White Median age, 15.5 years Many with prior attempt 75% have prior diagnosis of depressive disorder Have medications for depression Primary method of injury is by medication/drug OD Second leading method of injury is cutting/laceration 75% transferred to an inpatient psychiatric treatment facility Peak ED visits for suicide attempt occurred during May and August 2015 The majority of suicide attempts were female, white, and had a mean age of 15 and a half While many factors contributed to suicide attempts among the youth who were treated in the LAMC Emergency Department. Many of these youth had known risk factors for attempting suicide, including a prior history of a suicide attempt and diagnosed depression. The majority of youth received proper care and were transferred to a mental health treatment facility.

Recommendations Provide education to parents on navigating mental health care resources   Improve care coordination. Data suggest: youth who attempted suicide had previous exposure to mental health care 88% had history of mental illness; of those 86% had depressive disorder, 50% history of prior suicide attempt Primary care providers - screen youth for suicide risk; help combat negative social views, norms that keep individuals and families from seeking treatments, support Increase education regarding “means restrictions” http://www.sprc.org/resources-programs/calm-counseling-access-lethal-means Training for ED providers: http://www.sprc.org/events-trainings/advancing- suicide-prevention-practice-emergency-department-setting SAMSHA’s: “Preventing Suicide: A Toolkit for High Schools” Develop partnerships with community organizations and agencies in different sectors to combine resources, for example: PSA campaign developed by youth and aired on local radio

Recommendations Resources for primary care providers to screen for suicidal thoughts and behaviors: Zero Suicide (www.zerosuicide.com) Columbia Suicide Severity Rating Scale (http://www.cssrs.columbia.edu) MacArthur Depression Toolkit (http://www.integration.samhsa.gov/clinical- practice/macarthur_depression_toolkit.pdf) Behavioral Health in Primary Care: Clinical Strategies and Program Models for Working and High-Risk Youth (http://www.parecovery.org/documents/BH_Primary_Care.pdf) Recognizing and Responding to Suicide Risk in Primary Care (http://www.sprc.org/settings/primary-care/toolkit ) Engaging Primary Care Providers in Suicide Prevention (http://www.sprc.org/system/files/private/event-training/Wintersteen_Engaging.pdf)) Tip and Strategies for Billing for Mental Health Services in a Primary Care Setting (http://www.sprc.org/sites/default/files/tipsandstrategiesforbilling.pdf)

Thank You Report prepared by: Nicole Middaugh, ScD, MS, EIS Officer   Nicole Middaugh, ScD, MS, EIS Officer Centers for Disease Control and Prevention Assigned to New Mexico Department of Health Tierney Murphy, MD, MPH, Injury Epidemiologist Nancy Kirkpatrick, Youth Suicide Prevention Coordinator Kelly Gallagher, PhD, Community Health Epidemiologist Michael Landen, MD, MPH, State Epidemiologist New Mexico Department of Health

Questions?