1. 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

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

3. Methods
Trends in fatal and non-fatal suicidal behaviors among youth ages 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.

4. 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 – May 2016 among youth ages 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, , amd cases through may.

6. Medical Chart Abstraction: Suicide Attempt 16 visits met case definition from 2014-20163 11 2
Data from LAMC ED visits were abstracted from medical charts
We created a case definition as any ED visit from January – May 2016 among youth ages 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, , amd cases through may.
Visits in 2014
Visits in 2015
Visits in 2016

7. Suicide Deaths among Youth

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

9. Suicide Rate among Youth, 10-19 years, Los Alamos, Rio Arriba, Santa Fe, and Statewide, 1999-2015
During this 17 year period from 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:

10. Non-Fatal Intentional Self-Injury (Suicide Attempt)

11. Non-Fatal Intentional Self-Injury ED Visit Rates among Youth Aged Years by Geographic Region,
From 2010 – 2015, there were 65 visits to an emergency department for non-fatal intentional self-injury among youth 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 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), Statewide Emergency Department Data and 2015 Preliminary Statewide Emergency Department Data, September 23, 2016.

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

13. Suicidal Ideation

14. Suicidal Ideation Emergency Department Visit Rates Among Youth Aged Years by Geographic Region,
From 2010 – 2015, there were 95 visits to an emergency department with any diagnosis of suicidal ideation among youth 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 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, Statewide Emergency Department Data and 2015 Preliminary Statewide Emergency Department Data, September 23, 2016.

15. Suicidal Ideation Emergency Department Visit Rates Among Youth
Aged Years by Year, Los Alamos County,
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, Statewide Emergency Department Data and 2015 Preliminary Statewide Emergency Department Data, September 23, 2016.

16. LAMC Medical Chart Abstraction

17. LAMC ED Visits with any Complaint of Suicide Attempt
among Youth Aged 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, Medical record abstraction, LAMC Medical Records Department, May 9 and 11, 2016.

18. 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

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

20. 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.

21. 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.

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

23. 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.

24. 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

25. 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.

26. 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

27. 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, Statewide Emergency Department Data and 2016 Syndromic Surveillance Data, October 19, 2016.

28. 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).

29. 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.

31. 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).

32. Conclusions
, 4 suicides among Los Alamos County youth years
Not different from suicide rates compared to surrounding counties/statewide
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.

33. 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.

34. 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”
Training for ED providers: 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

35. Recommendations
Resources for primary care providers to screen for suicidal thoughts and behaviors:
Zero Suicide (
Columbia Suicide Severity Rating Scale (
MacArthur Depression Toolkit ( practice/macarthur_depression_toolkit.pdf)
Behavioral Health in Primary Care: Clinical Strategies and Program Models for Working and High-Risk Youth (
Recognizing and Responding to Suicide Risk in Primary Care ( )
Engaging Primary Care Providers in Suicide Prevention (
Tip and Strategies for Billing for Mental Health Services in a Primary Care Setting (

36. 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

37. Questions?