Background: Suicide is the leading cause of death among people with substance use disorders (SUDs). Together, 42% of emergency Department suicidal ideation-related visits were associated with SUDs in 2013. Though, numerous studies indicate ED-initiated interventions have been successful in reducing adult suicidal ideation and intentional self-inflicted injury, none are wide-spread; and while other studies recommend interventions outside the ED, none examine the role of local health departments (LHDs) in relation to suicide prevention.
Goal: The goal of this study is to examine whether LHDs’ activities are associated with reductions in the rate of suicidal ideation and intentional self-inflicted injury in the ED settings.
Objectives: The objective of this study is to examine whether LHDs’ active roles of health promotion are associated with reductions in the rate of suicidal ideation and intentional self-inflicted injury in the ED settings.
Approach: Using data sets linked from multiple sources, including 2012-2013 State ED Databases for the State of Maryland, the National Association of County and City Health Officials Profiles Survey, the Area Health Resource File, and U.S. Census data, we first employed multivariable models to examine whether LHDs’ active provisions of preventive care and medical services and LHDs’ health policy advocacy (such as affordable housing, mental health, education, etc.) were associated with the reduction of having suicidal ideation and intentional self-inflicted injuries. We then used an instrumental variables (IV) design to reduce the risk of endogeneity of LHDs’ activity measures.
Results: People with SUDs who committed suicidal ideation and intentional self-inflicted injuries were more likely to be White, had more chronic conditions, and were more likely to live in rural areas. The rate of suicidal ideation and intentional self-inflicted injury was 0.78% overall, but the rate increased to 7.26% of among patients with SUDs. Over 42% of ED suicidal ideation-related visits were associated with SUDs. After adjusting for individual-, hospital-, LHD-, and county-level characteristics, results of the IV approach demonstrated that LHDs’ provision of mental health preventive care and services was associated with 6% (p<0.001) and 7% (p<0.001) reduction of suicidal ideation and intentional self-inflicted injury rate respectively. Association of LHDs’ health policy advocacy was no longer significant after adjusting the endogeneity. These IV models passed the tests for (a) the validity of instruments, (b) over-identifying restrictions and (c) the endogeneity of LHD factors.
Importance to public health: Evidence on interventions that can effectively prevent suicide is extremely lacking. Suicide is the product of multiple causes; its prevention requires broad, interdisciplinary approaches. LHDs, as the center of community-engaged health programs and the major source of health care for vulnerable populations, are expected to design and implement activities that can reflect the community health needs and target specific psychological barriers.