Emergency Medical System responses to suicide-related calls — Maine, November 1999-October 2000

Morbidity and Mortality Weekly Report, Jan 25, 2002

Suicidal acts are morbid and potentially lethal events that are risks for subsequent completed suicide and possibly other health problems (e.g., substance abuse and depression) (1,2). Suicidal behavior also can have negative consequences on family members, friends, and caregivers (3). In 1996, the cost of health care and lost wages for suicide attempts in Maine was approximately $115 million (4). In 1999, a total of 1,079 persons were hospitalized in Maine for self-injurious behavior. Although Maine has no injury-related surveillance systems, the Maine Bureau of Health (MBOH) assessed the use of Emergency Medical Service (EMS) response data to estimate incidence of EMS responses to suicide-related calls in Maine and to summarize the distribution of these responses by patient and event characteristics. This report describes EMS suicide-related responses during November 1999-October 2000 and indicates that EMS data would be a useful component of an integrated statewide suicidal behavior surveillance system.

Maine EMS responders complete a run report form (RRF) for each emergency assistance call. RRF contains a check box titled "concern suicide," which is selected "for patients who have, relevant to this call/run, expressed or displayed any suicidal tendencies or attempts." For any RRF on which "concern suicide" is selected, personal identifiers are removed and the form is sent to the MBOH Injury Prevention Program (MIPP). RRF has defined fields for sex, age, date of birth, incident date, incident location, incident site (*), town of residence, insurance payor, and EMS service number. EMS responders can provide additional information in a free text field, from which MIPP extracts data on method of attempt or threat and circumstances surrounding the event.

Inclusion criteria for this analysis were 1) "concern suicide" box checked on the RRF, 2) confirmed Maine residency, 3) aged >10 years (+), and 4) presence of a unique RRF number. If RRFs were duplicated, only one was counted as a case. Of the 2,152 RRFs received during November 1999-October 2000, a total of 2,036 (95%) were eligible for inclusion in the analysis, of which 967 (47.5%) were made for the intra- or interinstitutional transportation of suicidal residents from nursing homes, psychiatric, correctional, or medical facilities (ss). Data were evaluated separately for all responses and for the 1,069 noninstitutional (NI) responses. All age-adjusted rates were standardized to the 2000 U.S. standard population and included both completed suicides and nonlethal attempts.

For all calls, age-adjusted EMS response rates to "concern suicide" in Maine were 179.2 per 100,000 females and 142.3 per 100,000 for males. For females, age-specific rates were highest among those aged 15-19 years (384.8); for males, rates were highest for those aged 20-24 year (258.1). Because geographic and event data are limited for the institutionalized subgroup, the remainder of the descriptive analysis was limited to the NI cases.

For the 1,069 NI cases, age-adjusted EMS response rates were 92.5 and 76.5 among females and males, respectively. Female rates of suicide-related EMS calls were highest among those aged 15-19 years (206.2), but were generally high among females aged 20-44 years (range: 138.8-160.2). Male rates of suicide-related EMS calls were highest among those aged 20-24 years (170.3) and high among those aged 15-19 and 25-34 years (range: 96.0-110.4). Age-specific rates were statistically similar for females aged 20-34 years and >55 years and for males aged 25-54 years. All other age-specific rate differences were statistically significant (p < 0.05). In comparison, suicide completion rates (derived from medical examiner data) were uniform across all female age groups (range: 0-10.7) and were highest among males aged [greater than or equal to]45 years (range: 25.0-34.8) (Figure 1).

Among the 1,069 NI responses, 761 (72.0%) were to the residence of the attempter. EMS calls were most frequent in the summer (27.1%) and least frequent in the winter and spring (23.5% and 23.3%, respectively).

Among the 963 (90.1%) NI cases for which method was documented, overdose (29.9%), "suicidal ideation only" 7.0%), and laceration (17.7%) were the most commonly documented methods. Attempts with firearms comprised 3.7%.

The case-fatality ratio for EMS calls was 3.8% (1.3% for females and 6.9% for males). Case-fatality ratios were highest among males aged [greater than or equal to]65 years (15.2%). Method employed also was related to fatality ratios, even in the minority of completions (n) receiving EMS response. Of the 36 EMS responses to firearm-related suicidal behavior, 21 (58.3%) were lethal by the time of RRF completion. Compared with drug overdoses (1.0% lethal), attempts by firearm and hanging receiving EMS response were 58 and 60 times more lethal, respectively.

Of the 1,069 events, circumstance was reported for 636 (59.5%); a total of 695 circumstances were reported. The most commonly reported circumstances were drug/substance abuse at the time of the incident (220 [31.7%] of all reported circumstances), patient-reported psychiatric illness (200 [28.8%]), domestic discord or violence (117 [16.8%]), and medical illness/pain (49 [7.1%]).

Reported by: N Sonnenfeld, Div of Community Health, Maine Bureau of Health; D Bailey, C DiCara, Injury Prevention Program; J Bradshaw, Maine Emergency Medical Svc. A Crosby, MD, Div of Violence Prevention, National Center for Injury Prevention and Control; K Askland, MD, EIS Officer, CDC.

Editorial Note: Among all states, Maine ranks 14th in rate of suicide deaths (13.4 per 100,000 population); this rate is 25% higher than the national rate (5). Despite the magnitude of the problem, no surveillance system exists in Maine to monitor suicidal behavior. The findings in this report indicate that EMS NI responses to suicide-related calls in Maine identified characteristics similar to those in community- and population-based studies of nonlethal suicidal behaviors (6-8) and might be an important component of a suicide surveillance system. Virtually all (99%) EMS response data in Maine from state-, municipal-, volunteer-, and fire-department-based and private services are compiled in a centralized database. In addition, Maine is developing an electronic reporting form and a mobile data input system for use across all 141 EMS services.