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Understanding Suicide Data

Why is data important to suicide prevention?

Describe patterns: Suicide rates vary across different groups of people, geographic regions, over time, etc. Determining patterns can effect where to put resources for an intervention.  

Determine risk factors and protective factors: These are factors that increase (risk factors) or decrease (protective factors)  the chance of a disease or event occurring (e.g. a prior suicide attempt is a risk factor for completing suicide, positive self-esteem is a protective factor).

Project future resource needs: If we know, for example,  that certain age groups are more at risk for suicide then we can target resources to prevention programs for that group.

Suggest hypotheses: Identifying differences in suicide rates across groups often suggests hypotheses for why those differences occur. For example, the western and southeastern states have higher suicide rates, on average. Reasons, or hypotheses, (e.g. differences in racial distribution, gun ownership levels, social isolation) for the regional differences are then proposed and investigated.

Track trends: For example, public health officials may collect data from the Youth Risk Behavior Surveillance System (YRBSS) to track changes in the number of high school youth who self-report that they have seriously considered suicide in the past twelve months. If there are increasing reports of suicidal ideation over time, the information may trigger school administrators to implement a prevention program.

Detect epidemics: For example, mortality (death) data may show a larger than expected increase in teen suicides during the last month, indicating that a suicide cluster (a group of suicides that occur closely in time and place) has occurred.

Evaluate prevention programs and policies: If after determining a trend or pattern in suicidal ideation, for example, school officials may decide to implement a peer counseling program.  The school should then track the number of students reporting suicidal ideation on the Youth Risk Behavior Survey or talking to school counselors in order to evaluate whether the peer counseling program is having the desired effect.

How is data gathered?

1.   Mortality Data: Suicide deaths.

General Strengths: Compared with morbidity data, mortality data are generally:

• More completely reported: Legally, all deaths have to be recorded and a death certificate issued. Recording a cause of injury death on a death certificate is legally required.
• More comprehensive: Deaths resulting from suicide are usually investigated and more information is collected than on nonfatal attempts.
• More accessible: Information from all death certificates become part of the national Vital Statistics Records system. This system produces public information that can be easily accessed online and is also used as the basis of many reports and analyses.

General Limitations:

• Provide an incomplete picture of the problem of suicidal behavior: Most suicide attempts do not result in death and, by definition, are not included in mortality data.
• Despite better reporting than morbidity data, not all suicides are reported:Sometimes there is not enough information to determine intent. Without conclusive evidence, potential suicides may be recorded as unintentional or undetermined on death certificates. Even if subsequent investigation determines that the death was a suicide, the death certificate may not be updated to reflect this finding. Medical examiners, coroners, doctors, and public safety professionals may not record a death as a suicide to spare the victim and his or her family the social stigma sometimes associated with a death by suicide (or to avoid other consequences such as voiding the victim's life insurance and thereby denying benefit's to the victim's family).
• Inconsistent case definitions about what determines a suicide create difficulty coding mortality data.

2.   Morbidity Data: Medically-treated, nonfatal suicide attempts.

General strengths:

• Provides a more complete picture: Morbidity data can potentially provide a more complete picture of the problem of suicidal behavior, because most suicide attempts do not result in death.

General Limitations:

• Less completely reported: While psychologically serious, many suicide attempts are not medically serious enough to require medical attention and so do not get reported/coded. Some attempts that do require medical attention are also not coded as suicide attempts. The social stigma associated with suicide-related behavior can lead victims, families, and medical professionals to conceal self-inflicted injuries. The use of "external cause of injury" codes in hospital data is not required in all states, so attempts may go unrecorded. Inconsistent case definitions for a suicide attempt create difficulty in coding. Stereotypes about who attempts suicide may lead to incorrect diagnoses. 

• Captures a biased view of the suicide injury problem: Hospital datasets are more accessible for public health surveillance than data from private physicians, clinics, and health maintenance organizations. However, hospital data may under- or over-represent certain sub-groups. For example, lower income people are more likely than higher income people to use emergency departments for the care of lower-severity medical problems. As a result, hospital data may over-represent suicide attempts among lower income people. People who are treated for a suicide attempt at a psychiatric facility or a Veteran's Affairs medical facility will also not be captured by hospital discharge data, as these facilities do not participate in the Uniform Hospital Discharge Data System.

3.   Self-Report Data on Suicidal Behavior: A variety of surveys capture self-reported data on suicidal behavior, including suicidal ideation (suicidal feelings and thoughts), plans, and nonfatal suicide attempts (the majority of which are not medically-treated).

General Strengths:

• Provides a more complete picture of individuals suffering from suicidal feelings or behaviors.

• Useful for evaluating trends over time: Because suicide is a relatively rare event, it is difficult measure the impact of a suicide prevention program on mortality data, particularly at the local level. Nonfatal attempts and suicidal ideation are far more frequent and therefore more sensitive to changes over time.

General Limitations:

• More difficult to accurately collect data about the way people feel or think versus how they behave.
• Subject to reporting biases. For example, high school students are asked on the Youth Risk Behavior Survey if they ever seriously considered suicide. This question is subject to recall bias (not all people will remember), social desirability bias (not all will want to admit suicidal feelings, even on an anonymous survey), and to definition issues. After all, what is meant by seriously considered suicide?

*SOURCE: Information was adapted from an online workshop provided by the Suicide Prevention Resource Center. National Center for Suicide Prevention Training. Retrieved on July 30, 2010 from http://training.sprc.org/

Center for Disease Control and Prevention Data Sources

Hospital Inpatient Discharge Data: Medical information about discharges includes up to seven diagnoses and up to four surgical and nonsurgical operations and procedures. Medical data are coded to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Basic demographic information is also included for patients discharged. Medical cost information is not collected in this survey.

Review of the terminology for the ICD-9-CM:

ICD-(International Classification of Disease) An internationally established classification system for coding and classifying mortality data (e.g. suicide); created by the World Health Organization. CM (Clinical Modification) This version of the ICD is used to code and classify morbidity data (e.g. suicide attempts) from inpatient and outpatient data, physicians' offices, and most National Center for Health Statistics' surveys.

ICD-10 The latest edition of the ICD. Uses X, Y, and U codes for coding external cause of injuries related to suicides. ICD-9-CM The latest edition of the ICD-CM. Uses E Codes for coding the external cause of injury related to suicide attempts and other self-harm.

External cause of injury codes- distinguishes the manner and the mechanism of an externally caused injury or death. For example, a self-inflicted gunshot wound describes the mechanism of injury (gun) and the manner (self-inflicted). These codes do NOT differentiate between suicide attempts and other types of intentionally self-inflicted injuries.

CHART: Major E Code categories for suicide from ICD-9 and their major equivalent categories in ICD-10.

ICD-9	Cause of Suicide or Self-Inflicted Injury	ICD-10
E 950.0-952.9	Poisoning	X60-X69
E 953.0-953.9	Hanging/ Strangulation/ Suffocation	X70
E954	Drowning/Submersion	X71
E 955.0-.4	Firearm	X72-X74
E 956	Cut / pierce with sharp instrument	X78-79
E 957.0-.9	Fall/ jumping	X80
E958.0	Jumping/lying before moving object	X81
E 958.1,.2	Fire / burn/ hot object	X76-77
E 958.5	Crashing of motor vehicle	X82
E 955.5,.9, E958.3-.4 E958.6-.8	Other	X83,X75, X79, U03
E 958.9 E 959	Unspecified Late Effects	X84 Y87.0

*SOURCE: ICD-9-CM information was adapted from an online workshop provided by the Suicide Prevention Resource Center. National Center for Suicide Prevention Training. Retrieved on July 30, 2010 from http://training.sprc.org/

National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP):
NEISS-AIP provides nationally representative data about all types and causes of nonfatal injuries treated in United States hospital emergency departments. CDC uses NEISS-AIP data to generate national estimates of nonfatal injuries, including those related to suicide.

National Hospital Ambulatory Medical Care Survey: The National Hospital Ambulatory Medical Care Survey collects data on the utilization and provision of ambulatory care services in hospital emergency and outpatient departments.

National Violent Death Reporting System: CDC has funded 18 states and established the National Violent Death Reporting System (NVDRS) to gather, share, and link state-level data on violent deaths. NVDRS provides CDC and states with a more accurate understanding of violent deaths. This enables policy makers and community leaders to make informed decisions about violence prevention programs, including those that address suicide.

The National Vital Statistics System: The National Vital Statistics System is the oldest and most successful example of inter-governmental data sharing. This system includes nationwide data on deaths due to all causes, including suicide.

WISQARS: WISQARS (Web-based Injury Statistics Query and Reporting System, pronounced "whiskers") is an interactive database that provides national injury-related morbidity and mortality data used for research and for making informed public health decisions.

Youth Risk Behavior Surveillance System (YRBSS): CDC's YRBSS monitors health risk behaviors that contribute to the leading causes of death and disability among young people in the United States, including suicide.

*SOURCE: Information adapted from the National Center on Disease Control and Prevention. Suicide: Data Sources. Injury Prevention & Control: Violence Prevention. Retrieved on July 30, 2010 from http://www.cdc.gov/ViolencePrevention/suicide/datasources.html