Rajeev Ramchand is with the RAND Corporation, Arlington, VA. Lisa Colpe and Michael Schoenbaum are with the National Institute of Mental Health, Bethesda, MD. Cynthia Claassen is with JPS Behavioral Health, JPS Health System, Fort Worth, TX. Sam Brinton is with The Trevor Project, Washington, DC. Colleen Carr is with the National Action Alliance for Suicide Prevention Secretariat and Education Development Center, Washington, DC. Richard McKeon is with the Substance Abuse and Mental Health Services Administration, Rockville, MD.
Corresponding author.Correspondence should be sent to Rajeev Ramchand, PhD, RAND Corporation, 1200 South Hayes St, Arlington, VA 22202 (e-mail: gro.dnar@dnahcmar). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
Note. The views expressed in this editorial do not necessarily represent the views of the National Institute of Mental Health, the National Institutes of Health, the Substance Abuse and Mental Health Services Administration, the Department of Health and Human Services, or the United States Government.
CONTRIBUTORSR. Ramchand led the writing of the editorial. All of the authors contributed equally to idea development and editing the final version of the editorial.
Accepted February 25, 2021. Copyright © American Public Health Association 2021COVID-19 and the precautionary measures put in place to prevent its spread have given rise to concerns about second-order mental health effects, including potential increases in suicide. Researchers have pointed out historic associations between the individual and combined effects of economic stress, social isolation, and decreased access to community supports on suicide rates. 1 The United States has also observed increases in the sale of firearms 2 and alcohol 3 —factors known to exacerbate suicide risk. After the May 2020 release of a video of George Floyd’s death, there were reports of elevated distress among Black and African American people, 4 which raised further concerns.
In response, the National Action Alliance for Suicide Prevention convened representatives from private and public sectors to create the Mental Health & Suicide Prevention National Response to COVID-19 (National Response). The first goal of the National Response was to identify strategic priorities to transform mental health awareness and suicide prevention nationwide. These priorities were published online in September 2020 at www.nationalmentalhealthresponse.org. This editorial discusses the fourth of these priorities: “Establish near real-time data collection systems to promptly identify changes in rates of suicide, overdose, and other key events, and of clusters or spikes in these outcomes.” We describe how the National Response has crafted a path forward for achieving the goal of near real-time mortality data with seven specific calls to action. Although this editorial focuses on mortality data, the priority area also emphasizes the importance of near real-time data on nonfatal suicide-related events (i.e., suicide attempts), with more information available at www.nationalmentalhealthresponse.org.
Mortality surveillance is critical for identifying the emergence of new and deadly diseases, monitoring trends in preventable deaths, raising awareness of fatal health conditions, and identifying strategies for preventing additional deaths. With national mortality data currently released 13 months or more after the end of a calendar year, the nation’s ability to accomplish these goals with existing data structures is limited.
The COVID-19 pandemic has illuminated problems with suicide surveillance in the United States. Data on COVID-19 mortality rates were being tracked and published online by counties, states, and territories. Private enterprises such as The COVID Tracking Project and Johns Hopkins University were then aggregating the data and presenting them to the public in near real-time. However, policymakers had no comparable data available on other health outcomes, such as changes in suicide rates, that might result from the public health measures put in place to prevent the virus’s spread. In the absence of such data, decision-makers were forced to make inferences about the relative impact of public safety measures, many of which were problematic. For example, some researchers produced nonvalidated extrapolations of the forecasted number of excess suicides based on past recessions. 5 No population-level information on trends in rates of intentional self-harm (including suicide attempts) could be tracked from emergency department syndromic surveillance data. Media reports on increases in call volume to the Disaster Distress Helpline capture calls about mental health and suicide as well as other issues (e.g., housing, financial), but we are unaware of publicly available data on use of the National Suicide Prevention Lifeline.
The National Response has identified seven priorities that, if adopted, could improve monitoring and tracking suicides so that the information can be used for near real-time decision-making and targeted interventions.
Call to Action 1. Increase funding for the public health data infrastructure at federal, state, territorial, and local levels.
Call to Action 2. Fund research on how to produce more timely assessments of suicides.Call to Action 3. Track and report survival as a patient-centered outcome for individuals with mental health and substance use issues and in relation to key index events such as emergency department presentation for suicidality or overdose and discharge from inpatient mental health and substance use treatment.
Call to Action 4. Mandate universal documentation of external cause of injury (e.g., deliberate self-harm, accident, assault) for all emergency department visits and hospitalizations involving injury.
Call to Action 5. Enhance the scope of data collected in death investigations to include information on sexual orientation, gender identity, and military and veteran status, as well as to improve the quality of data collected on race and occupation and industry.
Call to Action 6. Coordinate interaction between the Action Alliance and states, territories, and local jurisdictions to develop standardized, defensible ways to use data from existing (or newly created) sources in program planning, surveillance, outcome assessment, and policymaking
Call to Action 7. Create a National Response data dashboard that pulls together timely data feeds from relevant existing sources on fatal and nonfatal suicide events and related measures.
The COVID-19 pandemic has illustrated the threat posed by illness and disease and the importance of surveillance for early identification and monitoring. There are currently more than 2000 death investigation jurisdictions in the United States that vary by geography (state, county, or district) and oversight (coroner, medical examiner, or a combination thereof). This structuring leads to variation in—and presents challenges to improving—the quality and timeliness of mortality data. 6 Similarly, 57 separate jurisdictions across the US states and territories report mortality data to the national level, each with distinct practices and policies. The data systems on which many of these jurisdictions rely are antiquated: “sluggish, manual processes—paper records, spreadsheets, faxes and phone calls—[are] still in widespread use” that may result in “delayed detection and response to public health threats of all types.” 7
The National Response has prioritized increased funding for the public health data infrastructure, echoing the recent “Data: Elemental to Health” campaign spearheaded by the Council of State and Territorial Epidemiologists (CSTE). 7 CSTE calls for Congress to secure $1 billion over the next decade to modernize disease surveillance systems. There is opportunity for private sector involvement, by providing technological solutions at discounted costs to enhance efficiencies and share advances in data science, to improve the collection and analysis of mortality data.
Suicide is one of five manners of death listed on death certificates. Classifying a death as a suicide requires evidence that the cause of death (injury) is self-inflicted and that the individual intended to die as a result of the act. Death investigations for all injurious deaths take longer than other causes of death. In the case of suicide, only 50% of suicides are officially categorized within two months after the week of the death, 71% at three months, and 93% at six months, and almost all are coded by 10 months. 8 This is one of the reasons why annual national suicide data are typically only available 13 months or more after the end of a calendar year.
There is known variation in the time it takes to make a death determination by method of injury, 8 but there may also be variation across death investigation jurisdictions. Oregon, for example, publishes monthly provisional year-to-date mortality data on manner of death (including suicide) by county, and preliminary investigations of suicides during the COVID-19 pandemic have been published for Maryland, 9 Massachusetts, 10 and Connecticut. 11 The National Response advocates for researchers to identify additional jurisdictions collecting and presenting near real-time suicide mortality data, the impetus leading to the presentation of these data near real-time, barriers encountered, and data limitations.
“Nowcasting” is widely used in economics to predict the present, near future, and recent past of an economic indicator (e.g., gross domestic product growth) in the absence of complete information. Nowcasting attempts to measure events in real-time as opposed to forecasting, which uses historical data to project future trends. Existing data systems that might be useful in nowcasting suicide rates include health system data on nonfatal suicide events, data collected by emergency medical services, emergency department syndromic surveillance systems, and crisis lines. Data from other sources, such as Internet search terms and firearm or alcohol sales, may also be useful for nowcasting. Preliminary work by the Centers for Disease Control and Prevention suggests that weekly nowcasting that applies machine learning to multiple streams of data may provide accurate estimates of suicide. 12 Further research is needed to identify which data, or combinations of data, can be used to produce and validate accurate approaches to suicide nowcasting models. This research would also require public and private sector entities that own or manage useful data to make them available to researchers for nowcasting purposes.
Health care settings are critical for identifying and intervening with persons at risk for suicide. Data from the Mental Health Research Network estimate that 30% of persons who die by suicide have a health care visit in the week before their death—6.5% have an emergency department visit, 16.3% receive outpatient care, and 9.5% receive primary care. These rates are higher than among matched controls. 13 In California, individuals presenting to emergency departments have elevated suicide mortality rates in the year after being seen relative to demographic-matched controls. 14
Call to Action 3 echoes Recommendation 1.8 of the Interdepartmental Serious Mental Illness Coordinating Committee’s (ISMICC) 2017 report to Congress. By linking health care delivery data to mortality data, health systems can identify settings and patients with elevated suicide risk and direct suicide prevention services there. However, this approach requires addressing technical and resource barriers (among health systems and death data systems) as well as legal (e.g., Health Insurance Portability and Accountability Act) and policy barriers, including at least one hospital accreditation issue. Specifically, the suicide of any patient within 72 hours of discharge from a hospital, including an emergency department, is considered by The Joint Commission to be a “sentinel event” that requires investigation within a year of its occurrence. Health systems are likely to uncover more events when they begin to link data, which may be a disincentive for conducting routine medical record and mortality data linkage.
Self-inflicted nonfatal injuries and poisonings that require medical attention are identified in health records using a combination of injury diagnostic codes, which identify the nature of the injury and body part injured, and “external cause of morbidity” codes, which describe the intent of injury—accidental, deliberate, or of undetermined intent—as well as the mechanism by which the injury occurred. However, in more than half of US states, external cause codes are not routinely listed in a medical record. 15 Without enforceable mandates to do so, many health systems are not capturing data on intentional self-harm, resulting in an underestimate in national trends. This call to action is also recommended by The President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS) Task Force.
In addition to monitoring trends of suicides in the general population, death investigation data can be used to identify subpopulations with elevated risk, provided that such data are accurately recorded during death investigations. Although population-based research suggests elevated rates of suicide attempts among lesbian, gay, and bisexual adults 16 ; youths 17 ; and transgender populations, 18 Los Angeles, California, is the only jurisdiction that requires medical examiners to systematically document information on sexual orientation and gender identity at the time of death. 19 Standard death certificates ask whether the decedent was ever in the US Armed Forces but do not specify whether the decedent was a veteran, currently in the military on active duty, or a member of the National Guard or Reserves. This documentation does not require that the data be included on the official death certificate, only that the information be systematically collected, reported, and recorded in data systems that reflect results of death investigations.
The quality of data for certain data fields on the death record must also be improved. Some deaths caused by drug self-intoxication have manner of death coded as “accidental,” but “suicide” may be more appropriate or, as advocated by Rockett and Caine, 20 self-injury mortality may be needed as a new code on death records to enumerate all such deaths together. In fact, there are overlapping risk profiles in persons who die by suicide and persons who die by “unintentional” overdose. 14 Furthermore, only 51% of decedents who previously identified their race as American Indian or Alaskan Native had race correctly coded on their death certificates (most are misclassified as White), which should be improved. 21 Finally, identifying industries and occupations for elevated suicide risk (and thus, targeted attention) would also be useful, but autocoding procedures are not yet available to convert these text fields into numeric codes. 22
Most suicide prevention occurs locally. Prompted by the 2001 National Strategy for Suicide Prevention, every state currently has a statewide suicide prevention plan. Additionally, states, territories, tribal communities, and cities support suicide prevention activities via grant programs such as the Garrett Lee Smith Memorial Youth Suicide Prevention Program and initiatives such as the Governor’s and Mayor’s Challenges to Prevent Suicide Among Service Members, Veterans, and their Families. These initiatives should be empirically based, include surveillance as part of their efforts, and be evaluated with data. This point is emphasized in the Suicide Prevention Resource Center’s State Suicide Prevention Infrastructure framework, which provides states with recommendations for strengthening community suicide prevention programming. 23 Evaluations of Garrett Lee Smith grantees’ prevention initiatives provide examples of how mortality data can be used to understand the effects of these programs on youth suicide rates. 24
The COVID-19 pandemic has made clear the importance of using data from multiple sources in a single location to provide a more comprehensive picture of the burden of disease. Online tools, such as the COVID-19 Dashboard produced by Johns Hopkins, are used by policymakers, the media, researchers, and the public for up-to-date information on disease incidence, prevalence, case fatality, and mortality. 25 A dashboard for suicide could similarly provide near real-time information on morbidity and mortality, with additional data on geographic variation in suicide trends, rates in specific populations, and method of death. Colorado’s “Suicides in Colorado” data tool for communities is a useful prototype. However, a national dashboard could be expanded even further to provide data on nonfatal suicide-related events such as suicide attempts seen at emergency departments, suicide-related mobile crisis team responses, and call volume to crisis lines.
Limitations in the morbidity and mortality surveillance infrastructure have hindered the nation’s ability to understand the effects of the COVID-19 pandemic on suicide risk. This has direct implications for emergency resource decision-making and hinders policymakers’ ability to ensure that adequate resources (including monetary and programmatic) are maintained or newly delivered to communities and populations experiencing heightened suicide risk. These limitations are not new; many of the calls to action echo recommendations made previously by groups such as the CSTE, ISMICC, PREVENTS, and the Action Alliance’s Data and Surveillance Task Force. They are also built upon existing efforts already under way, including the National Center for Health Statistics Rapid Release mortality dashboard. The COVID-19 pandemic has created a sense of urgency that we have not seen before, and the National Response provides a forum to amplify previous recommendations and identify new ones. These seven calls to action create a pathway toward improving the timeliness and use of mortality data that not only responds to conditions created by the pandemic but also, if pursued, is likely to create a stronger and more supportive mental health and suicide prevention surveillance infrastructure.
We thank all members of the Mental Health & Suicide Prevention National Response to COVID-19 as well as past and present members of the National Action Alliance for Suicide Prevention’s Data and Surveillance Task Force.
The authors have no conflicts of interest to disclose.
1. Reger MA, Stanley IH, Joiner TE. Suicide mortality and coronavirus disease 2019: a perfect storm? JAMA Psychiatry. 2020; 77 (11):1093. doi: 10.1001/jamapsychiatry.2020.1060. [PubMed] [CrossRef] [Google Scholar]
3. National Institute on Alcohol Abuse and Alcoholism. Alcohol sales during the COVID-19 pandemic. National Institute on Alcohol Abuse and Alcoholism. https://pubs.niaaa.nih.gov/publications/surveillance-covid-19/COVSALES.htm
4. Flowers A. Depression and anxiety spiked among Black Americans after George Floyd’s death. The Washington Post. 2020. https://www.washingtonpost.com/health/2020/06/12/mental-health-george-floyd-census
5. Petterson S, Westfall JM, Miller BF. Well Being Trust. Oakland: CA; 2020. Projected Deaths of Despair From COVID-19 . [Google Scholar]
6. Hanzlick R. The conversion of coroner systems to medical examiner systems in the United States: a lull in the action. Am J Forensic Med Pathol. 2007; 28 (4):279–283. doi: 10.1097/PAF.0b013e31815b4d5a. [PubMed] [CrossRef] [Google Scholar]
8. Ahmad FB, Spencer MR. Timeliness of Death Certificate Data for Suicides. Vital Statistics Rapid Release, No 3. Hyattsville, MD: National Center for Health Statistics; 2018. [Google Scholar]
9. Bray MJC, Daneshvari NO, Radhakrishnan I, et al. Racial differences in statewide suicide mortality trends in Maryland during the coronavirus disease 2019 (COVID-19) pandemic. JAMA Psychiatry. 2021; 78 (4):444–447. doi: 10.1001/jamapsychiatry.2020.3938. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
10. Faust JS, Shah SB, Du C, Li SX, Lin Z, Krumholz HM. Suicide deaths during the COVID-19 stay-at-home advisory in Massachusetts, March to May 2020. JAMA Netw Open. 2021; 4 (1):e2034273. doi: 10.1001/jamanetworkopen.2020.34273. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
11. Mitchell TO, Li L. State-level data on suicide mortality during COVID-19 quarantine: early evidence of a disproportionate impact on racial minorities. Psychiatry Res. 2021; 295 :113629. doi: 10.1016/j.psychres.2020.113629. [PubMed] [CrossRef] [Google Scholar]
12. Choi D, Sumner SA, Holland KM, et al. Development of a machine learning model using multiple, heterogeneous data sources to estimate weekly US suicide fatalities. JAMA Netw Open. 2020; 3 (12):e2030932. doi: 10.1001/jamanetworkopen.2020.30932. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
13. Ahmedani BK, Westphal J, Autio K, et al. Variation in patterns of health care before suicide: a population case-control study. Prev Med. 2019; 127 :105796. doi: 10.1016/j.ypmed.2019.105796. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
14. Goldman-Mellor S, Olfson M, Lidon-Moyano C, Schoenbaum M. Association of suicide and other mortality with emergency department presentation. JAMA Netw Open. 2019; 2 (12):e1917571. doi: 10.1001/jamanetworkopen.2019.17571. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
15. Claassen C, Hughes B, Hedegaard H, Schoenbaum M, Elbasheer O. Paper presented at: International Association for Suicide Research; October 28. Miami: FL; 2019. Nonfatal suicide attempts: where’s the data? [Google Scholar]
16. Hottes TS, Bogaert L, Rhodes AE, Brennan DJ, Gesink D. Lifetime prevalence of suicide attempts among sexual minority adults by study sampling strategies: a systematic review and meta-analysis. Am J Public Health. 2016; 106 (5):e1–e12. doi: 10.2105/AJPH.2016.303088. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
17. Marshal MP, Dietz LJ, Friedman MS, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review. J Adolesc Health. 2011; 49 (2):115–123. doi: 10.1016/j.jadohealth.2011.02.005. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
18. Mueller SC, De Cuypere G, T’Sjoen G. Transgender research in the 21st century: a selective critical review from a neurocognitive perspective. Am J Psychiatry. 2017; 174 (12):1155–1162. doi: 10.1176/appi.ajp.2017.17060626. [PubMed] [CrossRef] [Google Scholar]
19. Haas AP, Lane AD, Blosnich JR, Butcher BA, Mortali MG. Collecting sexual orientation and gender identity information at death. Am J Public Health. 2019; 109 (2):255–259. doi: 10.2105/AJPH.2018.304829. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
20. Rockett IRH, Caine ED. Reconciling suicides with “accidental” drug-intoxication deaths: a behaviorally based definition of self-injury mortality. Am J Public Health. 2020; 110 (1):73–74. doi: 10.2105/AJPH.2019.305422. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
21. Arias E, Heron M, Hakes JK. The Validity of Race and Hispanic-Origin Reporting on Death Certificates in the United States: An Update. Hyattsville, MD: National Center for Health Statistics; 2016. [PubMed] [Google Scholar]
22. Griffin BA, Grimm GE, Smart R, et al. Data Sources, and Analytic Approaches. Santa Monica, CA: RAND Corporation; 2019. Comparing the Army’s Suicide Rate to the General US Population: Identifying Suitable Characteristics . [PMC free article] [PubMed] [Google Scholar]
23. Suicide Prevention Resource Center. State suicide prevention infrastructure. Suicide Prevention Resource Center. http://www.sprc.org/state-infrastructure
24. Godoy Garraza L, Kuiper N, Goldston D, McKeon R, Walrath C. Long-term impact of the Garrett Lee Smith Youth Suicide Prevention Program on youth suicide mortality, 2006-2015. J Child Psychol Psychiatry. 2019; 60 (10):1142–1147. doi: 10.1111/jcpp.13058. [PubMed] [CrossRef] [Google Scholar]
25. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020; 20 (5):533–534. doi: 10.1016/S1473-3099(20)30120-1. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
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