Publications

Importance: Emergency departments (EDs) have the potential to play a pivotal role in suicide risk detection and prevention, yet little is known about the profile of risk of suicide after ED visits in the United States. Objectives: To examine 1-year incidence of suicide and other mortality among ED patients who presented with nonfatal deliberate self-harm, suicidal ideation, or any other chief concern, and to examine sociodemographic and clinical factors associated with suicide mortality risk. Design, Setting, and Participants: This retrospective cohort study included statewide, all-payer, longitudinally linked ED patient records and mortality data from all California residents who presented to a California-licensed ED at least 1 time from January 1, 2009, to December 31, 2011, with deliberate self-harm, suicidal ideation but not self-harm, or neither (a 5% random sample). Age-, sex-, and race/ethnicity-adjusted standardized mortality ratios (SMRs) for suicide and other manners or causes of death were determined for each patient group using statewide mortality data. Data were analyzed from January 10 to July 18, 2019. Main Outcomes and Measures: Suicide and other manners or causes of death were ascertained using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Suicide rate and all mortality rates were measured per 100 000 person-years. Results: Among 648 646 individuals (mean [SD] age, 43.8 [20.6] years; 350 687 [54.1%] women) who visited an ED in California from 2009 to 2011, the rates of suicide deaths per 100 000 person-years in the year after index ED presentation were 693.4 deaths among 83 507 individuals presenting with deliberate self-harm (SMR, 56.8; 95% CI, 52.1-61.4), 384.5 deaths among 67 379 individuals presenting with suicidal ideation but not self-harm (SMR, 31.4; 95% CI, 27.5-35.2), and 23.4 deaths among 497 760 reference patients (SMR, 1.9; 95% CI, 1.6-2.3). Compared with the demographically matched general population, the rates of nonsuicide external-cause mortality were also increased among patients with self-harm (SMR, 14.2; 95% CI, 12.9-15.5), patients with suicidal ideation (SMR, 11.8; 95% CI, 10.6-13.0), and reference patients (SMR, 2.2; 95% CI, 2.0-2.3). In all 3 groups, the rates of suicide mortality per 100 000 person-years were higher among men (deliberate self-harm: 1011.1 deaths; suicidal ideation: 539.8 deaths; reference: 36.6 deaths), people 65 years or older (deliberate self-harm: 1919.5 deaths; suicidal ideation: 691.2 deaths; reference: 28.6 deaths), and non-Hispanic white patients (deliberate self-harm: 914.1 deaths; suicidal ideation: 511.6 deaths; reference: 33.8 deaths) than among their respective referent groups. Other sociodemographic factors and clinical diagnoses were associated with striking differences in suicide rates, but these patterns were heterogeneous across patient groups. Conclusions and Relevance: These findings suggest that ED patients with deliberate self-harm or suicidal ideation are associated with substantially increased risk of suicide and other mortality during the year after ED presentation. The process of planning for ED discharge may present opportunities to help ensure safe transitions to continuing outpatient mental health care and to consider broader risk for unintentional injury and other causes of premature mortality.

Objective. Adolescent self-harm rates have risen substantially in the U.S., yet health and social outcomes among contemporary self-harming youths are infrequently tracked and remain poorly understood. This study investigated long-term health service utilization (emergency department [ED] visits and inpatient admissions) and inpatient costs among a recent cohort of adolescent deliberate self-harm patients. Methods. This retrospective cohort study used statewide, all-payer, longitudinally-linked patient discharge data from California, USA. All CA residents aged 10-19 years presenting to EDs in 2010 with deliberate self-harm (n=5,396) were compared with two control groups: A random sample of adolescent patients with other complaints, matched on sex, age, residential ZIP code, and month of index visit (general control patients; n=14,921), and matched patients with psychiatric complaints but no self-harm (psychiatric controls; n=15,835). Study outcomes included five-year rates of subsequent ED visits, inpatient admissions, and inpatient costs, both overall and for psychiatric and non-psychiatric complaints separately. Results. Self-harm patients rates of ED utilization, inpatient admissions, and inpatient costs were significantly higher than those of general control patients (by 39%, 81%, and 21%, respectively), controlling for confounding demographic and utilization characteristics. Associations mostly persisted, though smaller in magnitude, in comparisons with psychiatric control patients. Both psychiatric and non-psychiatric complaints contributed to self-harming adolescents excess health service utilization and costs. Conclusion. Adolescent deliberate self-harm is associated with long-lasting and costly patterns of health service utilization, often but not exclusively for psychiatric complaints. Future research should investigate the pathways underlying these associations, and incorporate service utilization as a key patient outcome.

Background: Violent injuries are a leading cause of morbidity and mortality among youths. Little is known about adolescents patterns of and risk factors for repeat assault injuries, yet understanding who is at risk for repeated assaults is important for intervention and prevention efforts. Investigating these questions in population-based adolescent samples is particularly critical. Objective: Our aim was to estimate the 5-year cumulative incidence of and risk factors for repeat emergency department (ED) visits for assault injury among adolescents experiencing an index assault visit, and compare the method of injury for adolescents first and second visits. Methods: Statewide, longitudinal data from California were used to follow 17,845 adolescents who reported to an ED with assault-related injuries in 2010. Incidence rate ratios were estimated to examine risk factors for repeat assault injury within 1 year and 5 years following the index visit. Results: A total of 3273 (18.3%) assaulted adolescents experienced one or more additional assault injury ED visits during the full follow-up period. Only 37.3% of these repeat assaults occurred within the first year following the index assault. Of adolescents with a repeat assault injury, the method of injury often changed and followed no clear pattern. Sociodemographic characteristics (e.g., older age, black race) and history of prior ED visits for assault and mental health problems predicted increased risk of repeat assault. Conclusions: Previous work may underestimate the rate of repeated assault among adolescents. Adolescents with a history of violence involvement and mental health problems are at elevated risk for repeated assault, and should be targeted for intervention.

Objective: This study evaluated whether emergency de- partment (ED) patient presentations for problems related to mental and substance use disorders could be validly moni- tored by a syndromic surveillance system that uses chief complaints to identify mental disorders. Methods: The study used syndromic surveillance data on 146,315 ED visits to participating Fresno County, California, hospitals between January 1 and December 31, 2013. Free- text patient chief complaints are automatically classified into syndromes based on the developer s algorithms. Agreement was assessed between the algorithm s syndrome classifica- tion of mental health and substance abuse (MHSA) disorders and ICD-9-CM discharge diagnostic codes. Diagnosis and ED utilization patterns among patients with at least one visit with an MHSA syndrome classification were also examined. Results: Approximately 8% of ED visits during the study period received an MHSA syndrome classification. Overall agreement between MHSA syndrome classification and psychiatric- or substance use–related ICD-9 discharge diagnoses was high (k=.92, 95% confidence interval= .91–.92). Sensitivity (100%) and specificity (98.6%) of the MHSA syndrome classification were also very high. MHSA syndrome–classified patients exhibited high levels of health care andmorbidity burden compared with other patients. Conclusions: ED chief complaints can be utilized to reliably and validly ascertain the incidence of patient presentations for mental and substance use disorders in contexts in which discharge diagnoses are not routinely available. Wider adoption of MHSA-related syndrome algorithms by syn- dromic surveillance systems could be valuable for public mental health surveillance, service delivery, and resource planning efforts.

Research on the relationship between neighborhood characteristics and adolescents? risk of nonfatal suicidal behavior is scarce. We used California survey data to examine associations between measures of objective neighborhood quality (levels of violent crime, property crime, and socioeconomic disadvantage) and subjective neighborhood quality (perceptions of neighborhood safety and social cohesion) and adolescents? self-reported suicidal ideation and suicide attempt. Objective measures of neighborhood quality were unrelated to adolescents? risk of suicidal behavior. However, adolescents who perceived their neighborhoods to be less safe and less cohesive were 20%?45% more likely than nonsuicidal peers to report suicidal ideation and attempt.

Copyright © Cambridge University Press 2018 Background: The aim of this study was to build a detailed, integrative profile of the correlates of young adults feelings of loneliness, in terms of their current health and functioning and their childhood experiences and circumstances. Methods: Data were drawn from the Environmental Risk Longitudinal Twin Study, a birth cohort of 2232 individuals born in England and Wales in 1994 and 1995. Loneliness was measured when participants were aged 18. Regression analyses were used to test concurrent associations between loneliness and health and functioning in young adulthood. Longitudinal analyses were conducted to examine childhood factors associated with young adult loneliness. Results: Lonelier young adults were more likely to experience mental health problems, to engage in physical health risk behaviours, and to use more negative strategies to cope with stress. They were less confident in their employment prospects and were more likely to be out of work. Lonelier young adults were, as children, more likely to have had mental health difficulties and to have experienced bullying and social isolation. Loneliness was evenly distributed across genders and socioeconomic backgrounds. Conclusions: Young adults experience of loneliness co-occurs with a diverse range of problems, with potential implications for health in later life. The findings underscore the importance of early intervention to prevent lonely young adults from being trapped in loneliness as they age.

© 2017 Objective To describe the planning, development, pilot testing, fielding, and outcomes of a community health survey in a rural California county pursuing public health accreditation. Design Community partners helped the local health department develop the community health survey. Extensive English- and Spanish-language pilot testing was conducted over a period of four months. Final survey fielding was conducted online and at 20 community sites. Results 2189 completed surveys were collected. Total costs for developing and fielding the survey were approximately $25,000. Survey results indicated that alcoholism/drug abuse, breathing problems, and obesity were the primary health concerns of county residents. Benefits of conducting the community survey included strengthening inter-organizational partnerships between community partners, engaging a large and diverse respondent sample, and gathering information on a nuanced set of health indicators. Challenges included an unexpectedly high number of respondents and managing the needs of respondents with disabilities or poor literacy. Conclusion The information gathered from the community health survey was used in the implementation of a county-wide multi-agency strategic plan to address health priorities identified in the CHA. Engaging a broad set of community partners throughout the survey process was critical for ensuring the project s relevance and long-term regional impact.

Objectives. To test whether childhood maltreatment was a predictor of (1) having low educational qualifications and (2) not being in education, employment, or training among young adults in the United Kingdom today. Methods. Participants were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally representative UK cohort of 2232 twins born in 1994 to 1995. Mothers reported on child maltreatment when participants were aged 5, 7, 10, and 12 years. Participants were interviewed about their vocational status at age 18 years. Results. The unadjusted odds of having low educational qualifications or of not being in education, employment, or training at age 18 years were more than 2 times greater for young people with a childhood history of maltreatment versus those without. These associations were reduced after adjustments for individual and family characteristics. Youths who reported having a supportive adult in their lives had better education outcomes than did youths who had less support. Conclusions. Closer collaboration between the child welfare and education systems is warranted to improve vocational outcomes for maltreated youths. (Am J Y oung people who are currently tran-sitioning to adulthood face a challenging labor market and path to financial independence. 1 In the United States, unemployment rates have risen since 2000 for adolescents and young adults. 1,2 European youths face similar challenges. 3 The transition to adulthood is a critical point at which to alter trajectories for youths who are unemployed and have few, if any, educational qualifications. Predicting which young people are at highest risk for not being in education, employment, or training (NEET) is crucial to accurately target preventive services. A childhood history of maltreatment (e.g., abuse or neglect) is 1 such predictor of educational and employment outcomes. 4 Relatively high rates of school dropout and unemployment among young people with histories of maltreatment could reflect a causal process by which abuse and neglect result in cognitive impairments, poor mental health, or physical health problems that impinge on academic achievement and employment prospects. For example, youths who are exposed to abuse and neglect are at risk for emotional, behavioral, and academic problems that are predictive of school dropout and unemployment. 5,6 A second possibility is that the association between childhood maltreatment and adult education and employment outcomes is noncausal. For example, childhood maltreatment co-occurs with other robust risk factors for poor socioeconomic outcomes, namely family-and neighborhood-level poverty. 7 A number of studies have shown that the associations between maltreatment and poor education and employment outcomes become nonsignificant once adjustments are made for individual-and family-level risk factors such as IQ or family socioeconomic background. 8-10 By contrast, other studies have identified unique effects of childhood maltreatment on adult socioeconomic outcomes, even after accounting for co-occurring risk factors. 11 Finally, individuals with court-substantiated records of abuse and neglect who were followed prospectively into middle-adulthood had fewer educational qualifications and lower earnings, were only half as likely to be in a skilled job or to be employed, and were less likely to have assets such as stocks or a vehicle compared with demographically matched controls. 12 The current study is well suited to distinguish between social selection and social causation hypotheses about the relationship between childhood maltreatment and education and employment outcomes during the transition to adulthood. A social causation account posits that maltreatment negatively

Objective Childhood conduct problems are associated with poor functioning in early adulthood. We tested a series of hypotheses to understand the mechanisms underlying this association. Method We used data from the Environmental Risk (E-Risk) Longitudinal Twin Study, a birth cohort of 2,232 twins born in England and Wales in 1994 and 1995, followed up to age 18 years with 93% retention. Severe conduct problems in childhood were assessed at ages 5, 7, and 10 years using parent and teacher reports. Poor functioning at age 18 years, including cautions and convictions, daily cigarette smoking, heavy drinking, and psychosocial difficulties, was measured through interviews with participants and official crime record searches. Results Participants 18 years old with versus without a childhood history of severe conduct problems had greater rates of each poor functional outcome, and they were more likely to experience multiple poor outcomes. This association was partly accounted for by concurrent psychopathology in early adulthood, as well as by early familial risk factors, both genetic and environmental. Childhood conduct problems, however, continued to predict poor outcomes at age 18 years after accounting for these explanations. Conclusion Children with severe conduct problems display poor functioning at age 18 years because of concurrent problems in early adulthood and familial risk factors originating in childhood. However, conduct problems also exert a lasting effect on young people s lives independent of these factors, pointing to early conduct problems as a target for early interventions aimed at preventing poor functional outcomes.