Abstract
OBJECTIVE: Overall suicide mortality rates are higher among American Indians than in the general population and are particularly high among Indians residing in the upper Midwest. The identification, during encounters with health care providers, of individuals at high risk of suicide is a potential intervention strategy. The purpose of this study was to examine whether increased health care utilization and symptom patterns were associated with suicide and suicide attempts among American Indian patients in an Indian Health Service facility.
DESIGN: A case-control study design was used.
SETTING/PATIENTS: Cases of completed suicides over a 6-year period and cases of suicide attempts over a 15-month period were identified on a Plains Indian Reservation. The pattern of utilization of health services by these subjects prior to their suicide or attempt was compared with that of control subjects matched for age and gender.
MAIN RESULTS: Only 24% of subjects who died of suicide used the reservation clinic or hospital for services in the 6 months prior to their suicide, compared with 54% of controls (odds ratio [OR] 0.28; 95% confidence interval [CI], 0.09, 0.87). The patterns of symptom complaints and diagnoses for these visits did not differ significantly between case and control subjects. Case subjects who attempted suicide were more likely to be seen during the 6 months prior to their attempt than control subjects (57% vs 40%, OR 1.72; 95% CI 0.75, 3.93). Persons who attempted suicide were more likely to have documentation of psychological and interpersonal problems than were control subjects. Only 14% of subjects completing suicide had a previous history of suicide attempts.
CONCLUSIONS: In this region, American Indians who committed suicide were less likely to use clinical services provided by the Indian Health Service prior to their death. However, there was a relatively strong association between suicide attempts and the prior use of health services, particularly the use of mental health services. In this American Indian population, clinic-based methods for early detection and intervention to prevent imminent suicide would reach fewer than one fourth of suicide victims. Further research is needed to identify the usefulness of community outreach efforts to identify and intervene among individuals at high risk of death by suicide.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
O’Carroll PW, Rosenberg ML, Mercy JA. Suicide. In: Rosenberg ML, Fenley MA, eds. Violence in America. New York, NY: Oxford University Press; 1991.
Baker SP, O’Neill B, Ginsburg MJ, Li G. The Injury Fact Book. New York, NY: Oxford University Press; 1992;65–77.
Earls F, Escobar JI, Manson SM. Suicide in minority groups: epidemiologic and cultural perspectives. In: Blumenthal SJ, Kupfer DJ, eds. Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. Washington, DC: American Psychiatric Press; 1991.
Indian Health Service. Trends in Indian Health. Rockville, Md: U.S. Public Health Service; 1993.
Lin EHB, VonKorff M, Wagner EH. Identifying suicide potential in primary care. J Gen Intern Med. 1989;4:1–6.
Buzan RD, Weissberg MP. Suicide: risk factors and prevention in medical practice. Annu Rev Med. 1992;43:37–46.
Murphy GE. The physician’s responsibility for suicide, I: an error of commission. Ann Intern Med. 1975;83:301–4.
Murphy GE. The physician’s responsibility for suicide, II: errors of omission. Ann Intern Med. 1975;83:305–9.
Cunningham PJ. Access to care in the Indian Health Service. Health Aff (Millwood). 12:224-33.
Schlesselman JJ. Case Control Studies: Design, Conduct, Analysis. New York, NY: Oxford University Press; 1982.
Breslow NE, Day NE. Statistical Methods in Cancer Research. Lyon, France: International Agency for Research on Cancer; 1980;1.
Grossman DC, Soderberg R, Rivara FP. Prior injury and motor vehicle crash as risk factors for youth suicide. Epidemiology. 1993;4:115–9.
Fowler RC, Rich CL, Young D. San Diego Suicide Study, II: substance abuse in young cases. Arch Gen Psychiatry. 1986;43:962–5.
Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99–105.
Katon W, VonKorff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995;273:1026–31.
Rutz W, vonKnorring L, Walinder J. Frequency of suicide in Gotland after systematic postgraduate education of general practitioners. Acta Psychiatr Scand. 1989;80:151–4.
Rutz W, vonKnorring L, Walinder J. Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression. Acta Psychiatr Scand. 1992;85:83–8.
Grossman DC, Milligan BC, Deyo RA. Risk factors for suicide attempts among Navajo adolescents. Am J Public Health. 1991;81:870–4.
Manson SM, Beals J, Dick RW, Duclos C. Risk factors for suicide among Indian adolescents at a boarding school. Public Health Rep. 1989;104:609–14.
Dizmang LH, Watson J, May PA, Bopp J. Adolescent suicide at an Indian reservation. Am J Orthopsychiatry. 1974;44:43–9.
Neligh G. Secondary and tertiary prevention strategies applied to suicide among American Indians. Am Indian Alaska Native Mental Health Res. 1988;1:4–18.
Grossman DC, Putsch RW, Inui TS. The meaning of death to adolescents in an American Indian community. Fam Med. 1993;25:593–7.
Author information
Authors and Affiliations
Additional information
Supported in part by grant R49/CCR002570 from the Centers for Disease Control and Prevention.
The opinions expressed in this paper are solely those of the authors and not necessarily those of the Indian Health Service or the U.S. Public Health Service.
Rights and permissions
About this article
Cite this article
Mock, C.N., Grossman, D.C., Mulder, D. et al. Health care utilization as a marker for suicidal behavior on an American Indian reservation. J Gen Intern Med 11, 519–524 (1996). https://doi.org/10.1007/BF02599598
Issue Date:
DOI: https://doi.org/10.1007/BF02599598