High Service Use Seen in Medicaid Patients Who Later Died by Suicide

Medicaid patients who died by suicide in one state sample were very likely to make general medical and/or mental health visits shortly before their death, and those whose visits were within 30 days of suicide were more likely to have individual and co-occurring behavioral and general medical conditions.

The latter group was also more likely to be Medicaid-eligible because of disability, according to a report published last month in Psychiatric Services in Advance. The study was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA).

The report, which looked at Ohio state Medicaid data, is significant in at least two ways: it points to individual characteristics related to service use prior to suicide, and it suggests the value of using data from a circumscribed patient population to develop predictive models.

“The condition-specific suicide rates underscore that Medicaid enrollees with psychiatric disorders, especially in combination with substance use disorders and chronic general medical conditions, are a group at particularly high risk of suicide,” wrote the researchers, who are affiliated with Ohio State University, University at Albany, and SAMHSA. “Findings highlight the substantial public health significance of using Medicaid enrollment to designate a ‘virtual boundary’ around a subpopulation of U.S. health care consumers for purposes of targeted suicide prevention and intervention.”

Data for the study came from the Medicaid claims files of the Ohio Department of Mental Health and Addiction Services and death certificate files by the Ohio Department of Health. The two databases were linked using a deterministic, multistep algorithm based on combinations of an individual’s Social Security number, last name, first name, birth month, and birth year.

A total of 1,338 Ohio Medicaid enrollees aged 19 to 65 died by suicide in the study period. Data were extracted from Medicaid claims files for each of the 1,338 individuals in the year prior to suicide and included general medical, mental health, and substance use treatment visits to outpatient programs, inpatient facilities, or emergency rooms.

ICD-9-CM codes were linked with encounters, allowing for categorization of reasons for visits by primary diagnosis. These diagnoses were grouped into two categories: general medical visits and mental health or substance use treatment visits.

Most decedents (83 percent) made a general medical or mental health visit within one year of suicide, with half doing so within 30 days and 27 percent within one week before death. In the year before suicide, the median number of visits was 16, indicating a subgroup with intensive service utilization.

Decedents whose visits were proximal to suicide (within 30 days) rather than distal (31 to 365 days) were more likely to have individual and co-occurring behavioral and general medical conditions and to be Medicaid eligible through disability. Also in the year before suicide, decedents with serious psychiatric disorders were more likely than those without such disorders to make only mental health visits, and those with chronic general medical conditions were more likely than those without such conditions to make only general medical visits.

“Data on the frequency of visits indicate that a portion of decedents were intensive service users, and these individuals had severe clinical profiles,” the researchers stated. “Decedents who had more problems, as measured by all types of co-occurring conditions, were more likely than those without co-occurring conditions to have made visits within a month of suicide. In addition, decedents who received care in the month prior to suicide tended to be seen in settings consistent with their clinical profiles—those with serious psychiatric disorders were more likely than those without such disorders to make mental health visits, and those with chronic general medical conditions were more likely than those without such conditions to make general medical visits.”

Lisa Dixon, M.D., editor of Psychiatric Services and a professor of psychiatry at Columbia University and the New York State Psychiatric Institute, said the study is rich with data potentially informative about predictors for suicide.

“At the clinical level, the frequency with which individuals had health care visits in the week, month, and year prior to suicide underscores the fact that there may be opportunities for identification and risk and prevention,” she told Psychiatric News. “We can see the importance of the specific patient characteristics that may increase risk such as the co-occurrence of general medical, substance use, and mental health disorders.

“At the same time, since we cannot absolutely predict who will die by suicide, this paper has implications for the power of a system-level approach,” she said. “The patterns that emerged suggest the value of algorithms that might be able to identify those at greatest risk and do screening and prevention procedures within the group of individuals covered by Medicaid.” ■