Concept: Suicide and Attempted Suicide (Intentional Self Inflicted Injury)

Background

This concept contains operational definitions for both suicide and attempted suicide. An alternative term used by many researchers for attempted suicide is intentional self-inflicted injury. Typically, the definition for suicide is taken directly from cause of death in the Vital Statistics mortality data. Attempted suicide can be, and often is, identified from specific codes in hospital discharge abstracts or medical services/physician claims data. The definitions provided here use a broader scope that includes some non-suicide related codes (e.g. accidental poisoning) with a corresponding physician visit with a psychiatric tariff.

The original suicide related definitions were developed in the 2004 Mental Illness Disorder deliverable (Martens et al. (2004). In this deliverable a five year window was used to identify individuals. This was done to provide adequate numbers of suicides for reporting and statistical testing. Only individuals aged ten and older were used. Below this age there are very few cases of suicide and attempted suicide. To identify suicide, information is taken from the record of death in the Vital Statistics data. This data includes diagnoses using ICD-9 codes and ICD-10 codes, depending on the year of analysis.

In the Mental Illness Disorder (2004) and Profile of Metis Health Status and Healthcare Utilization in Manitoba (2010) deliverables by Martens et al., the Care of Manitobans Living with Chronic Kidney Disease deliverable by Chartier et al. (2015), and the Our Children, Our Future: The Health and Well-being of First Nations Children in Manitoba deliverable by Chartier et al. (2020), they investigate both suicide and suicide attempts. In the RHA Indicators Atlas, Fransoo et al. (2009), only investigates suicide.

Up until April 1, 2004 ICD-10-CA codes were not being used in the hospital discharge abstracts data. In the 2010 deliverable, ICD-10-CA codes for hospital discharge abstracts are available. The lists of ICD codes identified in these definitions have been updated in this concept to include ICD-9-CM, ICD-10 and ICD-10-CA codes.

Definitions

• Suicidal Individuals (Completed plus attempted)
  
  Suicidal individuals are individuals who attempted or completed suicide and are identified by the presence of specific ICD diagnosis codes in the data. Typically, analysis is restricted to those 10 years of age and older and cover a five year period. Completed suicide cases are identified from the ICD-9 or ICD-10 diagnoses codes in the Vital Statistics Mortality Registry data.
  
  
• Suicide Attempters
  
  Attempted suicide is identified from ICD-9-CM or ICD-10-CA diagnoses codes in the Hospital Abstracts data; or ICD-9-CM diagnoses codes combined with specific tariff codes in the Medical Services (Physician Claims) data.
  
  NOTE: Please see the "Suicide" and "Suicide Attempts" sections below for the diagnostic criteria for each grouping. We understand that the common use of suicidal includes those that think about or contemplate suicide. In our data we can only capture those that completed suicide (from Vital Statistics data) or those that attempted suicide and were coded as an attempt.

Suicide

Suicide, also referred to as "completed suicide", is the act of intentionally killing oneself. A number of poisoning codes have been included where it was felt that there would be a large number of possible intentional poisonings. In the code, these have been identified separately.

It is important to note that in the Vital Statistics mortality data prior to 2000, if the death is caused by injury or poisoning, external cause of injury codes (E-codes) in the E800-E999 range are coded in the primary cause of death variable. See the Vital Statistics - Use of ICD-9 Codes Identifying Cause of Death and the Cause of Death Coding in the MCHP Vital Statistics Mortality Registry Data concepts for more information.

In MCHP research, two different definitions of suicide have been used over time, differentiated by the inclusion/exclusions of "accidental poisonings".

1. Suicide - Including Accidental Poisonings

In this definition, which includes accidental poisonings, the following ICD codes are used to identify suicide from the primary cause of death field in the Vital Statistics Mortality data:


• accidental poisoning: ICD-9 codes E850-E854, E858, E862, E868; ICD-10 codes X40-X42, X46, X47
  
• poisoning with undetermined intent: ICD-10 codes Y10-Y12, Y16, Y17
  
• self-inflicted poisoning: ICD-9 codes E950-E952, ICD-10 codes X60-X69
  
• self-inflicted injury by hanging, strangulation and suffocation: ICD-9 code E953, ICD-10 code X70
  
• self-inflicted injury by drowning: ICD-9 code E954, ICD-10 code X71
  
• self-inflicted injury by firearms and explosives: ICD-9 code E955, ICD-10 codes X72-X75
  
• self-inflicted injury by smoke, fire, flames, steam, hot vapours and hot objects: ICD-9 codes E958.1, E958.2; ICD-10 codes X76, X77
  
• self-inflicted injury by cutting and piecing instruments: ICD-9 code E956; ICD-10 codes X78, X79
  
• self-inflicted injury by jumping from high places: ICD-9 code E957, ICD-10 code X80
  
• self-inflicted injury by jumping or lying before a moving object: ICD-9 code E958.0, ICD-10 code X81
  
• self-inflicted injury by crashing of motor vehicle: ICD-9 code E958.5, ICD-10-CA code X82
  
• self-inflicted injury by other and unspecified means: ICD-9 codes E958.3, E958.4, E958.6-E958.9; ICD-10 codes X83, X84
  
• late effects of self-inflicted injury: ICD-9 code E959

2. Suicide - NOT Including Accidental Poisonings

In this definition, from Fransoo et al. (2019) that does not include accidental poisonings, the following ICD codes are used to identify suicide from the "cause of death" field in the Vital Statistics Mortality data:


• Intentional self-harm: ICD-10 codes X60-X84;
  
• Late effects of intentional self-harm: ICD-10-CA code Y87.0
  
• Poisoning of undetermined intent: ICD-10 codes Y10-Y19
  
• Other events of undetermined intent: ICD-10 codes Y20-Y34
  
• Late effects of other events of undetermined intent: ICD–10–CA code Y87.2

NOTE: Events of undetermined intent (Y10-Y34) were included for the purposes of developing a more "inclusive" definition in an attempt to overcome suspected under-counting of suicides in administrative data; however accidental poisonings were not included in the counts of suicide deaths as the uncertainty around the cause of death was too high. See the Issues and Notes section below for more discussion on these codes.

Suicide Attempts

In several MCHP research projects, they also investigated suicide attempts. In some cases, analyses on suicide attempts do NOT include those events that resulted in death identified from the Vital Statistics data. Analyses are typically restricted to those aged 10 or more and cover a five-year time period. Suicide attempts were defined as the presence of any of hospital or physician / medical claims coding a suicide attempt using the following definitions:


• A hospitalization with a diagnosis for suicide or self-inflicted injury: ICD-9-CM codes E950-E959, ICD-10-CA codes X60-X84; OR
  
  
• A hospitalization with a diagnosis code for accidental poisoning: ICD-9-CM codes 965, 967, 969, 977.9, 986, E850-E854, E858, E862, E868; ICD-10-CA codes T39, T40, T42.3, T42.4, T42.7, T43, T50.9, T58, X40-X42, X44, X46, X47, Y10-Y12, Y16, Y17, only if there is a physician visit with a diagnosis code for accidental poisoning and a psychiatric tariff code either during the hospital stay or within 30 days post-discharge. Psychiatric tariff codes are as follows:
  
  
  • From the psychiatric schedule:
    • 8444 Psychotherapy - group of two to four patients
      
    • 8446 Psychotherapy - group of five or more patients
      
    • 8472 Child and Youth Management Conference
      
    • 8475 Psychiatry - Patient Care Family Conference
      
    • 8476 Psychiatric Social Interview
      
    • 8503 Complete history and psychiatric examination - adult
      
    • 8504 Complete history and psychiatric examination - child
      
    • 8553 Psychiatry Consultation - adult
      
    • 8554 Psychiatry Consultation - child
      
    • 8581 Psychotherapy - individual
      
    • 8584 Psychiatric care - individual
      
    • 8588 Electroshock therapy
      
    • 8596 Consultation - Unassigned patient - child
    
    
  • From the general schedule:
    • 8580 Psychotherapy - individual
      
    • 8587 Electroshock therapy
      
    • 8589 Psychotherapy - group
  
  NOTE: It may be possible to identify individuals that attempted suicide by lacerating themselves. Some work has been done in this area using laceration and wound repair in the physician / medical claims data. This work has not been validated and was not included in the Mental Health deliverable. SAS code specific to lacerations is provided below in the SAS Code section (internal access only).

Hospitalizations for Attempted Suicide

• In the Mental Illness Among Adult Manitobans deliverable by Chartier et al (2018), they looked at the hospitalization for attempted suicide. The following ICD codes are used to identify attempted suicide from "hospitalizations":
  
  
  • One or more hospitalizations with a diagnosis code for poisoning of undetermined intent, injury of undetermined intent, or accidental poisoning, only if there is a mental illness code during the hospital stay: ICD-9-CM codes E850-E854, E858, E862, E868 or ICD-10-CA codes Y10-Y34, T39, T40, T42.3, T42.4, T42.7, T43, T50.9, T58, X44, X46, X47.
  
  
• In the Our Children, Our Future: The Health and Well-being of First Nations Children in Manitoba deliverable by Chartier et al. (2020), an attempted suicide is defined by an inpatient hospitalization with an ICD-10-CA diagnosis code for suicide and self-inflicted injury, or with an ICD-10_CA diagnosis code for accidental poisoning combined with a psychiatric tariff code from medical claims during hospital stay or within 30 days of discharge. The following ICD codes were used to identify hospitalizations for attempted suicide:
  
  
  • ICD-10-CA codes: X40-X42, X44, X46, X47; X60-X69; X70; X71; X72-X75; X76, X77; X78, X79; X80; X81; X82; X83, X84; Y10-Y12; Y16, Y17.

Research Findings on Suicide and Attempted Suicide

The following list provides links to selected MCHP deliverables that report research-specific information related to suicide and suicide attempts:


• Martens et al. (2004) - Patterns of Regional Mental Illness Disorder Diagnoses and Service Use in Manitoba: A Population-Based Study - see Chapter 9: Suicide and Suicide Attempts
  
  
• Fransoo et al. (2009) - Manitoba RHA Indicators Atlas 2009 - see the section titled Suicide Rates
  
  
• Martens et al. (2010) - Health Inequities in Manitoba - see the section titled Suicide Deaths and Suicide Attempts
  
  
• Martens et al. (2010) - Profile of Metis Health Status and Healthcare Utilization in Manitoba - see the sections titled:
  
  
  • Suicide Rate
    
  • Suicide or Suicide Attempt Prevalence
  
  
• Chartier et al. (2012) - Health and Healthcare Utilization of Francophones in Manitoba - see the section titled Suicide or Suicide Attempt
  
  
• Brownell et al. (2012) - How are Manitoba's Children Doing? - this study looked at children aged 13 to 19 years old. See the section titled Suicide
  
  
• Fransoo et al. (2013) - The 2013 RHA Indicators Atlas - see section 3.8 Suicide Rates
  
  
• Smith et al. (2013) - Social Housing in Manitoba. Part II: Social Housing and Health in Manitoba: A First Look - see the section titled Suicide
  
  
• Chartier et al. (2015) - Care of Manitobans Living with Chronic Kidney Disease - this study investigated suicide and attempted suicide for residents aged 13 and older as a comorbidity to chronic kidney disease (CKD) and end stage kidney disease (ESKD). See:
  
  • technical definition of Suicide and Suicide attempts;
    
  • Key Findings - Chapter 4: Characteristics of Adults with End Stage Kidney Disease and Chronic Kidney Disease;
    
  • Table 4.2: Mental Disorders in Adults in End Stage Kidney Disease;
    
  • Table 4.6: Mental Disorders in Adults in Chronic Kidney Disease;
    
  • Key Findings - Chapter 5: Characteristics of Children with End Stage Kidney Disease and Chronic Kidney Disease; and
    
  • Table 5.2: Mental Disorders in Children.
  
  
• Chartier et al. (2016) - The Mental Health of Manitoba's Children - this study investigated suicide and attempted suicide for children aged 13 to 19 years of age. See the section titled Suicide and Attempted Suicide
  
  
• Chartier et al. (2018) - The Mental Illness Among Adult Manitobans - see the section titled Suicide
  
  
• Fransoo et al. (2019) - The 2019 RHA Indicators Atlas - see section 3.8 Suicide Rates in the deliverable.
  
  
• Chartier et al. (2020) - Our Children, Our Future: The Health and Well-being of First Nations Children in Manitoba investigated and analyzed suicide and attempted suicide by Health Regions, Tribal Council Areas and Income Quintiles for First Nations on-reserve, First Nations off-reserve, all First Nations and all other Manitobans. For more information, see the following sections in the deliverable:
  
  • Suicide
    
  • Hospitalization for Attempted Suicide

Issues and Notes

• In the future it is probably not necessary to use the physician claims and poisoning codes to identify attempted suicide. Using these codes is significantly more work and adds very little additional information.
  
  
• To be consistent with other sources of suicide data, in the future, programmers might consider using only the suicide / intentional self-harm codes.
  
  
• See notes under attempts regarding lacerations.
  
  
• There is a significant difference when comparing the number of suicides in Manitoba from Vital Statistics and the Medical Examiners office. The Medical Examiners office reports having a higher number of suicides than Vital Statistics.
  
  
• Be cautious when using codes outside of the ICD-10 range of X60-X84 (intentional self-harm) to identify suicide. In discussion at MCHP, codes within the Y10-Y34 range (poisoning and other events of undetermined intent) are thought to be events that can happen accidentally more often than intentionally. For example, Y18 - poisoning by and exposure to pesticides, undetermined intent - is more likely to be caused by inappropriate use/handling than an attempted self-harm.
  
  Using these Y10-Y-34 codes comes down to a question of sensitivity or specificity; do you want to capture all the potential suicides or just the ones that are known?