HEALTH-CARE UTILIZATION AS A MARKER FOR SUICIDAL-BEHAVIOR ON AN AMERICAN-INDIAN RESERVATION

OBJECTIVE: Overall suicide mortality rates are higher among American I ndians than in the general population and are particularly high among Indians residing in the upper Midwest. The identification, during enco unters with health care providers, of individuals at high risk of suic ide is a potential intervention strategy. The purpose of this study wa s to examine whether increased health care utilization and symptom pat terns 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 su icides over a 6-year period and cases of suicide attempts over a 15-mo nth period were identified on a Plains Indian Reservation, The pattern of utilization of health services by these subjects prior to their su icide or attempt was compared with that of control subjects matched fo r age and gender. MAIN RESULTS: Only 24% of subjects who died of suici de used the reservation clinic or hospital for services in the 6 month s prior to their suicide, compared with 54% of controls (odds ratio [O R] 0.28; 95% confidence interval [CI], 0.09, 0.87). The patterns of sy mptom complaints and diagnoses for these visits did not differ signifi cantly 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 documentatio n of psychological and interpersonal problems than were control subjec ts. Only 14% of subjects completing suicide had a previous history of suicide attempts. CONCLUSIONS: In this region, American Indians who co mmitted suicide were less likely to use clinical services provided by the Indian Health Service prior to their death. However, there was a r elatively strong association between suicide attempts and the prior us e of health services, particularly the use of mental health services. In this American Indian population, clinic-based methods for early det ection and intervention to prevent imminent suicide would reach fewer than one fourth of suicide victims. Further research is needed to iden tify the usefulness of community outreach efforts to identify and inte rvene among individuals at high risk of death by suicide.