In February 1990, a physician notified the Office of Epidemiology, New Mexico Department of Health (NMDH), of a possible cluster of suicides among high school students in Santa Fe County, New Mexico, after two male high school students committed suicide within a 4-day period. Because of concerns by school officials that the number of students attempting suicide in 1990 had increased, the NMDH began an epidemiologic investigation.

In 1989, there were an estimated 13,625 10- to 19-year-olds in Santa Fe County. Students attended one of three public high schools in the county, and one hospital provided emergency care; an Indian Health Service hospital provided care only to American Indians. A review of vital statistics data indicated that, from 1985 through 1988, three or fewer suicides occurred among 10- to 19-year-olds in the county each year, compared with six in 1989 (p less than 0.001, Poisson distribution) (Table 1).

The emergency department (ED) log at the county hospital was reviewed to determine the number of persons less than 20 years of age who were evaluated because of a suicide attempt or suicide ideation from January 1, 1986, through May 31, 1990. A case-patient was defined as a Santa Fe County resident less than 20 years of age who had had a physician diagnosis of either suicide attempt/gesture or suicide ideation. Because addresses were not listed in the ED log, county residents were identified by their home telephone number exchanges; persons who did not list a telephone number in the log were excluded from the review.

Two hundred eighteen persons who met the diagnostic criteria were evaluated in the hospital ED. Of these, 53 (24%) were excluded from the review because they had not listed a home telephone number. Of the 165 case-patients, seven (4%) had been evaluated twice. Case-patients ranged in age from 10 to 19 years (mean: 16 years); 102 (62%) were female, and 96 (58%) were hospitalized. Twenty-one (13%) were evaluated for suicide ideation, and 144 (87%) for a suicide attempt/gesture. Of those who had attempted suicide, 117 (81%) had ingested some type of drug, seven (5%) had had a self-inflicted laceration, one (1%) had had a self-inflicted gunshot wound, and one (1%) had attempted hanging. For 18 (13%) case-patients, the method of attempt was not specified.

Based on the total number of ED visits, the estimated rate of suicide attempts in February 1990 (3.7 per 1000 visits) was greater than the mean rate for February from 1986 through 1989 (1.2 per 1000) (p=0.03, Fisher's exact test) (Figure 1). In addition, for 1986--1989, rates during June, July, and August were consistently lower than during other months. Reported by: O Long, ED Burk, MD, JR Evaldson, MD, St. Vincent Hospital, Santa Fe; K Siler, MA, D Bianca, Teen Wellness Center, Santa Fe County Public Schools; P Totkamachi, New Mexico Vital Records and Statistics; MM Gallaher, MD, IN Vold, MPH, Office of Epidemiology, CM Sewell, DrPH, State Epidemiologist, New Mexico Dept of Health. Epidemiology Br, Div of Injury Control, Center for Environmental Health and Injury Control, CDC.

Editorial Note

Editorial Note:

Although suicide clusters have been studied previously (1,2), understanding of the epidemiology of suicide clusters and attempts, and potential risk factors, is limited. For example, because ready access to firearms may contribute to completed suicides among teenagers, limiting access to firearms may help to reduce the rate of suicides for young persons (3). Among teenagers in Santa Fe County, firearms were used in eight of the 12 completed suicides from January 1985 through May 1990.

Difficulties in ascertaining the true number of suicide attempts are an important barrier to improved understanding of this problem. In Santa Fe County, there were limitations in using the ED log as a means of identifying suicide attempts: only those persons who sought care at the hospital, whose diagnosis fit the case definition, and who provided a home telephone number could be identified. Nonetheless, because mental health referral patterns and diagnosis patterns did not change during the period studied, the changes in the number of persons identified as having attempted suicide probably accurately reflected changes in the true incidence of suicide attempts in Santa Fe County during that period.

Because of the associations between the perception of suicide clusters and additional suicide attempts, communities should respond to an apparent suicide cluster even before confirming the existence of a statistically significant cluster (4). For example, as a result of the perceived cluster of suicides and attempts, Santa Fe County implemented an adolescent suicide prevention program at the two public high schools in the city and used CDC guidelines (5) to organize a community response team. Because rates of suicide attempts are higher among teenagers during the school year, school-based intervention measures may be effective in reducing the number of attempts and completed suicides.

References

1. CDC. Cluster of suicides and suicide attempts---New Jersey. MMWR 1988;37:213--6.

2. Davidson LE, Rosenberg ML, Mercy JA, Franklin J, Simmons JT. An epidemiologic study of risk factors in two teenage suicide clusters. JAMA 1989;262:2687--92.

3. Sloan JH, Rivara FP, Reay DT, Ferris JA, Kellermann AL. Firearm regulations and rates of suicide: a comparison of two metropolitan areas. N Engl J Med 1990;322:369--73.

4. O'Carroll PW, Mercy JA. Responding to community-identified suicide clusters: statistical verification of the cluster is not the primary issue. Am J Epidemiol 1990;132(suppl 1):S196--202.

5. CDC. CDC recommendations for a community plan for the prevention and containment of suicide clusters. MMWR 1988;37(no. S-6):1--12.

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