Anne E. Rhodes

Emergency department data offer more representative deliberate self-harm (DSH) information than inpatient admission data. However, emergency department data may underestimate DSH if some records coded "undetermined" (UD) represent DSH. The data are from the National Ambulatory Care Reporting System. A total of 24,437 Ontario emergency department records for 2001/2002, coded DSH or UD, were analyzed. Age- and sex-specific estimates were compared under alternative DSH definitions. For every two emergency department presentations coded DSH, another was coded UD. Cut/Pierce injuries and poisonings coded UD appeared to represent DSH more often than did UD presentations involving other injuries. Among index episodes coded UD, the rate of subsequent DSH presentation was nearly ten times higher when cut/pierce injury or poisoning was involved. Including presentations coded UD among those coded DSH increased the 12-month cumulative incidence of DSH by up to 60%. Some emergency department presentations coded UD likely represent DSH.

Deliberate self-harm (DSH) is related to suicide and DSH repetition is common. DSH hospital presentations are often self-poisonings with medicinal agents. While older age and male sex are known risk factors for suicide, it is unclear how these factors are related to the nature and severity of medicinal self-poisoning (SP). Such knowledge can guide prevention strategies emphasizing detecting and treating mental illness and controlling access to means.

Objectives: To describe individuals who reported suicidal ideation but neither met the criteria for major depression (MD) nor were in contact with mental health services in the previous year. Method: Data were drawn from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). Conducted in 2002, the CCHS 1.2 was a cross-sectional population-based survey of 36 984 Canadian household residents aged 15 years or more. First, we described the individuals who reported suicidal ideation, were without MD, and were not in contact with mental health services ( n = 584) as well as their nonsuicidal counterparts ( n = 31 382) based on various demographic and health status variables. Second, to analyse whether these same variables are associated with mental health service contact(s) among suicidal individuals without MD, we compared those who were in contact with mental health services ( n = 209) to those who were not ( n = 584). Results: Almost one-half (47.9%) of the suicidal ideators were without both MD and a mental health service contact in the previous year. Individuals in this group were younger and exhibited greater morbidity than their nonsuicidal counterparts (without MD or mental health service contact) but did not differ by sex. Although male and female respondents were equally represented among the suicidal ideators without MD, male respondents were less likely to contact mental health services. Such contact was more likely among female respondents and individuals with an anxiety disorder. Conclusions: These findings underscore the need for further research evaluating early intervention programs that succeed in capturing suicidal youths, particularly male youths.

Objective: To determine the magnitude of depression and suicidal populations, the overlap between these populations, and the associated patterns of mental health service use. Method: We examined depression, suicidality (ideation and nonfatal behaviours), and the mental health service use of participants in the Canadian Community Health Survey Cycle 1.2: Mental Health and Well-Being. The sample comprised 36 984 household members aged 15 years or over. Results: Approximately 4% to 5% of the population suffered from a major depression or suicidality. About 2 of 3 of those who were suicidal did not suffer from depression, and over 70% of those with depression did not report suicidality. Persons with depression and suicidality or depression (but no suicidality) were the 2 groups most likely to report ambulatory mental health contacts, and the provider groups contacted most often included physicians. The use of provider groups was considerably lower for those who were suicidal (but had no depression). Whereas the latter were more likely to report contacts than not, suicidality, in and of itself, did not exert a strong effect on contact with any particular provider group. For those who were suicidal (but who had no depression), less than 1 in 3 reported any mental health service contact, including an inpatient mental health stay. Conclusions: The lack of contact by those who are suicidal (but who have no depression) is provocative, given that almost 2 of 3 of the suicidal subjects had no depression. Detrimental outcomes such as depression may develop without effective early interventions and uptake by a sufficient supply of appropriately trained and financially accessible personnel.

Estimates of the level of unmet need for mental health treatment often rely on self‐reported use of mental health services. However, depressed persons may over‐report their use in relation to administrative records if they are highly distressed. This study seeks to replicate and explicate the finding that persons at a high level of distress report more mental health service use than recorded in their healthcare records. The study sample, N=36,892, 12 years and older, was drawn from the 1996/97 Ontario portion of the Canadian National Population Health Survey. Respondents were individually linked to their administrative mental healthcare records 12 months backward in time. Of these, 96.5% agreed to the link and 23,063 (62.5%) were linked. Almost two‐thirds of those who were depressed in the past year were currently at a high level of distress. Differential reporting of use for highly distressed persons in excess of 100% remained in the use of different types of physician providers after adjustments for other potential determinants of use. Telescoping was also not an explanation. The patterns of differential reporting between groups expected to diverge and converge in their recall ability were consistent with a recall bias. As this study was not able to rule out a recall bias, it further accentuates concerns about the impact of bias in the measurement of mental health‐service use and inferences made concerning the determinants of use. Copyright © 2004 Whurr Publishers Ltd.

Studies of mental health services have emphasized that people in need are not receiving treatment. However, these studies, based on self‐reported use, may not be consistent with administrative records. This study compared self‐reports of mental health service use with administrative records in a large representative sample. Respondent reports within the Ontario portion of the 1994/95 Household Component of the National Population Health Survey (NPHS) were individually linked to the provincial mental‐health physician reimbursement claims. A total of 5,187 Ontarians, aged 12 years or more, reported on their use of mental healthcare within the NPHS and 4,621 (89%) consented and were successfully linked to administrative records.Comparisons between the two sources identified that the agreement for any use and volume of use was moderate to low and varied according to select respondent characteristics. These differences affected estimates of the associations with use and volume of use. People who reported high levels of distress reported more visits than those who did not and this effect was stronger in the self‐reported data.These results suggest that recall bias may be present. Regardless of the definition of care, access for those in need remains a concern despite universal medical insurance coverage. Copyright © 2002 Whurr Publishers Ltd.

Hospital separation data are used to study suicidal behaviour; however, there is little information about the appropriateness of these data for research and planning activities. The study purpose is to examine how consistently hospital separation E-code data reflect suicidal behaviours. Expert clinicians reviewed medical records of individuals who had a separation for self-poisoning to determine whether the self-poisoning was deliberate. Agreement among clinicians was evaluated and latent class analysis performed to derive a summary estimate of the prevalence of deliberate self-poisoning. This estimate was then compared to the prevalence of deliberate self-poisoning based on the external cause of injury (E-codes). Clinicians estimated the prevalence to be 63% higher than the E-code based prevalence. Much larger discrepancies were apparent among older age groups, those whose care was primarily medical in nature and those with a longer length of hospital stay. In acute care settings, self-poisonings among the elderly may not receive adequate attention and/or documentation. Estimating the prevalence of admissions for suicidal behaviour using hospital separation data is of questionable validity, particularly among older age groups.