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Age and gender differences in medical care utilization prior to suicide
Journal of Affective Disorders 146 (2013) 181–188
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Research report
Age and gender differences in medical care utilization prior to suicide Jaelim Cho a, Dae Ryong Kang b, Ki Tae Moon c, Mina Suh d, Kyoung Hwa Ha a, Changsoo Kim a,n, Il Suh a, Dong Chun Shin a, Sang Hyuk Jung e a
Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea Division of Clinical Research Affairs, Yonsei University College of Medicine, Seoul, Republic of Korea c Samsung Life Insurance, Seoul, Republic of Korea d National Cancer Center, Koyang, Republic of Korea e Department of Preventive Medicine, School of Medicine, Ewha Womans University, Seoul, Republic of Korea b
a r t i c l e i n f o
abstract
Article history: Received 16 June 2012 Received in revised form 2 September 2012 Accepted 2 September 2012 Available online 25 September 2012
Background: Analysis of temporal patterns of medical care utilization prior to suicide may aid in developing suicide prevention programs. The aim of this study was to investigate age and gender differences in temporal patterns of medical care utilization during 1 year prior to suicide. Methods: Medical care utilization data of all suicide completers in the Republic of Korea whose death occurred in 2004 (7903 men and 3620 women) was used. Differences among the quarters in medical expenditures and number of medical care visits were analyzed using a repeated measures analysis. Total medical expenditures were compared to those of age- and gender-matched controls by multiple logistic regression analysis. Results: Among suicides, 84% (81% in men, 91% in women) contacted medical care in the year prior to suicide. In 10–39 year-old women, the number of medical care visits for gastrointestinal disease increased significantly during the final 3 months prior to suicide. All suicide completers showed that the number of medical care visits for psychiatric disorders increased significantly during the final 3 months with the exception of 10–19 year age group. Total medical expenditures during the year prior to suicide were elevated significantly and associated significantly with suicide risk (OR, 1.20; 95% CI, 1.19–1.21). Limitations: Inaccuracies in the underlying disease and death statistics data may have led to misclassification bias. Conclusions: Medical care utilization increased as the date of suicide approached. There are age and gender differences in medical care utilization in the year prior to suicide. & 2012 Elsevier B.V. All rights reserved.
Keywords: Suicide Prevention Medical care utilization Psychiatric disorder
1. Introduction Suicide is a major public health problem worldwide, representing 1.4% of the Global Burden of disease (World Health Organization, 2005). Suicide rates in developed countries averaged 12 per 100,000 inhabitants in 2005 (OECD, 2008). In the Republic of Korea (ROK), suicide rates since 2003 have been among the highest in developed countries (OECD, 2008), averaging 24.2 per 100,000 inhabitants in 2004 (Statistics Korea, 2004). Compared to those in 2001, suicide rates have increased by 117% in 2010, averaging 31.2 per 100,000 inhabitants (Statistics Korea, 2010).
n Correspondence to: Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seoul, Republic of Korea. Tel.: þ82 2 2228 1880; fax: þ 82 2 392 8133. E-mail address: [email protected] (C. Kim).
0165-0327/$ - see front matter & 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2012.09.001
Psychiatric disorders such as depression are a significant predisposing factor for suicide. Epidemiologic and clinical studies suggested that about 90% of people who complete suicide have preexisting psychiatric disorders (Arsenault-Lapierre et al., 2004, Henriksson et al., 1993). This suggests that effective suicide prevention will involve a medical approach, including early detection and appropriate treatment of patients at risk for suicide. However, differences among countries in terms of culture and health care systems impact the ease of implementation of a medical approach. In Western countries, about a third of depressed patients commit suicide within 12 months of seeking psychiatric help (Hunt et al., 2006). Approximately three quarters of suicide victims contacted primary care providers in the year prior to suicide, while only one third contacted mental health professionals (Luoma et al., 2002). In Asian countries, depressed people are even less likely to contact mental health professionals due to negative cultural views of psychiatric disorders (Chiu et al., 2003; Hsu et al., 2008; Karasz, 2005). Hence, in these countries,
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non-psychiatrist physicians may be in a better position to prevent suicide than are psychiatrists. Epidemiologic research on medical care utilization prior to suicide may aid in developing effective suicide risk assessment and prevention programs. In the present study, national suicide data was used to investigate age and gender differences in temporal patterns of medical care utilization in suicide completers over a period of 1 year prior to suicide. Total medical expenditures of suicide completers were compared to those of a control group.
2. Methods
code according to the International Classification of Diseases, 10th revision (ICD-10); drugs prescribed; medical expenditures; health insurance premiums; and date of visit) are reported to the Health Insurance Review and Assessment Service (HIRA) for review of propriety. Medical care utilization data for suicide completers over a period of 1 year prior to suicide was obtained from HIRA (Park et al., 2008). In cases in which suicide was reported during hospital care or admission, we excluded the final medical care utilization data from the analysis because of the likelihood that this care was related to a fatal suicide attempt. Medical care utilization in suicide completers over a period spanning January 1, 2003 to December 31, 2004, and in controls from July 1, 2003 to June 30, 2004 was examined.
2.1. Study subjects Data on suicides that occurred in 2004 was obtained from the Death Statistics Database of the Korean National Statistical Office and from post-mortem examination findings provided by the Korean National Police Agency. The total number of suicide completers was 11,523 (7903 men and 3620 women). To compare medical expenditures in suicide completers vs. the general population, controls (n¼115,230) from among Koreans who were registered as health insurance subscribers, dependents of health insurance subscribers, or medical aid beneficiaries were randomly selected. Controls were frequency-matched with suicide completers by gender and age group (10–19, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, and Z80 years of age). This study was approved by the Institutional Review Board of Yonsei University Health System (approval number 4-201-0273), Seoul, ROK. 2.2. Medical care utilization As part of the Korean national health insurance program, medical care utilization data for all Koreans (including diagnosis
2.3. Statistical analysis The study sample was divided into four age groups: 10–19, 20–39, 40–64, and Z65 years of age. The individual’s health insurance premium, which in the ROK is based on family income and immovable property, was used as a proxy measure of socioeconomic status. The individual health insurance premium was categorized into quintiles based on premium statistics for all Koreans and assigned beneficiaries of the Medical Aid Program to the lowest quintile group (quintile 1 [Q1]). The area of residence was classified as metropolitan, urban, or rural. Medical expenditures were converted into U.S. dollars on the basis of the exchange rate as of July 1, 2004 (1 U.S. dollar ¼ 1152.50 Korean won). To ascertain underlying diseases, the disease code recorded for each visit was categorized into one of six disease groups: psychiatric disorder (F00-99), musculoskeletal disease (M00-99), cardiovascular disease (I00-99), respiratory disease (J00-99), gastrointestinal disease (K00-93), and injury (S00-99, T00-99). Cancer in the underlying disease group was
Table 1 Characteristics of suicide completers and total medical expenditures and number of medical care utilizations over a period of 1 year prior to suicide. Total (n¼11,523)
Men (n¼ 7903)
Women (n¼ 3620)
pa
Age, n (%) 10–19 years 20–39 years 40–64 years Z65 years
205 2857 5177 3284
Residence, n (%) Metropolitan Urban Rural
4603 (39.95) 5329 (46.25) 1591 (13.81)
3172 (40.14) 3637 (46.02) 1094 (13.84)
1431 (39.53) 1692 (46.74) 497 (13.73)
0.767
Health insurance premium rateb, n (%) Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
4162 2133 1914 1617 1697
2876 1485 1348 1089 1105
1286 648 566 528 592
0.004
Total medical expenditures (US$), mean (SD) Medical care utilizationsc, mean (SD) Total, n (%) Psychiatric disorder, n (%) Musculoskeletal disease, n (%) Cardiovascular disease, n (%) Respiratory disease, n (%) Gastrointestinal disease, n (%) Injury, n (%)
(1.78) (24.79) (44.93) (28.50)
(36.12) (18.51) (16.61) (14.03) (14.73)
1218.47 (2906.23) 11.35 9649 2884 3862 2738 4643 3834 3432
(12.09) (83.74) (25.03) (33.52) (23.76) (40.29) (33.27) (29.78)
117 1872 3921 1993
(1.48) (23.69) (49.61) (25.22)
(36.39) (18.79) (17.06) (13.78) (13.98)
1167.28 (2992.45) 9.91 6369 1645 2290 1707 2905 2440 2282
(11.28) (80.59) (20.81) (28.98) (21.60) (36.76) (30.87) (28.88)
88 985 1256 1291
(2.43) (27.21) (34.70) (35.66)
(35.52) (17.90) (15.64) (14.59) (16.35)
1330.37 (2705.52) 14.49 3280 1239 1572 1031 1738 1394 1150
(13.13) (90.61) (34.23) (43.43) (28.48) (48.01) (38.51) (31.77)
o0.001
0.005 o0.001 o0.001 o0.001 o0.001 o0.001 o0.001 o0.001 0.002
SD: Standard deviation. a
Significance of differences between men and women. Health insurance premium rate was used as a proxy measure of socioeconomic status. Quintile 1 is the lowest and quintile 5 is the highest. Medical aid beneficiaries were categorized as quintile 1. c Medical care utilization based on number of visits; subgroups based on number of patients who contacted the service at least once. b
J. Cho et al. / Journal of Affective Disorders 146 (2013) 181–188
not included because few patients (n¼649) were diagnosed with cancer and their use of medical care was relatively modest. To investigate medical care utilization in suicide completers, medical expenditures and the number of medical care visits during four quarterly periods over the year preceding suicide was examined: 12–10 months, 9–7 months, 6–4 months, and 3–0 months prior to suicide. Differences among the quarters in medical expenditures and number of medical care visits were analyzed using a repeated measures analysis (‘proc mixed’ procedure) after adjusting for age, residence, and health insurance premium rate, separately by gender. Interactions were explored by including interaction terms (quarter x age group, quarter x residence, quarter x health insurance premium quintile) in the mixed model. Additionally, differences by underlying disease in the number of medical care visits across quarters were explored after stratification of gender and age groups. To compare Table 2 Quarterly medical expenditures
a
183
total medical expenditures of suicide completers and controls, multiple logistic regression analysis was performed after adjusting for age, gender, residence, and socioeconomic status. SAS version 9.2 (SAS institute, Cary, NC) was used to conduct the statistical analyses. All statistical tests were two-tailed. Statistical significance was set at Po0.05. All analyses were blinded to the identity of suicide completers and controls through the use of randomly generated identification numbers.
3. Results Table 1 summarizes the characteristics of and medical care utilization data for the suicide completers. Among the suicide completers, 83.7% contacted medical care for any reason at least
over a period of 1 year prior to suicide, by gender.
12 to 10 months before suicide Total Age, mean (SD) 10–19 years 49.78 (152.17) 20–39 years 139.38 (496.10) 40–64 years 241.52 (904.44) Z65 years 302.21 (841.80) Residence, mean (SD) Metropolitan 233.83 (828.72) Urban 228.56 (814.89) Rural 224.20 (622.79) Health insurance premium ratec, mean (SD) Quintile 1 240.04 (786.45) Quintile 2 179.77 (702.51) Quintile 3 198.83 (675.43) Quintile 4 237.34 (886.92) Quintile 5 297.11 (949.93) Men Age, mean (SD) 10–19 years 35.29 (87.14) 20–39 years 139.04 (488.13) 40–64 years 219.91 (865.20) Z65 years 303.89 (906.68) Residence, mean (SD) Metropolitan 221.24 (815.36) Urban 212.55 (815.75) Rural 235.40 (690.30) Health insurance premium ratec, mean (SD) Quintile 1 223.15 (771.45) Quintile 2 186.66 (777.65) Quintile 3 199.43 (705.23) Quintile 4 213.54 (796.53) Quintile 5 282.36 (986.17) Women Age, mean (SD) 10–19 years 69.04 (208.60) 20–39 years 140.15 (511.37) 40–64 years 308.97 (1014.65) Z65 years 299.37 (730.40) Residence, mean (SD) Metropolitan 261.72 (857.25) Urban 262.99 (812.23) Rural 199.55 (438.64) Health insurance premium ratec, mean (SD) Quintile 1 277.81 (818.03) Quintile 2 163.99 (488.71) Quintile 3 197.40 (599.11) Quintile 4 286.42 (1048.17) Quintile 5 324.64 (878.45)
9 to 7 months before suicide
6 to 4 months before suicide
3 to 0 months before suicide
p o 0.001b
43.60 170.09 267.00 343.51
(125.87) (667.14) (990.73) (1024.95)
125.40 170.08 317.61 400.84
(600.17) (618.64) (1140.02) (1185.83)
322.35 300.47 417.98 555.48
(1952.60) (1420.87) (1506.50) (1336.57)
o 0.001
251.88 (830.45) 260.24 (960.90) 288.39 (1053.35)
312.00 (1125.44) 284.90 (1016.73) 325.37 (889.80)
435.27 (1659.29) 411.05 (1312.96) 451.46 (1228.76)
0.333
278.56 204.94 216.74 301.83 297.95
332.37 230.81 273.09 330.72 317.56
427.54 365.48 373.51 454.36 532.55
o 0.001
(883.57) (909.90) (773.95) (1169.02) (932.34)
(1196.16) (831.62) (949.00) (1196.82) (810.78)
(1448.97) (1407.05) (1110.57) (1693.13) (1587.80)
o 0.001b 55.10 156.07 243.59 367.11
(150.10) (655.53) (906.07) (1178.37)
114.82 142.49 307.69 394.85
(466.52) (534.41) (1160.49) (1051.23)
451.13 263.42 405.14 551.56
(2539.88) (1472.86) (1585.40) (1315.37)
o 0.001
244.12 (871.12) 250.45 (1013.4) 274.35 (799.31)
294.49 (1108.3) 267.97 (937.22) 333.49 (963.48)
432.30 (1810.08) 379.82 (1280.38) 439.72 (1294.24)
0.236
260.03 195.69 222.32 293.08 296.93
303.37 230.94 257.31 328.25 320.20
421.85 345.89 348.83 447.22 497.36
0.020
(883.63) (713.13) (815.51) (1288.49) (1010.55)
(1082.05) (922.12) (959.81) (1144.94) (852.70)
(1530.57) (1470.04) (1090.38) (1844.65) (1626.25)
o 0.001b 28.32 196.90 340.06 306.81
(81.84) (688.52) (1215.27) (725.54)
139.47 219.90 348.56 411.91
(744.37) (746.63) (1073.48) (1369.40)
151.14 370.81 458.06 561.54
(535.48) (1314.37) (1227.70) (1369.17)
o 0.001
269.07 (732.28) 281.27 (836.95) 319.31 (1465.40)
350.80 (1161.90) 321.30 (1168.90) 307.48 (701.42)
441.87 (1262.94) 478.19 (1378.38) 477.30 (1071.37)
0.561
320.02 226.15 203.46 319.87 299.86
397.24 230.51 310.67 335.83 312.63
440.27 410.36 432.31 469.07 598.25
0.021
(882.37) (1249.43) (665.05) (873.26) (766.09)
(146.84) (573.26) (922.51) (1298.42) (726.77)
(1247.77) (1250.69) (1156.10) (1328.60) (1512.57)
SD: Standard deviation. a
Medical expenditures were converted into U.S. dollars based on the exchange rate on July 1, 2004. Significant differences among quarters (within-group); other P values correspond to comparisons among subgroups (between-group); tested individually by repeated-measures data analysis after adjusting for age, residence, and health insurance premium rate. c Health insurance premium rate was used as a proxy measure of socioeconomic status. Quintile 1 is the lowest and quintile 5 is the highest. Medical aid beneficiaries were categorized as quintile 1. b
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once during the year preceding suicide; 25.0% contacted medical care for psychiatric disorders at least once during the year preceding suicide; and 67.0% contacted medical care for any reason within the final 3 months prior to suicide. Total medical expenditures and number of medical care visits prior to suicide were significantly higher in women than in men. In the year preceding suicide, 20.8% of men and 34.2% of women contacted medical care for psychiatric disorders. Table 2 presents the data on quarterly medical expenditures over the year preceding suicide. In both men and women, medical expenditures increased as the date of suicide approached. In both men and women, medical expenditures in the Z65 year age group were greater than those in other age groups. In men but not women, medical expenditures were greatest in the highest health insurance premium quintile (quintile 5; P¼0.02). There were no statistically significant differences in medical expenditures among residence groups in either men or women. None of the interaction terms were statistically significant in the repeated measures data analysis. Table 3 presents the number of medical care visits over the year preceding suicide. In both men and women, the number of visits increased as the date of suicide approached. In both men and women, the number of medical care visits by the Z65 year age group was significantly greater than that of the other age groups (Po0.001). In men (Po0.001), but not women (P¼ 0.11), the number of medical care visits was greatest in quintile 5. In men (Po0.001), but not women (P¼0.06), the number of medical care visits was greater in rural than in metropolitan or urban residence groups. Fig. 1 shows the number of medical care visits per quarter by underlying disease in men. The Z 65 year age group most frequently contacted medical care for cardiovascular or musculoskeletal disease, whereas all other age groups most frequently contacted medical care for psychiatric disorder or injury. In the 10–19 year age group, the number of visits for respiratory disease also was high. The number of medical care visits for injury increased, but not significantly, in the final quarter prior to suicide relative to the 12–10 month quarter in the 10–19 year age group (P ¼ 0.08). The number of medical care visits for psychiatric disorder or injury increased significantly in the 3–0 month quarter relative to the 12–10 month quarter in the 20–39 year and 40–64 year age groups. The number of medical care visits for all disease categories except musculoskeletal and respiratory disease increased in the 3–0 month quarter relative to the 12–10 month quarter in the Z 65 year age group. Fig. 2 shows the number of medical care visits per quarter by underlying disease in women. Overall the patterns were similar to those observed in men. Additionally, the number of medical care visits for gastrointestinal disease increased in the 3–0 month quarter relative to the 12–10 month quarter in the 10–19 age group (P ¼0.02) and the 20–39 year age group (P¼ 0.02), and the number of medical care visits for injury increased in the 3–0 month quarter relative to the 12–10 month quarter in the Z65 year group (P o0.001). In the multiple logistic regression analysis, after adjustments for age, gender, residence, and socioeconomic status, total medical expenditures were associated significantly with suicide risk (odds ratio per increase of 1000 U.S. dollars ¼1.20; 95% confidence interval¼1.19–1.21). Low socioeconomic status was associated with increased suicide risk (Q5 vs. Q1: OR ¼2.26; 95% CI ¼2.12–2.40, Q5 vs. Q2: OR ¼1.64; 95% CI ¼1.54–1.76, Q5 vs. Q3: OR¼ 1.39; 95% CI ¼1.30–1.49, Q5 vs. Q4: OR¼1.17; 95% CI ¼1.09–1.26). Area of residence (metropolitan vs. urban: OR ¼1.23; 95% CI ¼1.18–1.28, metropolitan vs. rural: OR ¼1.21; 95% CI ¼1.14–1.29) was associated with increased suicide risk.
Table 3 Medical care utilizations
a
over a period of 1 year prior to suicide, by gender.
12 to 10 months before suicide
9 to 7 months before suicide
6 to 4 months before suicide
Total Age, mean (SD) 10–19 years 1.18 (1.89) 1.27 (1.99) 1.49 20–39 years 1.48 (2.20) 1.56 (2.29) 1.61 40–64 years 2.34 (2.96) 2.41 (3.03) 2.57 Z 65 years 4.40 (3.83) 4.48 (3.89) 4.70 Residence, mean (SD) Metropolitan 2.63 (3.28) 2.69 (3.35) 2.81 Urban 2.59 (3.18) 2.69 (3.27) 2.82 Rural 3.23 (3.46) 3.27 (3.47) 3.56 Health insurance premium ratec, mean (SD) Quintile 1 2.65 (3.29) 2.76 (3.43) 2.89 Quintile 2 2.37 (3.05) 2.43 (3.07) 2.53 Quintile 3 2.48 (3.08) 2.51 (3.05) 2.67 Quintile 4 2.89 (3.30) 2.92 (3.40) 3.06 Quintile 5 3.27 (3.54) 3.38 (3.56) 3.63 Men Age, mean (SD) 10–19 years 1.21 (2.06) 1.55 (2.26) 1.61 20–39 years 1.21 (1.95) 1.24 (1.98) 1.28 40–64 years 2.03 (2.73) 2.07 (2.77) 2.22 Z 65 years 4.13 (3.77) 4.26 (3.87) 4.47 Residence, mean (SD) Metropolitan 2.30 (3.05) 2.35 (3.12) 2.45 Urban 2.24 (2.96) 2.34 (3.11) 2.46 Rural 2.89 (3.36) 2.89 (3.27) 3.18 Health insurance premium ratec, mean (SD) Quintile 1 2.24 (3.04) 2.36 (3.22) 2.49 Quintile 2 2.06 (2.78) 2.10 (2.82) 2.12 Quintile 3 2.26 (2.99) 2.24 (2.87) 2.38 Quintile 4 2.50 (3.06) 2.56 (3.15) 2.72 Quintile 5 3.04 (3.49) 3.09 (3.51) 3.34 Women Age, mean (SD) 10–19 years 1.15 (1.65) 0.90 (1.50) 1.33 20–39 years 2.01 (2.55) 2.17 (2.68) 2.25 40–64 years 3.30 (3.41) 3.47 (3.53) 3.66 Z 65 years 4.81 (3.87) 4.82 (3.91) 5.05 Residence, mean (SD) Metropolitan 3.35 (3.63) 3.43 (3.70) 3.61 Urban 3.35 (3.45) 3.45 (3.48) 3.61 Rural 3.97 (3.58) 4.12 (3.73) 4.40 Health insurance premium ratec, mean (SD) Quintile 1 3.57 (3.61) 3.64 (3.71) 3.77 Quintile 2 3.08 (3.50) 3.18 (3.46) 3.45 Quintile 3 2.99 (3.24) 3.16 (3.36) 3.38 Quintile 4 3.68 (3.62) 3.66 (3.75) 3.77 Quintile 5 3.72 (3.60) 3.93 (3.60) 4.16
3 to 0 months before suicide
p
o0.001b (1.95) (2.46) (3.29) (4.13)
o0.001
(3.46) 2.85 (3.55) (3.42) 2.89 (3.52) (3.72) 3.57 (3.72)
o0.001
(3.52) (3.24) (3.24) (3.53) (3.81)
o0.001
(2.22) (2.36) (3.17) (4.08)
1.39 1.68 2.60 4.76
2.91 2.53 2.72 3.19 3.71
(3.56) (3.38) (3.30) (3.69) (3.86)
o0.001b (1.76) (2.11) (2.97) (4.09)
o0.001
(3.19) 2.47 (3.24) (3.19) 2.47 (3.32) (3.56) 3.24 (3.59)
o0.001
(3.26) (2.85) (3.02) (3.29) (3.79)
o0.001
(2.35) (2.07) (2.86) (4.00)
1.30 1.31 2.23 4.53
2.49 2.15 2.41 2.79 3.39
(3.26) (3.08) (3.16) (3.51) (3.73)
o0.001b (2.03) (2.72) (3.79) (4.17)
1.50 2.37 3.77 5.11
(2.18) (2.89) (3.91) (4.17)
o0.001
(3.88) 3.68 (4.03) 0.060 (3.75) 3.78 (3.77) (3.91) 4.29 (3.91) (3.91) (3.83) (3.60) (3.87) (3.79)
3.85 3.41 3.46 4.03 4.31
(3.98) 0.105 (3.85) (3.51) (3.91) (4.03)
SD: Standard deviation. a
Medical care utilization based on number of visits. Significant differences among quarters (within-group); other P values correspond to comparisons among subgroups (between-group); tested individually by repeated-measures data analysis after adjusting for age, residence, and health insurance premium rate. c Health insurance premium rate was used as a proxy measure of socioeconomic status. Quintile 1 is the lowest and quintile 5 is the highest. Medical aid beneficiaries were categorized as quintile 1. b
4. Discussion A previous study found that approximately three quarters of suicide completers contacted primary care professionals in the year prior to suicide, whereas approximately one third contacted mental health services (Luoma et al., 2002). In Western countries with national health insurance systems, such as Denmark, 92.6% of suicide completers contacted general practitioners and 42.2% had a psychiatric admission in the year prior to suicide
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185
Fig. 1. Medical care utilization over a period of 1 year prior to suicide in men. nPo0.05 vs. 12–10 months prior to suicide; separate paired t-tests for each disease group. The number of medical care utilizations for each disease can surpass those of each subgroup because suicide completers could have contacted the same medical care service more than once in a quarter: (a) women, 10–19 years (n¼117), (b) women, 20–39 years (n¼1,872), (c) women, 40–64 years (n¼3,921) and (d) women, Z65 years (n¼1,993).
(Andersen et al., 2000). In the present study, 83.7% of Korean suicide completers contacted medical care at least once during the year preceding suicide, but only 25.0% contacted medical care for psychiatric disorders. Similar findings have been reported for Taiwan, an Asian country with a national health insurance system (Chang et al., 2009). Collectively, these findings suggest that the pattern of medical care utilization prior to suicide varies across countries due to differences in culture and medical care systems (De Boer et al., 1997). Additionally, a previous study suggested a difference between Asian-Americans and Caucasians in terms of medical care utilization for psychiatric disorders (Hsu et al., 2008). These results, together with ours, suggest the importance of taking cultural background into account when designing suicide prevention programs. In the present study, medical expenditures increased markedly during the final 3 months prior to suicide in all age groups. Additionally, the number of hospitalizations tended to increase as the date of suicide approached. These findings are consistent with those of a previous study that number of hospitalizations increased significantly in the final quarter prior to suicide relative to all other quarters (Deisenhammer et al., 2007). 4.1. Age and gender differences in medical care utilization The Z65 year age group contacted medical care most frequently for chronic disease, such as cardiovascular or musculoskeletal disease, whereas the younger age groups (10–64 years) contacted medical care most frequently for psychiatric disorders. Consistent with this, a previous study conducted in the ROK found
that the most common cause for suicide was physical in the elderly and psychiatric in young adults (Park et al., 2007). Because chronic conditions such as cardiovascular disease, cancer, and diabetes mellitus are associated with suicide in the elderly (Harwood et al., 2006, Juurlink et al., 2004, Quan et al., 2002), elderly patients might contact primary care providers more frequently than mental health services (Luoma et al., 2002). Moreover, in Asian cultures elderly people with depressive disorders tend to present with somatic symptoms, and this may also contribute to their likeliness to contact general practitioners (Chiu et al., 2003). These findings suggest that primary care physicians or other non-psychiatrist physicians may play an important role in suicide prevention in the elderly. In practice, the Gotland study revealed that the number of suicide significantly decreased after offering an educational program on depressive disorders for general practitioners, and the program was found to be more effective in the elderly (Rutz et al., 1989; Rutz et al., 1992). Medical care utilization in the 10–19 year age group did not increase significantly over the year preceding suicide in any disease category except gastrointestinal disease in women. Only 16.7% of people in the 10–19 year age group contacted medical care for psychiatric disorders at least once in the year preceding suicide, as compared to 23–28% of people in other age groups. This suggests that the majority of young people who are at risk for suicide do not contact an appropriate suicide prevention resource, as suggested in previous studies (Hunt et al., 2006, Renaud et al., 2009). In addition, in contrast to other age groups, the 10–19 year age group contacted medical care for psychiatric disorders less frequently as the date of suicide approached, although this trend
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Fig. 2. Medical care utilization over a period of 1 year prior to suicide in women. nPo0.05 vs. 12–10 months prior to suicide; separate paired t-tests for each disease group. The number of medical care utilizations for each disease can surpass those of each subgroup because suicide completers could have contacted the same medical care service more than once in a quarter: (a) women, 10–19 years (n¼88), (b) women, 20–39 years (n¼985), (c) women, 40–64 years (n¼1,256) and (d) women, Z65 years (n¼1,291).
was not statistically significant. These findings suggest that children and adolescents with psychiatric disorders currently have few resources for suicide prevention. To effectively prevent suicide in this age group, community-based strategies may be needed (Renaud et al., 2009), and patients with psychiatric disorders should be considered at high risk for suicide. However, we acknowledge that the sample size in our 10–19 year age group was small, and as a result, we may not have had sufficient statistical power to detect a difference in medical care utilization for psychiatric disorders. Future studies with larger datasets are necessary to confirm this finding. Although men are at higher risk for suicide than women (Isometsa and Lonnqvist, 1998; Levi et al., 2003; Rihmer and Kiss, 2002), this study showed that women contacted medical care in the year preceding suicide more frequently than did men, and that the proportion of women in each disease category was higher than the proportion of men, consistent with previous findings (Chang et al., 2009; Hawton, 2000; Isometsa et al., 1994). In women in the 10–19 year and 20–39 year age groups, gastrointestinal disease increased significantly during the final 3 months prior to suicide. While a small number of gastrointestinal diseases such as gastritis and non-infectious gastroenteritis were diagnosed during the period spanning 12–4 months prior to suicide, irritable bowel syndrome and non-specified
gastrointestinal diseases were diagnosed frequently during the final 3 months prior to suicide. These findings suggest that young women experiencing psychological distress are likely to present with functional gastrointestinal symptoms (Bennett et al., 1998; Koloski et al., 2003). ¨ and Martikainen, 2009; Qin Similar to previous studies (Maki et al., 2003), our findings suggest that low socioeconomic status is associated with increased suicide risk in a multiple logistic regression analysis. However, over 80% of suicide completers contacted medical care services, and there were no notable differences across quintiles in number of visits or medical expenditures. This suggests that low socioeconomic status is a risk factor for suicide but not an obstacle to suicide prevention. 4.2. Strengths and limitations A strength of our study is that we used a large, national representative suicide dataset. However, there are some limitations to be considered. First, injuries during the final 3 months prior to suicide might be intentional and related to fatal suicide attempts. For this reason we excluded data from the final medical care utilization of suicide completers from the analyses. However, in some cases the final medical care utilization may have been related to unintentional injury, in which case excluding these data
J. Cho et al. / Journal of Affective Disorders 146 (2013) 181–188
could have led us to underestimate total medical expenditures. Information about whether the final medical care utilization was related to intentional or unintentional injury would be helpful. Second, inaccuracies in the underlying disease and death statistics data may have led to misclassification bias. However, there is little reason to doubt the accuracy of the data. The Korean National Statistical Office reviews all reported deaths and interviews relatives if necessary to ensure the accuracy of the death statistics data. We also took into account postmortem examination data from the National Police Agency. Even if there were inaccuracies, this would have had little effect on our results because we focused on temporal patterns of medical care utilization over a period of a year prior to suicide rather than on specific diseases. 4.3. Strategies for suicide prevention By investigating age and gender differences in temporal patterns of medical care utilization in suicide completers, we have identified potential approaches for suicide prevention, including age-, gender-, and culture-based strategies. An agebased strategy would involve a community-based approach for young people such as suicide awareness curricula programs and gatekeeper programs for the teachers, school staff, parents and peers (Berman and Jobes, 1995; Kalafat and Elias, 1994; Renaud et al., 2009). Children and adolescents with psychiatric disorders should be considered at high risk for suicide. In the elderly, nonpsychiatrist physicians are in an important position for suicide prevention, as the elderly tend to contact medical care for chronic physical illnesses rather than psychiatric disorders. A genderbased strategy would focus on training medical care workers in early detection of suicide risk and increasing public awareness of psychiatric disorders such as depression in men (Rutz and Rihmer, 2009). Men are at higher risk of suicide than women (Isometsa and Lonnqvist, 1998; Levi et al., 2003; Rihmer and Kiss, 2002) but contact medical care services less frequently than women, and the proportion of men who are diagnosed as having a psychiatric disorder is lower than the proportion of women. Finally, a culture-based approach would seek to circumvent cultural obstacles to medical care utilization for psychiatric disorders (Hsu et al., 2008). The specifics of the approach necessarily will vary by country based on the racial and cultural characteristics of the population. Role of funding source This work was supported by Yonsei University College of Medicine, Seoul, Republic of Korea (Grant number 6-2011-0116).
Conflict of interest None.
Acknowledgments The authors would like to thank the National Statistical Office, National Police Agency, and Health Insurance Review and Assessment Service for providing the data.
Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jad.2012.09.001.
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Research report
Age and gender differences in medical care utilization prior to suicide Jaelim Cho a, Dae Ryong Kang b, Ki Tae Moon c, Mina Suh d, Kyoung Hwa Ha a, Changsoo Kim a,n, Il Suh a, Dong Chun Shin a, Sang Hyuk Jung e a
Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea Division of Clinical Research Affairs, Yonsei University College of Medicine, Seoul, Republic of Korea c Samsung Life Insurance, Seoul, Republic of Korea d National Cancer Center, Koyang, Republic of Korea e Department of Preventive Medicine, School of Medicine, Ewha Womans University, Seoul, Republic of Korea b
a r t i c l e i n f o
abstract
Article history: Received 16 June 2012 Received in revised form 2 September 2012 Accepted 2 September 2012 Available online 25 September 2012
Background: Analysis of temporal patterns of medical care utilization prior to suicide may aid in developing suicide prevention programs. The aim of this study was to investigate age and gender differences in temporal patterns of medical care utilization during 1 year prior to suicide. Methods: Medical care utilization data of all suicide completers in the Republic of Korea whose death occurred in 2004 (7903 men and 3620 women) was used. Differences among the quarters in medical expenditures and number of medical care visits were analyzed using a repeated measures analysis. Total medical expenditures were compared to those of age- and gender-matched controls by multiple logistic regression analysis. Results: Among suicides, 84% (81% in men, 91% in women) contacted medical care in the year prior to suicide. In 10–39 year-old women, the number of medical care visits for gastrointestinal disease increased significantly during the final 3 months prior to suicide. All suicide completers showed that the number of medical care visits for psychiatric disorders increased significantly during the final 3 months with the exception of 10–19 year age group. Total medical expenditures during the year prior to suicide were elevated significantly and associated significantly with suicide risk (OR, 1.20; 95% CI, 1.19–1.21). Limitations: Inaccuracies in the underlying disease and death statistics data may have led to misclassification bias. Conclusions: Medical care utilization increased as the date of suicide approached. There are age and gender differences in medical care utilization in the year prior to suicide. & 2012 Elsevier B.V. All rights reserved.
Keywords: Suicide Prevention Medical care utilization Psychiatric disorder
1. Introduction Suicide is a major public health problem worldwide, representing 1.4% of the Global Burden of disease (World Health Organization, 2005). Suicide rates in developed countries averaged 12 per 100,000 inhabitants in 2005 (OECD, 2008). In the Republic of Korea (ROK), suicide rates since 2003 have been among the highest in developed countries (OECD, 2008), averaging 24.2 per 100,000 inhabitants in 2004 (Statistics Korea, 2004). Compared to those in 2001, suicide rates have increased by 117% in 2010, averaging 31.2 per 100,000 inhabitants (Statistics Korea, 2010).
n Correspondence to: Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seoul, Republic of Korea. Tel.: þ82 2 2228 1880; fax: þ 82 2 392 8133. E-mail address: [email protected] (C. Kim).
0165-0327/$ - see front matter & 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2012.09.001
Psychiatric disorders such as depression are a significant predisposing factor for suicide. Epidemiologic and clinical studies suggested that about 90% of people who complete suicide have preexisting psychiatric disorders (Arsenault-Lapierre et al., 2004, Henriksson et al., 1993). This suggests that effective suicide prevention will involve a medical approach, including early detection and appropriate treatment of patients at risk for suicide. However, differences among countries in terms of culture and health care systems impact the ease of implementation of a medical approach. In Western countries, about a third of depressed patients commit suicide within 12 months of seeking psychiatric help (Hunt et al., 2006). Approximately three quarters of suicide victims contacted primary care providers in the year prior to suicide, while only one third contacted mental health professionals (Luoma et al., 2002). In Asian countries, depressed people are even less likely to contact mental health professionals due to negative cultural views of psychiatric disorders (Chiu et al., 2003; Hsu et al., 2008; Karasz, 2005). Hence, in these countries,
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non-psychiatrist physicians may be in a better position to prevent suicide than are psychiatrists. Epidemiologic research on medical care utilization prior to suicide may aid in developing effective suicide risk assessment and prevention programs. In the present study, national suicide data was used to investigate age and gender differences in temporal patterns of medical care utilization in suicide completers over a period of 1 year prior to suicide. Total medical expenditures of suicide completers were compared to those of a control group.
2. Methods
code according to the International Classification of Diseases, 10th revision (ICD-10); drugs prescribed; medical expenditures; health insurance premiums; and date of visit) are reported to the Health Insurance Review and Assessment Service (HIRA) for review of propriety. Medical care utilization data for suicide completers over a period of 1 year prior to suicide was obtained from HIRA (Park et al., 2008). In cases in which suicide was reported during hospital care or admission, we excluded the final medical care utilization data from the analysis because of the likelihood that this care was related to a fatal suicide attempt. Medical care utilization in suicide completers over a period spanning January 1, 2003 to December 31, 2004, and in controls from July 1, 2003 to June 30, 2004 was examined.
2.1. Study subjects Data on suicides that occurred in 2004 was obtained from the Death Statistics Database of the Korean National Statistical Office and from post-mortem examination findings provided by the Korean National Police Agency. The total number of suicide completers was 11,523 (7903 men and 3620 women). To compare medical expenditures in suicide completers vs. the general population, controls (n¼115,230) from among Koreans who were registered as health insurance subscribers, dependents of health insurance subscribers, or medical aid beneficiaries were randomly selected. Controls were frequency-matched with suicide completers by gender and age group (10–19, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, and Z80 years of age). This study was approved by the Institutional Review Board of Yonsei University Health System (approval number 4-201-0273), Seoul, ROK. 2.2. Medical care utilization As part of the Korean national health insurance program, medical care utilization data for all Koreans (including diagnosis
2.3. Statistical analysis The study sample was divided into four age groups: 10–19, 20–39, 40–64, and Z65 years of age. The individual’s health insurance premium, which in the ROK is based on family income and immovable property, was used as a proxy measure of socioeconomic status. The individual health insurance premium was categorized into quintiles based on premium statistics for all Koreans and assigned beneficiaries of the Medical Aid Program to the lowest quintile group (quintile 1 [Q1]). The area of residence was classified as metropolitan, urban, or rural. Medical expenditures were converted into U.S. dollars on the basis of the exchange rate as of July 1, 2004 (1 U.S. dollar ¼ 1152.50 Korean won). To ascertain underlying diseases, the disease code recorded for each visit was categorized into one of six disease groups: psychiatric disorder (F00-99), musculoskeletal disease (M00-99), cardiovascular disease (I00-99), respiratory disease (J00-99), gastrointestinal disease (K00-93), and injury (S00-99, T00-99). Cancer in the underlying disease group was
Table 1 Characteristics of suicide completers and total medical expenditures and number of medical care utilizations over a period of 1 year prior to suicide. Total (n¼11,523)
Men (n¼ 7903)
Women (n¼ 3620)
pa
Age, n (%) 10–19 years 20–39 years 40–64 years Z65 years
205 2857 5177 3284
Residence, n (%) Metropolitan Urban Rural
4603 (39.95) 5329 (46.25) 1591 (13.81)
3172 (40.14) 3637 (46.02) 1094 (13.84)
1431 (39.53) 1692 (46.74) 497 (13.73)
0.767
Health insurance premium rateb, n (%) Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
4162 2133 1914 1617 1697
2876 1485 1348 1089 1105
1286 648 566 528 592
0.004
Total medical expenditures (US$), mean (SD) Medical care utilizationsc, mean (SD) Total, n (%) Psychiatric disorder, n (%) Musculoskeletal disease, n (%) Cardiovascular disease, n (%) Respiratory disease, n (%) Gastrointestinal disease, n (%) Injury, n (%)
(1.78) (24.79) (44.93) (28.50)
(36.12) (18.51) (16.61) (14.03) (14.73)
1218.47 (2906.23) 11.35 9649 2884 3862 2738 4643 3834 3432
(12.09) (83.74) (25.03) (33.52) (23.76) (40.29) (33.27) (29.78)
117 1872 3921 1993
(1.48) (23.69) (49.61) (25.22)
(36.39) (18.79) (17.06) (13.78) (13.98)
1167.28 (2992.45) 9.91 6369 1645 2290 1707 2905 2440 2282
(11.28) (80.59) (20.81) (28.98) (21.60) (36.76) (30.87) (28.88)
88 985 1256 1291
(2.43) (27.21) (34.70) (35.66)
(35.52) (17.90) (15.64) (14.59) (16.35)
1330.37 (2705.52) 14.49 3280 1239 1572 1031 1738 1394 1150
(13.13) (90.61) (34.23) (43.43) (28.48) (48.01) (38.51) (31.77)
o0.001
0.005 o0.001 o0.001 o0.001 o0.001 o0.001 o0.001 o0.001 0.002
SD: Standard deviation. a
Significance of differences between men and women. Health insurance premium rate was used as a proxy measure of socioeconomic status. Quintile 1 is the lowest and quintile 5 is the highest. Medical aid beneficiaries were categorized as quintile 1. c Medical care utilization based on number of visits; subgroups based on number of patients who contacted the service at least once. b
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not included because few patients (n¼649) were diagnosed with cancer and their use of medical care was relatively modest. To investigate medical care utilization in suicide completers, medical expenditures and the number of medical care visits during four quarterly periods over the year preceding suicide was examined: 12–10 months, 9–7 months, 6–4 months, and 3–0 months prior to suicide. Differences among the quarters in medical expenditures and number of medical care visits were analyzed using a repeated measures analysis (‘proc mixed’ procedure) after adjusting for age, residence, and health insurance premium rate, separately by gender. Interactions were explored by including interaction terms (quarter x age group, quarter x residence, quarter x health insurance premium quintile) in the mixed model. Additionally, differences by underlying disease in the number of medical care visits across quarters were explored after stratification of gender and age groups. To compare Table 2 Quarterly medical expenditures
a
183
total medical expenditures of suicide completers and controls, multiple logistic regression analysis was performed after adjusting for age, gender, residence, and socioeconomic status. SAS version 9.2 (SAS institute, Cary, NC) was used to conduct the statistical analyses. All statistical tests were two-tailed. Statistical significance was set at Po0.05. All analyses were blinded to the identity of suicide completers and controls through the use of randomly generated identification numbers.
3. Results Table 1 summarizes the characteristics of and medical care utilization data for the suicide completers. Among the suicide completers, 83.7% contacted medical care for any reason at least
over a period of 1 year prior to suicide, by gender.
12 to 10 months before suicide Total Age, mean (SD) 10–19 years 49.78 (152.17) 20–39 years 139.38 (496.10) 40–64 years 241.52 (904.44) Z65 years 302.21 (841.80) Residence, mean (SD) Metropolitan 233.83 (828.72) Urban 228.56 (814.89) Rural 224.20 (622.79) Health insurance premium ratec, mean (SD) Quintile 1 240.04 (786.45) Quintile 2 179.77 (702.51) Quintile 3 198.83 (675.43) Quintile 4 237.34 (886.92) Quintile 5 297.11 (949.93) Men Age, mean (SD) 10–19 years 35.29 (87.14) 20–39 years 139.04 (488.13) 40–64 years 219.91 (865.20) Z65 years 303.89 (906.68) Residence, mean (SD) Metropolitan 221.24 (815.36) Urban 212.55 (815.75) Rural 235.40 (690.30) Health insurance premium ratec, mean (SD) Quintile 1 223.15 (771.45) Quintile 2 186.66 (777.65) Quintile 3 199.43 (705.23) Quintile 4 213.54 (796.53) Quintile 5 282.36 (986.17) Women Age, mean (SD) 10–19 years 69.04 (208.60) 20–39 years 140.15 (511.37) 40–64 years 308.97 (1014.65) Z65 years 299.37 (730.40) Residence, mean (SD) Metropolitan 261.72 (857.25) Urban 262.99 (812.23) Rural 199.55 (438.64) Health insurance premium ratec, mean (SD) Quintile 1 277.81 (818.03) Quintile 2 163.99 (488.71) Quintile 3 197.40 (599.11) Quintile 4 286.42 (1048.17) Quintile 5 324.64 (878.45)
9 to 7 months before suicide
6 to 4 months before suicide
3 to 0 months before suicide
p o 0.001b
43.60 170.09 267.00 343.51
(125.87) (667.14) (990.73) (1024.95)
125.40 170.08 317.61 400.84
(600.17) (618.64) (1140.02) (1185.83)
322.35 300.47 417.98 555.48
(1952.60) (1420.87) (1506.50) (1336.57)
o 0.001
251.88 (830.45) 260.24 (960.90) 288.39 (1053.35)
312.00 (1125.44) 284.90 (1016.73) 325.37 (889.80)
435.27 (1659.29) 411.05 (1312.96) 451.46 (1228.76)
0.333
278.56 204.94 216.74 301.83 297.95
332.37 230.81 273.09 330.72 317.56
427.54 365.48 373.51 454.36 532.55
o 0.001
(883.57) (909.90) (773.95) (1169.02) (932.34)
(1196.16) (831.62) (949.00) (1196.82) (810.78)
(1448.97) (1407.05) (1110.57) (1693.13) (1587.80)
o 0.001b 55.10 156.07 243.59 367.11
(150.10) (655.53) (906.07) (1178.37)
114.82 142.49 307.69 394.85
(466.52) (534.41) (1160.49) (1051.23)
451.13 263.42 405.14 551.56
(2539.88) (1472.86) (1585.40) (1315.37)
o 0.001
244.12 (871.12) 250.45 (1013.4) 274.35 (799.31)
294.49 (1108.3) 267.97 (937.22) 333.49 (963.48)
432.30 (1810.08) 379.82 (1280.38) 439.72 (1294.24)
0.236
260.03 195.69 222.32 293.08 296.93
303.37 230.94 257.31 328.25 320.20
421.85 345.89 348.83 447.22 497.36
0.020
(883.63) (713.13) (815.51) (1288.49) (1010.55)
(1082.05) (922.12) (959.81) (1144.94) (852.70)
(1530.57) (1470.04) (1090.38) (1844.65) (1626.25)
o 0.001b 28.32 196.90 340.06 306.81
(81.84) (688.52) (1215.27) (725.54)
139.47 219.90 348.56 411.91
(744.37) (746.63) (1073.48) (1369.40)
151.14 370.81 458.06 561.54
(535.48) (1314.37) (1227.70) (1369.17)
o 0.001
269.07 (732.28) 281.27 (836.95) 319.31 (1465.40)
350.80 (1161.90) 321.30 (1168.90) 307.48 (701.42)
441.87 (1262.94) 478.19 (1378.38) 477.30 (1071.37)
0.561
320.02 226.15 203.46 319.87 299.86
397.24 230.51 310.67 335.83 312.63
440.27 410.36 432.31 469.07 598.25
0.021
(882.37) (1249.43) (665.05) (873.26) (766.09)
(146.84) (573.26) (922.51) (1298.42) (726.77)
(1247.77) (1250.69) (1156.10) (1328.60) (1512.57)
SD: Standard deviation. a
Medical expenditures were converted into U.S. dollars based on the exchange rate on July 1, 2004. Significant differences among quarters (within-group); other P values correspond to comparisons among subgroups (between-group); tested individually by repeated-measures data analysis after adjusting for age, residence, and health insurance premium rate. c Health insurance premium rate was used as a proxy measure of socioeconomic status. Quintile 1 is the lowest and quintile 5 is the highest. Medical aid beneficiaries were categorized as quintile 1. b
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once during the year preceding suicide; 25.0% contacted medical care for psychiatric disorders at least once during the year preceding suicide; and 67.0% contacted medical care for any reason within the final 3 months prior to suicide. Total medical expenditures and number of medical care visits prior to suicide were significantly higher in women than in men. In the year preceding suicide, 20.8% of men and 34.2% of women contacted medical care for psychiatric disorders. Table 2 presents the data on quarterly medical expenditures over the year preceding suicide. In both men and women, medical expenditures increased as the date of suicide approached. In both men and women, medical expenditures in the Z65 year age group were greater than those in other age groups. In men but not women, medical expenditures were greatest in the highest health insurance premium quintile (quintile 5; P¼0.02). There were no statistically significant differences in medical expenditures among residence groups in either men or women. None of the interaction terms were statistically significant in the repeated measures data analysis. Table 3 presents the number of medical care visits over the year preceding suicide. In both men and women, the number of visits increased as the date of suicide approached. In both men and women, the number of medical care visits by the Z65 year age group was significantly greater than that of the other age groups (Po0.001). In men (Po0.001), but not women (P¼ 0.11), the number of medical care visits was greatest in quintile 5. In men (Po0.001), but not women (P¼0.06), the number of medical care visits was greater in rural than in metropolitan or urban residence groups. Fig. 1 shows the number of medical care visits per quarter by underlying disease in men. The Z 65 year age group most frequently contacted medical care for cardiovascular or musculoskeletal disease, whereas all other age groups most frequently contacted medical care for psychiatric disorder or injury. In the 10–19 year age group, the number of visits for respiratory disease also was high. The number of medical care visits for injury increased, but not significantly, in the final quarter prior to suicide relative to the 12–10 month quarter in the 10–19 year age group (P ¼ 0.08). The number of medical care visits for psychiatric disorder or injury increased significantly in the 3–0 month quarter relative to the 12–10 month quarter in the 20–39 year and 40–64 year age groups. The number of medical care visits for all disease categories except musculoskeletal and respiratory disease increased in the 3–0 month quarter relative to the 12–10 month quarter in the Z 65 year age group. Fig. 2 shows the number of medical care visits per quarter by underlying disease in women. Overall the patterns were similar to those observed in men. Additionally, the number of medical care visits for gastrointestinal disease increased in the 3–0 month quarter relative to the 12–10 month quarter in the 10–19 age group (P ¼0.02) and the 20–39 year age group (P¼ 0.02), and the number of medical care visits for injury increased in the 3–0 month quarter relative to the 12–10 month quarter in the Z65 year group (P o0.001). In the multiple logistic regression analysis, after adjustments for age, gender, residence, and socioeconomic status, total medical expenditures were associated significantly with suicide risk (odds ratio per increase of 1000 U.S. dollars ¼1.20; 95% confidence interval¼1.19–1.21). Low socioeconomic status was associated with increased suicide risk (Q5 vs. Q1: OR ¼2.26; 95% CI ¼2.12–2.40, Q5 vs. Q2: OR ¼1.64; 95% CI ¼1.54–1.76, Q5 vs. Q3: OR¼ 1.39; 95% CI ¼1.30–1.49, Q5 vs. Q4: OR¼1.17; 95% CI ¼1.09–1.26). Area of residence (metropolitan vs. urban: OR ¼1.23; 95% CI ¼1.18–1.28, metropolitan vs. rural: OR ¼1.21; 95% CI ¼1.14–1.29) was associated with increased suicide risk.
Table 3 Medical care utilizations
a
over a period of 1 year prior to suicide, by gender.
12 to 10 months before suicide
9 to 7 months before suicide
6 to 4 months before suicide
Total Age, mean (SD) 10–19 years 1.18 (1.89) 1.27 (1.99) 1.49 20–39 years 1.48 (2.20) 1.56 (2.29) 1.61 40–64 years 2.34 (2.96) 2.41 (3.03) 2.57 Z 65 years 4.40 (3.83) 4.48 (3.89) 4.70 Residence, mean (SD) Metropolitan 2.63 (3.28) 2.69 (3.35) 2.81 Urban 2.59 (3.18) 2.69 (3.27) 2.82 Rural 3.23 (3.46) 3.27 (3.47) 3.56 Health insurance premium ratec, mean (SD) Quintile 1 2.65 (3.29) 2.76 (3.43) 2.89 Quintile 2 2.37 (3.05) 2.43 (3.07) 2.53 Quintile 3 2.48 (3.08) 2.51 (3.05) 2.67 Quintile 4 2.89 (3.30) 2.92 (3.40) 3.06 Quintile 5 3.27 (3.54) 3.38 (3.56) 3.63 Men Age, mean (SD) 10–19 years 1.21 (2.06) 1.55 (2.26) 1.61 20–39 years 1.21 (1.95) 1.24 (1.98) 1.28 40–64 years 2.03 (2.73) 2.07 (2.77) 2.22 Z 65 years 4.13 (3.77) 4.26 (3.87) 4.47 Residence, mean (SD) Metropolitan 2.30 (3.05) 2.35 (3.12) 2.45 Urban 2.24 (2.96) 2.34 (3.11) 2.46 Rural 2.89 (3.36) 2.89 (3.27) 3.18 Health insurance premium ratec, mean (SD) Quintile 1 2.24 (3.04) 2.36 (3.22) 2.49 Quintile 2 2.06 (2.78) 2.10 (2.82) 2.12 Quintile 3 2.26 (2.99) 2.24 (2.87) 2.38 Quintile 4 2.50 (3.06) 2.56 (3.15) 2.72 Quintile 5 3.04 (3.49) 3.09 (3.51) 3.34 Women Age, mean (SD) 10–19 years 1.15 (1.65) 0.90 (1.50) 1.33 20–39 years 2.01 (2.55) 2.17 (2.68) 2.25 40–64 years 3.30 (3.41) 3.47 (3.53) 3.66 Z 65 years 4.81 (3.87) 4.82 (3.91) 5.05 Residence, mean (SD) Metropolitan 3.35 (3.63) 3.43 (3.70) 3.61 Urban 3.35 (3.45) 3.45 (3.48) 3.61 Rural 3.97 (3.58) 4.12 (3.73) 4.40 Health insurance premium ratec, mean (SD) Quintile 1 3.57 (3.61) 3.64 (3.71) 3.77 Quintile 2 3.08 (3.50) 3.18 (3.46) 3.45 Quintile 3 2.99 (3.24) 3.16 (3.36) 3.38 Quintile 4 3.68 (3.62) 3.66 (3.75) 3.77 Quintile 5 3.72 (3.60) 3.93 (3.60) 4.16
3 to 0 months before suicide
p
o0.001b (1.95) (2.46) (3.29) (4.13)
o0.001
(3.46) 2.85 (3.55) (3.42) 2.89 (3.52) (3.72) 3.57 (3.72)
o0.001
(3.52) (3.24) (3.24) (3.53) (3.81)
o0.001
(2.22) (2.36) (3.17) (4.08)
1.39 1.68 2.60 4.76
2.91 2.53 2.72 3.19 3.71
(3.56) (3.38) (3.30) (3.69) (3.86)
o0.001b (1.76) (2.11) (2.97) (4.09)
o0.001
(3.19) 2.47 (3.24) (3.19) 2.47 (3.32) (3.56) 3.24 (3.59)
o0.001
(3.26) (2.85) (3.02) (3.29) (3.79)
o0.001
(2.35) (2.07) (2.86) (4.00)
1.30 1.31 2.23 4.53
2.49 2.15 2.41 2.79 3.39
(3.26) (3.08) (3.16) (3.51) (3.73)
o0.001b (2.03) (2.72) (3.79) (4.17)
1.50 2.37 3.77 5.11
(2.18) (2.89) (3.91) (4.17)
o0.001
(3.88) 3.68 (4.03) 0.060 (3.75) 3.78 (3.77) (3.91) 4.29 (3.91) (3.91) (3.83) (3.60) (3.87) (3.79)
3.85 3.41 3.46 4.03 4.31
(3.98) 0.105 (3.85) (3.51) (3.91) (4.03)
SD: Standard deviation. a
Medical care utilization based on number of visits. Significant differences among quarters (within-group); other P values correspond to comparisons among subgroups (between-group); tested individually by repeated-measures data analysis after adjusting for age, residence, and health insurance premium rate. c Health insurance premium rate was used as a proxy measure of socioeconomic status. Quintile 1 is the lowest and quintile 5 is the highest. Medical aid beneficiaries were categorized as quintile 1. b
4. Discussion A previous study found that approximately three quarters of suicide completers contacted primary care professionals in the year prior to suicide, whereas approximately one third contacted mental health services (Luoma et al., 2002). In Western countries with national health insurance systems, such as Denmark, 92.6% of suicide completers contacted general practitioners and 42.2% had a psychiatric admission in the year prior to suicide
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Fig. 1. Medical care utilization over a period of 1 year prior to suicide in men. nPo0.05 vs. 12–10 months prior to suicide; separate paired t-tests for each disease group. The number of medical care utilizations for each disease can surpass those of each subgroup because suicide completers could have contacted the same medical care service more than once in a quarter: (a) women, 10–19 years (n¼117), (b) women, 20–39 years (n¼1,872), (c) women, 40–64 years (n¼3,921) and (d) women, Z65 years (n¼1,993).
(Andersen et al., 2000). In the present study, 83.7% of Korean suicide completers contacted medical care at least once during the year preceding suicide, but only 25.0% contacted medical care for psychiatric disorders. Similar findings have been reported for Taiwan, an Asian country with a national health insurance system (Chang et al., 2009). Collectively, these findings suggest that the pattern of medical care utilization prior to suicide varies across countries due to differences in culture and medical care systems (De Boer et al., 1997). Additionally, a previous study suggested a difference between Asian-Americans and Caucasians in terms of medical care utilization for psychiatric disorders (Hsu et al., 2008). These results, together with ours, suggest the importance of taking cultural background into account when designing suicide prevention programs. In the present study, medical expenditures increased markedly during the final 3 months prior to suicide in all age groups. Additionally, the number of hospitalizations tended to increase as the date of suicide approached. These findings are consistent with those of a previous study that number of hospitalizations increased significantly in the final quarter prior to suicide relative to all other quarters (Deisenhammer et al., 2007). 4.1. Age and gender differences in medical care utilization The Z65 year age group contacted medical care most frequently for chronic disease, such as cardiovascular or musculoskeletal disease, whereas the younger age groups (10–64 years) contacted medical care most frequently for psychiatric disorders. Consistent with this, a previous study conducted in the ROK found
that the most common cause for suicide was physical in the elderly and psychiatric in young adults (Park et al., 2007). Because chronic conditions such as cardiovascular disease, cancer, and diabetes mellitus are associated with suicide in the elderly (Harwood et al., 2006, Juurlink et al., 2004, Quan et al., 2002), elderly patients might contact primary care providers more frequently than mental health services (Luoma et al., 2002). Moreover, in Asian cultures elderly people with depressive disorders tend to present with somatic symptoms, and this may also contribute to their likeliness to contact general practitioners (Chiu et al., 2003). These findings suggest that primary care physicians or other non-psychiatrist physicians may play an important role in suicide prevention in the elderly. In practice, the Gotland study revealed that the number of suicide significantly decreased after offering an educational program on depressive disorders for general practitioners, and the program was found to be more effective in the elderly (Rutz et al., 1989; Rutz et al., 1992). Medical care utilization in the 10–19 year age group did not increase significantly over the year preceding suicide in any disease category except gastrointestinal disease in women. Only 16.7% of people in the 10–19 year age group contacted medical care for psychiatric disorders at least once in the year preceding suicide, as compared to 23–28% of people in other age groups. This suggests that the majority of young people who are at risk for suicide do not contact an appropriate suicide prevention resource, as suggested in previous studies (Hunt et al., 2006, Renaud et al., 2009). In addition, in contrast to other age groups, the 10–19 year age group contacted medical care for psychiatric disorders less frequently as the date of suicide approached, although this trend
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Fig. 2. Medical care utilization over a period of 1 year prior to suicide in women. nPo0.05 vs. 12–10 months prior to suicide; separate paired t-tests for each disease group. The number of medical care utilizations for each disease can surpass those of each subgroup because suicide completers could have contacted the same medical care service more than once in a quarter: (a) women, 10–19 years (n¼88), (b) women, 20–39 years (n¼985), (c) women, 40–64 years (n¼1,256) and (d) women, Z65 years (n¼1,291).
was not statistically significant. These findings suggest that children and adolescents with psychiatric disorders currently have few resources for suicide prevention. To effectively prevent suicide in this age group, community-based strategies may be needed (Renaud et al., 2009), and patients with psychiatric disorders should be considered at high risk for suicide. However, we acknowledge that the sample size in our 10–19 year age group was small, and as a result, we may not have had sufficient statistical power to detect a difference in medical care utilization for psychiatric disorders. Future studies with larger datasets are necessary to confirm this finding. Although men are at higher risk for suicide than women (Isometsa and Lonnqvist, 1998; Levi et al., 2003; Rihmer and Kiss, 2002), this study showed that women contacted medical care in the year preceding suicide more frequently than did men, and that the proportion of women in each disease category was higher than the proportion of men, consistent with previous findings (Chang et al., 2009; Hawton, 2000; Isometsa et al., 1994). In women in the 10–19 year and 20–39 year age groups, gastrointestinal disease increased significantly during the final 3 months prior to suicide. While a small number of gastrointestinal diseases such as gastritis and non-infectious gastroenteritis were diagnosed during the period spanning 12–4 months prior to suicide, irritable bowel syndrome and non-specified
gastrointestinal diseases were diagnosed frequently during the final 3 months prior to suicide. These findings suggest that young women experiencing psychological distress are likely to present with functional gastrointestinal symptoms (Bennett et al., 1998; Koloski et al., 2003). ¨ and Martikainen, 2009; Qin Similar to previous studies (Maki et al., 2003), our findings suggest that low socioeconomic status is associated with increased suicide risk in a multiple logistic regression analysis. However, over 80% of suicide completers contacted medical care services, and there were no notable differences across quintiles in number of visits or medical expenditures. This suggests that low socioeconomic status is a risk factor for suicide but not an obstacle to suicide prevention. 4.2. Strengths and limitations A strength of our study is that we used a large, national representative suicide dataset. However, there are some limitations to be considered. First, injuries during the final 3 months prior to suicide might be intentional and related to fatal suicide attempts. For this reason we excluded data from the final medical care utilization of suicide completers from the analyses. However, in some cases the final medical care utilization may have been related to unintentional injury, in which case excluding these data
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could have led us to underestimate total medical expenditures. Information about whether the final medical care utilization was related to intentional or unintentional injury would be helpful. Second, inaccuracies in the underlying disease and death statistics data may have led to misclassification bias. However, there is little reason to doubt the accuracy of the data. The Korean National Statistical Office reviews all reported deaths and interviews relatives if necessary to ensure the accuracy of the death statistics data. We also took into account postmortem examination data from the National Police Agency. Even if there were inaccuracies, this would have had little effect on our results because we focused on temporal patterns of medical care utilization over a period of a year prior to suicide rather than on specific diseases. 4.3. Strategies for suicide prevention By investigating age and gender differences in temporal patterns of medical care utilization in suicide completers, we have identified potential approaches for suicide prevention, including age-, gender-, and culture-based strategies. An agebased strategy would involve a community-based approach for young people such as suicide awareness curricula programs and gatekeeper programs for the teachers, school staff, parents and peers (Berman and Jobes, 1995; Kalafat and Elias, 1994; Renaud et al., 2009). Children and adolescents with psychiatric disorders should be considered at high risk for suicide. In the elderly, nonpsychiatrist physicians are in an important position for suicide prevention, as the elderly tend to contact medical care for chronic physical illnesses rather than psychiatric disorders. A genderbased strategy would focus on training medical care workers in early detection of suicide risk and increasing public awareness of psychiatric disorders such as depression in men (Rutz and Rihmer, 2009). Men are at higher risk of suicide than women (Isometsa and Lonnqvist, 1998; Levi et al., 2003; Rihmer and Kiss, 2002) but contact medical care services less frequently than women, and the proportion of men who are diagnosed as having a psychiatric disorder is lower than the proportion of women. Finally, a culture-based approach would seek to circumvent cultural obstacles to medical care utilization for psychiatric disorders (Hsu et al., 2008). The specifics of the approach necessarily will vary by country based on the racial and cultural characteristics of the population. Role of funding source This work was supported by Yonsei University College of Medicine, Seoul, Republic of Korea (Grant number 6-2011-0116).
Conflict of interest None.
Acknowledgments The authors would like to thank the National Statistical Office, National Police Agency, and Health Insurance Review and Assessment Service for providing the data.
Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jad.2012.09.001.
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