Suspected Suicide Attempts by Self-Poisoning Among Persons Aged 10–19 Years During the COVID-19 Pandemic

United States, 2020-2022

Rita Farah, PhD; Saumitra V. Rege, PhD; Ryan J. Cole, MD; Christopher P. Holstege, MD

Morbidity and Mortality Weekly Report. 2023;72(16):426-430.

Abstract and Introduction

Introduction

The World Health Organization declared COVID-19 a global pandemic on March 11, 2020.^[1] As strategies to mitigate the pandemic were implemented, concerns were raised that the containment efforts through quarantine and social distancing practices were negatively affecting the mental and physical health of children and adolescents.^[2] Suicide is a growing public health problem in the United States. In 2020, suicide was the second leading cause of death among persons aged 10–14 years and the third leading cause among those aged 15–24 years.^[3] The National Poison Data System (NPDS) database was used to examine trends in suspected suicide attempts by self-poisoning among persons aged 10–19 years before and during the COVID-19 pandemic. Compared with 2019 (prepandemic), during 2021, the overall rate of suspected suicide attempts by self-poisoning increased by 30.0% (95% CI = 28.6%–30.9%), rates among children aged 10–12 years, adolescents aged 13–15 years, and females increased 73.0% (67.4%–80.0%), 48.8% (46.7%–50.9%), and 36.8% (35.4%–38.2%), respectively, and these trends continued into the third quarter of 2022. Substances most frequently involved in overdoses were acetaminophen, ibuprofen, sertraline, fluoxetine, and diphenhydramine. Acetaminophen-involved overdoses increased 71% (67.4%–74.9%) in 2021 and 58.0% (54.5%–61.6%) in 2022. Diphenhydramine-involved overdoses increased 24.2% (19.9%–28.7%) in 2021 and 35.8% (31.2%–40.5%) in 2022. A comprehensive public health approach to suicide prevention, focused on children and adolescents and involving a partnership between families, school teachers, mental health professionals, and public health leadership is needed. The 9-8-8 Suicide and Crisis Lifeline provides crisis support for persons experiencing mental health–related distress and assists community members who are concerned about persons experiencing a mental health crisis.*

A retrospective review of the NPDS database, the data warehouse for all 55 U.S. poison control centers (PCCs), during January 1, 2016–September 30, 2022, was conducted. Each PCC submits, in near real-time, deidentified case data to NPDS after providing necessary poison exposure management and information services to callers from the general public and health care providers. Closed cases coded by specialists in poison information as intentional suspected suicide involving persons aged 10–19 years were included. The NPDS coding manual specifies that cases coded as intentional suspected suicide include suspected suicide attempts as well as intentional self-harm cases. Multiple substances (multiple exposures) can be reported for each call. Cases classified as a confirmed nonexposure (reliable and objective evidence that exposure to a pharmaceutical or nonpharmaceutical agent never occurred) and those involving persons of unknown age were excluded. Reported numeric age was used to manually compute three age group categories (10–12, 13–15, and 16–19 years). Trends in the frequency and rates of suspected suicide attempts by self-poisoning (suspected suicide attempts per 100,000 persons aged 10–19 years)^[4] were analyzed using Poisson regression methods and stratified by age group, sex, source of calls made to PCCs, level of care, substance involved, and clinical outcome. To assess the potential impact of the pandemic, yearly changes in suspected suicide attempt rates were compared between 2016 and 2022. The year 2019, the last calendar year before the pandemic, was considered the reference year. Monthly trends in suspected suicide attempt calls were plotted for January 2019–September 2022. Monthly counts of suspected suicide attempts and overall human exposure calls^† during the pandemic were compared with their corresponding 2019 reference months. Interpretation of trends in suspected suicide attempts considered the potential impact of changes in the monthly overall human exposure calls to PCCs. Data were analyzed using SAS statistical software (version 9.4; SAS Institute). Percent changes are reported with the corresponding 95% CIs. The study was conducted on deidentified NPDS data and was exempt from comprehensive Institutional Review Board review.

The yearly trend of suspected suicide attempt rates showed a sharp increase in 2021 compared with previous years. From 2019 to 2021, the overall number of human exposure calls to PCCs decreased 3.1%, from 2,148,141 to 2,080,917 (p<0.001); however, suspected suicide attempt calls increased (29.5%) in 2021 compared with prepandemic rates (2019). Calls to PCCs regarding suspected suicide attempts increased for both males and females (except between 2018 and 2019) and across all age groups (Table). In 2021, a statistically significant increase in the rate of suspected suicide attempts occurred among children aged 10–12 years (73.0%), adolescents aged 13–15 years (48.8%), and females (36.8%); this increase continued into September 2022. Call rates made to PCCs from health care facilities (29.0%) and the general public (33.0%) increased during 2021 as did admissions to psychiatric facilities (29.3%).

In 2021 and 2022, an analysis of substances involved in suspected suicide attempts found acetaminophen, ibuprofen, sertraline, fluoxetine, and diphenhydramine to be the substances most frequently involved, with a significant increase in acetaminophen- (71.0% and 58.0%, respectively) and diphenhydramine- (24.2% and 35.8%, respectively) involved overdoses compared with those in 2019. Overdoses involving ibuprofen (35.1%), fluoxetine (44.2%), and sertraline (32.3%) increased significantly in 2021 compared with prepandemic rates (2019) (Figure 1). Single-substance cases accounted for 430,051 (68%) suspected suicide attempt calls; acetaminophen (excluding combinations with other substances) was the most frequent single substance involved in suspected suicide attempts, accounting for 57,768 (13.4%) of single-substance cases.

(Enlarge Image)

Figure 1.

Rates of suspected suicide attempts by self-poisoning among persons aged 10–19 years reported to U.S. poison control centers, by substance*^,† — United States, January 1, 2016–September 30, 2022^§
*Trends in rates of suspected suicide attempts involving acetaminophen, ibuprofen, sertraline, and fluoxetine were statistically significant during 2016–2022 (reference year: 2019).
^†Trends in rates of suspected suicide attempts involving diphenhydramine were statistically significant during 2020–2022 (reference year: 2019).
^§Annualized rates were used to present data during January 1, 2019–September 30, 2022.

The monthly variation in suspected suicide attempt–related calls among persons aged 10–19 years increased during school months, with a sharp increase in September, and a decline during summer months (June and July) and winter breaks (December) (Figure 2). During the period when the national lockdown was implemented (April–May 2020), suspected suicide attempt–related calls were lower compared with those during the same months in 2019, 2021, and 2022 (p<0.001); the overall human exposure calls did not decrease during this same period. However, during June 2020–February 2022, monthly suspected suicide attempt–related calls were significantly higher than they were during the corresponding months of 2019 (with the exception of March–June 2020, when suspected suicide attempt–related calls were similar to those in 2019). The monthly overall human exposure calls to PCCs significantly declined beginning in August 2020 compared with the corresponding months during 2019 (Supplementary Table, https://stacks.cdc.gov/view/cdc/126401).

(Enlarge Image)

Figure 2.

Number of monthly suspected suicide attempts by self-poisoning among persons aged 10–19 years reported to U.S. poison control centers — United States, January 1, 2019–September 30, 2022

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Abstract and Introduction
Discussion
References
Sidebar

*https://www.cdc.gov/suicide/prevention/index.html
^†Total number of calls made to PCCs regarding actual or suspected human contact with any substance that was ingested, inhaled, absorbed, applied to, or injected into the body, regardless of toxicity or clinical manifestation. PCCs receive calls related to human and animal exposures.

Table. Frequency and rates* of suspected suicide attempts by self-poisoning among persons aged 10–19 years reported to U.S. poison control centers, by selected characteristics — National Poison Data System, United States, January 1, 2016–September 30, 2022
Characteristic	No.^† (rate)							% Rate change (95% CI)^†
Year	2016	2017	2018	2019	2020	2021	2022	2016	2017	2018	2020	2021	2022^†
Overall	79,984^§ (189.3)	87,553^§ (206.7)	88,227^§ (208.1)	88,535(209.2)	93,265^§(220.7)	114,664(272.0)	104,888^§(248.6)	−10.1 (−10.5 to −8.8)^§	−1.2 (−3.0 to −0.2)^§	−0.5 (−1.4 to 0.5)	5.4 (4.4 to 6.4)^§	30.0 (28.6 to 30.9)^§	18.6 (17.7 to 19.7)^§
Age group, yrs
10–12	3,450^§ (27.5)	4,286^§ (33.9)	4,951^§ (39.0)	5,473(43.4)	6,423^§(51.5)	9,396^§(76.1)	8,171^§(66.1)	−37.0 (−39.6 to −34.2)^§	−21.9 (−24.9 to −18.7)^§	−10.0 (−13.3 to 6.4)^§	17.8 (13.6 to 22.1)^§	73.0 (67.4 to 80.0)^§	50.4 (45.4 to 55.7)^§
13–15	30,572^§ (243.5)	33,207^§ (265.0)	33,278^§ (264.2)	34,007(268.8)	38,614^§(303.4)	50,844^§(397.6)	45,944^§(361.6)	−9.8 (−11.2 to −8.4)^§	−2.0 (−3.4 to −0.5)^§	−2.0 (−3.5 to −0.5)^§	13.2 (11.6 to 14.9)^§	48.8 (46.7 to 50.9)^§	34.9 (33.0 to 36.8)^§
16–19	45,810^§ (267.2)	49,914^§ (290.3)	49,848^§ (291.0)	48,902(286.4)	48,075^§(282.1)	54,249^§(318.7)	50,617^§(295.7)	−6.5 (−7.3 to −5.3)^§	1.8 (0.5 to 3.0)^§	1.8 (0.5 to 3.1)^§	−1.7 (−2.9 to −0.4)^§	11.1 (9.7 to 12.4)^§	3.4 (2.1 to 4.7)^§
Sex
Female	62,915^§ (303.3)	68,995^§ (332.9)	67,944 (327.4)	68,045(328.5)	73,270^§(354.2)	92,962^§(450.1)	83,131^§(402.6)	−7.6 (−8.4 to −6.6)^§	1.4 (0.3 to 0.8)^§	−0.3 (−1.3 to 0.8)	7.7 (6.6 to 8.9)^§	36.8 (35.4 to 38.2)^§	22.3 (21.1 to 23.6)^§
Male	16,969^§ (78.9)	18,452^§ (85.3)	20,174 (93.2)	20,362(94.3)	19,848^§(92.0)	21,467^§(99.7)	21,480^§(99.7)	−16.6 (−8.2 to −14.8)^§	−9.5 (−11.3 to −7.7)^§	−1.1 (−3.0 to 0.9)	−2.5 (−4.4 to −0.6)^§	5.6 (3.6 to 7.6)^§	5.6 (3.6 to 9.4)^§
Source of call
Health care facilities	64,137^§ (151.7)	70,986 (167.6)	71,690^§ (169.0)	71,061(167.9)	73,175^§(173.2)	91,522^§(216.9)	84,484^§(200.3)	−9.7 (−10.7 to −8.2)^§	−0.2 (−1.2 to 0.9)	0.8 (−0.3 to 1.8)	3.0 (2.0 to 4.1)^§	29.0 (27.7 to 30.3)	19.0 (17.7 to 20.2)
General public	15,688^§ (37.1)	16,390^§ (38.7)	16,397^§ (38.7)	17,321(40.9)	19,939^§(47.2)	22,997^§(54.5)	20,288^§(48.1)	−9.4 (−11.4 to −7.5)^§	−5.5 (−7.5 to −3.4)^§	−5.5 (−7.5 to −3.4)^§	15.2 (12.7 to 17.6)^§	33.0 (30.4 to 35.6)^§	17.3 (14.9 to 19.7)^§
Level of care
Admission to critical care unit	13,632^§ (32.3)	14,389^§ (34.0)	13,655^§ (32.2)	13,095(30.9)	13,105(31.0)	14,114^§(33.4)	11,879^§(28.0)	4.2(1.6 to 6.7)^§	9.8(7.3 to 12.5)^§	4.2(1.7 to 6.7)^§	0.1(−0.3 to 2.6)	8.0(5.4 to 10.6)^§	−9.2 (−11.4 to −6.9)^§
Admission to psychiatric facility	25,186^§ (59.6)	28,515^§ (67.3)	29,771^§ (70.2)	30,485(72.0)	31,636^§(74.9)	39,354^§(93.3)	35,924^§(85.2)	−17.4 (−18.8 to −16.0)^§	−6.6 (−8.1 to −5.0)^§	−2.5 (−4.0 to −0.9)^§	3.8 (2.2 to 5.5)^§	29.3 (27.3 to 31.2)^§	18.0 (16.2 to 19.9)^§
Clinical outcome
Major effect^¶	1,919^§ (4.5)	2,269^§ (5.3)	2,545^§ (6.0)	2,980^§(7.4)	3,139^§ (7.4)	3,757^§(8.9)	3,501^§(8.3)	−35.7 (−39.3 to −31.9)^§	−14.0 (−28.0 to −19.7)^§	−14.8 (−19.2 to −10.2)^§	5.3 (0.2 to 10.7)^§	26.1 (20.2 to 32.4)^§	17.6 (12.0 to 23.4)^§
Death**	37^§ (0.9)	33^§ (0.8)	51 (0.12)	59 (0.14)	55 (0.13)	65 (0.15)	59 (0.14)	−37.3 (−59.4 to −42.4)^§	−44.1 (−63.5 to −14.4)^§	13.7 (−40.7 to 25.6)	−6.8 (−35.6 to 34.7)	10.3 (−22.4 to 57.0)	0.1 (−30.2 to 43.6)
Substance^††
Acetaminophen	10,178^§ (24.1)	11,397^§ (26.9)	11,709^§ (27.6)	12,552(29.6)	15,141^§(35.8)	21,443^§(50.9)	19,805^§(46.8)	−18.9 (−21.0 to −16.8)^§	−9.3 (−11.6 to −7.0)^§	−6.9 (−9.3 to −4.5)^§	20.7 (17.9 to 23.6)^§	71.0 (67.4 to 74.9) ^§	58.0 (54.5 to 61.6)^§
Ibuprofen	11,851^§ (28.0)	13,015^§ (30.7)	13,162^§ (31.0)	13,353(31.5)	13,756^§(32.5)	18,017^§(42.7)	15,513^§(36.7)	−11.3 (−13.4 to −9.0)^§	−2.6 (−4.9 to −0.2)^§	−1.6 (−3.9 to −0.9)^§	3.1 (0.7 to 5.6)^§	35.1 (32.1 to 38.2)^§	16.3 (13.6 to 19.0)^§
Sertraline	4,366^§ (10.3)	5,079^§ (12.0)	5,488^§ (12.9)	5,791(13.7)	6,394^§(15.1)	7,651^§(18.1)	6,896^§(16.3)	−24.6 (−27.5 to −21.6)^§	−12.4 (−15.4 to −9.0)^§	−5.4 (−8.8 to −1.8)^§	10.5 (6.6 to 14.5)^§	32.3 (27.9 to 36.9)^§	19.2 (15.1 to 23.5)^§
Fluoxetine	3,935^§ (9.3)	4,518^§ (10.7)	4,943^§ (11.7)	592^§(12.5)	5,698^§(13.5)	7,620^§ (18.1)	6,812^§ (16.1)	−25.7 (−28.7 to −22.5)^§	−14.7 (−18.0 to −11.3)^§	−6.7 (−10.3 to −3.0)^§	7.7 (3.8 to 11.9)^§	44.2 (39.2 to 49.4)^§	28.9 (24.3 to 33.6)^§
Diphenhydramine	5,191^§ (12.3)	5,771^§ (13.6)	5,551^§ (13.1)	5,596(13.2)	5,864^§(13.8)	6,940^§(16.5)	7,587^§ (18.0)	−7.2 (−10.7 to −3.7)^§	3.1 (−0.7 to 6.9)	−0.1 (−4.6 to 2.8)	4.8 (1.1 to 8.8)^§	24.2 (19.9 to 28.7)^§	35.8 (31.2 to 40.5)^§

*Attempts per 100,000 population based on U.S. Census Bureau's midyear census.
^†Annualized rates were used to present data during January 1, 2019–September 30, 2022 (reference year: 2019).
^§Statistically significant.
^¶Symptoms resulting from exposures that were life-threatening or resulted in significant residual disability or disfigurement.
**Direct and indirect death reports were included.
^††Generic codes: acetaminophen alone (0072705, 0072707, and 0072000), ibuprofen (0234003), sertraline (310014), fluoxetine (0310011), and diphenhydramine alone (0159900, 0159000, and 0159850).