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A new injury mortality study, published by Lancet's EClinicalMedicine, exposes a mental health crisis that has unfolded across the United States over the past two decades, with study data having direct implications for suicide prevention efforts.

Suicides by drug self-intoxication are more difficult to determine for medical examiners and coroners in the U.S. than suicides that result from behaviorally and forensically obvious methods, such as death by firearm. Measuring self-injury mortality (SIM)—suicides plus estimated "nonsuicide" drug self-intoxication deaths—circumvents misclassification and more accurately accounts for fatal self-injuries.

Using this broader definition of suicide paints a drastically different picture. Counting suicides alone as the measure of fatal self-injury in the U.S. emphasizes only a high rate in western states. Yet measuring self-injury mortality, this new study describes a burgeoning national mental health crisis that actually encompasses all four major geographic regions (Northeast, Midwest, South and West).

Leading the study is Ian Rockett, Ph.D., of West Virginia University and the University of Rochester Medical Center. Co-investigators include URMC's Eric D. Caine, M.D., and Hilary Connery, M.D., Ph.D., of McLean Hospital and Harvard Medical School.

"Despite victims sharing many common risk factors, suicide and drug overdose deaths tend to be treated separately in the scientific literature, media, health care system, and by funding agencies and prevention programs," Rockett said. "Among these risk factors are unemployment, family discord, unmanaged and mismanaged physical pain, and various psychiatric disorders that include alcohol and other substance use disorders."

Rockett emphasized that, "While most people dying by overdose may not have intended to die, they were engaging in repetitive, intentional, self-injurious behaviors that they understood markedly increased their chances of dying prematurely. Calling these deaths 'accidents' (the forensic classification most often used in the U.S.) or 'unintentional' (the term used by the Centers for Disease Control and Prevention) mischaracterizes what occurred, even if it is consistent with the classifications used by medical examiners and coroners."

The research team tapped into cause-of-death data for all 50 states and Washington, D.C. from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research. After broadening the SIM definition, they found the national annual average percentage change in the SIM rate was 4.3% versus 1.8% for the suicide rate.

Early data indicate the Covid-19 pandemic is exacerbating the situation.

"Opioid and other drug-overdose deaths continue to rise in spite of medical efforts to make life-saving medications for opioid use disorder available to patients and communities," Connery said. "Many persons suffering drug use disorders become hopeless—they relapse frequently, continue to experience relationship losses, health consequences, and economic instability, and they frequently suffer other mental disorders, such as depression, post-traumatic stress disorder, and other anxiety disorders. We know that people with addiction have 10 times the rate of suicide compared to those without addiction."

Caine underscored that this work has major implications for future suicide prevention efforts. It is especially important to deploy programs "upstream" when groups and individuals can be helped with fundamentally distressing problems long before they ever become suicidal, he said. Recognizing a patient's full story -- risk factors, long-term health history, socioeconomic experiences -- is key to providing lifesaving, comprehensive care.

"The ultimate goal must be to prevent premature death," Caine said, "whether by suicide or fatal overdoses, or from the many systemic medical conditions that arise from the same group of risky, damaging behaviors."