Young people enrolled in Medicaid who commit suicide are disproportionately female, younger, and more likely to die by hanging, compared with non-Medicaid youth, results of a large, observational, population-based study suggest.

Nearly 40% of young people in the study who died by suicide were covered by Medicaid, according to study lead author Cynthia A. Fontanella, PhD, of the department of psychiatry and behavioral health at the Ohio State University, Columbus. Those findings, in addition to those of other studies indicating that youth enrolled in Medicaid endure more maltreatment and poverty-related adversity, suggest a need for health care delivery systems to develop “trauma-informed approaches” and implement them, Dr. Fontanella and her coauthors reported in the American Journal of Preventive Medicine.

“Effective suicide screening of enrollees could substantially decrease suicide mortality in the United States,” they wrote.

Dr. Fontanella and her coauthors reviewed death certificate data from the 16 most populous states to identify all youth aged 10-18 who committed suicide during 2009-2013. They identified 4,045 deaths from suicide based on state death certificate data in California, Florida, Georgia, Illinois, Indiana, Massachusetts, Michigan, Minnesota, New York, North Carolina, Ohio, Oregon, Texas, Virginia, Washington, and Wisconsin. To identify the subset of youth who were enrolled in Medicaid, they used Social Security numbers to link the death certificate data to data from a Medicaid database.

Out of 4,045 youth suicide deaths that occurred during that time period, 39% were among youth enrolled in Medicaid, the investigators found.

Although the overall suicide rate did not differ significantly between the Medicaid and non-Medicaid groups, investigators said they did identify significant differences in age and sex subgroups. Specifically, those in the Medicaid group had a 28% increased risk of suicide among the 10- to 14-year age subgroup, and a 14% increased risk of suicide among females, the findings showed. Moreover, the risk of death by hanging was 26% greater among the Medicare youth.

Dr. Fontanella and her coauthors reported several limitations. One is that the findings might not be generalizable to all 50 states. Also, they said, because suicide is underreported as a cause of death, the prevalence of suicide found in the study might have been underreported.

Nevertheless, the findings confirm the importance of Medicaid as a “boundaried” setting for efforts targeting youth suicide prevention, Dr. Fontanella and her associates wrote. Boundaried populations are those defined by a service setting or organizational function. In other words, they wrote, findings based on an analysis of service use patterns captured in Medicaid claims “could prove helpful in identifying periods known to be associated with heightened suicide risk, such as that immediately following discharge from inpatient psychiatric care.”

The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force has recommended that those populations be targeted for research on interventions designed to reduce suicide deaths, Dr. Fontanella and her coauthors wrote.

This is the first-ever study to evaluate suicide-related mortality among Medicaid-covered youth, the investigators said. Previous studies of suicide in Medicaid have focused on adults – specifically those in the Veterans Health Administration, specific state Medicaid programs, or health maintenance organization networks.

The American Foundation for Suicide Prevention and the National Institutes of Health funded the study. Dr. Fontanella and her coauthors reported no other financial conflicts of interest.

SOURCE: Fontanella CA et al. Am J Prev Med. 2019 Jan 17. doi: 10.1016/j.amepre.2018.10.008.