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Original Investigation
October 2016

Self-injury Mortality in the United States in the Early 21st CenturyA Comparison With Proximally Ranked Diseases

Author Affiliations
  • 1Department of Epidemiology, School of Public Health, West Virginia University, Morgantown
  • 2Injury Control Research Center, West Virginia University, Morgantown
  • 3Department of Biostatistics, School of Public Health, West Virginia University, Morgantown
  • 4Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
  • 5School of Nursing, Columbia University, New York, New York
  • 6Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand
  • 7Centre for Population Health Research, Curtin University, Perth, Australia
  • 8Pacific Institute for Research and Evaluation, Calverton, Maryland
  • 9Department of Emergency Medicine, New York University School of Medicine, New York
  • 10Office of the Medical Investigator, Department of Pathology, University of New Mexico School of Medicine, Albuquerque
  • 11Department of Epidemiology and Public Health, University of Maryland, Baltimore
  • 12Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
  • 13Injury Control Research Center for Suicide Prevention, University of Rochester Medical Center, Rochester, New York
JAMA Psychiatry. 2016;73(10):1072-1081. doi:10.1001/jamapsychiatry.2016.1870
Key Points

Question  What are the differences in the patterns of US self-injury mortality compared with 3 proximally ranked top 10 causes of death?

Findings  In this study, the crude mortality rate of self-injury mortality increased rapidly from 1999 to 2014, ultimately converging with the diabetes rate and surpassing the influenza and pneumonia and kidney disease rates, and the proportion of women dying of self-injury mortality increased dramatically. Additionally, more than 70% of self-injury decedents were younger than 55 years vs less than 12% of counterparts dying of diabetes, influenza and pneumonia, or kidney disease.

Meaning  Accurate characterization, measurement, and monitoring of self-injury mortality will be essential for etiologic understanding and for evaluating preventive and therapeutic interventions.


Importance  Fatal self-injury in the United States associated with deliberate behaviors is seriously underestimated owing to misclassification of poisoning suicides and mischaracterization of most drug poisoning deaths as “accidents” on death certificates.

Objective  To compare national trends and patterns of self-injury mortality (SIM) with mortality from 3 proximally ranked top 10 causes of death: diabetes, influenza and pneumonia, and kidney disease.

Data, Setting, and Participants  Underlying cause-of-death data from 1999 to 2014 were extracted for this observational study from death certificate data in the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research online databases. Linear time trends were compared by negative binomial regression with a log link function. Self-injury mortality was defined as a composite of suicides by any method and estimated deaths from drug self-intoxication whose manner was an “accident” or was undetermined.

Main Outcomes and Measures  Mortality rates and ratios, cumulative mortality in individuals younger than 55 years, and years of life lost in 2014.

Results  There were an estimated 40 289 self-injury deaths in 1999 and 76 227 in 2014. Females comprised 8923 (22.1%) of the deaths in 1999 and 21 950 (28.8%) of the 76 227 deaths in 2014. The estimated crude rate for SIM increased 65% between 1999 and 2014, from 14.4 to 23.9 deaths per 100 000 persons (rate ratio, 1.03; 95% CI, 1.03-1.04; P < .001). The SIM rate continuously exceeded the kidney disease mortality rate and surpassed the influenza and pneumonia mortality rate by 2006. By 2014, the SIM rate converged with the diabetes mortality rate. Additionally, the SIM rate was 1.8-fold higher than the suicide rate in 2014 vs 1.4-fold higher in 1999. The male-to-female ratio for SIM decreased from 3.7 in 1999 to 2.6 in 2014 (male by year: rate ratio, 0.98; 95% CI, 0.97-0.98; P < .001). By 2014, SIM accounted for 32.2 and 36.6 years of life lost for male and female decedents, respectively, compared with 15.8 and 17.3 years from diabetes, 15.0 and 16.6 years from influenza and pneumonia, and 14.5 and 16.2 years from kidney disease.

Conclusions and Relevance  The burgeoning SIM rate has converged with the mortality rate for diabetes, but there is a 6-fold differential in the proportion of SIM vs diabetes deaths involving people younger than 55 years and SIM is increasingly affecting women relative to men. Accurately characterizing, measuring, and monitoring this major clinical and public health challenge will be essential for developing a comprehensive etiologic understanding and evaluating preventive and therapeutic interventions.