6 - Emergency Department Visits and Hospitalizations due to Suicidal Behavior Among Youth Experiencing Homelessness in the U.S. During the COVID-19 Pandemic

Publication Number: 3005.6

Rie Sakai-Bizmark, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, United States; Benjamin F.. Henwood, University of Southern California, Los Angeles, CA, United States; Hiraku Kumamaru, Yokohama City University, Bunkyo-ku, Tokyo, Japan; Frank Wu, The Lundquist Institute for Biomedical Innovation, Torrance, CA, United States; Emily Marr, The Lundquist Institute, Torrance, CA, United States; Dennys Estevez, The Lundquist Insitute, Alhambra, CA, United States; Mark S.. Kaplan, UCLA, Los Angeles, CA, United States

Background: Suicide is a leading cause of death among teenagers in the U.S. Prior research shows rates of suicidal behavior are lower during summer and on weekends. However, youth experiencing homelessness (YEH) exhibit higher rates of suicidal behavior during these same periods.

Objective: This study tested whether YEH experienced increased rates of suicidal behavior following school closures in the spring of 2020, a period when rates in these behaviors declined among the general youth population.

Design/Methods: We used the 2016-2020 National (Nationwide) Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS), compiled by the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP). We identified encounters among individuals aged 17 and under who visited the emergency department (ED) or were hospitalized for suicidal behavior, identified through International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. YEH were identified using ICD-10-CM codes for homelessness or housing instability. Monthly trends in ED visits or hospitalizations for suicidal behavior during 2020 were assessed relative to historical patterns from 2016-2019 through four steps. First, we calculated the monthly rate per 100,000 using HCUP NIS/NEDS encounter counts with population data from the Continuum of Care Homeless Assistance Programs Homeless Populations and Subpopulations Reports for YEH and U.S. Census for domiciled youth. Second, using data from 2016-2019, we estimated month-specific means and 95% confidence intervals (CIs) of these rates. Third, we compared monthly values for 2020 against the monthly values from 2016-2019. Fourth, values in 2020 that fell outside the 95% CI were considered statistically significant deviations. To assess specificity, we also examined trends in ED visits and hospitalizations for other conditions among YEH.

Results: We identified 278 encounters among YEH (84 in 2020) and 109,256 among domiciled youth (23,701 in 2020). Among YEH, ED visits or hospitalizations for suicidal behavior increased in spring 2020, in contrast to a decline among domiciled youth. No comparable increases were observed for other conditions, indicating that the rise in ED visits or hospitalizations during this time was specific to suicide-related care rather than a broader shift in healthcare use among YEH.

Conclusion(s): These findings suggest that school closures had a disproportionate impact on YEH, underscoring the need for targeted suicide prevention efforts for this vulnerable population during future emergencies.

Monthly Trends in Emergency Department Visits and Hospitalizations for Suicidal Behavior Among Youth Experiencing Homelessness in 2020 Compared With Historical Patterns (2016-2019)
Monthly rates of suicidal behavior-related emergency department visits and hospitalizations per 100,000 youth experiencing homelessness. The blue line represents the 2016-2019 mean with shaded 95% confidence intervals, and the red dashed line represents observed rates in 2020. Higher rates were observed during spring and fall 2020 compared with historical patterns, in contrast to the decline seen among domiciled youth.

Monthly Trends in Emergency Department Visits and Hospitalizations for Suicidal Behavior Among Domiciled Youth in 2020 Compared With Historical Patterns (2016-2019)
Monthly rates of suicidal behavior-related emergency department visits and hospitalizations per 100,000 domiciled youth. The blue line represents the 2016-2019 mean with shaded 95% confidence intervals, and the red dashed line represents observed rates in 2020. A marked decline was observed in April 2020 compared with historical patterns, consistent with previously reported trends and supporting the validity of the analytic approach.

Monthly Trends in Emergency Department Visits and Hospitalizations for Other Conditions Among Youth Experiencing Homelessness in 2020 Compared With Historical Patterns (2016-2019)
Monthly rates of emergency department visits and hospitalizations for other (non-suicidal behavior-related) conditions per 100,000 youth experiencing homelessness. The blue line represents the 2016-2019 mean with shaded 95% confidence intervals, and the red dashed line represents observed rates in 2020. Patterns were consistent with historical trends, suggesting that the observed increase in suicidal behavior during 2020 was not attributable to overall changes in healthcare utilization.