Adolescent suicide in Quebec and prior utilization of medical services

Healthcare utilization, psychiatric disorders, and physical illnesses shortly before suicide mortality in adolescents in Taiwan

BACKGROUND

This study examined the pattern of medical utilization and the distribution of comorbidities shortly before death among adolescents who died from suicide and compared these data with those of living controls.

METHODS

From Taiwan's National Health Insurance Research Database, this study identified adolescents aged 10-19 years who died from suicide (n = 935) between 1 January 2000, and 31 December 2016, by linking each patient with the national mortality database. The researchers conducted a nested case-control study through risk set sampling, and for each case, 20 age- and sex-matched controls (n = 18 700) were selected from the general population. The researchers applied conditional logistic regression to investigate differences in medical utilization and physical and psychiatric comorbidities between cases and controls.

RESULTS

Cases had a higher proportion of contact with the psychiatric department but a similar proportion of contact with any non-psychiatric medical department within 1 year before suicide compared with controls. There were 18.6% of adolescent suicide victims who only had contacted with a psychiatric department 3 months before suicide. Moreover, cases had a higher proportion of contact with non-psychiatric services within 3 months before suicide, particularly with emergency, surgery, and internal medicine departments. Cases had higher risks of several psychiatric disorders and physical illnesses, including heart diseases, pneumonia, and ulcer disease, than did controls.

CONCLUSIONS

The findings of increased medical utilization and higher risks of physical and psychiatric comorbidities in adolescent suicide victims are crucial for developing specific interventions to prevent suicide in this population.

Risk Factors for Suicide Attempt During Outpatient Care in Adolescents With Severe and Complex Depression

Background: Young people receiving tertiary mental health care are at elevated risk for suicidal behavior, and understanding which individuals are at increased risk during care is important for treatment and suicide prevention. Aim: We aimed to retrospectively identify risk factors for attempted suicide during outpatient care and predict which young people did or did not attempt during care. Method: Penalized logistic regression analysis was performed in a small high-risk sample of 84 young people receiving care at Orygen's Youth Mood Clinic (age: 14-25 years, 51% female) to predict suicide attempt during care (N = 16). Results: Prediction of suicide attempt during care was only moderately accurate (Area Under the Receiver Operating Curve range 0.71; sensitivity 0.57) using a combination of sociodemographic, psychosocial, and clinical variables. The features that best discriminated both groups included suicidal ideation during care, history of suicide attempt prior to care, changes in appetite reported on the PHQ-9, history of parental separation, and parental mental illness. Limitation: Replication of findings in an independent validation sample is needed. Conclusion: While prediction of suicide attempt during care was only moderately successful, we were able to identify individual risk factors for suicidal behavior during care in a high-risk sample.

Factors Associated With Mental Health Disorders Among University Students in France Confined During the COVID-19 Pandemic

IMPORTANCE

The coronavirus disease 2019 (COVID-19) pandemic and quarantine measures have raised concerns regarding their psychological effects on populations. Among the general population, university students appear to be particularly susceptible to experiencing mental health problems.

OBJECTIVES

To measure the prevalence of self-reported mental health symptoms, to identify associated factors, and to assess care seeking among university students who experienced the COVID-19 quarantine in France.

DESIGN, SETTING, AND PARTICIPANTS

This survey study collected data from April 17 to May 4, 2020, from 69 054 students living in France during the COVID-19 quarantine. All French universities were asked to send an email to their students asking them to complete an online questionnaire. The targeted population was approximately 1 600 000 students.

EXPOSURE

Living in France during the COVID-19 quarantine.

MAIN OUTCOMES AND MEASURES

The rates of self-reported suicidal thoughts, severe distress, stress, anxiety, and depression were assessed using the 22-item Impact of Events Scale-Revised, the 10-item Perceived Stress Scale, the 20-item State-Trait Anxiety Inventory (State subscale), and the 13-item Beck Depression Inventory, respectively. Covariates were sociodemographic characteristics, precariousness indicators (ie, loss of income or poor quality housing), health-related data, information on the social environment, and media consumption. Data pertaining to care seeking were also collected. Multivariable logistic regression analyses were performed to identify risk factors.

RESULTS

A total of 69 054 students completed the survey (response rate, 4.3%). The median (interquartile range) age was 20 (18-22) years. The sample was mainly composed of women (50 251 [72.8%]) and first-year students (32 424 [47.0%]). The prevalence of suicidal thoughts, severe distress, high level of perceived stress, severe depression, and high level of anxiety were 11.4% (7891 students), 22.4% (15 463 students), 24.7% (17 093 students), 16.1% (11 133 students), and 27.5% (18 970 students), respectively, with 29 564 students (42.8%) reporting at least 1 outcome, among whom 3675 (12.4%) reported seeing a health professional. Among risk factors identified, reporting at least 1 mental health outcome was associated with female gender (odds ratio [OR], 2.10; 95% CI, 2.02-2.19; P < .001) or nonbinary gender (OR, 3.57; 95% CI, 2.99-4.27; P < .001), precariousness (loss of income: OR, 1.28; 95% CI, 1.22-1.33; P < .001; low-quality housing: OR, 2.30; 95% CI, 2.06-2.57; P < .001), history of psychiatric follow-up (OR, 3.28; 95% CI, 3.09-3.48; P < .001), symptoms compatible with COVID-19 (OR, 1.55; 95% CI, 1.49-1.61; P < .001), social isolation (weak sense of integration: OR, 3.63; 95% CI, 3.35-3.92; P < .001; low quality of social relations: OR, 2.62; 95% CI, 2.49-2.75; P < .001), and low quality of the information received (OR, 1.56; 95% CI, 1.49-1.64; P < .001).

CONCLUSIONS AND RELEVANCE

The results of this survey study suggest a high prevalence of mental health issues among students who experienced quarantine, underlining the need to reinforce prevention, surveillance, and access to care.

Integrating Suicide Risk Screening into Pediatric Ambulatory Subspecialty Care

Background

Suicide risk screening is recommended in pediatric care. To date, no previous studies illustrate the implementation of suicide risk screening in pediatric subspecialty care, even though chronic medical conditions are associated with a higher risk of suicide.

Methods

A large multidivision pediatric ambulatory clinic implemented annual suicide risk screening. Patients ages 9-21 years participated in suicide risk screening using the Ask Suicide-Screening Questions during the project. A multidisciplinary team employed quality improvement methods and survey-research design methods to evaluate the feasibility and acceptability of the screening process for patients, families, and medical providers.

Results

During the quality improvement project period, 1,934 patients were offered screening; 1,301 (67.3%) patients completed screening; 82 patients (6.3% of 1,301 patients) screened positive. The monthly compliance rate held steady at 86% following several Plan-Do-Study-Act cycles of improvement. The survey results demonstrate that providers rated the suicide risk screening process positively; however, a subset of providers indicated that the screening process was out of their scope of practice or impeded their workflow.

Conclusions

Suicide risk screening is feasible in pediatric specialty care and can identify at-risk patients. Continued efforts are needed to standardize suicide risk screening practices. Future directions include identifying factors associated with suicide risk in patients in pediatric subspecialty care settings.

A machine learning approach predicts future risk to suicidal ideation from social media data

Machine learning analysis of social media data represents a promising way to capture longitudinal environmental influences contributing to individual risk for suicidal thoughts and behaviors. Our objective was to generate an algorithm termed "Suicide Artificial Intelligence Prediction Heuristic (SAIPH)" capable of predicting future risk to suicidal thought by analyzing publicly available Twitter data. We trained a series of neural networks on Twitter data queried against suicide associated psychological constructs including burden, stress, loneliness, hopelessness, insomnia, depression, and anxiety. Using 512,526 tweets from N = 283 suicidal ideation (SI) cases and 3,518,494 tweets from 2655 controls, we then trained a random forest model using neural network outputs to predict binary SI status. The model predicted N = 830 SI events derived from an independent set of 277 suicidal ideators relative to N = 3159 control events in all non-SI individuals with an AUC of 0.88 (95% CI 0.86-0.90). Using an alternative approach, our model generates temporal prediction of risk such that peak occurrences above an individual specific threshold denote a ~7 fold increased risk for SI within the following 10 days (OR = 6.7 ± 1.1, P = 9 × 10-71). We validated our model using regionally obtained Twitter data and observed significant associations of algorithm SI scores with county-wide suicide death rates across 16 days in August and in October, 2019, most significantly in younger individuals. Algorithmic approaches like SAIPH have the potential to identify individual future SI risk and could be easily adapted as clinical decision tools aiding suicide screening and risk monitoring using available technologies.

[Relevance and experience of surveillance and brief contact intervention systems in preventing reattempts of suicide among children and adolescents]

In France, one adolescent out of ten has already attempted suicide. In this population, suicide reattempts are frequent and significantly impact the vital, morbid and functional long-term prognosis. For about fifteen years, surveillance and brief contact intervention systems (SBCIS) have been used to complete the French suicide reattempt prevention arsenal for youth. The relevance of such strategy appears once the mental health service gap observed at this period of life is considered. In addition to prompting better coordination between the different professional stakeholders, the SBCIS help to alleviate the adolescent's help-seeking barriers, especially the ambivalence between conquest of autonomy and need for help. The first results from the French SBCIS dedicated to children and adolescents are encouraging. Although they have to deal with specific challenges, we argue that they relevantly complement and potentiate the already available prevention resources, thus optimizing the whole prevention system for suffering youth.

Leveraging the Web and Social Media to Promote Access to Care Among Suicidal Individuals

After two decades of exponential development, the Internet has become an inseparable component of suicide prevention matters. More specifically, social media has turned out to be a privileged space for suicidal individuals to express their distress and seek support. Although this tendency carries with it specific risks and challenges, it creates unprecedented opportunities to face the challenges of help seeking and access to care. In this paper, we present the empirical, technological, and theoretical evidence supporting the implementation of a digitally augmented prevention policy that would increase its reach. Congruent to the clinical observations and theories on the help-seeking process, we argue that social media can help undertake three main functions of increasing proactivity to bring suffering Web users to care. The gateway function relates to the properties of social media interactions to leverage help-seeking barriers and enable ambivalent individuals to access the mental healthcare system. The communication outreach function aims to broadcast pro-help-seeking messages, while drawing on the functional structure of the social media network to increase its audience. The intervention outreach function consists in using machine learning algorithms to detect social media users with the highest risk of suicidal behaviors and give them a chance to overcome their dysfunctional reluctance to access help. We propose to combine these three functions into a single coherent operational model. This would involve the joint actions of a communication and intervention team on social networks, working in close collaboration with conventional mental health professionals, emergency service, and community resources.

Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017

Aim: To examine rates of contact with primary and mental health care prior to suicide in men and women and across a range of age categories. Method: The authors performed a systematic review of 44 studies from 2000 to 2017 of which 36 reported rates on contact with primary health care and 14 reported on contact with mental health care prior to suicide. Results: Contact with primary health care was highest in the year prior to suicide with an average contact rate of 80%. At one month, the average rate was 44%. The lifetime contact rate for mental health care was 57%, and 31% in the final 12 months. In general, women and those over 50 years of age had the highest rates of contact with health care prior to suicide. Conclusions: Contact with primary health care prior to suicide is common even in the final month before death. The findings presented in this study highlight the importance of placing suicide prevention strategies and interventions within the primary health care setting.

Suicide in Elementary School-Aged Children and Early Adolescents

BACKGROUND AND OBJECTIVES

Suicide in elementary school-aged children is not well studied, despite a recent increase in the suicide rate among US black children. The objectives of this study were to describe characteristics and precipitating circumstances of suicide in elementary school-aged children relative to early adolescent decedents and identify potential within-group racial differences.

METHODS

We analyzed National Violent Death Reporting System (NVDRS) surveillance data capturing suicide deaths from 2003 to 2012 for 17 US states. Participants included all suicide decedents aged 5 to 14 years (N = 693). Age group comparisons (5-11 years and 12-14 years) were conducted by using the χ² test or Fisher's exact test, as appropriate.

RESULTS

Compared with early adolescents who died by suicide, children who died by suicide were more commonly male, black, died by hanging/strangulation/suffocation, and died at home. Children who died by suicide more often experienced relationship problems with family members/friends (60.3% vs 46.0%; P = .02) and less often experienced boyfriend/girlfriend problems (0% vs 16.0%; P < .001) or left a suicide note (7.7% vs 30.2%; P < .001). Among suicide decedents with known mental health problems (n = 210), childhood decedents more often experienced attention-deficit disorder with or without hyperactivity (59.3% vs 29.0%; P = .002) and less often experienced depression/dysthymia (33.3% vs 65.6%; P = .001) compared with early adolescent decedents.

CONCLUSIONS

These findings raise questions about impulsive responding to psychosocial adversity in younger suicide decedents, and they suggest a need for both common and developmentally-specific suicide prevention strategies during the elementary school-aged and early adolescent years. Further research should investigate factors associated with the recent increase in suicide rates among black children.

Gender Differences in Youth Suicide and Healthcare Service Use

BACKGROUND

Healthcare service use among suicide decedents must be well characterized and understood since a key strategy for preventing suicide is to improve healthcare providers' ability to effectively detect and treat those in need.

AIMS

To determine gender differences in healthcare service use 12 months prior to suicide.

METHOD

Data for 1,231 young Quebec residents (≤ 25 years) who died by suicide between 2000 and 2007 were collected from public health insurance agency databases and coroner registers. Healthcare visits were categorized according to the setting (emergency department [ED], outpatient, and hospital) and their nature (mental health vs. non-mental health).

RESULTS

Girls were more likely than boys (82.5% vs. 74.9%, p = .011) to have used healthcare services in the year prior to death. A higher proportion of girls had used outpatient services (79.0% vs. 69.5%, p = .003), had been hospitalized (25.7% vs. 15.6%, p < .001) and had received a mental health-related diagnosis (46.7% vs. 33.1%, p < .001). However, no gender differences were observed in ED visits (59.5% vs. 54.5%, p = .150).

CONCLUSION

There is an important proportion of suicide decedents who did not receive a mental health diagnosis and healthcare services in the year prior to death. Future studies should focus on examining gender-specific individual and health system barriers among suicide decedents as well as the quality of care offered regarding detection and treatment.

When self-reliance is not safe: associations between reduced help-seeking and subsequent mental health symptoms in suicidal adolescents

The majority of suicidal adolescents have no contact with mental health services, and reduced help-seeking in this population further lessens the likelihood of accessing treatment. A commonly-reported reason for not seeking help is youths’ perception that they should solve problems on their own. In this study, we explore associations between extreme self-reliance behavior (i.e., solving problems on your own all of the time), help-seeking behavior, and mental health symptoms in a community sample of adolescents. Approximately 2150 adolescents, across six schools, participated in a school-based suicide prevention screening program, and a subset of at-risk youth completed a follow-up interview two years later. Extreme self-reliance was associated with reduced help-seeking, clinically-significant depressive symptoms, and serious suicidal ideation at the baseline screening. Furthermore, in a subset of youth identified as at-risk at the baseline screening, extreme self-reliance predicted level of suicidal ideation and depressive symptoms two years later even after controlling for baseline symptoms. Given these findings, attitudes that reinforce extreme self-reliance behavior may be an important target for youth suicide prevention programs. Reducing extreme self-reliance in youth with suicidality may increase their likelihood of appropriate help-seeking and concomitant reductions in symptoms.

Les interventions infirmières estimées bénéfiques par les adolescents à risque de suicide

Cette recherche identifie les interventions infirmières bénéfiques selon la perspective des adolescents à risque pour suicide. Quoique les infirmières du milieu hospitalier aient un niveau de contact direct, élevé et continu auprès du patient, il n’existe aucune recherche sur les interventions thérapeutiques offertes par ces dernières. Cette étude qualitative a pour but d’avancer nos connaissances quant au rôle de l’infirmière dans le rétablissement des adolescents suicidaires lors une hospitalisation psychiatrique. Neuf patients, de 15 à 18 ans, ont participé à des entrevues individuelles semi-structurées. Les résultats réaffirment la valeur thérapeutique d’un accompagnement personnalisé offert lors d’une relation d’aide collaborative et orientée vers les forces et potentiels du jeune et sa famille. Selon les répondants, les interventions bénéfiques sont réalisées pendant des expériences de vie ordinaires (tels que les événements de tous les jours) ainsi que pendant les périodes de crise ou de souffrance La création d’un milieu thérapeutique est soulignée de même que son impact sur la santé et rétablissement du jeune.

Gender and age differences among youth, in utilization of mental health services in the year preceding suicide in Taiwan

The primary objective of this study was to explore gender and age differences in the use of medical services during the year preceding suicide. Data were obtained from the mortality dataset of Department of Health and National Health Insurance Database. Included in the sample were 862 persons aged 12-24 years who committed suicide in Taiwan between 2001 and 2004. We compared the records of medical service utilization of adolescents (ages 12-18 years) with young adults (ages 19-24 years). Persons in both age groups contacted general practitioners more often than other types of medical providers in the year preceding suicide, with the exception of the month before suicide. Females made greater use of medical services than males in both age groups. Suicide prevention strategies should increase the emphasis in training non-psychiatric medical practitioners to identify and treat young persons at suicide risk.

Adolescent help-seeking and the Yellow Ribbon Suicide Prevention Program: an evaluation

The Yellow Ribbon Suicide Prevention Program has gained national and international recognition for its school- and community-based activities. After the introduction of Yellow Ribbon to a Denver-area high school, staff and adolescents were surveyed to determine if help-seeking behavior had increased. Using a pre-post intervention design, staff at an experimental school and comparison school were surveyed about their experiences with student help-seeking. Additionally, 146 students at the experimental high school were surveyed. Staff did not report any increase in student help-seeking, and students' reports of help-seeking from 11 of 12 different types of helpers did not increase; the exception was help-seeking from a crisis hotline, which increased from 2.1% to 6.9%. Further research with larger, more inclusive samples is needed to determine whether Yellow Ribbon is effective in other locations.

Recent and lifetime utilization of health care services by children and adolescent suicide victims: a case-control study

OBJECTIVE

In the present paper we describe a case-control study on the utilization of health care services prior to suicide (across different time periods) among children and adolescents aged 11 to 18 years in the Province of Quebec, Canada and matched healthy controls.

METHOD

Utilization of services (i.e., contact with general practitioners, mental health professionals, psychiatrists and/or youth protection groups) was examined at different time periods in 55 child and adolescent suicide victims and 54 matched community controls using proxy-based interviews and questionnaires. In addition, we examined the rates of detection of psychopathology by health care professionals, the use of psychotropic medications and the subjects' compliance with treatment.

RESULTS

Although more than 90% of child and adolescent suicide completers in our sample suffered from mental disorders, a significant proportion of them were left without appropriate healthcare support (including psychiatric consultation) in the period preceding their suicide. Also, 20% of suicide completers and no control subject made prior suicide attempts. More specifically, over two-thirds of suicide completers had no treatment contact within the month prior to the completion, while only 12.7% (n=7) of them were in contact with psychiatric services during that same period. Moreover, 56.4% (n=31) of the suicide completers had not been diagnosed as having a mental disorder at the time of their death, and 54.5% of the subjects' that received treatment (12 out of 22) were considered poorly compliant or not compliant at all according to their medical/psychosocial records. Finally, we also found that females seemed to have more psychiatric and mental health service contacts in the past month, that subjects with depressive and anxious disorders received more psychiatric and general mental health services in the past year, and that past month hospitalization was more often associated with alcohol abuse and psychosis.

LIMITATIONS

Relatively small sample size, and cross-sectional design.

CONCLUSIONS

Our findings indicate the need for an overall increase in the rates of healthcare services delivered to young subjects at risk for suicide, as well as better training of health professionals in detecting and treating youth psychopathology.

Variables associated with general practitioners taking on patients with common mental disorders

Objective The article assesses variables associated with general practitioners (GPs) taking on patients suffering from common mental disorders (CMD).Method The study is based on a sample of 398 GPs, representative of the 7199 equivalent full-time GPs practising in Quebec, the second-largest province of Canada. GPs were asked to answer a 143-item questionnaire related to their socio-demographic profile, clinical practice, patient characteristics, perceived interprofessional relationships, quality of care, and support strategies for improving continuity of care. Descriptive, bivariate, and multivariate analyses were performed.Results This study demonstrates that the following dimensions are associated with GPs taking on patients with CMD: (1) their interest and knowledge in dealing with such patients; (2) the relative simplicity of treating CMD cases; (3) the quality of, and interest in, mental healthcare collaboration; and (4) the availability of diversified services. The main enabling variable in GPs taking on CMD patients is their interest in mental disorders. Conversely, the principal impeding variable is their positive perception of relationships with psychiatric teams.Conclusions In accordance with current healthcare reforms, this study reinforces the need to promote GP interest and training in mental health care. Increasing GP co-ordination with psycho-social services, along with developing integrated care models including specialised care, is strongly recommended.

Control-group study of an intervention training program for youth suicide prevention

Few studies have examined whether training can improve competency in intervening with suicidal youths. In this study we attempted to verify the effectiveness of such a training program on helper competency. Forty-three helpers who received the training were compared with 28 helpers who did not. Participants who received the training improved in knowledge, attitudes, and intervention skills following the training, compared with the control group across measures. Their gains were maintained at 6-month follow-up. In this sample, implementation of a one-time training program improved helpers' competencies in youth suicide intervention.

Psychiatric services utilization in completed suicides of a youth centres population

BACKGROUND

From a retrospective study of youth centres (YCs) and coroner's files, we investigated youths' history of medical service utilization who died by suicide. This is the second of two papers on YCs population, the first paper having shown that the rate of psychopathology was higher in the YCs population compared to the general adolescent population.

METHODS

From 1995 to 2000, 422 youths, aged 18 years and younger, died as a result of suicide in Quebec. More than one-third received services from YCs at some point. Using the provincial physician payment and hospitalization database, we examined physical and psychiatric service utilization according to time intervals, as well as hospitalization for psychiatric reasons in the individuals' lifetime and in the year preceding suicide. Suicides were matched to living YCs youths for age, sex, and geographic area. YCs controls were then subdivided into two groups based on file information pertaining to the presence or absence of suicidal behavior or ideation.

RESULTS

Compared to living YCs youths, suicides had a higher rate of psychiatric service utilization in the week, month, 90 days, and year preceding suicide, as well as higher levels of lifetime hospitalization for psychiatric reasons than controls with or without a history of suicidal behavior or ideation. We found that 28.3% YCs suicides made use of psychiatric services in the year preceding suicide.

CONCLUSION

The rate of psychiatric service utilization by YCs youth suicides is substantially inferior to the needs of this population. Our study underscores the need for appropriate recognition of psychiatric and suicidal problems among YCs population by social and psycho-educational professionals. At the same time, it highlights the issues of general practitioners' risk identification, psychiatric referral and treatment. Our findings suggest the need for improved organization and coordination of psychiatric services to ameliorate treatment delivery.