Methods of suicide used by children and adolescents

Epidemiology and outcomes of severe injury patients related to suicide attempt or self-harm in Korea: Nationwide community-based study, 2016-2020

INTRODUCTION

Suicide is a major social issue in Korea. Suicide attempt or self-harm (SA/SH)-a risk factor for suicides-is in itself a major public health problem. Investigating vulnerable populations is the first step for designing an effective prevention program. This study aimed to investigate the epidemiology and outcomes of patients with severe injuries related to suicide attempts or self-harm (SA/SH) by age groups, using a nationwide database.

MATERIALS AND METHODS

This retrospective observational study was conducted in Korea between 2016 and 2020. Its participants were patients with severe injuries, who were treated by emergency medical service (EMS). From among injured patients who met the criteria for a field-based injury triage scheme or had a prehospital physiological abnormality, those with SA/SH were included. Exposure was based on age groups: adolescents (10-18 years), adults (19-64 years), and older adults (≥65 years). The study's outcomes were in-hospital mortality. Patients' characteristics and outcomes were compared by age groups and SA/SH mechanisms. Predictors of mortality were investigated using multivariable logistic regression analysis.

RESULTS

Among the 204,211 patients with severe injuries transferred by EMS, 43,945 (21.5 %) were SA/SH-related. Their median (interquartile) age was 48 (35-61) years, and 52.9 % were female patients. The common SA/SH mechanisms were: poisoning (67.6 %), hanging (16.3 %), and jumping (8.1 %). Overall, the mortality was 21.9 %, but it was higher for hanging (69.2 %) and jumping (62.0 %), than for common poisoning (6.5 %). Among adolescents, poisoning (46.1 %), followed by jumping (34.0 %) was common, and the mortality was 23.3 %. In the older adults, poisoning (68.6 %), followed by hanging (20.2 %) was common, and the mortality was 34.9 %. Older adults compared to adults, males compared to females, and hanging and jumping compared to poisoning, were associated with higher mortality.

CONCLUSIONS

More than 20 % of EMS treated patients with severe injury were SA/SH-related, and the mortality was over 20 %. Although poisoning was the most common mechanism, the high proportions of jumping and hanging with high mortality, resulted in adolescents and the older adults groups having high mortality. Therefore, designing target-specific SA/SH prevention programs based on age, sex, and common SA/SH mechanisms are necessary.

Characteristics and Circumstances of Suicide Among Children Aged 6 to 9 Years: 2006-2021

BACKGROUND

Limited research exists on suicide among children aged 5 to 9 years. The objective of this study was to examine characteristics of suicide in children younger than 10 years.

METHODS

Data are from the National Fatality Review-Case Reporting System (NFR-CRS) for years 2006 through 2021 for children aged 6 to 9 years who died by suicide. No suicide deaths were reported in NFR-CRS for children aged ≤ 5 years. Descriptive analyses by demographics and circumstances were conducted. A thematic analysis of prevention recommendations made by child death review teams was performed.

RESULTS

From 2006 to 2021, NFR-CRS identified 78 suicide decedents aged 6 to 9 years. The largest share were aged 9 years (72%), male (74%), non-Hispanic Black (42%), and died by hanging (86%) at home (91%). School-related problems (39%), history of child maltreatment (36%), history of mental health services (30%), argument with parents (23%), and familial discord (19%) were common circumstances. Key suicide prevention themes included education for caregivers and school staff, improved behavioral health services, and implementation of school policies and programs.

CONCLUSIONS

Results provide a more complete picture of suicide among younger children, improving understanding of their unique characteristics. It is recommended that program planners consider both age-appropriateness and the impacts of social (eg, racism) and structural inequities in their approaches to prevention, encompassing both community and school-based strategies. For pediatricians, results emphasize the importance of lethal means counseling, safety planning, and educating parents and caregivers on the distinct warning signs of suicide for younger children.

Weekly links among irritability and suicidal thoughts and behaviors in high-risk youth

BACKGROUND

Previous studies demonstrate a link between irritability and suicidal thoughts and behaviors (STBs) in youth samples. However, they have mostly assessed irritability in community samples and as a largely dispositional (i.e. trait-like) construct. Thus, it remains unclear to what extent links between irritability and STBs reflect within-person processes of elevated risk in clinically meaningful time periods.

METHODS

The present study used clinical data from 689 adolescents aged 12-19 years attending a total of 6,128 visits at a specialty Intensive Outpatient Program for depressed and suicidal youth to examine patterns in weekly assessments of irritability and STBs throughout treatment, including associations among trends and fluctuations departing from these trends via multilevel structural equation modeling. Youth completed self-report measures of irritability, depression, and STBs weekly as part of standard IOP clinical care.

RESULTS

Overall, two-thirds of variance in weekly irritable mood was accounted for by between-person differences and the remaining portion by weekly fluctuations. After controlling for depression, during weeks when youth were more irritable they experienced increased STBs. Rates of change in irritability and STBs tended to track together at early stages of treatment, but these effects were generally accounted for by depression severity.

CONCLUSIONS

Our results suggest that although changes in STBs are best accounted for by depression, irritability can be understood as a specific, proximal risk factor for youth STBs that exacerbates youth STBs in clinically informative timeframes above and beyond depression.

Suicide warning signs that are challenging to recognize: a psychological autopsy study of Korean adolescents

BACKGROUND

In South Korea, the leading cause of youth death has been suicide for about 20 years. In this study, we conducted a multi-method psychological autopsy to identify the psychiatric diagnosis, developmental history, personality traits, family history, school life, warning signs of suicide, and risk factors related to suicide for the first time in Korea.

METHODS

This was a postmortem, retrospective, and descriptive study of 36 adolescents who died by suicide between August 2015 and July 2021 in South Korea. We obtained qualitative and quantitative data from the Korean Psychological Autopsy of Adolescent, conducted by the Suicide and School Mental Health Institute, the official student mental health policy-focused research institute of the Korean Ministry of Education.

RESULTS

The adolescents comprised equal percentage of girls and boys. Approximately half of the deaths (55.6%) occurred at home and most (72.2%) involved jumping from a height. Most of the adolescents (97.2%) had one major psychiatric disorder before death, with depressive disorder being the most prevalent (75%). They were at a high risk for internet addiction before death. The most common personality trait was avoidance (28.6%), followed by submissiveness (27.3%). Half of the parents reported that the adolescents were satisfied with their school life and the teachers observed that they had no behavioral problems. One year before death, seven (19.4%) adolescents injured themselves and five (13.9%) had attempted suicide. Most of the deceased (80.6%) had expressed suicide warning signs to their families within one year before death. Adolescents had a long experience of family-related adverse events.

CONCLUSIONS

Most of the adolescents had mental health disorders and expressed suicidal intentions using verbal and nonverbal signs. However, it was challenging for families to recognize the risk signs because of adolescents' personality traits or a good school life. To prevent adolescent suicide, adolescents, parents, and teachers need to be educated to recognize signs of suicide warning signs and equipped to guide adolescents to appropriate care.

Socioeconomic status and psychiatric comorbidity associated with suicidal behavior among a sample of Egyptian patients who attended Tanta University emergency hospital for suicide-related problems

Background

Many studies found association between psychosocial factors and suicidal behavior; this association differs from one community to another, and this difference could affect the risk assessment and the management of suicidal behavior. The aim of this work was to evaluate the role of socioeconomic, cultural, and psychosocial profile including psychiatric comorbidity on individuals with suicidal behavior who attended Tanta University emergency hospital.

Results

Family troubles were the commonest cause of suicidal behavior (28%), and drug overdose was the commonest method of attempt (38%). Positive correlation is between age and score of Beck scale for suicidal ideation (p = 0.000) which indicates that suicidal ideation increases with age. Significant association is between psychiatric comorbidity and Beck’s scale for suicidal ideation (p = 0.019), with size of association (η = 0.58).

Regression analysis showed that older age, female sex, illiterates, widows, cases with psychiatric illness, and low socioeconomic status when act altogether are the significant predictor of suicidal ideation of our studied sample.

Conclusions

Our study demonstrated that studying psychosocial factors in individuals who came to emergency hospital of Tanta University could be a reflection of the community visiting this hospital asking for medical emergency service; the comprehensive and multifactorial assessment we have been adopted in this work could help in better understanding of the suicidal risk factors in this community and consequently help in part in tailoring the clinical service for this sector of patient.

Suizide im Kindes- und Jugendalter

Hintergrund

Suizide stellen in Westeuropa nach Verkehrsunfällen den zweit- oder drittgrößten Anteil an Todesfällen von Kindern, Jugendlichen und Heranwachsenden dar und sind eine extreme Belastung für die Hinterbliebenen.

Methodik

In der anonymisierten Datenanalyse wurden nichtnatürliche Todesfälle von Kindern, Jugendlichen und Heranwachsenden im Einzugsgebiet des Instituts für Rechtsmedizin Leipzig, Sachsen, im Zeitraum 1998–2017 analysiert. Suizide wurden auf die Häufigkeit bezüglich des Geschlechts und der Methode hin untersucht und ihr Zusammenhang mit Alkohol- oder Drogenkonsum und psychiatrischen Erkrankungen dargestellt.

Ergebnisse

Es zeigten sich signifikant mehr männliche als weibliche Suizidenten (p < 0,05). Keiner von ihnen war jünger als 12 Jahre. Als häufigste Suizidmethode erwies sich der Bahnsuizid (27 %), gefolgt von Sturz aus großer Höhe (22 %), Intoxikation (21 %) und Erhängen (12 %). Es zeigte sich ein signifikanter Zusammenhang zwischen Suiziden und positiven toxikologischen Befunden (X2 = 27,16; p < 0,001), und es konnten Hinweise auf psychiatrische Erkrankungen bei Suizidenten herausgearbeitet werden.

Schlussfolgerungen

Substanzmissbrauch und psychiatrische Erkrankungen sind mit Suiziden bei Kindern, Jugendlichen und Heranwachsenden assoziiert. Eine besondere Bedeutung wird in diesem Kontext psychiatrischen Erkrankungen beigemessen, da diese das Suizidrisiko stark erhöhen können. Eine große Rolle in der Suizidprävention spielt das soziale Umfeld. Dieses kann durch rechtzeitiges Erkennen möglicher Vorzeichen – beispielsweise Veränderung des Verhaltens, Verletzungen oder Substanzkonsum – entscheidend aktiv werden.

Trends in suicide methods in Switzerland from 1969 to 2018: an observational study

BACKGROUND

Suicide is a serious societal and health problem. We examined changes in rates of completed suicides in Switzerland between 1969-2018 with particular regard to different methods of suicide used in different subgroups of the resident population.

METHODS

We used data of the Swiss cause of death statistics and Poisson regression models to analyse annual incidence rates and calendar time trends of specific suicide methods used in population subgroups by sex (men vs women), age (10-29, 30-64, >64 years), and nationality (Swiss vs other citizenship).

RESULTS

There were 64,996 registered suicides between 1969 and 2018. Across these 5 decades, the overall suicide rate was higher in men than in women (incidence rate ratio [IRR] 2.62, 95% confidence interval [CI] 2.58-2.67), in Swiss citizens than in foreigners (IRR 2.02; 95% CI 1.97-2.07), and in older residents (>64 years) than in the age groups 30-64 years (IRR 1.35, 95% CI 1.32-1.37) and 10-29 years (IRR 2.37, 95% CI 2.32-2.43). After peaking in the 1980s, the overall suicide rate had declined in all of these population subgroups, with flattening trends over most recent years. The most common specific methods of suicide were hanging (accounting for 26.7% of all suicides) and firearms (23.6%). The rates of the specific suicide methods were usually higher in men, in Swiss citizens and in older residents, and they had typically declined over most recent decades in the population subgroups examined. However, some methods diverged from this general pattern, at least in some population subgroups. For instance, railway suicides most recently increased in younger and in male residents whereas suicides by gas and by drowning were only at a low level after rapid declines in the last millennium.

CONCLUSIONS

Restricting access to lethal means (e.g., detoxification of domestic gas), improvements in health care and media guidelines for responsible reporting of suicides are possible explanations for the generally declining suicide rates in Switzerland. Whereas some methods (e.g., poisoning by gases or drowning) had become rare, others continue to account for many suicides every year, at least in some population subgroups (e.g., firearms in older Swiss men or railway suicides in younger and in male residents). As different methods of suicide are chosen by different people or subgroups of the population, preventive efforts should include differentiated strategies and targeted measures to further reduce suicides in Switzerland and elsewhere.

Identifying and Managing Suicidality in Children and Adolescents with Chronic Pain: Evidence-Based Treatment Strategies

Children and adolescents with chronic pain are at an increased risk of suicidality. This narrative review article aims to inform clinical practice in the assessment and management of suicidality in youth with chronic pain. The article begins with a survey of the background and prevalence of youth with chronic pain. A review of the current evidence behind the increased risk of suicidality in youth with chronic pain follows. Contextualization of this data with general tenets of child and adolescent suicide risk and risk assessment is provided. Suicidology theory including the interpersonal theory of suicide is overviewed to help clinicians to conceptualize the reviewed data. Guiding parameters for the suicide risk assessment and management planning is presented. Concluding recommendations are made to guide clinical practice in the assessment and management of suicidality in youth with chronic pain.

Pediatric Train Injuries: A 10-Year Review From the Pennsylvania Trauma Outcomes Study Database

OBJECTIVES

Trains can cause severe injuries in pediatric patients requiring significant resource utilization. We sought to review train injuries in Pennsylvania to determine the burden of these injuries on the pediatric trauma system.

METHODS

We queried the Pennsylvania Trauma Outcomes Study Database to identify patients younger than 18 years injured by trains between 2007 and 2016. Demographics, hospital course, outcomes, and resource utilization were reviewed.

RESULTS

Thirty-five children from 17 Pennsylvania counties were included. Three counties accounted for 48.6% of injured children. The median age was 15.0 years, and most patients were White (60.0%) and male (77.1%). The median length of stay was 8.0 days and overall mortality 8.6%. Intensive care unit admission was required for 65.7%. The median Injury Severity and Functional Status at Discharge scores were 14.0 and 18.0, respectively. Major orthopedic injuries (fracture or amputation) were the most common (57.1%) followed by traumatic brain injury (45.7%), pneumothorax (14.3%), and solid organ injury (14.3%). Operative management was common with 65.7% undergoing surgery.

CONCLUSIONS

Injuries caused by trains can be severe and are most commonly orthopedic or traumatic brain injuries. Targeted safety interventions may be possible given the common mechanisms and geographic clustering of these injuries.

[Suicides Among Adolescents in a Major German City]

Suicides Among Adolescents in a Major German City Abstract. Objective: Adolescent suicide is a major contributor to the overall mortality in this age group. This study examined sex and age differences in suicide methods. Method: The investigation is based on death certificates from the years 1996 to 2019 of the city of Leipzig and includes all suicides in the age group under 25 years. The impact of sex and age on the method and location of suicide was examined using chi square statistics. Moreover, we verified the association between suicides and death by drug overdose through statistical regression. Results: 140 suicides were included in the study. The suicide methods differed between the age groups (χ^² = 17,878; p = .022). Individuals under 21 years of age committed suicide almost exclusively by strangulation, jumping from heights, railway suicide, or deliberate intoxication. With the onset of early adulthood, the spectrum of methods expanded. Suicide methods were also different between the sexes (χ^² = 35,166; p < .001): Male adolescents preferred highly lethal methods such as strangulation, whereas in female adolescents intoxication was the leading method of suicide, with a predominance of antidepressants. The annual rates of suicide and death by drug overdose were found to correlate (Pearson correlation = 0,571, p = .004). Minors (χ² = 3.125, p = .077) tended to avoid their own residential environment as a place of suicides compared to adults. Conclusion: When assessing the individual suicide risk and weighing safeguarding measures in clinical practice, the differences shown in the choice of methods should be taken into account.

Characteristics of suicides of young people in Porto Alegre, Southern Brazil, from 2010 to 2016

The purpose of this study was to describe demographic, toxicological, criminal, and medicolegal characteristics of suicides of young people aged up to 24 years examined by the Porto Alegre Medicolegal Office, from 2010 to 2016. This cross-sectional study collected data from the Porto Alegre Medicolegal Office and the Rio Grande do Sul State Police Department. The information was obtained from death certificates, toxicological analyses and police reports. Rates were calculated according to sex and age range (under 15 years old, 15 to 19 years old, and 20 to 24 years old) for comparing local with national data. There were 143 people who died by suicide in the period, 120 males and 23 females. Hanging was the most frequently used method, but in the range of 10 to 14 years old, firearm use was the predominant method. Fifty percent of male victims and 30% of female victims had some criminal history. Suicide rates in the study groups generally followed national trends. The relative frequency of suicide by firearm in this study diverged from international findings, as it was relatively more frequent in children under 15 years old and less frequent in older ranges. If confirmed, the finding draws attention to access to firearms in this age range. In older age ranges, adolescents and young adults were frequently involved in the criminal system. This finding may be useful for planning interventions involving both mental health education and screening for problems that may be associated with criminal involvement.

Predicting suicide attempts and suicide deaths among adolescents following outpatient visits

BACKGROUND

Few studies report on machine learning models for suicide risk prediction in adolescents and their utility in identifying those in need of further evaluation. This study examined whether a model trained and validated using data from all age groups works as well for adolescents or whether it could be improved.

METHODS

We used healthcare data for 1.4 million specialty mental health and primary care outpatient visits among 256,823 adolescents across 7 health systems. The prediction target was 90-day risk of suicide attempt following a visit. We used logistic regression with least absolute shrinkage and selection operator (LASSO) and generalized estimating equations (GEE) to predict risk. We compared performance of three models: an existing model, a recalibrated version of that model, and a newly-learned model. Models were compared using area under the receiver operating curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

The AUC produced by the existing model for specialty mental health visits estimated in adolescents alone (0.796; [0.789, 0.802]) was not significantly different than the AUC of the recalibrated existing model (0.794; [0.787, 0.80]) or the newly-learned model (0.795; [0.789, 0.801]). Predicted risk following primary care visits was also similar: existing (0.855; [0.844, 0.866]), recalibrated (0.85 [0.839, 0.862]), newly-learned (0.842, [0.829, 0.854]).

LIMITATIONS

The models did not incorporate non-healthcare risk factors. The models relied on ICD9-CM codes for diagnoses and outcome measurement.

CONCLUSIONS

Prediction models already in operational use by health systems can be reliably employed for identifying adolescents in need of further evaluation.

Comparison of Suicide Attempts and Suicide Deaths by Jumping from a High Place in Korean Children and Adolescents

Jumping from a high place is the most common method of suicide among Korean children and adolescents. The aim of this study was to examine the personal, family, and school life of Korean children and adolescents who chose jumping from a high place, among suicide attempts and suicide deaths, based on teachers’ reports. Data on suicide attempts and suicide deaths by jumping from a high place in children and adolescents were collected through the Ministry of Education in South Korea from 2016 to 2018. We compared sociodemographic variables, suicide-related variables, emotional and behavioral status, school life related variables, and variables related to family problems among suicide deaths (n = 262), actual suicide attempts (n = 50), and interrupted or aborted suicide attempts (n = 210). There were differences in educational stage (p < 0.001), place of suicide (p < 0.001), presence of suicide note (p < 0.05) and previous suicide attempt (p < 0.001) among the three groups. The total difficulty score on the Strength Difficulty Questionnaire of interrupted or aborted suicide attempts was higher than that of the other two groups. Our study suggests that the suicide death group tend to present fewer personal and family pathologies and better school adjustment than the suicide attempt group.

Increase in Pediatric Intensive Care Unit Hospitalizations Due to Toxic Ingestions during the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic and related community mitigation measures had a significant psychosocial impact. We suspected that more patients were admitted to our pediatric intensive care unit (PICU) for toxic ingestions since the start of the pandemic. We therefore investigated if PICU admissions related to toxic ingestions were higher in 2020 as a result of COVID-19 compared with previous years. We completed a cross-sectional study at a tertiary children's hospital comparing admissions to our PICU between April 2020 and October 2020, during which COVID-19 and community mitigation measures were in place, to those during the same 7-month period in the previous 3 years. Total PICU admissions, admissions for all toxic ingestions (intentional ingestions and accidental ingestions), and demographic and clinical characteristics of patients were compared. Total PICU admissions in 2020 during COVID-19 pandemic months were lower compared with the same months in the preceding 3 years (-16%, p < 0.001), however, admissions for toxic ingestions were higher during COVID-19 (+64%, p < 0.001). When separated by type, intentional (+55%, p  = 0.012) and accidental ingestions (+94%, p  = 0.021) were higher during COVID-19. COVID-19 with community mitigation measures has led to an increase in PICU admissions for intentional and accidental ingestions, indicating an increase in severity of toxic ingestions in children associated with the pandemic. Mental health of adolescents, and safety of infants and toddlers in their home environment, should be targeted with specific interventions in the ongoing COVID-19 pandemic.

First-person accounts of the processes and planning involved in a suicide attempt on the railway

BACKGROUND

The processes and planning involved in choosing and attempting to die by a particular method of suicide are not well understood. Accounts from those who have thought about or attempted suicide using a specific method might allow us to better understand the ways in which people come to think about, plan and enact a suicide attempt.

AIMS

To understand from first-person accounts the processes and planning involved in a suicide attempt on the railway.

METHOD

Thematic analysis was conducted of qualitative interviews (N = 34) undertaken with individuals who had contemplated or attempted suicide by train.

RESULTS

Participants explained how they decided upon a particular method, time and place for a suicide attempt. Plans were described as being contingent on a number of elements (including the likelihood of being seen or interrupted), rather than being fixed in advance. Participants mentally rehearsed and evaluated a particular method, which would sometimes involve imagining in detail what would happen before, during and after an attempt. The extent to which this involved others (train drivers, partners, friends) was striking.

CONCLUSIONS

By giving people free reign to describe in their own words the processes they went through in planning and undertaking a suicide attempt, and by not interpreting such accounts through a lens of deficit and pathology, we can arrive at important insights into how people come to think and feel about, plan and enact a suicide attempt. The findings have implications in terms of understanding suicide risk and prevention more broadly.

Prevalence and clinical correlates of self-harm and suicidality during admission of children in a mental health inpatient unit

Background

Self-harm and suicidality are common presentations in children and adolescents requiring a mental health inpatient admission. Although there are several studies on adolescents, there is relatively limited research into childhood self-harm and suicidality during such admissions.

Methods

A retrospective electronic file review was conducted on all children discharged from a national mental health inpatient children’s unit over a 6-year period. Several independent variables were compared between self-harm/suicidal and non-self-harm/non-suicidal children. Separate analyses investigated changes in self-harm/suicidality, functional outcomes, and risk assessment ratings between admission and discharge.

Results

A total of 105 children were included in this study. During admission, 65.7% of them reported self-harm thoughts, 61% engaged in self-harm, 50.5% expressed suicidal thoughts, and 14.3% engaged in suicidal behavior. Thoughts and acts of self-harm were associated with previous self-harm, longer admissions, and Attention Deficit Hyperactivity Disorder. Suicidality overlapped with self-harm and was strongly predicted by previous self-harm. The prevalence of self-harm and suicidal thoughts and acts significantly decreased during admission. Children in the non-self-harm group had marginally better functional outcomes upon discharge compared to those in the self-harm group. Children and parents/caregivers were similarly satisfied with treatment, irrespective of children’s self-harm/suicidality.

Conclusions

Self-harm and suicidality were widespread among children admitted to hospital. Better understanding of the mechanisms and factors related to self-harm and suicidality in this age group could help mitigate associated risks and improve existing safety strategies.

A 10-year ecological study of the methods of suicide used by Brazilian adolescents

Suicide among adolescents has become a major public health problem worldwide. Our study sought to describe the most commonly used methods of suicide among adolescents aged 10 to 19 years in Brazil between 2006 and 2015. Complete data were obtained from the Brazilian Health Informatics Department (DATASUS) and coded into seven categories of suicide methods. The following statistical analyzes were performed: chi-square (χ2) tests to examine the association between the frequency of each suicide method and the year; odds ratios (OR) and 95% confidence intervals (95%CI) compared the relative chances of each suicide method occurring between boys and girls. In total, 8,026 suicides among Brazilian adolescents were registered over the analyzed period. The most commonly used method of suicide by both sexes was hanging (2015 = 70.3%), and the most significant increase was observed in girls (2015 = 65.82%). The proportional use of arms (2006 = 14.2%; 2015 = 9.1%) and poisoning (2006 = 13.3%; 2015 = 9.2%) decreased over the period. The increase in hanging is worrisome, mostly due to difficulties to impose access barriers and to its high lethality. In such context, a comprehensive understanding of suicide behaviors among adolescents in Brazil should be drawn to inform general prevention measures and, more specifically, the reasons for the increase in hanging need to be further investigated.

Suicidality in Childhood and Adolescence

BACKGROUND

The suicide of minors in Germany is rare in absolute numbers: there were only 212 suicides among persons aged 10 to 20 in Germany in 2017. Nonetheless, in school surveys, 36.4-39.4% of those surveyed reported suicidal ideation, and 6.5-9% reported suicide attempts. Suicide among children and adolescents is thus a clinically and societally relevant problem.

METHODS

This review is based on pertinent articles retrieved by a selective literature search in the PubMed and PsycInfo databases (April 2019) employing the search terms "suicidality," "suicidal*," and "suicide," and on further information from several textbooks (1991-2017).

RESULTS

In children and adolescents with a mental illness, the risk of suicide is higher by a factor of 3 to 12. Mobbing experiences increase the suicide risk as well (odds ratio [OR] = 2.21, p <0.05). Non-suicidal self-injurious behavior (NSSB) is also a risk factor for both suicidal ideation (OR = 2.95) and suicide attempts (hazard ratio [HR] = 2.00). Intoxication with medications is the most common method of attempted suicide (67.7%). Most suicides are preceded by early warning signs. Psychiatric hospitalization is indicated for children and adolescents who are in acute danger of doing harm to themselves. Specific types of treatment, family-centered methods in particular, have been found to lessen the frequency of suicidal ideation and suicide attempts. The administration of antidepressant drugs to children and adolescents is controversial, as there is evidence of increased suicidality (but not mortality) for single medications. Antidepressant drugs should not, however, be withheld for this reason, if indicated. The prerequisite in all cases is close observation.

CONCLUSION

To prevent suicide and improve outcomes, risk factors for suicide must be considered, and the indications for primary and secondary preventive and therapeutic measures must be established. Online therapeutic modalities may become more widely used in the near future, particularly among young patients, who are well versed in the use of the Internet.

Annual Research Review: A meta-analytic review of worldwide suicide rates in adolescents

Suicide is a leading cause of death among youth worldwide. The purpose of the current review was to examine recent cross-national trends in suicide mortality rates among 10- to 19-year-olds. This study extracted suicide mortality data from the World Health Organization's (WHO) Mortality Database for the most recent year (since 2010) from any country with available high-quality data (as defined by the WHO's guidelines). Data on access to lethal means (firearms, railways) and measures of economic quality (World Bank Income Group) and inequality (Gini coefficients) were obtained from publicly available data sources. Cross-national suicide mortality rates in youth were heterogeneous. The pooled estimate across all ages, sexes, and countries was 3.77/100,000 people. The highest suicide rates were found in Estonia, New Zealand, and Uzbekistan. Suicide rates were higher among older compared with younger adolescents and higher among males than females. The most common suicide methods were hanging/suffocation and jumping/lying in front of a moving object or jumping from a height. Firearm and railway access were related to suicide deaths by firearms and jumping/lying, respectively. Economic quality and inequality were not related to overall suicide mortality rates. However, economic inequality was correlated with a higher ratio of male:female suicides. This study provides a recent update of cross-national suicide trends in adolescents. Findings replicate prior patterns related to age, sex, geographic region, and common suicide methods. New to this review are findings relating suicide method accessibility to suicide mortality rates and the significant association between income inequality and the ratio of male:female suicide. Future research directions include expanding the worldwide coverage to more low- and middle-income countries, examining demographic groupings beyond binary sex and to race/ethnicity within countries, and clarifying factors that account for cross-national differences in suicide trends.

Gender Characteristics in Methods of Chinese Rural Young Suicides

Suicidal men and women tend to use different means for suicide, but there has been a lack of studies on how Chinese male and female suicides are distributed on the various lethal methods. We studied 392 suicides (214 males and 178 females) consecutively sampled from selected rural areas of China, with the psychological autopsy (PA) design. It was found that majority of the Chinese rural young suicides died of swallowing pesticides or other farming chemicals (73.5%), and there was not much difference between men and women in all the suicide means as expected. Contrary to the findings in the United States, firearm was not available to Chinese civilians and was not the number one suicide means for the Chinese male suicides. In rural China, suicides with less violent methods outweighed those with violent methods in numbers, with more females chose less violent suicide methods than males. However, results of logistic regression showed that there was no significant association between gender and suicide methods in rural China. Mental disorders and impulsivity were also not associated with violent or less violent suicide methods. Our findings indicated that access to suicide means might be most important explanation of suicide methods. These findings may have certain implications on suicide prevention, and researchers and policy makers should take into consideration of the contexts of the people at risks of suicide.

Collecting evidence from distributed sources to evaluate railway suicide and trespass prevention measures

It can be difficult to select from available safety preventative measures, especially where there is limited evidence of effectiveness in different contexts. This paper describes application of a method to identify and evaluate wide-ranging preventative measures for rail suicide and trespass fatalities. Evidence from literature and industry sources was collated and reviewed in a two stage process to achieve consensus among experts on the likely effects of the measures and factors influencing their implementation. Multiple evaluation criteria were used to examine the measures from different perspectives. Fencing, awareness campaigns and different types of organisational initiatives were recommended for further testing. This is the first time evidence has been collected internationally across such a range of preventative measures. Commentary is provided on using this type of approach to select safety measures from a pool of prevention options, including how re-framing the scope of the exercise could identify alternative options for prevention. Practitioner summary: The findings give insight to how different measures work in different ways and how industry can consider this in strategic initiatives. The method could be used in future studies with different frames of reference (e.g. different timescales, level of ambition and safety context e.g. railway crossings or highway fatalities). Abbreviation: RESTRAIL: REduction of Suicides and Trespasses on RAILway property.

Annual Research Review: Suicide among youth - epidemiology, (potential) etiology, and treatment

BACKGROUND

Suicide is a leading cause of death and a complex clinical outcome. Here, we summarize the current state of research pertaining to suicidal thoughts and behaviors in youth. We review their definitions/measurement and phenomenology, epidemiology, potential etiological mechanisms, and psychological treatment and prevention efforts.

RESULTS

We identify key patterns and gaps in knowledge that should guide future work. Regarding epidemiology, the prevalence of suicidal thoughts and behaviors among youth varies across countries and sociodemographic populations. Despite this, studies are rarely conducted cross-nationally and do not uniformly account for high-risk populations. Regarding etiology, the majority of risk factors have been identified within the realm of environmental and psychological factors (notably negative affect-related processes), and most frequently using self-report measures. Little research has spanned across additional units of analyses including behavior, physiology, molecules, cells, and genes. Finally, there has been growing evidence in support of select psychotherapeutic treatment and prevention strategies, and preliminary evidence for technology-based interventions.

CONCLUSIONS

There is much work to be done to better understand suicidal thoughts and behaviors among youth. We strongly encourage future research to: (1) continue improving the conceptualization and operationalization of suicidal thoughts and behaviors; (2) improve etiological understanding by focusing on individual (preferably malleable) mechanisms; (3) improve etiological understanding also by integrating findings across multiple units of analyses and developing short-term prediction models; (4) demonstrate greater developmental sensitivity overall; and (5) account for diverse high-risk populations via sampling and reporting of sample characteristics. These serve as initial steps to improve the scientific approach, knowledge base, and ultimately prevention of suicidal thoughts and behaviors among youth.

Suicide in adolescents: findings from the Swiss National cohort

Suicide in adolescents is the second most common cause of death in this age group and an important public health problem. We examined sociodemographic factors associated with suicide in Swiss adolescents and analysed time trends in youth suicide in the Swiss National Cohort (SNC). The SNC is a longitudinal study of the whole Swiss resident population, based on linkage of census and mortality records. We identified suicides in adolescents aged 10-18 years from 1991 to 2013. A total of 2.396 million adolescents were included and 592 suicides were recorded, corresponding to a rate of 3.7 per 100,000 [95% confidence interval (CI) 3.4-4.0]. Rates increased with age from 0.0 per 100,000 at age 10 years to 14.8 per 100,000 (95% CI 12.6-17.5) at 18 years in boys, and from 0.0 to 5.4 per 100,000 (4.1-7.2) in girls. Being a boy, living in a single parent household, being an only or middle-born child, and living in rural regions were factors associated with a higher rate of suicide. Hanging was the most common method in boys, and railway suicides were most frequent in girls. There was no clear evidence for an increase or decrease over calendar time. We conclude that familial and socioeconomic factors including type of household, birth order and urbanity are associated with youth suicide in Switzerland. These factors should be considered when designing prevention programmes for youth suicide.

A Description of Suicides in the Army National Guard During 2007-2014 and Associated Risk Factors

Suicide, due to its increased occurrence in recent years, has been a chief concern of the U.S. military. While there have been many published studies on the topic, conspicuously absent are studies that have included reserve military personnel. To fill this gap, this study reports descriptive statistics of personnel information and events surrounding 706 Army National Guard suicides that had occurred from 2007 through 2014. Comparative personnel information for random samples of nonsuicides for similar years (8 years, 1,000 cases per year) allowed examining factors associated most with suicide. Findings were very similar to those observed in the active duty Army and civilian populations. Primary risk factors for suicide were as follows: age (young), gender (male), and race/ethnicity (White). Most suicides occurred in nonmilitary status (86%) involving personal firearms (72%). Most frequent events surrounding the suicide were as follows: poor military performance (36% of all suicides), parent-family relationship problems (28%), substance abuse (27%), past behavioral health problem (20%), current behavioral health problems (10%), income problems (22%), and full-time employment problems (18%). Implications of findings for suicide prevention are discussed.

Suicide in Childhood

Suicide by children younger than 11 is a sad and tragic occurrence. Indeed, suicidal ideation and behavior has been documented in children as young as ages 3 to 7. The current overview provides a discussion of the frequency of suicide in children and associated predisposing conditions, such as depression and abuse. In response to these tragic events, nursing interventions are also proposed. [Journal of Psychosocial Nursing and Mental Health Services, 54(10), 27-30.].

Injuries in jumpers - are there any patterns?

Suicide as a cause of death, affects every health system, and is a particular problem in heavily urbanised states and low and middle income countries (which account for 75% of suicide deaths). The World Health Organisation records that 800000 commit suicide each year, representing 1.4% of annual global deaths, and that suicide was the second leading cause of death in 15-29 year-olds across the world in 2012. In the United Kingdom, jumping from height accounts for 3%-5% of the 140000 suicide attempts annually is similar incidence to the rest of Europe. The Medline and EMBASE were interrogated for studies examining suicide caused by jumping from height. Manual screening of titles and abstracts was used to identify relevant works before data was extracted and systematically reviewed to identify the characteristics of a patient who jumps from height to commit suicide, delineate their patterns of injury and explore techniques that could be used to limit its occurrence. Emergency departments receiving patients who jump from a height need to have an understanding of the potential pathology that is likely to be encountered in order to deliver multidisciplinary, efficient and timely care in order that the impact of this devastating physical, psychological and social problem could modified to the benefit of the patients involved.

A systematic review of the literature on safety measures to prevent railway suicides and trespassing accidents

This review covers a central aspect in railway safety which is the prevention of suicides and trespassing accidents. The paper attempts to answer the following research question: 'What measures are available to reduce railway suicide and trespass, and what is the evidence for their effectiveness?' The review is based on 139 relevant publications, ranging from 1978 to 2014. The analysis aimed to identify the past and current trend in the prevention practice by looking both quantitatively and qualitatively at the recommended measures. According to the results, there has been a constant focus on suicide prevention, and only relatively recent interest in trespass countermeasures. The content analysis revealed 19 main preventative categories which include more than 100 specific measures. We identified 16 common categories against railway suicide and trespass, and 3 categories of specific measures to prevent suicide. There are only 22 studies which provide empirical support for the effectiveness of measures. Actual combinations of measures are barely evaluated, but several challenges emerge from the literature. The discussion focuses on the need for a unified approach to suicide and trespass prevention, and on the importance to consider the effect mechanism of the measures in order to design better interventions.

An observational study of bullying as a contributing factor in youth suicide in Toronto

OBJECTIVE

Bullying has been identified as a potential contributing factor in youth suicide. This issue has been highlighted in recent widely publicized media reports, worldwide, in which deceased youth were bullied. We report on an observational study conducted to determine the frequency of bullying as a contributing factor to youth suicide.

METHOD

Coroner records were reviewed for all suicide deaths in youth aged between 10 and 19 in the city of Toronto from 1998 to 2011. Data abstracted were recent stressors (including bullying), clinical variables, such as the presence of mental illness, demographics, and methods of suicide.

RESULTS

Ninety-four youth suicides were included in the study. The mean age was 16.8 years, and 70.2% were male. Bullying was present in 6 deaths (6.4%), and there were no deaths where online or cyberbullying was detected. Bullying was the only identified contributing factor in fewer than 5 deaths. The most common stressors identified were conflict with parents (21.3%), romantic partner problems (17.0%), academic problems (10.6%), and criminal and (or) legal problems (10.6%). Any stressor or mental and (or) physical illness was detected in 78.7% of cases. Depression was detected in 40.4% of cases.

CONCLUSIONS

Our study highlights the need to view suicide in youth as arising from a complex interplay of various biological, psychological, and social factors of which bullying is only one. It challenges simple cause-and-effect models that may suggest that suicide arises from anyone factor, such as bullying.

Suicide in children and young adolescents: a 25-year database on suicides from Northern Finland

Despite the large amount of research on adolescent suicidality, there are few detailed studies illustrating the characteristics of child and adolescent completed suicide. Our study presents the characteristics of child and adolescent suicides occurring over a period of 25 years within a large geographical area in Northern Finland, with a special focus on gender differences. The study sample included all 58 suicides among children and adolescents (<18 years) occurring in the province of Oulu in Finland between 1988 and 2012. The data is based on documents pertaining to establish the cause of death from forensic autopsy investigations. A register linkage to the data from the Finnish Hospital Discharge Register (FHDR) was also made. 79% of the suicide victims were male. Violent suicide methods predominated in both genders (males 98%, females 83%). While symptoms of mental illness were common, only a minority (15% of males and 17% of females) had a previous history of psychiatric hospitalization. 17% of females but none of the males had been hospitalized previously due to self-poisoning. A greater proportion of females than males had a history of self-cutting (33% vs. 7%) and previous suicide attempts (25% vs. 4%). 48% of males and 58% of females were under the influence of alcohol at the time of their suicide, and alcohol intoxication was related to suicides during the night. One fifth of the adolescents screened positive for substances other than alcohol. The results of this study indicate that there are similarities but also some differences in the characteristics of male and female suicides in adolescents.

Suizide im Kindes- und Jugendalter

Fragestellung: Für die Verbesserung suizidpräventiver Maßnahmen im Kindes- und Jugendalter sind aktuelle und regionale Daten zur psychosozialen Situation und Todesumstände der Suizidenten hilfreich. Methodik: Retrospektiv wurden alle im Zeitraum von 1996 bis 2008 rechtsmedizinisch bekannt gewordenen Suizidfälle bis zum Alter von 21 Jahren im Zuständigkeitsbereich des Instituts für Rechtsmedizin Frankfurt am Main deskriptiv ausgewertet. Es wurden 78 Todesfälle eingeschlossen und mit einer Vergleichsstichprobe von 1.797 erwachsenen Suizidenten (> 21 Jahre) verglichen. Ergebnisse: Im Untersuchungszeitraum zeigte sich ein Rückgang der Suizidhäufigkeit in der Altersklasse der ≤ 21-Jährigen um 44 %. Der Anteil Inhaftierter dieser Gruppe betrug 8.0 % im Vergleich zu 2.56 % in der Gruppe der Erwachsenen. Unterschiede zum Suizid im Erwachsenenalter zeigten sich auch im Hinblick auf suizidbegleitenden Substanzkonsum (seltenerer Nachweis von Alkohol, häufigerer Nachweis von Rauschdrogen) und Methodenwahl (häufigerer Bahnsuizid). Schlussfolgerungen: Inhaftierte Jugendliche bilden eine wichtige Risikogruppe für Suizidalität und sollten vermehrt gezielt präventive Maßnahmen erhalten. Die Hinweise für eine altersabhängige Assoziation von Drogenkonsum und Suiziden sollten in der jugendpsychiatrischen klinischen Tätigkeit Beachtung finden.

A longitudinal epidemiological comparison of suicide and other causes of death in Italian children and adolescents

The objective of the study is to evaluate temporal trends, gender effects and methods of completed suicide amongst children and adolescent (aged 10-17) when compared with temporal trends of deaths from other causes. Data were extracted from the Italian Mortality Database, which is collected by the Italian National Census Bureau (ISTAT) and processed by the Statistics Unit of National Centre for Epidemiology, Surveillance and Health Promotion (CNESPS) at the National Institute of Health (Istituto Superiore di Sanità). A total of 1,871 children and adolescents, age 10-17 years, committed suicide in Italy from 1971 to 2003 and 109 died by suicide during the last 3-year period of observation (2006-2008). The average suicide rate over the entire period of observation was 0.91 per 100,000; the rate was 1.21 for males and 0.59 for females. During the study period, the general mortality of children and adolescents, age 10-17 years, decreased dramatically, the average annual percentage change decrease was of -3.3% (95% CI -4.4 to -1.9) for males and -2.9% (95% IC -4.4 to -2.5) for females. The decrease was observed, for both genders, for all causes of deaths except suicide. For males, the most frequent method was hanging (54.5%), followed by shooting/fire arms (19.6%), falls/jumping from high places (12.7%); for females, the most frequent method, jumping from high places/falls, accounted for 35.7% of suicides during the whole study period. In conclusion, this study highlights that over the course of several decades suicide is a far less preventable cause of death as compared to other causes of death amongst children and adolescents. Our study demonstrated that suicide rates in adolescents are not a stable phenomenon over the 40 years period of study. It suggested that rates for males and females differed and varied in different ways during specific time periods of this study. National suicide prevention actions should parallel prevention measures implemented to reduce other causes of death.