Health Care Resources and Mental Health Service Use Among Suicidal Adolescents

Systematic Review and Meta-analysis: International Prevalence of Suicidal Ideation and Attempt in Youth

OBJECTIVE

Globally, rates of youth suicide vary considerably. Suicidal thoughts and behaviors (STB) are consistently associated with risk of death by suicide. However, international trends in STB have not yet been compared. To address this gap, an international meta-analysis of epidemiological and school-based studies that report on STB in youth was conducted.

METHOD

Systematic searches were conducted in PubMed and PsycINFO through April 2022. Eligible studies included prevalence of active suicidal ideation (SI) or suicide attempts (SA) in community youth younger than age 22. All studies were coded by 2 authors. Mixed models accounting for shared methods and including hypothesized moderators were conducted using the metafor package in R.

RESULTS

There were 371 effect sizes for SI, 94 for SI with a plan, and 316 for SA, representing 149 regions. Year of data collection ranged from 1981 to 2021. Participants were 6 to 21 years old. The prevalence of SI ranged across regions from 14.3% to 22.6%; the prevalence of SA ranged from 4.6% to 15.8%. Year was not associated with increasing STB prevalence except for studies from the United States, which showed increasing rates of SI and SA since 2007.

CONCLUSION

This is the most comprehensive meta-analysis of STB in youth, providing valuable data about how risk factors most commonly associated with suicide vary internationally and over time. International rates of STB among youth are not improving and may be getting worse in the United States, despite efforts to reduce suicide risk. Most studies did not report rates of SI or SA separately for LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and others) youth and youth of color. A better understanding of proximal risk at the individual level will be important to informing future prevention efforts, especially for high-risk groups.

Is anybody there? A longitudinal examination of help-seeking and suicidal risk among Latino, Black, and non-Hispanic white adolescents

INTRODUCTION

Understanding adolescents' and emerging adults' help-seeking behaviors is important to curb suicidal thoughts and behaviors (STB), especially among racial/ethnic minorities who have some of the highest chronic rates of STB in the United States. Learning how diverse groups of adolescents seek help during emotional crises can help us understand the stark health disparities related to suicide risk and respond to them in culturally informed ways.

METHODS

The study observed adolescents via a nationally representative sample (n = 20,745) over 14 years (National Longitudinal Study of Adolescents to Adult Health [Add Health]) to examine the association between help-seeking behaviors and STB. Longitudinal multinomial logistic regressions were run to assess for racial/ethnic and gender disparities.

RESULTS

Help-seeking was not protective for Black female STB but alternatively was protective for each male group (non-Hispanic white, Black, and Latino). Latinas in their early-to-late 20s with no self-reported STB were at an extremely high risk of suicide attempts just 6 years later.

CONCLUSIONS

This is the first study to examine race/ethnicity*gender in six independent groups to assess suicidality longitudinally among a nationally representative sample. Tailoring existing interventions to meet the needs of growing and diverse communities is critical for suicide prevention programs and policies.

Predictors of not receiving mental health services among people at risk of suicide: A systematic review

BACKGROUND

The majority of people who die by suicide are unknown to formal mental health services. The current review identified predictors of non-receipt of mental health services among individuals experiencing suicidal thoughts or behaviours. Such data provides insight into the needs and preferences of these individuals and inform improvements to existing services.

METHODS

PsycInfo, PubMed/Medline, CINAHL, and Web of Science were systematically searched from 1st January 1980 up to 20th September 2021. Included studies examined predictors of not receiving formal mental health services among people at risk of suicide. Study quality was assessed by adapting the Joanna-Briggs Institute Checklist for Analytical Cross-Sectional Studies. Findings were presented with narrative synthesis. PROSPERO registration: CRD42021256795.

RESULTS

Included studies (n = 35, sample range = 46-19,243) were predominately conducted in the United States. Non-receipt of services in nationally representative studies was varied (25.7-91.8%). Results indicate that non-receipt of mental health services among people with suicidality is associated with minority ethnicity, better perceived general health, lower psychological distress, lower severity of suicidality, no mental health diagnosis, lower perceived need for treatment and lower use of medical services.

LIMITATIONS

Limitations included few studies conducted in low-middle income countries, limited literature on key predictors of interest, and exclusion of informal sources of support.

CONCLUSION

Individuals with suicidality who are unknown to mental health services have diverse attributes. For some, non-use of services may result from low suicidal distress and perceived need for treatment. Further research is needed to understand why these predictors are associated with service non-use.

Socioeconomic differences in psychiatric treatment before and after self-harm: an observational study of 4,280 adolescents and young adults

BACKGROUND

Individuals in higher socioeconomic positions tend to utilise more mental health care, especially specialist services, than those in lower positions. Whether these disparities in treatment exist among adolescents and young adults who self-harm is currently unknown.

METHODS

The study is based on Finnish administrative register data on all individuals born 1986-1994. Adolescents and young adults with an episode of self-harm treated in specialised healthcare at ages 16-21 in 2002-2015 (n=4280, 64% female) were identified and followed 2 years before and after the episode. Probabilities of specialised psychiatric inpatient admissions and outpatient visits and purchases of psychotropic medication at different time points relative to self-harm were estimated using generalised estimation equations, multinomial models and cumulative averages. Socioeconomic differences were assessed based on parental education, controlling for income.

RESULTS

An educational gradient in specialised treatment and prescription medication was observed, with the highest probabilities of treatment among the adolescents and young adults with the highest educated parents and lowest probabilities among those whose parents had basic education. These differences emerged mostly after self-harm. The probability to not receive any treatment, either in specialised healthcare or psychotropic medication, was highest among youth whose parents had a basic level of education (before self-harm 0.39, 95% CI 0.34-0.43, and after 0.29, 95% CI 0.25-0.33 after) and lowest among youth with higher tertiary educated parents (before self-harm: 0.22, 95% CI 0.18-0.26, and after 0.18, 95% CI 0.14-0.22). The largest differences were observed in inpatient care.

CONCLUSIONS

The results suggest that specialised psychiatric care and psychotropic medication use are common among youth who self-harm, but a considerable proportion have no prior or subsequent specialised treatment. The children of parents with lower levels of education are likely to benefit from additional support in initiating and adhering to treatment after an episode of self-harm. Further research on the mechanisms underlying the educational gradient in psychiatric treatment is needed.

Availability and accessibility of primary mental health services for adolescents: an overview of national recommendations and services in EU

BACKGROUND

Mental health problems in adolescence can profoundly jeopardize adolescent current and future health and functioning. We aimed to describe existing recommendations and services regarding the delivery of primary mental health care for adolescents in 31 European countries.

METHODS

Data on the availability and accessibility of primary mental health services were collected, as part of the Horizon 2020-funded project Models of Child Health Appraised. One expert from each country answered a closed items questionnaire during years 2017-18.

RESULTS

All 31 participating countries had some policy or recommendations regarding the availability and accessibility of primary mental health services for adolescents, but their focus and implementation varied largely between and within countries. Only half of the participating countries had recommendations on screening adolescents for mental health issues and burdens. Merely a quarter of the countries had ambulatory facilities targeting specifically adolescents throughout the whole country. Just over half had some kind of suicide prevention programs. Same-day access to primary care in case of -health emergencies was possible in 21 countries, but often not throughout the whole country. Nineteen countries had strategies securing accessible mental health care for vulnerable adolescents.

CONCLUSIONS

Overall, around half of European countries had strategies securing access to various primary mental health care for adolescents. They frequently did not guarantee care over the whole country and often tackled a limited number of situations. EU countries should widen the range of policies and recommendations governing the delivery of mental health care to adolescents and monitor their implementation.

An Enhanced Social Networking Intervention for Young People with Active Suicidal Ideation: Safety, Feasibility and Acceptability Outcomes

Online social networking interventions have potential to support young people who experience suicidal thoughts by specifically addressing interpersonal risk factors for suicide, but may also pose a risk of harm. This uncontrolled, single-group pilot study aimed to evaluate the safety, feasibility, and acceptability of an enhanced online social networking intervention ("Affinity") among a sample of young people who experienced active suicidal ideation, and to explore potential changes in clinical outcomes and the therapeutic targets of the intervention. Twenty young people with current or recent suicidal ideation who were receiving treatment for depression at a tertiary-level mental health service were given access to Affinity for two months. Participants were assessed at baseline and 8-week follow-up; 90 percent reported clinical suicidal ideation at baseline. A priori criteria related to feasibility, safety and acceptability were satisfied. In terms of potential clinical effects, significant and reliable pre-post improvements were found on self-report outcomes including suicidal ideation. This study provides initial world-first evidence to support the use of an online intervention incorporating social networking as an adjunct to treatment for young people who experience suicidal ideation. The effectiveness of Affinity needs to be evaluated in a randomised controlled trial.

Supporting Our Valued Adolescents (SOVA), a Social Media Website for Adolescents with Depression and/or Anxiety: Technological Feasibility, Usability, and Acceptability Study

BACKGROUND

Supporting Our Valued Adolescents (SOVA), a social media website for adolescents, was designed to increase mental health literacy and address negative health beliefs toward depression and/or anxiety diagnosis and treatment. This stakeholder-informed site underwent iterative user testing to evolve into its current version with daily blog posts, round-the-clock site moderation, and Web-based peer interaction to create an online support community.

OBJECTIVE

The aim of this study was to evaluate the technological feasibility (at least 100 users on the site, logging in 12 to 18 times in the first 6 weeks) and acceptability of the SOVA site determined by the System Usability Scale (SUS).

METHODS

Adolescents and young adults (aged 14-26 years) with a self-reported history of depressive and/or anxiety symptoms were recruited to access the research website (sova.pitt.edu). Participants were screened out if they reported active suicidality or a prior suicide attempt. Baseline survey measures included demographics, symptomatology using the Patient Health Questionnaire-9 modified for adolescents (PHQ-9A) and Screen for Child Anxiety Related Disorders (SCARED-C), and mental health treatment history. The 6-week follow-up measures taken in addition to the symptomatology, included feasibility (total number of log-ins), usability, and acceptability of SOVA using SUS.

RESULTS

Most of the 96 participants identified as female (75% [72/96]) and white (67% [64/96]). Most participants (73% [70/96]) reported having taken prior professional psychological help. The average PHQ-9A score was 11.8 (SD 5.5), and for SCARED-C, 85% (80/94) of the participants reported a score consistent with being susceptible to a diagnosed anxiety disorder. There were 46% (41/90) of eligible users who ever logged in. Out of the total users who ever logged in, the mean of total log-ins over the entire study was 4.1 (SD 6.9). Median number of users rated the user-friendliness of the site as "good." The average SUS score was 71.2% (SD 18.7), or a "C-grade," which correlated to an acceptable range. The participants reported to have liked the "easy-to-understand format" and "positive, helpful atmosphere," but they also reported a desire for greater social interaction. Iterative recruitment resulted in incremental improvements to the site.

CONCLUSIONS

The SOVA site met feasibility goals of recruiting almost 100 users and establishing acceptable usability. Subsequent interventions are planned to increase site engagement and to evaluate efficacy in increasing uptake of primary care-recommended depression and/or anxiety treatment.

Disparities in access to care in marginalized populations

PURPOSE OF REVIEW

The current article reviews recent literature related to three groups whose health is affected by barriers to the healthcare system: refugee and immigrant populations; youth who are lesbian, gay, bisexual, transgender, queer, or questioning; and those with mental health problems.

RECENT FINDINGS

Refugee and immigrant populations are increasing worldwide, and recent work has focused on improving their access to mental, dental, and preventive care. Lesbian, gay, bisexual, transgender, queer, or questioning youth have unique healthcare needs but frequently lack a support system and may not be forthcoming about their sexuality or sex identity. A rising number of children are being diagnosed with mental health disorders, but due to multiple factors, youth are not receiving the care they need.

SUMMARY

Pediatric healthcare providers should be aware of the unique challenges faced by youth displaced from their country of origin, who are lesbian, gay, bisexual, or transgender or are questioning their sexuality or sex identity, and who struggle with mental health disorders. Toolkits, other educational resources, and novel technological advances can assist pediatricians in ensuring optimal health care of these at-risk groups.