Repetition risk for adolescent self-poisoning: a multiple event survival analysis

A pragmatic randomised controlled trial and economic evaluation of family therapy versus treatment as usual for young people seen after second or subsequent episodes of self-harm: the Self-Harm Intervention - Family Therapy (SHIFT) trial

BACKGROUND

Self-harm in adolescents is common and repetition rates high. There is limited evidence of the effectiveness of interventions to reduce self-harm.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of family therapy (FT) compared with treatment as usual (TAU).

DESIGN

A pragmatic, multicentre, individually randomised controlled trial of FT compared with TAU. Participants and therapists were aware of treatment allocation; researchers were blind to allocation.

SETTING

Child and Adolescent Mental Health Services (CAMHS) across three English regions.

PARTICIPANTS

Young people aged 11-17 years who had self-harmed at least twice presenting to CAMHS following self-harm.

INTERVENTIONS

Eight hundred and thirty-two participants were randomised to manualised FT delivered by trained and supervised family therapists (n = 415) or to usual care offered by local CAMHS following self-harm (n = 417).

MAIN OUTCOME MEASURES

Rates of repetition of self-harm leading to hospital attendance 18 months after randomisation.

RESULTS

Out of 832 young people, 212 (26.6%) experienced a primary outcome event: 118 out of 415 (28.4%) randomised to FT and 103 out of 417 (24.7%) randomised to TAU. There was no evidence of a statistically significant difference in repetition rates between groups (the hazard ratio for FT compared with TAU was 1.14, 95% confidence interval 0.87 to 1.49; p = 0.3349). FT was not found to be cost-effective when compared with TAU in the base case and most sensitivity analyses. FT was dominated (less effective and more expensive) in the complete case. However, when young people's and caregivers' quality-adjusted life-year gains were combined, FT incurred higher costs and resulted in better health outcomes than TAU within the National Institute for Health and Care Excellence cost-effectiveness range. Significant interactions with treatment, indicating moderation, were detected for the unemotional subscale on the young person-reported Inventory of Callous-Unemotional Traits (p = 0.0104) and the affective involvement subscale on the caregiver-reported McMaster Family Assessment Device (p = 0.0338). Caregivers and young people in the FT arm reported a range of significantly better outcomes on the Strengths and Difficulties Questionnaire. Self-reported suicidal ideation was significantly lower in the FT arm at 12 months but the same in both groups at 18 months. No significant unexpected adverse events or side effects were reported, with similar rates of expected adverse events across trial arms.

CONCLUSIONS

For adolescents referred to CAMHS after self-harm, who have self-harmed at least once before, FT confers no benefits over TAU in reducing self-harm repetition rates. There is some evidence to support the effectiveness of FT in reducing self-harm when caregivers reported poor family functioning. When the young person themselves reported difficulty expressing emotion, FT did not seem as effective as TAU. There was no evidence that FT is cost-effective when only the health benefits to participants were considered but there was a suggestion that FT may be cost-effective if health benefits to caregivers are taken into account. FT had a significant, positive impact on general emotional and behavioural problems at 12 and 18 months.

LIMITATIONS

There was significant loss to follow-up for secondary outcomes and health economic analyses; the primary outcome misses those who do not attend hospital following self-harm; and the numbers receiving formal FT in the TAU arm were higher than expected.

FUTURE WORK

Evaluation of interventions targeted at subgroups of those who self-harm, longer-term follow-up and methods for evaluating health benefits for family groups rather than for individuals.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN59793150.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 12. See the NIHR Journals Library website for further project information.

Population attributable risk of factors associated with the repetition of self-harm behaviour in young people presenting to clinical services: a systematic review and meta-analysis

The repetition of hospital-treated self-harm by young people is common. However, little work has summarised the modifiable factors associated with this. A thorough understanding of those factors most strongly associated with repetition could guide the development of relevant clinical interventions. We systematically reviewed four databases (EMBASE, Medline, PubMed and PsycINFO) until 15 April 2016 to identify all observational studies of factors for the repetition of self-harm or suicide reattempts (together referred to as 'self-harm behaviour') in young people. We quantified the magnitude of association with odds ratios (OR) and 95% confidence intervals (CIs) and calculated the population attributable risk (PAR) and population preventable fraction (PPF) for modifiable factors to provide an indication of the potential impact in reducing subsequent self-harm behaviour in this population. Seventeen studies were included comprising 10,726 participants. Borderline personality disorder (OR 3.47, 95% CI 1.84-6.53; PAR 42.4%), any personality disorder (OR 2.54, 95% CI 1.71-3.78; PAR 16.3%), and any mood disorder (OR 2.16, 95% CI 1.09-4.29; PAR 42.2%) are important modifiable risk factors. Severity of hopelessness (OR 2.95, 95% CI 1.74-5.01), suicidal ideation (OR 2.01, 95% CI 1.43-2.81), and previous sexual abuse (OR 1.52, 95% CI 1.02-2.28; PAR 12.8%) are also associated with repetition of self-harm. We recommend that clinical services should focus on identifying key modifiable risk factors at the individual patient level, whilst the reduction of exposure to child and adolescent sexual abuse would also be a useful goal for public health interventions.

Epidemiology of overdose episodes from the period prior to hospitalization for drug poisoning until discharge in Japan: An exploratory descriptive study using a nationwide claims database

Background

Little is known about the nationwide epidemiology of the annual rate, causative substance, and clinical course of overdose-related admission. We aimed to describe the epidemiology of overdose episodes from the period prior to hospitalization for drug poisoning until discharge to home.

Methods

We assessed all cases of admission due to overdose (21,663 episodes) in Japan from October 2012 through September 2013 using the National Database of Health Insurance Claims and Specific Health Checkups of Japan.

Results

The annual rate of overdose admission was 17.0 per 100,000 population. Women exhibited two peaks in admission rates at 19–34 years (40.9 per 100,000) and ≥75 years (27.8 per 100,000). Men exhibited one peak in the admission rate at ≥75 years (23.7 per 100,000). Within 90 days prior to overdose, ≥60% and ≥9% of patients aged 19–49 years received a prescription for benzodiazepines and barbiturates, respectively. In addition, 59% of patients aged ≥75 years received a prescription for benzodiazepines prior to overdose, 47% had a history of congestive heart failure, and 24% had a diagnosis of poisoning by cardiovascular drugs. The proportion of patients with recent psychiatric treatments decreased with age (65.1% in those aged 35–49 years and 13.9% in those aged ≥75 years).

Conclusions

The findings emphasize the need for overdose prevention programs that focus on psychiatric patients aged 19–49 years who are prescribed benzodiazepines or barbiturates and on non-psychiatric patients aged ≥75 years who are prescribed benzodiazepines or digitalis.

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Benzodiazepines were prescribed to ≥59% of overdose patients aged ≥19 years.

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Cardiovascular drugs were frequently ingested among overdose patients aged ≥75 years.

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The proportions of patients with recent psychiatric treatments decreased with age.

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Overdose prevention should be optimized according to the age-related differences.

Risk of recurrent overdose associated with prescribing patterns of psychotropic medications after nonfatal overdose

OBJECTIVE

We aimed to estimate risk of recurrent overdose associated with psychosocial assessment by psychiatrists during hospitalization for nonfatal overdose and prescribing patterns of psychotropic medications after discharge.

METHODS

A retrospective cohort study was conducted using a nationwide claims database in Japan. We classified patients aged 19-64 years hospitalized for nonfatal overdose between October 2012 and September 2013 into two cohorts: 1) those who had consulted a psychiatrist prior to overdose (n=6,790) and 2) those who had not (n=4,950). All patients were followed up from 90 days before overdose until 365 days after discharge.

RESULTS

Overall, 15.3% of patients with recent psychiatric treatment had a recurrent overdose within 365 days, compared with 6.0% of those without psychiatric treatment. Psychosocial assessment during hospital admission had no significant effect on subsequent overdose, irrespective of treatment by psychiatrists before overdose. There was a dose-response relationship for the association of benzodiazepine prescription after overdose with subsequent overdose in either cohort, even after accounting for average daily dosage of benzodiazepines before overdose and other confounders. In patients with recent psychiatric treatment, the cumulative proportion of recurrent overdose at 365 days was 27.7% for patients receiving excessive dosages of benzodiazepines, 22.0% for those receiving high dosages, 15.3% for those receiving normal dosages, and 7.6% for those receiving no benzodiazepines. In patients without psychiatric treatment, the cumulative proportion of recurrent overdose at 365 days was 24.3% for patients receiving excessive dosages of benzodiazepines, 18.0% for those receiving high dosages, 9.0% for those receiving normal dosages, and 4.1% for those receiving no benzodiazepines.

CONCLUSION

Lower dose of benzodiazepines after overdose is associated with lower risk of subsequent overdose.

Adolescent deliberate self-poisoning in South-East Melbourne

OBJECTIVE

To describe the characteristics of adolescents presenting with deliberate self-poisoning (DSP) to a large Australian healthcare network.

METHOD

This is a retrospective chart review of 12-17 year olds presenting to three Monash Health EDs with self-poisoning from January 2012 to December 2014.

RESULTS

There were 35 207 adolescent presentations in the study period. A total of 721 cases were for DSP (2%), and 501 (1.4%) presented with recreational or accidental self-poisoning. The most common DSP toxicants were paracetamol (28%), non-steroidal anti-inflammatory agents (15%) and serotonin reuptake inhibitors (10%). Of the DSP presentations, 96% were impulsive events; 23% of patients (n = 129) presented on multiple occasions, and 67% of all DSP cases had a past psychiatric history, particularly depression (57%). Disposition for DSP patients included 60% discharged home, 6% short stay unit, 19% medical admission, 13% psychiatric admission and 2% intensive care unit admission. There were no mortalities.

CONCLUSION

Adolescent DSP presentations frequently involved impulsive ingestion of over-the-counter medications, suggesting less access to prescription medications. Additionally, pre-existing mental health history and re-presentation were common. Initiatives to prevent DSP might include an increased focus on the early identification and management of mental health problems in adolescents in the community.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

OBJECTIVE

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.

METHOD

Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSION

The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

Self-Harm Intervention: Family Therapy (SHIFT), a study protocol for a randomised controlled trial of family therapy versus treatment as usual for young people seen after a second or subsequent episode of self-harm

BACKGROUND

Self-harm is common in the community with a lifetime prevalence of 13 %. It is associated with an elevated risk of overall mortality and suicide. People who harm themselves are high users of public services. Estimates of the 1-year risk of repetition vary between 5 and 15 % per year. Currently, limited evidence exists on the effectiveness of clinical interventions for young people who engage in self-harm. Recent reviews have failed to demonstrate any effect on reducing repetition of self-harm among adolescents receiving a range of treatment approaches. Family factors are particularly important risk factors associated with fatal and non-fatal self-harm among children and adolescents. Family therapy focuses on the relationships, roles and communication patterns between family members, but there have been relatively few studies of specifically family-focused interventions with this population. The Self-Harm Intervention: Family Therapy (SHIFT) Trial was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme (grant no. 07/33/01) following a commissioned call for this research.

METHODS/DESIGN

SHIFT is a pragmatic, phase III, multicentre, individually randomised, controlled trial comparing Family Therapy (FT) with treatment as usual (TAU) for adolescents aged 11 to 17 who have engaged in at least two episodes of self-harm. Both therapeutic interventions were delivered within the National Health Service (NHS) Child and Adolescent Mental Health Services (CAMHS) in England. Participants and therapists were, of necessity, aware of treatment allocation, but the researchers were blind to the allocations to allow unbiased collection of follow-up data. Primary outcome data (repetition of self-harm leading to hospital attendance 18 months post-randomisation) were collected from the Health and Social Care Information Centre (HSCIC), augmented by directed searches of medical records at Acute Trusts. Secondary outcome data (including suicidal intent, depression, hopelessness and health economics) were collected at 12 and 18 months post-randomisation via researcher-participant interviews and by post at 3 and 6 months.

DISCUSSION

SHIFT will provide a well-powered evaluation of the clinical and cost effectiveness of Family Therapy for young people who have self-harmed on more than one occasion. The study will be reported in 2016, and the results will inform clinical practice thereafter.

TRIAL REGISTRATION

ISRCTN59793150 . 26 January 2009.

Exposure to psychotropic medications prior to overdose: a case-control study

RATIONALE

Little is known about psychotropic medication prescriptions prior to drug overdose.

OBJECTIVES

We aimed to examine the possible associations between the risk of overdose and exposures to various psychotropic medications.

METHODS

We conducted a matched case-control study of 3 groups of patients aged 12-74 years, using a large-scale health insurance claims database in Japan (population 1.2 million). A total of 351 cases with drug poisoning were compared with two control groups without overdose: 1755 patients with any treatment (general controls) and those with depression (high-risk controls). Current, past, and nonusers were patients most recently exposed to psychotropic medications ≤ 90 days, 91-180 days, and ≥ 180 days before the index date.

RESULTS

Current sedative-hypnotic use was associated with an increased odds of overdose relative to general control nonusers (odds ratio [OR], 21.5; 95 % confidence interval [CI], 9.7-47.8) and high-risk control nonusers (OR, 2.6; 95 % CI, 1.9-3.5). In the comparison of cases and high-risk controls, the ORs for overdose were higher among excessive dosage users than among usual dosage users (OR, 4.3; 95 % CI, 3.0-6.1), among barbiturate users than among benzodiazepine/Z-drug only users (OR, 4.5; 95 % CI, 2.3-8.7), and among multiple provider episodes than among single provider episodes (OR, 4.4; 95 % CI, 1.7-11.0). Psychiatrists prescribed more than 77 % of potentially questionable prescriptions.

CONCLUSIONS

These results highlight the need for psychiatrists to monitor prescribed medications and balance the benefits and risks of pharmacological treatments.

Self-poisoning with medications in adolescents: a national register study of hospital admissions and readmissions

OBJECTIVE

To examine characteristics of hospital admissions and risk factors associated with rehospitalization for self-poisoning with medications in adolescents aged 10-19 years.

METHOD

This study used data from the Norwegian Patient Register from 2008 to 2011. The main outcome was hospital readmission within the observation period. A complementary log-log regression model was used to assess the effect of characteristics at index hospital admission on readmission.

RESULTS

Of 1497 patients, 76.4% were females and 89.8% were aged 15-19 years. At their first hospital admission, about one third received a secondary psychiatric diagnosis. Females (47.5%) were registered with an E-code for intentional self-harm more often than males (33.7%), and females were more often than males discharged to further treatment (27.8% vs. 21.5%). As many as 18.4% were rehospitalized for self-poisoning by medications. Significant predictors for hospital readmission were female sex [hazard ratio (HR) = 2.4, 95% confidence interval (CI) 1.7-3.6], discharge to further treatment (HR = 2.3, 95% CI 1.8-2.9) and psychiatric secondary diagnoses (HR = 1.5, 95% CI 1.2-1.9).

CONCLUSION

This national study demonstrated significant sex differences in adolescents treated in hospital for self-poisoning with medications. Psychiatric secondary diagnoses had a strong predictive effect on readmission, which indicates the importance of psychiatric/psychosocial assessment of adolescents who are admitted to hospital for self-poisoning with medications.

Child maltreatment and repeat presentations to the emergency department for suicide-related behaviors

OBJECTIVES

To identify factors associated with repeat emergency department (ED) presentations for suicide-related behaviors (SRB) - hereafter referred to as repetition - among children/youth to aid secondary prevention initiatives. To compare rates of repetition in children/youth with substantiated maltreatment requiring removal from their parental home with their peers in the general population.

METHODS

A population-based (retrospective) cohort study was established for children/youth with a first ED SRB presentation at risk for repetition in the Province of Ontario, Canada between 1 January 2004 and 31 December 2008. Children/youth legally removed from their parental home because of substantiated maltreatment (n=179) and their population-based peers (n=6,305) were individually linked to administrative health care records over time to ascertain social, demographic, and clinical information and subsequent ED presentations for SRB during follow-up. These children/youth were described and their repetition-free probabilities over time compared. To identify factors associated with repetition we fit multivariable, recurrent event survival analysis models stratified by repetition and present unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Children/youth with substantiated maltreatment (as noted) were two times more likely to have repetition than their peers after adjustments for social, demographic, and clinical factors (conditional on prior ED SRB presentations). A number of these factors were independently associated with repetition. No one factor distinguished between having a first and second repetition nor was more strongly associated with repetition than another.

CONCLUSIONS

The risk of repetition is higher in children with substantiated maltreatment (as noted) than their peers. No one factor stood out as predictive of repetition. Implications for secondary prevention initiatives include a non-selective approach, sensitive to family difficulties and the need to better contextualize repetition and harness data linkages.

Characteristics, procedural differences, and costs of inpatients with drug poisoning in acute care hospitals in Japan

OBJECTIVES

This study aimed to describe the clinical and procedural characteristics of drug poisoning, to examine procedural differences between drug poisoning repeaters and non-repeaters, and to estimate the costs of drug poisoning.

METHODS

A retrospective cohort study of a nationally representative sample of 6585 inpatients with drug poisoning was conducted, using the administrative database of the Diagnosis Procedure Combination/Per-Diem Payment System in 2008.

RESULTS

Although only 3% of patients required surgery and 65% were discharged from the hospitals within 3 days, greater than 30% were admitted to tertiary emergency care (i.e., high-level emergency care) centers that provide care to severely ill and trauma patients who require intensive care. Only 30% of patients received psychiatric consultation during hospitalization. In addition, repeaters were less likely to be admitted to hospitals by ambulance (67% vs. 76%) and more likely to be discharged within 3 days (77% vs. 65%) than non-repeaters. The annual economic burden of drug poisoning in Japan was $66 million (¥7.7 billion), with the population aged 20-39 years accounting for 50% of these costs.

CONCLUSION

This study highlights the need for optimally allocating resources and improving prevention strategies.

Psychosocial assessment and repetition of self-harm: the significance of single and multiple repeat episode analyses

BACKGROUND

Self-harm is a common reason for presentation to the Emergency Department. An important question is whether psychosocial assessment reduces risk of repeated self-harm. Repetition has been investigated with survival analysis using various models, though many are not appropriate for recurrent events.

METHODS

Survival analysis was used to investigate associations between psychosocial assessment following an episode of self-harm and subsequent repetition, including (i) one repeat, and (ii) recurrent repetition (≤5 repeats) using (a) an independent episodes model, and (b) a stratified episodes model based on a conditional risk set. Data were from the Multicentre Study on Self-harm in England, 2000 to 2007.

RESULTS

Psychosocial assessment following an index episode of self-harm was associated with a 51% (95% CI 42%-58%) decreased risk of a repeat episode in persons with no psychiatric treatment history, and 26% (95% CI 8%-34%) decreased risk in those with a treatment history. For recurrent repetition, assessment was associated with a 57% (95% CI 51%-63%) decreased risk of repetition assuming independent episodes, and 13% (95% CI 1%-24%) decreased risk accounting for ordering and correlation of episodes by the same person (stratified episodes model). All models controlled for age, gender, method, history of self-harm, and centre differences.

LIMITATIONS

Some missing data on psychiatric treatment for non-assessed patients.

CONCLUSIONS

Psychosocial assessment appeared to be beneficial in reducing the risk of repetition, especially in the short-term. Findings for recurrent repetition were highly dependent on model assumptions. Analyses should fully account for ordering and correlation of episodes by the same person.

Group therapy for repeated deliberate self-harm in adolescents: failure of replication of a randomized trial

OBJECTIVE

To replicate a study, which found group therapy superior to routine care in preventing the recurrence of self-harming behavior in adolescents who had deliberately harmed themselves on at least two occasions.

METHOD

Single blind study with parallel randomized groups undertaken in three sites in Australia. The primary outcome measure was repetition of self-harm, assessed on average after 6 and 12 months. Secondary outcome measures included suicidal ideation, psychiatric disorder, and service use.

RESULTS

Seventy-two adolescents aged 12 to 16 years (91% female subjects) were randomized to group therapy or routine care. Primary outcome data were available for 68 of the 72 randomized participants. More adolescents randomized to group therapy than those randomized to routine care had self-harmed by 6 months (30/34 versus 23/34, chi = 4.19, p =.04), and there was a statistically nonsignificant trend for this pattern to be repeated in the interval of 6 to 12 months (30/34 versus 24/34, chi = 3.24, p =.07). There were few differences between the treatment groups on secondary outcome measures, other than a trend for greater improvement over time on global symptom ratings among the experimental group compared with the control group.

CONCLUSIONS

Our findings contradict those of the original study. Some differences in participant characteristics between the studies, along with less experience at the Australian sites in delivering the intervention, may have accounted for the different outcome. The benefit of group therapy for deliberate self-harm is unproven outside the environment in which it was originally developed.

Is medicine use in adolescence risk behavior? Cross-sectional survey of school-aged children from 11 to 15

PURPOSE

To examine the association between smoking, drunkenness, and medicine use for headache, stomachache, difficulties in getting to sleep, and nervousness in a representative sample of 11- to 15-year-old school-aged children.

DESIGN

Cross-sectional school-based survey.

SETTING

A random sample of schools in Denmark in 2002.

PARTICIPANTS

All students in the fifth, seventh and ninth grades in these schools, n = 4824.

MEASUREMENTS

Self-reported medicine use for headache, stomachache, difficulties in getting to sleep, and nervousness within the last month; self-reported experience of drunkenness; self-reported smoking.

RESULTS

There was a strong and graded association between drunkenness and medicine use, even in models adjusted for the symptom for which the medicine was taken. There was a similar association between medicine use and smoking.

CONCLUSIONS

The findings suggest that medicine use can be regarded as part of a cluster of risk behaviors among young people.

An examination of cutting and other methods of DSH among children and adolescents presenting to an outpatient psychiatric clinic in New Zealand

This article explores the issue of cutting among children and adolescents presenting to an outpatient child and adolescent mental health service in New Zealand. Of interest is the extent to which children and adolescents who cut themselves also carry out other forms of deliberate self-harm (DSH). This study found that there was much cross over in the methods of DSH used and that cutters were not a distinguishable group. Therefore, those who present to mental health services with cutting need to be treated as carrying significant risk of fatality.

Substance use and suicidal conduct: a study of adolescents hospitalized for suicide attempt and ideation

AIM

To study the prevalence of psychoactive substance use disorder (PSUD) among suicidal adolescents, psychoactive substance intoxication at the moment of the attempt, and the association between PSUD at baseline and either occurrence of suicide or repetition of suicide attempt(s).

METHODS

186 adolescents aged 16 to 21 y hospitalized for suicide attempt or overwhelming suicidal ideation were included (T0); 148 of them were traced again for evaluations after 6 mo (T1) and/or 18 mo (T2). DSM-IV diagnoses were assessed each time using the Mini International Neuropsychiatric Interview.

RESULTS

At T0, 39.2% of the subjects were found to have a PSUD. Among them, a significantly higher proportion was intoxicated at the time of the attempt than those without PSUD (44.3% vs 25.4%). Among the 148 adolescents who could be traced at either T1 or T2, two died from suicide and 30 repeated suicide attempts once or more times. A marginally significant association was found between death by suicide/repetition of suicide attempt and alcohol abuse/dependence at baseline (OR=3.3, 95% CI 0.7-15.0; OR=2.6, 95% CI 0.7-9.3). More than one suicide attempt before admission to hospital at T0 (OR=3.2, 95% CI 1.1-10.0) and age over 19 y at T0 (OR=3.2, 95% CI 1.1-9.2) were independently associated with the likelihood of death by suicide or repetition of suicide attempt.

CONCLUSION

Among adolescents hospitalized for suicide attempt or overwhelming suicidal ideation, the risk of death or repetition of attempt is high and is associated with previous suicide attempts--especially among older adolescents--and also marginally associated with PSUD; these adolescents should be carefully evaluated for such risks and followed up once discharged from the hospital.