Children and young people who die by suicide: childhood-related antecedents, gender differences and service contact

Progesterone receptor distribution in the human hypothalamus and its association with suicide

The human hypothalamus modulates mental health by balancing interactions between hormonal fluctuations and stress responses. Stress-induced progesterone release activates progesterone receptors (PR) in the human brain and triggers alterations in neuropeptides/neurotransmitters. As recent epidemiological studies have associated peripheral progesterone levels with suicide risks in humans, we mapped PR distribution in the human hypothalamus in relation to age and sex and characterized its (co-) expression in specific cell types. The infundibular nucleus (INF) appeared to be the primary hypothalamic structure via which progesterone modulates stress-related neural circuitry. An elevation of the number of pro-opiomelanocortin+ (POMC, an endogenous opioid precursor) neurons in the INF, which was due to a high proportion of POMC+ neurons that co-expressed PR, was related to suicide in patients with mood disorders (MD). MD donors who died of legal euthanasia were for the first time enrolled in a postmortem study to investigate the molecular signatures related to fatal suicidal ideations. They had a higher proportion of PR co-expressing POMC+ neurons than MD patients who died naturally. This indicates that the onset of endogenous opioid activation in MD with suicide tendency may be progesterone-associated. Our findings may have implications for users of progesterone-enriched contraceptives who also have MD and suicidal tendencies.

Conversational agents for depression screening: A systematic review

OBJECTIVE

This work explores the advances in conversational agents aimed at the detection of mental health disorders, and specifically the screening of depression. The focus is put on those based on voice interaction, but other approaches are also tackled, such as text-based interaction or embodied avatars.

METHODS

PRISMA was selected as the systematic methodology for the analysis of existing literature, which was retrieved from Scopus, PubMed, IEEE Xplore, APA PsycINFO, Cochrane, and Web of Science. Relevant research addresses the detection of depression using conversational agents, and the selection criteria utilized include their effectiveness, usability, personalization, and psychometric properties.

RESULTS

Of the 993 references initially retrieved, 36 were finally included in our work. The analysis of these studies allowed us to identify 30 conversational agents that claim to detect depression, specifically or in combination with other disorders such as anxiety or stress disorders. As a general approach, screening was implemented in the conversational agents taking as a reference standardized or psychometrically validated clinical tests, which were also utilized as a golden standard for their validation. The implementation of questionnaires such as Patient Health Questionnaire or the Beck Depression Inventory, which are used in 65% of the articles analyzed, stand out.

CONCLUSIONS

The usefulness of intelligent conversational agents allows screening to be administered to different types of profiles, such as patients (33% of relevant proposals) and caregivers (11%), although in many cases a target profile is not clearly of (66% of solutions analyzed). This study found 30 standalone conversational agents, but some proposals were explored that combine several approaches for a more enriching data acquisition. The interaction implemented in most relevant conversational agents is text-based, although the evolution is clearly towards voice integration, which in turns enhances their psychometric characteristics, as voice interaction is perceived as more natural and less invasive.

The association between academic pressure and adolescent mental health problems: A systematic review

BACKGROUND

Academic pressure is a potential contributor to adolescent mental health problems, but international evidence on this association has never been synthesised.

METHODS

We conducted the first systematic review of the association between academic pressure and adolescent depression, anxiety, self-harm, suicidality, suicide attempts and suicide. We searched MEDLINE, PsycINFO, ERIC and Web of Science (core collection) up to November 24, 2022, for studies of school-going children or adolescents, which measured academic pressure or timing within the school year as the exposure and depression, anxiety, self-harm, or suicidal ideation, attempts or suicide as outcomes. Risk of bias was assessed using the Mixed Methods Appraisal Tool. We used narrative synthesis to summarise the evidence. The review was prospectively registered with PROSPERO (CRD42021232702).

RESULTS

We included 52 studies. Most studies assessed mixed anxiety and depressive symptoms (n = 20) or depressive symptoms (n = 19). Forty-eight studies found evidence of a positive association between academic pressure or timing within the school year and at least one mental health outcome.

LIMITATIONS

Most studies were cross-sectional (n = 39), adjusted for a narrow range of confounders or had other limitations which limited the strength of causal inferences.

CONCLUSIONS

We found evidence that academic pressure is a potential candidate for public health interventions which could prevent adolescent mental health problems. Large population-based cohort studies are needed to investigate whether academic pressure is a causal risk factor that should be targeted in school- and policy-based interventions.

FUNDING

UCL Health of the Public; Wellcome Institutional Strategic Support Fund.

Online harms? Suicide-related online experience: a UK-wide case series study of young people who die by suicide

BACKGROUND

Few studies have examined online experience by young people who die by suicide.

METHODS

A 3-year UK-wide consecutive case series of all young people aged 10-19 who died by suicide, based on national mortality data. We extracted information on the antecedents of suicide of 544 of these 595 deaths (91%) from official investigations, mainly inquests.

RESULTS

Suicide-related online experience was reported in 24% (n = 128/544) of suicide deaths in young people between 2014 and 2016, equivalent to 43 deaths per year, and was more common in girls than boys (OR 1.87, 95% CI 1.23-2.85, p = 0.003) and those identifying as LGBT (OR 2.35, 95% CI 1.10-5.05, p = 0.028). Searching for information about method was most common (n = 68, 13%), followed by posting suicidal ideas online (n = 57, 10%). Self-harm, bereavement (especially by suicide), social isolation, and mental and physical ill-health were more likely in those known to have suicide-related online experience compared to those who did not. 29 (5%) were bullied online, more often girls (OR 2.84, 1.34-6.04, p = 0.007). Online bullying often accompanied face-to-face bullying (n = 16/29, 67%).

CONCLUSIONS

Suicide-related online experience is a common, but likely underestimated, antecedent to suicide in young people. Although its causal role is unclear, it may influence suicidality in this population. Mental health professionals should be aware that suicide-related online experience - not limited to social media - is a potential risk for young patients, and may be linked to experiences offline. For public health, wider action is required on internet regulation and support for children and their families.

Self-harm in university students: A comparative analysis of data from the Multicentre Study of Self-harm in England

BACKGROUND

Increases in poor mental health and suicide have been identified among university students in the UK. However, little is known about self-harm in this group.

AIMS

To describe and identify care needs of university aged-students who self-harm via comparisons with an age-equivalent non-student group who self-harm.

METHODS

Observational cohort data from The Multicentre Study of Self-harm in England were used to investigate students aged 18 to 24 years who presented to emergency departments for self-harm, 2003 to 2016. Data were collected via clinician reports and medical records from five hospitals in three English regions. Characteristics, rates, repetition, and mortality outcomes were investigated.

RESULTS

The student sample included 3491 individuals (983, 28.2 % men; 2507, 71.8 % women; 1 unknown) compared to 7807 (3342, 42.8 % men; 4465, 57.2 % women) non-students. Self-harm increased over time in students (IRR 1.08, 95%CI 1.06-1.10, p < 0.01) but not in non-students (IRR 1.01, 95%CI 1.00-1.02, p = 0.15). There were differences in monthly distribution of self-harm with more presentations by students in October, November, and February. Characteristics were broadly similar, but students reported more problems with studying and mental health. Repetition (HR 0.78, 95%CI 0.71-0.86, p < 0.01) and mortality (HR 0.51, 95%CI 0.33-0.80, p < 0.01) were lower in students than non-students.

CONCLUSIONS

Self-harm in students may be directly related the student experience, such as academic pressure, relocation, and the transition to independent living. Wellbeing initiatives targeting these factors, alongside mental health awareness training for academic and non-academic staff may help to support students at risk.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluating Postvention Services and the Acceptability of Models of Postvention: A Systematic Review

BACKGROUND

Suicide is a major public health issue that increases the risk of suicide for those bereaved by suicide themselves. There is a lack of evaluation of the effectiveness and acceptability of suicide postvention services supporting those bereaved by suicide.

AIMS

This review aimed to assess evaluations of postvention services supporting those bereaved by suicide and the acceptability of methods of postvention.

METHODS

Searches of peer-reviewed literature identified 36 studies for inclusion. 22 studies evaluated specific postvention services, 14 evaluated models of postvention.

RESULTS

Using the Mixed Methods Appraisal Tool, mixed-methods and qualitative postvention evaluation and acceptability research produce high-quality studies. Studies rated as low quality reflect poor reporting, rather than ineffective services.

CONCLUSION

Further evaluation of community-based postvention services within the UK is needed. This would evidence that services in the UK are effective in supporting those bereaved by suicide. Evaluation would benefit services in accessing funding, improve service development and provide holistic support.

Bereavement and suicide bereavement as an antecedent of suicide in children and young people: Prevalence and characteristics

INTRODUCTION

There is limited research into bereavement and suicide bereavement as an antecedent of suicide in young people.

METHODS

We extracted information on the antecedents of suicide from official reports, primarily coroner inquests, on a 3-year national consecutive case series of all UK deaths by suicide in people aged 10-19.

RESULTS

Between 2014 and 2016, there were 595 suicides by young people. 134 (25%) had been previously or recently bereaved; 51 (9%) by suicide, mainly of a friend or acquaintance. This is equivalent to 1 in 4 and 1 in 11, respectively, of all young people who die by suicide. Bereavement added to existing adversities - many antecedents of suicide were more likely in young people who were bereaved compared to those who were not, but there were few differences in the experiences of young people bereaved by suicide compared to other causes.

LIMITATIONS

This was an observational, not a risk factor study, and we did not use a control group. It is difficult to obtain data on non-suicide controls due to the ethical implications in contacting families, and the fact of suicide itself, its impact on disclosure and the reluctance of potential controls distorting any comparisons.

CONCLUSION

Lasting bereavement support needs to be routinely and immediately available for young people, including those who have experienced the death of a friend or acquaintance. Vigilance of agencies for bereaved young people is required, especially if there is evidence of other adversities.

People Who Die by Suicide Without Receiving Mental Health Services: A Systematic Review

Introduction

The majority of people who die by suicide have never seen a mental health professional or been diagnosed with a mental illness. To date, this majority group has largely been ignored, with most existing research focusing on predictors of suicide such as past suicide attempts. Identifying the characteristics of people who die by suicide without receiving services, often with a fatal first attempt, is crucial to reduce suicide rates through guiding improvements to service pathways and “just in time” interventions.

Methods

In this systematic review, PsycInfo, PubMed, CINAHL, and Web of Science were searched for peer-reviewed articles published from 1980 to 1st March 2021. Included studies examined predictors of non-receipt of formal mental health services among people who died by suicide. Data were extracted from published reports and the quality of included studies was assessed using a modified version of the Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies. This review was registered with PROSPERO, CRD 42021226543.

Results

Sixty-seven studies met inclusion criteria, with sample sizes ranging from 39 to 193,152 individuals. Male sex, younger or older age, and rural location were consistently associated with non-receipt of mental health services. People not receiving mental health services were also less likely to have a psychiatric diagnosis, past suicidal behavior or contact with general health services, and more likely to use violent means of suicide. There was some evidence that minority ethnicity and psychosocial stressors were associated with service non-receipt.

Conclusion

People who die by suicide without receiving mental health services are likely to have diverse profiles, indicating the need for multifaceted approaches to effectively support people at risk of suicide. Identifying the needs and preferences of individuals who are at risk of suicide is crucial in developing new support pathways and services, and improving the quality of existing services.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42021226543.

Suicide After Contact With Child and Adolescent Mental Health Services-A National Registry Study

BACKGROUND

Research has shown a strong association between suicide and mental disorders, and people in contact with services for mental health and substance use are known to be at high risk of suicide. Still, few studies have previously described suicide among young people in contact with Child and Adolescent Mental Health Services.

AIM

The aim of this study is to examine the prevalence of contact and suicide rates by gender and age groups, and to describe patient demographics and service utilization in secondary mental health services.

METHODS

All young people in contact with Child and Adolescent Mental Health Services in the year prior to death in the period 2008-2018 were identified by linking the Norwegian Cause of Death Registry and the Norwegian Patient Registry. We estimated the prevalence of contact and suicide rates among those with and without contact, by gender and age groups. Characteristics of treatment contact were compared between boys and girls. Variables with significant differences were entered into a multivariate logistic regression model using gender as an outcome.

RESULTS

More girls (39.7%) than boys (11.8%) had contact with Child and Adolescent Mental Health Services in the year prior to death. Among girls, suicide rates per 100,000 patients increased linearly in the age groups 10-13, 14-16, and 17-19 years: 5, 22, and 38 per 100,000 patients, respectively. Among boys, the suicide rate increased sharply from 7 per 100,000 patients in the age group 14-16 years to 40 per 100,000 patients in the 17-19-year-old group. In the age-adjusted multivariate model, boys were 4.07 (1.22-14.44, p = 0.024) times more likely to have terminated contact at the time of death.

CONCLUSION

This study shows gender differences in both suicide rates and service utilization among young people in contact with Child and Adolescent Mental Health Services before suicide, and future studies should focus on identifying the causes of these gender differences in service contact.

Pandemic-related emergency psychiatric presentations for self-harm of children and adolescents in 10 countries (PREP-kids): a retrospective international cohort study

To examine the differences in hospital emergency psychiatric presentations for self-harm of children and adolescents during the covid-19 lockdown in March and April 2020 compared with the same period in 2019. Retrospective cohort study. We used electronic patient records from 23 hospital emergency departments in ten countries grouped into 14 areas. We examined data on 2073 acute hospital presentations by 1795 unique children and adolescents through age 18. We examined the total number of emergency psychiatric hospital presentations and the proportion of children and adolescents presenting with severe self-harm as our two main outcome measures. In addition, we examined sociodemographic and clinical characteristics and clinical management variables for those presenting with self-harm. To compare the number of hospital presentations between 2020 and 2019 a negative binomial model was used. For other variables, individual participant data (IPD) meta-analyses were carried out. Emergency psychiatric hospital presentations decreased from 1239 in 2019 to 834 in 2020, incident rate ratio 0.67, 95% CI 0.62-0.73; p < 0.001. The proportion of children and adolescents presenting with self-harm increased from 50% in 2019 to 57% in 2020, odds ratio 1.33, 1.07-1.64; p = 0.009 but there was no difference in the proportion presenting with severe self-harm. Within the subpopulation presenting with self-harm the proportion of children and adolescents presenting with emotional disorders increased from 58 to 66%, odds ratio 1.58, 1.06-2.36; p = 0.025. The proportion of children and adolescents admitted to an observation ward also decreased from 13 to 9% in 2020, odds ratio 0.52, 0.28-0.96; p = 0.036. Service planners should consider that, during a lockdown, there are likely to be fewer emergency psychiatric presentations. Many children and adolescents with psychiatric emergencies might not receive any service. A focus on developing intensive community care services with outreach capabilities should be prioritised.

Child suicide rates during the COVID-19 pandemic in England

Background

There is concern about the impact of COVID-19, and the control measures to prevent the spread, on children's mental health. The aim of this work was to identify if there had been a rise of childhood suicide during the COVID pandemic.

Method

Using data from England's National Child Mortality Database (NCMD) the characteristics and rates of children dying of suicide between April and December 2020 were compared with those in 2019. In a subset (1st January to 17th May 2020) further characteristics and possible contributing factors were obtained.

Results

A total of 193 likely childhood deaths by suicide were reported. There was no evidence overall suicide deaths were higher in 2020 than 2019 (RR 1.09 (0.80-1.48), p = 0.584) but weak evidence that the rate in the first lockdown period (April to May 2020) was higher than the corresponding period in 2019 (RR 1.56 (0.86-2.81), p = 0.144). Characteristics of individuals were similar between periods. Social restrictions (e.g. to education), disruption to care and support services, tensions at home and isolation appeared to be contributing factors.

Limitations

As child suicides are fortunately rare, the analysis is based on small numbers of deaths with limited statistical power to detect anything but major increases in incidence.

Conclusion

We found no consistent evidence that child suicide deaths increased during the COVID-19 pandemic although there was a possibility that they may have increased during the first UK lockdown. A similar peak was not seen during the following months, or the second lockdown.

Suicide in children and young people: Can it happen without warning?

BACKGROUND

Parents bereaved by suicide often say the death of their loved one happened "out of the blue". It is common for suicide in young people to be preceded by a number of indications of risk, including self-harm, the communication of suicidal ideas, and recent contact with services. We examined whether there is a group of young people who die by suicide without explicit warning signs, and if they indicate risk indirectly, through other suicide risk factors.

METHODS

Using national mortality data, we identified a three-year UK national case series of deaths by suicide in people aged 10-19. We extracted information on the antecedents of suicide from coroner inquests and other official investigations into these deaths.

RESULTS

There were 595 suicides by young people between 2014 and 2016. We obtained data for 544 (91%). Around a third (n = 161, 30%) had no known history of suicidal ideas or self-harm. This group also had low rates of other risk factors for suicide, including substance misuse, a mental health diagnosis, recent adverse life events, and of contact with services.

LIMITATIONS

We relied on information provided to inquests and other investigations: under-reporting, especially on sensitive issues, is likely. Families and other witnesses may have under-reported warning signs that suggest they could have intervened.

CONCLUSION

Suicide after minimal warning appears to be relatively common in young people. Suicidal ideas may develop rapidly in this age group and crisis services should therefore be widely available. Future prevention cannot rely on explicit expressions of risk.