Hospitalization for Suicide Ideation or Attempt: 2008-2015

ADHD and cognitive disengagement syndrome symptoms related to self-injurious thoughts and behaviors in early adolescents

The current study examined attention-deficit/hyperactivity disorder (ADHD) dimensions and cognitive disengagement syndrome (CDS) symptoms in relation to self-injurious thoughts and behaviors (SITBs) in an early adolescent sample. Participants were 341 adolescents ages 10-12 years (52.2% female; 37.8% people of color) recruited from the community. Caregivers reported on CDS and ADHD symptoms. Adolescents completed a rating scale and were administered an interview assessing SITBs. We estimated associations using logistic regression in a stepped fashion: (1) no adjustment, (2) adjustment for sex, race, family income, and psychotropic medication use, and (3) further adjustment for depressive symptoms. In this early adolescent community sample, 22.9% reported a history of suicidal ideation, 8.2% reported a history of a suicide plan, 6.2% reported a history of non-suicidal self-injury (NSSI), and 16.4% met a clinical cutoff for current suicide risk. Across most analyses using rating scale or interview methods, higher mean CDS scores were related to endorsement of suicidal ideation and planning. ADHD inattentive (IN) and hyperactive-impulsive (HI) symptoms were associated with endorsement of NSSI, and ADHD-IN symptoms were associated with thoughts of suicide and/or plan measured via questionnaire, though effects were less robust and not significant, potentially due to low base rates impacting statistical power. This study adds to a growing body of research highlighting the importance of screening for CDS symptoms among individuals with and without ADHD. More research, especially longitudinal work, is needed that examines possible differential pathways to SITBs by ADHD and CDS symptoms to advance SITB prevention, early detection, and intervention.

Using a Digital Mental Health Intervention for Crisis Support and Mental Health Care Among Children and Adolescents With Self-Injurious Thoughts and Behaviors: Retrospective Study

BACKGROUND

Self-injurious thoughts and behaviors (SITBs) are increasing dramatically among children and adolescents. Crisis support is intended to provide immediate mental health care, risk mitigation, and intervention for those experiencing SITBs and acute mental health distress. Digital mental health interventions (DMHIs) have emerged as accessible and effective alternatives to in-person care; however, most do not provide crisis support or ongoing care for children and adolescents with SITBs.

OBJECTIVE

To inform the development of digital crisis support and mental health care for children and adolescents presenting with SITBs, this study aims to (1) characterize children and adolescents with SITBs who participate in a digital crisis response service, (2) compare anxiety and depressive symptoms of children and adolescents presenting with SITBs versus those without SITBs throughout care, and (3) suggest future steps for the implementation of digital crisis support and mental health care for children and adolescents presenting with SITBs.

METHODS

This retrospective study was conducted using data from children and adolescents (aged 1-17 y; N=2161) involved in a pediatric collaborative care DMHI. SITB prevalence was assessed during each live session. For children and adolescents who exhibited SITBs during live sessions, a rapid crisis support team provided evidence-based crisis support services. Assessments were completed approximately once a month to measure anxiety and depressive symptom severity. Demographics, mental health symptoms, and change in the mental health symptoms of children and adolescents presenting with SITBs (group with SITBs) were compared to those of children and adolescents with no SITBs (group without SITBs).

RESULTS

Compared to the group without SITBs (1977/2161, 91.49%), the group with SITBs (184/2161, 8.51%) was mostly made up of adolescents (107/184, 58.2%) and female children and adolescents (118/184, 64.1%). At baseline, compared to the group without SITBs, the group with SITBs had more severe anxiety and depressive symptoms. From before to after mental health care with the DMHI, the 2 groups did not differ in the rate of children and adolescents with anxiety symptom improvement (group with SITBs: 54/70, 77% vs group without SITBs: 367/440, 83.4%; χ21=1.2; P=.32) as well as depressive symptom improvement (group with SITBs: 58/72, 81% vs group without SITBs: 255/313, 81.5%; χ21=0; P=.99). The 2 groups also did not differ in the amount of change in symptom severity during care with the DMHI for anxiety (t80.20=1.37; P=.28) and depressive (t83.75=-0.08; P=.99) symptoms.

CONCLUSIONS

This study demonstrates that participation in a collaborative care DMHI is associated with improved mental health outcomes in children and adolescents experiencing SITBs. These results provide preliminary insights for the use of pediatric DMHIs in crisis support and mental health care for children and adolescents presenting with SITBs, thereby addressing the public health issue of acute mental health crisis in children and adolescents.

Admissions to paediatric medical wards with a primary mental health diagnosis: a systematic review of the literature

OBJECTIVE

To systematically review the literature describing children and young people (CYP) admissions to paediatric general wards because of primary mental health (MH) reasons, particularly in MH crisis.

DESIGN

PubMed, Embase, PsycINFO, Web of Science and Google Scholar were searched, with no restriction on country or language. We addressed five search questions to inform: trends and/or the number of admissions, the risk factors for adverse care, the experiences of CYP, families/carers and healthcare professionals (HCPs) and the evidence of interventions aimed at improving the care during admissions.Two reviewers independently assessed the relevance of abstracts identified, extracted data and undertook quality assessment. This review was registered with PROSPERO (CRD42022350655).

RESULTS

Thirty-two studies met the inclusion criteria. Eighteen addressed trends and/or numbers/proportions of admissions, 12 provided data about the views/experiences of HCPs, two provided data about CYP's experiences and four explored improving care. We were unable to identify studies examining risk factors for harm during admissions, but studies did report the length of stay in general paediatric/adult settings while waiting for specialised care, which could be considered a risk factor while caring for this group.

CONCLUSIONS

MH admissions to children's wards are a long-standing issue and are increasing. CYP will continue to need to be admitted in crisis, with paediatric wards a common location while waiting for assessment. For services to be delivered effectively and for CYP and their families/carers to feel supported and HCPs to feel confident, we need to facilitate more integrated physical and MH pathways of care.

PROSPERO REGISTRATION NUMBER

CRD42022350655.

Development and Implementation of Postdischarge Text Messages to Adolescents With Suicidal Thoughts and Behaviors Through Caring Contacts: Implementation Study

BACKGROUND

Youth suicide is a pressing public health concern, and transitions in care after a suicidal crisis represent a period of elevated risk. Disruptions in continuity of care and emotional support occur frequently. "Caring contacts" validating messages post discharge have the potential to enhance connections with patients and have been shown to improve outcomes. More recently, positive outcomes have been noted using caring contact text messages (SMS and MMS), which hold promise for engaging patients in a pediatric setting, but there are few studies describing the large-scale implementation of such an approach.

OBJECTIVE

This study aims to describe the process of developing and implementing automated caring contacts within a quality improvement framework, using a standardized series of supportive texts and images, for adolescents discharged from high-acuity programs at a large midwestern pediatric hospital. We describe lessons learned, including challenges and factors contributing to success.

METHODS

We implemented the caring contacts intervention in 3 phases. Phase 1 entailed developing supportive statements and images designed to promote hope, inclusivity, and connection in order to create 2 sets of 8 text messages and corresponding images. Phase 2 included piloting caring contacts manually in the hospital's Psychiatric Crisis Department and Inpatient Psychiatry Unit and assessing the feasibility of implementation in other services, as well as developing workflows and addressing legal considerations. Phase 3 consisted of implementing an automated process to scale within 4 participating hospital services and integrating enrollment into the hospital's electronic medical records. Process outcome measures included staff compliance with approaching and enrolling eligible patients and results from an optional posttext survey completed by participants.

RESULTS

Compliance data are presented for 4062 adolescent patients eligible for caring contacts. Overall, 88.65% (3601/4062) of eligible patients were approached, of whom 52.43% (1888/3601) were enrolled. In total, 94.92% (1792/1888) of enrolled participants completed the program. Comparisons of the patients eligible, approached, enrolled, and completed are presented. Primary reasons for eligible patients declining include not having access to a mobile phone (686/1705, 40.23%) and caregivers preferring to discuss the intervention at a later time (754/1705, 44.22%). The majority of patients responding to the optional posttext survey reported that the texts made them feel moderately to very hopeful (219/264, 83%), supported (232/264, 87.9%), that peers would be helped by these texts (243/264, 92%), and that they would like to keep receiving texts given the option (227/264, 86%).

CONCLUSIONS

This study describes the successful implementation of automated postdischarge caring contacts texts to scale with an innovative use of images and demonstrates how a quality improvement methodology resulted in a more effective and efficient process. This paper also highlights the potential for technology to enhance care for at-risk youth and create more accessible, inclusive, and sustainable prevention strategies.

The InterSECT Framework: a proposed model for explaining population-level trends in substance use and emotional concerns

Across high-income countries, adolescent emotional concerns have been increasing in prevalence over the past two decades and it is unclear why this is occurring, including whether and how substance use relates to these changing trends. On the other hand, substance use has been generally declining, and little is known about the role of emotional concerns in these trends. Several studies have explored the changes in co-occurring substance use and emotional concerns among adolescents over time, with mixed results and inconsistent messaging about the implications of the findings. In response, we developed a theoretical framework for exploring the intersection between trends in substance use and emotional concerns (InterSECT Framework). This framework includes a discussion and related examples for 3 core hypotheses: (1) strengthening of co-occurrence, or the "hardening" hypothesis; (2) co-occurrence staying the same, or the "consistency" hypothesis; and (3) weakening of co-occurrence, or the "decoupling" hypothesis. This framework seeks to guide the conceptualization, evaluation, and understanding of changes in the co-occurrence of substance use and emotional concerns over time, including outlining a research agenda informed by pre-existing research and youth perspectives.

Examining temporal trends in psychological distress and the co-occurrence of common substance use in a population-based sample of grade 7-12 students from 2013 to 2019

PURPOSE

Characterizing trends and correlates of adolescent psychological distress is important due to observed global increases over the last 20 years. Substance use is a commonly discussed correlate, though we lack an understanding about how co-occurrence of these concerns has been changing over time.

METHODS

Data came from repeated, representative, cross-sectional surveys of grade 7-12 students across Ontario, Canada conducted biennially from 2013 to 2019. Poisson regression with robust standard errors was used to examine changes in the joint association between psychological distress (operationalized as Kessler-6 [K6] scores ≥ 13) and substance use over time. Weighted prevalence ratios (PR) and their 99% confidence intervals were estimated, where p < 0.01 denotes statistical significance.

RESULTS

The prevalence of psychological distress doubled between 2013 and 2019, with adjusted increases of about 1.2 times each survey year. This biennial increase did not differ based on sex, perceived social standing, school level, or any substance use. Students using substances consistently reported a higher prevalence of psychological distress (between 1.2 times and 2.7 times higher). There were similarly no differential temporal trends based on substance use for very high distress (K6 ≥ 19) or K6 items explored individually.

CONCLUSION

Psychological distress steeply increased among adolescents and substance use remains important to assess and address alongside distress. However, the magnitude of temporal increases appears to be similar for adolescents reporting and not reporting substance use.

Patterns of health service use for children with mental disorders in an Australian state population cohort

OBJECTIVES

The rate of mental health services provided to children and young people is increasing worldwide, including in Australia. The aim of this study was to describe patterns of hospital and ambulatory mental health service use among a large population cohort of adolescents followed from birth, with consideration of variation by age, sex and diagnosis.

METHODS

Characteristics of services provided for children with mental disorder diagnoses between birth and age 17.5 years were ascertained for a population cohort of 85,642 children (52.0% male) born between 2002 and 2005, from 'Admitted Patients', 'Emergency Department' and 'Mental Health Ambulatory' records provided by the New South Wales and Australian Capital Territory Health Departments.

RESULTS

A total of 11,205 (~13.1%) children received at least one hospital or ambulatory health occasion of service for a mental health condition in the observation period. More than two-fifths of children with mental disorders had diagnoses spanning multiple categories of disorder over time. Ambulatory services were the most heavily used and the most common point of first contact. The rate of mental health service contact increased with age across all services, and for most categories of mental disorder. Girls were more likely to receive services for mental disorders than boys, but boys generally had an earlier age of first service contact. Finally, 3.1% of children presenting to mental health services experienced involuntary psychiatric inpatient admission.

CONCLUSIONS

The extent of hospital and ambulatory-based mental healthcare service among children emphasises the need for primary prevention and early intervention.

Characteristics of drug overdose suicide attempts presenting to the psychiatric emergency department of Beijing Anding Hospital

BACKGROUND

Overdose-related suicide attempts represent a significant portion of self-harm presentations in the psychiatric emergency department (ED). Identifying specific patient characteristics associated with these attempts holds promise for pinpointing drug classes with elevated risk and paving the way for tailored suicide prevention interventions. This study aims to examine the demographic profiles of ED patients who had experienced overdose-related suicide attempts.

METHODS

This retrospective study was conducted at Beijing Anding Hospital, Capital Medical University, from January 2020 to December 2021. Patients with psychiatric drug overdose suicide attempts presenting to the psychiatric ED were included. Sociodemographic characteristics and the specific classes of drugs involved were collected, and analysed descriptively.

RESULTS

This study examined 252 overdose patients, excluding 51 patients treated with alcohol or nonpsychiatric drugs, and a total 201 cases were included. The mean age of the patients was 28 ± 16 years (median 23, range 12-78), and 82% (n = 165) of the sample were females. Notably, nearly half (45%) of the patients were aged ≤ 20 years. While the number of cases decreased with increasing age, a significant increase was observed in 2021 compared to 2020. Benzodiazepines (BZDs) were the most frequently implicated substance class (n = 126, 63%), followed by antidepressants (n = 96, 48%), antipsychotics (n = 44, 22%), Z-drugs (n = 43, 21%), and mood stabilizers (n = 36, 18%). For adolescents, antidepressants (n = 52, 71%) overtook BZDs (n = 38, 52%) as the most common drug. The monthly distribution of cases revealed peaks in April and November. Furthermore, 21% (n = 42) of patients ingested more than two psychotropic medications concurrently. Finally, approximately half (n = 92) of the patients required inpatient admission for further treatment. Comparisons between hospitalized and nonhospitalized patients did not reveal any significant differences.

CONCLUSIONS

The present study revealed a greater prevalence of suicide overdose attempts among young females receiving prescriptions for antidepressants and/or BZDs. This finding suggests a potential need for enhanced monitoring of suicidal behaviour in this specific population when prescribing psychotropic medications. These findings contribute to the growing body of knowledge regarding drug overdose suicide attempts in psychiatric emergency settings and underscore the importance of further research to develop targeted prevention interventions.

Psychosocial Correlates of Suicidal Ideation and Behavior in Adolescents and Preadolescent Children Discharged from an Emergency Department in Israel

OBJECTIVES

Adolescent suicidal behavior is highly prevalent in pediatric psychiatric emergency departments, and there is a growing occurrence of such behavior among preadolescent children. This study aims to examine the psychosocial factors associated with nonfatal suicidal behaviors in children (<12 years old) and adolescents (aged 12-18), to gain insight into unique and shared characteristics of suicidal behavior across these two age groups.

METHOD

This study investigates the psychosocial characteristics associated with suicidal ideation and behaviors in an emergency department sample of 183 children and adolescents aged 7-18 years in Israel. Participants completed a diagnostic interview, and self-report and parent-report questionnaires of psychosocial measures. Cross-sectional correlational and regression analyses were used to determine significant correlates of suicidal outcomes within the two age groups.

RESULTS

Among adolescents, females exhibited a higher prevalence of suicidal thoughts and behaviors, while in children, both boys and girls showed similar rates. Depression correlated with suicidal ideation for both adolescents and children. In children, anxiety and conduct symptoms were associated with suicidal behavior, whereas in adolescents, suicidal behavior was associated with depression and anxiety.

CONCLUSIONS

The present findings contribute to the growing understanding of factors associated with suicidal thoughts and behaviors among children in comparison to adolescents. These findings underscore the importance of targeting specific risk factors when developing assessment and intervention strategies tailored to the two age groups.

Measures of Suicidal Thoughts and Behaviors in Children and Adolescents: A Systematic Review and Recommendations for Use in Clinical and Research Settings

Empirically supported measures of suicidal thoughts and behaviors (STBs) are needed to serve as reference outcomes for suicide risk screening tools and to monitor severity and treatment progress in children and adolescents with STBs. The present paper systematically reviewed existing measures of STBs in youth and studies evaluating their psychometric properties and clinical utility. Measures were then evaluated on reliability, validity, and clinical utility. Sixteen articles (20 independent samples) were found with psychometric data with youth samples for eight measures. Interview-based measures were found to have the strongest psychometric support and clinical utility. Significant limitations exist for all self-report measures due to inherent characteristics of these measures that cannot be remedied through additional psychometric study. There is an urgent need for the development and validation of new self-report measures of STBs, particularly for preadolescent children, sexual and gender minority youth, and racial/ethnic minority youth.

Autistic traits in adolescents in psychiatric inpatient care: Clinical and demographic characteristics and correlates

Background

Rates of psychiatric hospitalization among adolescents in the United States are rising, with many adolescents presenting to these settings with diverse clinical presentations, including autistic traits. To our knowledge, there has been little research identifying clinical characteristics of adolescents with autistic traits admitted to psychiatric inpatient units, which may be leveraged to improve assessment and treatment practices.

Method

In the current study, we examined clinical and demographic characteristics of 195 adolescents admitted to an adolescent psychiatric inpatient unit. Specifically, we investigated the prevalence of adolescents endorsing elevated autistic traits and tested associations between autistic traits, psychiatric symptoms (anxiety, depression, suicidal thoughts), and key demographic variables (age, sex, gender, sexual orientation).

Results

Results show that over half of the adolescents admitted to the psychiatric inpatient unit reported elevated autistic traits on a short screening questionnaire. Higher autistic traits were significantly associated with more severe depressive symptoms, though to a small degree. Autistic traits were not associated with anxiety symptoms, suicidal thoughts, nor social disconnectedness, and did not differ by sex, gender identity, nor sexual orientation.

Conclusions

Findings highlight the challenge of diagnostic overshadowing among adolescents in crisis and the need for more rigorous measures designed for an inpatient setting to improve risk stratification, clinical assessments, intervention approaches, and discharge planning.

Translating Suicide Safety Planning Components Into the Design of mHealth App Features: Systematic Review

BACKGROUND

Suicide safety planning is an evidence-based approach used to help individuals identify strategies to keep themselves safe during a mental health crisis. This study systematically reviewed the literature focused on mobile health (mHealth) suicide safety planning apps.

OBJECTIVE

This study aims to evaluate the extent to which apps integrated components of the safety planning intervention (SPI), and if so, how these safety planning components were integrated into the design-based features of the apps.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically analyzed 14 peer-reviewed studies specific to mHealth apps for suicide safety planning. We conducted an analysis of the literature to evaluate how the apps incorporated SPI components and examined similarities and differences among the apps by conducting a comparative analysis of app features. An independent review of SPI components and app features was conducted by downloading the available apps.

RESULTS

Most of the mHealth apps (5/7, 71%) integrated SPI components and provided customizable features that expanded upon traditional paper-based safety planning processes. App design features were categorized into 5 themes, including interactive features, individualized user experiences, interface design, guidance and training, and privacy and sharing. All apps included access to community supports and revisable safety plans. Fewer mHealth apps (3/7, 43%) included interactive features, such as associating coping strategies with specific stressors. Most studies (10/14, 71%) examined the usability, feasibility, and acceptability of the safety planning mHealth apps. Usability findings were generally positive, as users often found these apps easy to use and visually appealing. In terms of feasibility, users preferred using mHealth apps during times of crisis, but the continuous use of the apps outside of crisis situations received less support. Few studies (4/14, 29%) examined the effectiveness of mHealth apps for suicide-related outcomes. Positive shifts in attitudes and desire to live, improved coping strategies, enhanced emotional stability, and a decrease in suicidal thoughts or self-harm behaviors were examined in these studies.

CONCLUSIONS

Our study highlights the need for researchers, clinicians, and app designers to continue to work together to align evidence-based research on mHealth suicide safety planning apps with lessons learned for how to best deliver these technologies to end users. Our review brings to light mHealth suicide safety planning strategies needing further development and testing, such as lethal means guidance, collaborative safety planning, and the opportunity to embed more interactive features that leverage the advanced capabilities of technology to improve client outcomes as well as foster sustained user engagement beyond a crisis. Although preliminary evidence shows that these apps may help to mitigate suicide risk, clinical trials with larger sample sizes and more robust research designs are needed to validate their efficacy before the widespread adoption and use.

Link between neurodevelopmental disorders and suicidal risk in children

INTRODUCTION

Suicide represents a significant public health issue among children and adolescents. However, in this population, while the literature seems to support a link between suicidal risk and neurodevelopmental disorders, there are still few studies on the subject. The psychopathological description of children who have realized a suicide attempt with a high potential for lethality, which can be defined as "serious", appears to resemble that of children who have died by suicide. This study aimed to characterize the dimensional aspects of the neurodevelopmental profile of a population of children and adolescents hospitalized at Necker-Enfants-Malades Hospital for a serious suicide attempt.

METHODS

This is an observational, prospective, and single-center study. Questionnaires for collecting general information and dimensional scales of neurodevelopment (Autism-Tics, ADHD, and Other Comorbidities Inventory, Social Responsiveness Scale, and Conners-3 for parents) were used. This study included 21 patients aged 9 to 15 years at the time of their hospitalization.

RESULTS

The results supported the presence of at least one neurodevelopmental disorder (autistic traits, attention-deficit/hyperactivity disorder, learning disorder, or motor disorder) in 70% (n=14) of the subjects, and at least one behavioral disorder (oppositional defiant disorder, conduct disorder) in 65% (n=13) of these subjects.

CONCLUSION

The observed frequency of traits indicative of neurodevelopmental disorders in our population was higher than that observed in the general population, without the presented symptoms being eligible for categorical diagnosis. Considering the dimensional aspects of neurodevelopmental symptoms would therefore enable better identification of children at suicidal risk and more tailored interventions to contribute to the prevention of suicide in children.

De-escalation of the Agitated Pediatric Patient: A Standardized Patient Case for Pediatric Residents

Introduction

Over the past 5 years, pediatric mental health emergencies requiring emergency safety evaluations and inpatient boarding of pediatric patients requiring psychiatric admission have increased. Pediatric trainees must learn to effectively and safely de-escalate a patient with agitated or aggressive behavior, as mental health patients take up a larger proportion of their patient population. This standardized patient case addresses gaps in knowledge and skills to ameliorate the care of children and adolescents with behavioral crises in the hospital.

Methods

Resident learners were presented with a teenage patient admitted to the hospital and awaiting inpatient psychiatric placement for suicidal ideation who became acutely agitated with aggressive behaviors. Learners were expected to attempt to verbally de-escalate the patient and select an appropriate pharmacologic agent for decreasing agitation in the patient. A standardized debrief was conducted with the assistance of child and adolescent mental health experts.

Results

Twenty-two learners participated in this activity. Residents' confidence in their management skills of the acutely agitated pediatric patient significantly increased after completion of the activity. Seventy-three percent of learners felt confident or very confident in their de-escalation skills at the end of the case, and 86% agreed that the case improved their confidence in managing acute agitation scenarios on the inpatient wards.

Discussion

This case led to overall increased self-efficacy in caring for the acutely agitated pediatric patient. Future iterations may include multidisciplinary learners of various skill levels and evaluating changes in patient-centered outcomes, such as restraint use, after implementation of the case.

Mental Health-Related Outpatient Visits Among Adolescents and Young Adults, 2006-2019

Importance

Concerns over the mental health of young people have been increasing over the past decade, especially with the rise in mental health burden seen during the COVID-19 pandemic. Examining trends in mental health-related outpatient visits provides critical information to elucidate contributing factors, identify vulnerable populations, and inform strategies to address the mental health crisis.

Objective

To examine characteristics and trends in mental health-related outpatient visits and psychotropic medication use among US adolescents and young adults.

Design, Setting, and Participants

A retrospective cross-sectional analysis of nationally representative data from the National Ambulatory Medical Care Survey, an annual probability sample survey, was conducted from January 2006 to December 2019. Participants included adolescents (age 12-17 years) and young adults (age 18-24 years) with office-based outpatient visits in the US. Data were analyzed from March 1, 2023, to September 15, 2023.

Main Outcomes and Measures

Mental health-related outpatient visits were identified based on established sets of diagnostic codes for psychiatric disorders. Temporal trends in the annual proportion of mental health-related outpatient visits were assessed, including visits associated with use of psychotropic medications. Analyses were stratified by age and sex.

Results

From 2006 to 2019, there were an estimated 1.1 billion outpatient visits by adolescents and young adults, of which 145.0 million (13.1%) were associated with a mental health condition (mean [SD] age, 18.4 [3.5] years; 74.0 million females [51.0%]). Mental health-related diagnoses were more prevalent among visits by male (16.8%) compared with female (10.9%) patients (P < .001). This difference was most pronounced among young adults, with 20.1% of visits associated with a psychiatric diagnosis among males vs 10.1% among females (P < .001). The proportion of mental health-related visits nearly doubled, from 8.9% in 2006 to 16.9% in 2019 (P < .001). Among all outpatient visits, 17.2% were associated with the prescription of at least 1 psychotropic medication, with significant increases from 12.8% to 22.4% by 2019 (P < .001).

Conclusions and Relevance

In this cross-sectional study, there were substantial increases in mental health-related outpatient visits and use of psychotropic medications, with greater overall burden among male patients. These findings provide a baseline for understanding post-pandemic shifts and suggest that current treatment and prevention strategies will need to address preexisting psychiatric needs in addition to the effects of the COVID-19 pandemic.

Impact of social media "challenges" on poison center case volume for intentional ingestions among school-aged children: an observational study

INTRODUCTION

Mental health problems among youth have escalated over the past decade, with increased rates of self-harm, including suicide attempts by ingestion. Social media use has been linked to youth mental health, including "challenges" urging youth to ingest substances for recreational and other purposes. We hypothesized that social media challenges for particular substances would temporally correspond with increased ingestions of these substances.

METHODS

We identified peak Google Trends search times for social media ingestion challenges involving diphenhydramine, laundry pods, nutmeg, and cinnamon, and used data from America's Poison Centers National Poison Data System to plot reported ingestions 3 months before and after peak searches in school-aged children.

RESULTS

There were 2,169 individuals in the analysis. Diphenhydramine was the most frequently reported ingestion for misuse/abuse and suicidal purposes (n = 266 and 1,609, respectively). For all ingestions together, 45 percent (n = 979) had a moderate health effect, and 6.35 percent (n = 137) had a major health effect. Time of peak searches corresponded with increased ingestions for each substance.

DISCUSSION

We found a temporal relationship between peak Google Trends searches for ingestion challenges and ingestions of that substance reported to United States poison centers. Compared to misuse/abuse ingestions, most suicidal ingestions peaked 1-2 months later, suggesting a public health opportunity for intervention.

LIMITATIONS

This retrospective observational study does not establish causal effect. All data are a result of self-reporting of the exposures, which may lead to a reporting bias. Google Trends is not the only search engine and likely underestimates the true incidence of social media posts.

CONCLUSIONS

Additional research is needed on the relationship between social media and youth mental health, particularly around "challenges" that place youths' health at risk. There may be opportunities for intervention to decrease medical and mental health sequelae of these challenges.

Research, practice, and data informed investigations of child and youth suicide: A science to service and service to science approach

BACKGROUND

Suicide rates for children and adolescents have been increasing over the past 2 decades. In April 2023, the National Institute of Mental Health (NIMH) convened a two-day workshop to address child and youth suicide.

PURPOSE

The workshop focus was to discuss the state of the science and stimulate a collaborative response between researchers, death investigators, and data collection teams to build a science to service and service to science approach toward understanding - and ultimately preventing - this growing problem of child and youth suicide.

HIGHLIGHTS

Topics that meeting participants highlighted as worthy of further consideration for research and practice were: increasing awareness among death investigators, medical examiners, and coroners that child suicide deaths under age 10 years do occur and should be investigated and documented accordingly; emphasizing the value of science based protocols for child and youth death investigations to enhance consistency of approaches; and articulating needs for postvention services to suicide loss survivors.

OUTCOMES

The importance of collecting an accurate and complete cause and manner of death (i.e., unintentional, suicide, homicide, undetermined) among all child decedents, and demographic information such as race, ethnicity, and sexual/gender minority status was underscored as critical for enhanced surveillance. For prevention efforts, approaches to assessing and understanding suicidal thoughts and behaviors among diverse groups of children, and the variability in proximal and distal risk factors are needed to inform opportunities for preventive interventions for diverse communities. The need for consistent measures and processes to improve death investigations, fatality review committees, and coordination between data collection systems and agencies was also raised.

PRACTICAL APPLICATIONS

Collaborations among researchers, death investigators, and data collection teams can help to fully describe the child and youth suicide crisis and provide actionable information for new research, and prevention and response efforts.

Mental Health Admissions to Paediatric Wards Study (MAPS): protocol of a prospective study of mental health admissions to paediatric wards in England using surveillance and qualitative methods

INTRODUCTION

Children and young people (CYP) presenting with a mental health (MH) crisis are frequently admitted to general acute paediatric wards as a place of safety. Prior to the pandemic, a survey in England showed that CYP occupied 6% of general paediatric inpatient beds due to an MH crisis, and there have been longstanding concerns about the quality of care to support these patients in this setting. MAPS aims to generate a Theory of Change (ToC) model to improve the quality of care for CYP admitted to acute paediatric services after presenting with an MH crisis. Here, we describe work packages (WPs) 2 and 3 of the study, which have been granted ethics approval.

METHODS AND ANALYSIS

We will undertake a national (England), sequential, mixed-methods study to inform a ToC framework alongside a stakeholder group consisting of patients, families/carers and healthcare professionals (HCPs). Our study consists of four WPs undertaken over 30 months. WP2 is limited to working with stakeholders to develop a data collection instrument and then use this in a prospective study of MH admissions over 6 months in 15 purposively recruited acute paediatric wards across England. WP3 consists of gathering the views of CYP, their families/carers and HCPs during admissions using semistructured interviews.

ETHICS AND DISSEMINATION

WP2 and WP3 received ethical approval (ref: 23/LO/0349). We will publish the overall synthesis of data and the final ToC to improve care of CYP with MH crisis admitted to general acute paediatric settings. As co-producers of the ToC, we will work with our stakeholder group to ensure wide dissemination of findings. Potential impacts will be upon service development, new models of care, training and workforce planning.

PROSPERO REGISTRATION NUMBER

CRD42022350655.

Comparative Effectiveness of Ultra-Brief, IPT-A Based Crisis Intervention for Suicidal Children and Adolescents

BACKGROUND

In recent years, suicidal thoughts and behaviors have become increasingly common among children and adolescents, leading to an elevation in the number of visits to emergency departments in pediatric hospitals. In Israel, the rising demand for mental health treatment due to suicidal distress is also salient, creating prolonged wait periods and low case acceptance rates. Addressing the urgent need for streamlined interventions, the present study outlines the design and results of a non-inferiority effectiveness trial of an ultra-brief suicide crisis intervention based on Interpersonal Psychotherapy for Adolescents (IPT-A-SCI).

METHODS

309 children and adolescents presenting to the Depression and Suicide Clinic at Schneider Children's Medical Center of Israel with depressive and anxiety symptoms and/or suicidal ideation/behavior were assigned to either IPT-A-SCI, Treatment as Usual (TAU), or waitlist condition. Assessments were conducted pre- and post-intervention/after five sessions/five weeks (as secondary assessments) in accordance with group assignment.

RESULTS

At secondary assessment, post IPT-A-SCI, suicide ideation, and behavior as well as depression and anxiety symptoms significantly decreased, with no group differences observed between IPT-A-SCI, TAU, and control groups.

CONCLUSION

IPT-A-SCI is feasible and as effective as the standard treatment in reducing suicidal, depressive, and anxiety symptoms among children and adolescents.

Big ideas series: self-regulation shift theory: trauma, suicide, and violence

BACKGROUND

Traumatic stress, suicide, and impulsive violence arguably are three of the most consequential problems facing societies today. Self-regulation shift theory is introduced to capture the underlying coping dynamics involved in these three grave challenges.

OBJECTIVES

Self-regulation shift theory, based in a nonlinear dynamical systems framework, focuses on critical psychological self-regulation thresholds and the role of cognitive self-appraisals in human adaptation to help understand these three significant societal challenges.

METHODS

This essay reviews existing evidence within the posttraumatic adaptation process utilizing SRST for understanding dynamic self-regulation. This is followed by integrating SRST within existing current theoretical models for suicidal behaviors and violent outbursts.

CONCLUSIONS

The essay concludes with methodological suggestions for future research applying SRST and how this research offers important opportunities to develop early warning systems that promote hope when hope seems impossible.

The intersection of race, ethnicity, and gender and the prevalence of suicidal thoughts and behaviors

The prevalence of suicidal thoughts and behaviors across distinct intersections of race/ethnicity and gender among adolescents remains understudied. The current study seeks to address this important gap in suicide scholarship using a statewide representative sample of U.S. Florida middle school and high school adolescents. Data drawn from the 2022 Florida Youth Substance Abuse Survey (FYSAS) (N = 41,764) were analyzed to examine disparities in suicidal thoughts and suicide attempts among 26 racial/ethnic and gender subgroups of middle school and high school aged adolescents. Survey-weighted prevalence estimates for both suicidality outcomes were generated, and binary contrasts were used to assess the statistical significance of the differences in the probabilities between members of each subgroup and youth belonging to all other subgroups. Our results indicate that the prevalence of suicidal thoughts and attempts was highly gendered and varied according to racial/ethnic subgroups. Native American girls reported more suicidal thoughts (49.9%) and attempts (16.5%) in the past 12 months than any race/gender group. Other racial/ethnic and gender groups that reported particularly high rates of suicidal thoughts and attempts were West Indian/Caribbean female adolescents (48.8% and 13.4%, respectively), Puerto Rican female adolescents (48.5% and 14.7%, respectively), and Black/non-Hispanic female adolescents (19.9% and 15.6%, respectively). Because certain gender and race/ethnic subgroups are at an increased risk for suicidality, more research is needed to better understand the risk and protective factors to determine which suicide prevention strategies might best serve each group.

Assessing suicidal thoughts and behaviors and nonsuicidal self-injury in autistic and non-autistic early adolescents using the Columbia Suicide Severity Rating Scale

LAY ABSTRACT

Autistic adolescents are more likely to experience suicidal thoughts and behaviors and nonsuicidal self-injury than non-autistic adolescents, per caregiver- and self-report on single-item questionnaires. Comprehensive, clinician-rated measures of suicide risk have not been used to measure suicidal thoughts and behaviors and nonsuicidal self-injury in autistic youth despite greater parent-child rating discrepancies among autistic youth than their non-autistic peers. The Columbia Suicide Severity Rating Scale is a widely used, clinician-rated measure of suicide risk that has not been tested with autistic youth. In this study, the Columbia Suicide Severity Rating Scale was employed to assess suicidal thoughts and behaviors and nonsuicidal self-injury in a community sample of 239 early adolescents (10:0-13:9 years old), of whom 138 youth were autistic and 101 were not autistic. Multiple analyses examined diagnostic (autistic vs non-autistic) and sex-based (male vs female) differences in suicidal thoughts and behaviors and nonsuicidal self-injury, as well as youth consistency in reporting across self- and clinician-rated measures. Findings show that a greater proportion of autistic youth reported lifetime suicidal thoughts and nonsuicidal self-injury than non-autistic youth; however, there were no sex-based differences. The majority of non-autistic youth were consistent in reporting suicidal thoughts on self- and clinician-rated measures; however, nearly one in five autistic youth disclosed suicidal thoughts on a self-report measure but not to a psychiatrist on the Columbia Suicide Severity Rating Scale. Findings suggest that autism diagnostic status, but not sex, confers significant risk for suicidal thoughts and behaviors and nonsuicidal self-injury in early adolescents and that the Columbia Suicide Severity Rating Scale may be a useful measure of suicide risk for some autistic youth, but it may not detect all autistic youth experiencing suicidal thoughts.

The rapid stabilization pathway: impact of a brief inpatient intervention on the length of stay and readmissions among psychiatrically hospitalized adolescents

BACKGROUND

Suicide is the second leading cause of death among adolescents in the United States (Centers for Disease Control and Prevention [CDC], 2017, Death rates due to suicide and homicide among persons age 10-24: United States, 2000-2017) constituting a significant public health crisis. The demand for psychiatric emergency services and inpatient beds is increasing, while the number of beds available decreases or remains static (National Association of State Mental Health Program Directors, 2017, Trend in psychiatric inpatient capacity, United States and Each State, 1970-2014. www.nasmhpd.org/sites/default/files/TACPaper.2.Psychiatric-Inpatient-Capacity_508C.pdf) leading to delays in treatment and exacerbation of symptoms for some adolescents awaiting care. This pilot project describes the development, feasibility, and acceptability of a creative, values-based safety planning intervention for adolescents hospitalized on an acute inpatient psychiatric unit and the impact of this intervention on length of stay and readmissions to acute psychiatric care.

METHODS

Thirty patients experiencing a suicidal crisis participated in the Rapid Stabilization Pathway (RSP) during their inpatient psychiatric admission.

RESULTS

Results indicate that, compared to patients who underwent inpatient treatment as usual (TAU), RSP patients were discharged after a significantly shorter length of stay (4 vs. 6.1 weekdays respectively, p < .001). Further, there was no significant difference in readmission to the inpatient unit or to the psychiatric emergency room among RSP and TAU patients at 30, 60, and 90 days postdischarge.

CONCLUSIONS

These findings have significant implications for acute inpatient programming. The RSP intervention treated patients in a shorter amount of time without any increase in re-admissions. Further, the shortened length of stay allowed for more patients to be treated on the inpatient unit and a significant cost savings. Future directions for programming and outcome research are discussed.

Implementation of a Children's Hospital Acute Care Behavior Response Team

BACKGROUND

Pediatric patients with behavioral needs are frequently admitted to the hospital for medical care; when behavioral crises occur, patients and staff are at risk for injury. Our aim was to implement a behavior response team (BRT) to increase the days between employee injury due to aggressive patient interactions on the inpatient medical units from 99 to 150 over 1 year.

METHODS

A multidisciplinary team used quality improvement methods to design and implement the BRT system that includes 2 options: huddle to proactively plan for patients exhibiting early signs of escalation and STAT for immediate help for patients with imminent risk of harm to self or others. Using run and statistical process control charts, we tracked events per month, days between Occupational Safety & Health Administration-recordable events, and violent restraint use over time for 1 year after implementation. Staff pre and postimplementation surveys were compared to assess staff perception of safety and support provided by the BRT intervention.

RESULTS

The BRT was implemented across the inpatient system in July 2020, with an average number of 13 events per month. Days between Occupational Safety & Health Administration-recordable events remained stable with a maximum of 134 days. Restraint use remained stable at 0.74 per 1000 patient days. The perception of behavioral support available to staff increased significantly pre to postsurvey.

CONCLUSIONS

The implementation of a BRT can improve staff perception of support and confidence in safely caring for patients with behavior needs on the inpatient medical unit, although additional provider- and system-level improvements are needed to prevent employee injuries.

Skills to Enhance Positivity in adolescents at risk for suicide: Protocol for a randomized controlled trial

BACKGROUND

Suicide and suicidal behavior during adolescence have been steadily increasing over the past two decades. The preponderance of interventions focuses on crisis intervention, underlying psychiatric disorders, regulating negative affect, and reducing cognitive distortions. However, low positive affectivity may be a mechanism that contributes to adolescent suicidal ideation and behaviors independent of other risk factors. Skills to Enhance Positivity (STEP) is an acceptance-based intervention, designed to increase attention to, and awareness of, positive affect and positive experiences. Results from a pilot RCT demonstrated engagement of the target (positive affect) and a decrease in clinical outcomes (suicidal events; i.e., either a suicide attempt or an emergency intervention for an acute suicidal crisis), providing support to test the clinical effectiveness of STEP in a larger clinical trial with clinical staff implementing the intervention.

OBJECTIVE

To test the effectiveness of STEP, compared to Enhanced Treatment as Usual (ETAU), in reducing suicidal events and ideation in adolescents admitted to inpatient psychiatric care due to suicide risk. We hypothesize that those randomized to STEP, compared to ETAU, will have lower rates of suicide events, active suicidal ideation (SI), and depressed mood over the 6-month follow-up period. We hypothesize that those randomized to STEP, compared to ETAU, will demonstrate greater improvement in the hypothesized mechanisms of attention to positive affect stimuli and gratitude and satisfaction with life.

METHODS

Participants will be randomized to either STEP or ETAU. STEP consists of four in-person sessions focused on psychoeducation regarding positive and negative affect, mindfulness meditation, gratitude, and savoring. Mood monitoring prompts and skill reminders will be sent via text messaging daily for the first month post-discharge and every other day for the following two months. The ETAU condition will receive text-delivered reminders to use a safety plan provided at discharge from the hospital and healthy habits messages, matched in frequency to the STEP group. This trial was registered on 6 August 2021 (ClinicalTrials.gov NCT04994873).

RESULTS

The STEP protocol was approved by the National Institute of Mental Health (NIMH) Data and Safety Monitoring Board on March 4, 2022. The RCT is currently in progress.

DISCUSSION

The STEP protocol is an innovative, adjunctive treatment that has the potential to have positive effects on adolescent suicidal ideation and attempts beyond that found for standard treatment alone.

Cannabis use disorder, suicide attempts, and self-harm among adolescents: A national inpatient study across the United States

BACKGROUND

Suicide is among the top three causes of adolescent mortality. There is a scarcity of research examining cannabis use and suicidal behavior in adolescents.

OBJECTIVES

To determine the association between cannabis use disorder (CUD) and suicide attempt/self-harm in a hospitalized sample of adolescents.

METHODS

We conducted a cross-sectional observation study using data from the Nationwide Inpatient Sample collected over four years from January 1, 2016, through December 31, 2019. We included adolescents aged 10-19 hospitalized during the above period (N = 807,105). The primary outcome was suicide attempt/self-harm and the main predictor was CUD. The International Classification of Diseases Tenth Revision (ICD 10) diagnostic codes was used to identify a diagnosis of CUD, suicide attempt/self-harm, and other diagnoses included in the analyses. Adolescents diagnosed with CUD (n = 53,751) were compared to adolescents without CUD (n = 753,354). Univariate and multivariate logistic regressions were conducted to determine the association between CUD and suicide attempts/self-harm.

RESULTS

807,105 adolescent hospitalizations were analyzed, of which 6.9% had CUD. Adolescents with CUD were more likely to be older (17 years vs. 15 years), female (52% vs. 48%), have depression (44% vs. 17%), anxiety (32% vs. 13%), an eating disorder (1.9% vs. 1.2%), ADHD (16.3% vs. 9.1%), Conduct Disorder (4.1% vs. 1.3%), Alcohol Use Disorder (11.9% vs. 0.8%), Nicotine Use Disorder (31.1% vs. 4.1%), Cocaine Use Disorder (5.4% vs. 0.2%), Stimulant Use Disorder (0.8% vs. 0.4%) and report suicide attempts/self-harm (2.8% vs. 0.9%) [all ps<0.001]. After adjusting for potential confounders, CUD was associated with a higher risk of suicide attempts/self-harm (OR = 1.4, 95% CI 1.3-1.6, p <0.001). Post-hoc analyses showed the presence of depression moderated the association between CUD and suicide attempts/self-harm in that adolescents with CUD and depression had 2.4 times the odds of suicide attempt/self-harm compared to those with CUD but no depression after controlling for potential confounders (p<0.001).

CONCLUSIONS

Our study provides evidence for the association between CUD and suicide risk among hospitalized adolescents and underscores the importance of recognizing and addressing co-occurring mental and substance use disorders along with CUD to mitigate suicide risk. Identifying high-risk adolescents in inpatient settings provides an opportunity for intervention.

Neurocognitive and clinical characteristics of elementary school-aged children with a history of suicidal thoughts and behaviors

BACKGROUND

Suicidal thoughts and behaviors (STBs) in elementary school-aged youth have increased in recent years. Understanding the risks associated with childhood STBs is necessary for prevention efforts.

METHODS

The current study examined clinical and neurocognitive characteristics of a community sample of elementary school-aged children with (STB+) and without (STB-) a history of STBs. The final sample included 93 families with children average age of 7.8 years (SD = 1.3). Children in this sample were racially diverse, evenly split by sex, and most identified as non-Hispanic. Neurocognitive functioning was assessed using computerized behavioral measures. Child clinical characteristics were assessed using self-report measures and STB history was assessed using semi-structured interviews.

RESULTS

Of the 93 families, 64 STB- children and 29 STB+ children participated. On average, STB+ children were older, reported higher levels of depressive and anxiety symptoms, and were more likely to have a parental history of suicidal behavior (PH+). Regarding neurocognitive functioning, STB+ children exhibited lower raw scores for both the NIH Dimensional Change Card Sort Task (NIH-DCCS) and NIH Flanker Inhibitory Control and Attention Test (NIH-Flanker). Multivariable regression analyses revealed raw scores for NIH-DCCS and NIH-Flanker, PH+ status, and child age were associated with childhood STBs.

LIMITATIONS

Prospective data is needed to confirm cross-sectional findings.

CONCLUSIONS

Poorer neurocognitive functioning and PH+ status may serve as risk markers for STBs in elementary school-aged children. Targeting prevention programming for these risks may reduce the likelihood of STBs in at-risk elementary school-aged youth.

Characteristics of Patients Associated With Restraint Use at a Midwest Children's Hospital

BACKGROUND AND OBJECTIVES

Restraint use is associated with negative mental health outcomes, injury risk, and known disparities in use. Improved understanding of restraint use among hospitalized children is critical given the increased frequency of hospitalized children with complex and/or acute mental health needs. Our objective is to describe the demographic and clinical features of children associated with mechanical restraint.

METHODS

In a single-center retrospective cohort study of patients hospitalized from 2017 to 2021, restraint encounters were identified from electronic health records. Odds of restraint was modeled as a function of patient demographic and clinical characteristics, as well as hospitalization characteristics using logistic regression modeling adjusted for clustering of hospitalizations within patients and for varying lengths of stay.

RESULTS

Among 29 808 children (46 302 encounters), 225 patients (275 encounters) had associated restraint use. In regression modeling, odds of restraint were higher with restraint at the preceding hospitalization (adjusted odds ratio [aOR] 8.6, 95% confidence interval [CI] 4.8-15.5), diagnosis of MH conditions such as psychotic disorders (aOR 5.4, 95% CI 2.7-10.4) and disruptive disorders (aOR 4.7, 95% CI 2.8-7.8), male sex (aOR 1.9, 95% CI 1.5-2.5), and Black race (aOR relative to White patients 1.9, 95% CI 1.4-2.6).

CONCLUSIONS

Our results suggest racial inequities in restraint use for hospitalized children. This finding mirrors inequities in restraint use in the emergency department and adult settings. Understanding the behavioral needs of such patients may help in reducing restraint use and improving health equity.

Exploring Service Use Disparities among Suicidal Black Youth in a Suicide Prevention Care Coordination Intervention

OBJECTIVE

The aim of this study is to examine service utilization disparities among Black youth participating in Linking Individuals Needing Care (LINC), a 90-day research-informed suicide care coordination intervention.

METHODS

An open trial pilot was conducted to examine the effectiveness of LINC in increasing access to and engagement in mental health and non-mental health services among suicidal youth (N = 587). Other variables of interest included service use facilitators and service use barriers. Generalized linear mixed models with binomial distribution and logit link were performed to ascertain if service use facilitators and barriers were associated with service utilization and if disparities in service use and engagement existed between Black and White suicidal youth through a comparative analysis.

RESULTS

Service utilization differences were found between Black and White youth. While Black and White youth were both likely to engage in individual therapy (OR = 1.398, p < .001) and non-mental health services (OR = 1.289, p < .001), utilization rates for mental health and medication management services were lower for Black (55.1% to 60.6%) youth compared to White (66.0% to 71.0%) youth. Specifically, Black youth were significantly less likely than Whites to receive medication management (OR = .466, p = .002). Systemic barriers such long waitlists for care (OR = 1.860, p = .039) and poor relationship with providers (OR = 7.680, p = .028) increased odds of engagement in non-mental health services. Clinical disorders and engagement in suicide-related behaviors increased the likelihood of obtaining care from both medication management and non-mental health services.

CONCLUSION

Care coordination services for suicidal youth can increase access and engagement in mental health and non-mental health services. Culturally adapted models attending to cultural and social assets of Black families are needed to reduce disparities and suicide risk among Black youth.

The Effects of the First Phase of the Covid-19 Pandemic on the Mental Health of Children and Adolescents With preexisting Psychiatric Conditions

Few studies have examined the impact of the initial school closures and stay-at-home orders on those vulnerable children and adolescents with preexisting psychiatric conditions. In our study, we explore the impact on this population and identify risk and resilience factors by looking both at those children who were impacted negatively as well as those who were impacted positively by this period. Questionnaires were administered by child and adolescent psychiatrists to 101 parents of child and adolescent outpatients in a mental health clinic as well as 75 of the adolescents, themselves, during the initial stay-at-home orders in Israel. Parents and their children were asked how the situation changed the symptoms for which the children are being treated at our clinic. Information regarding demographic, family, and individual factors was also gathered. The largest group of parents (44%) reported improvement in their child's symptoms during this period, whereas 33% reported no change and 25% reported worsening. Risk factors included parental stress and level of child preoccupation with Covid-19. The major protective factor was parental presence. Although home confinement during the Covid-19 pandemic can lead to worsening mental health status among children, it can also provide an opportunity for those with previous mental health conditions to improve and strive. For these children to improve during such a period, decreased social and academic demands and increased parental presence seem to be key factors. For those who deteriorate, identifying and targeting parental stress can be as important as targeting the child's stress during such times.

Electronic health records identify timely trends in childhood mental health conditions

BACKGROUND

Electronic health records (EHRs) data provide an opportunity to collect patient information rapidly, efficiently and at scale. National collaborative research networks, such as PEDSnet, aggregate EHRs data across institutions, enabling rapid identification of pediatric disease cohorts and generating new knowledge for medical conditions. To date, aggregation of EHR data has had limited applications in advancing our understanding of mental health (MH) conditions, in part due to the limited research in clinical informatics, necessary for the translation of EHR data to child mental health research.

METHODS

In this cohort study, a comprehensive EHR-based typology was developed by an interdisciplinary team, with expertise in informatics and child and adolescent psychiatry, to query aggregated, standardized EHR data for the full spectrum of MH conditions (disorders/symptoms and exposure to adverse childhood experiences (ACEs), across 13 years (2010-2023), from 9 PEDSnet centers. Patients with and without MH disorders/symptoms (without ACEs), were compared by age, gender, race/ethnicity, insurance, and chronic physical conditions. Patients with ACEs alone were compared with those that also had MH disorders/symptoms. Prevalence estimates for patients with 1+ disorder/symptoms and for specific disorders/symptoms and exposure to ACEs were calculated, as well as risk for developing MH disorder/symptoms.

RESULTS

The EHR study data set included 7,852,081 patients < 21 years of age, of which 52.1% were male. Of this group, 1,552,726 (19.8%), without exposure to ACEs, had a lifetime MH disorders/symptoms, 56.5% being male. Annual prevalence estimates of MH disorders/symptoms (without exposure to ACEs) rose from 10.6% to 2010 to 15.1% in 2023, a 44% relative increase, peaking to 15.4% in 2019, prior to the Covid-19 pandemic. MH categories with the largest increases between 2010 and 2023 were exposure to ACEs (1.7, 95% CI 1.6-1.8), anxiety disorders (2.8, 95% CI 2.8-2.9), eating/feeding disorders (2.1, 95% CI 2.1-2.2), gender dysphoria/sexual dysfunction (43.6, 95% CI 35.8-53.0), and intentional self-harm/suicidality (3.3, 95% CI 3.2-3.5). White youths had the highest rates in most categories, except for disruptive behavior disorders, elimination disorders, psychotic disorders, and standalone symptoms which Black youths had higher rates. Median age of detection was 8.1 years (IQR 3.5-13.5) with all standalone symptoms recorded earlier than the corresponding MH disorder categories.

CONCLUSIONS

These results support EHRs' capability in capturing the full spectrum of MH disorders/symptoms and exposure to ACEs, identifying the proportion of patients and groups at risk, and detecting trends throughout a 13-year period that included the Covid-19 pandemic. Standardized EHR data, which capture MH conditions is critical for health systems to examine past and current trends for future surveillance. Our publicly available EHR-mental health typology codes can be used in other studies to further advance research in this area.

Self-harm in 5-to-24 year olds: Retrospective examination of hospital presentations to emergency departments in New South Wales, Australia, 2012 to 2020

There is some evidence that self-harm presentations in children and young people have increased over the past decade, yet there are few up-to-date studies examining these trends. This study aims to describe trends in the rates and severity of emergency department self-harm presentations for youth aged 5-24 years in New South Wales, Australia between 1 January 2012 and 31 December 2020. We analysed self-harm hospital presentations using join point analysis to compare quarterly growth in rates and urgency of presentation since 2012 by age group and sex. Binomial logistic modelling was used to identify risks for re-presentation for self-harm, including age group, sex, country of birth, mode of arrival, inpatient status, triage category, rurality, and socio-economic disadvantage. In total, 83,111 self-harm presentations for 51,181 persons were analysed. Overall rates of self-harm among those aged 5-24 years increased by 2.4% (p < .001) per quarter in females and 1.6% (p < .001) per quarter in males, with statistically significant average quarterly increases observed across all age groups. Overall and age-specific self-harm triage urgency rates increased statistically significantly for potentially serious, and potentially- and immediately life-threatening categories. A higher likelihood of re-presentation to any emergency department for self-harm was associated with younger age, female, residing in a regional area, arriving by ambulance, admitted as an in-patient, and a more severe index self-harm presentation. Hospital self-harm presentations have been growing steadily over the past decade, with the greatest growth in the youngest people. Understanding the reasons for these sustained upward trends is a priority for suicide prevention.

Urgent Psychiatric Consultations for Suicidal Ideation and Behaviors in Italian Adolescents during Different COVID-19 Pandemic Phases

Access to the emergency department (ED) for acute psychiatric problems, especially for suicide attempts (SA), has increased in the last decade. This increase has exceptionally accelerated after the COVID-19 pandemic. The aim of this project was to study the increase in acute psychiatric care demand of children and adolescents in the short and medium term after the pandemic, in relation to public health measures and in comparison with a pre pandemic reference period. We retrospectively studied 5445 child psychiatric (CP) consultations requested for any reason and for suicide attempt (SA), suicidal ideation (SI) and non-suicidal self-injury (NSSI) in a pediatric ED during three different pandemic periods in Italy (from March 2020 to May 2022) and compared them to a pre-pandemic reference period (from January 2018 to February 2020). Monthly CP consultations for any reason increased significantly by 2.2 times from 70.9 in 2018 to 157 in 2022 (p < 0.001). During the pandemic, monthly CP consultations for any reason increased significantly from 75/month in the first lockdown to 153/month in the second lockdown, remaining stable in the following year. CP consultations for SA increased significantly from 5/month in the first lockdown to 16/month in the second. Consultations for SI increased gradually but significantly from the pre-pandemic period to the end of the pandemic. Juveniles evaluated for SA during the pandemic vs. pre-pandemic more frequently attempted suicide by self-poisoning and less frequently by precipitation, and they were more likely to be diagnosed with a major depressive disorder. CP consultations for any reason and for suicide attempts significantly increased in the decade before the pandemic and peaked in the second lockdown period in Italy.

Trends and Seasonality of Emergency Department Visits and Hospitalizations for Suicidality Among Children and Adolescents in the US from 2016 to 2021

Importance

The detection of seasonal patterns in suicidality should be of interest to clinicians and US public health officials, as intervention efforts can benefit by targeting periods of heightened risk.

Objectives

To examine recent trends in suicidality rates, quantify the seasonality in suicidality, and demonstrate the disrupted seasonality patterns during the spring 2020 COVID-19-related school closures among US children and adolescents.

Design, Setting, and Participants

This population-based, descriptive cross-sectional study used administrative claims data from Optum's deidentifed Clinformatics Data Mart Database. Participants included children aged 10 to 12 years and adolescents aged 13 to 18 years who were commercially insured from January 1, 2016, to December 31, 2021. Statistical analysis was conducted between April and November 2022.

Exposures

Month of the year and COVID-19 pandemic.

Main Outcomes and Measures

Rates and seasonal patterns of emergency department (ED) visits and hospitalizations for suicidality.

Results

The analysis included 73 123 ED visits and hospitalizations for suicidality reported between 2016 and 2021. Among these events, 66.1% were reported for females, and the mean (SD) age at the time of the event was 15.4 (2.0) years. The mean annual incidence of ED visits and hospitalizations for suicidality was 964 per 100 000 children and adolescents (95% CI, 956-972 per 100 000), which increased from 760 per 100 000 (95% CI, 745-775 per 100 000) in 2016 to 1006 per 100 000 (95% CI, 988-10 024 per 100 000) in 2019, with a temporary decrease to 942 per 100 000 (95% CI, 924-960 per 100 000) in 2020 and a subsequent increase to 1160 per 100 000 (95% CI, 1140-1181 per 100 000) in 2021. Compared with January, seasonal patterns showed peaks in April (incidence rate ratio [IRR], 1.15 [95% CI, 1.11-1.19]) and October (IRR, 1.24 [95% CI, 1.19-1.29]) and a nadir in July (IRR, 0.63 [95% CI, 0.61-0.66]) during pre-COVID-19 years and 2021. However, during the spring of 2020, which coincided with school closures, seasonal patterns were disrupted and April and May exhibited the lowest rates.

Conclusions and Relevance

The findings of this study indicated the presence of seasonal patterns and an observed unexpected decrease in suicidality among children and adolescents after COVID-19-related school closures in March 2020, which suggest a potential association between suicidality and the school calendar.

Effect of an Emergency Department Process Improvement Package on Suicide Prevention: The ED-SAFE 2 Cluster Randomized Clinical Trial

Importance

Suicide is a leading cause of deaths in the US. Although the emergency department (ED) is an opportune setting, ED-initiated interventions remain underdeveloped and understudied.

Objective

To determine if an ED process improvement package, with a subfocus on improving the implementation of collaborative safety planning, reduces subsequent suicide-related behaviors.

Design, Setting, and Participants

The Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial, a stepped-wedge cluster randomized clinical trial conducted in 8 EDs across the US, used an interrupted time series design with three 12-month sequential phases: baseline, implementation, and maintenance. A random sample of 25 patients per month per site 18 years and older who screened positive on the Patient Safety Screener, a validated suicide risk screener, were included. The primary analyses focused on those who were discharged from the ED, while secondary analyses focused on all patients who screened positive, regardless of disposition. Data were collected on patients who presented for care from January 2014 to April 2018, and data were analyzed from April to December 2022.

Interventions

Each site received lean training and built a continuous quality improvement (CQI) team to evaluate the current suicide-related workflow in the ED, identify areas of improvement, and implement efforts to improve. Each site was expected to increase their universal suicide risk screening and implement collaborative safety planning for patients at risk of suicide who were discharged home from the ED. Site teams were centrally coached by engineers experienced in lean CQI and suicide prevention specialists.

Main Outcomes and Measures

The primary outcome was a composite comprising death by suicide or suicide-related acute health care visits, measured over a 6-month follow-up window.

Results

Across 3 phases, 2761 patient encounters were included in the analyses. Of these, 1391 (50.4%) were male, and the mean (SD) age was 37.4 (14.5) years. A total of 546 patients (19.8%) exhibited the suicide composite during the 6-month follow-up (9 [0.3%] died by suicide and 538 [19.5%] of a suicide-related acute health care visit). A significant difference was observed for the suicide composite outcome between the 3 phases (baseline, 216 of 1030 [21%]; implementation, 213 of 967 [22%]; maintenance, 117 of 764 [15.3%]; P = .001). The adjusted odds ratios of risk of the suicide composite during the maintenance phase was 0.57 (95% CI, 0.43-0.74) compared with baseline and 0.61 (0.46-0.79) compared with the implementation phase, which reflect a 43% and 39% reduction, respectively.

Conclusions and Relevance

In this multisite randomized clinical trial, using CQI methods to implement a department-wide change in suicide-related practices, including the implementation of a safety plan intervention, yielded a significant decrease in suicide behaviors in the maintenance period of the study.

Trial Registration

ClinicalTrials.gov Identifier: NCT02453243.

Brief Interventions for Self-injurious Thoughts and Behaviors in Young People: A Systematic Review

Rates of self-injurious thoughts and behaviors (SITBs) increase sharply across adolescence and remain high in young adulthood. Across 50 years of research, existing interventions for SITBs remain ineffective and inaccessible for many young people in particular need of mental healthcare. Briefer intervention options may increase access to care. However, many traditional interventions for SITBs take 6 months or more to complete-making it difficult for providers to target SITBs under real-world time constraints. The present review (1) identifies and (2) summarizes evaluations of brief psychosocial interventions for SITBs in young people, ages 10-24 years. We conducted searches for randomized and quasi-experimental trials conducted in the past 50 years that evaluated effects of "brief interventions" (i.e., not exceeding 240 min, or four 60-min sessions in total length) on SITBs in young people. Twenty-six articles were identified for inclusion, yielding a total of 23 brief interventions. Across all trials, results are mixed; only six interventions reported any positive intervention effect on at least one SITB outcome, and only one intervention was identified as "probably efficacious" per standard criteria for evidence-based status. While brief interventions for SITBs exist, future research must determine if, how, and when these interventions should be disseminated.

A systems science approach to identifying data gaps in national data sources on adolescent suicidal ideation and suicide attempt in the United States

BACKGROUND

Suicide is currently the second leading cause of death among adolescents ages 10-14, and third leading cause of death among adolescents ages 15-19 in the United States (U.S). Although we have numerous U.S. based surveillance systems and survey data sources, the coverage offered by these data with regard to the complexity of youth suicide had yet to be examined. The recent release of a comprehensive systems map for adolescent suicide provides an opportunity to contrast the content of surveillance systems and surveys with the mechanisms listed in the map.

OBJECTIVE

To inform existing data collection efforts and advance future research on the risk and protective factors relevant to adolescent suicide.

METHODS

We examined data from U.S. based surveillance systems and nationally-representative surveys that included (1) observations for an adolescent population and (2) questions or indicators in the data that identified suicidal ideation or suicide attempt. Using thematic analysis, we evaluated the codebooks and data dictionaries for each source to match questions or indicators to suicide-related risk and protective factors identified through a recently published suicide systems map. We used descriptive analysis to summarize where data were available or missing and categorized data gaps by social-ecological level.

RESULTS

Approximately 1-of-5 of the suicide-related risk and protective factors identified in the systems map had no supporting data, in any of the considered data sources. All sources cover less than half the factors, except the Adolescent Brain Cognitive Development Study (ABCD), which covers nearly 70% of factors.

CONCLUSIONS

Examining gaps in suicide research can help focus future data collection efforts in suicide prevention. Our analysis precisely identified where data is missing and also revealed that missing data affects some aspects of suicide research (e.g., distal factors at the community and societal level) more than others (e.g., proximal factors about individual characteristics). In sum, our analysis highlights limitations in current suicide-related data availability and provides new opportunities to identify and expand current data collection efforts.

Family therapy for adolescents with depression and suicidal ideation: A systematic review and meta-analysis

OBJECTIVE

To systematically review and meta-analyze the effectiveness of family therapy compared to other active treatments for adolescents with depressive disorders or suicidal ideation.

METHOD

We conducted a systematic search of The Cochrane Central Register of Controlled Trials, Medline, Embase, PsycINFO, AMED, CINAHL and Web of Science and performed two meta-analyses of outcomes for depressive symptoms and suicidal ideation.

RESULTS

We screened 5,940 records and identified 10 randomized controlled studies of family therapy for depressive disorder or suicidal ideation in adolescents with an active treatment comparison group. Nine studies reported outcome measures of depressive symptoms and four reported outcome measures of suicidal ideation. The meta-analysis showed no significant difference between family therapy and active comparison treatments for end-of-treatment levels of depression. For suicidal ideation our meta-analysis showed a significant effect in favour of family therapy over comparison treatments for suicidal ideation.

CONCLUSIONS

Based on the current body of research, we found that family therapy is not superior to other psychotherapies in the treatment of depressive disorder. However, family therapy leads to significantly improved outcomes for suicidal ideation, compared to other psychotherapies. The evidence for the treatment of depression is of low quality needs more research.

Acute mental health service use in adolescents with suicidal thoughts and behaviours: Impact on outpatient care

INTRODUCTION

Youth with suicidal thoughts and behaviours often present to acute emergency care settings for assessment. Timely outpatient follow up may reduce return acute care visits. The primary aim of our study was to describe clinical and contextual differences between youth who do and do not use acute care once connected to outpatient services.

METHODS

A 24-month retrospective chart review of suicidal youth aged 13-16 (n = 45) presenting for outpatient mental health treatment. Youth who used acute services during the study period (ASU) or did not (non-ASU) were compared on demographic, risk profile, and mental health service use.

RESULTS

The mean age of participants was 14.6 years (73% female). Suicide risk profile at baseline did not differ between groups, but was significantly higher in ASU youth at 24 months. There were more youth in service at the end of the study period in the ASU group compared to the non-ASU group (11% vs 55%).

CONCLUSION

Youth who do continue to access acute services may be at higher risk of suicidality even after outpatient treatment. Although it is unclear whether this is linked to outpatient engagement, it raises further questions about this population and how they respond to community based mental healthcare.

Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019

Importance

Approximately 1 in 6 youth in the US have a mental health condition, and suicide is a leading cause of death among this population. Recent national statistics describing acute care hospitalizations for mental health conditions are lacking.

Objectives

To describe national trends in pediatric mental health hospitalizations between 2009 and 2019, to compare utilization among mental health and non-mental health hospitalizations, and to characterize variation in utilization across hospitals.

Design, Setting, and Participants

Retrospective analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative database of US acute care hospital discharges. Analysis included 4 767 840 weighted hospitalizations among children 3 to 17 years of age.

Exposures

Hospitalizations with primary mental health diagnoses were identified using the Child and Adolescent Mental Health Disorders Classification System, which classified mental health diagnoses into 30 mutually exclusive disorder types.

Main Outcomes and Measures

Measures included number and proportion of hospitalizations with a primary mental health diagnosis and with attempted suicide, suicidal ideation, or self-injury; number and proportion of hospital days and interfacility transfers attributable to mental health hospitalizations; mean lengths of stay (days) and transfer rates among mental health and non-mental health hospitalizations; and variation in these measures across hospitals.

Results

Of 201 932 pediatric mental health hospitalizations in 2019, 123 342 (61.1% [95% CI, 60.3%-61.9%]) were in females, 100 038 (49.5% [95% CI, 48.3%-50.7%]) were in adolescents aged 15 to 17 years, and 103 456 (51.3% [95% CI, 48.6%-53.9%]) were covered by Medicaid. Between 2009 and 2019, the number of pediatric mental health hospitalizations increased by 25.8%, and these hospitalizations accounted for a significantly higher proportion of pediatric hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]). The percentage of mental health hospitalizations with attempted suicide, suicidal ideation, or self-injury diagnoses increased significantly from 30.7% (95% CI, 28.6%-32.8%) in 2009 to 64.2% (95% CI, 62.3%-66.2%) in 2019. Length of stay and interfacility transfer rates varied significantly across hospitals. Across all years, mental health hospitalizations had significantly longer mean lengths of stay and higher transfer rates compared with non-mental health hospitalizations.

Conclusions and Relevance

Between 2009 and 2019, the number and proportion of pediatric acute care hospitalizations due to mental health diagnoses increased significantly. The majority of mental health hospitalizations in 2019 included a diagnosis of attempted suicide, suicidal ideation, or self-injury, underscoring the increasing importance of this concern.

Implicit identification with death detects and predicts short-term suicide risk among adolescents discharged from the emergency room

BACKGROUND

Implicit identification with death, measured by the Death-Suicide-Implicit Association Test (D/S-IAT), has been found to predict long-term suicide risk among adolescents. However, previous studies did not examine the predictive utility of D/S-IAT on short-term suicide risk trajectories among adolescents, especially during the critical period following discharge from the emergency room (ER) due to suicide behaviors.

OBJECTIVE

This study examined the ability of the D/S-IAT to discriminate and predict suicide risk trajectories during the month following initial suicide risk assessment, among adolescents recently discharged from the ER.

METHODS

One hundred and fifteen adolescents aged 9-18 years (77.4% female) were assessed at clinic intake. All participants completed D/S-IAT and self-report measures for suicide risk, depression, and anxiety during intake and 1-month follow-up.

RESULTS

The D/S-IAT distinguished and predicted participants with continued heightened suicide risk at follow-up, above and beyond depression, anxiety, and suicide risk level at intake.

CONCLUSIONS

Along with conventional measures, D/S-IAT may be utilized to predict short-term suicide risk during post-ER discharge.

Caregiver Experiences of Adolescent School Reentry After Adolescent Hospitalization Due to Suicidal Thoughts and Behaviors: Recommendations to Improve Reentry Practices

BACKGROUND

Suicide rates among adolescents increased over the past few decades. Following psychiatric hospitalization, many adolescents return to school, a context that can influence recovery. Families can play an integral role in supporting adolescents through the hospitalization and school reentry process; however, little research has focused on family experiences during adolescent school reentry. Grounded in ecological systems theory, the aim of the present study was to explore the experiences of caregivers whose children were hospitalized for suicidal thoughts and behaviors (STBs) and provide recommendations for the school reentry process.

METHODS

In-depth interviews were conducted with caregivers (n = 19) whose adolescents returned to school following hospitalization for suicide-related crises. Researchers analyzed the transcribed interviews using applied thematic analysis.

RESULTS

Themes emerged regarding academic difficulties during hospitalization; breakdowns in communication between schools, families, and hospitals; logistical challenges during the school reentry planning process; and challenges navigating peer relationships and academics following school reentry.

IMPLICATIONS AND CONCLUSIONS

Few reentry recommendations account for the specific challenges faced by families. Recommendations informed by caregiver experiences are needed to ensure that families can effectively support the recoveries of their children. This study presents caregiver-informed recommendations to facilitate an improved reentry process for caregivers and adolescents.

Sex differences in depression: An immunological perspective

Depression is a heterogenous disorder with symptoms that present differently across individuals. In a subset of people depression is associated with alterations of the immune system that may contribute to disorder onset and symptomology. Women are twice as likely to develop depression and on average have a more sensitive adaptive and innate immune system when compared to men. Sex differences in pattern recognition receptors (PRRs), release of damage-associated molecular patterns (DAMPs), cell populations, and circulating cytokines play a critical role in inflammation onset. Sex differences in innate and adaptive immunity change the response of and repair to damage caused by dangerous pathogens or molecules in the body. This article reviews the evidence for sex specific immune responses that contribute to the sex differences in symptoms of depression that may account for the higher rate of depression in women.

Distress Signals: Age Differences in Psychological Distress before and during the COVID-19 Pandemic

Psychological distress reached historically high levels in 2020, but why, and why were there pronounced age differences? We address these questions using a relatively novel, multipronged approach, part narrative review and part new data analyses. We first updated previous analyses of national surveys that showed distress was increasing in the US and Australia through 2017 and then re-analyzed data from the UK, comparing periods with and without lockdowns. We also analyzed the effects of age and personality on distress in the US during the pandemic. Results showed distress levels and age differences in distress were still increasing through 2019 in the US, UK, and Australia. The effects of lockdowns in 2020 revealed the roles of social deprivation and fear of infection. Finally, age-related differences in emotional stability accounted for the observed age differences in distress. These findings reveal the limitations of analyses comparing pre-pandemic and pandemic periods without accounting for ongoing trends. They also suggest that differences in personality traits such as emotional stability modulate responses to stressors. This could explain age and individual differences in both increases and decreases in distress in response to changes in the level of stressors such as those occurring prior to and during the COVID-19 pandemic.

Pharmacologic restraint use for children experiencing mental health crises in pediatric hospitals

BACKGROUND

Children in mental health crises are increasingly admitted to children's hospitals awaiting inpatient psychiatric placement. During hospitalization, patients may exhibit acute agitation prompting pharmacologic restraint use.

OBJECTIVE

To determine hospital-level incidence and variation of pharmacologic restraint use among children admitted for mental health conditions in children's hospitals.

DESIGN, SETTING, AND PARTICIPANTS

We examined data for children (5 to ≤18 years) admitted to children's hospitals with a primary mental health condition from 2018 to 2020 using the Pediatric Health Information System database. Hospital rates of parenteral pharmacologic restraint use per 1000 mental health bed days were determined and compared after adjusting for patient-level and demographic factors. Cluster analysis (k-means) was used to group hospitals based on overall restraint use (rate quartiles) and drug class. Hospital-level factors for pharmacologic restraint use were compared.

RESULTS

Of 29,834 included encounters, 3747 (12.6%) had pharmacologic restraint use. Adjusted hospital rates ranged from 35 to 389 pharmacologic restraint use days per 1000 mental health bed days with a mean of 175 (standard deviation: 72). Cluster analysis revealed three hospitals were high utilizers of all drug classes. No significant differences in pharmacologic restraint use were found in the hospital-level analysis.

CONCLUSIONS

Children's hospitals demonstrate wide variation in pharmacologic restraint rates for mental health hospitalizations, with a 10-fold difference in adjusted rates between highest and lowest utilizers, and high overall utilizers order medications across all drug classes.

Exploring Place-Based Differences in Suicide and Suicide-Related Outcomes Among North Carolina Adolescents and Young Adults

PURPOSE

Suicide is an ongoing public health crisis among youth and adolescents, and few studies have investigated the spatial patterning in the United States among this subpopulation. Potential precursors to suicide in this vulnerable group are also on the rise, including nonfatal self-injury.

METHODS

This study uses emergency department data, death certificates, and violent death reporting system data for North Carolina from 2009 to 2018 to investigate spatial clusters of self-injury and suicide.

RESULTS

Findings show that the demographic characteristics of individuals committing fatal and nonfatal self-injury are quite different. Self-injury and completed suicides exhibited different geographical patterns. Area-level measures like micropolitan status and measures of racial and income segregation predicted the presence of high-risk suicide clusters. Suicides among Native Americans and veteran status/military personnel also were associated with higher risk suicide clusters.

DISCUSSION

Future interventions should target these specific high-risk locations for immediate reductions in adolescent and youth suicides.