Jennifer Bethell

Suicidality, depression, and mental health service use in Canada

Objective: To determine the magnitude of depression and suicidal populations, the overlap between these populations, and the associated patterns of mental health service use. Method: We examined depression, suicidality (ideation and nonfatal behaviours), and the mental health service use of participants in the Canadian Community Health Survey Cycle 1.2: Mental Health and Well-Being. The sample comprised 36 984 household members aged 15 years or over. Results: Approximately 4% to 5% of the population suffered from a major depression or suicidality. About 2 of 3 of those who were suicidal did not suffer from depression, and over 70% of those with depression did not report suicidality. Persons with depression and suicidality or depression (but no suicidality) were the 2 groups most likely to report ambulatory mental health contacts, and the provider groups contacted most often included physicians. The use of provider groups was considerably lower for those who were suicidal (but had no depression). Whereas the latter were more likely to report contacts than not, suicidality, in and of itself, did not exert a strong effect on contact with any particular provider group. For those who were suicidal (but who had no depression), less than 1 in 3 reported any mental health service contact, including an inpatient mental health stay. Conclusions: The lack of contact by those who are suicidal (but who have no depression) is provocative, given that almost 2 of 3 of the suicidal subjects had no depression. Detrimental outcomes such as depression may develop without effective early interventions and uptake by a sufficient supply of appropriately trained and financially accessible personnel.

Pediatric Suicide-Related Presentations: A Systematic Review of Mental Health Care in the Emergency Department

STUDY OBJECTIVE We evaluate the effectiveness of interventions for pediatric patients with suicide-related emergency department (ED) visits. METHODS We searched of MEDLINE, EMBASE, the Cochrane Library, other electronic databases, references, and key journals/conference proceedings. We included experimental or quasiexperimental studies that evaluated psychosocial interventions for pediatric suicide-related ED visits. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data and a second checked for completeness and accuracy. Consensus was reached by conference; disagreements were adjudicated by a third reviewer. We calculated odds ratios, relative risks (RRs), or mean differences for each studys primary outcome, with 95% confidence intervals (CIs). Meta-analysis was deferred because of clinical heterogeneity in intervention, patient population, and outcome. RESULTS We included 7 randomized controlled trials and 3 quasiexperimental studies, grouping and reviewing them according to intervention delivery: ED-based delivery (n=1), postdischarge delivery (n=6), and ED transition interventions (n=3). An ED-based discharge planning intervention increased the number of attended post-ED treatment sessions (mean difference=2.6 sessions; 95% CI 0.05 to 5.15 sessions). Of the 6 studies of postdischarge delivery interventions, 1 found increased adherence with service referral in patients who received community nurse home visits compared with simple placement referral at discharge (RR=1.28; 95% CI 1.06 to 1.56). The 3 ED transition intervention studies reported (1) reduced risk of subsequent suicide after brief ED intervention and postdischarge contact (RR=0.10; 95% CI 0.03 to 0.41); (2) reduced suicide-related hospitalizations when ED visits were followed up with interim, psychiatric care (RR=0.41; 95% CI 0.28 to 0.60); and (3) increased likelihood of treatment completion when psychiatric evaluation in the ED was followed by attendance of outpatient sessions with a parent (odds ratio=2.78; 95% CI 1.20 to 6.67). CONCLUSION Transition interventions appear most promising for reducing suicide-related outcomes and improving post-ED treatment adherence. Use of similar interventions and outcome measures in future studies would enhance the ability to derive strong recommendations from the clinical evidence in this area.

Age-sex differences in medicinal self-poisonings: a population-based study of deliberate intent and medical severity.

BackgroundDeliberate self-harm (DSH) is related to suicide and DSH repetition is common. DSH hospital presentations are often self-poisonings with medicinal agents. While older age and male sex are known risk factors for suicide, it is unclear how these factors are related to the nature and severity of medicinal self-poisoning (SP). Such knowledge can guide prevention strategies emphasizing detecting and treating mental illness and controlling access to means.MethodsMedicinal SP presentations by 18,383 residents of Ontario, Canada, aged 12 years and older, who presented to a hospital emergency department in that province between April 1, 2001–March 31, 2002 were characterized by the agents taken, identification of deliberate intent and medical severity.ResultsWe found distinct age-sex differences in the nature and severity of medicinal SP. In youths, aged 12–17, about 40% of presentations involved analgesics, typically not prescribed and most often the acetaminophen agent-group. Females aged 12–64 were identified as deliberate more often than their male counterparts and this pattern occurred in most agent-groups, even among those who took antidepressants. The acetaminophen agent-group was most consistently associated with medical severity and this effect was strongest among female youths. Although medicinal SP was less frequent in the elderly, these presentations tended to be more medically serious and less often identified deliberate.ConclusionsThe high proportion of medicinal SP in youths involving agents typically not prescribed and the medical severity of the acetaminophen agent-group underscore how prevention strategies must extend beyond controlling access to antidepressants. Despite a higher risk for suicide, males and the elderly may not have their deliberate intent detected and therefore, may not receive appropriate treatment. The emergency department can serve as important link to mental health care and usage patterns can provide feedback about the need for system-level enhancements and DSH surveillance.

Sex Differences in Childhood Sexual Abuse and Suicide-Related Behaviors

Child sexual abuse and suicide-related behaviors are associated, but it remains unclear if the strength of this association differs in boys and girls. In a systematic review of this association in children and youth, we identified 16 relevant studies, all cross-sectional surveys of students. The association is stronger in boys specific to suicide attempt(s). Adjustments for potential confounding variables explained some, but not all of this sex difference. While additional research would strengthen causal inferences, this sex difference may be influenced by the nature and timing of child sexual abuse as well as the sex of the perpetrator, which in turn shapes the disclosure of these events.

Child maltreatment and onset of emergency department presentations for suicide-related behaviors

OBJECTIVES To determine whether the rates of a first presentation to the emergency department (ED) for suicide-related behavior (SRB) are higher among children/youth permanently removed from their parental home because of substantiated maltreatment than their peers. To describe the health care settings accessed by these children/youth before a first SRB presentation to help design preventive interventions. METHODS A population-based (retrospective) cohort of 12-17-year-olds in Ontario, Canada was established. Children/youth removed from their parental home because of the above noted maltreatment (n=4683) and their population-based peers (n=1,034,546) were individually linked to administrative health care records over time to ascertain health service use and subsequent ED presentations for SRB during follow-up. Person-time incidence rates were calculated and Cox regression models used to estimate adjusted hazard ratios (HR) and corresponding 95% confidence intervals (CI). RESULTS After controlling for demographic characteristics and prior health service use, maltreated children/youth were about five times more likely to have a first ED presentation for SRB compared to their peers, in both boys (HR: 5.13, 95% CI: 3.94, 6.68) and girls (HR: 5.36, 95% CI: 4.40, 6.54). CONCLUSIONS Children/youth permanently removed from their parental home because of substantiated child maltreatment are at an increased risk of a first presentation to the ED for SRB. The prevention of child maltreatment and its recurrence and the promotion of resilience after maltreatment has occurred are important avenues to study toward preventing ED SRB presentations in children/youth. Provider and system level linkages between care sectors may prevent the need for such presentations by providing ongoing environmental support.

Child Maltreatment and Repeat Presentations to the Emergency Department for Suicide-Related Behaviors.

OBJECTIVES To identify factors associated with repeat emergency department (ED) presentations for suicide-related behaviors (SRB) - hereafter referred to as repetition - among children/youth to aid secondary prevention initiatives. To compare rates of repetition in children/youth with substantiated maltreatment requiring removal from their parental home with their peers in the general population. METHODS A population-based (retrospective) cohort study was established for children/youth with a first ED SRB presentation at risk for repetition in the Province of Ontario, Canada between 1 January 2004 and 31 December 2008. Children/youth legally removed from their parental home because of substantiated maltreatment (n=179) and their population-based peers (n=6,305) were individually linked to administrative health care records over time to ascertain social, demographic, and clinical information and subsequent ED presentations for SRB during follow-up. These children/youth were described and their repetition-free probabilities over time compared. To identify factors associated with repetition we fit multivariable, recurrent event survival analysis models stratified by repetition and present unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS Children/youth with substantiated maltreatment (as noted) were two times more likely to have repetition than their peers after adjustments for social, demographic, and clinical factors (conditional on prior ED SRB presentations). A number of these factors were independently associated with repetition. No one factor distinguished between having a first and second repetition nor was more strongly associated with repetition than another. CONCLUSIONS The risk of repetition is higher in children with substantiated maltreatment (as noted) than their peers. No one factor stood out as predictive of repetition. Implications for secondary prevention initiatives include a non-selective approach, sensitive to family difficulties and the need to better contextualize repetition and harness data linkages.

Childhood physical abuse and suicide-related behavior: A systematic review

Childhood physical abuse is associated with suicide-related behavior. We investigate how shared environment with perpetrator(s) identified as a family member or parent/parental figure or an adult at home contribute to this association. This systematic review of school- and population-based studies in children and youth reports on five relevant studies. The association was statistically significant in each study, and when examined the association was independent of childhood sexual abuse and other factors. Childhood physical abuse may translate into suicide-related behavior through mechanisms unique from childhood sexual abuse. Future research is needed to strengthen causal inferences to inform the prevention of suicide-related behavior.

Sex differences in suicides among children and youth: the potential impact of help-seeking behaviour

Objective: To describe sex differences in health service use among children and youth who died by suicide. Method: This is a retrospective study of children and youth (aged 10 to 25 years) living in Ontario who died by suicide between April 1, 2003, and December 31, 2007. Coroner records were individually linked to outpatient physician visit, emergency department (ED) presentation, and inpatient stay administrative health care records for 724 people (192 girls and 532 boys). Only 77 (10.6%) were aged 10 to 15 years. The health services types used, number of contacts made, and the last contact were compared in boys and girls. Results: About 80% of subjects had contact with the health care system in the year before their death, typically to an outpatient physician and (or) the ED. However, not all were seen for mental health reasons. Girls had more outpatient physician and ED contact than boys and closer in time to their death. Further, girls were more likely than boys to have contact in more than one setting. Still, boys and girls did not differ in their use of an outpatient psychiatrist, some ED presentations, and in the nature and number of inpatient stays. Conclusions: While most people were seen by an outpatient physician and (or) in the ED in the year before their death, not all received mental health care. Further research is needed to determine whether boys and girls who died by suicide differ from their peers in their health service use to guide preventive interventions.

Suicidal Ideators Without Major Depression-Whom Are We Not Reaching?

Objectives: To describe individuals who reported suicidal ideation but neither met the criteria for major depression (MD) nor were in contact with mental health services in the previous year. Method: Data were drawn from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). Conducted in 2002, the CCHS 1.2 was a cross-sectional population-based survey of 36 984 Canadian household residents aged 15 years or more. First, we described the individuals who reported suicidal ideation, were without MD, and were not in contact with mental health services (n = 584) as well as their nonsuicidal counterparts (n = 31 382) based on various demographic and health status variables. Second, to analyse whether these same variables are associated with mental health service contact(s) among suicidal individuals without MD, we compared those who were in contact with mental health services (n = 209) to those who were not (n = 584). Results: Almost one-half (47.9%) of the suicidal ideators were without both MD and a mental health service contact in the previous year. Individuals in this group were younger and exhibited greater morbidity than their nonsuicidal counterparts (without MD or mental health service contact) but did not differ by sex. Although male and female respondents were equally represented among the suicidal ideators without MD, male respondents were less likely to contact mental health services. Such contact was more likely among female respondents and individuals with an anxiety disorder. Conclusions: These findings underscore the need for further research evaluating early intervention programs that succeed in capturing suicidal youths, particularly male youths.

Repeat self-harm: application of hurdle models

Among those who present to the emergency department for self-harm, many will repeat. Self-harm repetition is an outcome of interest in both observational and intervention studies. However, few such studies analyse the number of repeat self-harm presentations. Here, hurdle models are introduced as a potentially useful statistical method for these analyses. Emergency department data from the Province of Ontario, Canada, are used to illustrate an example of implementing hurdle models and interpreting their results.