Robin Skinner

Suicide among children and adolescents in Canada: trends and sex differences, 1980–2008

Background: Suicide is the second leading cause of death for young Canadians (10–19 years of age) — a disturbing trend that has shown little improvement in recent years. Our objective was to examine suicide trends among Canadian children and adolescents. Methods: We conducted a retrospective analysis of standardized suicide rates using Statistics Canada mortality data for the period spanning from 1980 to 2008. We analyzed the data by sex and by suicide method over time for two age groups: 10–14 year olds (children) and 15–19 year olds (adolescents). We quantified annual trends by calculating the average annual percent change (AAPC). Results: We found an average annual decrease of 1.0% (95% confidence interval [CI] −1.5 to −0.4) in the suicide rate for children and adolescents, but stratification by age and sex showed significant variation. We saw an increase in suicide by suffocation among female children (AAPC = 8.1%, 95% CI 6.0 to 10.4) and adolescents (AAPC = 8.0%, 95% CI 6.2 to 9.8). In addition, we noted a decrease in suicides involving poisoning and firearms during the study period. Interpretation: Our results show that suicide rates in Canada are increasing among female children and adolescents and decreasing among male children and adolescents. Limiting access to lethal means has some potential to mitigate risk. However, suffocation, which has become the predominant method for committing suicide for these age groups, is not amenable to this type of primary prevention.

Canada-Wide Effect of Regulatory Warnings on Antidepressant Prescribing and Suicide Rates in Boys and Girls

Objective: To examine the impact of the Health Canada regulatory warnings regarding antidepressant (AD) prescribing on suicide rates in boys and girls under the age of 18 and aged 18 to 19 years in Canada between 2004 and 2009. We hypothesized that an increase in suicide rates would be specific to girls, reflecting higher AD prescribing rates in girls than boys. Method: We graphed and tested the difference between Canada-wide suicide rates before and after the regulatory warning periods (either from 1995 to 2006 or from 1995 to 2009) in boys and girls under the age of 18 or aged 18 to 19 years. For comparison with prior studies, we estimated rate ratios and 95% confidence intervals using either Poisson regression or negative binomial regression. Results: There was no statistically significant increase in suicide rates in girls under the age of 18, or aged 18 to 19 years in response to the AD regulatory warnings. In boys under the age of 18 or aged 18 to 19 years, suicide rates declined after 2003. Conclusions: We did not find increased rates of suicide after the AD regulatory warnings in boys or girls under the age of 18 or aged 18 to 19 years in Canada-wide rates. However, this does not rule out the possibility that such an effect occurred in some jurisdictions in girls and (or) the regulatory warnings prevented the trend toward declining suicide rates. Factors influencing the downward trend in boys merit further attention.

Time trends in medically serious suicide-related behaviours in boys and girls.

Objective: To determine whether emergency department (ED) presentations for suicide-related behaviours (SRBs) in boys and girls were identified as more clinically acute in the ED in the period after the regulatory warnings against prescribing antidepressants and during the global economic recession, and to characterize the medical severity of SRBs among boys and girls to aid surveillance activities. Method: Among Ontario boys and girls (aged 12 to 17 years) presenting to the ED with an incident (index) ED SRB event between fiscal years (FYs) 2002 to 2010, we compared the number of high (compared with lower) acuity events in FYs 2005 to 2010 to those in FYs 2002 to 2004. We described the SRB method by its acuity and tested the linearity of varying trends in the SRB method in boys and girls. Results: In both boys and girls, high acuity events were 50% greater after FY 2004 than before, regardless of subsequent admission, and most common among boys and girls who self-poisoned. In girls, opposing linear trends before and after FY 2004 were observed in the proportion of self-poisonings and cut (or) pierce SRB methods. Throughout the study period, there was a linear decline in the proportion of boys presenting to the ED with other methods. Conclusions: The previously reported increase in hospital admissions after the warnings and during the recession is unlikely artifactual. An equivalent increase in high acuity events was also evident among those not subsequently admitted. The reasons for varying responses in boys and girls by SRB method warrant further study.

Suicide in Canada: Is Poisoning Misclassification an Issue?

Objective: The aim of this study is to compare Canadian suicide rates with other external causes of death to examine potential poisoning misclassifications as a contributor to suicide underreporting. Method: The study used Statistics Canada mortality data from 2000 to 2011 to calculate sex-and age-specific ratios by external cause of injury codes. Results: The overall Canadian suicide rate, as well as the poisoning suicide rate, declined over the study timeframe by an average annual percentage change (AAPC) of 1.0% each year. However, unintentional and undetermined poisonings increased significantly during the timeframe. Unintentional poisoning mortality (primarily narcotics and hallucinogens, including opioids) increased in proportion to suicides for both sexes, although females were consistently higher. The undetermined death to suicide ratio was higher and increasing for females. Poisonings of undetermined intent increased over time to comprise 47% to 80% of the undetermined death category for males and females combined. Conclusions: Canadian poisoning suicide rates declined, in contrast to rising unintentional and undetermined poisoning mortality rates. This trend is similar to that of the United States, supporting the hypothesis that misclassification of poisoning deaths may also be an issue in Canada.

Les soins médicaux de jeunes hommes et de jeunes femmes qui décèdent par suicide

Objective: Prior year medical care was compared among youth dying by suicide to their peers. Effect modification of these associations by age or place of residency (rural versus larger community sizes) was examined in a large, medically insured population. Method: This population-based case control study used data from the Office of the Chief Coroner in Ontario, Canada, linked to health care administrative data to examine associations between medical care for mental health or other reasons (versus no medical care) and suicide. Decedents (n = 1203 males and n = 454 females) were youth (aged 10 to 25 years) who died by suicide in Ontario between April 2003 and March 2014, inclusive. Peers of the same ages were frequency matched to decedents on sex and place of residency. Logistic regression was used to calculate odds ratios and 95% confidence intervals and to test effect modification. Results: Associations with mental health care were stronger in decedents than peers with a gradation of care (i.e., outpatient only, emergency department [ED], inpatient care) in both sexes. However, these associations were weaker among youth living in rural communities. Furthermore, older males (aged 18 to 25 years) were less likely than younger males (aged 10 to 17 years) to access the ED (ambulatory care only). This decrease was observed in rural and larger communities alongside no increase in medical care for other reasons. Conclusions: Geographical and age-related barriers to mental health care exist for youth who die by suicide. Preventive efforts can address these barriers, intervening early and integrating services, including the ED.

Emergency Department Presentations and Youth Suicide: A Case-Control Study

Objective: We estimate associations between emergency department (ED) diagnoses and suicide among youth to guide ED care. Method: This ED-based case-control study used data from the Office of the Chief Coroner and all EDs in Ontario, Canada. Cases (n = 697 males and n = 327 females) were aged 10 to 25 years who died by suicide in Ontario between April 2003 and March 2014, with an ED contact in the year before their death. Same-aged ED-based controls were selected during this time frame. Crude and adjusted odds ratios (aORs) and 95% confidence intervals were calculated. Results: Among youth diagnosed with a mental health problem at their most recent ED contact (41.9% cases, 5% controls), suicide was elevated among nonfatal self-inflicted: ‘other’ injuries, including hanging, strangulation, and suffocation in both sexes (aORs > 14); cut/pierce injuries in males (aOR > 5); poisonings in both sexes (aORs > 2.2); and mood and psychotic disorders in males (aORs > 1.7). Among those remaining, ‘undetermined’ injuries and poisonings in both sexes (aORs > 5), ‘unintentional’ poisonings in males (aOR = 2.1), and assault in both sexes (aORs > 1.8) were significant. At least half of cases had ED contact within 106 days. Conclusions: The results highlight the need for timely identification and treatment of mental health problems. Among those with an identified mental health problem, important targets for suicide prevention efforts are youth with self-harm and males with mood and psychotic disorders. Among others, youth with unintentional poisonings, undetermined events, and assaults should raise concern.

Classification of Undetermined Deaths by Poisoning: Suicidal or Unintentional

In Canada, poisoning deaths are classified as unintentional, suicide, homicide or undetermined. However, there is a significant proportion of deaths which are classified as undetermined. This work describes a methodology to classify cases of poisoning-related deaths that were misclassified as undetermined, using data from the Canadian Coroner and Medical Examiner Database (CCMED). The research work used Decision Trees (DTs), Case-Based Reasoning (CBR), and Artificial Neural Networks (ANNs), using a number of known cases of suicides and of unintentional deaths, to classify undetermined cases as a suicide or an unintentional poisoning. The performance achieved a sensitivity of 96% (true positives or suicides), a specificity of 84% (true negatives or unintentional), and an area under the Receiver Operating Characteristic Curve (ROC) of 0.96. The results will help to calculate better estimates of the rates of suicides and of unintentional deaths by poison.

Emergency Department presentations for injuries related to cribs

Introduction Safe design and use of cribs is fundamental to infant safety. Because international coding (ICD) does not specify crib-related injuries, few surveillance systems provide data to study these injuries. Methods The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) collects information on injuries treated in the emergency departments of 11 paediatric and 3 general hospitals. Its database was used to study crib-related injuries to children under 5 years of age, 1990–2007. Results 3201 cases were identified. The proportion of crib cases among all CHIRPP injuries remained relatively constant over time. The median age was 16 months (IQR, 1023 months). The male to female ratio was 1.2:1. Falls out of cribs accounted for 75% of injuries followed by body part entrapment (7.2%), accessing hazardous objects (2.3%) and crib malfunction (<1%). Head/face/neck injuries occurred in 56% of cases and among these half were closed head injuries. A novel scale was developed to classify the severity of these injuries; the majority (82.5%) were minor, 5.2% moderate and 1.4% serious/fatal. In this study 4.5% of infants were admitted to hospital and there was one death (suffocation related to bedding materials). Discussion Although Canada introduced product standards for cribs before 1990 (updates pending), crib-related injuries continue to occur. Injuries could be reduced through review/enforcement of standards, and, vigilance by parents regarding: correct installation and maintenance of approved cribs, minimising bedding and removing extra objects, removing hazards around the crib, and, discontinuing use when a child can climb out.