The risk of suicide attempt by a child or adolescent is highest after a contact with a psychiatric department
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Question
Question
Is there an increased risk of children and adolescents committing or attempting suicide after contact with a psychiatric department?
Population
72 765 people born in Denmark between 1983 and 1989 (3465 cases and 69 300 controls). Data for every individual born in the eligible period were extracted from Danish national registers (403 431 individuals). Of the total number, 3465 had attempted suicide (cases) between their 10th birthday and 31 December 2005, when they would be up to the age of 22 years. Each of these cases was matched with 20 non-suicidal controls for age, gender and being alive at the time of the suicide attempt.
Setting
General population, Denmark; from 1983 to 2005.
Prognostic factors
The focal prognostic factor was contact with a psychiatric department. This was defined as use of psychiatric services provided by psychiatric hospital units, including hospitalisation, outpatient treatment, emergency psychiatric services and all other day and night services. Admissions to psychiatric wards on the day of an attempted suicide and suicide attempts made on the first day of admission to a psychiatric department were excluded. The analyses were adjusted for parental confounders including parental contact with a psychiatric department, level of education and income, death, use of psychopharmacological drugs and marital status.
Outcomes
Suicide attempt.
Methods
Design
Nested case-control study.
Follow-up period
Up to 12 years (assessed retrospectively).
Main results
Young people who had a contact with a psychiatric department were 12.26 times more likely to have had a suicide attempt than those who had no contact (p<0.0001). While only 4.35% of the controls had been hospitalised, among the cases, 34.46% had been hospitalised prior to their suicide attempt. The risk was at its highest immediately after discharge from a psychiatric department and decreased as the time passed (adjusted RR 1 week after discharge vs no contact: 300.2, 95% CI 168.8 to 533.6; adjusted RR more than 5 years after discharge vs no contact: 2.77, 95% CI 1.84 to 4.17). Also, the greater the number of contacts with a psychiatric department the higher their suicide attempt risk (adjusted RR for more than 10 contacts vs 1–2 contacts: 2.37, 95% CI 1.32 to 4.23; adjusted RR for 3–5 contacts vs 1–2 contacts: 1.09, 95% CI 0.86 to 1.37). Adjusted analyses showed that psychiatric disorder factors significantly associated with risk of suicide attempt were depression (mild: RR 1.90, 95% CI 1.47 to 2.45; moderate and severe: RR 1.52, 95% CI 1.11 to 2.08); neurotic disorder (RR 1.40, 95% CI 1.15 to 1.69); adult personality and behaviour disorders (RR 1.40, 95% CI 1.07 to 1.83); and emotionally unstable personality disorder (RR 1.74, 95% CI 1.29 to 2.36). Taking certain medications was significantly associated with suicide risk: psychoanaleptics (RR 7.21, 95% CI 6.42 to 8.11), antipsychotics (RR 3.95, 95% CI 3.36 to 4.66) and drugs for substance dependence (RR 3.30, 95% CI 2.00 to 5.43).
Conclusions
The risk of suicide attempt by a child or adolescent is highest shortly after discharge from the last contact with a psychiatric department, and declines over time.
Notes
The study did not identify completed suicides, or suicide attempts that did not require contact with medical services.
This was defined as contact with medical services resulting from a suicide attempt (contact code E4) and a relevant International classification of Diseases 10 (ICD-10) or ICD-8 diagnosis (ICD-10: S617-S619, X60-X84, T36-T60, T65; ICD8: E9500-E9599).
Abstracted from
ChristiansenE, LarsenKJ. Young people's risk of suicide attempts after contact with a psychiatric department - a nested case-control design using Danish register data.J Child Psychol Psychiatry2012;53:16–25.
Sources of funding: Not reported.
Commentary
Suicidal behaviour in adolescents is a very challenging public health problem with huge societal and human costs. People with mental illness are generally regarded to be the most at risk, particularly those who have recently been in need of psychiatric treatment, according to a number of studies in adult samples. The national Danish register linkage study by Christiansen and Larsen clearly demonstrates that there is a similar and strong peak in the risk of suicide attempts in adolescents immediately after discharge from a psychiatric department. This study also shows that the increased risk persists for several years after discharge. Prevention strategies targeting youth suicidal behaviour have often strongly emphasised general population measures such as promoting awareness or coping-oriented programmes. A stronger focus on high-risk groups in a clinical context may, however, be warranted. More vigorous and systematic routines for follow-up of at risk adolescents should be implemented; in most cases this is feasible to implement through closer collaboration between treatment providers at different care levels and local community agencies.1 As indicated in this study, teenagers with personality disorders and multiple diagnoses are at a particularly high risk of suicidal behaviour. These teenagers commonly have complex and severe problems in regulating their emotions, impulses and behaviours and they are often more challenging to engage and retain in treatment than normal teens. They should be offered treatment programmes designed to respond specifically to their needs. Treatment should be delivered by clinicians who know how to actively engage avoidant and reluctant teens who may have severe misconceptions about mental illness and treatment. A number of specific treatment models, for example, dialectical behaviour therapy, have been developed to fill these requirements and should be made more widely available. Left untreated, adolescents with this type of problems have a significantly increased risk not only of suicide attempts, but also of completed suicide.
Competing interests: None.
Mork E, Mehlum L, Fadum EA, et al. Collaboration between general hospitals and community health services in the care of suicide attempters in Norway: a longitudinal study. Ann Gen Psychiatry2010; 9:26.
