Increasing paediatric emergency visits for suicide-related concerns during COVID-19.

Suicidal ideation and suicide attempts are common during adolescence, with an international prevalence of 14–23% for suicidal ideation, and 5–17% for suicide attempts among people younger than 22 years.1Van Meter AR Knowles EA Mintz EH Systematic review and meta-analysis: international prevalence of suicidal ideation and attempt in youth.J Am Acad Child Adolesc Psychiatry. 2022; (published online Dec 20.)https://doi.org/10.1016/j.jaac.2022.07.867Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar Despite this high prevalence, only a minority of adolescents seek medical help for suicide-related concerns.2Geulayov G Casey D McDonald KC et al.Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study.Lancet Psychiatry. 2018; 5: 167-174Summary Full Text Full Text PDF PubMed Scopus (150) Google Scholar Yet, when they do, rapid interventions are often necessary given the acute risks for health and safety. In a systematic review and meta-analysis of 42 studies, Sheri Madigan and colleagues3Madigan S Korczak DJ Vaillancourt T et al.Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis.Lancet Psychiatry. 2023; (published online March 9.)https://doi.org/10.1016/S2215-0366(23)00036-6Summary Full Text Full Text PDF Scopus (15) Google Scholar compared paediatric emergency department visits for suicidal ideation, suicide attempts, and self-harm before the COVID-19 pandemic with those during the pandemic, among adolescents younger than 19 years. They identified an increase in visits for attempted suicide during the pandemic (rate ratio 1·22, 90% CI 1·08–1·37). Among older adolescents (mean age 16·3 years), emergency department visits for self-harm increased (1·18, 1·00–1·39), but they did not for younger adolescents (mean age 9·0 years). When considering emergency department visits for suicidal ideation, there was an increase (1·08, 0·93–1·25). These findings are striking given that the authors found that rates of emergency department visits for all health concerns in this age group decreased during the period (0·68, 0·62–0·75), including for other mental health problems (0·81, 0·74–0·89). Their search identified data from 18 countries (78% of studies were conducted in North America or Europe), representing more than 11 million emergency department visits. Trends in paediatric emergency department visits for suicide-related concerns need to be monitored in real time, in parallel with suicide deaths, to inform data-driven decisions. Even during the COVID-19 pandemic, following trends across time is important given that the increase in mental illness symptoms among young people described in the early stages of the pandemic4Kauhanen L Wan Mohd Yunus WMA Lempinen L et al.A systematic review of the mental health changes of children and young people before and during the COVID-19 pandemic.Eur Child Adolesc Psychiatry. 2022; 12: 1-19Google Scholar might evolve as humanity begins to cope and live with the virus. The published data available to Madigan and colleagues3Madigan S Korczak DJ Vaillancourt T et al.Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis.Lancet Psychiatry. 2023; (published online March 9.)https://doi.org/10.1016/S2215-0366(23)00036-6Summary Full Text Full Text PDF Scopus (15) Google Scholar largely focus on the situation in 2020 (35 of 42 studies reported data from 2020, and seven of 42 from 2021). More up to date surveillance data are needed to obtain a more current understanding of the situation. Notably, the increase in emergency department visits for either suicidal ideation or suicide attempt, described by the authors, was higher among females (rate ratio 1·39, 90% CI 1·04–1·88) than among males (1·06, 0·92–1·24). The reasons for such a discrepancy are certainly multifactorial, but a few studies have shown a more pronounced worsening of psychological symptoms from before to during the pandemic in girls versus boys, which might have played a contributing role.4Kauhanen L Wan Mohd Yunus WMA Lempinen L et al.A systematic review of the mental health changes of children and young people before and during the COVID-19 pandemic.Eur Child Adolesc Psychiatry. 2022; 12: 1-19Google Scholar Greater use of services is to be expected when mental illness burden and symptom severity are on the rise, but whether increases in paediatric emergency department visits during the COVID-19 pandemic were primarily driven by factors related to sex and gender remains unclear. Nonetheless, stigma around mental illness and a lack of sex-and-gender-inclusive services could represent substantial barriers to care, for example among males and gender-diverse young people who might not feel at ease receiving care in paediatric emergency departments.5Rice SM Purcell R McGorry PD Adolescent and young adult male mental health: transforming system failures into proactive models of engagement.J Adolesc Health. 2018; 62: S9-17Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar Although suicide rates are higher among males than females across the globe, males might be less likely to seek professional help for mental illness concerns and to disclose suicidal ideation and attempts than females.6Hawton K Saunders KE O'Connor RC Self-harm and suicide in adolescents.Lancet. 2012; 379: 2373-2382Summary Full Text Full Text PDF PubMed Scopus (1249) Google Scholar Such disparities raise questions about the role of stigma surrounding young men's mental health, which could prevent them from disclosing symptoms and accessing necessary help and support. Young people who have attempted suicide are at increased risk for a range of consequences that persist during adulthood, including poor physical and mental health, and social and economic outcomes, underscoring the importance of offering treatment options that go beyond immediate suicide risk assessment and management.7Goldman-Mellor SJ Caspi A Harrington H et al.Suicide attempt in young people: a signal for long-term health care and social needs.JAMA Psychiatry. 2014; 71: 119-127Crossref PubMed Scopus (216) Google Scholar There is a high demand placed on mental health services worldwide. As such, young people might have to wait several weeks, or even months, before receiving the care they need for suicide-related concerns. The development of virtual care services, which accelerated during the pandemic, might help to reduce waiting times and to improve access, but recent work suggests that online services might not always be equivalent to in-person services.8Schwartz L Levy J Endevelt-Shapira Y et al.Technologically-assisted communication attenuates inter-brain synchrony.Neuroimage. 2022; 264119677Crossref PubMed Scopus (5) Google Scholar Given the high rates of emergency department visits for suicide-related concerns during adolescence, paediatric health-care providers need to receive adequate training in therapeutic risk assessment, formulation, and management, and they need to conduct appropriate safety planning.9Hawton K Lascelles K Pitman A Gilbert S Silverman M Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management.Lancet Psychiatry. 2022; 9: 922-928Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar Although most paediatric residency programme directors and paediatric chief residents practising in the USA rate suicide prevention training during residency as extremely or very important, only a minority report being adequately prepared to conduct suicide risk assessments.10Schoen LE Bogetz AL Hom MA Bernert RA Suicide risk assessment and management training practices in pediatric residency programs: a nationwide needs assessment survey.J Adolesc Health. 2019; 65: 280-288Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar The accelerated increase in emergency department visits for suicide-related concerns observed in young people, especially young girls, since the beginning of the COVID-19 pandemic should be considered as an urgent call to action. It is now up to professional and governing bodies to take appropriate steps to offer appropriate preventive services and care to those in need. We declare no competing interests. M-CG holds a Canada Research Chair in Youth Mental Health and Suicide Prevention and NC is supported by a Junior 1 salary award from the Fonds de recherche du Québec–Santé. M-CG and NC are supported by the Observatory for Children's Education and Health. Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysisThe integration of mental health support within community health and the education system—including promotion, prevention, early intervention, and treatment—is urgently needed to increase the reach of mental health support that can mitigate child and adolescent mental distress. In future pandemics, increased resourcing in some emergency department settings would help to address their expected increase in visits for acute mental distress among children and adolescents. Full-Text PDF