Suicide and suicide attempts in children and adolescents in the child welfare system

Background:

Few population studies have examined the psychiatric outcomes of children and adolescents in the child welfare system, and no studies have compared outcomes before and after entry into care. Our objective was to assess the relative rate (RR) of suicide, attempted suicide, admission to hospital and visits to physicians’ offices among children and adolescents in care compared with those not in care. We also examined these outcomes within the child welfare population before and after entry into care.

Methods:

We used population-level data to identify children and adolescents 5 to 17 years of age who were in care in Manitoba for the first time between Apr. 1, 1997, and Mar. 31, 2006, and a comparison cohort not in care. We compared the two cohorts to obtain RRs for the specified outcomes. We also determined RRs within the child welfare population relative to the same population two years before entry into care.

Results:

We identified 8279 children and adolescents in care for the first time and a comparison cohort of 353 050 children and adolescents not in care. Outcome rates were higher among those in care than in the comparison cohort for suicide (adjusted RR 3.54, 95% confidence interval [CI] 2.11–5.95), attempted suicide (adjusted RR 2.11, 95% CI 1.84–2.43) and all other outcomes. However, adjusted RRs for attempted suicide (RR 0.27, 95% CI 0.21–0.34), admissions to hospital and physician visits decreased after entry into care.

Interpretation:

Children and adolescents in care were at greater risk of suicide and attempting suicide than those who were not in care. Rates of suicide attempts and hospital admissions within this population were highest before entry into care and decreased thereafter.In Canada, about 76 000 children and adolescents are under the care of provincial child and family services.¹ In Manitoba, more than 7000 children and adolescents were in the care of child and family services in 2008. Many of them had experienced abuse and neglect, or death or conflict in their families, along with disability or emotional problems.^2–13 Concerns have been raised that the Canadian child welfare system does not provide adequate resources and supports to mitigate the effects of abuse and neglect.¹⁴ Although the health outcomes of this population are a frequent topic of concern in the media, population-based research describing these outcomes is limited.To our knowledge, only two studies of a population cohort of children and adolescents in care have been published to date, both describing the psychiatric morbidity and mortality of children and adolescents in care in Sweden.^4,6 These studies found greater rates of suicide, suicide attempts and psychiatric hospital admissions among children in care than in the general population. However, these studies had substantial limitations. Although they used the general population as a comparison group, they did not analyze for the presence of psychiatric morbidity in the period before entry into care. This omission limits the ability to draw conclusions about whether the poor outcomes of these children were associated with disruptions in their lives and families related to involvement in the child welfare system or whether they were a consequence of their life, health and psychological characteristics before they entered the care system.The first objective of the current study was to assess the relative rates (RRs) of suicide and attempted suicide and the number of hospital admissions and visits to physicians’ offices among children and adolescents with a history of being in the care of child and family services in Manitoba, relative to the general population of children and adolescents not in care. The second objective was to assess the RR of attempting suicide and the number of hospital admissions and physician visits in the child welfare population before and after entry into care.     

180 例自杀死亡者自杀方式及其自杀环境的法医学回顾性研究

目的:调查自杀死亡者对自杀方式和自杀环境的选择是否因性别、年龄和社会经济阶层的不同而存在差异性。方法:运用自编调查表,调查了昆明市公安局及其四个分区(五华区、西山区、盘龙区、官渡区)公安局2008年1月至2010年10月备案登记的180例自杀案例,将这些案例分为三组:性别组、年龄组和社会经济阶层组,分组后采用SPSS11.5统计学软件进行检验分析。结果:不同性别和不同社会经济阶层对自杀方式的选择不存在显著性差异;不同年龄段对自杀方式的选择存在显著性差异;不同性别和不同年龄段对自杀环境的选择存在显著性差异,不同社会经济阶层对自杀环境的选择不存在显著性差异。结论:自杀事件是一种复杂的社会现象,虽然它的发生受到众多复杂因素的影响,但不同的自杀人群对自杀方式和自杀环境的选择存在一定的特殊性,法医学工作者在实际工作中,对自杀死亡事件的鉴定需要扎实的理论知识和丰富的工作经验。     

Expressions of Anxiety in African Americans: Ethnography and the Epidemiological Catchment Area Studies

High levels of anxiety have long been reported forAfrican Americans. Recent analyses of EpidemiologicalCatchment Area (ECA) data have failed to support this,although contemporary ethnographies have discussedimportant African American folk idioms of anxiety. This study compares ethnographically reported symptomsof anxiety in African Americans to those reported inthe ECA data. A multivariate analysis of femaleAfrican American and European American differences incomparable ECA and ethnographic symptoms wasperformed. Significant differences were found not inethnicity but in education levels. Alternativeinterpretations are discussed. Methodologicalproblems are discussed highlighting limitations ofboth household survey research, such as the ECAproject, and ethnography.     

Enterocytozoon bieneusi Genotypes in Cattle on Farms Located within a Water Catchment Area

Enterocytozoon bieneusi is a microsporidian found in humans and other animals around the world. Investigations in some countries, such as the U.S., have indicated the importance of E. bieneusi as a zoonotic water‐ and food‐borne pathogen. However, there is scant epidemiological information on E. bieneusi in animals in many countries including Australia. Here, we conducted the first molecular epidemiological study of E. bieneusi in farmed cattle in Victoria, Australia, to assess whether these bovids are carriers of “zoonotic” genotypes of E. bieneusi. A total of 471 individual faecal samples were collected from calves of < 3 mo and of 3–9 mo of age. Genomic DNAs were extracted from individual faecal samples and then subjected to nested PCR‐based sequencing of the internal transcribed spacer (ITS) of nuclear ribosomal DNA to identify E. bieneusi and define genotypes. Enterocytozoon bieneusi was detected in 49 of the 471 samples (10.4%). An analysis of ITS sequence data revealed three known genotypes (BEB4, I, and J) and three novel genotypes (designated TAR_fc1 to TAR_fc3). Phylogenetic analysis showed that genotypes BEB4, I, J, TAR_fc1, and TAR_fc2 clustered with genotypes identified previously in humans, indicating that cattle are carriers of E. bieneusi with zoonotic potential.     

Fish Species Diversity,Distribution, and Dispersal in the Rivers of the Penzhina Bay Catchment Area

Journal of Ichthyology - New expedition data, analysis of unpublished archives, and questionnaire information made it possible to clarify the ichthyofauna species diversity and to assess the...     

The Impact of the Extreme Floods in July 1997 on the Ichthyocenosis of the Oder Catchment Area (Czech Republic)

Changes in the ichthyocenosis of five smaller streams of 2nd to 4th order existing in the spring section of the River Odra (Oder) catchment area, in the territory of the Czech Republic, were observed before and after the catastrophic floods of July 1997. Quantitative catches using electro-fishing were performed in June, August, and September 1997, i.e. a month before and 2 months after the floods. The maximum flow of water in the examined sites usually reached or exceeded the limit of the so-called ȁ8once in a century high waterȁ9. Extreme floods did not influence statistically the proven average readings of species diversity of ichthyocenosis in the examined sites (p = 0.5625), species variety (p = 0.7316), abundance per hectare (p = 0.3125), and biomass per hectare (p = 0.4375). A distinctive decline in abundance and also in the biomass of the ichthyocenosis took place in geomorphic reaches. Significant incisions and alterations in the routes of the streams were also observed. Statistical data of catches of key reophilous fish species from the River Oder catchment basin, all of which were affected by the floods, in the periods 1995–1996, 1997, and 1998–1999, were evaluated. Catches of the species of Salmo trutta and Thymallus thymallus in 1997 considerably increased. Only Thymallus thymallus experienced a more pronounced decrease in the years after the floods, when compared with the average readings made in the period 1995–1996. The readings of the adult abundance of Barbus barbus and Chondrostoma nasus did not prove a negative impact of the floods on the adult population of both species in the assessed years. Our findings suggest that the original fish communities may be naturally well adapted to culmination flows.     

Experimental Methods for Kinetic Study of Suicide Substrates

Abstract

The kinetic study of the enzymatic inactivation originated by suicide substrates can be carried out by means of two alternative approaches. One method considers the substrate concentration as practically constant during the assay time and provides explicit equations of product concentration vs. time. The other method involves the significant consumption of the substrate, yielding implicit equations of time vs. product concentration. The utility of both methods is discussed and adequate experimental conditions for their correct application are established.     

What Interrupts Suicide Attempts in Men: A Qualitative Study

Despite higher rates of suicide in men, there is a dearth of research examining the perspectives and experiences of males at risk of suicide, particularly in terms of understanding how interventions can be tailored to men’s specific needs. The current study aimed to examine factors assisting, complicating or inhibiting interventions for men at risk, as well as outlining the roles of family, friends and others in male suicide prevention. Thirty-five male suicide survivors completed one-to-one interviews, and forty-seven family and friends of male suicide survivors participated in eight focus groups. Thematic analysis revealed five major themes: (1) development of suicidal behaviours tends to follow a common path associated with specific types of risk factors (disrupted mood, unhelpful stoic beliefs and values, avoidant coping strategies, stressors), (2) men at risk of suicide tend to systematically misinterpret changes in their behaviour and thinking, (3) understanding mood and behavioural changes in men enables identification of opportunities to interrupt suicide progression, (4) distraction, provision of practical and emotional supports, along with professional intervention may effectively interrupt acute risk of harm, and (5) suicidal ideation may be reduced through provision of practical help to manage crises, and helping men to focus on obligations and their role within families. Findings suggest that interventions for men at risk of suicidal behaviours need to be tailored to specific risk indicators, developmental factors, care needs and individuals’ preferences. To our knowledge this is the first qualitative study to explore the experiences of both suicidal men and their family/friends after a suicide attempt, with the view to improve understanding of the processes which are effective in interrupting suicide and better inform interventions for men at risk.     

Suicide in Birmingham

The number of deaths from suicide in the City of Birmingham has fallen dramatically over the past eight years. Investigation shows that this seems to be wholly due to a reduction in deaths due to domestic coal-gas.     

Re-Moralizing the Suicide Debate

Contemporary approaches to the study of suicide tend to examine suicide as a medical or public health problem rather than a moral problem, avoiding the kinds of judgements that have historically characterised discussions of the phenomenon. But morality entails more than judgement about action or behaviour, and our understanding of suicide can be enhanced by attending to its cultural, social, and linguistic connotations. In this work, I offer a theoretical reconstruction of suicide as a form of moral experience that delineates five distinct, yet interrelated domains of understanding: the temporal, the relational, the existential, the ontological, and the linguistic. Attention to each of these domains, I argue, not only enriches our understanding of the moral realm but also provides a heuristic for examining the moral traditions and practices that constitute contemporary understandings of suicide.     

Antidepressant Utilization and Suicide in Europe: An Ecological Multi-National Study

Background

Research concerning the association between use of antidepressants and incidence of suicide has yielded inconsistent results and is the subject of considerable controversy. The first aim is to describe trends in the use of antidepressants and rates of suicide in Europe, adjusted for gross domestic product, alcohol consumption, unemployment, and divorce. The second aim is to explore if any observed reduction in the rate of suicide in different European countries preceded the trend for increased use of antidepressants.

Methods

Data were obtained for 29 European countries between 1980 and 2009. Pearson correlations were used to explore the direction and magnitude of associations. Generalized linear mixed models and Poisson regression distribution were used to clarify the effects of antidepressants on suicide rates, while an autoregressive adjusted model was used to test the interaction between antidepressant utilization and suicide over two time periods: 1980–1994 and 1995–2009.

Findings

An inverse correlation was observed in all countries between recorded Standardised Death Rate (SDR) for suicide and antidepressant Defined Daily Dosage (DDD), with the exception of Portugal. Variability was marked in the association between suicide and alcohol, unemployment and divorce, with countries depicting either a positive or a negative correlation with the SDR for suicide. Every unit increase in DDD of an antidepressant per 1000 people per day, adjusted for these confounding factors, reduces the SDR by 0.088. The correlation between DDD and suicide related SDR was negative in both time periods considered, albeit more pronounced between 1980 and 1994.

Conclusions

Suicide rates have tended to decrease more in European countries where there has been a greater increase in the use of antidepressants. These findings underline the importance of the appropriate use of antidepressants as part of routine care for people diagnosed with depression, therefore reducing the risk of suicide.     

Barriers to Hyperglycemia Control in Hospitalized Patients: a Descriptive Epidemiologic Study

ObjectiveTo identify barriers that prevent appropriate control of hyperglycemia in a university teaching hospital and to document their frequency in patients hospitalized for cardiothoracic surgery.MethodsIn this observational study, our inpatient diabetes team identified barriers to adequate glycemic control for diabetic patients in the cardiothoracic surgical intensive care unit between September 1, 2006, and January 3, 2007. Data were collected through chart review and patient and staff interviews. Blood glucose concentrations greater than 160 mg/dL prompted intervention, which involved speaking to the prescribing practitioner and making a treatment recommendation. Each intervention was reviewed by the diabetes nurses using the critical incident technique. The nurses determined which underlying barriers were responsible for the lack of glycemic control and had necessitated the intervention.ResultsOf 105 patients, 6 (5.7%) demonstrated good glucose control (75% of their blood glucose measurements were 80-160 mg/dL) and did not require intervention, and 99 (94.3%) required intervention. Diabetes nurses intervened 202 times; each patient averaged 2.04 interventions during their hospital stay. Nurses coded 398 barriers to the 202 interventions; each intervention had between 1 and 5 barriers coded as the underlying reason(s) for the intervention. Thirty barriers to adequate glycemic control were identified. Eight barriers represented 74% of the barriers encountered. Therapeutic reluctance was the most common followed by inappropriate titration of medication, lack of basal insulin, lack of weekend staff trained in diabetes management, use of a sliding scale, inappropriate medications being prescribed, knowledge deficit of the weekend staff, and outpatient diabetes medications not being restarted.ConclusionsWe identified the most frequent barriers to adequate glycemic control in this group of patients and suggest how limited resources should be focused to improve glycemic control. Barrier incidence should be determined in other populations of diabetic patients. (Endocr Pract. 2008;14:813-819)     

Effectiveness of a Multimodal Community Intervention Program to Prevent Suicide and Suicide Attempts: A Quasi-Experimental Study

Background

Multilevel and multimodal interventions have been suggested for suicide prevention. However, few studies have reported the outcomes of such interventions for suicidal behaviours.

Methods

We examined the effectiveness of a community-based multimodal intervention for suicide prevention in rural areas with high suicide rates, compared with a parallel prevention-as-usual control group, covering a total of 631,133 persons. The effectiveness was also examined in highly populated areas near metropolitan cities (1,319,972 persons). The intervention started in July 2006, and continued for 3.5 years. The primary outcome was the incidence of composite outcome, consisting of completed suicides and suicide attempts requiring admission to an emergency ward for critical care. We compared the rate ratios (RRs) of the outcomes adjusted by sex, age group, region, period and interaction terms. Analyses were performed on an intention-to-treat basis and stratified by sex and age groups.

Findings

In the rural areas, the overall median adherence of the intervention was significantly higher. The RR of the composite outcome in the intervention group decreased 7% compared with that of the control group. Subgroup analyses demonstrated heterogeneous effects among subpopulations: the RR of the composite outcome in the intervention group was significantly lower in males (RR = 0.77, 95% CI 0.59–0.998, p = 0.0485) and the RR of suicide attempts was significantly lower in males (RR = 0.39, 95% CI 0.22–0.68, p = 0.001) and the elderly (RR = 0.35, 95% CI 0.17–0.71, p = 0.004). The intervention had no effect on the RR of the composite outcome in the highly populated areas.

Interpretation

Our findings suggest that this community-based multimodal intervention for suicide prevention could be implemented in rural areas, but not in highly populated areas. The effectiveness of the intervention was shown for males and for the elderly in rural areas.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00737165","term_id":"NCT00737165"}}NCT00737165 UMIN Clinical Trials Registry UMIN000000460