Pilot Program Tackles Growing Problem of Child Suicide

VIENNA, Austria — A new pilot program, created by clinicians and investigators from 6 European countries, aims to reduce the rate of child suicides, which is a growing problem worldwide.

The Suicidality: Treatment Occurring in Pediatrics (STOP) project uses kid-friendly and age-appropriate computer screens inside hospitals and emergency departments to help young patients to report in a safe environment any suicidal behaviors they may have. A warning about a possible increased risk for suicide is then automatically sent to clinicians.

"Suicide is one of the most common causes of death in young people today," STOP program lead Paramala J. Santosh, MD, PhD, from the Child and Adolescent Mental Health Services Department at Maudsley Hospital in London, United Kingdom, said to attendees here at the 25th European College of Neuropsychopharmacology (ECNP) Congress.

Dr. Paramala Santosh

"With our project, we are hoping we can use it to identify whether we can pick up suicidal ideation and intent much before the act, and can therefore intervene quicker," added Dr. Santosh.

Philippe Courtet, PhD, professor of psychiatry at the University of Montpellier, in France, and chairman of the Department of Emergency Psychiatry at the Academic Hospital in Montpellier, noted that suicidal ideation will be included for the first time in the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Dr. Philippe Courtet

"The general population largely ignores the magnitude of this phenomenon of suicidal behavior," said Dr. Courtet, who is also cochair of the ECNP-supported network on suicidal behavior and chair of the Suicide Task Force for the World Federation of Societies of Biological Psychiatry.

"The issue of what is suicidal behavior in children is clearly a medical issue and not just a social problem. And early interventions are of the upmost importance."

Common Cause of Death

"Although suicide in childhood and early adolescence is rare, risk of onset of suicidal ideation increases rapidly during adolescence and young adulthood, which then stabilizes in early midlife," Dr. Santosh said in a release.

"The prevalence rates in adolescents cross-nationally are reported to be 19.8% to 24.0% for suicide ideation and 3.1% to 8.8% for suicide attempts."

A study published this spring in the Canadian Medical Association Journal, and reported at the time by Medscape Medical News, showed that suicide rates are increasing significantly for adolescent girls in Canada — with suffocation the preferred method.

"Suicide is [now] 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," write that study's investigators.

According to the American Academy of Child and Adolescent Psychiatry, in the United States, suicide is the third leading cause of death for adolescents and young adults between the ages of 15 and 24 years, and it is the sixth leading cause of death for those between the ages of 5 and 14 years.

Lack of Care

Previous research has shown that common contributors to suicidality in youth include genetic vulnerability, psychiatric comorbidity (especially mood disorders), psychosocial factors, prior suicide attempts by the young person or a family member, substance abuse, social alienation, availability of means, escalating self-harm, and trauma.

A study recently published in the Archives of Pediatric and Adolescent Medicine, and reported by Medscape Medical News, showed that suicidal ideation is more than twice as common in youth who have been victimized in any way compared with those who have experienced bullying.

Media, especially the Internet, can also be a dangerous influence.

"There are currently many Web sites that can actually assist kids in getting methods of how to commit suicide," said Dr. Santosh.

Unfortunately, "less than half of young people who committed suicide actually received psychiatric care," he reported. Therefore, "universal measures aimed at young people in general and targeted initiatives focused on high-risk groups are needed."

He added that training general practitioners and other clinicians to recognize and treat depression and suicidality, providing cognitive-behavioral therapy, and providing specialized emergency department interventions may all be useful in treating suicidal youth.

"The important thing is that evaluations need to be done regularly. And unless you pick up that someone is at risk, you're not going to be able to prevent it," said Dr. Santosh.

Innovative Web-based System

The STOP project was formed by a consortium of child mental health specialists across Europe to assess whether measures reported by young patients can determine suicidal ideation and/or behaviors after a new medication is initiated, which would then automatically trigger a warning to clinicians that an intervention may be needed.

As part of the project, the group created the Web-based STOP Suite of Suicidality Measures, which also measures medication side effects, risk factors, and even protective factors through a system called HealthTracker.

HealthTracker is a confidential, Web-based health monitoring system that provides children and adolescents, parents, and teachers with separate entries to do assessments for a young patient.

In addition, separate 10-minute questionnaire modules are set up by age groups and by sex. For example, an adolescent girl's module is significantly different from the one set up for children younger than the age of 8 — which includes animations and more illustrations of things such as symptoms, as well as an overall gaming feel.

"We found that children as young as 5 were able to understand these concepts the way they were presented. And they're now able to tell us what their problems are, which previously they could not. This includes problems they have at home, in school, or on the playground," said Dr. Santosh.

"We found that all of the children are so comfortable with the Internet that they appear to be telling us more online than they are face-to-face. I think it's just the way children are used to dealing with things now."

The information is then pulled together into a computer-generated classification of suicidality for clinicians, based upon the European Classification of Suicide-Related Thoughts and Behavior and the Columbia Classification Algorithm of Suicidal Assessment.

Global Rollout

Although the project is currently being piloted in children and adolescents, the investigators have also started 3 cohort studies.

One study includes children with bronchial asthma and no mental illness at all. Of these, 120 are being treated with montelukast, and 120 are receiving other treatments. The purpose is to assess whether HealthTracker is an acceptable system in the nonpsychological setting of general pediatrics.

The second study includes 240 adolescents who have been clinically diagnosed with depression. Of these, 120 are receiving fluoxetine, and 120 are receiving cognitive-behavioral therapy. Its purpose is see whether the system "can pick up suicidality arising from the condition itself, and also whether it can allow for any differentiation in effects of treatment," explained Dr. Santosh.

The final group is made up of 400 adolescents receiving risperidone for aggression and conduct disorder compared with 250 of their healthy peers, "to let us check what we need to do to use this in the general population for screening purposes."

The investigators hope to release their findings of these studies in the next 2 years. If the results bear out, Dr. Santosh said that he hopes to roll out the system all across the world, including in the United States.

Future of Care

"I think this is a very interesting and very important project," Dr. Courtet told Medscape Medical News.

"Many general practitioners and even psychiatrists don't ask their young patients about suicide. So it's important to systematically assess this in a very easy way."

He added that "this is the future of care for suicidal patients. They are a very difficult group to care for. So I think that we need to use new technology through smart phones and the Internet to detect problems, to follow up with the patient, and to improve our care."

However, during the question-and-answer session following the presentation, Dr. Courtet asked whether the STOP system might be prone to "many false alarms."

Dr. Santosh replied that that was in part why 1 of the cohort studies includes healthy control participants, to monitor how the system works with all types of children.

"There will still be false-positives, for sure. But this is not to take the place of clinical care. It's just to assist in decision making. It's letting someone else ask the initial questions for you and then using the limited time available to us in an appropriate manner, and to dig deeper if needed," he explained.

After his presentation, Dr. Santosh told Medscape Medical News that a problem not usually discussed is that the concept of death is very different for children of different ages.

"For example, children under 6 don't understand that death is permanent. They think they're like a cartoon character, such as on South Park — that if they die, they'll wake up the next day and be fine," he said.

"So it's important for clinicians to work with kids to help them to understand it is permanent. And then things can change."

Overall, he said that he would tell clinicians that it is very important to trust children when they say they are miserable, and to diagnose and treat depression if found.

"Often clinicians and social workers and social services think it's normal for a child to be unhappy when they have a lot of stresses, and it's okay for them to be depressed. But that's not good enough if they are genuinely suffering from a condition which requires treatment," said Dr. Santosh.

25th European College of Neuropsychopharmacology (ECNP) Congress. Presented October 14, 2012.