Dramatic Rise in Suicide-Related Visits at Children's Hospitals

Batya Swift Yasgur, MA, LSW

May 16, 2018

The percentage of children and adolescents presenting at US pediatric hospitals for suicidal ideation (SI) or suicidal attempts (SAs) doubled from 2008 to 2015, new research shows.

After studying more than 100,000 encounters for SI and SAs, the researchers found that the annual percentage increased from 0.66% in 2008 to 1.82% in 2015. The highest rates consistently occurred in fall and spring.

"One of the take-home messages of our findings for children's hospitals and healthcare delivery systems is that this problem is not going to go away overnight and may continue to increase," lead author Gregory Plemmons, MD, associate professor of pediatrics, Vanderbilt University School of Medicine and Monroe Carell Junior Children's Hospital, Nashville, Tennessee, told Medscape Medical News.

"Don't be afraid to talk about suicide with teens and families, and know your resources locally when you encounter a child or teen who may be suicidal, because this is one area of healthcare where a missed intervention can truly be deadly," he said.

The study was published online May 16 in Pediatrics.

Vulnerable "Boarders"

Suicide is the third leading cause of death in US adolescents. Age-adjusted rates have rised 24% during the past 15 years, the researchers note.

SI and SAs are associated not only with increase risk for repeat attempts but also with subsequent deaths, they note.

Although children's hospitals generally serve as "regional referral centers of expertise for many pediatric physical health conditions, little is known about their role in providing SI and/or SA care at a time when national rates of youth suicides appear to be increasing," the authors observe.

Moreover, many pediatric hospitals have reported shortages of mental health clinicians during the past decade, and pediatricians report lack of adequate training and skills to manage mental health complaints.

"We were motivated to conduct this study because we began to notice in our own children's hospital about 10 years ago that we were beginning to see an increase in the number of children admitted to a medical bed for suicide ideation or attempt, due to the lack of psychiatric beds while they waited for placement," said Plemmons.

"The unfortunate term sometimes used for this fragile and vulnerable population is 'boarders,' " he added.

The authors therefore chose to "examine changes in the burden of SI and SA encounters at children's hospital EDs [emergency departments] and inpatient units, and the demographic and clinical characteristics of these children, as well as trends."

The researchers used the Pediatric Health Information System database to identify ED encounters, observation stays, and inpatient hospitalizations for children and adolescents aged 5 to 17 years during the period 2008 to 2015.

The outcome was the percentage of total encounters for SI and SAs in each month of the study period. This was calculated by dividing the number of SI and SA encounters by the total number of encounters each month.

Beyond calculating average changes in annual percentages during the study period, the researchers also examined seasonal trends.

Vacation Protective?

The researchers identified 115,856 encounters for SI and SAs during the study period (1.21% of the 9,574,229 total encounters across 31 hospitals).

Of the SI and SA encounters (n = 67,588), more than half (58.3%) resulted in an inpatient hospitalization in a children's hospital. Of these, 13.2% of cases required intensive care.

Of the encounters, the largest percentages were found in adolescents between the ages of 15 and 17, followed by those 12 to 14 years old, and then by 5- to11-year-olds (50.2%, 37%, and 12.8%, respectively).

Nearly two thirds of encounters (n = 74,599; 64.4%) involved girls.

Of the total annual encounters during the study period, the percentage of SI and SA encounters more than doubled, increasing from 0.66% in 2008 to 1.82% in 2015 (absolute difference in percent: 1.16; 95% confidence interval [CI], 1.13 - 1.18; P < .001).

This overall increase represented an average annual increase of 0.16 percentage points (95% CI, 0.15 - 0.17; P < .001).

Total annual encounters for all diagnoses increased from by 43% during the study period; by contrast, total annual encounters for SI and SAs increased by 292%.

These increases were found in ED as well as inpatient settings, although there were slightly higher increases in ED encounters.

The smallest percentage increase was seen in patients aged 5 to 11 years (average annual increase of 0.02 percentage points; 95% CI, 0.01 - 0.02), compared with patients aged 12 to 14 years (average annual increase of 0.25 percentage points; 95% CI, 0.21 - 0.27) and those aged 15 to 17 years (average annual increase of 0.27 percentage points; 95% CI, 0.23 - 0.30; P < .001 for both comparisons).

The increases were higher for girls than for boys. They were highest in non-Hispanic white youth, followed by youth of other races, non-Hispanic African American youth, and Hispanic youth.

Importantly, the researchers observed seasonal variation in encounters for SI and SAs.

On average, during the study period, only 18.5% (95% CI, 18.0 - 19.0) of total annual SI and SA encounters occurred during summer months. For example, only 5.9% of all these encounters occurred July (95% CI, 5.6 - 6.1).

The highest peaks were found in the fall and spring. Almost twice as many encounters occurred in October than in July (9.9%; 95% CI, 9.2 - 10.7), followed by March (9.7%; 95% CI, 9.2 - 10.1).

"We were surprised to find that the increase is nationwide," Plemmons recounted.

Possible reasons for the increase in suicidality include the rise of social media and cyberbullying, the increased stress and anxiety reported by teens, and lack of connectedness, he noted.

"We were also surprised to see the strong temporal association with the academic calendar," he added.

He suggested that in youngsters, vacations and school breaks may be "somewhat protective, which is interesting because in adults, May, June, and July are higher months for suicide."

Road Map

Commenting on the study for Medscape Medical News, Cora Collette Breuner, MD, MPH, professor, Department of Pediatrics, Division of Adolescent Medicine, and chair, Committee on Adolescence, American Academy of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, who was not involved with the study, urged clinicians "not to be bummed out when you read this."

Rather, "the take-home message of this study is that it gives you a road map what to do with this higher number of youngsters who are suicidal, rather than just throwing your hands in the air and thinking that these kids are doomed," she emphasized.

She advised clinicians to "be aware of the trend, especially the seasonality —which may be connected not only to academics but also to changes in sleep patterns during fall and spring."

Additionally, "as found in the study, kids as young as 5 years old can also have thoughts of self-harm," she said.

She recommended the Patient Health Questionnaire–9 as an "easy screen." If a child scores higher than 10 on that measure, "you need to go further as a clinician to identify what's going on," she said.

It is also important for clinicians to have resources in place so that if they identify a suicidal youngster, they "don't have to 'board' a kid in the ED while waiting for a psychiatry bed to open up and scramble to find a therapist," she emphasized.

Plemmons encouraged clinicians to become "advocates locally for supporting mental health resources and funding."

He noted that "most hospitals more than likely are already aware of the 'September effect,' but it may help in utilization planning."

The study received no external funding. The authors and Dr Breuner have disclosed no relevant financial relationships.

Pediatrics. Published online May 16, 2018. Abstract

For more Medscape Psychiatry news, join us on Facebook and Twitter.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.