Developing Suicide Warning Signals from Related Information to Better Support Clinical Assessment and Prevention of Suicide Among Young People

This week on the blog Nadine Dougall (professor at Napier University in Edinburgh) and Jan Savinc (Research Fellow at Napier University of Edinburgh) share the outcomes of their study on childhood adversity and admission to hospital for mental health problems prior to suicide (CHASE study).

Suicide is the leading explanation for death amongst young people worldwide, with wide-ranging public health impacts and devastating consequences for families and communities. Suicide rates were rising before the pandemic, with significant increases amongst adolescents and young people, and increased suicide prevention is urgently needed.

It is crucial to search out ways to forestall premature death by intervening early within the lives of youngsters and adolescents, before suicidal behaviour occurs.

Published evidence has widely described risk aspects for later suicide, including episodes of mental health and self-harm. More recently, childhood adversity has also come to the fore, with research showing it to be a risk factor for later suicide. However, the relative contribution of mental health, self-harm, or childhood adversity in any combination across the lifespan prior to the event of suicidal behavior has been unknown. Furthermore, the study designs which were used previously have been suboptimal, as they’ve relied on the memory of people affected by childhood adversity.

In our study, we wanted to search out out when young individuals who died by suicide had previously been admitted to a general hospital or psychiatric facility due to childhood adversity (e.g. abuse, violence or neglect) or due to mental health problems (including self-harm) – a time when healthcare professionals could intervene. We selected a powerful longitudinal study design that allowed us to follow all hospital data for young individuals who died by suicide and compare them with a control population. This design allowed us to avoid the recall bias present in lots of other published studies.

The research data were chosen from cradle to grave, made possible by NHS Scotland data and National Records of Scotland death records, which have been routinely and exceptionally kept since 1981. This enabled us to trace the hospital records of 2477 people born since 1981 who died by suicide as much as the age of 36 years. We were also in a position to link maternal health and death data. We compared this with data from 24,777 randomly chosen people from the overall population, matched for age, sex and place of residence. We published the study protocol.

We found that 76% of deaths by suicide occurred in young men, with a median age of 23. The majority (81%) of men who died had First admission of patients to the overall hospital forassault(see “Key Findings 5” below). Two-thirds (68%) of girls were First admitted to hospital with co-registeredunfavorable social circumstances‘. We also found that 3.5% of girls and a couple of.3% of men who died by suicide had experienced the death of a mother, compared with 0.7% and 1.1% in the overall population. Experience of care was also an element, with 2.5% of those that died by suicide having been admitted to or discharged from care/foster homes or other institutional settings by the age of 18, compared with 0.2% in the overall population.

Note:Young individuals who were first admitted to hospital with a mental health problem and childhood adversity were 9.2 times more more likely to die by suicide (key findings 6) and significantly more likely than those with mental health problems alone. Excerpts from the important infographic (link below)

In terms of mental health, 22% of people that committed suicide (35% of girls and 18% of men) had First psychiatric diagnosis between the ages of 10 and 17 compared with only 4% of the overall population (6% of girls and 4% of men). Mental health was an umbrella category for a variety of conditions, including self-harm. The highest variety of admissions under the age of 18 for men and girls who died by suicide were for ‘self-harm/poisoning’, with 30% of girls having the sort of admission, 10 times greater than 3% of girls in the overall population. The corresponding figures for men were 9% and 1% respectively. In decreasing order of frequency, the remaining admissions were related to diagnoses related to alcohol/other conditions, substance use, mood and anxiety. We also found that ‘accidental poisoning’ was more common in those that died by suicide, with 3.3% having the sort of admission compared with 0.4% of the overall population.

But the important thing finding of the study was that hospital admissions for people under 18 were related to adversity (e.g., abuse or mistreatment) AND a mental health diagnosis (in any order) First admission) produced the very best likelihood of subsequent suicide for the young person (see ‘key findings 6’). This was higher than admissions for mental health reasons alone (which included self-harm categories). Further information might be obtained from our research infographics (attached) and/or by accessing the important open access publication (https://doi.org/10.1192/bjo.2024.69).

In conclusion, nurses and other healthcare employees should prioritize suicide prevention amongst adolescents admitted to hospital after previous adversarial childhood experiences. AND mental health records, as these have been linked to significantly higher rates of suicide amongst young people. This might be a part of the chance formulation and a part of any psychosocial assessment as beneficial Nice NG225 GuidelinesThis study also showed the necessity for higher information sharing between general hospital and psychiatric systems, previously reported elsewhere. It is crucial to recognise the warning signs to look out for in suicidal thoughts and behaviours, but way more must be done to link services and their data. Given that healthcare data systems are usually not linked inside and across the UK, it’s inevitable that healthcare staff are losing information that would higher support clinical judgement. The strongest association in young individuals with one variety of condition was self-harm in adolescence.

There is a window of opportunity for nurses and other healthcare professionals to discover and flag up potentially ‘at risk’ teenagers and supply supportive interventions to forestall future suicidal behaviour. Perhaps in the longer term the emergency department could have a greater ‘red flag’ system to alert nurses and other healthcare professionals to previous admissions for childhood adversity and mental health problems and to raised support staff with clinical judgements related to potential suicide. Other data sets, equivalent to GP, school, social care or police records, for instance, might be used to increase the seek for red flags and help people get the assistance they need. It is probably going that ambulance and cops got here into contact with lots of the people on this study in pre-hospital emergency care who later died by suicide. Therefore, finding ways to alter policy and practice in relation to improving information sharing and response between and inside emergency services also offers significant opportunities to discover and support teenagers at biggest future risk of suicide.

Nadine Dougall is Professor of Mental Health and Data Science at Napier University in Edinburgh. She might be contacted at n.dougall@napier.ac.uk Or @nadinedougall

Jan Savinc is a research fellow in health data science at Napier University in Edinburgh. He might be contacted at j.savinc@napier.ac.uk Or @jsavinc

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