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Suicidality among child and adolescent psychiatric inpatients: time trend study comparing 2000 and 2011

  • Kim KronströmEmail author
  • Elina Tiiri
  • Elina Jokiranta-Olkoniemi
  • Anne Kaljonen
  • Andre Sourander
Open Access
Original Contribution

Abstract

Child and adolescent inpatient treatment has faced major changes since the year 2000, including shorter inpatient stays and a greater use of psychotropic drugs. This study explored changes and correlates of suicidal threats and suicide acts among inpatients, by comparing Finnish cross-sectional surveys from 2000 to 2011. A questionnaire that explored the background, diagnosis and treatment characteristics of inpatients was sent to all child and psychiatric wards in Finland. The data collection was carried out on specified days in 2000 and 2011. We received comprehensive data on 504 patients from 64/69 (93%) wards in 2000 and on 412 patients from 75/79 (95%) wards in 2011. The Spectrum of Suicidal Behaviour Scale was used to explore suicidality. The prevalence of suicidality did not change in this nationwide study: suicidal threat rates were 38% in 2000 and 37% in 2011, and suicide attempts in both years were 11%. The prevalence of suicidal acts was higher among girls and teenagers, while low general functioning, defined as Children’s Global Assessment Scale scores of under 30, was associated with both suicidal threats and acts. Violent acts were associated with both suicidal threats and acts in 2000, but not in 2011. Despite changes in treatment practices and shorter inpatient stays, the prevalence of suicidality in child and adolescent inpatient treatment remained unchanged in Finland in 2000 and 2011.

Keywords

Adolescent psychiatry Child psychiatry Inpatient treatment Suicidality Time trend study 

Introduction

Suicide is one of the leading global causes of death, especially among adolescents and young adults [1]. The estimates on trends in suicide rates among young people vary across the world, from increases [2] to stable rates [3], with significant differences between individual countries. In Finland, suicides among adolescents declined by one-third during 2000 [4]. Suicidal thoughts and behaviors during childhood and adolescence are robust risk factors for adult suicidality and poor psychiatric and functional outcomes in general [5]. Population-based studies show that 12–14% of adolescents have reported suicidal thoughts at some point in their lives and 4–7% have reported suicide attempts [6, 7].

There is a clear need to study suicidality among children and adolescents in inpatient settings for several reasons. First, suicidality is one of the most common reasons for admissions to inpatient treatment and there is an increased risk of suicidal behavior during inpatient treatment [8, 9, 10, 11]. Second, adolescents treated in inpatient settings have more risk factors for suicidality than their peers. These include depression, low self-worth, dysfunctional families, adverse childhood experiences and not feeling that they are part of their peer groups [12, 13, 14]. Third, previous suicide attempts are also major risk factors for suicidality after inpatient hospitalization [15, 16]. Growing knowledge on suicidality among inpatients can help us to develop more effective evaluations and treatment methods and lower the risks of successful suicides. In recent years, there has been growing need to develop intensive open care services as an alternative to inpatient care. These seem to be equally effective, from a clinical point of view, but are also more cost-effective [17, 18]. However, most studies on intensive open care services have excluded young people with acute suicidality [17].

There are several trends that could have had an impact on the prevalence of suicidality among child and adolescent inpatients. The expansion of child and adolescent open care psychiatry [19] provides treatment for a larger number of young patients with mental health problems [20]. If a larger proportion of suicidal children and adolescents receive adequate open care treatment, the need for hospital treatment for such patients could decrease. At the same time, the growth of open care services may improve our ability to detect suicidal children and adolescents. The growth in the number of suicidal patients that have been reported could have led to increases in referrals to hospital treatment because of suicidality.

Since the year 2000, there has been a trend toward shorter inpatient treatment stays [21, 22, 23] and this trend could also have increased the prevalence of suicidality among inpatients. Shorter inpatient treatment times could imply that children and adolescent with less acute and less severe symptoms are discharged from hospital sooner and that inpatient treatment focuses more on suicidal inpatients.

The use of psychotropic medications has also grown rapidly, both in inpatient care [24, 25, 26, 27] and in outpatient care [28, 29], which might have led to decreasing suicidality among children and adolescents. At the same time, the diagnosis of depression has become more common in both inpatient and outpatient child and adolescent patient populations [23, 30, 31]. As depression is a major risk factor for suicidality [32], the rising prevalence of depression could have an impact on prevalence of suicidality. Thus, there are trends that may have both increased and decreased the prevalence of suicidality in child and adolescent inpatient treatment.

Information about service use can be obtained from registers and patient records, but this data lacks systematic information on suicidality. To obtain reliable information about the prevalence of suicidality, and changes in inpatient populations, we need to collect information using cross-sectional surveys with the same methodology and target populations. This paper reports the first nationwide study to examine the prevalence, risk factors and time trend changes of suicidality using two cross-sectional, nationwide samples in 2000 and 2011 that employed the same methodology.

Materials and methods

Procedure and subjects

The data collection for this study was carried out in 2000 and 2011 and a five-page questionnaire that explored the background, diagnostic and treatment characteristics of inpatients was circulated to all child and psychiatric wards in Finland. The psychiatrists responsible for inpatient treatment were asked to fill in a questionnaire for every inpatient up to the age of 18 years who occupied a child or adolescent psychiatric bed on the chosen study day in each of the 2 years. Day patients treated in hospital wards were classified as inpatients for the purpose of this study. In 2000, there were 69 wards that provided 547 inpatient beds treating patients who just attended during the day or stayed in the unit. The data gathered in that year covered 504 inpatients in 64/69 (93%) wards, as five wards declined to take part. In 2011, data were supplied on 412 inpatients from 75/79 (95%) wards, as four wards declined to take part.

The data in this study were based on the answers that the psychiatrists gave in 2000 and 2011 on every child or adolescent receiving relevant psychiatric treatment. The five-page questionnaire comprised 22 questions about the inpatient ward and medical and background data on the patients. Both the procedure and the questionnaire have previously been described in more detail in our previous paper [23]. This paper focuses on changes in suicidal behavior and attempts between 2000 and 2011 and how suicidality correlated with the general functioning, violence, background information and diagnostic characteristics of the psychiatric inpatients.

The chairman of the ethical committee of the University Hospital of Turku has given a statement which says that due to the methodology of this study, there was no need for application to be made to the ethical committee. The data did not include details that would enable identification of and individual patient.

Instruments

The psychiatrist responsible for the treatment estimated the suicidality during the ongoing inpatient treatment using the Spectrum of Suicidal Behaviour Scale [8, 33], which has been widely used and found to have a high inter-rater reliability [34, 35]. The five-point scale covers: (1) no suicidal ideation or behavior, (2) suicidal ideas, (3) suicidal threats, (4) mild suicide attempts, and (5) serious suicide attempts. In this study we divided the responses into three groups for the analysis: (1) no suicidality, (2) suicidal threats, including suicidal ideas and suicidal threats, and (3) suicidal attempts, which included mild and serious suicide attempts.

The patients were diagnosed as a result of normal hospital procedures in accordance with the International Classification of Diseases-Tenth Revision (ICD-10). The psychiatrists were asked to report the one or two most important psychiatric diagnoses and both were taken into account in the analysis. This means that one patient can appear in more than one diagnostic group. For practical reasons, we have only reported diagnoses given to more than ten inpatients or 3% of the total study cohort in either 2000 or 2011. The following diagnostic groups were analyzed: depression, psychosis, mania/bipolar disorder, anxiety disorders, obsessive compulsive disorder, eating disorders, childhood affective disorder, substance use, conduct or oppositional disorder, developmental disorder, autism spectrum disorders, attachment disorder and attention-deficit hyperactivity disorder (ADHD).

The patients’ general functioning levels at the time of data collection were evaluated with the Children’s Global Assessment Scale (CGAS) [36, 37, 38], which is designed to reflect the lowest level of functioning of a child or adolescent during a specific time period. The CGAS values range from one for the most functionally impaired child to 100 for the least impaired. In the questionnaire used in this study, the CGAS scores were reported at 10-point intervals, i.e., 1–10, 11–20 and so on. For the analysis, we divided inpatients into three groups according to their CGAS scores: 0–30, 31–40 and 41–100. These cutoff scores were based on the CGAS scores that would produce clinically relevant groups. Inpatients who scored 30 or lower were, by definition, unable to function in most situations. Those with CGAS scores of 31–40 had major impairment in several areas and those who scored 41 or more had good general functioning. The level of aggression or violence displayed by the inpatients was evaluated with the six-point Spectrum of Assaultive Behaviour Scale [39]. The five-point scale covers: (1) no violent ideas or behavior, (2) violent thoughts, (3) violent threats, (4) a less serious violent act, (5) a serious violent act and (6) killing someone. For our analysis, we divided the patients into two groups: those scoring 1–3 were categorized as performing no violent acts and those scoring 4–6 were categorized as performing violent acts.

Statistical methods

Statistically significant differences between the frequency distributions were tested with Pearson’s Chi-square test or, in the case of small frequencies, with Fisher’s exact test. The differences in nominal outcome suicidality—no suicidality, suicide threats or suicide acts—were analyzed with multinomial logistic regression analysis. The interactions of year (2000 or 2011), gender (boy or girl) and age (0–12 or 13–18 years) were tested and, if there were nearly significant interactions (p < 0.10), were analyzed further by dividing the data by the interactive effect. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated to quantify the significant associations. P values of less than 0.05 were considered significant. All statistical analyses were carried out using SAS version 9.4 (SAS, Cary, NC, USA).

Results

Patient characteristics and suicidality

Table 1 shows that the prevalence of suicide threats at the two time points were similar, at 38% in 2000 and 37% in 2011, while the prevalence of suicidal acts were 11% in both years. In both genders, 36–38% of the inpatients made suicidal threats, whereas the prevalence of suicide acts was significantly higher among the girls than boys (19% vs. 4%, OR 6.2, 95% CI 3.7–10.5). There was no significant difference in the prevalence of suicidal threats between children (under 13 years) and teenagers (13–18 years), whereas suicidal acts were more common among teenagers (17 vs. 4%, OR 5.0, 95% CI 2.8–8.9). As shown in Figs. 1 and 2, we studied the prevalence of suicidal threats and acts separately for boys and girls in the age groups 0–9, 10–12, 13–15 and 16–18 years. The trend for suicidal acts increased strongly among girls aged 10–12 years, when compared to younger girls aged 0–9 years, and the rate of 10% was also significantly higher than the 2% recorded for boys aged 10–12 years (OR 6.2, 95% CI 1.4–27.7).
Table 1

The unadjusted associations, and associations adjusted by year, gender and age, between patient characteristics and suicidality (no problems/suicide threats/suicide attempts), with no suicidality as the reference group

 

N

P

Unadjusted

Adjusted with year, gender and age

Suicidal threat

Suicidal act

 

Suicidal threat

Suicidal act

N (%)

OR (95% CI)

N (%)

OR (95% CI)

P

OR (95% CI)

OR (95% CI)

Year

 

0.9580

       

 2000

502

 

189 (38)

 

54 (11)

    

 2011

409

 

151 (37)

1.0 (0.7–1.3)

43 (11)

1.0 (0.6–1.5)

   

Gender

 

< 0.0001

       

 Boy

498

 

191 (38)

 

20 (4)

    

 Girl

394

 

142 (36)

1.2 (0.9–1.6)

76 (19)

6.2 (3.7–10.5)***

   

Age (years)

 

< 0.0001

       

 0–12

406

 

167 (41)

 

15 (4)

    

 13–18

489

 

164 (34)

0.9 (0.7–1.2)

81 (17)

5.0 (2.8–8.9)***

   

CGAS

 

0.0009

    

0.0046

  

 41–100

540

 

199 (37)

0.6 (0.4–1.0)*

43 (8)

0.3 (0.2–0.5)***

 

0.6 (0.4–1.0)*

0.3 (0.2–0.6)***

 31–40

228

 

86 (38)

0.7 (0.4–1.1)

26 (11)

0.4 (0.2–0.8)*

 

0.7 (0.4–1.2)

0.5 (0.3–1.1)

 0–30

109

 

45 (41)

1.0

22 (20)

1.0

 

1.0

1.0

Living with biological parents

 

0.4778

    

0.6464

  

 No

114

 

45 (39)

 

15 (13)

    

 Yes

797

 

295 (37)

0.8 (0.6–1.3)

82 (10)

0.7 (0.4–1.3)

 

0.9 (0.6–1.4)

0.7 (0.4–1.4)

Violent act

 

0.0027

   

< 0.0001

  

 No

657

 

229 (35)

 

63 (10)

    

 Yes

230

 

100 (43)

1.6 (1.2–2.2)**

32 (14)

1.9 (1.2–3.1)**

 

1.9 (1.3 -2.7)***

5.3 (2.9–9.5)***

Psychosis

 

0.1297

    

0.3929

  

 No

807

 

296 (37)

 

82 (10)

    

 Yes

104

 

44 (42)

1.4 (0.9–2.2)

15 (14)

1.7 (0.9–3.3)

 

1.4 (0.9–2.2)

1.1 (0.6–2.2)

Depression

 

< 0.0001

    

0.0021

  

 No

700

 

256 (37)

 

55 (8)

    

 Yes

211

 

84 (40)

1.5 (1.1–2.1)*

42 (20)

3.5 (2.2–5.6)***

 

1.5 (1.0–2.1)*

2.4 (1.4–3.9)***

Anxiety disorder

 

0.8630

    

0.8510

  

 No

816

 

303 (37)

 

86 (11)

    

 Yes

95

 

37 (39)

1.1 (0.7–1.7)

11 (12)

1.2 (0.6–2.3)

 

1.1 (0.7–1.8)

0.9 (0.5–2.0)

Eating disorder

 

0.0138

    

0.0262

  

 No

839

 

323 (39)

 

84 (10)

    

 Yes

72

 

17 (24)

0.5 (0.3–0.9)*

13 (18)

1.6 (0.8–3.1)

 

0.4 (0.2–0.8)**

0.6 (0.3–1.2)

Developmental disorder

 

0.0229

    

0.1748

  

 No

854

 

322 (38)

 

96 (11)

    

 Yes

57

 

18 (32)

0.6 (0.4–1.1)

1 (2)

0.1 (0.0–0.9)*

 

0.6 (0.3–1.1)

0.3 (0.0–2.2)

Autism spectrum disorder

 

0.0914

    

0.6613

  

 No

857

 

319 (37)

 

96 (11)

    

 Yes

54

 

21 (39)

0.9 (0.5–1.6)

1 (2)

0.1 (0.0–1.1)

 

1.0 (0.6–1.8)

0.4 (0.1–3.0)

ADHD

 

0.1274

    

0.5011

  

 No

847

 

319 (38)

 

94 (11)

    

 Yes

64

 

21 (33)

0.7 (0.4–1.2)

3 (5)

0.3 (0.1–1.1)

 

0.8 (0.4–1.4)

1.6 (0.4–5.8)

Conduct disorder

 

0.0006

    

0.0043

  

 No

692

 

236 (34)

 

83 (12)

    

 Yes

219

 

104 (47)

1.6 (1.2–2.2)**

14 (6)

0.6 (0.3–1.1)

 

1.8 (1.3–2.5)**

1.5 (0.8–3.0)

Emotional disorder

 

0.3383

    

0.2751

  

 No

829

 

304 (37)

 

91 (11)

    

 Yes

82

 

36 (44)

1.3 (0.8–2.1)

6 (7)

0.7 (0.3–1.7)

 

1.3 (0.8–2.1)

0.6 (0.3–1.6)

*p < 0.05; **p < 0.01;***p < 0.001

Fig. 1

Suicidal threats among girls and boys, presented as percentages for the age groups 0–9, 10–12, 13–15 and 16–18 years

Fig. 2

Suicidal threats among girls and boys, presented as percentages for the age groups 0–9, 10–12, 13–15 and 16–18 years

When we analyzed the combined data from 2000 to 2011, we found that suicidal acts were more prevalent among inpatients with poor general functioning, defined by a low CGAS score. While 8% of inpatients with a CGAS score of more than 41 had performed suicidal acts, the prevalence was 20% in inpatients with a CGAS score of under 30 (OR 0.3, 95% CI 0.2–0.5). There were significantly less suicidal acts among inpatients with CGAS scores of 31–40 compared to those with CGAS scores under 30 (OR 0.4, 95% CI 0.2–0.8). The association between suicidal acts and CGAS scores of 31–40 disappeared when we controlled the analysis using just the 730 “day and night inpatients” and excluded the 128 day patients treated in the hospital wards. This was the only significant association between suicidality and other variables that was incompatible between the two analyses, namely the analysis of all patients treated in the hospital wards and the analysis that only included the “day and night inpatients”.

Inpatients who committed violent acts had a higher likelihood of both suicidal threats (43% vs. 35%, OR 1.6, 95% CI 1.2–2.2) and suicidal acts (14% vs. 10%, OR 1.9, 95% CI 1.2–3.1) compared to inpatients who did not commit violent acts. The association between violence and suicidality also remained statistically significant in the adjusted multivariate model, which took into account gender, age (under or over 13 years) and the year of the study.

As presented in Table 2, we analyzed the interactions between study year, age and gender with suicidality and diagnoses. A significant interaction was found with regard to suicidality between the study year and violent acts, as violent acts were positively associated with both suicidal threats (p = 0.0006) and suicidal acts (p < 0.0001) in the year 2000, but there were no such associations in 2011. Furthermore, when the inpatients with violent acts were analyzed, we found significant decrease in suicidal acts between 2000 and 2011 (p = 0.002).
Table 2

Interactions between year, age and gender and suicidality

 

N

P

Suicidal threats

Suicidal acts

N (%)

OR (95% CI)

N (%)

OR (95% CI)

Act and year

     

Violent act in year 2000

< 0.001

    

 No

363

 

124 (34)

 

29 (8)

 

 Yes

135

 

62 (46)

2.1 (1.4–3.3)**

24 (18)

3.5 (1.9–6.6)***

Violent act in year 2011

0.5988

    

 No

294

 

105 (36)

 

34 (12)

 

 Yes

95

 

38 (40)

1.1 (0.7–1.9)

8 (8)

0.7 (0.3–1.7)

Eating disorder in year 2000

0.0225

    

 No

477

 

180 (38)

 

47 (10)

 

 Yes

25

 

9 (36)

1.4 (0.5–3.6)

7 (28)

4.1 (1.5–11.7)**

Eating disorder in year 2011

0.0155

    

 No

362

 

143 (40)

 

37 (10)

 

 Yes

47

 

8 (17)

0.3 (0.1–0.7)**

6 (13)

0.9 (0.4–2.3)

Autism spectrum disorder in year 2000

0.1514

    

 No

421

 

174 (41)

   

 Yes

27

 

15 (56)

1.8 (0.8–3.9)

n = 1, so no analysis

Autism spectrum disorder in year 2011

0.0577

    

 No

340

 

145 (43)

   

 Yes

26

 

6 (23)

0.4 (0.2–1.0)

n = 1, so no analysis

Diagnosis and gender

      

Psychosis, boys

0.0138

    

 No

446

 

169 (38)

 

14 (3)

 

 Yes

52

 

22 (42)

1.4 (0.8–2.6)

6 (12)

4.7 (1.7–13.3)**

Psychosis, girls

0.7546

    

 No

345

 

122 (35)

 

67 (19)

 

 Yes

49

 

20 (41)

1.3 (0.7–2.5)

9 (18)

1.0 (0.5–2.4)

Depression, boys

 

0.9982

    

 No

423

 

162 (38)

 

17 (4)

 

 Yes

75

 

29 (34)

1 (0.6–1.7)

3 (4)

1.0 (0.3–3.7)

Depression, girls

 

< 0.0001

    

 No

261

 

88 (34)

 

38 (15)

 

 Yes

133

 

54 (41)

2.0 (1.2–3.3)**

38 (29)

3.3 (1.9–5.8)***

*p < 0.05; **p < 0.01;***p < 0.001

Diagnosis and suicidality

In the analysis of the whole data, as presented in Table 1, depression was the diagnosis that was most strongly associated with suicidality. Suicidal threats (40% vs. 37%, OR 1.5, 95% CI 1.1–2.1) and suicidal acts (20% vs. 8%, OR 3.5, 95% CI 2.2–5.6) were more common among depressed inpatients than among other inpatients. The association with depression and suicidality also remained statistically significant in the adjusted model. Of the other diagnoses, having a conduct disorder was associated with suicidal threats (47% vs. 34%, OR 1.6, 95% CI 1.2–2.2) and this association remained in the adjusted model. Having a developmental disorder was associated with fewer suicidal acts (2% vs. 11% OR 0.1, 95% CI 0.0–0.9), but did not show significant associations with suicidality in the adjusted model.

When we analyzed possible interactions (Table 2), we found that in 2000 eating disorders were associated with suicidal acts (p = 0.0072), whereas in 2011 inpatients with eating disorders made fewer suicidal threats than other inpatients (p = 0.0041). There were no significant associations found between the inpatients’ age and the other variables we studied.

When interactions related to gender were studied, we found that having a psychosis was associated with a higher likelihood of suicidal acts among boys (p = 0.037), but not suicidality among girls. The opposite was true with regard to depression: among girls depression was associated with both suicidal threats (p = 0.0046) and suicidal acts (p < 0.0001), whereas depression was not associated with suicidality among boys.

Discussion

The prevalence of suicidal threats and attempts among child and adolescent psychiatry inpatients remained stable in Finland from 2000 to 2011. This stability is noteworthy, because there were major changes in both inpatient and outpatient child and adolescent care in Finland during this period, as outlined earlier. In Finland, there has been a trend toward shorter hospital stays, a rapid increase in the use of psychotropic medication in inpatient and outpatient care and an increase in diagnoses of depression [11, 19, 23, 27], which could have had an impact on the prevalence of suicidality.

We found that the prevalence of suicidal threat during inpatient treatment was between 29 and 44% among both genders and across different age groups treated in child and adolescent psychiatric wards. Suicidal acts by boys during inpatient treatment were quite rare: the prevalence was less than 5% in younger age groups, but increased to 11% in the oldest age group of 16–18 years. The prevalence of suicidal acts among girls increased gradually as they got older and reached 29% in the oldest age group. The finding that suicidal acts were more common among girls and teenagers, than boys and children, agreed with previous studies [6, 40, 41]. Female teenagers generally posed a higher risk of suicidal threats and acts than males, but successful suicides were more common among males [42, 43, 44]. The association between low general functioning and suicidal threats and acts was also in line with previous findings [35].

There were associations between violent acts and both suicidal threats and acts in 2000, but no such associations were found in 2011. At the same time, the prevalence of adolescent inpatients with psychosis more than halved from 23 to 11%, as did conduct disorders, from 21 to 8% [23]. Due to the strong interrelation between violent acts and suicidality in both psychosis and conduct disorders [45, 46], it is possible the decrease of inpatients with these conditions from 2000 to 2011 made the association between violence and suicidality disappear.

Depression was associated with both suicidal threats and acts among inpatients. A further analysis showed that the association between depression and suicidality was solely down to the strong association among girls. It was somewhat surprising to us that we did not find any association between depression and suicidality among boys, as the link has been well documented in both genders [47, 48, 49]. The prevalence of suicidal threats among boys diagnosed with depression was 34% in our study, which was lower than the prevalence among inpatients boys with other diagnoses (38%). Possible explanations for the lack of any statistical association between suicidal threats and depression among boys include the high prevalence of suicidal threats among boys with other diagnoses, such as conduct disorders. Both the number of depressive inpatients and the number of suicidal acts were much smaller among boys than girls. Due to this, the analysis of the association between suicidal acts and depression among boys resulted in wide confidence intervals and the fact that we found no significant association may be due to the lack of statistical power.

Psychosis was associated with suicidal acts among boys, but there was no statistical association between psychosis and suicidality in girls. Suicidal threats were common in both genders with psychosis, but these did not reach statistical significance. It seems likely that the association between suicidality and psychosis is weaker among teenage inpatients [50] than the strong association found in other patient populations [47, 51, 52]. This may have been due to the high level of suicidal threats and acts among inpatient with other diagnoses than psychosis.

Strengths and limitations

The main strength of this study was our very good national coverage of child and teenage inpatients, which produced a wealth of comparable data, as both of the study years used the same methodology and target groups. The population using the inpatient treatment services in our study was highly selective and there are significant differences in treatment systems between countries. Due to this, the results of this study cannot be generalized to other populations or countries. The clinicians were the only informants and the information that was received was based on their clinical evaluation, as no systematic structured interviews were performed. The main limitation of this study was the lack of operationalized criteria for scoring the questionnaire and no checks on the inter-rater reliability with regard to suicidality, violence, CGAS or diagnoses.

Conclusion

This study showed that the prevalence of suicidal threats and suicidal acts during inpatient treatment in child and adolescent psychiatry remained stable from 2000 to 2011 in Finland. The risk of suicidal acts was particularly high in teenage girls. Although comprehensive studies on this topic are scarce, it seems likely that suicidality is also a major, ongoing challenge in child and adolescent inpatient treatment in other countries.

Notes

Acknowledgements

Open access funding provided by University of Turku (UTU) including Turku University Central Hospital.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K et al (2009) Global patterns of mortality in young people: a systematic analysis of population health data. Lancet 374(9693):881–892CrossRefGoogle Scholar
  2. 2.
    World Health Organization (2014) Preventing suicide: a global imperative. http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1
  3. 3.
    McLoughlin AB, Gould MS, Malone KM (2015) Global trends in teenage suicide: 2003–2014. QJM 108:765–780CrossRefGoogle Scholar
  4. 4.
    Official Statistics of Finland (2018) Causes of death [e-publication]. 2015. Statistics Finland, Helsinki (ISSN: 1799-5078) Google Scholar
  5. 5.
    Copeland WE, Goldston DB, Costello EJ (2017) Adult associations of childhood suicidal thoughts and behaviors: a prospective, longitudinal analysis. J Am Acad Child Adolesc 56:958–965CrossRefGoogle Scholar
  6. 6.
    Cash SJ, Bridge JA (2009) Epidemiology of youth suicide and suicidal behavior. Curr Opin Pediatr 21:613–619CrossRefPubMedCentralGoogle Scholar
  7. 7.
    Nock MK, Green JG, Hwang I, McLaughlin KA, Samson NA, Zaslasvsky AM, Kessler RC (2013) Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents. Results from the national comorbidity surveys replication adolescent supplement. JAMA Psychiatry 70:300–310CrossRefGoogle Scholar
  8. 8.
    Pfeffer C, Newcorn J, Kaplan B, Mizruchi MS, Plutchik R (1988) Suicidal behavior in adolescent psychiatric inpatients. J Am Acad Child Adolesc Psychiatry 27:357–361CrossRefGoogle Scholar
  9. 9.
    Haavisto A, Sourander A, Ellilä H, Välimäki M, Santalahti P, Helenius H (2003) Suicidal ideation and suicide attempts among child and adolescent psychiatric inpatients in Finland. J Affect Disord 76:211–221CrossRefGoogle Scholar
  10. 10.
    Wilson LS, Kelly BD, Morgan S, Harley M, O’Sullivan M (2012) Who gets admitted? Study of referrals and admissions to an adolescent psychiatry inpatient facility over a 6-month period. Ir J Med Sci 181:555–560CrossRefGoogle Scholar
  11. 11.
    Wash G, Sara G, Ryan CJ, Large M (2015) Meta-analysis of suicide rates among psychiatric in-patients. Acta Psychiatr Scand 131:174–185CrossRefGoogle Scholar
  12. 12.
    Lipschitz DS, Winegar RK, Nicolaou AL, Hartnick EW, Michele BA, Southwick SM (1999) Perceived abuse and neglect as risk factors for suicidal behavior in adolescent inpatients. J Nerv Ment Disk 187:32–39CrossRefGoogle Scholar
  13. 13.
    Gronholt B, Ekkeberg O, Wichstrom L, Haldorsen T (2000) Young suicide attempters: a comparison between a clinical and epidemiological sample. J Am Acad Child Adolesc Psychiatry 39:868–875CrossRefGoogle Scholar
  14. 14.
    Isohookana R, Riala K, Hakko H, Räsänäen P (2013) Adverse childhood experiences and suicidal behavior of adolescent psychiatric inpatients. Eur Child Adolesc Psychiatry 22:13–22CrossRefGoogle Scholar
  15. 15.
    Larsson B, Ivarsson T (1998) Clinical characteristics of adolescent psychiatric inpatients who attempted suicide. Eur Child Adolesc Psychiatry 7:201–208CrossRefGoogle Scholar
  16. 16.
    Paik J-W, Kim KH, Lee SM, Na K-S, Hong M (2018) Postdischarge suicide and death in South Korean children and adolescents hospitalized for a psychiatric illness. J Am Acad Child Adolesc Psychiatry 57:508–514CrossRefGoogle Scholar
  17. 17.
    Kwok KHR, Yuan SNV, Ougrin D (2016) Review: alternatives to inpatient care for children and adolescents with mental health disorders. Child Adolesc Ment Health 21:3–10CrossRefGoogle Scholar
  18. 18.
    Ougrin D, Corrigall R, Poole J, Zundel T, Sarhane M, Slater V et al (2018) Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trial. Lancet Psychiatry 5(6):477–485CrossRefPubMedCentralGoogle Scholar
  19. 19.
    Pirkola S, Sohlman B (2005) Atlas of mental health. Statistics from Finland. http://www.julkari.fi/bitstream/handle/10024/110627/Atlas%20of%20Mental%20Health2005.pdf;sequence=1
  20. 20.
    Sourander A, Lempinen L, Klomek AB (2016) Changes in mental health, bullying behavior, and service use among eight-year-old children over 24 years. J Am Acad Child Adolesc Psychiatry 55:717–772CrossRefGoogle Scholar
  21. 21.
    Case BG, Olfson M, Marcus SC, Siegel C (2007) Trends in the inpatient mental health treatment of children and adolescents in US community hospitals between 1990 and 2000. Arch Gen Psychiatry 64:89–96CrossRefGoogle Scholar
  22. 22.
    Meagher SM, Rajan A, Wyshak G, Goldstein J (2013) Changing trend in inpatient care for psychiatrically hospitalized youth: 1991–2008. Psychiatry Q 84:159–168CrossRefGoogle Scholar
  23. 23.
    Kronström K, Ellilä H, Kuosmanen L, Kaljonen A, Sourander A (2016) Changes in the clinical features of child and adolescent inpatient: a nationwide time-trend study from Finland. Nord J Psychiatry 70:436–441CrossRefGoogle Scholar
  24. 24.
    Gilat Y, Ben-Dor DH, Magen A, Wowolvick L, Verslerchik M, Weizman A, Zalsman G (2010) Trends in prescribing of psychotropic medications for inpatient adolescents in Israel: a 10 years retrospective analysis. Eur Psychiatry 26:265–269CrossRefGoogle Scholar
  25. 25.
    Haapasalo-Pesu K-M, Erkolahti R, Saarijarvi S, Aalberg V (2014) Prescription of psychotropic drugs in adolescent psychiatry wards in Finland. Nord J Psychiatry 58:213–218CrossRefGoogle Scholar
  26. 26.
    Song QY, Guo LT (2013) Trends in prescribing of psychotropic medications for inpatient children and adolescents, 2000–2010: a study from China. Int Clin Psycopharmacol 28:193–199Google Scholar
  27. 27.
    Kronström K, Kuosmanen L, Ellilä H, Kaljonen A, Sourander A (2018) National time trend changes in psychotropic medication of child and adolescent psychiatric inpatients across Finland. Child Adolesc Ment Health 23:63–70CrossRefGoogle Scholar
  28. 28.
    Steinhausen HC (2014) Recent international trends in psychotropic medication prescriptions for children and adolescent. Cur Child Adolesc Psychiatry 24:635–640CrossRefGoogle Scholar
  29. 29.
    Olfson M, Druss BG, Marcus SC (2015) Trends in mental health care among children and adolescents. N Engl J Med 372:2029–2038CrossRefGoogle Scholar
  30. 30.
    Bor W, Dean AJ, Naiman J, Hayatbakhsh R (2014) Are child and adolescent mental health problems increasing in the 21st century? A systematic review. Aust N Z J Psychiatry 14:606–616CrossRefGoogle Scholar
  31. 31.
    Collishaw S (2014) Annual research review: secular trends in child and adolescent mental health. J Child Psychol Psychiatry 56:370–393CrossRefGoogle Scholar
  32. 32.
    Hawton K, Sauders KEA, O’Connor RC (2012) Self-harm and suicide in adolescents. Lancet 279:2372–2382Google Scholar
  33. 33.
    Pfeffer CR, Klerman GL, Hurt SW, Kakuma T, Peskin JR, Siefker CA (1993) Suicidal children grow up: rates and psychosocial risk factors for suicide attempts during follow-up. J Am Acad Child Adolesc 32:106–113CrossRefGoogle Scholar
  34. 34.
    Pfeffer CR, Solomon G, Plutchik R, Mizruchi MS, Weiner A (1982) Suicidal behavior in latency-age psychiatric inpatients: a replication and cross validation. J Am Acad Child Psychiatry 21:564–569CrossRefGoogle Scholar
  35. 35.
    Hukkanen R, Sourander A, Bergroth L (2003) Suicidal ideation and behavior in children’s homes. Nord J Psychiatry 57:131–137CrossRefGoogle Scholar
  36. 36.
    Bird HR, Canino G, Rubio-Stipec M, Ribera JC (1987) Further measures of the psychometric properties of the children’s global assessment scale. Arch Gen Psychiatry 44:821–824CrossRefGoogle Scholar
  37. 37.
    Shaffer D, Gould MS, Brasic J, Ambrosini P, Fischer P, Bird H, Aluwahlia S (1983) A children’s global assessment scale (CGAS). Arch Gen Psychiatry 40:1228–1231CrossRefGoogle Scholar
  38. 38.
    Sourander A, Helenius H, Piha J (1996) Child psychiatric short-term inpatient treatment: CGAS as follow-up measure. Child Psychiatry Hum Dev 27:93–104CrossRefGoogle Scholar
  39. 39.
    Pfeffer C, Plutchik R, Mizruchi M (1993) Predictors of assaultiveness in latency age children. Am J Psychiatry 140:31–35Google Scholar
  40. 40.
    Becker DF, Grilo CM (2007) Prediction of suicidality and violence in hospitalized adolescents: comparison by sex. Can J Psychiatry 52:572–580CrossRefGoogle Scholar
  41. 41.
    Kwon A, Song J, Yook K-H, Jon D-I, Jung MH, Hong N, Hong HJ (2016) Predictors of suicide attempts in clinically depressed Korean adolescents. Clin Psychopharmacol Neurosci 14:383–387CrossRefPubMedCentralGoogle Scholar
  42. 42.
    Cannetto SS, Sakinofsky I (1998) The gender paradox in suicide. Suicide Life Threat Behav 28:1–23Google Scholar
  43. 43.
    Bridge JA, Goldstein TR, Brent DA (2006) Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry 47:372–394CrossRefGoogle Scholar
  44. 44.
    McMahon EM, Keeley H, Cannon M, Arensman E, IJ Perry, Clarke M et al (2014) The iceberg of suicide and self-harm in Irish adolescents: a population-based study. Soc Psychiatry Psychiatr Epidemiol 49:1929–1935CrossRefGoogle Scholar
  45. 45.
    Witt K, Hawton K, Fazel S (2014) The relationship between suicide and violence in schizophrenia: analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) dataset. Schizophr Res 154:61–67CrossRefPubMedCentralGoogle Scholar
  46. 46.
    Apter A, Gothelf D, Orbach I, Weizman R, Ratzoni G, Har-Even D, Tyano S (1995) Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. J Am Acad Child Adolesc Psychiatry 34:912–918CrossRefGoogle Scholar
  47. 47.
    Alasaarela L, Hakko H, Riala K, Riipinen P (2017) Association of self-reported impulsivity to nonsuicidal self-injury, suicidality, and mortality in adolescent psychiatric inpatients. J Nerv Ment Dis 205:340–345CrossRefGoogle Scholar
  48. 48.
    Asarnow JR, Miranda J (2014) Improving care for depression and suicide risk in adolescents: innovative strategies for bringing treatments to community setting. Annu Rev Clin Psychol 10:275–303CrossRefPubMedCentralGoogle Scholar
  49. 49.
    Chin YR, Choi K (2015) Suicide attempts and associated factors in male and female korean adolescents a population-based cross-sectional survey. Community Ment Health J51:862–866CrossRefGoogle Scholar
  50. 50.
    Falcone T, Mishra L, Carlton E, Lee C, Butler RS, Janigro D, Simon B, Franco K (2010) Suicidal behavior in adolescents with first-episode psychosis. Clin Schizophr Relat Psychoses 4:34–40CrossRefPubMedCentralGoogle Scholar
  51. 51.
    Austad G, Joa I, Johannessen JO, Larsen TK (2015) Gender differences in suicidal behaviour in patients with first-episode psychosis. Early Interv Psychiatry 9:300–307CrossRefGoogle Scholar
  52. 52.
    Nordentoft M, Madsen T, Fedyszyn I (2015) Suicidal behavior and mortality in first-episode psychosis. J Nerv Ment Dis 203:387–392CrossRefGoogle Scholar

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© The Author(s) 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.Department of Adolescent PsychiatryTurku University Hospital, Hospital District of Southwest FinlandTurkuFinland
  2. 2.Research Centre for Child PsychiatryUniversity of TurkuTurkuFinland
  3. 3.Department of Child PsychiatryTurku University Hospital, Hospital District of Southwest FinlandTurkuFinland
  4. 4.Turku Institute for Child and Youth ResearchUniversity of TurkuTurkuFinland

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