Family Practice Vol. 19, No. 5, 461-465
© Oxford University Press 2002
Fifteen year olds at risk of parasuicide or suicide: how can we identify them in general practice?
University of Glasgow Department of Psychological Medicine, The Academic Centre, Gartnavel Royal Hospital,
a Department of Child and Adolescent Psychiatry, Royal Hospital for Sick Children, Yorkhill NHS Trust and
b Department of General Practice, University of Glasgow, Glasgow, UK.
YL McNeill (née Potts), University of Glasgow Department of Psychological Medicine, The Academic Centre, Gartnavel Royal Hospital, Great Western Road, Glasgow G12 0XH, UK; E-mail: yp1r{at}clinmed.gla.ac.uk
McNeill YL, Gillies ML and Wood SF. Fifteen year olds at risk of parasuicide or suicide: how can we identify them in general practice? Family Practice 2002; 19: 461–465.
Received 6 September 2001; Revised 4 February 2002; Accepted 13 May 2002.
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Abstract |
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Background. Within most western countries, suicide is the second leading cause of death amongst adolescents.
Objectives. This paper aims to help GPs identify 15-year-old adolescents at increased risk from parasuicide and suicide.
Methods. The authors reviewed the case notes of 2359 fifteen year olds from 34 randomly selected general practices. Subjects were divided into two groups: (i) those who had made a suicide attempt at age 15; and (ii) those who had made no suicide attempt at age 15. The main outcome measures were the differences between those who had made a suicide attempt and those who had not with respect to GP consulting rates and reasons for consulting.
Results. The 26 subjects (1%) who had attempted suicide at age 15 consulted their GP four times per year compared with 2.3 times for those who had not attempted suicide. Twice as many adolescents who had attempted suicide consulted for upper respiratory tract infection (URTI), and nearly nine times as many consulted more than once for mental health concerns. The average attendance rate for those who had attempted suicide was greater than for those in the control comparison group who consulted their GP for mental health concerns; the attendance rate of those in the control group who had not consulted for mental health issues was lower still.
Conclusions. (i) Fifteen year olds more at risk from parasuicide can be found amongst frequent attenders at general practice. (ii) Consulting more than once for mental health concerns or URTI where there are no physical signs could be an indicator of suicide risk.
Keywords. Adolescents of 15 years, attendance at general practice, mental health, parasuicide, suicide.
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Introduction |
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Suicidal behaviour has been reported to be a worldwide problem. In a study with >40 000 individuals from many countries including the USA, France, Lebanon and New Zealand, suicidal ideation was reported in up to 20% of subjects (New Zealand), whilst up to 6% had attempted suicide (Puerto Rico).1 In the last decade, suicide amongst adolescents has increased more dramatically than it has in the general population. Within most Western countries, suicide is the second leading cause of death amongst adolescents, surpassed only by death from accidents.2
In 1998, the prevalence of suicide in Scotland amongst those aged 15 years was 3.1 per 100 000 population (Registrar General, 2001). The two suicides occurring in Scotland in 1998 were male and within the Greater Glasgow Health Board area (GGHB), making the rate of suicide in GGHB 18.3 per 100 000 population. Comparison of the prevalence of suicide in Scotland with the GGHB area between 1991 and 1995 has shown that suicide amongst those aged 15–19 is higher in the GGHB area, 10.2 per 100 000 compared with 8.3 per 100 000.3
Although the exact estimate of parasuicide per 100 000 adolescents worldwide is unknown, the World Health Organization (WHO) has estimated it to be between 40 and 100 times higher than the suicide rate recorded each year. Individuals who attempt suicide are more than twice as likely to die from suicide in the next 13 years in comparison with the general population.4 In 1998 within the GGHB area, 60 fifteen year olds (11 males and 49 females) attempted suicide.5 Self-poisoning was the only means of parasuicide. Approximately 2% of people admitted to hospital with self-poisoning in Scotland go on to commit suicide within a year.6 Therefore, at least one of these 60 teenagers will have died by the end of 1999.
Attempted suicide puts great strain on NHS resources. In Scotland in 1998, 358 fifteen year olds were admitted to hospital for self-inflicted injury or poisoning.3 Each day, seven hospital beds in the GGHB area are taken up by self-poisoning. The majority of admissions are females aged 15–24 and males aged 25–34 years.6
It is noteworthy that prevalence rates for parasuicide in Scotland are obtained from Accident and Emergency reports and therefore may be an underestimation. A study carried out in the USA in 1998 among high school students found that 7.7% had attempted suicide whilst only 2.6% had required medical attention following the attempt.7 If this finding was generalized to the GGHB area, the rate of parasuicide amongst 15 year olds in 1998 would be closer to 180 compared with the reported 60.5
In 1998, the authors reviewed the general practice case notes of 2359 fifteen year olds from the West of Scotland for attendance with psychiatric symptoms or illness.8 An unexpected finding concerned those who had attempted suicide. This paper concentrates on the parasuicide findings. The results presented are the differences between 15 year olds who made suicide attempts and those who did not with respect to GP consulting rates and the reason for consulting. Thus, this paper aims to help GPs identify adolescents more at risk from parasuicide.
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Methods |
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Subjects were divided into those who had attempted suicide whilst aged 15 (n = 26) and those who had not (n = 2333). Those who had made no suicide attempt will be referred to as the control group, and this was composed of 52% females. Of the 26 subjects who had made a suicide attempt at 15 years, 65% were female.
The small parasuicide sample (1%) restricted the statistical analysis to cross-tabulations, analysis of frequency distributions and chi-squared analysis. Analysis was conducted using SPSS for Windows (version 9). It could be argued that the implication of this study cannot be generalized as the results were obtained from a small sample. However, in 1998, 60 fifteen year olds in the GGHB area were admitted for parasuicide and the present study contains information on nearly half of that number.
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Results |
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Amongst the parasuicide group, 21 subjects (15 females and six males) had made one suicide attempt, four (two females and two males) had made two attempts and one (male) had made three attempts. There was an indication of parasuicide in the GP case notes of four subjects. In all others (n = 22), the only reference to the suicide attempt came from the Accident and Emergency correspondence.
Attendance
Control subjects..
Control subjects consulted their GP on average 2.3 times per year (SD = 2.80), with females consulting more than males (3:2). The distribution of attendance shows that 30% of the controls had not consulted their GP in the year studied. However, one-third had consulted their GP more than the average for this group (i.e. more than twice in one year), 11% had consulted their GP >5 times and 2% >10 times within 1 year (Table 1
).
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Parasuicide subjects.. The average attendance rate for adolescents who had attempted suicide at age 15 was four times per year, with males and females consulting equally. Eleven per cent of the parasuicide subjects had not consulted in the year studied. Whilst over one-third of young people attended more than the average for this group, 35% consulted
5 times and 11% >10 times (Table 1
). The percentage of subjects who consulted >5 times and who consulted >10 times in 1 year were both greater for the parasuicide group than the control group (Table 1). As shown in Table 2, there is a linear relationship between attendance rate and number of suicide attempts in 1 year. Therefore, as the numbers of suicide attempts increase, the attendance rate at general practice increases.
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Reasons for attendance
Control subjects.. The most commonly reported diagnosis was upper respiratory tract infection (URTI) including sore throats and tonsillitis (Table 3
), with 8% consulting more than once with such complaints. Mental health concerns were reported less frequently: 3% of patients consulted their GP for mental health concerns, with 1% consulting more than once. Information in the GP case notes identified 90 control subjects (4%) with symptoms of a mental health problem such as eating disorder or depression, and a further 17 (1%) with possible mental health problems. However, no subjects in the control group attended psychological services whilst aged 15. The 65 subjects (3%) who had attended psychological services before the age of 15 showed higher GP attendance rates in comparison with the remainder of the group—over half had attended more than the average, whilst 38 and 11% had attended >5 and >10 times, respectively. One subject had attended 31 times; this individual had not been seen in psychological services in that year but presented each time in general practice for weight monitoring due to a diagnosis of anorexia.
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Parasuicide subjects.. As with the control group, the most common reason for consulting was URTI; however, more than twice as many as in the control group consulted more than once for such complaints (19%). Adolescents who had attempted suicide had consulted their GP nearly as often for mental health concerns as for sore throats (Table 3
); 19% consulted more than once whilst 11% consulted more than twice for various mental health concerns. Unlike the control group, this group consulted equally for acne and for abdominal pains, and nearly one-quarter consulted for headaches (Table 3). Although the possible influence of drugs or alcohol on parasuicide or prior consultation behaviour was not explored specifically in this study, there was no mention of either in the general practice case notes examined. |
Discussion |
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Parasuicide may be seen as a way to express and communicate feelings such as despair, hopelessness and anger rather than an intent to kill oneself. In a review of 1699 Australian 15–16 year olds conducted at 44 schools in the state of Victoria, one in 20 subjects admitted to self-harm in the previous 12 months, whilst only one in 200 reported that their attempt was with intent to kill themselves.9 It has been suggested that the high prevalence of parasuicide amongst adolescents could be seen as reflecting difficulty communicating their emotional problems. This may be the case for the control group in the present study, as only a small percentage of this group reported mental health concerns despite approximately half reporting feeling "sad, unhappy or low" during the year of study.8 In comparison, adolescents who have attempted suicide consult almost equally for mental health concerns as for URTI, suggesting that the more severe the mental health problem the easier adolescents find communicating their concerns to their GP. However, despite communicating the problem, some individuals still attempt suicide, possibly as Kreitman10 suggested as a further cry for help. If the parasuicide was a cry for help, it is of concern that only a proportion are answered as just over half were referred to psychological services, and the event was recorded by GPs in only 15% of the individuals’ general practice notes. However, it is not possible to ascertain from this whether no entry in the GP case notes meant that the GP did not discuss the attempt with their patient at their next appointment.
Portegijs et al.11 suggest that most psychiatric morbidity in adolescents can be found among frequent attenders at general practice. The results of the present study offer support to this belief as the attendance rate for adolescents who attempted suicide was higher than for those who had made no suicide attempt. Analysis of the attendance rate of the control group also suggests that those with mental health concerns are seen frequently in general practice. When the control group is divided into those who had possible mental health concerns and those who had none, the former group attended the general practice over three times as often as the latter group. In comparison with the parasuicide group, whose attendance rate increases proportionally to the number of attempts, the attendance rate of those with possible mental health concerns was much lower, suggesting that the more severe the mental health concern the more the attendance at general practice. In short, the attendance rate for controls without mental health problems was lower than for those with mental health problems, which is in turn lower than for those who attempted suicide. This suggests, therefore, that as mental health concerns increase in severity, general practice attendance increases, and possibly the ease of communicating also increases.
Understanding both the medical history and psychological profile of adolescents who attempt suicide is of grave importance. Follow-up studies of people admitted to hospital for self-poisoning have shown a markedly increased risk of suicide in the years afterwards. In a 10-year follow-up in Denmark, 103 of the 974 patients aged 15 years and over completed suicide in the following years—a 30 times greater risk compared with the general population.12 Thus, amongst the 26 adolescents reported in this study, it can be estimated on this basis that three will commit suicide successfully in the future. More seriously, of the five who have attempted suicide on two or more separate occasions, the chance of completed suicide is even higher.
The main implications from the present study focus on the need to identify individuals at risk of parasuicide and the need for psychological intervention following attempted suicide. Recent research has shown that self-harm and parasuicide patients who discharge themselves from hospital before an initial psychiatric assessment is complete have a considerably increased rate of repetition.13 It is important that adolescents receive psychiatric input and are closely monitored in primary care in the following months even if they do not communicate a continuing need for help. Attempts immediately following an initial communication of suicide ideation have been found to be more successful than those following frequent such communications.14 Our study suggests that a large proportion of adolescents may not be monitored following a suicide attempt. Findings from the WHO/European multicentre study on parasuicide support this conclusion.15 All parasuicides in Oxford from 1989 to 1992 amongst individuals aged 15–19 years were recorded as part of the above study. Of the 585 individuals who made a suicide attempt, only 51% of those making a first attempt and 70% of those making a repeat attempt were referred for any form of aftercare. When 11th and 12th grade students in the USA who had attempted suicide were asked to suggest ways to prevent a fictitious individual committing suicide, the most popular responses were "parents showing caring" (32%), "better home environment" (13%), "talk to someone" (13%), "improve self-coping" (12%) and "get professional help" (11%).16 Data from nine European research centres found that of all adolescent parasuicides between 1989 and 1992, 35% of those who attempted suicide for the first time and 21% of those who had made previous attempts were not referred for aftercare.15
The final implication concerns the possible potential to identify those at risk from attempting suicide. Morris17 reported that one-third of mental health problems are presented in general practice as somatic complaints, in particular recurrent abdominal pains and headaches.18 In our study, it was found that over twice as many adolescents who had attempted suicide consulted more than twice for URTI in comparison with the control group, whilst nearly nine times as many consulted more than once for mental health concerns.
An increased level of awareness of possible indicators of suicide risk in 15 year olds might alert GPs to consider intervention. More specifically, young people who consult more than four times per annum, more than twice for URTI where there are no physical signs, or more than once with mental health concerns should prompt action such as referral to child and adolescent mental health services. The relationship between parasuicide and completed suicide already referred to means that these young people do need to be taken seriously.
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References |
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1 Weissman MM, Bland RC, Canino GJ et al. Prevalence of suicide ideation and suicide attempts in nine countries. Psychol Med 1999; 29: 9–17.[ISI][Medline]
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17 Morris K. Increase in teen boys’ suicidal behaviours linked to alcohol misuse. Lancet 1998; 352: 459.
18 Livingston R, Taylor JL, Crawford SL. A study of somatic complaints and psychiatric diagnosis in children. J Am Med Assoc 1988; 27: 185–187.
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