JPED Journal

Introduction

In the world of teenagers, suicide and its entire lexical field has become more and more frequent in all discussions, media, daily life, questioning all professionals (care, teaching, educational), as well as loved ones, for more than 10 years. According to the NIMH [1], suicide is defined as death caused by self-directed injurious behavior with intent to die, as a result of the behavior. A suicide attempt (SA) is a non-fatal, self-directed, potentially injurious behavior with intent to die. A suicide attempt might not result in injury. Suicidal ideations (SI) refers to thinking about, considering, or planning suicide, as a possible way out in a context of emotional pain. In addition, a suicidal crisis is an evolution of mental processes, with a variable duration, whose major risk is  suicide. During adolescence, looking for suicidal equivalents, these self-directed injurious behavior often repetitive where intent to die is not explicit (for examples: some scarifications, or addictions, or certain eating disorders), is also interesting.

In 2014, World Health Organization (WHO) raise awareness of suicide as a public health issue in a report “Preventing suicide, a global imperative” [2]. Suicide prevention is an integral part of the plan. About mental health of adolescents in particular, WHO described in 2021 that globally one in seven 10-19-yearolds experiences a mental disorder, accounting for 13% of the global burden of disease in this age group [3]. In 2023, WHO [4] updates the suicide figures about adolescent and young adult health: 1) Depression and anxiety are among the leading causes of illness and disability among adolescents; 2) Half of all mental health disorders in adulthood start by age 14, but most cases are undetected and untreated; 3) Suicide is among the leading causes of death in people aged 15–19 years; 4) One key fact is that over 1.5 million adolescents and young adults, aged 10-24 years, died in 2021, about 4500 every day. Moreover a systematic analysis showed the leading causes of death were self harm in 15-19 year old females and road traffic injuries in 15-19 year old men [5].

In France, Epidemiology center on medical causes of death (CépiDc) of the National Institute of Health and Medical Research (Inserm) estimated 8 366 suicides in 2017 [6], with the assumption of an underestimation of 10%, and in particular 25 deaths by suicide (2.3 %) in subjects aged 1-14, 326 (13.5%) in subjects aged 15-24. Consequently, the share of suicide in the overall French mortality is significantly higher, among young people of both sexes than among elderly people. Nevertheless, average standardized rates of deaths by suicide vary widely depending on the region in the country and seem relatively lower in the southern French regions, below the Loire, as Auvergne-Rhône-Alpes. So, between 2015 and 2017 [6], in the whole of France (excluding Mayotte), the rate of deaths by suicide was 14.0 per 100.000 residents while it was 12.4 per 100 000 residents in the Auvergne-Rhône-Alpes region. The gradual decline in suicide mortality in our region has been confirmed since 2000 (average drop in the standardized rate of 2.1% per year) [7]. However, since 2014, an upward trend in the age group 15-29 years has been recorded [7]. The data concerning suicide attempts and suicidal thoughts declared during adolescence through the use of two surveys (ESCAPAD and ESPAD) [8] piloted by the French Observatory of Drugs and Drug Addiction (OFDT) highlighted : 1) as in the WHO figures [4], suicide is the second leading cause of death for young people aged 15 to 24; nearly 3% of all teenagers aged 17 reported having attempted suicide during their lifetime, resulting in hospitalization, and one in ten adolescents (10.4%) having thought about suicide, at least once, in the last twelve months.

In addition to this worrying development on suicide, the covid 19 pandemic has increased adolescent distress [9-12]. Consultations for this medical reason have exploded in Pediatric emergency Department [13-14]. Note however, numerous articles have been published on the subject of suicide attempts among young people, but the heterogeneity of data collection methods makes it challenging to compare them [15]. In the same way, few studies have been carried out in teenagers in crisis who have received care from pediatricians and child psychiatrists [16]. Our study focuses thus on this partnership between Pediatric emergency Department - Child and adolescent psychiatry Department, with the creation of a new adolescent psychiatric unit, focused on crisis symptomatology. Our main objectives were first to compare hospitalization durations in Pediatric emergency Department for these teenagers in distress, and second to measure the rate of suicide attempt recidivism, within the first six months, before and after the opening of the new adolescent psychiatry unit.

Method

Study design

The study design was retrospective and prospective, single-center, descriptive and comparative, over a period of 3 months before (period 1) and 3 months after (period 2), the opening of a new adolescent psychiatric unit, an intensive outpatient center for teenagers, on 2022, April the 19^th. For more details, the design follows the lines of the French national call for projects DGOS/ R4/2019/175 “Structuring the pathway for teenagers in child psychiatry” [17] whose objective were to allocate new measures in child psychiatry and to response, for us in particular (Figure 1), on the care area in France, South Isere (38). With cooperation of Grenoble-Alpes University Hospital Center (GA-UH), France Student Clinic Grenoble-La Tronche and Isere area (38), the specialized psychiatric establishment, Alpes Isere Hospital Center (CHAI Centre Hospitalier Alpes Isère), the boss in the adolescent psychiatry sector, proposed a crisis unit, making the link in all the adolescent healthcare area. The main principle of the outpatient crisis unit for adolescents was designed to respond quickly to the suffering of teenagers, with the idea of reducing the workload on pediatric emergencies and overloaded colleagues in the South Isere area.

Figure 1: location of the country and the city of the study.

Population

Inclusion criteria

Were collected all the adolescents (12-17 years of age), admitted to the Pediatric emergency Department of GA-UH for a suicide attempt or suicidal ideations. For safety and monitoring, these young patients were admitted, in particular, on a bed in the shortterm unit of the Pediatric emergency Department (GA-UH).

The duration of the study extended over two periods of 3 months, one before the opening of the new adolescent psychiatric unit in CHAI, the other after the opening of CHAI’s unit. Iinitially, according to the national calendar of the call for projects, the unit was to open in 2021, November and we had projected period 1 on 2021, March-June and period 2 on 2022, March-June. However, the development work for the opening of the unit was delayed and the unit was only able to open on 2022, April, the 19^th. So, period 1 was kept on 2021, March-June, and period 2 was shifted to 2022, May-August.

Exclusion criteria

Were excluded all the adolescents with 1) age outside 12-17 years; 2) crisis symptoms where mental retardation, a state of agitation or prolonged hospitalization were at the forefront of the clinical picture; 3) a lack of precise domiciliation; and 4) an opposition from parents or from the teenager himself for the study.

Measures

With the agreements of the doctors responsible for Pediatric Department (GA-UH), Child and adolescent Psychiatry Department (CHAI) and the head doctor of Pediatric emergency Department (GA-UH), were collected all eligible subjects admitted in Pediatric Emergency Department (GA-UH): N = 138 in period 1 and N = 146 in period 2. In both periods, in a retrospective mode, all medical files with a reason for admission to child psychiatry were examined such that each period contains 92 medical records (Figure 2). Suicidal crisis clinic was searched with SA, SI, and history (personal medical/ surgical/ child psychiatric and family psychiatric). Were also noted 1) sociodemographic data (age, sex, number of siblings, sibling position, lifestyle, schooling, parents’ marital status); 2) current and passed treatment; and 3) total length of hospital stay in Pediatric emergency Department.

Finally in both periods, in a prospective mode for each subject, the question of suicidal recidivism at 3 and 6 months was followed, through the possibility of readmission in Pediatric emergency Department.

Figure 2: Study and chronology

Care

Grenoble-Alpes University Hospital Center, Pediatric Emergency Department

In Pediatric emergency Department, adolescents are welcomed and cared for by a multidisciplinary team: doctors, nurses, educators, psychologists. Furthermore, parents, relatives or other person close to the youth, are received in order to better understand the situation. Safety measures are ensured throughout the hospitalization [18]. Depending on clinic and problem, a shortterm bed is offered to take some distance from the acute crisis and monitor the young patient over several hours or even days. According to recommendations¹⁹, the length of stay in short-term bed from Pediatric Emergency Department should not exceed two consecutive nights or around 48 hours; however, the reality is sometimes quite different and this is very frequently exceeded.

At the end of the care, a referral is made, either towards hospitalization in another unit, or towards discharge with recommendations [18, 20].

Specialized Psychiatric establishment, adolescent intensive outpatient center

On the new teen psychiatric unit, the adolescent intensive outpatient center, Pediatric emergency Department assessments are continued and deepened on the medical, nursing, psychological and socio-educational dimensions. Various therapeutic mediations (artistic, physical, some of which are in partnership with the city of Grenoble, or the Isere area) are used. Links with family, relatives and the entire network around the young person are also examined. This care system with an outpatient schedule of 5 half-days, after the stay in Pediatric emergency Department, is presented as soon as the adolescent presents symptoms of a crisis and even more so if he is suicidal.

In general, admissions from Pediatric emergency Department are prioritized on the new psychiatric unit. Each day, from Monday to Friday, an emergency consultation slot is reserved for a potential admission, or an urgent consultation. So, each week, the intensive adolescent outpatient center can receive an average of 5 new adolescents. Adolescent, relatives and care professionals commit in each adolescent care project, and sign a care contract for these 5 half-days.

For each patient lastly, a care orientation is worked on after the 5 half-days schedule, after a multi-professional synthesis meeting. Only a few adolescents will continue treatment for a period of two months. The lengths of stay at the adolescent intensive outpatient center are announced from the outset and are relatively strict in order to allow for continuous turnover.

Finally, in this new adolescent system under construction, it should be noted that this adolescent intensive outpatient center is a link designed in conjunction with crisis beds, for young patients with more severe symptoms. The plan would be to create six beds dedicated to the crisis center, open 24/7. All  the new crisis unit is not intended to provide regular long-term care for patients, and must be coordinated with the various players involved in the patient’s care project.

Ethical Concerns

The study was carried out in accordance with ethical principles for medical research involving humans (World Medical Association WMA, Declaration of Helsinki). The Clinical Research and Innovation Department of the Grenoble University Hospital, which works under agreement with the psychiatric establishment (CHAI), validated the research protocol. All participants (and the legal guardians, for minors) received appropriate information; the study was explained on request and a poster was placed in the waiting room of the Pediatric emergency Department

All data were collected anonymously with an alphanumeric code, from computerized medical records, by a single operator, to ensure consistency and accuracy.

Statistical analysis

Firstly, statistical analysis was performed to determine the required sample size for the study, in order to obtain results with satisfactory statistical power. This calculation of the number of subjects required was thus estimated from various factors, such as the expected reduction in length of hospital stay and variability in this measure, based on historical data from previous months. The result was at least N = 91 for each period studied and we opted for N = 92 in each period, in order to secure data.

Secondly, descriptive statistics were used. For continuous variables, quantitative data were presented with mean, standard deviation, median, quartile, minimum and maximum. For qualitative variables, frequency and percentage were conducted. To compare variables, for quantitative data, Student’s t test or non-parametric tests (depending on the validity conditions) were realized and for quantitative data, univariate tests such as Chi-square test or Fischer test were followed. Analysis and statistical testing were conducted using JAMOVI software. Results

Population characteristics

Sociodemographic and clinical characteristics, for both periods studied, can be observed in (Table 1). Overall, the total population (N = 184) appeared relatively homogeneous with a mean age 14.64 ± 1.34 years (mean =14.56 ± 1.39 y in period 1, vs mean = 14.68 ± 1.25 y in period 2; p = 0.608), an over-representation of girls (85.3 %). However, note that a statistically significant difference was found in the sex ratio with more boys over period 2 (8.7 % boys in period 1 vs 20.7 % in period 2; p = 0.022) and more suicide attempts in period 2 (33.7 % in period 1 vs 50 % in period 2; p = 0.025 . There was also a statistical significant difference in terms of parental marital status, with parents more frequently separated in period 2 (parents separated 47.1 in period 1 vs 62.1 % in period 2; p = 0.048).

On an overview, the adolescent population in crisis of the study was illustrated through a place of the eldest in the siblings (close 40 %) and around 20 % of subjects mentioned school bullying, while between 8 to 13 % of teenagers have dropped out of school. About psychopathology, social history (around 11.5 % of adolescents were dependent on child welfare), medical history (around 10 % of teenagers with chronic illness), and even more psychiatric history were very present before admission to the Pediatric emergency Department: 1) previous suicide attempt (more than a third of adolescents); 2) previous scarifications (more than 60 % of cases); 3) previous private sector consulting (around 50 %); 4) previous treatment (about half were taking anxiolytics and about a third were taking antidepressants); 5) addictions (approximately a quarter reported using tobacco and 15.4 % cannabis).

Table 1: Sociodemographic and clinical characteristics for both periods studied.

Data on hospitalization in Pediatric emergency Department and suicidal gesture

Data about hospitalization in Pediatric emergency Department and suicidal gesture were summarized in (Tables 2a, 2b, and 2c). Firstly, in terms of admissions to Pediatric emergency Department, they occurred significantly more at night over period 2 (55.4 % in period 1 vs 70.7 % in period 2; p = 0.032). Secondly however, there is no statistically significant difference either in the accompanying persons present with the teenagers (majority = parental support), or in hospital referrals following admission. In both periods studied, approximately three quarters (72.8 % in period 1 vs 77.2 % in period 2) of admissions to Pediatric emergency Department, for an adolescent meeting the inclusion criteria (so with already an admission in short-term bed), were followed by an extension of the stay in the short-term bed in this same Pediatric emergency Department (GA-UH). A fifth of these teenagers admissions (20.7 % in period 1 vs 18.5 % in period 2) were directed to the specialized psychiatric establishment (CHAI) within the Child and adolescent psychiatric Department.

Regarding suicidal gestures (Table 2b), 31 were analyzed over period 1 and 46 over period 2. Both periods studied did not present a statistically significant difference about the modality of the suicide attempt (p = 0.807). Voluntary poisoning was the most common, with 77.4 % in period 1 and 84.8 % in period 2. Other modalities such as phlebotomy, hanging, defenestration were poorly represented in both periods. About voluntary drug intoxication as shown in Table 2c, pharmaceutical[NC1]  drugs have been usually involved and in particular paracetamol, but without a statistically significant difference between both periods (paracetamol 75 % in period 1 vs 56.4 % in period 2; p = 0.966). The only difference observed was the presence of more multidrug gestures in period 1 compared to period 2 (45.8 % vs 12.8 %; p = 0.013).

Table 2a: Hospitalization in Pediatric emergency Department[NC2] 

Table 2b: Suicidal gesture characteristics (N = 77)

Table 2c: Voluntary Drug Intoxication (N = 63)

Table 2: Data on hospitalization in Pediatric emergency Department and suicidal gesture.

Evolution from Pediatric emergency Department

For both periods studied, evolution from Pediatric emergency Department was presented in Table 3a. Despite the opening of the new teen unit, with the overall figures on the evolution from Pediatric emergency Department and data on discharge, no statistically significant difference were highlighted, neither in the duration of hospitalization (p = 0.590), nor in the recidivism of suicide attempt at 3 and 6 months (respectively, p = 0.7333 and p = 0.844). Nevertheless, with the opening of the new teen unit, it was obvious that a statistically significant difference appeared in the referral after discharge from the Pediatric emergency Department (p<0.001).

Only in period 2, so the period which was able to benefit from the presence of the new teen unit in its care offering, the evolution from Pediatric emergency Department to the adolescent intensive outpatient center was presented in table 3b. It was then interesting and probably reassuring to note that a statistically significant difference was found in recidivism at 3 and 6 months (respectively p = 0.001 and p < 0.001) if the subject is treated in the adolescent intensive outpatient center. In fact, no recidivism of suicide attempt was found at 3 and 6 months for subjects recruited, and who benefit from adolescents intensive outpatient center (Table 3a, 3b).

Table 3a: Evolution from Pediatric emergency Department for both periods studied.

Table 3b: Recidivism for adolescents cared in Adolescent intensive outpatient center.

Table 3: Evolution from Pediatric emergency Department.

Discussion

Summary of main results

The aim of our study was to assess the impact of a new teen unit from specialized psychiatric establishment, Alpes Isere Hospital Center (CHAI Centre Hospitalier Alpes Isère), the adolescent intensive outpatient center, on the management of adolescents hospitalized for suicide attempts and suicidal ideation, in the Pediatric emergency Department from Grenoble-Alpes University Hospital Center. In this work thus, before and after the opening of the new teen psychiatry unit, we compared length of stay in short-term beds from Pediatric emergency Department and suicidal recidivism at 3 and 6 months. In both periods studied, the total population of selected adolescents appeared relatively homogeneous with a mean age 14.64 ± 1.34 years, an over-representation of girls, and very frequent presence of a personal psychiatric history (previous suicide attempt, or scarifications, or addictions; previous care) with a significant school or family problem. Despite the expectations of Pediatric, emergency Department for adolescents in crisis, with the opening of the new unit, the length of stay in short-term bed has not decreased but no suicide attempt recidivism was found at 3 and 6 months for the teenagers who have benefited from care within the adolescent intensive outpatient center. The new unit and the partnership with Pediatric emergency Department would seem effective in reducing the risk of suicidal recidivism for adolescents in crisis.