Pain and suicidality in children and adolescents: a longitudinal population-based study

Associations between mental health and cervical, thoracic, and lumbar back pain in adolescents: A cross-sectional study

BACKGROUND

Low back pain is a significant emergent health disorder in adolescence. It is predicted that around 843 million subjects worldwide will present this condition in 2050. We investigated whether symptoms of anxiety, depression, and suicidal behavior are associated with back pain in adolescents.

METHODS

This is a cross-sectional school-based study including 4514 student participants aged 14-19 years. Data were collected using the WHO's "Global School-Based Student Health Survey". Anxiety symptoms were assessed with the Social Anxiety Scale for Adolescents. The Depression Scale of the Center for Epidemiologic Studies was used to estimate depressive symptomatology. Suicidal behaviors were assessed with two questions about thoughts and plans for suicide. The presence (yes, no) of each of cervical, thoracic, and lumbar back pain were assessed with the use of a drawing of the human body with spine areas delimited. Multivariable logistic regression analyses were used to study the presence of three outcomes of back pain (cervical, thoracic, and lumbar) and associated factors.

RESULTS

Adolescents with cervical pain were more likely to report social anxiety (OR = 1.0, CI: 1.00-1.02). Depression symptomatology was associated with pain in the tree segments of the spine: cervical (OR = 1.01, CI: 1.00-1.02), thoracic (OR = 1.02, CI: 1.01-1.02), and lumbar (OR = 1.02, CI: 1.01-1.02). No association was observed between suicidal behavior and cervical (OR = 0.86 CI: 0.743-1.017), thoracic (OR = 0.92, CI: 0.79-1.08), and lumbar back pain (OR = 0.86, CI: 0.73-1.01).

LIMITATIONS

It is not possible to affirm causality in the interpretation of findings.

CONCLUSIONS

Social anxiety and depression symptomatology were associated with back pain in adolescents.

Veterans at High Risk for Post-COVID-19 Suicide Attempts or Other Self-Directed Violence

Importance

US veterans have a higher risk of suicide than the general civilian population. Research suggests that COVID-19 infection is associated with increased risk of suicide attempts or other forms of self-directed violence (SDV) among veterans.

Objective

To identify subgroups of veterans with high risk of post-COVID-19 suicide attempts or SDV.

Design, Setting, and Participants

This is a retrospective cohort study conducted using data from the Veteran Health Administration (VHA). Participants included VHA enrollees with a first case of COVID-19 between May 1, 2021, and April 30, 2022, residing in the 50 states or Washington, DC.

Exposure

COVID-19 infection.

Main Outcomes and Measures

The main outcome was a suicide attempt or SDV 12 months after COVID-19 infection. Latent class analysis was used to identify subgroups. Outcome rates and 95% CIs per 10 000 veterans were calculated. Multinomial regressions were used to model outcome risk and marginal risk ratios with 99.5% CIs to compare outcome risk across latent classes.

Results

The cohort included 285 235 veterans with COVID-19 and was predominantly male (248 118 veterans [87.0%]) and younger than 65 years (171 636 veterans [60.2%]). Chronic pain (152 788 veterans [53.6%]), depression (98 093 veterans [34.4%]), and posttraumatic stress disorder (79 462 veterans [27.9%]) diagnoses were common. The 12-month outcome rate was 73.8 events per 10 000 (95% CI, 70.7-77.0 events per 10 000). Two latent classes with high rates of suicide attempt or SDV were identified. The first high-risk subgroup (46 693 veterans [16.4%]) was older (34 472 veterans [73.8%] aged ≥65 years) and had a high prevalence of physical conditions (43 329 veterans [92.8%] had hypertension, and 36 824 veterans [78.9%] had chronic pain); the 12-month outcome rate was 103.7 events per 10 000 (95% CI, 94.7-113.3 events per 10 000). The second high-risk subgroup (82 309 veterans [28.9%]) was generally younger (68 822 veterans [83.6%] aged <65 years) with a lower prevalence of physical conditions but high prevalence of mental health conditions (61 367 veterans [74.6%] had depression, and 50 073 veterans [60.8%] had posttraumatic stress disorder); the 12-month outcome rate was 162.9 events per 10 000 (95% CI, 154.5-171.8 events per 10 000), and compared with the lowest risk subgroup, the 12-month risk of suicide attempts or SDV was 14 times higher in this subgroup (risk ratio, 14.23; 99.5% CI, 10.22-19.80).

Conclusions and Relevance

In this cohort study of veterans with COVID-19, 2 veteran subgroups with distinct health profiles had high rates of suicide attempts and SDV, suggesting that different groups may require different approaches to suicide prevention after COVID-19.

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

Suicidal Ideation and Attempts Among Youth With Physical-Mental Comorbidity in Canada: Proposal for an Epidemiological Study

BACKGROUND

Evidence suggests that having a chronic physical illness (CPI; eg, asthma, diabetes, and epilepsy) is an independent risk factor for suicidality (ie, suicidal ideation or attempts) among youth. Less is known about the mechanisms linking CPI and suicidality. Some evidence suggests that mental illness (eg, depression and anxiety) or neurodevelopmental disorder (eg, attention-deficit/hyperactivity disorder) mediates or moderates the CPI-suicidality association. Missing from the knowledge base is information on the association between having co-occurring CPI and mental illness or neurodevelopmental disorder (MIND) on youth suicidality.

OBJECTIVE

This study uses epidemiological data from the 2019 Canadian Health Survey of Children and Youth (CHSCY) to study the intersection of CPI, MIND, and suicidality in youth. We will estimate prevalence, identify predictors, and investigate psychosocial and service use outcomes for youth with CPI-MIND comorbidity versus other morbidity groups (ie, healthy, CPI only, and MIND only).

METHODS

Conducted by Statistics Canada, the CHSCY collected data from 47,850 children (aged 1-17 years) and their primary caregiving parent. Measures of youth CPI, MIND, family environment, and sociodemographics are available using youth and parent informants. Information on psychiatric services use is available via parent report and linkage to national administrative health data found in the National Ambulatory Care Reporting System and the Discharge Abstract Database, which allow the investigation of hospital-based mental health services (eg, emergency department visits, hospitalizations, and length of stay in hospital). Questions about suicidality were restricted to youths aged 15-17 years (n=6950), which form our analytic sample. Weighted regression-based analyses will account for the complex survey design.

RESULTS

Our study began in November 2023, funded by the American Foundation for Suicide Prevention (SRG-0-008-22). Access to the linked CHSCY microdata file was granted in May 2024. Initial examination of CHSCY data shows that approximately 20% (1390/6950) of youth have CPI, 7% (490/6950) have MIND, 7% (490/6950) seriously considered suicide in the past year, and 3% (210/6950) had attempted suicide anytime during their life.

CONCLUSIONS

Findings will provide estimates of suicidality among youth with CPI-MIND comorbidity, which will inform intervention planning to prevent loss of life in this vulnerable population. Modeling correlates of suicidality will advance understanding of the relative and joint effects of factors at multiple levels-information needed to target prevention efforts and services. Understanding patterns of psychiatric service use is vital to understanding access and barriers to services. This will inform whether use matches need, identifying opportunities to advise policy makers about upstream resources to prevent suicidality. Importantly, findings will provide robust baseline of information on the link between CPI-MIND comorbidity and suicidality in youth, which can be used by future studies to address questions related to the impact of the COVID-19 pandemic and associated countermeasures in this vulnerable population of youth.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57103.

The association between parent mental health and pediatric chronic pain: a systematic review and meta-analysis

ABSTRACT

Mental health problems are common among parents of children with chronic pain and associated with worse outcomes for the child with chronic pain. However, the effect sizes of these associations between parent mental health and pediatric chronic pain vary widely across studies. The aim of this systematic review and meta-analysis was to generate pooled estimates of the (1) prevalence of mental health problems among parents of children with chronic pain and (2) associations between parent mental health and the (2a) presence of child chronic pain and (2b) functioning of children with chronic pain. Embase, MEDLINE, PsycINFO, Web of Science, and CINAHL were searched up to November 2022. Observational studies that examined symptoms or diagnoses of parent anxiety, depression, or general distress and the presence of child chronic pain and/or related functioning were included. From 32,848 records, 2 coders identified 49 studies to include in random-effects meta-analyses. The results revealed that mental health problems among parents of children with chronic pain were common (anxiety: 28.8% [95% CI 20.3-39.1]; depression: 20.0% [15.7-25.2]; general distress: 32.4% [22.7-44.0]). Poorer parent mental health was significantly associated with the presence of chronic pain (anxiety: OR = 1.91 [1.51-2.41]; depression: OR = 1.90 [1.51-2.38]; general distress: OR = 1.74 [1.47-2.05]) and worse related functioning (ie, pain intensity, physical functioning, anxiety and depression symptoms; r s = 0.10-0.25, all P s < 0.05) in children. Moderator analyses were generally nonsignificant or could not be conducted because of insufficient data. Findings support the importance of addressing parent mental health in the prevention and treatment of pediatric chronic pain.

Service use and costs in adolescents with pain and suicidality: a cross-sectional study

Background

Persistent/recurrent pain for more than three months and suicidality (suicide and self-harm related thoughts and behaviours) are serious and co-occurring health problems in adolescence, underscoring the need for targeted support. However, little is known about service use and costs in adolescents with pain-suicidality comorbidity, compared to those with either problem alone. This study aimed to shed light on service use and costs in adolescents with pain and/or suicidality, and the role of individual and school characteristics.

Methods

We analysed cross-sectional, pre-intervention data from a large cluster randomised controlled trial, collected between 2017 and 2019 on a representative sample of 8072 adolescents (55% female; aged 11-15 years; 76% white) in 84 schools in the UK. We explored service use settings, covering health, social, educational settings, and medication for mental health problems over three months. Data were analysed using descriptive statistics and two-part hurdle models to obtain odds ratios (ORs) and incident rate ratios (IRRs).

Findings

9% of adolescents reported comorbidity between pain and suicidality, 11% only suicidality, 13% only pain, and 66% neither pain nor suicidality. Approximately 55% of adolescents used services, especially general practitioner visits, outpatient appointments for injuries and contacts with a school nurse or pharmacist. Compared to adolescents with neither pain nor suicidality: (i) adolescents with pain (OR 3.79, 95% CI 2.63-5.48), suicidality (1.68, 1.12-2.51), and pain-suicidality comorbidity (2.35, 1.26-4.41) were more likely to use services and (ii) if services were used, they were more likely to have higher total costs (Pain: IRR 1.25, 95% CI 1.11-1.42; Suicidality: 1.27, 1.11-1.46; Comorbidity: 1.57, 1.34-1.85).

Interpretation

In our study, adolescents with pain and suicidality reported increased contact with health, social, and educational services, which could provide an opportunity for suicide prevention. Given the diversity of identified settings, multi-sector suicide prevention strategies are paramount.

Funding

Wellcome Trust [WT104908/Z/14/Z; WT107496/Z/15/Z]; Stiftung Oskar-Helene-Heim.

Identifying and Managing Suicidality in Children and Adolescents with Chronic Pain: Evidence-Based Treatment Strategies

Children and adolescents with chronic pain are at an increased risk of suicidality. This narrative review article aims to inform clinical practice in the assessment and management of suicidality in youth with chronic pain. The article begins with a survey of the background and prevalence of youth with chronic pain. A review of the current evidence behind the increased risk of suicidality in youth with chronic pain follows. Contextualization of this data with general tenets of child and adolescent suicide risk and risk assessment is provided. Suicidology theory including the interpersonal theory of suicide is overviewed to help clinicians to conceptualize the reviewed data. Guiding parameters for the suicide risk assessment and management planning is presented. Concluding recommendations are made to guide clinical practice in the assessment and management of suicidality in youth with chronic pain.