Youth suicide and hospital-presenting suicide attempts: Examination of risk factors for multiple suicide attempts in adolescence

Abstract

Background:

The suicide rate among adolescents around the world has increased rapidly. There are many risk factors for attempting suicide, but not all have been clarified yet. Therefore, it is very important to identify risk factors. This study evaluated adolescents with a history of suicide attempts and their association with chronic diseases. Besides, to check whether they attempted suicide multiple times. Other clinical features related to multiple suicide attempts were investigated.

Method:

This study used a multicentre, retrospective cross-sectional design; 253 adolescents admitted to emergency departments in 2019 for suicide attempts were evaluated.

Results:

Adolescents with chronic disease were at greater risk for both single and multiple suicide attempts and patients had a 6.14 times higher risk of multiple attempts (p = .013). The likelihood of multiple attempts did not differ according to the presence of somatic or psychiatric disease. Multiple attempters were more likely to poison themselves with their therapeutic drugs (p = .002).

Conclusion:

When adolescents with a chronic disease present to the emergency services after a single suicide attempt using their therapeutic drugs, families should be informed regarding the potential for further attempts.

Keywords

Adolescent multiple suicide attempts chronic disease self-poisoning risk factor

Introduction

One of the most important issues in society today is suicide and it is an important public health problem worldwide (Carballo et al., 2020). Suicide is the fourth leading cause of death among 15–19-year-olds and 77% of global suicides occur in low- and middle-income countries (World Health Organization [WHO], 2021). Suicidality risk is multifactorial and risk factors include chronic psychiatric health problems (such as depression, anxiety, bipolar disorder, substance use disorders, etc.), a previous suicide attempt and family history of suicide (Shain, 2016; Slap et al., 2001). Studies have shown that chronic somatic diseases such as chronic pain, cancer, coronary heart disease and asthma are associated with suicide and that having more than two physical diseases increases suicide mortality (Ahmedani et al., 2017; Greydanus et al., 2010; Juurlink et al., 2004; Ravaioli et al., 2020; K. M. Scott et al., 2010).

In adolescent studies, it is indicated that children with neurological diseases such as epilepsy had greater odds of bipolar disorder, psychosis and suicide attempt/ideation (Thibault et al., 2016). Moreover, there are studies showing that the presence of disease of any organ or physical system significantly increases the risk of subsequent suicide, regardless of gender, individual psychiatric background or socio-economic status (Qin et al., 2013).

In adolescents, self-poisoning is the most common method of suicide (Canner et al., 2018). Children with a chronic disease are usually on one or more medications and in the USA nearly one in five children use medication and 9% receive more than two medications (Hales et al., 2018). As a result, adolescents with a chronic disease can access medicines easily and these are used for suicide attempts.

This study aimed to establish the underlying risk factors for adolescent suicide attempts. Patients with and without a chronic disease who presented to paediatric emergency departments after suicide attempts were compared, examining whether adolescents attempted single or multiple suicides and also noting other clinical features.

Materials and methods

Data sources and management

The study was a multicentre, retrospective cross-sectional, medical record-based study of paediatric patients admitted to <<city name>>Education and Research Hospital and <<hospital name>>Training and Research Hospital Paediatric Emergency Department for suicide attempts with self-poisoning in 2019. Our institutional ethics committee approved this study (Decision number: 2020-309). Adolescent patients aged 10 to 18 years were included in the study.

In the hospitals where the study was conducted, only the cases with poisoning as a cause of suicide attempts are accepted to the paediatric emergency services. Adolescents who attempt suicide due to other traumatic causes, such as firearm injuries, hanging and motor vehicle accidents, are monitored and treated by the trauma department in the adult emergency services. All poisoning cases are accepted as forensic cases in the emergency departments in our country and forensic case reports are compiled by specialist doctors. In paediatric emergencies, the reports are compiled by paediatricians.

In cases of poisoning admitted to the paediatric emergency department there is also sub-diagnosis, such as drug poisoning and exposure to other chemicals or pesticides. Cases of self-poisoning were classified using ICD-10 codes X40 (unintentional) and X60 (intentional self-poisoning). Medical records of patients were assessed through the system. Based on the statements of adolescents and according to the ICD-10 codes in the system, it was decided whether they attempted suicide or not, and if so they were included in this study. Such evaluation was made by paediatricians at the hospitals where the study was conducted. The following individuals were excluded from study: those thought to have taken medication by mistake; cases not considered to be suicide attempts; and diagnostic cases falling under various ICD-10 chapter headings (Chapter XV, pregnancy and childbirth; Chapter XVI, certain conditions of the prenatal period; and Chapters XIX and XX, covering all accidental poisoning).

The demographic characteristics of the cases were obtained from the electronic medical records, including age, gender, marital status, educational attainment, social/legal problems and substance use. Substance use was considered if the substances were found in urine drug level laboratory tests. Urine screening was not performed for all poisoning cases and focused on the identification of substances such as opiates, opioids, cocaine and amphetamine derivatives. Cases that required a high level of care in the intensive care unit or that died by suicide were recorded.

The presence of chronic disease was checked for in all cases. Chronic, non-communicable diseases were classified as psychiatric or somatic. Patients without a chronic disease were classified as having no chronic disease. The number of suicide attempts was also recorded. Patients were classified as a single attempter (SA) if they had made only one suicide attempt and as a multiple attempter (MA) if they had made more than one suicide attempt.

Regarding self-poisoning, the patients were divided into two groups: those who attempted suicide with drugs prescribed for their chronic diseases were classified into the Own medication group; those who used the drugs of another person in the household comprised the Someone else’s medication group.

Statistical analysis

The statistical analyses were performed using SPSS software (version 21.0; IBM Corp., Armonk, NY, USA). The normality of the data was tested with the Shapiro–Wilk’s test. Numerical variables are expressed as the mean ± standard deviation (SD). Groups with normally distributed data were compared using Student’s t-test whereas groups with non-normally distributed data were compared using the Mann–Whitney U test. Categorical variables were compared using the chi-square (χ²) test. Univariate logistic regression analyses were performed and p ⩽ .05 indicated statistical significance.

Results

The sociodemographic and clinical characteristics of the patients are summarized in Table 1. It was found that approximately 2% of the patients abused substances. Death due to suicide occurred in 1 of 253 cases (0.4%). Of the patients, 227 (89.7%) made a single suicide attempt and 26 (10.3%) made multiple attempts. Age, gender, marital status, social/legal problems, intensive care unit hospitalization and education status were not associated with the number of suicide attempts (p > .05).

Table 1.

Descriptive statistics for sample characteristics (N = 253).

Variables	n (%)	M (SD)
Gender
Female	196 (77.5)	–
Male	57 (22.5)	–
Age	–	15.89 (1.66)
Marital status
Married	9 (3.6)	–
Unmarried	226 (89.3)	–
Unknown	18 (7.1)	–
Educational attainment
Primary school	20 (7.9)	–
High school	159 (62.8)	–
Drop out	13 (5.1)	–
Unknown	61 (24.1)	–
Social-legal problem
Yes	5 (2)	–
No	248 (98)	–
Intensive care unit hospitalization
Yes	42 (16.6)	–
No	211 (83.4)	–

Chronic disease was detected in 172 (68%) patients: 35.2% had a somatic disease and 32.8% had a psychiatric disease. Tables 2 and 3 summarize the somatic and psychiatric diseases, respectively, along with the relevant ICD-10 chapters. Musculoskeletal, endocrine, nutritional and metabolic diseases were among the most common somatic diseases whereas anxiety and conduct disorders were among the most common psychiatric diseases. Table 4 summarizes the relationship between medical condition and the number of suicide attempts. There was no statistically significant difference between the proportions for no chronic disease, psychiatric disease and somatic disease (p = .532). Table 5 summarizes the relationship between the presence of chronic disease and the number of suicide attempts; 65.2% of the SAs and 92.3% of the MAs had a chronic disease. The presence of chronic disease in the patients was significantly associated with suicide attempts in both SAs and MAs, regardless of the type of disease (p = .004). Additionally, we also evaluated the relationship between chronic disease presence and the number of suicide attempts. Using univariate logistic regression analysis, the patients with chronic disease had a 6.14-fold higher risk of multiple attempts compared with those with single attempts (p = .013; 95% CI [0.036, 0.678]).

Table 2.

Somatic diseases according to the ICD-10 chapter headings.

ICD-10 chapter	Dıagnostic category: chapter heading	Suicide cases
ICD-10 chapter	Dıagnostic category: chapter heading	n	%
III	Blood and immune mechanism disorders	5	2
IV	Endocrine, nutritional and metabolic diseases	16	6.2
VI	Nervous system diseases	10	4
VII and VIII	Sensory organ diseases	9	3.5
IX	Circulatory system diseases	6	2.4
X	Respiratory system diseases	6	2.4
XI	Digestive system diseases	5	2
XII	Skin diseases	9	3.6
XIII	Musculoskeletal system diseases	17	6.7
XIV	Genitourinary system diseases	5	2
XVIII	Unspecified symptoms, signs and abnormal clinical and laboratory findings	1	0.4
		89	35.2

Table 3.

Psychiatric diseases according to the ICD-10 chapter headings.

Diagnostıc category: chapter heading	Suicide cases
Diagnostıc category: chapter heading	n	%
Anxiety disorders	41	16.2
Depressive disorders	8	3.1
Bipolar disorder	5	2
Conduct disorder	22	8.7
Attention deficit hyperactivity disorder	2	0.8
Substance use	5	2
Total	83	32.8

Table 4.

Type of medical condition and relation to the number of suicide attempts.

Medical condition	Number of suicide attempts		Total n (%)	p-Value
Medical condition	Single (%)	Multiple (%)	Total n (%)	p-Value
No chronic disease	79 (97.5)	2 (2.5)	81 (32)	.532
Psychiatric disease	70 (84.3)	13 (15.7)	83 (32.8)
Somatic disease	78 (87.6)	11 (12.4)	89 (35.2)
Total n (%)	227 (89.7)	26 (10.3)	253 (100)

Table 5.

Relationship between chronic disease presence and number of suicide attempts.

	Number of suicide attempts		Total n (%)	p-Value
	Single	Multiple	Total n (%)	p-Value
Chronic disease
Absence
Count	79	2	81	.004
% Within chronic disease	97.5%	2.5%	100%
% Within number of suicide attempts	34.8%	7.7%	32%
Presence
Count	148	24	172
% Within chronic disease	86%	14%	100%
% Within number of suicide attempts	65.2%	92.3%	68%
Total n (%)
Count	227 (100%)	26 (100%)	253
% Within chronic disease	89.7%	10.3%	100%
% Within number of suicide attempts	100%	100%	100%

The number of suicide attempts was also evaluated according to drug group, as shown in Table 6. The majority of patients in the SA group attempted suicide with someone else’s medication (79.3%). In contrast, in the MA group, 50% of patients attempted suicide with their own medication. It was found that those who attempted suicide with both their own and someone else’s medicine were more likely to attempt suicide once (p = .002).

Table 6.

Number of suicide attempts and relation to drug groups.

	Own medication	Someone else’s medication	Total	p-Value
Number of suicide attempts
Single
Count	47	180	227	.002
% Within suicide groups	20.7	79.3	100
% Within drug groups	78.3	93.3	89.70
Multiple
Count	13	13	26
% Within suicide groups	50	50	100
% Within drug groups	21.7	6.7	10.3
Total
Count	60	193	253
% Within suicide groups	23.7	76.3	100
% Within drug groups	100	100	100

According to drug group, when the cases of suicide attempts were evaluated it was found that 60 (23.7%) attempted suicide with their own treatment drug, 193 (76.3%).

In Someone else’s medication group (193 patients) there were 180 patients (93.2%) who were SAs. Of the 227 patients in the SA group, 180 (79.3%) attempted suicide with someone else’s medication and 47 (20.7%) attempted with their own medication.

On the other hand, in the MA group 13 patients (6.7%) attempted suicide with someone else’s medication and 21.7% attempted with their own drugs; the difference was significant (OR = 3.83, 95% CI [1.66, 8.81], p = .002).

Discussion

The main result of the present study was that having a chronic disease increases suicide rates regardless of the number of suicide attempts. Over 20 years, it is known that chronic disease and poor physical health increased suicidal thoughts directly or indirectly. Having a chronic disease increased the feelings of lack of control, hopelessness/entrapment and pain intolerance, while also negatively impacting coping (Joiner, 2007; O’Connor & Kirtley, 2018). It has been shown that suicide attempts increase in children with psychiatric or chronic somatic diseases, but the surprising part of this study is that having a somatic disease is a risk factor for suicide as well as psychiatric disease. It is believed that patients with psychiatric diseases are more likely to attempt suicide (Chou et al., 2016; Dickerson Mayes et al., 2015; Goldston et al., 2009; Halfon et al., 2013), but the reported suicide rates among those with psychiatric and somatic diseases are very similar to our findings, especially in MAs.

A previous suicide attempt is the most important indicator of future attempts (Ribeiro et al., 2016), but not all suicide cases attempt multiple times. Some studies have examined the relationship between adolescent chronic diseases and multiple suicide attempts, finding that patients with physiological and functional impairment were more likely to be MAs (Defayette et al., 2020; Payne et al., 2009; Vajda & Steinbeck, 2000). In the present study, it was found that if an adolescent has a chronic somatic disease and has attempted suicide once, there is an increased risk of multiple attempts.

When the literature was reviewed, it was seen that the suicide attempt is associated with a specific disease (Ikeda et al., 2001; Wang et al., 2009). It was shown in this study that the main risk factor for a suicide attempt is the presence of any chronic disease, not the specific type of disease (somatic or psychiatric). This may be due to a reduction in the ability of children with chronic disease to cope, either due to pain or because adolescents are more vulnerable to chronic disease-related stress (Dean-Boucher et al., 2020). If a disease in an adolescent causes social isolation or prevents communication with peers, they may feel hopeless and lacking in control and thus may be more vulnerable than their peers to suicidal thoughts and behaviours (Sawyer et al., 2007; Suris et al., 2004).

One of the reasons for the low number of MAs among our patients with no chronic disease might be related to the patterns of suicidal behaviour seen in adolescents. Childhood traumatic experiences and impulsive behaviour are powerful determinants of suicidal ideation in teenagers (Koyama et al., 2020), therefore adolescents with no underlying disease may make a single attempt secondary to impulsive behaviour.

This study analysed adolescents with chronic diseases from a novel perspective. Self-poisoning is the most common method of suicide in adolescence, making adolescents a high-risk target group for secondary prevention (Geulayov et al., 2019; Hawton et al., 2020; Suris et al., 2004). Suicide risk is increased for many years after the first suicide attempt, therefore sustained prevention efforts are very important (Finkelstein et al., 2015). Many studies have shown that children and adolescents with a chronic disease need pharmacotherapy and long-term treatment (Merandi et al., 2017; Rappaport et al., 2011). In this study, it was found that SAs performed suicide attempts with drugs belonging to other people in their household, whereas 3.83-fold more MAs than SAs attempted suicide with their own medicines. Therefore, adolescents with a chronic disease who receive pharmacotherapy and attempt suicide should be followed closely due to the risk of additional suicide attempts. Families of adolescents should perhaps supervise the ingestion of therapeutic drugs. If parents use medications for chronic disease, they should take precautions to prevent easy access to these medicines for their adolescent children. When adolescents present to the emergency services with a single suicide attempt and have a chronic disease, especially if they have attempted suicide using their own therapeutic drugs, emergency doctors should inform their families about the risk of additional suicide attempts. Before discharging the patient, the paediatrician and parent should discuss a safety plan and review how to safely store the medicines (J. Scott et al., 2018). It can be life-saving for families to have information on how adolescents use their medicines and to be warned about the storage of medicines (Horowitz et al., 2020).

Limitations and future directions

The main limitation of this study is that it is a retrospective, cross-sectional study and the case details extracted from the clinic’s database cannot be verified in terms of data accuracy. Also, the sample size was not very large and only the self-poisoning cases were included. Further studies should investigate all suicide cases, including other traumatic causes such as firearm injuries, hanging and motor vehicle accidents. Despite these limitations, the relative strength of this study was that it was found to be a new risk factor for suicide in adolescents with a chronic disease and taking medication.

Conclusions

Paediatricians play an important role in preventing adolescent suicides. Paediatric emergency departments are pioneering ways to successfully identify and manage suicide risk. Adolescents with a chronic disease who receive pharmacotherapy and attempt suicide should be followed closely due to the risk of additional suicide attempts. It can be life-saving for paediatricians to pay attention to this detail.

Footnotes

Acknowledgements

Our warmest thanks go to Başak N Akyıldız for encouraging us to conduct this study. We also thank Gamze Talih, Şaban Tubaş, Aydın Esen, Esra Ermiş Turak and Fırat Demirci for their help.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Filiz Tubaş

Feyza Husrevoglu Esen

References

Ahmedani

B. K.

Peterson

E. L.

Rossom

R. C.

Lynch

C. Y.

Waitzfelder

B. E.

Owen-Smith

A. A.

Hubley

Prabhakar

Williams

L. K.

Zeld

Mutter

Beck

Tolsma

Simon

G. E.

(2017). Major physical health conditions and risk of suicide. American Journal of Preventive Medicine, 53(3), 308–315. https://doi.org/10.1016/j.amepre.2017.04.001

Canner

J. K.

Giuliano

Selvarajah

Hammond

E. R.

Schneider

E. B.

(2018). Emergency department visits for attempted suicide and self harm in the USA: 2006–2013. Epidemiology and Psychiatric Sciences, 27(1), 94–102. https://doi.org/10.1017/S2045796016000871

Carballo

J. J.

Llorente

Kehrmann

Flamarique

Zuddas

Purper-Ouakil

Hoekstra

P. J.

(2020). Psychosocial risk factors for suicidality in children and adolescents behalf of the STOP Consortium. Coghill, 29, 759–776. https://doi.org/10.1007/s00787-018-01270-9

Chou

W.-J.

Liu

T.-L.

H.-F.

Yen

C.-F.

(2016). Suicidality and its relationships with individual, family, peer, and psychopathology factors among adolescents with attention-deficit/hyperactivity disorder. Research in Developmental Disabilities, 53–54, 86–94. https://doi.org/10.1016/j.ridd.2016.02.001

Dean-Boucher

Robillard

C. L.

Turner

B. J.

(2020). Chronic medical conditions and suicidal behaviors in a nationally representative sample of American adolescents. Social Psychiatry and Psychiatric Epidemiology, 55(3), 329–337. https://doi.org/10.1007/s00127-019-01770-2

Defayette

A. B.

Adams

L. M.

Whitmyre

E. D.

Williams

C. A.

Esposito-Smythers

(2020). Characteristics of a first suicide attempt that distinguish between adolescents who make single versus multiple attempts. Archives of Suicide Research, 24(3), 327–341.

Dickerson Mayes

Calhoun

S. L.

Baweja

Mahr

. (2015). Suicide ideation and attempts in children with psychiatric disorders and typical development. Crisis, 36(1), 55–60. https://doi.org/10.1027/0227-5910/a000284

Finkelstein

Macdonald

E. M.

Hollands

Hutson

J. R.

Sivilotti

M. L. A.

Mamdani

M. M.

Koren

Juurlink

D. N.

(2015). Long-term outcomes following self-poisoning in adolescents: A population-based cohort study. The Lancet Psychiatry, 2(6), 532–539. https://doi.org/10.1016/S2215-0366(15)00170-4

Geulayov

Casey

Bale

Brand

Clements

Farooq

Kapur

Ness

Waters

Tsiachristas

Hawton

(2019). Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-Harm: A long-term follow-up study. The Lancet Psychiatry, 6(12), 1021–1030. https://doi.org/10.1016/S2215-0366(19)30402-X

10.

Goldston

D. B.

Daniel

S. S.

Erkanli

Reboussin

B. A.

Mayfield

Frazier

P. H.

Treadway

S. L.

(2009). Psychiatric diagnoses as contemporaneous risk factors for suicide attempts among adolescents and young adults: Developmental changes. Journal of Consulting and Clinical Psychology, 77(2), 281–290. https://doi.org/10.1037/a0014732

11.

Greydanus

Patel

Pratt

(2010). Suicide risk in adolescents with chronic illness: Implications for primary care and specialty pediatric practice: A review. Developmental Medicine & Child Neurology, 52(12), 1083–1087.

12.

Hales

C. M.

Kit

B. K.

Ogden

C. L.

(2018). Trends in prescription medication use among children and adolescents—United States, 1999–2014. JAMA, 319(19), 2009–2020. https://doi.org/10.1001/jama.2018.5690

13.

Halfon

Labelle

Cohen

Guilé

J.-M.

Breton

J.-J.

(2013). Juvenile bipolar disorder and suicidality: A review of the last 10 years of literature. European Child & Adolescent Psychiatry, 22(3), 139–151. https://doi.org/10.1007/s00787-012-0328-z

14.

Hawton

Bale

Brand

Townsend

Ness

Waters

Clements

Kapur

Geulayov

(2020). Mortality in children and adolescents following presentation to hospital after non-fatal self-harm in the Multicentre Study of Self-Harm: A prospective observational cohort study. The Lancet Child & Adolescent Health, 4(2), 111–120. https://doi.org/10.1016/S2352-4642(19)30373-6

15.

Horowitz

Tipton

M. V

Pao

(2020). Primary and secondary prevention of youth suicide. Pediatrics, 145(Suppl. 2), S195–S203. https://doi.org/10.1542/peds.2019-2056H

16.

Ikeda

R. M.

Kresnow

M. J.

Mercy

J. A.

Powell

K. E.

Simon

T. R.

Potter

L. B.

Durant

T. M.

Swahn

M. H.

(2001). Medical conditions and nearly lethal suicide attempts. Suicide & Life-Threatening Behavior, 32(Suppl. 1), 60–67. https://doi.org/10.1521/suli.32.1.5.60.24207

17.

Joiner

(2007). Why people die by suicide. Harvard University Press.

18.

Juurlink

D. N.

Herrmann

Szalai

J. P.

Kopp

Redelmeier

D. A.

(2004). Medical illness and the risk of suicide in the elderly. Archives of Internal Medicine, 164(11), 1179–1184. https://doi.org/10.1001/archinte.164.11.1179

19.

Koyama

Zai

C. C.

Bryushkova

Kennedy

J. L.

Beitchman

J. H.

(2020). Predicting risk of suicidal ideation in youth using a multigene panel for impulsive aggression. Psychiatry Research, 285, 112726. https://doi.org/10.1016/j.psychres.2019.112726

20.

Merandi

Sapko

Catt

Hoffman

J. M.

(2017). Medication reconciliation. Pediatrics in Review, 38(1), 54.

21.

O’Connor

R. C.

Kirtley

O. J.

(2018). The integrated motivational-volitional model of suicidal behaviour. Philosophical Transactions of the Royal Society of London: Series B: Biological Sciences, 373(1754), 20170268. https://doi.org/10.1098/rstb.2017.0268

22.

Payne

R. A.

Oliver

J. J.

Bain

Elders

Bateman

D. N.

(2009). Patterns and predictors of re-admission to hospital with self-poisoning in Scotland. Public Health, 123(2), 134–137. https://doi.org/10.1016/j.puhe.2008.12.002

23.

Qin

Webb

Kapur

Sørensen

H. T.

(2013). Hospitalization for physical illness and risk of subsequent suicide: A population study. Journal of Internal Medicine, 273(1), 48–58. https://doi.org/10.1111/j.1365-2796.2012.02572.x

24.

Rappaport

D. I.

Collins

Koster

Mercado

Greenspan

Lawless

Hossain

Sharif

(2011). Implementing medication reconciliation in outpatient pediatrics. Pediatrics, 128(6), e1600–e1607.

25.

Ravaioli

Crocetti

Mancini

Baldacchini

Giuliani

Vattiato

Bucchi

Falcini

(2020). Suicide death among cancer patients: New data from northern Italy, systematic review of the last 22 years and meta-analysis. European Journal of Cancer (Oxford, England: 1990), 125, 104–113. https://doi.org/10.1016/j.ejca.2019.08.019

26.

Ribeiro

J. D.

Franklin

J. C.

Fox

K. R.

Bentley

K. H.

Kleiman

E. M.

Chang

B. P.

Nock

M. K.

(2016). Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: A meta-analysis of longitudinal studies. Psychological Medicine, 46(2), 225–236. https://doi.org/10.1017/S0033291715001804

27.

Sawyer

S. M.

Drew

Yeo

M. S.

Britto

M. T.

(2007). Adolescents with a chronic condition: Challenges living, challenges treating. Lancet (London, England), 369(9571), 1481–1489. https://doi.org/10.1016/S0140-6736(07)60370-5

28.

Scott

Azrael

Miller

(2018). Firearm storage in homes with children with self-harm risk factors. Pediatrics, 141(3), e20172600. https://doi.org/10.1542/peds.2017-2600

29.

Scott

K. M.

Hwang

Chiu

W.-T.

Kessler

R. C.

Sampson

N. A.

Angermeyer

Beautrais

Borges

Bruffaerts

de Graaf

Florescu

Fukao

Maria Haro

Kovess

Levinson

Posada-Villa

Scocco

Nock

M. K.

(2010). Chronic physical conditions and their association with first onset of suicidal behavior in the World Mental Health Surveys. Psychosomatic Medicine, 72(7), 712–719. https://journals.lww.com/psychosomaticmedicine/Fulltext/2010/09000/Chronic_Physical_Conditions_and_Their_Association.15.aspx

30.

Shain

(2016). Suicide and suicide attempts in adolescents. Pediatrics, 138(1), e20161420. https://doi.org/10.1542/peds.2016-1420

31.

Slap

Goodman

Huang

(2001). Adoption as a risk factor for attempted suicide during adolescence. Pediatrics, 108(2), E30. https://doi.org/10.1542/peds.108.2.e30

32.

Suris

J.-C.

Michaud

P.-A.

Viner

(2004). The adolescent with a chronic condition. Part I: Developmental issues. Archives of Disease in Childhood, 89(10), 938–942. https://doi.org/10.1136/adc.2003.045369

33.

Thibault

D. P.

Mendizabal

Abend

N. S.

Davis

K. A.

Crispo

Willis

A. W.

(2016). Hospital care for mental health and substance abuse in children with epilepsy. Epilepsy & Behavior: E&B, 57(Pt A), 161–166. https://doi.org/10.1016/j.yebeh.2016.01.031

34.

Vajda

Steinbeck

(2000). Factors associated with repeat suicide attempts among adolescents. The Australian and New Zealand Journal of Psychiatry, 34(3), 437–445. https://doi.org/10.1080/j.1440-1614.2000.00712.x

35.

Wang

S.-J.

Fuh

J.-L.

Juang

K.-D.

S.-R.

(2009). Migraine and suicidal ideation in adolescents aged 13 to 15 years. Neurology, 72(13), 1146–1152. https://doi.org/10.1212/01.wnl.0000345362.91734.b3

36.

World Health Organization. (2021). Suicide worldwide in 2019: Global health estimates. Author. Retrieved March 29, 2022, from https://www.who.int/publications/i/item/9789