COVID-19, young people, and suicidal behaviour – Authors' reply

In their Correspondence about our meta-analysis on changes in paediatric emergency department visits during the COVID-19 pandemic,1Madigan S Korczak DJ Vaillancourt T et al.Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis.Lancet Psychiatry. 2023; 10: 342-351Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar Sarah Steeg and colleagues assert that our evidence for a substantial increase does not equate to good evidence in clinical settings. We disagree. Our predefined threshold for substantial was intended to be clinically meaningful: an extra one in every ten emergency department visits to a health setting for a given pathology (eg, suicide attempt) attributable to COVID-19. Our predefined threshold for good evidence accounts for sampling uncertainty: a probability of 0·75–0·95 for a substantial increase. These thresholds apply across all settings, but Steeg and colleagues assert incorrectly that the thresholds should be linked to the quality of the studies. Steeg and colleagues also question our use of 90% versus 95% CIs. Coverage of 90% intervals is consistent with the thresholds for the level of evidence and with an alpha of 0·05 for rejection of non-significant and significant hypotheses (inferiority, superiority, and equivalence testing).2Hopkins WG Replacing statistical significance and non-significance with better approaches to sampling uncertainty.Front Physiol. 2022; 13962132Crossref PubMed Scopus (4) Google Scholar The 95% interval for attempted suicide would be 1·06–1·41, which also constitutes good evidence of a rate increase and would be statistically significant. Steeg and colleagues further note that we did not disaggregate our results by health setting. We had already noted the problem of insufficient data to include study moderators in the full analysis, and we had several strategies for dealing with the moderating effects of age, sex, and geographical location. When more data are published, the moderating effect of health setting should be estimated. They criticise the distinction we made between attempted suicide and self-harm. We agree that terminology in this area is contentious. Their position is that we should consider only a single outcome—self-harm regardless of intent. Yet the evidence suggests otherwise.3Brausch AM Gutierrez PM Differences in non-suicidal self-injury and suicide attempts in adolescents.J Youth Adolesc. 2010; 39: 233-242Crossref PubMed Scopus (253) Google Scholar, 4Zetterqvist M Lundh L-G Svedin CG A comparison of adolescents engaging in self-injurious behaviors with and without suicidal intent: self-reported experiences of adverse life events and trauma symptoms.J Youth Adolesc. 2013; 42: 1257-1272Crossref PubMed Scopus (49) Google Scholar, 5Geoffroy M-C Bouchard S Per M et al.Prevalence of suicidal ideation and self-harm behaviours in children aged 12 years and younger: a systematic review and meta-analysis.Lancet Psychiatry. 2022; 9: 703-714Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Among adolescents (ie, those aged 14–18 years in North America and those aged 15–17 years in Europe) who have engaged in self-harm, suicide attempts are associated with greater severity of psychiatric symptoms, more adverse life events, and greater interpersonal conflicts in community-based studies in North America3Brausch AM Gutierrez PM Differences in non-suicidal self-injury and suicide attempts in adolescents.J Youth Adolesc. 2010; 39: 233-242Crossref PubMed Scopus (253) Google Scholar and Europe.4Zetterqvist M Lundh L-G Svedin CG A comparison of adolescents engaging in self-injurious behaviors with and without suicidal intent: self-reported experiences of adverse life events and trauma symptoms.J Youth Adolesc. 2013; 42: 1257-1272Crossref PubMed Scopus (49) Google Scholar Our coding of outcomes was also in keeping with another meta-analysis in this area5Geoffroy M-C Bouchard S Per M et al.Prevalence of suicidal ideation and self-harm behaviours in children aged 12 years and younger: a systematic review and meta-analysis.Lancet Psychiatry. 2022; 9: 703-714Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar and the findings of an international survey of suicide experts—namely, that intention matters.6De Leo D Goodfellow B Silverman M et al.International study of definitions of English-language terms for suicidal behaviours: a survey exploring preferred terminology.BMJ Open. 2021; 11e04340Crossref PubMed Scopus (30) Google Scholar Getting the story of the effects of the pandemic right is important. Our meta-analysis of 42 studies with more than 11 million paediatric emergency department visits across 18 countries represents a rigorous approach to quantifying pandemic changes for attempted suicide, self-harm, and suicidal ideation. However, as with all meta-analyses, we are beholden to the data available. We look forward to extending our findings when more data are available and published. TV has received honoraria for presentations related to youth suicide during the pandemic and is also the Chair of the COVID-19 Task Force and the Children and Schools working group for the Royal Society of Canada and is the President of the International Society for Research on Aggression. DJK has received grant funding related to research on youth suicide from the Canadian Institutes of Health Research, Sobey's Foundation, and SickKids Foundation in the past 36 months. All other authors declare no competing interests. Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countriesThis is the first study to examine suicides occurring in the context of the COVID-19 pandemic in multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term mental health and economic effects of the pandemic unfold. Full-Text PDF COVID-19, young people, and suicidal behaviourThe COVID-19 pandemic and its effects on mental health continue to preoccupy researchers, clinicians, and policy makers alike. Evidence for its effects on suicidal behaviours remains relatively sparse but data suggest no increase, or even decrease, in suicide and hospital presentations for self-harm.1,2 Young people (ie, those 18 years and younger) have been a particular concern, with some evidence that children and young people's mental health deteriorated following the pandemic. Sheri Madigan and colleagues'3 systematic review aimed to plug an important gap in the literature by comparing paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the pandemic. Full-Text PDF COVID-19, young people, and suicidal behaviourSheri Madigan and colleagues'1 systematic review evaluates whether the COVID-19 pandemic has affected paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation. They report that the combined rate of emergency department visits for attempted suicide and suicidal ideation increased among girls (rate ratio 1·39, 90% CI 1·04–1·88), whereas there was no significant change among boys (1·06, 0·92–1·24).1 We were interested in this difference between the sexes because the COVID-19 pandemic appears to have had a greater impact on the behaviour of girls than boys in Japan. Full-Text PDF