Characteristics of adolescents who visit the emergency department following suicide attempts: comparison study between adolescents and adults

Suicide is one of the most important issues related to mental health, both personally and socially. Every year close to 800,000 people died from suicide, and suicide attempt rate are about 10 times higher than suicide rate [1, 2]. According to OECD’s survey results, in South Korea in the year 2013, 28.7 people per 100,000 population attempted suicide and recorded the 1st place with more than twice the suicide rate of other OECD countries [3, 4]. This serious suicide problem applies not only to adults but also to adolescents. The most common cause of death among teenagers in Korea in 2016 is suicide [5]. Unlike other OECD countries, the death rate of adolescents’ suicides in Korea has shown an increasing trend [6].

Suicide attempts are caused by complex factors such as genetic, environmental, cultural and psychiatric factors [7]. Adolescents’ suicide attempts differ from those of adults, because of their physical changes and their varied emotional experiences in their environment. According to previous studies, adolescents attempted suicide more impulsively than adults and opted for less fatal methods of attempts [8]. Suicide attempters among adolescents had fewer number of psychiatric diagnoses [9] and their mental disorders are easily less identified or diagnosed by professional [10]. Also they had fewer suicidal motivations due to economic problems and physical illnesses, and used more over the counter drug poisoning as a suicide attempt than adults [11].

Although previous studies have described risk factors for suicide and suicidal behavior in adolescents [12‐14], very few studies have directly compared demographic and clinical features with adults. In addition, most of these studies were carried out with patients hospitalized after attempted suicide. Therefore, the study conducted on patients visiting the emergency department (ED) is very limited. Considering that the proportion of patients admitted to medical facilities due to attempted suicide is small, the results of previous researches are limited in representing the characteristics of the entire suicide attempt [15].

Since suicide attempt in adolescents is a risk factor for subsequent retries and suicide death, identifying the distinct characteristics of patients who visited an ED has clinical significance in establishing prevention strategies for adolescents’ suicides. We hypothesized that unique characteristics may have influenced suicidal behavior in adolescent group and identification of the characteristics of suicide attempters among adolescents will help establish efficient preventive strategies (i.e., specific target, points of access, methods, and intensity of care). In the context, the purpose of this study was to identify the demographic and clinical characteristics of suicide attempts in adolescents compared with those of adults who visited the ED.

This is the first study to directly compare the characteristics of suicide attempts in adolescents who visit the ED compared to those of adults. We tried to discover the characteristics of suicide attempts in adolescents, comparing social demographic, clinical, suicide-related factors, for a total of 149 adolescents and 1427 adults under the age of 65.

Women in both groups were more than men, which was the same as the results of previous studies [11, 18, 19]. The rate of hospitalization was significantly higher in adults. (23.5% vs 31.9%). Previous studies have shown a various rate of hospital admissions after suicide attempts. In one study, about 34% of adolescent suicides attempters were hospitalized [15], and in another study, 26.9% of attempters were hospitalized [20]. In addition, about one-third of the patients visiting the ED was hospitalized after attempting regardless of age [19]. Admission rates are influenced by various factors, such as the medical system and management guideline, so it is difficult to directly compare them. In this study, it is estimated that the high medical lethality of suicides in adults is associated with the high admission rates in adults.

At the time of visiting the ED, 41.5% of the adolescents had a history of suicide attempt, which was significantly higher than adults. The rate of suicide attempts in previous adolescent suicide attempts in the ED was 53.3% in the UK and 37.9% in the European multicenter study, similar to those in the present study [21, 22]. In previous studies compared with adults, one study found that adults were more likely to attempt suicide [8], but, other study reported no significant difference [11]. These studies were conducted on inpatients, so the proportion of patients who had a history of attempt is high and difficult to compare with the results of this study. Also, in this study, since adolescents tend to attempt suicide with relatively little intent compared to adults, these pattern of suicide attempts may have been repeated. However, as in adults, adolescents’ repeated suicide attempts increase the risk of subsequent suicide re-attempts and are also a factor that increases the likelihood of suicide death [23]. According to previous studies, about 15% of suicide re-attempts occurred in six months, 13.6–24% in a year [24‐26]. In addition, considering our findings shows that adolescents had little previous psychiatric diagnosis or history of treatment, in reality, psychological assessment and intervention after suicide attempt may not have been properly made. This suggests that it is urgent and important to establish strategies for early detection and intervention after the first suicide attempt by adolescents.

In the adolescents group, diagnosis of an adjustment disorder was greater than that of adults, and it was consistent with the results of previous comparison study [8]. Also, 21% of adolescents in psychological autopsy study conducted in Finland were diagnosed as adjustment disorders, similar to 26% in this study [27]. However, the difference was significant only in male adolescents. One study showed that female adolescents report more of the symptoms of depressed mood and guilt than male in depressive disorder [28]. It cannot be ruled out that the female adolescents were more likely to have been diagnosed with depressive disorder due to the high level of expression of symptoms, whereas the male adolescents were diagnosed with an adjustment disorder, in the ER where diagnosis is made with limited information. Research using a structured interview tools on more samples should be carried out to identify gender differences in the psychiatric diagnosis of adolescents.

The results of our study show that a majority of adolescents attempt suicide in the context of interpersonal conflicts, whereas a majority of adults attempt suicide in the context of economic problems. These findings are consistent with the earlier studies that have reported interpersonal issues as the most common motivation for adolescents’ suicide attempts [7, 11, 18, 21]. Various changes in relationships, emotional instability, and a lack of coping skills in dealing with them may lead adolescents to suicide attempt [7, 29]. Therefore, it is necessary to provide educations on coping skills for various interpersonal issues and stress management to prevent adolescents’ suicide attempt.

Poisoning was the most common method of suicide attempt for both groups. But adults were more likely to try to suicide attempt by overdosing on psychiatric medications or herbicides/pesticides while adolescents were more prone to analgesics. It is consistent with previous studies that adolescents prefer to take analgesics as a way to suicide attempt [8], and there are also reports that legislation regarding package size of analgesics is effective in preventing suicides [30]. This is understandable in terms of availability, as analgesics are easy to get. Another consideration is the high risk of suicide in adolescents already abusing analgesics. The previous study has shown that approximately 4.7% of adolescent misuse over-the-counter drugs, with higher prevalence of psychiatric illness and suicides than non-users [26]. Because some adolescents who abuse analgesics use them to reduce sleep or anxiety [31], it is possible that the adolescents who used the analgesic drug as a self-medication used it as a way to suicide attempt. This can be seen as similar to using psychiatric drugs in adult suicide attempters. Assessment of risk of suicide might be required in adolescent patients suspected of abuse of analgesics, as well as evaluation of analgesics abuse is needed in adolescent at suicide-risk.

A notable result was that adolescents had more attempted joint suicide than adults. In particular, the difference was significant only among female adolescents. Previous research reported that contagious nature of self-harm appears in young adults, especially in female adolescents [32]. Contagion in suicidal behavior has been explained as being caused by assortative selection of peer group or shared relationship stress [32, 33]. In our study, by similar mechanisms, it is estimated that female adolescents’ joint suicides were reported more commonly. Female has a higher empathy for others than male [34]. So, we can consider the possibility that the motive was enhanced by others to attempt joint suicide or the suicidality was shared by vulnerable individuals in stressful state [33]. Furthermore, considering that most suicide attempters communicate their suicidal intentions prior to suicide, we should pay attention to suicidal communication before suicide [35]. Previous study had limits to identify the contagious nature of suicides at the school level. The results of this study provide more direct evidence to the hypothesis that adolescent suicides tend to be more contagious, since the results show that adolescents try to joint suicide attempt more than adults. However, researches on joint suicide are scarce, especially in studies aimed at adolescents. The study was conducted on patients visiting the ED only, so it was not clear whether adolescents attempted joint suicide more than adults. Although there is no significant difference between both groups, it is possible that the proportion of transfer to the ED after being rescued is relatively small because adults attempt suicide in a fatal method such as CO intoxication. Therefore, a study on the joint suicides of adolescents, especially of female, is needed in the future.

This study is the first direct comparison study of the socio-demographic, clinical, and suicide-related factors between adolescents and adults based on ED. Interpersonal problems are the main motivation for adolescent suicides, and previous suicide attempts were more frequent than adults. It also showed a tendency to attempt suicide with a lower intention to die and a relatively lesser degree of lethality than adults. Among them, taking analgesics is the most common method, so measures need to be taken against over-the-counter drug use by adolescents. Major depressive disorders were also the most common diagnosis, with adjustment disorders accounting for a significant proportion. Therefore, based on these results, there is an early need for therapeutic and social intervention to prevent adolescent suicide attempts. Our results highlight the importance of specific and individualized preventive strategies for adolescent suicide attempters. Moreover, careful assessment and appropriate treatment for underlying psychopathologies in suicide attempters among adolescents should be considered.