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Toxicity of paracetamol grossly under-estimated
- ATRAYEE GHATAK (18 April 2005)
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The evidence on youth suicide prevention
- Philip A Crowley (18 April 2005)
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Suicide in young people
- Joav Merrick, Gil Zalsman (21 April 2005)
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The term 'deliberate' is unhelpful
- Peter J Miller, Marie Armstrong, Nurse Consultant (29 April 2005)
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From small ACYRNs: youth suicide prevention in Canada
- Neil Andersson, Dawn Caldwell, April Maloney, and Nancy Gibson (9 May 2005)
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ATRAYEE GHATAK, Specialist Registrar, Paediatrics Arrowe Park Hospital , Wirral , CH49 5PE
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Dear Editor, Working as a specialist registrar in Paediatrics, I read with interest the Clinical Review “Suicide and deliberate self harm in young people”1. Hawton and James state that self –poisoning makes up 90% of cases of deliberate self harm presenting to hospital. Paracetamol continues to top the list of drugs usually chosen for deliberate overdoses. What I find worryingly true, is that a large proportion of adolescents, though aware that paracetamol can cause harm, grossly under-estimate the extent of hepato-toxicity and side effects that paracetamol poisoning can produce. Awareness of the harmful effects of paracetamol has certainly increased since the 1976 study by Gazzard et al.2, as is borne out by more recent studies3,4 . The authors opine that this difference presumably reflects extensive media information about poisoning with paracetamol and awareness of deaths resulting from overdose. These same studies also show however, a persistence of the lack of knowledge about the specific effects that an overdose might have and the timing of such effects. Legislation to limit the size of packs of paracetamol and salicylates was introduced in the United Kingdom in September 1998. Mortality and morbidity associated with self-poisoning using these drugs has decreased substantially since that time5. Nevertheless, paracetamol remains widely available. This, together with lack of clear knowledge about its potential dangerousness and an absence of early symptoms of hepatotoxicity make it an attractive, though potentially lethal choice even in those situations where death is clearly not the intended outcome. There is thus a need to address the issues associated with paracetamol overdoses in adolescents. School drug education programmes may serve as a suitable forum where these issues may be discussed and thus further help reduce the problem of self-poisoning in young people. Yours sincerely,
Reference 1. Hawton K, James A. Suicide and deliberate self harm in young people. BMJ. 2005 Apr 16;330(7496):891-4 2. Gazzard BG, Davis M, Spooner J, Williams R. Why do people use paracetamol for suicide? BMJ 1976;i:212-3. 3. Hawton K, Ware C, Mistry H, Hewitt J, Kingsbury S, Roberts D, Weitzel H. Why patients choose paracetamol for self poisoning and their knowledge of its dangers. BMJ. 1995 Jan 21;310(6973):164. 4. Gilbertson RJ, Harris E, Pandey SK, Kelly P, Myers W Paracetamol use, availability, and knowledge of toxicity among British and American adolescents. Arch Dis Child. 1996 Sep;75(3):194-8. 5. Hawton K, Townsend E, Deeks J, Appleby L, Gunnell D, Bennewith O, Cooper J Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. BMJ. 2001 May 19;322(7296):1203-7 Competing interests: None declared |
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Philip A Crowley, Specialist in Public Health Medicine Institute of Public Health in Ireland, 5 th Floor, Bishop's Square, Redmond's Hill, Dublin 2, Irelan
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Dear Editor, Hawton and James' review on youth suicide and deliberate self-harm (1) is a timely reminder of the public health importance of suicide as a cause of death in young people. A recent evidence briefing on youth suicide prevention (2) completed by myself and co-authors with the Health Development Agency and the Institute of Public Health in Ireland highlighted the gaps in research on this important area. The briefing is a review of systematic reviews and meta-analyses and draws on some of Keith Hawton's previous work. Many of the reviews found that primary research in this area lacked sufficient programme description to allow the interventions to be replicated in other areas. The briefing highlighted the difficulty in finding answers to youth suicide prevention through randomised controlled trials. Suicide is a rare outcome and requires large trials in order to develop significant findings and it is difficult to isolate the impact of the study intervention amidst other factors affecting the context of the lives of young people under study. Suicide in young people is a complex outcome with many often co- existing risk factors and future suicide prevention practice needs to be carefull evaluated so that we can build the evidence base. Promising approaches such as providing contact cards for those who have harmed themsleves and initiatives focussing on developing young people's problem- solving and self esteem should be pursued and studied. In designing programmes for prevention we should engage young people in their development. Dr Philip Crowley 1. Hawton K, James A. Suicide and deliberate self harm in young people. BMJ 2005; 330: 891-894 2. Crowley P, Kilroe J, Burke S. Youth Suicide Prevention : An evidence briefing. Health Development Agency, 2004. Competing interests: None declared |
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Joav Merrick, Medical director National Institute of Child Health and Human Development, Office Med Director,Jerusalem, Israel, Gil Zalsman
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EDITOR---This comment in response to the excellent review on adolescent suicide by Keith Hawton and Antony James (1). Suicide is now the third leading cause of death among adolescents and young adults in the age group of 15-24 years (2,3). The rate of suicide among the 15-24 year olds in United States has increased from 2.7 per 100,000 in 1950 to 13.2 per 100,000 in 1990 (2). There seem to be many reasons for this fivefold increase, but increased substance abuse, television and video violence and the easy access to firearms looks like substantial reasons for this dramatic increase. Suicidal behavior, sometimes exaggerated through the media, has resulted in 4% of American high school students attempting suicide within the last 12 months and 8% having made an attempt within their lifetime (2). The biggest increase in the suicide rate has been seen in the 15-19 year old group, but in the last ten years the rate among the 10-14 year olds have increased over 100% (2). SUICIDE WORLDWIDE The World health Organization (WHO) has studied suicide around the world since 1950 (4) and found an overall increase from 10.1 per 100,000 in 1950 to 16 per 100,000 in 1995 in all ages. In 1950 the study was based on data from only 21 countries, but in 1995 data was supplied from 105 countries. This fact in itself can make some of the differences in the figures. Over the years the trend has shown a predominance of suicide rates of males over females, which has been relatively constant, but with a slight increase from 3.2:1 in 1950 to 3.6:1 in 1995. One exception is rural China, where females rates are 1.3 times higher than males. The highest suicide rates are found in the Baltic region (e.g Estonia with 64.3 for males and 14.1 for females), but in absolute figures one fourths of all world suicides are committed in China and India. China alone accounts for 20% of all suicides in the world. SUICIDE IN ISRAEL Since 1955 the total suicide rates in Israel have remained relatively stable with a peak in 1975 (8.4 per 100,000) and a rate of 5.4 in 1996 (4). In 1955 rates for females were highest, but afterwards males always have had higher rates. The male:female suicide ratio has gradually increased to 3.2:1 in 1996 from 1.3:1 in 1960 (4). In 1995 suicide rates increased progressively with aging. The suicide rate for the age group 15- 24 years was 2.9 per 100,000 in 1955, but had increased to 5.0 in 1995. Information on suicidal behavior of Israeli adolescents can be found in a national survey conducted in 1994 (5), where students from grade 10 and 11 were asked about such behavior in the year prior to the study. The study found that 20.6% of the girls and 13.5% of the boys reported having thought seriously about attempting suicide. A suicide attempt had been planned by 8-10%, 6-7% had attempted suicide and 3-4% had made a suicide attempt that required treatment by a physician, paramedic or nurse. Rates in such surveys are much higher than official Ministry of Health registration, but nevertheless should be taken seriously. Students who reported thinking about, planning or attempting suicide were more likely to report feelings of unhappiness, moodiness and loneliness. CONCLUSIONS In conclusion, adolescent suicide attempts and actual suicide are a public health concern and we agree that all people who have caused selfharm in a serious way should be assessed in the hospital by a child and adolescent psychiatrist in order to conduct a psychosocial assessment and prevent further harm. AFFILIATION Joav Merrick, MD, DMSc is professor of child health and human development, director of the National Institute of Child Health and Human Development and the medical director of the Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, Israel. E-mail: jmerrick@internet-zahav.net. Website: www.nichd-israel.com Gil Zalsman, MD, is Deputy director of Geha Mental Health Center, Chief of Child and Adolescent Psychiatry at Petach Tiqva in Israel affiliated with the Sackler School of Medicine, Tel Aviv University, Israel (E-mail: zalsman@post.tau.ac.il), but currently at the Neuroscience Department, New York State Psychiatric Institute, Columbia University Medical Center, New York, NY, USA. REFERENCES 1. Hawton K, James A. Suicide and deliberate self harm in young people. BMJ 2005;330:891-4. 2. Brent DA. Mood disorders and suicide. In: Green M, Haggerty RJ, Weitzman M, eds. Ambulatory pediatrics, 5th Edition. Philadelphia: WB Saunders, 1999,447-54. 3. American Academy of Pediatrics Committee on adolescence. Suicide and suicide attempts in adolescents. Pediatrics 2000;105(4):971-4. 4. WHO. Mental and behavioral disorders. Figures and facts about suicide. Geneva: World Health Organization, WHO/MNH/MBD/99.1, 1999. 5. Harel Y, Kani D, Rahav G. Health behaviors in school-aged children: A World Health Organization cross-national study. Jerusalem: JDC -Brookdale Institute, 1997. Competing interests: None declared |
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Peter J Miller, Consultant Child and Adolescent Psychiatrist Thorneywood, CAMHS, Porchester Road,Nottingham, NG3 6LF, Marie Armstrong, Nurse Consultant
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EDITOR – Hawton and James use the term deliberate self-harm in their otherwise excellent article¹. The term ‘deliberate’ implies premeditation and wilfulness, yet self-harm is heterogeneous, sometimes spontaneous, compulsive and with little awareness and conscious thought. Recent NICE guidelines² have removed the word deliberate, using just ‘self-harm’ as a description. Use of the derogatory phrase ‘deliberate self-harm’ will continue to stigmatise service users. 1. Hawton K & James A (2005) Suicide and deliberate self-harm in young people. BMJ, vol. 330, 16 April, p891 – 894. 2. NICE (2004) Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Clinical guideline 16, July. Competing interests: None declared |
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Neil Andersson, Executive, director CIETcanada,, Dawn Caldwell, April Maloney, and Nancy Gibson
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We welcome the recent articles about youth suicide, drug misuse, sexual abuse and family breakdown (1), and the importance of engaging youth today in building healthy habits for the future (2). Suicide in Canada is six times more common among Aboriginal youth than among other Canadians of the same age group (3). Unlike many other personal health issues, suicide not only destroys the individual, it also damages entire communities. This is particularly true among close-knit Aboriginal communities. Yet suicide and its causes have seldom been fully addressed within the community context. The Aboriginal Community Youth Resilience Network (ACYRN) departs from conventional academic-led urban suicide research. To begin with, the research is owned and controlled by Aboriginal interests, placing university researchers in a responsive support rather than in a research leadership role. ACYRN attempts to strengthen existing Aboriginal (predominantly rural) community-building processes in an evidence-based manner. The project measures specific Aboriginal ways of promoting youth resilience. ACYRN involves Aboriginal communities at all the stages of research, from design through reporting and lesson sharing among communities. Two communities took the lead in development of the survey instrument. To date, youth from nine communities have completed this questionnaire, fine- tuned to the specific needs of each community by local steering committees. The results feed into a community-wide and inter-community dialogue on suicide prevention, involving other community sources of knowledge (for example, Elders, youth, spiritual and health service workers). Expected solutions will be a community-specific mix of interventions: primary prevention, intervention for those with risk factors, post-vention (care of those who attempt suicide), capacity building and policy development. To date, 15 Aboriginal communities in Nova Scotia, New Brunswick, Ontario, Alberta and the North West Territories have joined ACYRN, funded by the Canadian Institutes of Health Research. (1) Hawton K, James A. Suicide and deliberate self harm in young people. BMJ. 2005,330;891-4 (2) Viner MR and Barker M. Young people's health: the need for action. BMJ. 2005,330;901-3 (3) Canadian Institute of Child Health, The Health of Canada’s Children, CICH: Ottawa, 2000, as cited in Advisory Group on Suicide Prevention, Acting on What We Know: Preventing Youth Suicide in First Nations. Health Canada, Ottawa, March 2003, pp23 Competing interests: None declared |
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