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.

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

Suicidality is a common public health concern in young people. Previous research has highlighted pain as a key correlate of suicidality in young people. However, the long-term experience of pain may vary between individuals, and the relationship between distinct pain trajectories and suicidality is poorly understood. This study aims to describe the number and nature of distinct pain trajectories, their demographic and clinical correlates, including baseline suicidality, and whether identified pain trajectories may predict future suicidality. Secondary data analyses were performed, using longitudinal data from the British Child and Adolescent Mental Health Survey (N = 7977), collected at five timepoints between 2004 and 2007 on a population-based sample of UK youth (5-16 years). Data were collected from up to three respondents (parents, teachers, and 11 + year-olds). Latent Class Growth Analysis was used to identify distinct pain trajectories, explore predictors of these trajectories, and establish whether trajectories predicted future suicidality. We identified the following four pain trajectories: increasing (33.6%), decreasing (4.5%), persistent/recurrent probability of pain (15.7%), and no pain (46.2%). Pain trajectories were associated with unique demographic and clinical correlates. Only the persistent/recurrent (vs. no-pain) trajectory was predicted by baseline suicidality (aOR = 2.24; 95% bootstrap-CI = 1.59-3.26). Furthermore, the persistent/recurrent trajectory predicted future suicidality (aOR = 1.03, 95% bootstrap-CI = 1.01-1.06), after controlling for baseline suicidality, psychiatric disorder, age, and gender. Findings provide a better understanding of correlates associated with distinct pain trajectories and long-term risk of suicidality in young people, suggesting a bidirectional pain-suicidality association and emphasising the need of targeted support for young people with persistent/recurrent pain.

Does depression moderate the relationship between pain and suicidality in adolescence? A moderated network analysis.

BACKGROUND: Whilst growing research suggests that pain is associated with suicidality in adolescence, it remains unclear whether this relationship is moderated by co-morbid depressive symptoms. The present study aimed to investigate whether the pain-suicidality association is moderated by depressive symptoms. METHODS: We performed secondary analyses on cross-sectional, pre-intervention data from the 'My Resilience in Adolescence' [MYRIAD] trial (ISRCTN ref: 86619085; N=8072, 11-15 years). Using odds ratio tests and (moderated) network analyses, we investigated the relationship between pain and suicidality, after controlling for depression, anxiety, inhibitory control deficits and peer problems. We investigated whether depression moderates this relationship and explored gender differences. RESULTS: Overall, 20% of adolescents reported suicidality and 22% reported pain, whilst nine percent of adolescents reported both. The experience of pain was associated with a four-fold increased risk of suicidality and vice versa (OR=4.00, 95%-CI=[3.54;4.51]), with no gender differences. This cross-sectional association remained significant after accounting for depression, anxiety, inhibitory control deficits and peer problems (aOR=1.39). Depression did not moderate the pain-suicidality association. LIMITATIONS: The item-based, cross-sectional assessment of pain and suicidality precludes any conclusions about the direction of the effects and which aspects of suicidality and pain may drive this association. CONCLUSIONS: Our findings underscore the need to consider pain as an independent risk correlate of suicidality in adolescents. Longitudinal research should examine how this relationship develops during adolescence. Clinically, our findings emphasise the need to assess and address suicidality in adolescents with pain, even in the absence of depressive symptoms.

Exploring the relationship between pain and self-harm thoughts and behaviours in young people using network analysis.

BACKGROUND: Self-harm thoughts and behaviours (SHTBs) are a serious public health concern in young people. Emerging research suggests that pain may be an important correlate of SHTBs in young people. However, it remains unclear whether this association is driven by the shared association with other correlates of SHTBs. This study used network analysis to delineate the relationship between SHTBs, pain and other correlates of SHTBs in a population-based sample of young people. METHODS: We performed secondary analyses, using data from 7977 young people aged 5-16 years who participated in the British Child and Adolescent Mental Health Survey in 2004. We used χ2 tests and network analysis to examine the complex interplay between SHTBs, pain and other correlates of SHTBs, including psychiatric disorders, childhood trauma, stressful life events, parental distress, family dysfunction, peer problems and inhibitory control deficits. RESULTS: Pain was associated with a doubled risk of SHTBs, and likewise, SHTBs were associated with a doubled risk of pain. Furthermore, network analysis showed that although pain was significantly associated with all measured correlates of SHTBs, except family dysfunction, pain was most strongly associated with SHTBs, after accounting for these measured correlates. CONCLUSIONS: To the best of our knowledge, this is the first study to utilise network analysis to provide novel insights into the complex relationship between SHTBs, pain and other known correlates of SHTBs in young people. Results suggest that pain is an independent correlate of SHTBs. Future research should aim to identify underlying mechanisms.

A randomized clinical trial of mindfulness-based cognitive therapy for women with irritable bowel syndrome-Effects and mechanisms.

OBJECTIVE: Irritable bowel syndrome (IBS) is a chronic disorder of brain-gut interaction. Previous studies suggest that mindfulness could be therapeutic for IBS patients, however no study has evaluated the effects of mindfulness-based cognitive therapy adapted for patients with IBS (MBCT-IBS). A 6-week MBCT-IBS course was designed to reduce symptoms and increase quality of life. This study aimed to evaluate the effects of MBCT-IBS and to investigate its therapeutic mechanisms in a randomized controlled trial. METHOD: Sixty-seven female patients with IBS were randomized to MBCT-IBS (MG; n = 36) or a waitlist (WL; n = 31) control condition. Patients completed standardized self-report measures of IBS symptom severity, IBS quality of life, maladaptive illness cognitions (catastrophizing, visceral anxiety sensitivity) and mindfulness at baseline, after 2 treatment sessions, at posttreatment, and at 6-week follow-up. Self-referential processing of illness and health was measured with an implicit association test (IAT). RESULTS: The MG reported significantly greater reductions in IBS symptoms (p = .003) and improvements in quality of life (p < .001) at follow-up compared with the WL. Changes in visceral anxiety sensitivity and pain catastrophizing at posttreatment and reductions in the IAT-score after 2 sessions combined with increases in nonjudgmental awareness at posttreatment mediated reductions in IBS symptoms. CONCLUSIONS: MBCT-IBS has the potential to reduce IBS symptoms and increase quality of life. MBCT-IBS may exert its effect on IBS symptoms via reducing maladaptive illness cognitions and activating changes in self-processing (reducing biases in self-referent processing of illness and health and increasing nonjudgmental awareness). (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The relationship between pain and suicidal vulnerability in adolescence: a systematic review.

Leading suicide theories and research in adults suggest that pain can exacerbate the suicidal risk of an individual. Although pain and suicidality (including suicidal ideation, behaviour, and death by suicide) both increase in prevalence during adolescence, the relationship between these factors remains unclear. We aimed to systematically review the empirical evidence for such an association in adolescence. We included 25 observational studies published between January 1961 and December 2018, exploring the potential association between pain and suicidality in adolescents aged 10-19 years. Across various samples and manifestations of pain and suicidality, we found that pain approximately doubles the suicidal risk in adolescents, with a few studies suggesting that pain can predict suicidality longitudinally. Although depression was an important factor, it did not fully explain the association between pain and suicidality. Evidence for associations between pain characteristics and suicidality is sparse and inconclusive, and potentially hides developmental differences between adolescents and adults. Identification of psychological mediators and moderators is required to develop interventions tailored to the needs of adolescents experiencing pain. This study is registered with the PROSPERO database, number CRD42018097226.

Is There a Relationship between Suicidal Intent and Lethality in Deliberate Self-Poisoning?

The relationship between suicidal intent and lethality of deliberate self-poisoning (DSP) episodes and their associations with suicide have yielded contradictory findings. The aims of this study were to investigate the association between patients' suicidal intent and independently rated lethality of DSP episodes, and whether the association changes over time. Eighty-nine DSP patients were investigated longitudinally. Self-reported suicidal intent, including perceived likelihood of dying, wish to die, and whether or not the DSP was considered a suicide attempt, was measured at the time of the index episode (t1), 3 months (t2), and 12 months (t3) later. Lethality was assessed independently by three clinical toxicologists. Lethality was significantly associated with patients' reported wish to die (p = .01) and perceived likelihood of dying (p = .04) at t1, but not at t2 and t3. No association was found between whether the episode was considered a suicide attempt or not and lethality at t1, t2, or t3. Lethality and suicidal intent should be considered as largely separate dimensions of self-harm. Clinicians should bear this in mind during clinical assessment, especially regarding historical information.

Looking Back on Self-Poisoning: The Relationship between Depressed Mood and Reporting of Suicidal Intent in People Who Deliberately Self-Poison.

Lifetime worst-point suicidality is associated with risk of subsequent death by suicide. Yet little is known about how people who deliberately self-poison (DSP) change their appraisal of suicidal intent of a single DSP episode over time. We assessed whether suicidal intent for a single index episode of DSP changed over time and factors associated with such change. We studied 202 patients admitted for DSP (66.3% female, all Caucasian), 18-85 years old (M = 37.8, SD = 14.8), using a longitudinal design (0, 3, and 12 months). The primary outcome measure was change in suicidal intent for a single index DSP episode, analyzed using multilevel modeling. Wish to die and whether the episode was considered a suicide attempt increased significantly with depressed mood. Wish to die associated with the index episode also increased over time independently of depressed mood. No association with time or depressed mood was found for perceived likelihood of dying. Depressed mood was strongly associated with appraisal of suicidal intent associated with a DSP episode. In suicide risk assessment, reports of the nature and severity of past DSP should be interpreted in light of current mood.

Biclustering Models for Two-Mode Ordinal Data.

The work in this paper introduces finite mixture models that can be used to simultaneously cluster the rows and columns of two-mode ordinal categorical response data, such as those resulting from Likert scale responses. We use the popular proportional odds parameterisation and propose models which provide insights into major patterns in the data. Model-fitting is performed using the EM algorithm, and a fuzzy allocation of rows and columns to corresponding clusters is obtained. The clustering ability of the models is evaluated in a simulation study and demonstrated using two real data sets.

Ian Curtis: Punk rock, epilepsy, and suicide.

Ian Curtis was the front man of the post-punk band Joy Division. He suffered from epilepsy and actively incorporated his experiences of the disease in his lyrics. Curtis had frequent epileptic seizures, both on and off stage. After dying from suicide in 1980, he became a legend in the post-punk milieu. The impact which the epilepsy, the epilepsy treatment, and comorbid depression had on his artistic life and premature death is not well known.

Epilepsy is Dancing.

In "Epilepsy is Dancing", in Antony and the Johnsons' album "The Crying Light"(2009), the lyrics and accompanying music video depicts an epileptic seizure in which the person is transferred to another beautiful and magical world. This may be called "enchanted epilepsy"; i.e., the experience of epilepsy as deeply nourishing and (positively) transforming, is conveyed not only in the lyrics but also the visual and auditory qualities of the video. The seizure in the video gives associations to Shakespeare's "A Midsummer Night's dream". If epilepsy appears in music lyrics, the focus is mostly on negative aspects of the illness, such as horror, fear and repulsive sexuality associated with the fits [1,2]. Contradictory to these lyrics, Anthony and the Johnsons' song is an example of a positive portrayal of epilepsy. It is open to a multitude of meanings, emotional valence and appraisal of epilepsy. By widening the experiential range associated with epileptic seizures, these lyrics highlight the inherently construed nature of epileptic experience. The song stands out in several ways. First, it describes epilepsy in positive terms, prioritising the euphoric, ecstatic, potentially empowering and enhancing aspects of epileptic seizures. Second, the lyrics and accompanying video point to divine experiences associated with epileptic seizures. Through the lyrics and the music video we are, as an audience, able to sense a snicket of an epileptic seizure, but also the universal experience of loosing control.

Change in access to prescribed medication following an episode of deliberate self-poisoning: a multilevel approach.

OBJECTIVE: Patients with a history of deliberate self-poisoning (DSP) are prescribed a greater amount of medication than the general public. DSP is the most robust risk factor for repeat episodes of DSP and subsequent death by suicide, and one might therefore expect that access to prescribed medication would be reduced following an episode of DSP. However, it is unclear whether access to prescribed medication changes after an episode of DSP. The objectives of this study were to investigate changes in 1) overall, psychotropic, non-psychotropic and the psychotropic subgroup antidepressant prescribed medication availability in DSP patients following an episode of DSP, 2) prescribing of the medication ingested in the episode, and 3) potential effects of gender, age and repeater status on such change. METHODS: The design was longitudinal. We included 171 patients admitted for DSP between January 2006 and March 2007. Data on patients' prescriptions prior to admission were retrieved from The Norwegian Prescription Database. The outcome measure was the difference between medication load in the year following compared to the year prior to the DSP episode. RESULTS: There was a significant increase in total medication load following DSP, including both psychotropic and non-psychotropic medication. Antidepressant medication load remained stable. There was a tendency for access to drugs ingested in the episode to increase following the episode, albeit not significantly. Medication load increased with age across all medication groups irrespective of time period and gender. CONCLUSIONS: The findings show that physicians do not curb prescribing to patients who have recently deliberately self-poisoned. Moreover, they highlight the need for cautious and judicious prescribing for these patients, in combination with psychological and social interventions.

Prescribed medication availability and deliberate self-poisoning: a longitudinal study.

OBJECTIVE: The availability of prescribed medication to patients who engage in deliberate self-poisoning (DSP) is not known, and it is not clear whether patients choose drugs prescribed to them for self-poisoning. The objectives of this study were to investigate (1) prescribed medication availability in DSP patients compared to the general population, (2) whether patients use their prescribed medication in their DSP episodes, (3) differences between patients who ingest prescribed medication and those who do not, and (4) the time between the last collection of prescribed medication used for DSP and the DSP episodes. METHOD: The design was longitudinal. We included 171 patients admitted for DSP to 3 hospitals in Eastern Norway between January 2006 and March 2007. Data on patients' prescriptions prior to admission were retrieved from the Norwegian Prescription Database (22.5 months of observation time). The primary outcome measure was type and amount of drugs ingested in the DSP episode. RESULTS: DSP patients had a much greater prescribed medication load compared to the general population, with a mean of 30 prescriptions collected in the year prior to DSP. In total, 77.2% of patients ingested drugs that they had collected, whereas 25% of patients used drugs collected the week prior to admission. The tendency to ingest collected drugs increased with age (OR = 1.1, 95% CI = 1.01 to 1.11, P = .01). Patients who collected sedatives were more likely to use these for self-poisoning than patients who collected antidepressants. CONCLUSIONS: The much greater medication load of DSP patients is particularly important given their tendency to ingest their prescribed medication in self-poisoning episodes. The study indicates that timing of collection of medication prior to an episode is less important than general medication load. More attention should be directed to the total medication load for individuals at risk of self-harm.