Development and psychometric properties of the “Suicidality: Treatment Occurring in Paediatrics (STOP) Risk and Resilience Factors Scales” in adolescents

Suicidality in the child and adolescent population is a major public health concern. There is, however, a lack of developmentally sensitive valid and reliable instruments that can capture data on risk, and clinical and psychosocial mediators of suicidality in young people. In this study, we aimed to develop and assess the validity of instruments evaluating the psychosocial risk and protective factors for suicidal behaviours in the adolescent population. In Phase 1, based on a systematic literature review of suicidality, focus groups, and expert panel advice, the risk factors and protective factors (resilience factors) were identified and the adolescent, parent, and clinician versions of the STOP-Suicidality Risk Factors Scale (STOP-SRiFS) and the Resilience Factors Scale (STOP-SReFS) were developed. Phase 2 involved instrument validation and comprised of two samples (Sample 1 and 2). Sample 1 consisted of 87 adolescents, their parents/carers, and clinicians from the various participating centres, and Sample 2 consisted of three sub-samples: adolescents (n = 259) who completed STOP-SRiFS and/or the STOP-SReFS scales, parents (n = 213) who completed one or both of the scales, and the clinicians who completed the scales (n = 254). The STOP-SRiFS demonstrated a good construct validity—the Cronbach Alpha for the adolescent (α = 0.864), parent (α = 0.842), and clinician (α = 0.722) versions of the scale. Test–retest reliability, inter-rater reliability, and content validity were good for all three versions of the STOP-SRiFS. The sub-scales generated using Exploratory Factor Analysis (EFA) were the (1) anxiety and depression risk, (2) substance misuse risk, (3) interpersonal risk, (4) chronic risk, and (5) risk due to life events. For the STOP-SRiFS, statistically significant correlations were found between the Columbia-Suicide Severity Rating Scale (C-SSRS) total score and the adolescent, parent, and clinical versions of the STOP-SRiFS sub-scale scores. The STOP-SRiFS showed good psychometric properties. This study demonstrated a good construct validity for the STOP-SReFS—the Cronbach Alpha for the three versions were good (adolescent: α = 0.775; parent: α = 0.808; α = clinician: 0.808). EFA for the adolescent version of the STOP-SReFS, which consists of 9 resilience factors domains, generated two factors (1) interpersonal resilience and (2) cognitive resilience. The STOP-SReFS Cognitive Resilience sub-scale for the adolescent was negatively correlated (r = − 0.275) with the C-SSRS total score, showing that there was lower suicidality in those with greater Cognitive Resilience. The STOP-SReFS Interpersonal resilience sub-scale correlations were all negative, but none of them were significantly different to the C-SSRS total scores for either the adolescent, parent, or clinician versions of the scales. This is not surprising, because the items in this sub-scale capture a much larger time-scale, compared to the C-SSRS rating period. The STOP-SReFS showed good psychometric properties. The STOP-SRiFS and STOP-SReFS are instruments that can be used in future studies about suicidality in children and adolescents

Development and psychometric properties of the “Suicidality:Treatment Occurring in Paediatrics (STOP) Risk and Resilience Factors Scales” in adolescents

Suicidality in the child and adolescent population is a major public health concern. There is, however, a lack of developmentally sensitive valid and reliable instruments that can capture data on risk, and clinical and psychosocial mediators of suicidality in young people. In this study, we aimed to develop and assess the validity of instruments evaluating the psychosocial risk and protective factors for suicidal behaviours in the adolescent population. In Phase 1, based on a systematic literature review of suicidality, focus groups, and expert panel advice, the risk factors and protective factors (resilience factors) were identified and the adolescent, parent, and clinician versions of the STOP-Suicidality Risk Factors Scale (STOP-SRiFS) and the Resilience Factors Scale (STOP-SReFS) were developed. Phase 2 involved instrument validation and comprised of two samples (Sample 1 and 2). Sample 1 consisted of 87 adolescents, their parents/carers, and clinicians from the various participating centres, and Sample 2 consisted of three sub-samples: adolescents (n = 259) who completed STOP-SRiFS and/or the STOP-SReFS scales, parents (n = 213) who completed one or both of the scales, and the clinicians who completed the scales (n = 254). The STOP-SRiFS demonstrated a good construct validity—the Cronbach Alpha for the adolescent (α = 0.864), parent (α = 0.842), and clinician (α = 0.722) versions of the scale. Test–retest reliability, inter-rater reliability, and content validity were good for all three versions of the STOP-SRiFS. The sub-scales generated using Exploratory Factor Analysis (EFA) were the (1) anxiety and depression risk, (2) substance misuse risk, (3) interpersonal risk, (4) chronic risk, and (5) risk due to life events. For the STOP-SRiFS, statistically significant correlations were found between the Columbia-Suicide Severity Rating Scale (C-SSRS) total score and the adolescent, parent, and clinical versions of the STOP-SRiFS sub-scale scores. The STOP-SRiFS showed good psychometric properties. This study demonstrated a good construct validity for the STOP-SReFS—the Cronbach Alpha for the three versions were good (adolescent: α = 0.775; parent: α = 0.808; α = clinician: 0.808). EFA for the adolescent version of the STOP-SReFS, which consists of 9 resilience factors domains, generated two factors (1) interpersonal resilience and (2) cognitive resilience. The STOP-SReFS Cognitive Resilience sub-scale for the adolescent was negatively correlated (r = − 0.275) with the C-SSRS total score, showing that there was lower suicidality in those with greater Cognitive Resilience. The STOP-SReFS Interpersonal resilience sub-scale correlations were all negative, but none of them were significantly different to the C-SSRS total scores for either the adolescent, parent, or clinician versions of the scales. This is not surprising, because the items in this sub-scale capture a much larger time-scale, compared to the C-SSRS rating period. The STOP-SReFS showed good psychometric properties. The STOP-SRiFS and STOP-SReFS are instruments that can be used in future studies about suicidality in children and adolescents

Psychosocial risk factors for suicidality in children and adolescents

Suicidality in childhood and adolescence is of increasing concern. The aim of this paper was to review the published literature identifying key psychosocial risk factors for suicidality in the paediatric population. A systematic two-step search was carried out following the PRISMA statement guidelines, using the terms ‘suicidality, suicide, and self-harm’ combined with terms ‘infant, child, adolescent’ according to the US National Library of Medicine and the National Institutes of Health classification of ages. Forty-four studies were included in the qualitative synthesis. The review identified three main factors that appear to increase the risk of suicidality: psychological factors (depression, anxiety, previous suicide attempt, drug and alcohol use, and other comorbid psychiatric disorders); stressful life events (family problems and peer conflicts); and personality traits (such as neuroticism and impulsivity). The evidence highlights the complexity of suicidality and points towards an interaction of factors contributing to suicidal behaviour. More information is needed to understand the complex relationship between risk factors for suicidality. Prospective studies with adequate sample sizes are needed to investigate these multiple variables of risk concurrently and over time

Detecting Suicide as an Adverse Drug Reaction: Association between Suicide and Montelukast

The hypothesised association between leukotriene receptor antagonists (LTRA) and suicide is not clear. In this thesis, causality assessments of Individual Case Safety Reports (ICSRs) and a novel pharmaco-vigilance method using electronic healthcare records (EHRs) are used to examine the strength of this hypothesis. This thesis is also the first to describe the application of the self-controlled case series (SCCS) methodology to the study of suicide and LTRA using UK primary care data. There are 5 components: 1) an initial screening of VigiBase, a global database of ICSRs for drugs associated with suicide; 2) a review of the literature for evidence of an association of suicide with montelukast; 3) an assessment of the strength of this association using causality assessments of ICSRs, and an overall causality assessment using multiple data sources in accordance to the Bradford Hill guidelines of causality; 4) Temporal-Pattern Discovery (TPD), a novel data-mining method, was applied to UK EHRs to complement signal detection; 5) an observational study using an SCCS methodology was used to examine whether LTRAs are associated with an increased risk of suicide attempts. We found montelukast to be amongst medication with the most number of global ICSRs for suicide-related adverse events in young people aged 2-17. However, causality assessment of ICSRs revealed that reports were often incomplete and did not strengthen this hypothesis. Also, complementary signal detection using the TPD method in EHRs did not detect a signal. Finally, the SCCS study using EHRs from a UK primary care database did not provide evidence to support the hypothesis; on the contrary we found the risk of suicide attempts decreased after cessation of a course of LTRAs in females (IRR=0.46 95%CI 0.22, 0.96). In conclusion, there is little evidence to support an association between suicide and montelukast, however this link cannot be excluded

Leukotriene receptor antagonists and suicide: a self-controlled case series study

Oral Presentation - Paediatrics – Mental and General HealthConference Theme: Applying pharmacoepidemiology to improve health care in AsiaAim/Objective: In March 2008 the suicide of a 15 year old boy captured media attention. The suicide was attributed to the exposure of montelukast, a leukotriene receptor antagonist (LTRA) used to treat asthma and allergies. The presence of, unknown and unmeasured confounders are limitations in observational studies, particularly in the study of suicide which has several risk factors. The self-controlled case series (SCCS) method automatically controls for fi xed confounders. Objectives: To investigate the association of suicide and LTRAs using the SCCS method in the UK. Method: Electronic healthcare records of patients with a record of suicide attempt (including suicide and self -harm, poisoning-selfinfl icted, injury–self infl icted, cause of overdose-deliberate) and exposure to LTRAs during the period of 1st January 1998 to 1st January 2011 were extracted from the Health Improvement Network (THIN) database of anonymised records from contributing UK general practices. A risk period of thirty days before and after exposure to LTRA and control periods within the observation time of each patient were identifi ed. A Poisson analysis conditioned on the event was used to calculate the Incidence Rate Ratio (IRR). Results: A total of 236 cases of fi rst attempts of suicide were identifi ed. The IRR for a risk period of 30 days after the start of treatment with LTRA was 0.32 (95% CI 0.04-2.42; P=0.268). Conclusion: Our study does not support the association between the use of LTRA and suicide attempts within the fi rst thirty days of exposure to LTRA. Further studies with larger number of cases are needed

Asthma and suicide-related adverse events: a review of observational studies

Suicide is a major public health concern. There are several risk factors associated with suicide. Chronic illnesses, such as asthma, have been linked to an increased risk of suicide-related events. This study reviews the evidence of an association between asthma and suicide using published epidemiological observational studies. An electronic search using PubMed and EMBASE was performed. Studies that investigated the association of asthma with suicide-related behaviour were selected. Studies were examined to form a descriptive analysis. Six observational studies met the selection criteria, of which at least one suicide-related adverse event was studied. Three studies investigated completed suicide, two suicide attempts and four suicide ideation. Two of the studies focused on individuals aged <18 yrs. Evidence from observational data support the hypothesis of an association between asthma and suicide-related behaviour (ideation, attempts and completion); however, epidemiological studies, with more objective measures and larger sample sizes, adjusting for a wider scope of suicide-related confounding factors (e.g. comorbidities), and with a longitudinal design, are needed for a more conclusive answer

Asthma and suicide-related adverse events: A review of observational studies

Suicide is a major public health concern. There are several risk factors associated with suicide. Chronic illnesses, such as asthma, have been linked to an increased risk of suiciderelated events. This study reviews the evidence of an association between asthma and suicide using published epidemiological observational studies. An electronic search using PubMed and EMBASE was performed. Studies that investigated the association of asthma with suicide-related behaviour were selected. Studies were examined to form a descriptive analysis. Six observational studies met the selection criteria, of which at least one suicide-related adverse event was studied. Three studies investigated completed suicide, two suicide attempts and four suicide ideation. Two of the studies focused on individuals aged <18 yrs. Evidence from observational data support the hypothesis of an association between asthma and suicide-related behaviour (ideation, attempts and completion); however, epidemiological studies, with more objective measures and larger sample sizes, adjusting for a wider scope of suicide-related confounding factors (e.g. comorbidities), and with a longitudinal design, are needed for a more conclusive answer. © ERS 2011.link_to_subscribed_fulltex

Increased prescribing of psychotropic drugs to children and adolescents in the UK

Contributed Papers Session 5: Watch out for Minor Issues! - Use and Safety of Drugs in pediatric populations: no. 18-003The 6th Asian Confernece on Pharmacoepidemiology (ACPE) and 2011 Annual Meeting of the Committee of Pharmacoepidemiology of Chinese Pharmaceutical Association (AMCP-CPA), Beijing, China, 28-30 October 2011

Montelukast and Suicide: Causality Assessment Using Spontaneous Reports and Bradford Hill Guidelines

Contributed Papers Session 1: Treat with Caution! - Use and Safety of Drugs in special populations: no. 09-005The 6th Asian Confernece on Pharmacoepidemiology (ACPE) and 2011 Annual Meeting of the Committee of Pharmacoepidemiology of Chinese Pharmaceutical Association (AMCP-CPA), Beijing, China, 28-30 October 2011