Clinical Context

Rates of depressive symptoms among children and adolescents have increased during the COVID-19 pandemic, but the pandemic may have only accelerated a previous trend toward higher rates of depression among young people. Boers and colleagues evaluated how the use of social media and other screen time could be contributing to this problem, and their study results were published in the September 2019 issue of JAMA Pediatrics.^[1]

Researchers performed a secondary analysis of a randomized clinical trial of interventions focused on the prevention of drug and alcohol use among 3826 adolescents. In both between-person and within-person analyses during the 4-year study period, each additional hour of social media use was associated with a significant increase in depression symptoms. This result was statistically significant and was mirrored in a within-person analysis of television viewing. The study analysis suggested that there was a causative effect of social media and television use and depression symptoms, as opposed to an effect of screen time eliminating time for healthy behaviors such as exercise.

Although multiple studies have tracked trends in depression symptoms among children and adolescents, there is less research on the issue of suicidality in this group. The current study addresses this question.

Study Synopsis and Perspective

Suicide attempts spurring calls to poison control centers more than quadrupled among US children aged 10 to 12 years from 2000 to 2020, according to research published online March 14 in JAMA Pediatrics.^[2]

For all children older than 9 years, the proportion of suicide attempts increased as misuse or abuse of potentially poisonous substances declined. Only very young children (aged 6-9 years) saw no increase in suicide attempts, the study found.

"It's a huge problem we're seeing in emergency departments [EDs]. It's exponentially blowing up numbers across the nation," said David Sheridan, MD, an ED pediatric physician at the Oregon Health and Science University, in Portland, who led the study.

Adolescents or preteenagers who have attempted suicide can sit in EDs "for days or weeks" as they wait to be placed elsewhere in the hospital or an outpatient facility, Dr Sheridan told Medscape Medical News. The delays not only are unpleasant for the children, he said, but they also strain hospitals by leaving less space available for emergency care.

"It's really tough on the entire healthcare system, and most importantly, it's really rough on the families who are going through a crisis," Dr Sheridan said. He noted that young people often attempt suicide by taking excessive quantities of common over-the-counter products found in many medicine cabinets (acetaminophen, ibuprofen, diphenhydramine), not items marked "poison."

The researchers examined calls from 2000 to 2020 recorded in the National Poison Data System, which is maintained by the American Association of Poison Control Centers. Of more than 1.2 million total calls, 854,000 involved girls. A poison control data analyst determined whether the call involved attempted suicide or deliberate misuse/abuse of a potentially poisonous substance.

The researchers identified 1005 deaths, and nearly 29% of ingestions led to health outcomes that were considered worse than minor.

During the 20-year period, more than 90% of the calls involved children aged at least 13 years, with approximately 72,000 (5.7%) pertaining to children aged 10 to 12 years. Most calls for children aged 13 years and older were for suicide attempts. Suspected suicide attempts accounted for about 50% of the total calls to poison control centers among children aged 10 to 12 years in 2000, a figure that had ballooned to 80% by 2020, according to the researchers.

Dr Sheridan said that because both the frequency and the proportion of calls related to suicide attempts rose among children aged 10 to 12 years, by 2020, poison control centers were fielding 4.5 times as many suicide-related calls among persons of this age group as they had in 2000. This jump was the largest such increase for any age group in the study, he noted.

The reasons for such a large rise among preadolescents are unclear, the researchers note. The increase became apparent around 2013, at the time many popular social networks launched. Dr Sheridan's group cited studies showing an association between increased time on social networks or watching television and depression in adolescence, but said that further research is needed to understand the root causes of this increase.

The latest study did not specifically look at the effect of the COVID-19 pandemic on suicide among young people. The Centers for Disease Control and Prevention reported a sharp rise in suicide attempts among youth during the early months of the pandemic, especially among girls aged 12 to 17 years.^[3] By February 2021 suicide attempts within this group had climbed by 50.6% compared with 2 years earlier.

Although suicide attempts are concerning enough, successful attempts are even more worrisome, experts said. "The increase in the rate of suicidal ingestion among 10- to 12-year-olds vs 13- to 18-year-olds is consistent with youth suicide mortality trends between 2010 and 2020," Jeff Bridge, PhD, an epidemiologist at Nationwide Children's Hospital, Columbus, Ohio, told Medscape Medical News. From 2010 to 2020, suicide rates increased by 50% among 13- to 18-year-olds, Dr Bridge said, and more than doubled in children aged 10 to 12 years.

The latest study captured only calls to poison control centers and so did not count suicide attempts that did not result in a call for help. Another limitation is that poison control data are not stratified by race or ethnicity, prompting Bridge to urge researchers to look specifically at the effect of race and ethnicity on these trends.

"This study supports screening for suicide risk as young as 10 years old," Dr Bridge, who recently coauthored an article about improving suicide screening among pediatric primary care physicians, told Medscape Medical News.^[4]

Dr Sheridan said he agreed that prevention is essential: "The ER is where kids come when they're in crisis. Trying to be more preventative by diagnosing or picking up on this earlier, I think, is really important."

Sheridan and Bridges have disclosed no relevant financial relationships.

JAMA Pediatrics. Published online March 14, 2022.

Clinical Implications

• In a previous study, the use of social media and watching television were both associated with higher rates of depression symptoms among adolescents. The study analysis suggested that there was a causative effect of social media and television use and depression symptoms, as opposed to an effect of screen time eliminating time for healthy behaviors such as exercise.
• In the current study, the rate of suicidal ingestions increased among children and adolescents between 2000 and 2020, led by a strong increase among children between 10 and 12 years of age.
• Implications for the healthcare team: The healthcare team should monitor for symptoms of depression and suicidality among preadolescents since the number of suicidal ingestions among children and adolescents is underestimated, study data between 2000 and 2020 found that many cases are not reported to the National Poison Data System.

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