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Abstract
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The COVID-19 pandemic and its effects on mental health continue to preoccupy researchers, clinicians, and policy makers alike. Evidence for its effects on suicidal behaviours remains relatively sparse but data suggest no increase, or even decrease, in suicide and hospital presentations for self-harm. Young people (ie, those 18 years and younger) have been a particular concern, with some evidence that children and young people's mental health deteriorated following the pandemic. Sheri Madigan and colleagues' systematic review aimed to plug an important gap in the literature by comparing paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the pandemic. What should we make of their findings? We would argue that they are not as straightforward as they seem.
The study reports "good evidence of an increase in emergency department visits for attempted suicide during the pandemic (rate ratio 1·22, 90% CI 1·08-1·37)". Is it really the case that a rate ratio indicating a possible 20% increase in risk with a lower limit for the 90% (not 95%) CI of 1·08 is good evidence? It is according to the thresholds the authors used (appendix p 8), but good evidence in these statistical terms does not necessarily equate to good evidence in real-world clinical settings or good evidence to guide policy makers. The thresholds do not appear to be linked to the quality of the studies from which the estimates were derived or the clinical meaningfulness of their findings. On the basis of the authors' own criteria, the magnitude of the changes were described as slight to small in the main text of the paper. No "predefined thresholds", either for categorising magnitude of changes or for interpreting 90% CI limits, can adequately account for the quality of the evidence on which pooled estimates are based, or the different health settings represented. Terminology in suicidal behaviour is contentious but the authors have made interpretation more challenging by examining suicide attempts and self-harm separately, finding an overall reduction for one but not the other. There is strong rationale for avoiding the dubious distinction between acts of harm with and without suicidal intent. This categorisation is highly likely to have led to the inclusion of episodes labelled as self-harm in the suicide attempt group and vice versa. For example, in our study,5
self-harm describes episodes with and without suicidal intent and those with fluctuating intent.
Language: en |