Support for screening includes favorable feasibility studies,favorable attitudes by parents and adolescents toward suicide risk screening in general EDs,and the potential to identify adolescents with previously unrecognized suicide risk who are receiving no MH services.Although suicidal ideation is a well-established suicide risk factor,study findings suggest that screening questions about current suicidal ideation or a recent suicide attempt are insufficient if used as the sole triage or “go-no go” questions for determining whether or not a youth may be at risk for suicide. As seen in this study and others, not all individuals who make suicide attempts report current suicidal ideation.Furthermore, suicidal ideation is only a modest predictor of suicide attempts within clinical samples of adolescents and has failed to predict suicide attempts among adolescent males in the year following their psychiatric hospitalization.A computerized adaptive screen, which is under development in the ED-STARS study,may be more effective in identifying the full range of youth at risk for suicidal behavior. Further research is also recommended to examine the longitudinal trajectories of youth who report a past history of suicide risk only. They may represent a subgroup that denies current problems for fear of intervention, being stigmatized by self or others, or a loss of freedom if hospitalized. Our study sample was comprised entirely of adolescents who were known to be at elevated risk for suicide based on previously identified risk factors. Nevertheless,wholesale vertical grow factories the fact that 46% of the sample reported a history of multiple suicide attempts is striking.
The rate varied from a low of 34% for the HX-STB profile to a high of 71% for the S-STB+AGG profile. The overall high rate for this sample is consistent with that documented by a recent study that sampled psychiatrically hospitalized adolescents and reported a similar multiple attempt rate of 53%.It is also notable that sexual and physical abuse characterized a significant minority of adolescents who fit each of the five identified profiles, which is consistent with results from a recent meta-analysis of the association between childhood maltreatment and suicide risk.These findings suggest that, although profile characteristics varied, all youth in our sample were at elevated risk, pointing to the importance of better understanding issues of mental health service utilization. In this study, race was differentially distributed across latent classes. There were small proportions of Black adolescents in S-STB+AGG and S-STB classes, which were the classes most likely to have a history of MHSU and to present to the ED with a psychiatric chief complaint. Thus, the difference in MHSU by race parallels the difference in the distribution of latent class profiles for MHSU. The disparities in MHSU for minority groups have been well documented.It is important to understand the factors that influence clinicians’ and caregivers’ decisions on the need to use mental health care for their patients and children, and barriers to access these services. This study had multiple strengths including its large sample size; the recruitment of adolescents from pediatric EDs in PECARN, which were characterized by geographic, racial/ethnic, and economic diversity; and the broad range of risk factors available for LCA. Findings should be considered, however, within the context of study limitations. This study was conducted in the pediatric EDs of large academic health systems, which are not representative of all medical EDs, including those of smaller community hospitals. In addition, because we were assessing a broad range of risk factors and working within the time and space constraints of EDs, with a consideration of patient burden, many risk factors were assessed with brief, adapted scales.
In addition, the choices we made in limiting variables for the LCA may differ from those of other investigators, as it is possible to examine multiple iterations. Although more than half of the adolescents who screened positive for suicide risk did not present to the ED with a psychiatric chief complaint, it is possible that some of them had another chief complaint yet did receive psychiatric help. Also, if we only rely on lifetime MHSU, it is not possible to know if these services occurred before or after the STB. We also do not have information about diagnosed psychiatric disorders, which could be expected to impact MHSU. Finally, our LCA profile descriptors use simple summaries to capture multidimensional concepts and do not perfectly characterize each individual within those groups. For example, a non-negligible proportion of adolescents in the HX-STB class had multiple suicide attempts. Addressing the heterogeneity of clinical presentations among adolescents at elevated risk for suicide attempts, we identified five profiles of adolescents at risk with differing patterns of risk factors. MHSU was relatively common among adolescents characterized by the profiles with recent and severe suicidal thoughts and behavior, with or without aggression. However, MHSU was much less common among adolescents who only reported a history of suicidal thoughts and behavior, despite the fact that many of these youth had a lifetime history of multiple suicide attempts and/or other known suicide risk factors. MHSU was also lower among adolescents from racial and ethnic minority groups. In addition to implementing effective strategies for the recognition of suicide risk, this suggests the importance of facilitating treatment engagement and retention. Some of the strategies found to be helpful include the incorporation of motivational interviewing principles and attention to family stress, family coping, and broader family system issues.Care navigators and matching the race and ethnicity of clinical providers and families may also be helpful.
Finally, a recent review of 50 randomized controlled trials examining the effectiveness of treatment engagement interventions for child mental health services concluded that specific interventions can improve engagement and work across youth with varying racial and ethnic identifications, and mental health problems.In this the largest qualitative study among South Africans who smoke heroin, we found that trajectories to smoked heroin use were heavily influenced by social and structural factors. Similar to transition to injection heroin use in other settings , participants’ friends, peers, drug merchants, and others who were using and/or selling heroin figured prominently in the initiation narratives of those who started smoking heroin in this context. For example, participants’ social contacts distributed heroin to participants, glamorized its use, and/or encouraged its use . Participants seemed to exhibit a “peer preference” and assorted with like-minded peers, some of whom were already smoking heroin . The impact of social and structural factors could also be observed among participants who reported initiating heroin as a means to manage psychosocial distress. For example, “walking through the squatter camp” or otherwise being exposed to environments where people were smoking marijuana influenced these participants’ trajectories. The concept of a “risk environment” is a useful framework to evaluate HIV risk among people who inject drugs , and applied here captures the dynamic interactions between practices, places, people, beliefs,wholesale vertical grow factory and other social and structural factors surrounding the people who transitioned to smoked heroin in our study. Although prior marijuana use was ubiquitous among both participants with vertical and horizontal trajectories, social and structural influences on initiation narratives were also ubiquitous. According to the Gateway Hypothesis , smoking marijuana may have been facilitative to smoking heroin. However, rather than marijuana use is a critical stage in a sequence to smoking heroin, our findings suggest that the connection between smoking marijuana and smoking heroin may be enhanced by overlapping or shared risk environments. Both marijuana and heroin are smoked in a similar cigarette form and used or distributed by people who share the same spaces. Exposure to the social context of marijuana and heroin use, and not exposure to marijuana itself, was a critical event in the trajectory toward smoked heroin use. Altogether these data support a growing body of literature demonstrating that social and structural forces are important mediators of substance use initiation . Accordingly, describing trajectories as vertical and horizontal in this context is not meant to imply a sequence to drug use but instead to characterize different groups at risk for smoked heroin initiation. For example, several participants with horizontal trajectories reported trying heroin to alleviate the negative effects of hard drugs and heavy alcohol use. Although the use of heroin to “facilitate the descent” from crack cocaine has been described in Senegal , ours is the first report of the initiation of heroin to moderate the intoxicating effects and/or paranoia from stimulant use and as a means to stop drinking alcohol. Participants often started smoking heroin under these circumstances upon the advice of their social contacts.
Because of a high prevalence of poly substance use among heroin users throughout Africa , these types of horizontal trajectories underscore the importance of understanding knowledge and attitudes toward substance use treatment and providing access to comprehensive treatment services. Our findings are largely consistent with what has been observed in other heroin epidemics across Africa. Vertical trajectories of smoked heroin initiation have been similarly described in Tanzanian youth who are introduced to heroin-laced cigarettes . Economic pressures, rapid modernization, and parental mortality in the HIV epidemic have been implicated in disrupting family structures and leaving youth vulnerable to drug use . Limited opportunities to participate in the formal economy bring youth and adults into informal spaces where they can be exposed to drug use . In the context of stress and financial hardship, drug use may be an appealing means to cope, and drug dealing may be a means to make a living in the informal marketplace . The similarities between South Africa and Tanzania are worrisome because, if the heroin epidemic in South Africa follows the same path, South Africa may also experience a marked expansion of injection heroin use. In Tanzania, the less refined, “brown” heroin was primarily smoked in the 1980s and 1990s . From 1998–2003, a variety of factors fueled an increase in injection use: 1) the high from smoking heroin waned with repeated exposure to the drug, 2) the more refined, “white” heroin became available, and 3) the tools for injection became more widely available . The absence of a similar widespread transition in South Africa may be due to the availability of white heroin and/or the “technology” of injection drug use. In addition to monitoring substance use treatment statistics and epidemiological surveys, following inventories of heroin seizures, reviewing reports of healthcare utilization for injection-related health problem, and conducting periodic qualitative research examining pathways of initiation among heroin users could also reveal trends in injection drug use. If there is a significant shift in the number of people smoking heroin who transition to injection, HIV incidence will likely also increase. Additional surveillance can inform efforts to scale up needle and syringe programs and medication-assisted treatment with methadone or buprenorphine. Our data also suggest that smoked heroin may be subject to specific social and structural forces that inhibit initiation of injection use. Unlike in Tanzania , people initiating smoked heroin in South Africa do not appear to progress rapidly to injection drug use. In fact, smoked heroin and injection heroin use may occur in distinct risk environments. According to participants, these risk environments diverge along racial lines. Despite efforts to dismantle apartheid-related policies of racial segregation in South Africa, racial disparities persist post-apartheid . Resultant social and structural inequalities affect economic and health outcomes , and societal transitions may also influence drug use trends in communities and populations . Research comparing people who inject heroin with those who smoke heroin may provide additional insight into “ecological containment” or other aspects of the risk environment that might explain group differences in drug use . Research of this nature will also inform the development of interventions specifically to address social and structural determinants of health affecting people who smoke heroin and their communities . In the context of these differences, it is difficult to compare our findings to research on injection heroin use. For example, in Tanzania it is reported that people initiating others into injection heroin use were generally older than the initiates , but the presence of disparate age relationships between initiators and initiates of smoked heroin was not described in our narratives. Additionally, it may be difficult to apply interventions targeting injection drug use to this population. Nevertheless, similarities between to social and structural influences on initiation of smoked and injection heroin use suggest approaches to prevent injection heroin and other substance use may be relevant in this context.