Suicidal Ideation

Addictive Screen Use Trajectories and Suicidal Behaviors, Suicidal Ideation, and Mental Health in US Youths

Author/s: 
Yunyu Xiao, PhD, Yuan Meng, PhD, Timothy T. Brown, PhD

Importance: Increasing child and adolescent use of social media, video games, and mobile phones has raised concerns about potential links to youth mental health problems. Prior research has largely focused on total screen time rather than longitudinal addictive use trajectories.

Objectives: To identify trajectories of addictive use of social media, mobile phones, and video games and to examine their associations with suicidal behaviors and ideation and mental health outcomes among youths.

Design, setting, and participants: Cohort study analyzing data from baseline through year 4 follow-up in the Adolescent Brain Cognitive Development Study (2016-2022), with population-based samples from 21 US sites.

Exposures: Addictive use of social media, mobile phones, and video games using validated child-reported measures from year 2, year 3, and year 4 follow-up surveys.

Main outcomes and measures: Suicidal behaviors and ideation assessed using child- and parent-reported information via the Kiddie Schedule for Affective Disorders and Schizophrenia. Internalizing and externalizing symptoms were assessed using the parent-reported Child Behavior Checklist.

Results: The analytic sample (n = 4285) had a mean age of 10.0 (SD, 0.6) years; 47.9% were female; and 9.9% were Black, 19.4% Hispanic, and 58.7% White. Latent class linear mixed models identified 3 addictive use trajectories for social media and mobile phones and 2 for video games. Nearly one-third of participants had an increasing addictive use trajectory for social media or mobile phones beginning at age 11 years. In adjusted models, increasing addictive use trajectories were associated with higher risks of suicide-related outcomes than low addictive use trajectories (eg, increasing addictive use of social media had a risk ratio of 2.14 [95% CI, 1.61-2.85] for suicidal behaviors). High addictive use trajectories for all screen types were associated with suicide-related outcomes (eg, high-peaking addictive use of social media had a risk ratio of 2.39 [95% CI, 1.66-3.43] for suicidal behaviors). The high video game addictive use trajectory showed the largest relative difference in internalizing symptoms (T score difference, 2.03 [95% CI, 1.45-2.61]), and the increasing social media addictive use trajectory for externalizing symptoms (T score difference, 1.05 [95% CI, 0.54-1.56]), compared with low addictive use trajectories. Total screen time at baseline was not associated with outcomes.

Conclusions and relevance: High or increasing trajectories of addictive use of social media, mobile phones, or video games were common in early adolescents. Both high and increasing addictive screen use trajectories were associated with suicidal behaviors and ideation and worse mental health.

What Parents Should Know About Gun Safety in the Home and Vehicle

Author/s: 
Rebecca J. Palmer, Leila H. DeWitt, Lindsay A. Thompson

This Patient Page describes safety measures parents can take to protect children from gun violence.

Guns are now the leading cause of death for children in the US.

Guns are even more lethal than motor vehicle crashes. The reasons for this gun violence increase in children are multiple, including a rapid rise in gun purchases, an increase in depression and anxiety in children and adolescents, and widespread stress from a global pandemic. The causes of these injuries and deaths vary by age. Younger children are more commonly injured unintentionally. Curious toddlers can find guns and fire them quickly. Older children and adolescents are more likely to be harmed by homicide or suicide.

The most important factor for children being injured or killed by guns is having a gun in the home where a child lives or the car where a child rides. Adults must make sure their guns are stored safely to prevent access by a child or adolescent. There are gun locks, safes, and other techniques to promote safer storage. As an additional safety measure, caregivers should strongly consider removing guns entirely from the home or vehicle, especially when children are older than about 11 years. These youths know how to find and access guns, even if they are stored safely. Considering the increase in mood disorders and risk of suicidal behaviors in older children and adolescents, they should not be around guns.

Parents and caregivers should follow the Be SMART framework to improve gun safety:

S: Secure all guns in your home and vehicle.

M: Model responsible behavior around guns.

A: Ask about unsecured guns in other homes.

R: Recognize the role of guns in suicide.

T: Tell others to Be SMART.

Treatment of Depression in Children and Adolescents: A Systematic Review. Comparative Effectiveness Review No. 224

Author/s: 
Viswanathan, M, Kennedy, SM, McKeeman, J, Christian, R, Coker-Schwimmer, Cook Middleton, Bann, C, Lux, L, Randolph, Forman-Hoffman, V

Background. Depressive disorders can affect long-term mental and physical health functioning among children and adolescents, including increased risk of suicide. Despite access to several nonpharmacological, pharmacological, and combined treatment options for childhood depression, clinicians contend with sparse evidence and are concerned about harms associated with treatment.

Methods. We conducted a systematic review to evaluate the efficacy, comparative effectiveness, and moderators of benefits and harms of available nonpharmacological and pharmacological treatments for children and adolescents with a confirmed diagnosis of a depressive disorder (DD)—major depressive disorder (MDD), persistent depressive disorder (previously termed dysthymia) or DD not otherwise specified. We searched five databases and other sources for evidence available from inception to May 29, 2019, dually screened the results, and analyzed eligible studies.

Results. We included in our analyses data from 60 studies (94 articles) that met our review eligibility criteria. For adolescents (study participants’ ages range from 12 to 18 years) with MDD, cognitive behavioral therapy (CBT), fluoxetine, escitalopram, and combined fluoxetine and CBT may improve depressive symptoms (1 randomized controlled trial [RCT] each, n ranges from 212 to 311); whether the magnitude of improvement is clinically significant is unclear. Among adolescents or children with MDD, CBT plus medications (8–17 years) may be associated with lower rates of relapse (1 RCT [n = 121]). In the same population (6–17 years), selective serotonin reuptake inhibitors (SSRIs) may be associated with improved response (7 RCTs [n = 1,525]; risk difference [RD], 72/1,000 [95% confidence interval (CI), 2 to 24], I2 = 9%) and functional status (5 RCTs [n = 941]; standardized mean difference, 0.16 [95% CI, 0.03 to 0.29]; I2 = 0%). For adolescents or children with any DD (7–18 years), CBT or family therapy may be associated with improvements in symptoms, response, or functional status (1 RCT each, n ranges from 64 to 99). Among children with any DD (7–12 years), family-based interpersonal therapy may be associated with improved symptoms (1 RCT, n = 38). Psychotherapy trials did not report harms. SSRIs may be associated with a higher risk of serious adverse events among adolescents or children with MDD (7–18 years; 9 RCTs [n = 2,206]; RD, 20/1,000 [95% CI, 1 to 440]; I2, 4%) and with a higher risk of withdrawal due to adverse events among adolescents with MDD (12–18 years; 4 RCTs [n = 1,296], RD, 26/1,000 [95% CI, 6 to 45]; I2, 0%). Paroxetine (1 RCT [n = 180]) may be associated with a higher risk of suicidal ideation or behaviors among adolescents with MDD (12–18 years). Evidence was insufficient to judge the risk of suicidal ideation or behavior for other SSRIs for adolescents and children with MDD or other DD (7–18 years) (10 RCTs [n = 2,368]; relative risk, 1.14 [95% CI, 0.89 to 1.45]; I2, 8%). However, this report excluded data on inpatients and those without depressive disorders, whom the Food and Drug Administration included in finding an increased risk of suicidality for all antidepressants across all indications.

Conclusion. Efficacious treatments exist for adolescents with MDD. SSRIs may be associated with increased withdrawal and serious adverse events. No evidence on harms of psychotherapy were identified.

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