The association of exposure to suicide-related Internet content and emergency department visits in children: A population-based time series analysis.
To date however, no study has explored the association between suicide-related Internet content (defined as any web page or video depicting self-injury or self-harm (16)) on YouTube and ED visits for suicide-related diagnoses in children. Emergency physicians are often the initial providers of care for suicidal children, and it is hoped that the results of this study will inform resource allocation in this setting.
On September 7, 2012, Amanda Todd, a 15-year old Canadian, posted a nine-minute YouTube video entitled "My Story: Struggling, bullying, suicide and self-harm", which depicted a series of flashcards telling of her experiences being bullied. (17) The video post received enormous publicity after her suicide on October 10, 2012, receiving over 1 600 000 views in three days, (18) with news websites around the world providing a link to it. Given the purported links between the Internet and suicidal behaviour and the rise in suicide-related ED visits, our research question was: Among Ontario children age 11-17 years, was the release of Amanda Todd's YouTube video associated with an increase in average monthly ED visit rates for suicide-related diagnoses? Evidence supporting the Internet's role in suicide contagion may enable mental health clinicians to provide anticipatory guidance to children at risk of suicide. We hypothesized that the sudden surge in views of Amanda Todd's video was associated with an increase in average monthly ED visits for the composite outcome of SI, intentional self-poisoning and intentional self-harm in children.
We conducted a population-based, time-series analysis using the National Ambulatory Care Reporting System (NACRS) database from the Canadian Institute for Health Information (CIHI) during the period from April 2002 to December 2013. NACRS involves a standard data collection and reporting tool to capture data for ambulatory care visits, including EDs. A time series analysis is a statistical method for analyzing data that is accrued in time order that accounts for an internal structure such as seasonal variation. Using aggregate data, we identified all patients age 11-17 years who presented to Ontario EDs using International Classification of Disease and Health Related Problems, Tenth Revision, Canada (ICD-10-CA) codes for suicidal ideation (R45.851), intentional self-poisoning (X60-X69) and intentional self-harm (X70-X84). These discharge diagnoses were used previously to explore the impact of media coverage on adolescent suicidal behaviour (4, 19, 20) and were chosen because we felt they comprehensively encompassed the range of suicide-related behaviour. Self-harm encompasses suicidal attempts (20) and is a major risk factor for suicide. (19) Individuals in the NACRS database could only have one diagnostic code assigned and we excluded repeat visits by the same individual over the study period to avoid inflating point estimates. The age range was chosen to reflect the demographic with the highest risk of suicidal behaviour. (1) The study was approved by Western University's Health Sciences Research Ethics Board.
Exposure of interest
The exposure of interest was October 2012, the month that Amanda Todd's suicide was announced, as this coincided with the widespread viewing of her YouTube video in the three days that followed. To our knowledge, this represented the most highly publicized adolescent suicide featured on this social medium. We acquired data for a prolonged duration of time before the event in order to procure a more valid estimate of baseline trends in ED visit rates.
Measures of suicide-related behaviour
We divided the study period into monthly intervals giving a total of 140 consecutive data points, 15 of which followed the announcement of Amanda Todd's suicide, which in turn prompted the sudden surge in views of her YouTube video. For each period, we collected the total number of ED visits, final discharge diagnosis (SI, self-poisoning and intentional self-harm), age range, year and month of presentation, death and intensive care unit (ICU) admission rates resulting from the index ED visit.
Demographic variables were summarized using absolute values and percentages. The primary outcome was an addition of the average monthly rate of ED visits for the three ICD-10-CA diagnoses and expressed as the number of visits per 10 000 total ED visits as a single composite variable. Secondary outcomes were the number of ICU admissions and deaths resulting from the ED visit and the overall change in ED visit rates for the entire study period. We limited the sample to older children given the higher prevalence of suicidal behaviour in this demographic. (2, 20) An a priori decision was made to stratify data by sex based on the higher prevalence of suicidal behaviour in females. (19, 20) We applied an interrupted time series analysis using autoregressive integrated moving-average (ARIMA) models to examine the impact of Amanda Todd's death announcement in October 2012 on the average monthly rates of ED visits for the composite outcome. The ARIMA model uses a t-ratio to test the significance of the difference between the regression model's slope before and after October 2012. We also modeled the overall trend for the composite outcome across the entire study period. We expressed the results of inferential testing using p-values. We accounted for heteroscedasticity and used correlograms depicting autocorrelation, partial autocorrelation and inverse autocorrelation functions to guide initial model selection and account for seasonality and cyclic changes. The presence of white noise was evaluated by examining the autocorrelations at various lags using the Ljung-Box chi-square statistic. Stationarity was assessed using the augmented Dickey-Fuller test. The date of Amanda Todd's suicide and surge in views of her YouTube video was reflected as a ramp function in the regression model. All p-values were two-sided and a value of <0.05 was interpreted as significant. Data were analyzed using SAS version 9.3 (Cary, NC).
Of a total of 4 775 658 ED visits over the study period, there were 36 854 visits for SI, 17 130 visits for intentional self-poisoning, and 8074 visits for intentional self-harm in children 11-17 years. Of these visits, 457 resulted in death or admission to the ICU (Table 1). There was a statistically significant increase in the overall average monthly ED visit rate for the composite outcome (p = 0.02) and death or ICU admission (p = 0.006) from April 2002 to December 2013 (Table 2).
There was no significant change in the average monthly ED visit rate for the composite outcome before and after the announcement of Amanda Todd's death in October 2012 among all children (119.8 versus 219.2 respectively, p = 0.5) (Table 3), among females (167.4 versus 316.8 respectively, p = 0.47) (Table 2; Figure 1) or among males (74.7 versus 116.9 respectively, p = 0.33) (Table 3; Figure 2). Directionally similar results were seen for all component ICD-10 CA diagnoses of SI, self-poisoning and self-harm (Table 3).
There was no significant change in the average monthly rate of ED visits leading to death and ICU stay before and after the announcement of Amanda Todd's death in October 2012 among all children, among males or among females (Table 3).
In this population-based study of ED visits across Ontario, we found that ED visit rates for SI, self-harm and self-poisoning increased among children from 2002 to 2013. However, there was no evidence that this increase was related to the release of Amanda Todd's widely viewed YouTube video that detailed the events leading up to her suicide. Our results have important implications for caregivers and mental health clinicians and provide contrary evidence to the notion that increased ED visits for suicidal behaviour in children can be attributed to suicide-related Internet content.
Although absolute increases were seen in ED visit rates for the composite outcome following the announcement of Amanda Todd's death, these differences did not reach statistical significance compared to the overall increase in ED visit rates from 2002 onwards. Our finding that ED visits for suicide-related diagnoses increased from 2002 to 2013 among older children is consistent with that described by Ting et al., who found more than a 100% increase in the number of ED visits in the US for attempted suicide and self-harm from 1993 to 2008. The largest increase was seen in adolescents age 15-19 years. (2) Canadian data from 1980 to 2008 also suggest an increase in suicide rates among female children and adolescents. (1) Multiple theories have been put forward, including an increase in treatment-seeking behaviour (21) and decreased rates of prescribing antidepressants to children following the Food and Drug Administration's (FDA) black box warning. (22) Health Canada issued a similar warning in 2004. Gibbons et al. postulated that the FDA's black box warning may have led to a decrease in the number of children diagnosed and pharmacologically treated for depression, (23) however, no studies have explored this in a Canadian population.
Our findings stood in contrast with much of the evidence supporting a link between suicide-related Internet content and self-harm behaviour. (9, 24, 25) One possible explanation is that our outcome of interest was ED visits for suicide-related behaviour, rather than passive contemplation of self-harm, as the latter may not have been captured by the clinician's final diagnosis. Suicide-related Internet use has been correlated with an increased risk of self-harm and depression. (25) Our results countermand this notion but raise the possibility that ED visits may not be a promising indicator to assess the effect of the circumstances surrounding a suicide publicized on social media on subsequent suicide behaviour. An alternative explanation is the possibility that Amanda Todd's video may have provided an opportunity for children at risk of suicide to realize that their peers face similar challenges, thereby ameliorating feelings of isolation and promoting online communication with friends and family. The latter has been associated with a decline in depressive symptoms and the resulting support network has shown beneficial effects on mental well-being. (26)
Only one study to date has explored the relationship between ED visits for mental health concerns and highly publicized suicides of two local teenagers in the media. Among children age 12-18 years, the authors found a significant increase in ED presentations for mental illness, substance misuse or abuse, and intentional self-harm, but no significant effect on suicidal status (ideation, plan, gesture or attempt) or psychiatric hospitalization rate. (4) Their findings were somewhat contradictory to ours and may be due to differences in the sampling frame. Leon et al. studied ED visits at a single Canadian academic centre within a narrow geographic region of Ontario, in contrast to our sample which included all Ontario EDs, possibly making an association easier to observe. Differences in ED visits for mental health concerns such as self-harm vary across the urban to rural spectrum (20) and higher suicide rates have been described in rural areas. (27) In addition, the two teenage victims resided in the same region as the ED under study. Local awareness and subsequent imitative behaviour may have led to increased ED visits within that geographic region. Two incidents of suicide contagion in Massachusetts (28) and New Zealand (29) support the notion that geographic proximity may play a role in suicide contagion. We did not explore suicide-related diagnoses in EDs proximate to the city in which Amanda Todd lived, primarily because we were interested in whether Internet exposure could influence children with no personal or socio-cultural affinity to her community. Near-universal access to the Internet and the vast number of views her video received suggested that the audience comprised a large proportion of individuals outside her community. Social media can also be a key resource and a powerful communication tool for understanding and psychologically supporting potentially suicidal individuals. (30) There is evidence that access to social media may exert a protective effect on adolescent well-being. The social networking site Facebook was reported to help post-secondary students at risk of suicide obtain online social support. (31) At a policy level, social media may be a feasible and effective way to educate high-risk populations with limited access to face-to-face care. A social media campaign designed to reach youth through Internet-based, social networking sites, including Facebook and Twitter, has been shown to improve adolescent attitudes towards mental health, personal stigma, and social distance up to one year following its launch. (32) Future research should explore how social media sites such as YouTube may be used as a platform to implement initiatives such as a national suicide prevention strategy, an initiative that is currently lacking in Canada. (33)
There are a number of limitations to our work. Inherent to the observational and retrospective nature of the data are threats to internal validity. We could not verify the accuracy of the discharge diagnoses and this, together with misclassification of diagnoses, may have led to under-reporting of suicide-related concerns. In contrast, although we selected ICD-10-CA codes that we assumed would comprehensively encompass suicidal behaviour, we could not verify suicidal intent. This may have led to over-reporting of suicide-related concerns. However, we believe that the large sample size and inclusion of data from across the range of urban to rural and academic and non-academic EDs enhance the generalizability of our results. We also did not collect data on completed suicides unrelated to the index visit. In addition, the use of aggregate data precluded our ability to identify other important risk factors for suicidal behaviour, such as co-morbid psychiatric illness, family history, and urban versus rural settings. Finally, similarly to Leon et al., our approach did not allow us to confirm that the patients comprising the data set were actually exposed to video and the details surrounding the highly profiled suicide of Amanda Todd on YouTube, and therefore, our results may be susceptible to ecological fallacy. By the same rationale, we could not account for other, potentially protective Internet content that may have been viewed at the same time. While it is safe to assume that most youth are highly connected to social media and possibly our exposure of interest, future work should involve a large longitudinal cohort of at-risk individuals, a valid method of documenting social media exposure, and comprehensive follow-up using validated tools to assess suicidality.
This population-based study found ED visit rates for suicide-related diagnoses increased among male and female children in Ontario age 11-17 years from 2002 to 2013. However, the increase from October 2012 to December 2013 was not associated with a highly publicized YouTube video depicting the events surrounding an adolescent suicide. Given the widespread popularity of social media among adolescents, future studies should explore whether and how these media can identify and support children at risk of suicide.
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Received: January 13, 2017
Accepted: July 1, 2017
Naveen Poonai, MD, [1-3] Shruti Mehrotra, [1, 2] Muhammad Mamdani, PhD, [4, 5] Anastasia Patmanidis, MD,  Michael Miller, PhD,  Javeed Sukhera, MD,  Quynh Doan, MDCM, MHSc, PhD 
[1.] Department of Pediatrics, Western University, London, ON
[2.] Division of Emergency Medicine, Western University, London, ON
[3.] Children's Health Research Institute, London Health Sciences Centre, London, ON
[4.] Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON
[5.] Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON
[6.] Department of Psychiatry, Western University, London, ON
[7.] Division of Emergency Medicine, Department of Pediatrics, University of British
Columbia, BC Children's Hospital, Emergency Department, Vancouver, BC
Correspondence: Dr. Naveen Poonai, Department of Pediatrics, Division of Emergency Medicine, Western University, 800 Commissioners Road East, London, ON N6A 2V5, Tel: 519-685-8500, ext. 52011, E-mail: firstname.lastname@example.org
Conflict of Interest: None to declare.
Caption: Figure 1. Average monthly initial ED visit rate for the composite outcome for females before and after October 2012 (vertical line). The solid line represents point estimates from the interrupted time-series analysis. The p value is for the trend difference in average monthly ED visit rates before and after the announcement of Amanda Todd's death in October 2012
Caption: Figure 2. Average monthly initial ED visit rate for the composite outcome for males before and after October 2012 (vertical line). The solid line represents point estimates from the interrupted time-series analysis. The p value is for the trend difference in average monthly ED visit rates before and after the announcement of Amanda Todd's death in October 2012
Table 1. Number of ED visits (% of total ED visits) by sex from April 2002 to December 2013 Composite Suicidal Intentional Intentional ideation self-poisoning self-harm Male 19 252 (0.8) 13 304 (0.5) 3599 (0.2) 2349 (0.1) Female 42 806 (1.8) 23 550 (1.0) 13 531 (0.6) 5725 (0.3) Total 62 058 (1.3) 36 854 (0.8) 17 130 (0.4) 8074 (0.2) Death or ICU Total number admission of ED visits Male 34 (0.001) 2 441 836 Female 423 (0.02) 2 333 822 Total 457 (0.01) 4 775 658 Table 2. Average monthly rate* (and number1) of ED visits for suicide-related outcomes before and after the announcement of Amanda Todd's death in October 2012 April 2002 to October 2012 to September 2012 December 2013 Primary outcomes Composite Male 74.7 (16 460) 116.9 (2792) Female 167.4 (34 876) 316.8 (7930) Total 119.8 (51 336) 219.2 (10 722) Suicidal ideation Male 50.7 (11 169) 89.4 (2135) Female 89.1 (18 555) 199.6 (4995) Total 69.3 (29 724) 145.8 (7130) Intentional self- poisoning Male 14.5 (3195) 16.9 (404) Female 33.6 (11 515) 80.5 (2016) Total 34.3 (14 710) 49.5 (2420) Intentional self-harm Male 9.5 (2096) 10.6 (253) Female 23.1 (4806) 36.7 (919) Total 16.1 (6902) 24 (1172) Secondary outcomes Death or ICU admission Male 0.2 (34) 0(0) Female 1.9 (392) 1.2 (31) Total 1 (426) 0.6 (31) Number of ED visits Male 2 203 021 238 815 Female 2 083 519 250 303 Total 4 286 540 489 118 p value ([double dagger]) Primary outcomes Composite Male 0.33 Female 0.47 Total 0.5 Suicidal ideation Male 0.28 Female 0.3 Total 0.33 Intentional self- poisoning Male 0.66 Female 0.8 Total 0.61 Intentional self-harm Male 0.75 Female 0.61 Total 0.4 Secondary outcomes Death or ICU admission Male 0.94 Female 0.9 Total 0.71 Number of ED visits Male Female Total * Average monthly rate expressed as number of ED visits for a given ICD-10 CA diagnosis per 10 000 ED visits. ([dagger]) Data in parentheses represent the total number of ED visits for a given ICD-10 CA diagnosis. ([double dagger]) p values are for the trend difference in average monthly ED visit rate before and after October 2012. Table 3. Average monthly rate * (and number ([dagger])) of ED visits for suicide-related outcomes by sex from April 2002 to December 2013 Composite Suicidal ideation Male 78.8 (19 252) (p = 0.02) 54.5 (13 304) (p = 0.009) ([double dagger]) Female 183.4 (42 806) (p = 0.02) 100.9 (23 550) (p = 0.003) Total 129.9 (62 058) (p = 0.02) 77.2 (36 854) (p = 0.003) Intentional Intentional self-harm self-poisoning Male 14.7 (3599) (p = 0.55) 9.6 (2349) (p = 0.17) Female 58 (13 531) (p = 0.66) 24.5 (5725) (p = 0.2) Total 35.9 (17 130) (p = 0.68) 16.9 (8074) (p = 0.37) Death or ICU Total number admission of ED visits Male 13.9 (34) (p = 0.008) 2 441 836 Female 1.8 (423) (p = 0.03) 2 333 822 Total 1 (457) (p = 0.006) 4 775 658 * Average monthly rate expressed as number of ED visits for a given ICD-10 CA diagnosis per 10 000 ED visits. ([dagger]) Data in parentheses represent the total number of ED visits for a given ICD-10 CA diagnosis. ([double dagger]) p values are for the overall trend in average monthly ED visit rates from April 2002 to December 2013.
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|Title Annotation:||QUANTITATIVE RESEARCH|
|Author:||Poonai, Naveen; Mehrotra, Shruti; Mamdani, Muhammad; Patmanidis, Anastasia; Miller, Michael; Sukhera|
|Publication:||Canadian Journal of Public Health|
|Date:||May 1, 2017|
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