Suicidal Ideation and Attempts Among Youth With Physical-Mental Comorbidity in Canada: Proposal for an Epidemiological Study

Background Evidence suggests that having a chronic physical illness (CPI; eg, asthma, diabetes, and epilepsy) is an independent risk factor for suicidality (ie, suicidal ideation or attempts) among youth. Less is known about the mechanisms linking CPI and suicidality. Some evidence suggests that mental illness (eg, depression and anxiety) or neurodevelopmental disorder (eg, attention-deficit/hyperactivity disorder) mediates or moderates the CPI-suicidality association. Missing from the knowledge base is information on the association between having co-occurring CPI and mental illness or neurodevelopmental disorder (MIND) on youth suicidality. Objective This study uses epidemiological data from the 2019 Canadian Health Survey of Children and Youth (CHSCY) to study the intersection of CPI, MIND, and suicidality in youth. We will estimate prevalence, identify predictors, and investigate psychosocial and service use outcomes for youth with CPI-MIND comorbidity versus other morbidity groups (ie, healthy, CPI only, and MIND only). Methods Conducted by Statistics Canada, the CHSCY collected data from 47,850 children (aged 1-17 years) and their primary caregiving parent. Measures of youth CPI, MIND, family environment, and sociodemographics are available using youth and parent informants. Information on psychiatric services use is available via parent report and linkage to national administrative health data found in the National Ambulatory Care Reporting System and the Discharge Abstract Database, which allow the investigation of hospital-based mental health services (eg, emergency department visits, hospitalizations, and length of stay in hospital). Questions about suicidality were restricted to youths aged 15-17 years (n=6950), which form our analytic sample. Weighted regression-based analyses will account for the complex survey design. Results Our study began in November 2023, funded by the American Foundation for Suicide Prevention (SRG-0-008-22). Access to the linked CHSCY microdata file was granted in May 2024. Initial examination of CHSCY data shows that approximately 20% (1390/6950) of youth have CPI, 7% (490/6950) have MIND, 7% (490/6950) seriously considered suicide in the past year, and 3% (210/6950) had attempted suicide anytime during their life. Conclusions Findings will provide estimates of suicidality among youth with CPI-MIND comorbidity, which will inform intervention planning to prevent loss of life in this vulnerable population. Modeling correlates of suicidality will advance understanding of the relative and joint effects of factors at multiple levels—information needed to target prevention efforts and services. Understanding patterns of psychiatric service use is vital to understanding access and barriers to services. This will inform whether use matches need, identifying opportunities to advise policy makers about upstream resources to prevent suicidality. Importantly, findings will provide robust baseline of information on the link between CPI-MIND comorbidity and suicidality in youth, which can be used by future studies to address questions related to the impact of the COVID-19 pandemic and associated countermeasures in this vulnerable population of youth. International Registered Report Identifier (IRRID) DERR1-10.2196/57103


Strengths
In a comprehensive study, the team aims to utilize a vast database of population-based data to investigate the relationship between suicidality in young individuals and associated mental health issues, as well as other health problems, including neurodevelopmental disorders.They also have a variety of socio-economic factors available for analysis.This is a multi-faceted issue that needs unraveling to effectively target risks and related treatments, including preventive measures.This topic, which is less explored, holds potential to inform policy interventions and healthcare service delivery, particularly for a higher risk group of young individuals with physical-MND comorbidities (PMC).The study will explore the dose-response relationship among PMC.This is a crucial area of research as the issue of suicide in young people with physical-MND comorbidities is understudied.This study will be the first to systematically investigate the associations between these factors using a substantial sample size.Unraveling the impact of physical and neurodevelopmental co-morbidities on suicide risk in youth is a significant goal of this research.

Weaknesses
This research is related to suicide ideation and behavior among individuals aged 15-17.The data comes from a cross-sectional survey, which means it captures a snapshot of the population at a particular time.However, because it's a cross-sectional study, it doesn't provide a clear timeline of when the diagnoses were made.
The study does note that all suicidal ideation and behavior occurred within the last 12 months, which could be seen as a limitation.It might be challenging to fully understand the precursor history or the progression of suicidal ideation and behavior over time due to this limitation.

Strengths
The team possesses the necessary expertise in analyzing extensive public health datasets, bolstered by prior grant support and pre-existing work that scrutinizes physical and mental health within these datasets.Notably, they have previously received a grant from the American Foundation for Suicide Prevention (AFSP), indicating their successful track record in research.The principal investigator, an accomplished suicide researcher and trained biostatistician/epidemiologist, leads the team.The other members contribute their unique expertise, collectively forming a robust investigative team with a solid foundation for the successful completion of the proposed objectives.

Weaknesses
The work and funding for this project are primarily Canadian, with no additional support from other North American sources.The individual assigned as a data analyst for this work, who is being funded, possesses less experience compared to the other investigators involved in the project.

Strengths
This study utilizes a public health dataset to investigate the origins of suicidal thinking and behavior, with a particular focus on youth who have physical, mental, and developmental health issues.It delves into the intersections and individual contributions of each aspect to suicidal thoughts and behaviors.This is the first population-based study on suicidal ideation associated with Physical, Mental, and Developmental (PMC) health issues, using a representative sample of the Canadian youth population.It marks the first time this unique survey is being employed to probe into suicide risk in this specific population.The novelty of this investigation lies in its systematic examination of the specific contributions of covariates and moderators to suicide thoughts and behaviors.

Weaknesses
This research utilizes an indirect method to investigate relationships with suicide, using a dataset that was initially created for other purposes.This approach primarily demonstrates potential associations rather than providing a comprehensive understanding of cause and effect.The sample for the study is derived from population survey data of youths aged 15-17, which raises questions about the applicability of the study's findings to a wider youth population.Additionally, the analytic strategies employed are relatively basic, and while a genuinely multi-predictor model approach might have been constrained by the low rates, innovative approaches have been suggested in the past to analyze small populations or lowrate events.However, these novel strategies are not discussed in this study.

Strengths
The researchers are planning to infer relationships within a large population-based dataset.They intend to use standard and suitable statistical models to answer the research questions using the available data.Their approach to utilizing the survey data is meticulous, accounting for survey weights and suggesting suitable statistical analyses.They propose to test the impact of potential risk and attenuating factors.

Weaknesses
This study focuses on 15-17-year-olds, uncovering associations but not causes.The health issues identified are based on surveys, not actual diagnoses, and may not represent all significant conditions for this age group.Key conditions like pediatric cancers are missing, potentially skewing results.The study's findings may be compromised due to the analysis of long-lasting physical and mental conditions.The presence of physical, mental, and psychosocial health conditions is likely interconnected.The use of an urban-rural dichotomy for mental health resource availability seems inappropriate.There may be confusion about the use of a multinomial logistic regression model, which should be a multilevel one.The use of count data models for counting outcomes isn't discussed.The proposed approach for Aim 5 could be misleading.There's no mention of plans to address survivor bias, a significant issue as individuals with severe comorbidities may have passed away before age 15.The statistical analysis plan is unclear about the inclusion of moderators and interactions.

Strengths
The previous usage of this dataset is already supported, with costs identified, for both obtaining and analyzing it.This dataset is set within an excellent scientific environment, which ensures a successful completion of the proposed research.

Weaknesses
No significant weaknesses identified

Budget and Period of Support
The content does not require any changes.The budget and project duration are suitable for the accomplishment of all five specific goals.However, the timeline might be overly generous considering that data availability and merging won't pose any issues, allowing many of these analyses to be completed within the first year.The budget is sufficient but somewhat atypical, as the majority of costs are for securing data access and for a part-time data analyst.The data access costs are quite substantial, as evidenced by the attached quote from Statistics Canada, which states a cost of $55,375 USD for the linkage and resulting dataset for analysis.The total project cost, including taxes, is $63,585 as stated in the letter from the organization.It's important to note that the investigators are already receiving support from their respective departments.

Strengths
This innovative proposal could offer new insights into teen suicide, impacting policy and clinical practice.The research proposal centers on understanding teen suicide tendencies, especially in those with health conditions.It aims to study the link between suicidality and physical, mental, and chronic conditions among Canadian youth.The team, database, and extensive analysis of risk factors will be crucial for this study.

Weaknesses
The study delves into the causes of suicide; however, it does not immediately contribute to prevention or treatment strategies.The omission of physical conditions and the timing of suicide behaviors may hinder causal inference, which could potentially restrict the applicability of the study's findings.Moreover, the survey nature of the study does not permit longitudinal analysis, thus limiting the ability to thoroughly investigate causal effects.