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In Quebec, suicide is currently the second cause of death among youths aged 10 to 19 years, exceeded only by motor vehicle accidents (1). Some groups demonstrate a higher risk of suicide: young people receiving services at YCs (in Quebec, a single type of government agency with 16 regional branches is mandated by law to provide social services, foster care, rehabilitation programs, and juvenile detention to troubled youths) (2), youths with a family history of suicide (3), and young Aboriginals (4–6). A committee that included the Quebec College of Physicians, the Association of Quebec Youth Centres, and the Quebec government ombudsman reported that at least one-third of the adolescents who committed suicide had previously received YC services. Those who were still receiving or had received YC services had a 5.5 times greater risk of suicide than youths in the general population (2). In 2000–2001, the population aged 18 years and under in Quebec was estimated to number around 1 700 000; approximately 5.3% had received some type of social services (7). Services are given under 3 laws: the Youth Protection Act (www.canlii.org/qc/laws/sta/p-34.1/20050616/whole.html), which addresses youths referred to YC services as a result of parental neglect, behavioural problems, or similar issues; the Act Respecting Health Services and Social Services (www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/ telecharge.php?type=2&file=/S_4_2/S4_2_A.html); and the Young Offenders Act (http://laws.justice.gc.ca/en/Y-1/), related to delinquent behaviours. Youth receiving YC services are mainly followed up in their families by their social workers but may be placed in foster care, residential settings, or rehabilitation resource centres, depending on their status. Between 40% and 52% of the teenagers receiving YC services showed at least one psychiatric disorder, including alcohol consumption (87.7%) and drug consumption (78.4%) (8). Three studies found a high proportion (27.8% to 64.4%) of youths in YCs showing serious suicidal behaviours (9–11). It is also indicated that suicide attempt rates were 4 to 10 times higher in YC services than in the general population (9–12). Five US studies of juvenile delinquents reported lifetime suicidal ideation or attempt rates ranging from 12.4% to 61.0% (13–17). While these findings support the hypothesis of high levels of suicide attempts and suicidal ideation in YC users, nothing has, to our knowledge, been published on completed suicide in that population. However, it is known that about 90% of youths in the general population who died by suicide suffered from one or more psychiatric disorders (18–21). Further, adolescents with disruptive disorders (who constitute the major proportion of youths in YC services) were found to be at risk for completed suicide when comorbid substance abuse and past history of suicide attempt were present (22). This paper outlines characteristics of a sample of adolescent suicides in YC services. MethodUsing a case–control design, we studied demographic and clinical data from individuals aged 12 to 18 years who died by suicide in Quebec between January 1, 1995, and April 23, 2000. Systematic examination of coroner’s office and YC services electronic databases revealed 422 suicides; of these, 143 youths had received YC services. From that subsample, 53 YC files were available, other files having been cleared according to the YC archival regulations. Subjects were matched for sex, age, and geographic area with living control subjects who had also received YC services. We use a randomized procedure to identify the file of the corresponding subject receiving services at the time of death of the index case. Five categories were defined: interval between YC service and suicide; clinical features of the suicide; information relative to past history of suicidal ideation or attempts; indicators of psychopathology; and adverse events. The first author used a coding grid to collect data obtained from a thorough search of coroner’s office and YC files. We considered significant comparisons and set a probability of type I error lower than 5%. Ethics approval for this study was provided by the local IRB. ResultsThe 53 suicide cases who had active YC files comprised 42 boys and 11 girls (ratio of 3.8:1), which is similar to the general population ratio of youth aged 10 to 19 years (3.6:1) (1). The mean age was 16.8 years (girls 16.98 years, SD 1.4; boys 15.96 years, SD 1.9). This sample was representative of the 143 YC subjects who died by suicide, in terms of age (mean 16.6 years, SD 1.53; F1,95 = 0.21, P = 0.65) and sex distribution (Fisher’s P = 0.71) (Figure 1). Of the group, 52.8% (28/53) were receiving services at the time of their death; 20% had received services in the past 6 months, while 91.1% had received those services in the past 12 months (Table 1). Most suicides took place at home (Table 2). The main methods were by hanging (73.6%) and by firearms (18.9%). Of the cases, 88.7% (47/53) had been screened for alcohol and drugs by the coroner’s office: 46.8% (22/47) had used alcohol and drugs immediately prior to death, with alcohol and drugs achieving toxic levels in 31.9% (15/47). In the group who died by suicide in YC resources rather than at home, 3 were intoxicated.
Our analyses revealed 2 control subgroups: we found files containing references to a history of suicidal ideation or attempts, and we found other files that contained no such references. The suicide group, compared with the control group having no indication of suicidal ideation or attempts, showed more characteristics of mental disorders: indicators of major depression were present in 44.0% and 1.2%, respectively (Fisher’s P = 0.001), and use of hard drugs was mentioned in 41.4% and 14.3 %, respectively (Fisher’s P = 0.02). Evidence of conduct disorder was high in all groups, but in the suicide group, there were more indicators of aggression toward people or animals (48.8%, compared with 22.3%; c2 = 9.74, df 1; P < 0.01), threats and intimidation (50.0%, compared with 27.7%; c2= 10.84, df 1; P < 0.01), and running away at least twice (35.0%, compared with 12.8%; c2= 11.30, df 1; P < 0.01). A previous suicide attempt was found in 53.6% of the suicide group but only in 4.0% of the control group. Among suicides, compared with the control group, we found more placements (3.10, compared with 1.53; F = 13.10, df 1; P < 0.001), more relational conflict and affective loss (76.5.0,% compared with 53.5%; c2= 5.80, df 1; P < 0.05), and more disciplinary measures applied by the YC (41.1%, compared with 16.5%; c2= 9.05, df 1; P < 0.01). ConclusionWe found that 33.9% of youths who completed suicide in Quebec had received YC services. Those suicides had been almost entirely committed at the time of or in the year following the services. About one-half of the youths had used alcohol or drugs prior to death, and almost one-third were considered to be intoxicated at the time of suicide. Indicators of depression and conduct disorders, as well as adverse events, were more frequent, compared with the control group; more than one-half had already shown a previous suicide attempt. These findings are consistent with a US sample of youths in foster care that showed 37% to have a current psychiatric disorder and 61% to have a lifetime psychiatric disorder (23). In that study, substance use was linked with suicidal behaviour by its effect of increasing stress and exacerbating cooccurring psychopathology, especially among impulsive adolescents, a finding which is also congruent with our results (24). This study is based on retrospective assessments of files, a method that has methodological limitations. A psychological autopsy study would have been a more accurate method. However, our results suggest that suicide and psychopathology are rather high in the YC population. Some might argue that suicide is not always preventable, others that some situations might have not been managed optimally. We think that interventions to be promoted should focus on screening at the initial contact with YC services; such screening should include a specific assessment for prior suicide attempts and psychiatric disorders. Implementation of a medical multidisciplinary team should be coordinated with psychiatry and psychoeducational services. Increased attention should be given to the period surrounding discharge from the YC: transition to independence is a difficult time for youth, especially for those leaving the out-of-home care system (25,26). Moreover, detailed case studies (for example, in collaboration with the coroner’s office) might also help guide us to better interventions for suicidal youths. Funding and SupportThis study was funded by the Direction de la planification stratégique et de l’évaluation du Ministre de la Santé et des Services sociaux du Québec, the Desjardins Sécurité Financière, and l’Association des Centres Jeunesse du Québec. Dr Renaud is currently a Canadian Institutes of Health Research Young Investigator. References1. Institut de la statistique du Québec. Décès et taux de mortalité selon la cause, le sexe et le groupe d’âge au Québec en 2002; 22 juillet 2004. Available: www.stat.gouv.qc.ca. Accessed 2005 July 20. 2. Farand L, Chagnon F, Renaud J. Completed suicides among Quebec adolescents involved with juvenile justice and child welfare services. Suicide Life Threat Behav 2004;34(1):24–35. 3. Brent D. Risk factors for adolescent suicide and suicidal behavior: mental and substance abuse disorders, family environmental factors and life stress. Suicide Life Threat Behav 1995;25:52–63. 4. Kirmayer LJ, Fletcher C, Boothroyd LJ. Suicide among the Inuit of Canada. In: Leenars A, Wenckstem I, Sakinofsky I, Dyck RJ, Kral MJ, Blanc RC, editors. Suicide in Canada. Toronto (ON): University of Toronto Press; 1997. p 189–211. 5. Boothroyd LJ, Kirmayer LJ, Spreng S, Malus M, Hodgins S. Completed suicides among the Inuit of northern Quebec, 1982–1996: a case–control study. CMAJ 2001;165:749–55. 6. Royal Commission on Aboriginal Peoples. Choosing life: special report on suicide among Aboriginal people. Ottawa (ON): Supply and Services; 1995. 7. Association des centres jeunesse du Québec. Le monde des centres jeunesse : au service de plus de 100,000 jeunes et leur famille : des gens de coeur et de valeur, du 18 au 24 novembre 2002 : cahier de presse. Montreal (QC): L’Association; 2002. 8. Pauzé R, Toupin J, Dery M, Mercier H. Les soins aux jeunes en difficulté, volet I. Portrait des jeunes inscrits B la prise en charge des centres jeunesse du Québec et description des services reçus au cours des premiers mois. Rapport de recherche. Groupe de recherche sur l’inadaptation sociale de l’enfance (GRISE), Sherbrooke (QC): Université de Sherbrooke; 2000. 9. Desrosiers M, Coderre R, Bastien MF, Hamel S. 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DSM-III-R Axes I and II diagnoses in suicides among 13- to 19-year-olds in Finland. Arch Gen Psychiatry 1991;48:834–9. 21. Shafii N, Carrigan S, Whittinghill JR, Derrick A. Psychological autopsy of completed suicide in children and adolescents. Am J Psychiatry 1985;142:1061–4. 22. Renaud J, Brent DA, Birmaher B, Chiapetta L, Bridge J. Suicide in adolescents with disruptive disorders. J Am Acad Child Adolesc Psychiatry 1999;38:846–51. 23. McMillen JC, Scott LD, Zima BT, Ollie MT, Munson MR, Spitznagel E. Use of mental health services among older youths in foster care. Psychiatr Serv 2004;55:811–7. 24. Esposito-Smythers C, Spirito A. Adolescent substance use and suicidal behavior: a review with implications for treatment research. Alcohol Clin Exp Res 2004;28(5 Suppl):77S–88S. 25. Courtney ME, Piliavin I, Grogan-Kaylor A, Nesmith A. Foster youth transitions to adulthood: a longitudinal view of youth leaving care. Child Welfare 2001;80:685–717. 26. Courtney ME, Barth RP. Pathways of older adolescents out of foster care: implications for independent living services. Soc Work 1996;41(1):75–83. Author(s)Manuscript received October 2004, revised, and accepted February 2005. 1. Assistant Professor, Université de Montréal, Montreal, Quebec; CIHR Young Investigator, Montreal, Quebec. 2. Assistant Professor, Université du Québec B Montréal, Montreal, Quebec. 3. Assistant Professor, McGill University, Montreal, Quebec; CIHR Investigator, Montreal, Quebec. 4. Assistant Professor, Université de Montréal, Montreal, Quebec. Address for correspondence: Dr J Renaud, CHU mère-enfant Sainte-Justine, 3175 Côte Sainte-Catherine, Montréal, QC H3T 1C5 e-mail: johanne_renaud@SSSS.gouv.qc.ca
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