Brazilian research on child and adolescent suicide: looking at the past to plan the future

Suicide in children and adolescents is a major public health concern across low- and middle-income and high-income countries alike, with approximately 140,000 youth aged 10-24 years dying by suicide every year worldwide.¹,² Although rare in absolute numbers, suicide in children and adolescents is the second or third leading cause of death among youth aged 14-24 years in many countries, including Brazil. Furthermore, the prevalence of suicide attempt and suicidal ideation in this age range is among the highest across the lifespan. Preventing suicidal attempt and ideation is a key public health issue, as they are the most important and consistently identified risk factors for suicide. Additionally, apart from the increased likelihood of suicide, suicide attempt and ideation in youth have a profound impact on young people’s lives during a sensitive period for the establishment of adult health. For example, studies have shown that adolescents who attempt suicide are more likely to report long-term socioeconomic problems, including a higher likelihood of needing welfare assistance, dropping out from high school, and being unemployed.³

In a recent issue of the Brazilian Journal of Psychiatry, Piccin et al.⁴ examined the research output on suicide in children and adolescents in Brazil. The authors performed a systematic search of the literature indexed in PubMed/MEDLINE from the date of database inception to December 31, 2017 and identified 146 studies meeting the inclusion criteria (i.e., studies investigating self-harm or suicide-related outcomes in individuals ≤19 years old and including at least 5 Brazilian participants). The description of these studies revealed several important findings on the nature of suicide research in Brazil. First, all of the identified studies can be classified as epidemiological and observational. No other methodologies, such as intervention or neurobiological studies, have been applied to date in child and adolescent populations in Brazil. Second, only a minority of the identified studies specifically investigated suicide-related outcomes in children and adolescents. Third, despite the relevance of suicide attempt and suicidal ideation in child and adolescent-focused research, more than half of the identified studies focused on suicide mortality.

Research on child and adolescent suicide in Brazil has the potential to be of great interest for an international audience and to significantly advance our understanding of such a complex phenomenon. Indeed, despite cultural variability in suicide manifestations, most of what we know about suicide in children and adolescents comes from research conducted in high-income countries, particularly in North America and Northern Europe. A systematic summary of the current state of suicide research in children and adolescents in Brazil, a middle-income country, would therefore be useful to further advance the research effort towards understanding youth suicide. Most importantly, looking at the past allows one to better plan for the future. After systematically reviewing previous work, what direction should research on suicide in Brazil follow? We believe Brazil has much potential to contribute to the field. First, observational epidemiological research is likely to continue providing important information on the epidemiology of suicide and can lead to further advancements, e.g., by exploiting high-quality longitudinal datasets such as those in the Pelotas cohorts.⁵ Refining official statistics to offer accurate representation of suicide rates and trends over time would be a key added value to epidemiological research on pediatric suicide. Second, it is increasingly clear that neurobiological factors are strongly implicated in the etiology of suicide.² Developing this field of research, perhaps relying on existing facilities and resources available in major universities and research centers, would be an asset to advance research on the biological basis of youth suicide. Third, translating current research findings into concrete actions requires a rigorous investigation of the efficacy of population-based and clinical interventions. Most evidence for the efficacy of the available preventive interventions for suicide comes from high-income countries. Therefore, conducting trials of their efficacy in the Brazilian context is a necessary step to promote suicide prevention and to adapt interventions to the specific reality of Brazil. Finally, given the significant cultural and socioeconomic diversity of Brazilian society, a fine-grained understanding of cultural variations of suicide phenomena – including stigma, risk and protective factors, and barriers/facilitators to the implementation of preventive programs – would be highly informative for youth suicide prevention.

Just as every study, the work of Piccin et al. has some limitations. The most important one, in our view, is the absence of a narrative description of the results of included studies. Indeed, despite their systematic and rigorous literature search, the authors did not present a narrative review of the main findings and research themes. This is a missed opportunity because such a description would have been highly informative about future directions for Brazilian research in pediatric suicide. A second shortcoming is the limitation of the search to studies published in journals indexed in the MEDLINE platform. Although the authors did not restrict their search to articles published in English, widening their search to include gray literature and country-specific databases and repositories would have given a much more complete view of the research on child and adolescent suicide in Brazil. For example, works such as master’s and doctoral theses often contain rigorous investigations or pilot research in understudied communities, which are highly informative at the local level even if they are not always published in indexed journals.

In spite of these shortcomings, the work by Piccin et al. is important to remind us that, while valuable information has already been produced on youth suicide in Brazil, we still have much to learn in order to address a problem that will only become more serious as Brazil develops.

References

• ¹
  Hawton K,O’Connor RC. Self-harm in adolescence and future mental health. Lancet. 2012;379:198-9.
• ²
  Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet. 2016;387:1227-39.
• ³
  Mars B, Heron J, Crane C, Hawton K, Lewis G, Macleod J, et al. Clinical and social outcomes of adolescent self harm: population based birth cohort study. BMJ. 2014;349:g5954.
• ⁴
  Piccin J, Manfro PH, Caldieraro MA, Kieling C. The research output on child and adolescent suicide in Brazil: a systematic review of the literature. Braz J Psychiatry. 2020;42:209-13.
• ⁵
  Gonçalves H, Wehrmeister FC, Assunção MC, Tovo-Rodrigues L, Oliveira IO, Murray J, et al. Cohort profile update: the 1993 Pelotas (Brazil) birth cohort follow-up at 22 years. Int J Epidemiol. 2018;47:1389-90e.

Publication Dates

• Publication in this collection
  1 June 2020
• Date of issue
  Sep-Oct 2020

History

• Received
  10 Apr 2020
• Accepted
  14 Apr 2020