Increasing numbers of youth think about ending their lives. Meanwhile, accessibility of mental healthcare is poor, with substantial waiting lists for youth with suicidal thoughts. It is unknown what the impact is of (changes in) mental healthcare policy on the number of suicide attempts and non-suicidal self-injuries in youth. The ‘PISA project’ will a) analyse the national and local policy context, b) create a research database, c) explore the temporal association between youth mental health policy and self-harm incidents, and d) develop a research agenda. 

Are you thinking about suicide? Contact 113 Suicide Prevention 24/7 free and anonymously via 0800-0113 or chat on 113.nl. 

This study aims to: 

1) provide a structured analysis of the youth mental healthcare policy context, and create a database that includes changes in governance, organization, and financing of mental healthcare, changes in clinical guidelines and interventions, changes in demographics, availability (e.g. waiting lists), the Covid-19 pandemic, and other key changes impacting youth mental healthcare since 2015. This is done with literature review and qualitative- and quantitative data collection, using document analysis and semi-structured interviews/focus groups with policymakers and healthcare professionals. Various policy and stakeholder analysis techniques, including root-cause analysis, will be used to analyse the data. 

2) create a local research database of suicide attempts and non-suicidal self-injuries in youth. This will be done in Haaglanden Medical Center, where part of the required data has already been collected in the context of a study on case management to prevent repeat self-harm incidents. The approach is to combine a clinical ‘emergency department’ database with a ‘business intelligence’ database and extend these data by manually collecting additional information from the Hospital Information System (patient files).  

3) explore trends or sudden changes in the local number of suicide attempts and non-suicidal self-injuries. This will be done by descriptive analyses, Poisson regression to determine year-on-year incidence rate ratios and the yearly trend in these, and multivariable logistic regression analysis to identify factors associated with suicide attempt risk. Independent variables will include suicide attempts and non-suicidal self-injuries, but a separate analysis will also focus on repeat attempts/incidents. Repeat events may have a stronger association with hampered access to the right type of care after the first event. 

The team combines three unique strengths needed for this study: 

• TU Delft brings expertise on complex systems analysis. As part of the ‘policy analysis’ section, Dr. Naomi van der Linden is experienced in healthcare financing and policy analysis, focusing on acute care systems.
• Erasmus University through Prof. Leona Hakkaart brings expertise on health technology assessment and mental healthcare, including research experience in youth mental healthcare.
• Haaglanden Medical Center through Dr. Christien van der Linden brings expertise on clinical epidemiology and in-depth knowledge of the data and study setting. She has been involved in suicide prevention projects since 2005.

Upcoming results 

The project is still ongoing, both the quantitative and qualitative papers are being written. The realized output is the conference abstract, a first paper that’s been submitted to BJPsych Open in March and the first illustration (see above). The visual is oriented towards future follow-up projects, which will focus on quantifying the societal value of promising suicide prevention interventions, to inform funding decisions. In the PISA study, the hospital costs of suicide attempts are captured. In the figure, a system-wide, societal perspective is recommended in economic evaluations of suicide-related interventions.