Do antidepressants reduce suicide rates?

Investigators from a number of countries have linked temporal declines in the rate of completed suicide in children and adults to the increasing utilization of selective serotonin reuptake inhibitor (SSRI) antidepressants. They suggest that the relationship is causal. We undertook a thorough literature search of the rates of completed suicide using data from 1980 onwards, from the World Health Organization, the US National Center for Health Statistics, and related studies, in order to ascertain if a broad array of epidemiological evidence would or would not support a consistent association between suicide completion and SSRI utilization. The major findings were: (1) within and between countries, suicide rates vary prominently by age group; (2) national differences are marked with respect to a temporal association between rates of completed suicide and SSRI utilization; (3) in nearly half of the countries of the world, the decline in the suicide rate preceded the onset of the use of SSRIs; (4) suicide rates have fluctuated dramatically over the last century; and (5) the association between declining rates of completed suicides and increased SSRI use in the USA between 1990 and 1999 was no longer present between 2000 and 2004. We conclude that available ecological evidence does not support an inverse temporal relationship between rates of completed suicide and SSRI utilization.

Mental health services for youths in foster care and disabled youths.

OBJECTIVES: This study assessed whether mental health services for youths differ with respect to medical assistance aid category. METHODS: Computerized claims for 15,507 youths with Medicaid insurance in a populous county of a mid-Atlantic state were used to establish population-based prevalence estimates of mental disorders and psychotherapeutic treatments during 1996. RESULTS: An analysis of service claims revealed that the prevalence of mental disorders among youths enrolled in foster care (57%) was twice that of youths receiving Supplemental Security Income (SSI; 26%) and nearly 15 times that of other youths receiving other types of aid (4%). Rates of mental health service use were pronounced among foster care youths aged 6 to 14 years. Attention deficit/hyperactivity disorder, depression, and developmental disorders were the most prevalent disorders. Stimulants, antidepressants, and anticonvulsants were the most prevalent medications. CONCLUSIONS: Youths enrolled in foster care and youths receiving SSI use far more mental health services than do youths in other aid categories. Additional research should evaluate the complexity and outcomes of mental health services for youths in foster care.

Pemoline hepatotoxicity and postmarketing surveillance.

OBJECTIVE: To review the numerous reports of hepatotoxic adverse drug reactions (ADRs) ascribed to pemoline that were sent to the U.S. Food and Drug Administration (FDA) between 1975 and 1996 and to describe the medical community's lack of awareness of these reports. METHOD: All ADR reports from 1975 through 1996 wherein pemoline was the suspect agent were obtained from the FDA MedWatch Internet site, and some details of nine pemoline-related deaths in youths were obtained directly from the FDA. The published literature on this subject was fully reviewed. RESULTS: (1) In premarketing clinical trials with pemoline in the early 1970s, hepatic abnormalities were noted in enzyme levels (1%-3% of youths receiving maintenance treatment), during rechallenges (6 of 6), and in biopsies (2 of 2). (2) Between 1975 and 1989, 12 cases of jaundice and 6 deaths in youths ascribed to pemoline hepatotoxicity were reported to the FDA. (3) The first medical literature report of a serious ADR ascribed to pemoline was in a 1989 letter to the editor. (4) Physicians generally only became aware of serious pemoline hepatotoxicity in December 1996. (5) Pemoline use increased until 1997. CONCLUSION: Limitations in postmarketing surveillance and public reporting in the United States, particularly in the 1980s, largely accounted for delays in an appropriate response to pemoline hepatotoxicity.

Services and prevention: pharmacoepidemiology of antidepressant use.

Between 1988 and 1994, data from 3 large sites revealed a 3-5 fold increase in the prevalence of antidepressant (ATD) treatment for U.S. youths aged 2-19 years. In 1994, the ATD prevalence for youths of this age ranged from 13 per 1000 (in the HMO) to 18 per 1000 (in 2 state Medicaid systems). Males predominated in the 10-14-year-olds treated with ATDs, whereas females predominated among 15-19-year-olds. Caucasians were more than twice as likely to receive ATD therapy than their African-American counterparts. Primary care providers were the major source of ATD prescriptions for youths. The leading diagnoses in primary care were ADHD followed by depression, whereas the diagnostic order was reversed for youths who received psychiatric services. This review provides details concerning these patterns and trends in ATD treatment of youths from community-based clinical data sources. In addition, the role of these data in an expanded, comprehensive psychotropic knowledge base is discussed. Finally, the implications of an expanded knowledge base for ATD treatments are discussed in regard to generating research questions on effectiveness and safety and to improve treatment consensus within a public-health perspective.

Antidepressant treatment in children and adolescents: bridging the gap between efficacy and effectiveness.

This review of antidepressant treatments in children and adolescents emphasizes the gap between efficacy data derived from randomized clinical trials (RCTs) and the limited effectiveness data from community-based practices. Part one is a brief review of data from randomized, double-blind clinical trials to assess the evidence base for the major approved indications for antidepressants in youths. Part two reviews information gaps in the evidence from RCTs. Part three discusses nonexperimental evidence of the use of antidepressants, including surveys of prescription sales, physician surveys, and population-based data. Part four presents a comprehensive model for assessing the use of antidepressants in youths in the community. The model aims to answer a range of public health-oriented questions and is intended to improve treating physicians' and clinical care providers' ability to manage medications for optimal patient benefit. Suggestions are made for engaging health service providers, health insurers, academicians, advocates, and the government in building the necessary infrastructure to make effectiveness as vital as efficacy to the model of drug therapy evaluation.

Stimulant treatment in Maryland public schools.

OBJECTIVE: A statewide school survey was performed to provide naturalistic data on the prevalence of medication administered to Maryland public school students for the treatment of attention deficit hyperactivity disorder (ADHD) to clarify the concern of some state legislators about stimulant treatment for youths. METHODS: In April 1998, school nurses supervised a survey of all Maryland public school students medicated during school hours for ADHD. The data collected on these students included: type of medication administered, gender, school level, race/ethnicity, special education and Section 504 status, and the specialist of the prescriber. RESULTS: Of the 816 465 students surveyed, 20 050 (2. 46%) received methylphenidate and 3721 (0.46%) received other medications for ADHD. Other major findings were: 1) methylphenidate constituted 84% of all the medication administered for ADHD; 2) the male:female ratio of the medication's recipients was 3.5:1 and 4.3:1 in elementary and secondary school, respectively; 3) black and Hispanic students received methylphenidate at approximately half the rate of their white counterparts; 4) 45% of all students receiving methylphenidate had special education status and an additional 8% had Section 504 status; and 5) nurse practitioners were the prescribers of 3% of the methylphenidate prescribed to Maryland students. CONCLUSIONS: This large, population-based, point prevalence study of medication administered to students for ADHD adds new and updated findings on prevalence variations, rates for minority and special education/Section 504 students, and specialty prescriber rates.

Are stimulants overprescribed for youths with ADHD?

Critics of stimulant treatment for youths with attention deficit hyperactivity disorder (ADHD) have increased their rhetoric of late, contending that the leading medication for it, Ritalin, is vastly overprescribed. Additionally, they claim that Ritalin (methylphenidate) is inherently dangerous and that the entire system of the diagnosis and treatment of ADHD is seriously flawed. The critics view the underlying reason for the "epidemic" as societal, due to our modern pace of living, our competitive society, and our consumer emphasis. Rejoinders to and clarifications of the more tangible points of the critics are presented, followed by a discussion of some more practical and legitimate concerns for researchers in this area. These concerns include changes within the ADHD category, the clinical need for multiple sources of diagnostic data, infrequent teacher-physician communication, problematic ADHD/conduct disorder comorbidity in adolescence, and the limited amount of community-based research.

Trends in the prescribing of psychotropic medications to preschoolers.

CONTEXT: Recent reports on the use of psychotropic medications for preschool-aged children with behavioral and emotional disorders warrant further examination of trends in the type and extent of drug therapy and sociodemographic correlates. OBJECTIVES: To determine the prevalence of psychotropic medication use in preschool-aged youths and to show utilization trends across a 5-year span. DESIGN: Ambulatory care prescription records from 2 state Medicaid programs and a salaried group-model health maintenance organization (HMO) were used to perform a population-based analysis of three 1-year cross-sectional data sets (for the years 1991, 1993, and 1995). SETTING AND PARTICIPANTS: From 1991 to 1995, the number of enrollees aged 2 through 4 years in a Midwestern state Medicaid (MWM) program ranged from 146,369 to 158,060; in a mid-Atlantic state Medicaid (MAM) program, from 34,842 to 54,237; and in an HMO setting in the Northwest, from 19,107 to 19,322. MAIN OUTCOME MEASURES: Total, age-specific, and gender-specific utilization prevalences per 1000 enrollees for 3 major psychotropic drug classes (stimulants, antidepressants, and neuroleptics) and 2 leading psychotherapeutic medications (methylphenidate and clonidine); rates of increased use of these drugs from 1991 to 1995, compared across the 3 sites. RESULTS: The 1995 rank order of total prevalence in preschoolers (per 1000) in the MWM program was: stimulants (12.3), 90% of which represents methylphenidate (11.1); antidepressants (3.2); clonidine (2.3); and neuroleptics (0.9). A similar rank order was observed for the MAM program, while the HMO had nearly 3 times more clonidine than antidepressant use (1.9 vs 0.7). Sizable increases in prevalence were noted between 1991 and 1995 across the 3 sites for clonidine, stimulants, and antidepressants, while neuroleptic use increased only slightly. Methylphenidate prevalence in 2- through 4-year-olds increased at each site: MWM, 3-fold; MAM, 1.7-fold; and HMO, 3.1-fold. Decreases occurred in the relative proportions of previously dominant psychotherapeutic agents in the stimulant and antidepressant classes, while increases occurred for newer, less established agents. CONCLUSIONS: In all 3 data sources, psychotropic medications prescribed for preschoolers increased dramatically between 1991 and 1995. The predominance of medications with off-label (unlabeled) indications calls for prospective community-based, multidimensional outcome studies.

Psychotherapeutic medication patterns for youths with attention-deficit/hyperactivity disorder.

OBJECTIVES: (1) To describe temporal patterns of office visits for attention-deficit/hyperactivity disorder (ADHD) and stimulant treatment for 5- to 14-year-old US youths; (2) to compare youth visits for ADHD with and without melication according to patient demographics, physician specialty, reimbursement source, and comorbid diagnoses; and (3) to compare office visits for youths with ADHD in relation to common medication patterns (stimulants alone, stimulants with other psychotherapeutic medication, and nonstimulant psychotherapeutic medications alone). DESIGN: Survey based on a national probability sample of office-based physicians in the United States. SETTING: Physician offices. PARTICIPANTS: A systematically sampled group of office-based physicians. MAIN OUTCOME MEASURES: National estimates of office visits for ADHD and psychotherapeutic drug visits for ADHD for each year and for a combined 8-year period. RESULTS: Youth visits for ADHD as a percentage of total physician visits had a 90% increase, from 1.9% in 1989 to 3.6% in 1996. Stimulant therapy within ADHD youth visits rose from 62.6% in 1989 to 76.6% in 1996. While the majority of non-ADHD youth visits were conducted by primary care physicians, one third of ADHD youth visits were managed by psychiatry and neurology specialists. Health maintenance organization insurance was the reimbursement source for 17.9% of non-ADHD youth visits but only 11.7% of ADHD youth visits. Complex medication therapy was more likely to be prescribed by psychiatrists and less likely to be related to visits with health maintenance organization reimbursement. CONCLUSIONS: National survey estimates in the 1990s confirm the substantial increase in visits for youths diagnosed as having ADHD, with more than three quarters of these visits associated with psychotherapeutic medication treatment. Physician specialty and reimbursement source variables identify distinct patient populations with a gradient in psychotherapeutic medication patterns from single-drug standard (stimulant) therapy to complex multidrug treatment regimens for which evidence-based scientific information is lacking.

Prevalence variations in psychotropic treatment of children.

This study was undertaken to clarify several aspects of the estimation of prevalence of three commonly use pediatric psychotropic agents, namely, methylphenidate, desipramine, and imipramine. The study aims are threefold: (1) to show the variability of drug prevalence by comparing estimates from three data sources; (2) to show the misleading impression that can be created by reporting drug prevalence estimates based on counts of prescriptions rather than persons; (3) to show the utility of gender-by-age-specific prevalence of drug use as a marker for diagnosis. Two data sources that yield population-based prescription estimates were available: 1991 Medicaid administrative claims data for prescriptions from a mid-Atlantic state and 1991 prescription records of the northwest region of Kaiser Permanente, a staff-model health maintenance organization (HMO). Another source of data consists of the 1991 National Ambulatory Medical Care Survey, which records medication information reported during physician office visits. Data analysis consists of quantitative estimates of (1) drug prevalence from each source; (2) the ratio of prescription claims to persons; and (3) the proportion of drug use according to age and gender. Methylphenidate and desipramine prevalence had a twofold greater use among state Medicaid enrollees compared with HMO enrollees. Average claims-to-person ratios of 5:1 suggest better accuracy using persons with medication rather than prescription counts. Gender-by-age-specific prevalence rates showed that 75% of the drug use for desipramine among those less than 15 years old was found among males, whereas 75% of the desipramine use among those 15 or older was found among females, suggesting its use for the treatment of attention deficit-hyperactivity disorder among young males and for depression among older females. The variability of community physician decision making in pediatric psychopharmacology is better understood by observing drug prevalence rates from different settings. National sampling efforts should be undertaken to verify regional and setting-specific prevalence findings and to learn the reasons for their fluctuation.

Racial disparity in psychotropic medications prescribed for youths with Medicaid insurance in Maryland.

DESIGN: A retrospective analysis was conducted using state Medicaid prescription drug reimbursement claims for youths aged 5 through 14 years according to the race of the recipients of psychotropic and medical drugs. METHOD: A person-based data set was created from Medicaid administrative data for fiscal year 1991 from the state of Maryland to yield the following: (1) estimates of prevalence of prescription recipients per 100 eligible enrollees; (2) relative prescription use ratios according to race (African-American versus Caucasian); and (3) the interrelation of race and geographic region on prescription prevalence. RESULTS: Five major findings were observed: (1) African-American youths with Medicaid insurance aged 5 through 14 were less than half (39% to 52%) as likely to have been prescribed psychotropic medications as Caucasian youths with Medicaid insurance; (2) the relative difference for nonpsychotropic medication classes was much less pronounced: African-American youths were prescribed nonpsychotropic medications at a rate 60% to 87% of the Caucasian youths' rate; (3) the stimulants (essentially methylphenidate) had the most disparate African-American/Caucasian ratio (1:2.5); (4) the racial disparity for psychotropics was not altered by partial (noncontinuous enrollment) eligibility status; and (5) although geographic variation reduced the racial disparity, the substantial racial difference (1:2.0) remained. CONCLUSION: Compared with Caucasians, African-American youths aged 5 through 14 with Medicaid insurance coverage showed a distinctly lower rate of treatment with psychopharmacological agents.

Adolescent/adult differences in suicidal behavior and outcome.

A comprehensive literature review compared the patterns of suicide and suicidal behavior for adolescents and adults to identify age-related similarities and differences. Particular attention was given to follow-up rates of suicide by psychiatrically treated persons in these age groups. The major findings were that (1) adults and adolescent suicide completers were similar with respect to their gender ratio, use of guns in the attempt, completion of the initial attempt, and serious psychopathology; (2) adolescents differed from adults in suicidal behavior in their greater attempt rate, higher attempt/completion ratio, and lower rates of short and intermediate completion following psychiatric treatment; (3) the suicide outcome following psychiatric hospitalization is eightfold greater in adults than in youths during the first 3.5 years postdischarge; and (4) the 5:1 male/female ratio is the same for both adolescent attempters who later suicide and for all U.S. 15-19-year-old suicide completers. The frequent practice of combining adult and adolescent suicide and suicide behavior findings can result in misleading conclusions.

Methylphenidate patterns among Medicaid youths.

Treatment of attentional disorders in America has increased dramatically in recent years. This trend is accounted for partly by lengthening the duration of treatment into adulthood for some individuals as well as by increased treatment among girls. Beyond these factors, the role of economic status, race, and geographic region to explain the variation in methylphenidate use is not well understood. Computerized administrative data were used to explore the influence of several sociodemographic factors on the prevalence of methylphenidate use. The data source consisted of Maryland Medicaid prescription drug reimbursement claims data for FY1991 for children ages 5 to 14 years. In effect, the study was restricted to a sample of patients with limited income. The study aims included (1) measuring gender-, age-, race-, and region-specific methylphenidate prevalence for this restricted income population; (2) comparing the Caucasian:African-American (C:A-A) ratio for methylphenidate with the C:A-A ratio for several drug therapies having non-psychotropic uses, specifically the anti-asthma drug, theophylline, and antibiotics for infections; and (3) estimating the average daily dose of methylphenidate from prescription claims data. Total drug-specific prevalence among the 5-14 year olds was 2.2 percent for methylphenidate while age-specific prevalence varied from 0.4 percent (5 year olds) to 3.4 percent (9 year olds). The gender ratio was 3.7:1 (M:F), confirming the increasing trend for girls to receive this medication. Substantial variation across eight defined regions of the state was observed. Racial differences were pronounced: African-Americans were 2.5 times less likely to receive methylphenidate than Caucasian youths. As hypothesized, non-psychotropic drug use was distinctly different from psychotropic drug use in terms of race: theophylline was 1.5 times more likely to be found for African-Americans than Caucasians, whereas antibiotic prescriptions were 1.5 times more likely to be prescribed to Caucasian youths. Average daily dose of methylphenidate was estimated to be 18.7 +/- 10.4 mg for 5-9 year olds and 26.8 +/- 14.0 mg for 10-14 year olds. This brief report confirms the typically lower rate among African-American Medicaid youths for most prescription drugs. The dramatic racial disparity for the psychotropic agent methylphenidate is a new and compelling finding which should be verified among other economic groups. Diagnostic, referral, and cultural bias should be ruled out as possible explanations for the observed differences.

Sources of data for pharmacoepidemiological studies of child and adolescent psychiatric disorders.

In view of the dramatic shift to managed care models for United States health care delivery, reliable information on the prevalence and variations in psychopharmacological drug therapies for youth in community practice settings is essential. Pharmacoepidemiology, the study of medication use in large populations, aims to accomplish that challenging task. This article offers child psychopharmacologists a brief introduction to data sources for pharmacoepidemiology. Knowledge of these data sources combined with epidemiological methods for data analysis is a beginning step to assess the psychotropic medication prescribing patterns of community physicians. This review is organized in the following sequence: (1) characteristics of the "usual practice environment" according to setting, patient population, and physician characteristics; (2) validity issues related to data sources and their potential for outcomes research; (3) data sources divided into primary and secondary types that are described in terms of their features, advantages, and limitations, followed by examples of selected applied studies using such information; (4) procedures for analyzing secondary data; (5) data analytic and longitudinal approaches; and (6) access, confidentiality, and funding. A goal for future investigators in this emerging field is to develop applied research that is clinically sophisticated, methodologically sound, and public health-minded.

Changing patterns of psychotropic medications prescribed by child psychiatrists in the 1990s.

The active (1994) and closed (1988 to 1992) outpatient records of youths seen in four separate community mental health centers (CMHC) in Baltimore County, Maryland were reviewed in mid-1994 to document recent changes in the medication-prescribing practices of local child psychiatrists. Inpatient summaries of previously hospitalized CMHC youths were also reviewed to supplement the outpatient medication assessment with hospital data. This regional survey of medication treatments in child psychiatry revealed that, during the half decade before 1994, there was an increase in overall psychotropic medication treatment, multiple concurrent medication treatments (polypharmacy), and antidepressant treatment with serotonin reuptake inhibitors (SRIs). Inpatient youths were consistently prescribed more psychotropic medications and diagnosed more frequently with major depressive disorder than outpatients. Medications typically used to first treat mood disorders became the predominant medication prescribed for both outpatients and inpatients by child psychiatrists in 1994, leading to a proportional decline in prescribed stimulant treatment. The shift from tricyclic antidepressants to SRI antidepressants in the 1990s by child psychiatrists matches the same recent practice shift by adult psychiatrists. Likewise, the increased prescription of drugs to treat mood disorders and the increased rate of polypharmacy notable of late among child psychiatrists now also mirrors adult psychiatry practice. Wide geographic variations in neuroleptic and antidepressant medication patterns were noted, even among facilities in the same metropolitan region. After psychiatric hospitalization, most youths who continued treatment at a CMHC outpatient clinic discontinued their inpatient medications within 3 months; the sole exception were children who had been placed on psychostimulants.

Central Stimulant Treatment of Childhood Attention Deficit Hyperactivity Disorder : Issues and Recommendations from a US Perspective.

The use of CNS stimulants for the treatment of attention deficit hyperactivity disorder (ADHD) in children has steadily increased in most areas of the world over the last 30 years. In mid-1995, at least 1.5 million US children were receiving methylphenidate or dexamphetamine (dextroamphetamine). However, in other countries these agents are not used as widely.Specific stimulant-induced benefits for children with ADHD include: improved school grades, more completed classroom work, fewer reprimands for disruptive behaviour, improved handwriting, and improved behaviour at home and in social situtions. Stimulants benefit at least 75% of children with ADHD and are remarkably well tolerated, having few (for the most part minor and temporary) adverse effects.However, the benefits of stimulants that are obvious in most patients with ADHD during a brief clinical trial are primarily symptomatic. Although the behavioural benefits of stimulants are generally present during each period of treatment for as long as the ADHD condition exists (and children with ADHD are now often staying on stimulant medication into their mid-teens), the treatment has not been shown to change the long term outcome of the disorder.Before prescribing stimulants, paediatric physicians need to perform a careful diagnostic assessment for ADHD using multiple sources of information, including detailed ratings of the child's behaviour from his/her teachers and from a parent. If at baseline, the child's academic and behavioural adjustment in the classroom is good, stimulant medication would be inappropriate. However, if the child's pattern of ADHD has consistently and seriously interfered with his/her classroom and home adjustment, stimulant treatment should be actively considered. Should stimulant therapy be initiated, knowledgeable medical follow-up is required.

Self-reported suicide attempts by adolescents.

A thorough medical literature review of adolescent self-reported suicide attempts focused on comparing the following: (1) the prevalence of attempts in anonymous vs. face-to-face surveys; (2) the prevalence rates in the United States and Canada vs. those reported elsewhere; and (3) the prevalence of attempt findings vs. self-harm behavior in anonymous surveys. The major findings were: (1) 29 anonymous self-report questionnaire studies from nine countries revealed that a median of 7-10% of adolescent students acknowledged having made one or more suicide attempts; (2) seven structured interview studies revealed a 3-4% lifetime prevalence of attempted suicide by adolescents; (3) self-report questionnaire responses failed to reveal any overlap between deliberate self-harm behavior and suicide attempts; (4) nonanonymous studies had an unusually high rate of refusal. Thus, self-reported suicide attempts are surprisingly frequent in adolescence and are reported two to three times more often under conditions of anonymity. Furthermore, youths report self-harm behavior as distinct from suicide attempts.

Increased methylphenidate usage for attention deficit disorder in the 1990s.

OBJECTIVE: To estimate the increased use and the prevalence of methylphenidate (Ritalin) treatment of youth with attention deficit disorder (ADD) during the 1990s. DESIGN: Using time-trend findings from two large population-based data sources, three pharmaceutical databases, and one physician audit, a best-fit estimate of the usage and the usage trends for methylphenidate treatment over the half decade from 1990 through 1995 was sought. SETTING: Five regions in the United States (US) and the nation as a whole. PATIENTS: Youths on record as receiving methylphenidate for ADD. RESULTS: The findings from regional and national databases indicate that on average, there has been a 2.5-fold increase in the prevalence of methylphenidate treatment of youths with ADD between 1990 and 1995. In all, approximately 2.8% (or 1.5 million) of US youths aged 5 to 18 were receiving this medication in mid-1995. The increase in methylphenidate treatment for ADD appears largely related to an increased duration of treatment; more girls, adolescents, and inattentive youths on the medication; and a recently improved public image of this medication treatment. CONCLUSION: The database findings presented serve to correct exaggerated media claims of a 6-fold expansion of methylphenidate treatment, although they do not clarify the issue of the appropriateness of this treatment.

A comparison of studies from the United States and western Europe on psychiatric hospitalization referrals for youths exhibiting suicidal behavior.

A comprehensive literature review that rates of adolescent suicide-behavior based referrals from emergency rooms (ER) to psychiatric impatient facilities in the United States (U.S.) and in Western Europe (WE). Also compared on both sides of the Atlantic were the characteristics of suicidal youths seen at the ER and those admitted to psychiatric hospital units. The major findings were as follows. (1) Youths at both geographical locations who were seen at the ERs for suicidal behavior were very similar with respect to age and gender. (2) A median of 39% of youths seen in U.S. ERs for suicidal behavior were referred for inpatient psychiatric treatment; in WE, the median was 12%. (3) In the U.S., suicidal youths referred from the ER to psychiatric inpatient care were predominantly female (2.5:1) and mainly midadolescent in age (median age = 15). (4) In WE, the majority of those suicidal youths referred for psychiatric hospitalization were male (1:1.2) and in their late adolescent years (median age = 17). Thus, far fewer but more at risk youths presenting with suicidal behavior were admitted to psychiatric hospitals in WE than in the U.S. Presumably this is due largely to cross-Atlantic differences in malpractice patterns, academic perspectives, and medical care financing.