Date Published: January 26, 2017
Publisher: Public Library of Science
Author(s): Caterina Zanus, Sara Battistutta, Renata Aliverti, Marcella Montico, Silvana Cremaschi, Luca Ronfani, Lorenzo Monasta, Marco Carrozzi, Christian Schmahl.
The objective of the present study was to describe the incidence and the characteristics of Self-Injurious Thoughts and Behaviors (SITBs), among adolescents aged 11–18 admitted, over a two year period, to all the Emergency Departments of a Region of North-eastern Italy through a comprehensive analysis of medical records. A two-step search was performed in the regional ED electronic database. First, we identified the cases that had been clearly diagnosed as SITBs by an Emergency Department physician. Secondly, suspect cases were detected through a keyword search of the database, and the medical records of these cases were hand screened to identify SITBs. The mean annual incidence rate of SITBs was 90 per 100,000 adolescents aged 11–18 years. Events were more frequent in females. Drug poisoning was the most frequently adopted method (54%). In 42% of cases a diagnosis of SITB was not explicitly reported by the physician. In 65% of cases adolescents were discharged within hours of admission. Only 9% of patients started a psychiatric assessment and treatment program during hospital stay. This research confirms the high incidence of SITBs among adolescents and highlights the difficulty in their proper diagnosis and management. Such difficulty is confirmed by the fact that only a few patients, even among those with a clear diagnosis, were sent for psychiatric assessment. Correct identification and management of SITB patients needs to be improved, since SITBs are an important public health problem in adolescence and one of the main risk factors for suicide.
Suicide is a major public health concern in adolescents, being the second leading cause of death in young people worldwide,  thus prevention initiatives aimed at young people, especially those at high risk, are strongly needed. 
All of the 21 EDs of Friuli Venezia Giulia (FVG) were involved in this retrospective study covering a two-year period (2005–2006). The study was coordinated by the Child Neurology and Psychiatry Department of the Institute for Maternal and Child Health—IRCCS “Burlo Garofolo” of Trieste. FVG is located in the North East of Italy and has a population of about 1,200,000 people. In this Region a standard electronic database is in use to report clinical information on all patients who access EDs. This database was first searched to identify adolescents aged between 11 and 18 admitted for SITBs to the EDs of the Region during the study period.
The electronic records of 53,198 ED admissions of adolescents aged 11–18 years were analyzed (Fig 1). Seventy-eight episodes of SITBs were identified in Step 1. The Step 2 keyword search allowed us to identify further 777 accesses suspected to be SITBs, and the analysis of their medical records allowed us to detected 57 additional cases of SITBs. A total of 135 SITBs, over the two-year period of study, were thus finally identified; they involved 120 adolescents as there were some repeated acts. These cases accounted for 0.2% of the total 53,198 admissions to the EDs.
To our knowledge, this is the first epidemiological study with full coverage of all emergency departments of an Italian Region, describing adolescent admissions to EDs for SITBs. In order to provide the most accurate evaluation of all SITBs, a two-step procedure was adopted for the identification of cases. Step 1 allowed us to collect clearly diagnosed SITB cases, while in Step 2 we focused on identifying misdiagnosed and undiagnosed SITBs.
Our data highlight the importance of improving the ability of ED staff to identify and report SITBs, to help evaluate subsequent readmissions, considering that the repetition of the act is an important risk factor. Since the ED is often the first and only health care contact point, adolescents accessing the service for SITBs need to be recognized, diagnosed, and given appropriate treatment to help prevent them from attempting suicide in the future.