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Epidemiological characteristics in suicidal adolescents seen in the emergency department
Características epidemiológicas de las tentativas de suicidio en adolescentes atendidos en Urgencias
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According to the Instituto Nacional de Estadística (National Institute of Statistics), the rate of suicide in youth (15–19 years) in 2012 was 2.38 per 100,000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It is estimated that for every completed suicide, there are between 10 and 40 suicide attempts.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Suicide attempts in youth are associated with impulsivity, the pessimistic perspective of introverted adolescents, the onset of psychiatric disorders and the start of substance use.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> The most frequent method used for attempting suicide in Spain is medication overdose, and differs from other types of paediatric pharmaceutical poisoning in the longer time elapsed until medical care is sought, a higher proportion of combined drug intoxication, and the clinical manifestations.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The management of these patients in Paediatric Emergency Departments (PEDs) must be interdisciplinary and include a thorough psychiatric evaluation. This evaluation will assess the current risk of suicide, the presence of psychiatric comorbidities, and the type of treatment and followup that patients will require after emergency care. The aim of our study was to describe the epidemiological and clinical characteristics of suicide attempts and to differentiate patients that attempted suicide on impulse from those in whom suicidal ideation preceded the attempt. We also analysed patients that attempted suicide by self-poisoning.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a retrospective analytical and observational study in the PED of a tertiary women's and children's hospital that serves a population of 1,300,000 inhabitants and receives 100,000 paediatric visits per year. A psychiatrist is available around the clock to see patients that have been referred specifically for psychiatric assessment. The study included adolescents (12–18 years) that attempted suicide between 2008 and 2012. We collected data for the following variables: age, sex, previous psychiatric history, previous attempts, suicide method, referral for psychiatric assessment, sustained suicidal ideation prior to the attempt, and outcome of the attempt. For patients with poisoning that received care at the PED (excluding those referred for psychiatric assessment), we also collected data pertaining to: ambulance transport, time elapsed between exposure to the toxic substance and PED care, presenting symptoms, management of the poisoning and need for admission. We analysed whether there were clinical or epidemiological differences between patients that attempted suicide on impulse and patients that had prior sustained suicidal ideation. We assessed the impulsivity of the attempt based on the judgement of the psychiatrist that provided emergency care. The study was approved by the research ethics committee of the hospital. We performed the statistical analysis with the application SPSS v 20.0 for Windows (IBM Corporation; Armonk, USA).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0015" class="elsevierStylePara elsevierViewall">We included 241 patients that attempted suicide. The yearly rate of suicide attempts per 1000 adolescents served in the emergency department was 4.2‰ (IQR, 3.7–4.8‰). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the epidemiologic characteristics of the patients. Forty-two patients (17.4%) had attempted suicide before. The time elapsed between the last prior attempt and the attempt analysed in the study was documented for 25 patients (59.5%), and was less than one year in 19 patients (76%). Forty-four patients (18.3%) were referred from other health care facilities. The most frequently used suicide method was poisoning (227; 94.2% of cases), mostly with pharmaceutical agents (215; 94.7%). The predominant drug class was psychotropic drugs (involved in 72.1% of intentional medication overdoses): benzodiazepines (81; 37.7%), antidepressants (34; 15.8%) and antipsychotics (20; 9.3%). The second most commonly involved drug class was analgesics (68; 31.6%), most often paracetamol (35; 16.3%). Of all cases, 33.6% (72) corresponded to combined drug intoxication. All patients survived, four of them (1.7%) with sequelae: three had multiple lesions due to jumping from heights and one had caustic oesophagitis. Of the 227 patients that attempted suicide by self-poisoning, 186 (81.9%) went directly to the PED (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The time elapsed between exposure to the toxic substance and the PED visit, documented in 137 of the patients (73.7%), was 3<span class="elsevierStyleHsp" style=""></span>h (IQR, 2–7<span class="elsevierStyleHsp" style=""></span>h). Digestive tract decontamination was performed in 75 patients (33%), and in 35.5% (27) of these patients, decontamination included gastric lavage. Of the 110 patients admitted to hospital, 7 (6.4%) were admitted to the Intensive Care Unit. The psychiatric evaluation determined that 24.5% (59) of the patients had sustained suicidal ideation prior to the attempt. When we compared this group to the group of patients that attempted suicide on impulse, we observed that suicidal ideation was more common in males and in patients that had made previous attempts, and was associated with a higher incidence of sequelae. In the subset of patients that attempted suicide by poisoning, sustained suicidal ideation was more frequent in patients that were male, had a history of psychiatric illness, presented with clinical manifestations of poisoning and required admission. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the association between the clinical and epidemiological characteristics of the patients and the presence of suicidal ideation prior to the attempt.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">This study shows that suicide attempts among adolescents are more frequent in female individuals and are most commonly an impulsive act. Consistent with our findings, there is evidence that up to 90% of patients that attempt suicide have a psychiatric disorder, most frequently major depression.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Between 20% and 47% of adolescent psychiatric patients have attempted suicide by age 18 years.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> A family history of suicide<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> and having attempted suicide before<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> are other known risk factors. In adolescents, the recurrent suicide attempt rate in the first year of followup ranges between 6% and 14%.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In our study, 7.9% of patients reported having attempted suicide at least once before in the preceding year. The method used most frequently in Spain is intentional medication overdose and, consistent with previous studies,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> benzodiazepines were the most commonly involved drug. In case series in the United Kingdom, paracetamol is the most frequently ingested substance,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> and in countries where there is access to firearms, they are the most common method.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Availability is a significant factor in the choice of method; and in this regard, we ought to note the widespread availability, based on our data, of psychopharmaceuticals in the Spanish population. In the subset of patients that attempted suicide by self-poisoning, a high percentage underwent digestive decontamination despite the long time elapsed since ingestion of the substance. The percentage that underwent gastric lavage was also considerable (35.5%) and far above the standard proposed by quality indicators for paediatric poisoning cases (<10%).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The complexity of the situation may motivate a more aggressive management that is not always justified. Our study showed that sustained suicidal ideation was more frequent in patients that were male, had a psychiatric illness and/or had previously attempted suicide. The literature has described that male attempters complete suicide more frequently and using more violent means, and are more likely to have antisocial and substance use disorders.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Patients with sustained suicidal ideation prior to the attempt presented with clinical manifestations of poisoning more frequently, which suggests that they may achieve more severe levels of intoxication than patients who attempt suicide on impulse.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The limitations of the study are those characteristic of a retrospective design. Due to the absence of objective indicators for measuring the impulsivity of the attempt and the duration of suicidal ideation prior to the attempt, we estimated these variables based on the subjective criteria of the psychiatrist on call, and thus our results must be interpreted with caution. Since we did not have access to clinical toxicological data on patients that received care at other facilities and were referred solely for psychiatric evaluation, we were not able to analyse the entire subset of patients that had attempted suicide by self-poisoning. Our study showed that patients that are male, have a history of psychiatric illness, have made a previous attempt and/or present with symptoms of poisoning in the emergency room are more likely to have had sustained suicidal ideation before the attempt and are at higher risk of attempting suicide again. These patients require thorough psychiatric evaluation and close monitoring.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres677608" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec683593" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres677609" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec683594" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-02-28" "fechaAceptado" => "2015-04-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec683593" "palabras" => array:3 [ 0 => "Attempted suicide" 1 => "Poison" 2 => "Adolescent" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec683594" "palabras" => array:3 [ 0 => "Tentativa de suicidio" 1 => "Intoxicación voluntaria" 2 => "Adolescencia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Suicide attempt in adolescents is a major global health problem. In order to prevent them, the risk factors need to be identified. The present study evaluates the clinical and epidemiological aspects of adolescent patients after attempted suicide, who were seen in an emergency department.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Description of retrospective study of patients younger than 18 years who visited emergency department unit after a suicide attempt, during the period from 2008 to 2012.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 241 patients were included, of whom 203 were female. The median age of the patients was 15.6 years. Psiquiatric history was present in 65.1% of the patients. The most frequent suicide mechanism was drug overdose (94.2%). Attempted suicide ideation was more common in males and in patients with previous attempts, and were also more related to sequels. Moreover, patients with an overdose were associated with psychiatric history and clinical toxicity.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients with any of the following characteristics; male, psychiatric history, a history of previous suicide attempts and/or clinical toxicity at the time of the visit in the emergency centre, were more associated suicidal ideation before the attempt. Therefore, they had greater severity and risk repeating the attempt. They require a careful psychiatric evaluation and close monitoring.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La tentativa de suicidio en adolescentes es un grave problema de salud a nivel mundial. Para desarrollar medidas preventivas es necesario identificar factores de riesgo. El objetivo del estudio es describir y analizar las características epidemiológicas y clínicas de los pacientes que acuden al Servicio de Urgencias Pediátrico (SUP) tras presentar una tentativa de suicidio.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de los pacientes menores de 18 años visitados en un SUP tras tentativa de suicidio entre 2008 y 2012.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se obtuvo una muestra de 241 pacientes, 84,2% mujeres, con una mediana de edad de 15,6 años. El 65,1% de los pacientes presentaba antecedentes psiquiátricos, siendo el más frecuente el trastorno depresivo (61 pacientes). El mecanismo suicida más frecuente fue la intoxicación medicamentosa con 94,2% de los casos.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La presencia de ideación suicida estable previamente a la tentativa fue más frecuente en los varones y en pacientes con tentativas previas, y se relacionó con la aparición de secuelas en mayor proporción. Además, en los pacientes con intoxicación se relacionó también con presentar antecedentes psiquiátricos y con la aparición de clínica de toxicidad.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los pacientes varones, con antecedentes psiquiátricos, con antecedentes de tentativas suicidas previas y/o con clínica de toxicidad en el momento de atención en el SUP presentan con más frecuencia ideación suicida estable previa a la realización de la tentativa y, por tanto, mayor gravedad y riesgo de repetirla. Requieren, por tanto, una valoración psiquiátrica cuidadosa y un seguimiento estrecho.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as: Margarit Soler A, Martínez Sanchez L, Martínez Monseny A, Trenchs Sainz de la Maza V, Picouto González MD, Villar Cabeza F, et al. Características epidemiológicas de las tentativas de suicidio en adolescentes atendidos en Urgencias. An Pediatr (Barc). 2016;85:13–17.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Previous presentation: This study was presented at the XVIII Reunión Anual de la Sociedad Española de Urgencias de Pediatría; 2003; Granada, Spain.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Categorical variables are expressed as absolute frequency and percentage, continuous variables as median and interquartile range.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CSMIJ, Centro Salud Mental Infanto-Juvenil (Child and Adolescent Mental Health Centre).</p>" "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Age (years)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.6 (14.6–16.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Female sex</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">203 (84.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Psychiatric history</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">157 (65.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Depressive disorder \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (38.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Behaviour disorder \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 (27.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Eating disorder \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (12.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (11.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Substance use history</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tobacco \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (70.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cannabis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (54.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Alcohol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (32.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Method</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Self-poisoning<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">227 (94.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Self-harm with sharp object \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (5.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Jumping from heights \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (2.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hanging \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Sustained suicidal ideation preceding the attempt</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 (24.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1112097.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics of patients that received care for poisoning at the PED (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>186)</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Age in years and female sex</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.0 (14.7–17.0); 155 (83.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Psychiatric history</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">119 (64.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Ambulance transport</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">113 (60.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Number of toxic substances involved</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">117 (62.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 (23.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>≥3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (13.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Poisoning with prescribed medications</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 (26.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Presenting symptoms</span><span class="elsevierStyleSup">d</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98 (52.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neurologic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76 (77.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Psychiatric \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Digestive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (24.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Poisoning management</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Decontamination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 (40.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Activated charcoal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69 (92.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Gastric lavage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (34.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Antidote \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (7.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Discharge destination</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Admission to hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">110 (59.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Psychiatric outpatient clinic/CSMIJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76 (40.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1112096.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Eighteen polysubstance users.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Five patients used two methods were used in a single attempt: self-poisoning and self-harm with a sharp object.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Most patients presented more than one symptom.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Epidemiological characteristics of patients that attempted suicide (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>241).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Categorical variables are expressed as absolute frequency and percentage, continuous variables as median.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Data were considered statistically significant for <span class="elsevierStyleItalic">p</span>-values less than 0.05 (presented in boldface).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sustained suicidal ideation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Impulsive attempt \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Total sample (n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">=</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">241)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>59) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>182) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.672 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 (72.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">160 (87.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">.006</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Psychiatric history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 (74.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">113 (62.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.080 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Substance use history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (16.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27 (14.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.695 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Previous suicide attempt \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (27.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">.024</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Poisoning as single suicide method \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51 (86.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">171 (94.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.091 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sequelae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (5.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">.046</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Poisoned patients seen at the PED (n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">186)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>144) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.940 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (71.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">125 (86.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">.019</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Psychiatric history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 (78.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">86 (59.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">.025</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Substance use history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (14.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.962 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Previous suicide attempt \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (26.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (14.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.079 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Poisoning symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 (81.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 (44.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold"><.001</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Decontamination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (45.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 (38.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.460 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Antidote \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (7.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.906 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 (83.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 (52.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold"><.001</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1112095.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Association between the presence of sustained suicidal ideation and clinical and epidemiological characteristics of the patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" 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Apter" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/YCO.0b013e3283155508" "Revista" => array:7 [ "tituloSerie" => "Curr Opin Psychiatry" "fecha" => "2009" "volumen" => "22" "paginaInicial" => "1" "paginaFinal" => "6" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19122527" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1521691811000862" "estado" => "S300" "issn" => "15216918" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Suicidal behavior in pediatric population neurobiology and the missing links in assessing risk among patients with bipolar disorder" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Nanayakkara" 1 => "K. Pullagurla" 2 => "M. Pavuluri" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "titulo" => "The neurobiological basis of suicide" "paginaInicial" => "333" "paginaFinal" => "346" "edicion" => "1st ed." "serieFecha" => "2012" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intoxicaciones voluntarias como intento de suicidio" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Garrido" 1 => "J.J. García" 2 => "E. Carballo" 3 => "C. Luaces" 4 => "J.A. Alda" 5 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 10 | 17 |
| 2024 October | 75 | 42 | 117 |
| 2024 September | 53 | 25 | 78 |
| 2024 August | 55 | 53 | 108 |
| 2024 July | 45 | 31 | 76 |
| 2024 June | 44 | 30 | 74 |
| 2024 May | 53 | 24 | 77 |
| 2024 April | 46 | 44 | 90 |
| 2024 March | 26 | 24 | 50 |
| 2024 February | 32 | 24 | 56 |
| 2024 January | 18 | 18 | 36 |
| 2023 December | 25 | 20 | 45 |
| 2023 November | 22 | 30 | 52 |
| 2023 October | 30 | 30 | 60 |
| 2023 September | 28 | 18 | 46 |
| 2023 August | 33 | 25 | 58 |
| 2023 July | 39 | 30 | 69 |
| 2023 June | 50 | 29 | 79 |
| 2023 May | 41 | 27 | 68 |
| 2023 April | 33 | 17 | 50 |
| 2023 March | 35 | 21 | 56 |
| 2023 February | 26 | 19 | 45 |
| 2023 January | 22 | 20 | 42 |
| 2022 December | 34 | 18 | 52 |
| 2022 November | 50 | 38 | 88 |
| 2022 October | 33 | 37 | 70 |
| 2022 September | 22 | 29 | 51 |
| 2022 August | 32 | 46 | 78 |
| 2022 July | 23 | 32 | 55 |
| 2022 June | 28 | 27 | 55 |
| 2022 May | 30 | 37 | 67 |
| 2022 April | 28 | 40 | 68 |
| 2022 March | 47 | 53 | 100 |
| 2022 February | 18 | 27 | 45 |
| 2022 January | 34 | 35 | 69 |
| 2021 December | 38 | 40 | 78 |
| 2021 November | 35 | 43 | 78 |
| 2021 October | 50 | 75 | 125 |
| 2021 September | 32 | 49 | 81 |
| 2021 August | 16 | 41 | 57 |
| 2021 July | 24 | 38 | 62 |
| 2021 June | 37 | 47 | 84 |
| 2021 May | 33 | 41 | 74 |
| 2021 April | 74 | 45 | 119 |
| 2021 March | 38 | 33 | 71 |
| 2021 February | 14 | 16 | 30 |
| 2021 January | 35 | 26 | 61 |
| 2020 December | 19 | 44 | 63 |
| 2020 November | 14 | 24 | 38 |
| 2020 October | 21 | 19 | 40 |
| 2020 September | 19 | 21 | 40 |
| 2020 August | 22 | 11 | 33 |
| 2020 July | 19 | 17 | 36 |
| 2020 June | 20 | 20 | 40 |
| 2020 May | 23 | 17 | 40 |
| 2020 April | 11 | 12 | 23 |
| 2020 March | 19 | 19 | 38 |
| 2020 February | 28 | 18 | 46 |
| 2020 January | 14 | 16 | 30 |
| 2019 December | 29 | 14 | 43 |
| 2019 November | 25 | 17 | 42 |
| 2019 October | 11 | 7 | 18 |
| 2019 September | 19 | 7 | 26 |
| 2019 August | 23 | 15 | 38 |
| 2019 July | 26 | 27 | 53 |
| 2019 June | 15 | 21 | 36 |
| 2019 May | 53 | 25 | 78 |
| 2019 April | 29 | 25 | 54 |
| 2019 March | 19 | 7 | 26 |
| 2019 February | 27 | 18 | 45 |
| 2019 January | 22 | 15 | 37 |
| 2018 December | 37 | 24 | 61 |
| 2018 November | 95 | 33 | 128 |
| 2018 October | 119 | 16 | 135 |
| 2018 September | 51 | 15 | 66 |
| 2018 August | 1 | 0 | 1 |
| 2018 July | 2 | 0 | 2 |
| 2018 June | 3 | 0 | 3 |
| 2018 May | 3 | 0 | 3 |
| 2018 April | 13 | 0 | 13 |
| 2018 March | 19 | 0 | 19 |
| 2018 February | 8 | 0 | 8 |
| 2018 January | 8 | 0 | 8 |
| 2017 December | 14 | 0 | 14 |
| 2017 November | 15 | 0 | 15 |
| 2017 October | 15 | 0 | 15 |
| 2017 September | 14 | 0 | 14 |
| 2017 August | 8 | 0 | 8 |
| 2017 July | 12 | 2 | 14 |
| 2017 June | 16 | 7 | 23 |
| 2017 May | 26 | 5 | 31 |
| 2017 April | 12 | 8 | 20 |
| 2017 March | 8 | 2 | 10 |
| 2017 February | 9 | 7 | 16 |
| 2017 January | 7 | 3 | 10 |
| 2016 December | 24 | 20 | 44 |
| 2016 November | 27 | 26 | 53 |
| 2016 October | 18 | 25 | 43 |
| 2016 September | 31 | 8 | 39 |
| 2016 August | 37 | 6 | 43 |
| 2016 July | 37 | 15 | 52 |
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