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Suicide and self-harm trends in recent immigrant youth in Ontario, 1996-2012: a population-based longitudinal cohort study
  1. Natasha Ruth Saunders1,2,3,4,
  2. Michael Lebenbaum3,
  3. Therese A Stukel3,5,6,
  4. Hong Lu3,
  5. Marcelo L Urquia3,5,6,7,8,
  6. Paul Kurdyak3,5,6,9,
  7. Astrid Guttmann1,2,3,4,5,6
  1. 1 Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Canada
  2. 2 Department of Pediatrics, University of Toronto, Toronto, Canada
  3. 3 Institute for Clinical Evaluative Sciences, Toronto, Canada
  4. 4 Child Health Evaluative Sciences, Sickkids Research Institute, Toronto, Canada
  5. 5 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
  6. 6 Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
  7. 7 Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
  8. 8 Manitoba Centre for Health Policy, Department of Community Health Services, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
  9. 9 Centre for Addiction and Mental Health, Toronto, Canada
  1. Correspondence to Dr Natasha Ruth Saunders; natasha.saunders{at}


Objective To describe the trends in suicide and emergency department (ED) visits for self-harm in youth by immigration status and immigrant characteristics.

Design Population-based longitudinal cohort study from 1996 to 2012 using linked health and administrative datasets.

Setting Ontario, Canada.

Participants Youth 10 to 24 years, living in Ontario, Canada.

Exposure The main exposure was immigrant status (recent immigrant (RI) versus long-term residents (LTR)). Secondary exposures included region of birth, duration or residence, and refugee status.

Main outcome measure Trends over time in suicide and ED self-harm were modelled within consecutive 3-year time periods. Rate ratios were estimated using Poisson regression models.

Results 2.5 to 2.9 million individuals were included per cohort period. LTR suicide rates ranged from 7.4 to 9.4/100 000 male person-years versus 2.2–3.4/100 000 females. RI’s suicide rates were 2.7–7.2/100,000 male versus 1.9–2.7/100 000 female person-years. Suicide rates were lower among RI compared with LTR (adjusted relative rate (aRR)=0.70, 95% CI=0.57 to 0.85) with different mechanisms of suicide. No significant time trend in suicide rates was observed (p=0.40). ED self-harm rates for LTR and RI were highest in females (2.6–3.4/1000 LTR females versus 1.1–1.5/1000 males, 1.2–1.8/1000 RI females versus 0.4–0.6/1000 males). RI had lower rates of self-harm compared with LTR (aRR=0.60, 95% CI=0.56 to 0.65). Stratum-specific rates showed a steeper decline per period in RI compared with LTR (RI: aRR=0.85, 95% CI=0.81 to 0.89; LTR: aRR=0.91, 95% CI=0.90 to 0.93). Observed trends were not universal across region of origin and by refugee status.

Interpretation Suicide rates have been stable and ED self-harm rates are declining over time among RI youth. These trends by important subgroups should continue to be monitored to allow for early identification of subpopulations of immigrant youth in need of targeted and culturally appropriate public health interventions.

  • immigration
  • death
  • intentional injury
  • refugee
  • mental health

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors NRS conceptualised and designed the study, interpreted the results, drafted the initial manuscript, revised the manuscript and approved the final manuscript as submitted. ML, TAS, MLU, PK and AG conceptualised and designed the study, interpreted the results, revised the manuscript and approved the final manuscript as submitted. HL conceptualised and designed the study, analysed the data, interpreted the results, revised the manuscript and approved the final manuscript as submitted. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

  • Funding AG is funded through an Applied Chair in Reproductive and Child Health Services and Policy Research from the Canadian Institutes for Health Research (CIHR). MLU holds a CIHR New Investigator Award. Data cutting and analysis for this project were supported by a grant for the Mental Health and Addictions Evaluation Framework Team (MHASEF) at the Institute for Clinical Evaluative Sciences from the Ontario Ministry of Health and Long-Term Care (MOHLTC). This study was supported by the Institute for Clinical Evaluative Sciences (ICES),which is funded by an annual grant from the Ontario MOHLTC.

  • Disclaimer The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI) and Immigration, Refugees and Citizenship Canada (IRCC). However, the analyses, conclusions, opinions and statements expressed herein are those of the authors and not necessarily those of CIHI or IRCC.

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval Sunnybrook Health Sciences Centre Resesarch Ethics Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data setfrom this study is held securely in coded form at the Institute for ClinicalEvaluative Sciences (ICES). While data sharing agreements prohibit ICES frommaking the data set publicly available, access may be granted to those whomeet pre-specified criteria for confidential access, available at . The full data set creation plan is availablefrom the authors upon request.

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