Psychosocial risk factors of child and adolescent completed suicide

Ideação suicida na adolescência: prevalência e fatores associados

OBJETIVO: Avaliar a prevalência de ideação suicida, assim como de seus fatores associados, em adolescentes entre 15 e 18 anos da cidade de Pelotas (RS). MÉTODOS: 960 adolescentes responderam a um questionário autoaplicado e sigiloso em estudo transversal de base populacional. A ideação suicida foi aferida por meio do item 17 do SRQ-20, que avalia transtornos psiquiátricos menores. Para a análise estatística, utilizou-se a regressão logística. RESULTADOS: A prevalência de ideação suicida foi de 7,7%. A baixa escolaridade da mãe, a baixa escolaridade do adolescente, o sedentarismo, o uso de álcool e de outras substâncias e o comportamento agressivo mantiveram associação estatisticamente significativa com ideação suicida. CONCLUSÃO: Programas preventivos devem preferencialmente atingir adolescentes de baixa escolaridade que apresentem comportamento agressivo e relatem uso de substâncias.

Factors accounting for youth suicide attempt in Hong Kong: a model building

This study aimed at proposing and testing a conceptual model of youth suicide attempt. We proposed a model that began with family factors such as a history of physical abuse and parental divorce/separation. Family relationship, presence of psychopathology, life stressors, and suicide ideation were postulated as mediators, leading to youth suicide attempt. The stepwise entry of the risk factors to a logistic regression model defined their proximity as related to suicide attempt. Path analysis further refined our proposed model of youth suicide attempt. Our originally proposed model was largely confirmed. The main revision was dropping parental divorce/separation as a risk factor in the model due to lack of significant contribution when examined alongside with other risk factors. This model was cross-validated by gender. This study moved research on youth suicide from identification of individual risk factors to model building, integrating separate findings of the past studies.

Parental divorce, parental depression, and gender differences in adult offspring suicide attempt

Research suggests parental divorce during childhood increases risk of suicide attempt for male but not female offspring. The negative impact on offspring associated with parental divorce may be better explained by parental psychopathology, such as depression. We examined whether adult offspring of parental divorce experience elevated risk of suicide attempt, controlling for parental history of depression, and whether the risk varies by the gender of the offspring. Using the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the sample consists of respondents who experienced parental divorce (N = 4895). Multivariable regressions controlled for age, race/ethnicity, income, marital status, and parental history of depression. Females living with their fathers were significantly more likely to report lifetime suicide attempts than females living with their mothers, even after controlling for parental depression. Findings suggest that childhood/adolescent parental divorce may have a stronger impact on suicide attempt risk in female offspring than previously recognized.

Suicidal ideation in adolescents aged 11 to 15 years: prevalence and associated factors

OBJECTIVE

To verify the prevalence and associated factors of suicidal ideation among adolescents aged 11 to 15 years.

METHOD

Cross-sectional population-based study. Adolescents completed a self-report that contained the Children's Depression Inventory. Suicidal ideation was measured according to item 9 of the Children's Depression Inventory. Multivariate logistic regression analysis was applied using a hierarchical model.

RESULTS

1145 adolescents were invited to participate, and 1039 were interviewed (refusal rate: 9.26%). The prevalence of suicidal ideation was 14.1%. Factors associated to suicidal ideation: female gender, current alcohol consumption, use of illicit drugs, symptoms indicating conduct disorders and high Children's Depression Inventory scores for depressive symptoms.

CONCLUSION

Prevention strategies should focus on female adolescents, especially those sexually active with probable mental health problems and substance use.

Epidemiology of youth suicide and suicidal behavior

PURPOSE OF REVIEW

Suicide is the third leading cause of death among young people in the U.S. and represents a significant public health problem worldwide. This review focuses on recent developments in our understanding of the epidemiology and risk factors for adolescent suicide and suicidal behavior.

RECENT FINDINGS

The suicide rate among children and adolescents in the U.S. has increased dramatically in recent years and has been accompanied by substantial changes in the leading methods of youth suicide, especially among young girls. Much work is currently underway to elucidate the relationships between psychopathology, substance use, child abuse, bullying, internet use, and youth suicidal behavior. Recent evidence also suggests sex-specific and moderating roles of sex in influencing risk for suicide and suicidal behavior.

SUMMARY

Empirical research into the causal mechanisms underlying youth suicide and suicidal behavior is needed to inform early identification and prevention efforts.

Comprehending childhood bereavement by parental suicide: a critical review of research on outcomes, grief processes, and interventions

The experience of bereavement by parental suicide is not well understood, as evidenced by the lack of empirically supported interventions for this underserved population. This article reviews quantitative and qualitative research on the psychopathological outcomes and thematic characteristics of childhood and adolescent suicide survivorship and moderating variables such as life stressors, stigma, the manner of communication about the suicide, and the surviving parent's functioning. The authors outline several approaches to intervention and address conceptual and methodological challenges within the field. With the ultimate goal of efficacious intervention, recommendations for future priorities and the use of unconventional research methods are offered.

Suicide and mental illness in parents and risk of suicide in offspring: a birth cohort study

BACKGROUND

A family history of completed suicide and psychiatric illness has been identified as risk factors for suicide.

AIMS

To examine the risk of offspring suicide in relation to parental history of suicide and other parental risk factors.

METHOD

The study population consisted of 7,177 adult offspring born 1959-1961 and their parents from the Copenhagen Perinatal Cohort. Cohort members and their parents who had committed suicide were identified in the Danish Causes of Death Registry (follow-up until December 31, 2005), while information on psychiatric hospitalisation history was obtained from the Danish Psychiatric Central Research Register.

RESULTS

Forty-eight cohort members, 77 mothers and 133 fathers had committed suicide during the follow-up. Independent of parental psychiatric illness and social status, parental suicide significantly increased suicide risk in offspring (hazard ratio 4.40 with 95% CI 1.81-10.69). A stronger effect of parental suicide was observed in offspring without a history of psychiatric hospitalisation.

CONCLUSION

Parental history of suicide is a risk factor for suicide in offspring, but primarily in offspring without psychiatric hospitalisation.

Suicide among Italian adolescents: 1970-2002

The purpose of the present study was to analyze sex and regional differences in the suicide rate of adolescents and the methods they used for suicide in Italy during the period 1970-2002. Temporal trends and regional variations in suicide for Italian adolescents were retrieved from the Italian database on mortality for the period 1970-2002, collected by the Italian Census Bureau and processed by the Italian National Institute of Health-Statistics Unit. In the period 1970-2002, 3,069 adolescent suicides were monitored in Italy. Analyses of these suicides identified significant differences by region of residence and sex. Males were 2.1 times more likely than females to kill themselves. Male and female suicides had inverse trends in the years analyzed, so that the sex difference at the present time is the result of a continuous increase in male suicides and a decrease in female suicides since 1970. The dramatic peaks observed over the time period studied cannot be attributed to a single cause, indicating that further studies are needed to better understand the phenomenon.

Religion and suicide

Religion impacts suicidality. One's degree of religiosity can potentially serve as a protective factor against suicidal behavior. To accurately assess risk of suicide, it is imperative to understand the role of religion in suicidality. PsycINFO and MEDLINE databases were searched for published articles on religion and suicide between 1980 and 2008. Epidemiological data on suicidality across four religions, and the influence of religion on suicidality are presented. Practice guidelines are presented for incorporating religiosity into suicide risk assessment. Suicide rates and risk and protective factors for suicide vary across religions. It is essential to assess for degree of religious commitment and involvement to accurately identify suicide risk.

Drug ingestions in children 10-14 years old: an old problem revisited

To determine changes in rates of drug ingestions in 10-14 year old children in our country, a retrospective chart review of 10-14 year olds hospitalized for drug ingestion between 1993-1995 and 2000-2004 was performed. Odds ratios and Chi-square were used for analyses. From 1993-1995 there were 92.8 ingestions/100,000 children/year; from 2000-2004 there were 63.3 ingestions/100,000 children/year. More males ingested in 2000-2004 than 1993-1995 (26.3% vs.14.2% O.R. 2.15 [1.19, 3.92]). More patients took psychiatric medications in 2000-2004 than 1993-1995 (38.9% vs. 27.0%, O.R. 1.72 [1.06, 2.80]). More patients ingested SSRIs in 2000-2004 than 1993-1995; fewer ingested tricyclics. Hospitalization rates for drug ingestions have decreased. There has been a change in drug ingested, and more males are ingesting drugs.

Suicidality in Pediatric Bipolar Disorder

This article describes what is known about the epidemiology of suicidal ideation and behavior in pediatric bipolar disorder. Risk factors associated with suicidality in this population are reviewed in detail. Clinical recommendations for assessment, management and treatment are provided based on the literature to date.

Childhood predictors of deliberate self-harm behavior and suicide ideation in korean adolescents: a prospective population-based follow-up study

The aim of this study was to investigate predictors of adolescence suicidality in a longitudinal study. Additionally, the prevalence of deliberate self-harm behavior and suicide ideation at age 7 and during middle school were examined. Initial assessment data was obtained from 1998 to 2000, and a follow-up assessment was performed in 2006 when the original subjects became middle school students. The addresses and names of 1,857 subjects were located from the original data; they were 910 boys and 947 girls. The subjects were evaluated with the Korean version of the Child Behavior Checklist (K-CBCL), which was administered by the parents of the children, and by various demographic and psychosocial factors. They were reassessed using self reports on the Korea Youth Self Report (K-YSR); in particular, replies to items related to self-harm behavior and suicide ideation were recorded. A logistic regression analysis showed that the factors of gender, economic status, the overall amount of behavior problems, the tendency to internalizing and externalizing problems, somatic problems, thought problems, delinquent behavior, and aggressive behavior were independent predictors of adolescent suicide ideation and self-harm behavior. The importance of total behavior problems suggested that adolescent difficulty is a consequence of an accumulation of various risk factors. Accordingly, clinicians must consider a range of internalizing and externalizing issues, especially overall adaptation, for suicide intervention.

Suicide ideation among college students: a multivariate analysis

The goal of this study was to develop a multi-dimensional model that might explain suicide ideation among college students. Face-to-face interviews were conducted with 1,249 first-year college students. An estimated 6%(wt) of first-year students at this university had current suicide ideation. Depressive symptoms, low social support, affective dysregulation, and father-child conflict were each independently associated with suicide ideation. Only 40%(wt) of individuals with suicide ideation were classified as depressed according to standard criteria. In the group who reported low levels of depressive symptoms, low social support and affective dysregulation were important predictors of suicide ideation. Alcohol use disorder was also independently associated with suicide ideation, while parental conflict was not. Results highlight potential targets for early intervention among college students.

Admission to intensive care for parasuicide by self-poisoning: variation by time cycles, climate and the lunar cycle

The aim of this study was to characterize patients after self-poisoning with suicidal intent regarding age, sex and type of substances ingested, as well as to identify temporal variations of attempted suicides and associations with climate variables and the lunar cycle. During the years 2002-2004, a total of 691 patients were admitted for self-poisoning parasuicides. The male to female ratio was 1:1.65 with mean ages of 39 and 37 years, respectively. Benzodiazepines and antidepressants were the most frequently taken substances. A significant variation with the time of the day with a peak before midnight was observed for both sexes. Variation with the day of the week was less clear and showed a peak incidence for parasuicides on Mondays. There was no significant variation with the monthly or annual cycle. The frequency of parasuicides was associated with "bad weather" (precipitation). No association of parasuicide incidences to the lunar cycle was observed.

Psychosocial and psychiatric factors associated with adolescent suicide: a case-control psychological autopsy study

This study aimed at the investigation of psychosocial and psychiatric risk factors of adolescent suicide by means of a case-control psychological autopsy study. Relatives and other informants of 19 suicide victims and 19 matched psychiatric controls were interviewed by means of a semi-structured interview schedule. Psychiatric controls included adolescents, individually matched according to gender, age and time between interview and suicide/admission, who had been admitted to a Psychiatric Department with suicidal ideation or attempted suicide at admission. Results showed that suicide victims had been exposed more frequently to suicidal behaviour by friends and through media and experienced more relational problems in the past year. Suicidal communication was less frequently reported in suicide victims than in controls and when communication did occur, it was less often directed towards parents. Treatment of psychiatric disorders was significantly less found in suicide victims. Psychiatric control patients were more likely to have comorbidity of psychiatric disorder, conduct disorder, delinquency or academic difficulties. This study showed significant differences between young suicide victims and psychiatric controls for life events, exposure, communication and treatment. These results also suggest that more symptoms and more externalizing behaviour can be observed in psychiatric control patients which could indicate more warning signals of possible psychiatric problems for the environment, which could result in more help-seeking behaviour and treatment.

Suicide in juveniles and adolescents in the United Kingdom

BACKGROUND

Suicide is a leading cause of death among youths. Comparatively few studies have studied recent trends over time, or examined rates and characteristics of service contact in well-defined national samples.

METHODS

Data on general population suicides and mid-year population estimates were used to calculate suicide rates (per 100,000/year) among youths aged 10-19 years in the United Kingdom. We then determined the proportion of youths who had been in mental health service contact in the year prior to death. Social and clinical data were collected via questionnaires sent to clinicians who had provided care.

RESULTS

The general population rate of suicide was higher in males than females, and was higher in 15-19-year-olds compared to 10-14-year-olds. Suicide rates for 10-19-year-olds declined by 28% between 1 January 1997 and 31 December 2003 (compared with an 8% reduction in those aged >19 years); the fall was particularly marked for males. Mental health service contact was low at 14% (compared with 26% for adults), especially for males (12%). Youths in mental health contact were characterised by: diagnosis of affective disorder, mental illness history, residential instability, self-harm, and substance misuse. Over half of youths were living with parents and one-fifth were in full-time education.

CONCLUSIONS

The suicide rate for 10-19-year-olds in the UK appeared to fall between 1997 and 2003. Further monitoring of suicide rates is needed to determine whether this trend has continued for the most recent years (e.g., 2004-7). The fall in rates may have been related to socio-economic or clinical factors. The rate of contact with services was low compared to adults, particularly in males. This is concerning because young males have the highest suicide rate in the UK. Suicide prevention in young people is likely to require a multi-agency approach.

Adolescent Suicidal Behavior and Substance Use: Developmental Mechanisms

Adolescent suicidal behaviors and substance use are disturbingly common. Research suggests overlap of some of the etiological mechanisms for both adolescent suicidal behavior and substance use, yet clear understanding of the complex relations between these behaviors and their causal underpinnings is lacking. A growing body of evidence and a diathesis model (Mann et al. 1999; Mann, 2003) highlight the importance of impulse control as a proximal risk factor for adolescent suicidal and substance use behaviors. This literature review extends current theory on the relationships between adolescent suicidal behavior and substance use by: (1) examining how, when, and to what extent adolescent development is affected by poor impulse control, stressful life events, substance use behavior, and biological factors; (2) presenting proposed causal mechanisms by which these risk factors interact to increase risk for suicidal behaviors and substance use; and (3) proposing specific new hypotheses to extend the diathesis model to adolescents at risk for suicide and substance use. More specifically, new hypotheses are presented that predict bidirectional relationships between stressful life events and genetic markers of 5-HT dysregulation; substance use behavior and impulsivity; and substance use behavior and suicide attempts. The importance of distinguishing between different developmental trajectories of suicidal and substance use behaviors, and the effects of specific risk and protective mechanisms are discussed. Use of new statistical approaches that provide for the comparison of latent growth curves and latent class models is recommended to identify differences in developmental trajectories of suicidal behavior and substance use. Knowledge gained from these prospective longitudinal methods should lead to greater understanding on the timing, duration, and extent to which specific risk and protective factors influence the outcomes of suicidal behavior and substance use. In turn, findings from these studies should inform researchers who conduct future treatment and prevention studies.

Risk factors for suicide attempts among Korean adolescents

This study examined the rate of suicide attempts and relevant variables and identified risk factors for suicide attempts among Korean adolescents. A cross-sectional study was performed using an anonymous, self-report questionnaire. A total of 2,100 Korean adolescents, including 1,321 student adolescents and 779 delinquent adolescents, were selected using a proportional stratified random sampling method for this study. The results showed the rate of suicide attempts to be 11.6%, with delinquent adolescents reporting a higher rate of suicide attempts than student adolescents. Adolescent suicide attempts indicated higher levels of dysfunctional family dynamics and maladaptive personalities. In addition, adolescents who attempted suicide expressed a significantly lower level of life satisfaction and less effective coping strategies compared with those adolescents who had not attempted suicide. Logistic regression analysis revealed that five predictive risk factors appeared to be statistically significant: coping strategy, parental child-rearing pattern, depression, parent-child relationship, and psychosomatic symptoms, in this order at p < 0.05.

Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies

The purpose of the present review is to evaluate the effects of common risk factors for suicide by meta-analyses using data extracted from studies based on the psychological autopsy method. We focused on five common risk factors of suicide: substance-related disorders, mood disorders, adverse marital status, adverse employment status, and self-harm behaviors. A total of 24 articles were identified from MEDLINE in which the crude odds ratio (OR) could be calculated for the above five risk factors through 30 April 2007, using such search keywords as "suicide," "psychological autopsy," and "case-control study." Overall, both substance-related disorders [OR = 5.24; 95% confidence interval (CI) = 3.30-8.31] and mood disorders [OR = 13.42; 95% CI = 8.05-22.37] were strongly associated with suicidal risk. Suicidal attempt and deliberate self-harm, which can directly lead to completed suicide, have been shown to be very strongly associated with suicidal risk [OR = 16.33; 95% CI = 7.51-35.52]. Effects of social factors such as adverse marital and employment status were relatively small. As substance-related disorders and mood disorders were strongly associated with an increased risk of completed suicide, the comorbidity of these two disorders should be paid a maximum attention. The effective prevention of suicide depends on whether we can successfully incorporate these personal factors as well as social factors into an adequate multi-factorial model.

Familial transmission of suicidal behavior

Adoption and twin studies show that familial transmission of suicidal behavior is partly attributable to genetic factors. Transmission of suicidal behavior is mediated by transmission of impulsive aggression or neuroticism and neurocognitive deficits. The most plausible explanations for nongenetic familial transmission are the intergenerational transmission of abuse and adverse familial environments. Bereavement and relationship disruption contribute to suicidal risk via the development of complicated grief, although long-term effects may be mediated by a complex chain of interrelated events. Imitation may contribute to suicidal risk, at least in attempted suicide. However, so-called family environmental factors often are related to risk factors that are heritable. Conversely, genetic factors exert their impact on depression and suicidal behavior via interaction with a stressful environment.

Pregnancies in high psychosocial risk groups: research findings and implications for early intervention

Besides the well-known risk factors for youth suicidal behavior, recent evidence suggests that risk for youth suicidal behavior can be determined even very early in life, during the prenatal and perinatal period. Low birth weight and short birth length adjusted for gestational age were found to increase the risk for suicidal behavior, particularly by violent means. Several parental factors like low parental socioeconomic status, teenage and single parenthood, multiparity and parental psychopathology, substance abuse and suicidal behavior have been linked to an increase in youth suicidal behavior. Effective collaboration among the sectors within health care and social services is crucial for early detection and adequate intervention.

Interaction of child and family psychopathology leading to suicidal behavior

According to the Centers for Disease Control and Prevention, suicide is the third leading cause of death in adolescence in the United States. Nonfatal forms of suicidal behavior are the most common reasons for the psychiatric hospitalization of adolescents in many countries. The risk for suicide attempt among offspring of suicide completers is multifactorial, challenging experts to develop a strategy that includes assessment and management that consider these factors. Although treatment of depression is necessary, antisuicide treatment strategies that solely target depression may not be sufficient to reduce suicidal risk. Other factors, such as impulsive aggression and parental history of sexual abuse, also contribute to suicidal risk.

Maternal suicidality and suicide risk in offspring

A considerable number of studies linking family history and high risk for suicide have reported that suicidality runs in families. Community studies that avoid a selection effect confirm these findings. These results seem independent of comorbidities such as depression, anxiety, substance use, and personality disorders. Furthermore, the results are stable over treatment settings, different age groups, and gender. Community studies interviewing families directly (family interview method) are primarily focused on maternal suicidality and suicidality in offspring. Two studies observed some indications for suicide attempts in young offspring of mothers (and fathers) who had attempted suicide compared with offspring of mothers who had no suicidality.

Adverse childhood experiences and suicidal behavior

Early experiences of physical and sexual abuse and parental neglect are risk factors for suicidal behavior in adolescence and adulthood. This article reviews the correlational, retrospective findings, emphasizing the more recent prospective and familial transmission studies that explore the factors mediating the relationship between childhood abuse/neglect and suicidal behavior. Related areas of research such as protective factors and the personality traits that are possible risk factors that mediate this relationship are reviewed. Research on the neurobiologic correlates of trauma that might have implications for understanding suicidal behavior is discussed, and several models for the study of the relationship between childhood adverse experiences and suicidal behavior are described.

Les taux de suicide des jeunes hommes québécois : facteurs de risques et de protection

Des indicateurs socioprofessionnels, familiaux et scolaires ont été mis en relation avec les taux de suicide des jeunes hommes et femmes de 15-19 ans et 20-24 ans pour la période 1979-1999. Des corrélations significatives montrent que la croissance des taux est reliée positivement pour les adolescents de 15-19 ans à l’augmentation des taux de divorce et de familles monoparentales et que les taux de suicide sont négativement reliés aux taux d’activité. Plusieurs indicateurs scolaires montrent également des relations significatives avec ces taux de suicide. Toutefois, lorsque l’ensemble des indicateurs sont introduits dans des analyses de régression dans un modèle multivarié, seuls les taux de divorce et de familles monoparentales conservent leur pouvoir de prédiction chez les hommes des deux catégories d’âge. Ces analyses ne retiennent que le taux de familles monoparentales chez les filles de 15-19 ans et le taux d’activité chez celles de 20-24 ans. Les résultats suggèrent l’augmentation de certains facteurs à risque du suicide chez les jeunes, reliée à une dislocation grandissante des familles, premier lieu des relations d’attachement. D’autre part, les difficultés d’accéder à l’emploi chez les jeunes femmes contribueraient à affaiblir le soutien social qui permet la confirmation de leur valeur et l’accès à leur autonomie.

Suicide ideation among later elementary school-aged youth

Suicide is extremely rare among persons under age 15 years old. Nationwide, it has been reported that 18% of students in grade 6 had thoughts of killing themselves. The Social Disintegration Model (SDM) summarizes intra-personal, interpersonal, peer network, physical and heath risk behaviour characteristics that may influence suicide ideation. As part of a larger study to test a family strengthening programme, 179 later elementary school children from two cities responded to 20 items about their participation in health risk behaviour. Sixteen youth indicated they had thought of killing themselves. Based on the SDM, these 16 youth were compared with the larger sample on measures of ways of coping; family communication, functioning and caring; school connectedness, pubertal development; and alcohol use and weapon carrying. Youth who responded positively to the 'thought of killing self' screening question, felt less connected to their school, used more internalizing behaviours and reported less cohesion, open communication, supervision and family caring than youth who answered no. Youth who thought of killing themselves may benefit from additional school support to feel more comfortable and connected at school. Community resources may help parents modify child-rearing behaviours. Building communication among parents and youth may prevent suicidal behaviour among young adolescents.

Sleep disturbance preceding completed suicide in adolescents

We examined sleep difficulties preceding death in a sample of adolescent suicide completers as compared with a matched sample of community control adolescents. Sleep disturbances were assessed in 140 adolescent suicide victims with a psychological autopsy protocol and in 131 controls with a similar semistructured psychiatric interview. Rates of sleep disturbances were compared between groups. Findings indicate suicide completers had higher rates of overall sleep disturbance, insomnia, and hypersomnia as compared with controls within both the last week and the current affective episode. Group differences in overall sleep disturbance (both within the last week and present episode), insomnia (last week), and hypersomnia (last week) remained significant after controlling for the differential rate of affective disorder between groups. Similarly, overall sleep disturbance (last week and present episode) and insomnia (last week) distinguished completers in analyses accounting for severity of depressive symptoms. Only a small percentage of the sample exhibited changes in sleep symptom severity in the week preceding completed suicide, but of these, a higher proportion were completers. These findings support a significant and temporal relationship between sleep problems and completed suicide in adolescents. Sleep difficulties should therefore be carefully considered in prevention and intervention efforts for adolescents at risk for suicide.

Familial transmission of suicidal behavior: factors mediating the relationship between childhood abuse and offspring suicide attempts

BACKGROUND

Self-reported childhood sexual abuse is associated with major depression and with suicidal behavior. The current study investigates the relationship between reported childhood abuse and the familial transmission of suicidal behavior and other related risk factors.

METHOD

507 offspring of 271 parent probands with DSM-IV major depressive disorder were compared according to the reported childhood abuse history on demographic, diagnostic, and clinical variables related to risk for suicidal behavior. Both self-report and clinical interview measures assessed history of childhood physical and sexual abuse. The study was conducted from May 1997 to February 2004.

RESULTS

Reported childhood sexual abuse, but not physical abuse, in the proband correlated with suicide attempts, posttraumatic stress disorder, earlier onset of major depressive disorder, higher levels of impulsivity, and greater likelihood of childhood sexual abuse in the offspring and was rarely perpetrated by the affected parent. A reported history of childhood physical abuse was related to more lifetime aggression in the offspring.

CONCLUSIONS

Reported childhood sexual abuse is a risk factor for suicidal behavior in parent and offspring. Transmission of suicide risk across generations is related to the familial transmission of sexual abuse and impulsivity. Sexual abuse is not directly transmitted by the victim to the next generation and may be related to family dynamics related to sexual abuse.

Evaluation of clinical prognostic models for suicide attempts after a major depressive episode

OBJECTIVE

In this study, we compare the performance of prognostic models of increasing complexity for prediction of future suicide attempt.

METHOD

Using data from a 2-year prospective study of 304 depressed subjects, a series of Cox proportional hazard regression models were developed to predict future suicide attempt. The models were evaluated in terms of discrimination (the ability to rank subjects in order of risk), calibration (accuracy of predicted probabilities of attempt), and sensitivity and specificity of risk group stratification based on cross-validated predicted probabilities.

RESULTS

Although an additive model with past attempt, smoking status, and suicidal ideation achieved 75% (cross-validated) sensitivity and specificity, models that performed best in terms of discrimination included interactions between predictor variables.

CONCLUSION

As several models had similar predictive power, clinical considerations and ease of interpretation may have a significant role in the final stage of model selection for assessing future suicide attempt risk.

Risk factors for suicide in China's youth: a case-control study

BACKGROUND

Suicide is the most common cause of death among youth in China.

METHOD

A case-control psychological autopsy study in 23 geographically representative disease surveillance points around China collected information from family members and close associates of 114 persons aged 15-24 years who died by suicide (cases) and 91 who died of other injuries (controls).

RESULTS

Among the 114 suicides 61% were female, 88% lived in rural villages, 70% died by ingesting pesticides (most commonly stored in the home), 24% previously attempted suicide, and 45% met criteria of a mental illness at the time of death. Multivariate logistic regression identified several independent risk factors: severe life events within 2 days before death (OR 31.8, 95% CI 2.6-390.6), presence of any depressive symptoms within 2 weeks of death (OR 21.1, 95% CI 4.6-97.2), low quality of life in the month before death (OR 9.7, 95% CI 2.8-34.1), and acute stress at time of death (moderate: OR 3.1, 95% CI 0.8-11.9; high: OR 9.1, 95% CI 1.2-66.8). A significant interaction between mental illness at time of death and gender indicated that diagnosis was an important predictor of suicide in males (OR 14.0, 95% CI 2.6-76.5) but not in females (OR 0.3, 95% CI 0.0-3.6). Prior suicide attempt was related to suicide in the univariate analysis (OR 57.5) but could not be included in the multivariate model because no controls had made prior attempts.

CONCLUSIONS

Suicide prevention efforts for youth in China must focus on restricting access to pesticides, early recognition and management of depressive symptoms and mental illnesses, improving resiliency, and enhancing quality of life.

What prevents adolescents from seeking help after a suicide education program?

Perceived barriers to help-seeking among adolescents attending a suicide education program were examined. A total of 854 high school students in Colorado completed one of two questionnaires, measuring barriers to help-seeking for self or friend. The most prominent barriers for self were: inability to discuss problems with adults, self-overconfidence, fear of hospitalization, and lack of closeness to school adults. The most prominent barriers for troubled friends were: friendship concerns, unapproachability of school adults, fear of friend's hospitalization, and underestimating friend's problems. Results reveal multiple constraints limiting the program's utilization, supporting the need for comprehensive system approaches to suicide prevention.

Social and interpersonal factors relating to adolescent suicidality: a review of the literature

This article reviews the empirical literature concerning social and interpersonal variables as risk factors for adolescent suicidality (suicidal ideation, suicidal behavior, death by suicide). It also describes major social constructs in theories of suicide and the extent to which studies support their importance to adolescent suicidality. PsychINFO and PubMed searches were conducted for empirical studies focused on family and friend support, social isolation, peer victimization, physical/sexual abuse, or emotional neglect as these relate to adolescent suicidality. Empirical findings converge in documenting the importance of multiple social and interpersonal factors to adolescent suicidality. Research support for the social constructs in several major theories of suicide is summarized and research challenges are discussed.

Prevalence and correlates of suicidal behaviour among adolescents in southwest Nigeria

BACKGROUND

Despite being recognized by the World Health Organization as a significant social and health concern, information on suicidal behaviours in Nigerian adolescents is unknown.

AIMS

To establish the prevalence and associated psychosocial correlates of suicidal ideation and attempts in Nigerian youth.

METHODS

Stratified sampling was used to identify youth aged 10-17 years who completed the Nigeria version of the Global School Health Questionnaire (GSHQ) and the Diagnostic Predictive Scale (DPS) for youths (suicidal behaviour questions) in a classroom setting.

RESULTS

A total of 1429 youth completed the instruments. Over 20% reported suicidal ideation and approximately 12% reported that they had attempted suicide in the last year. Adolescents living in urban areas, from polygamous or disrupted families, had higher rates of suicidal behaviour. Multiple psychosocial factors such as sexual abuse, physical attack and involvement in physical fights were significant predictors of suicidal behaviour.

CONCLUSION

Factors associated with suicidal ideation and behaviours are similar to those found in other studies but the rates of both suicidal ideation and attempts are towards the upper limit of rates for youth. This study suggests that there is an urgent need for Nigerian policymakers and health providers to review and address this issue.

Current psychiatric morbidity, aggression/impulsivity, and personality dimensions in child and adolescent suicide: a case-control study

OBJECTIVE

The present study was designed to evaluate psychiatric risk factors for child and adolescent suicide, and to determine the association between impulsive-aggressive and other personality traits, and suicide completion in this population.

METHOD

Psychiatric diagnoses, impulsive-aggressive and other personality traits were assessed in 55 child and adolescent suicide victims and 55 community controls using semi-structured proxy-based interviews and questionnaires.

RESULTS

The most significant psychiatric risk factors associated with child and adolescent suicide were depressive disorders (OR=48.414, 95% CI 6.247-375.185), substance/alcohol abuse disorder (OR=5.365, 95% CI 1.434-20.076), and disruptive disorders (OR=13.643, 95% CI 2.292-23.16). Additionally, suicide victims showed higher scores on lifetime aggression/impulsivity, and harm avoidance. However, after logistic regression, the only independent significant predictors of suicide in this age group were the presence of depressive disorders (Adjusted OR (AOR)=39.652, 95% CI 4.501-349.345), substance/alcohol abuse disorders (AOR=7.325, 95% CI 1.127-47.62), and disruptive disorders (AOR=6.464, 95% CI 1.422-29.38).

LIMITATIONS

Relatively small sample size, and cross-sectional design.

CONCLUSIONS

Our findings confirm the existence of a particular clinical profile of children and adolescents at high risk for suicide. Additionally, our results reinforce the need for improved understanding of the interrelationships between stressors, depression, substance/alcohol abuse disorders, disruptive disorders and personality traits/dimensions in youth suicidal behavior.

Risk factors for the incidence and persistence of suicide-related outcomes: a 10-year follow-up study using the National Comorbidity Surveys

BACKGROUND

We report prospective associations of baseline risk factors with the first onset and persistence of suicide-related outcomes (SROs; ideation, plans, gestures, and attempts) over a 10-year interval among respondents who participated in both the 1990-02 National Comorbidity Survey (NCS) and the 2000-02 National Comorbidity Survey follow-up (NCS-2).

METHODS

A total of 5001 NCS respondents were re-interviewed (87.6% of baseline sample) in the NCS-2. Three sets of baseline (NCS) risk factors were considered as predictors of the first onset and persistence of SROs: socio-demographics, lifetime DSM-III-R disorders, and SROs.

RESULTS

New onsets included 6.2% suicide ideation, 2.3% plan, 0.7% gesture, and 0.9% attempts. More than one-third of respondents with a baseline history of suicide ideation continued to have suicide ideation at some time over the intervening decade. Persistence was lower for other SROs. The strongest predictors of later SROs were baseline SROs. Prospective associations of baseline mental disorders with later SROs were largely limited to the onset and persistence of ideation.

LIMITATIONS

Although data were gathered prospectively, they were based on retrospective reports at both baseline and follow-up.

CONCLUSIONS

Baseline history of SROs explained much of the association of mental disorders with later SROs. It is important clinically to note that many of the risk factors known to predict onset of SROs also predict persistence of SROs.

Detecting and treating depression among adolescents presenting for reproductive care: realizing opportunities

This article reviews typical symptoms of depression presented by adolescents in the reproductive care practice setting, provides an overview of the assessment process, and offers options for referral and/or treatment of this common, yet often unrecognized, mood disorder. Because females have a two-fold higher prevalence rate of depressive disorders as compared to males of the same age and because reproductive care providers have exceptional access to females during the early reproductive years, these physicians have a unique, but often unrealized, opportunity to detect and initiate treatment and/or referrals for depression in adolescent patients. Indeed, adolescents often discuss symptoms of depression with their reproductive care provider with an expectation that they will serve as a "first responder" in terms of assisting in the management of the depression. Thus, it is important that the provider have an understanding of the disorder, its symptoms, and possible treatment modalities. Reproductive care providers are uniquely qualified to identify, assess, and treat many types of mood disorders in adolescent females.

Smoking, psychosocial factors, psychopathologic behavior, and other related conditions in hospitalized youth suicide attempters

BACKGROUND

Comorbidity of suicidal behavior with various risk factors has been reported. This study examines the combined effect and the interactions of the most prominent risk factors in hospitalized suicide attempters.

METHOD

Seventy-six successive hospitalized suicide attempters and 76 matched control subjects, 9 to 20 years old, were subjected to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I and Axis II diagnoses and were interviewed for the use of licit and illicit substances. Also, 18 control subjects with the same psychiatric disorders diagnosed in the attempters were examined. Logistic regression analysis was applied to determine the independent effect of the risk factors to suicide attempts.

RESULTS

The findings showed an 18-fold greater frequency of psychiatric disorders, a 14-fold greater frequency of other conditions that may be a focus of clinical attention (mainly relational problems), a 9.7-fold greater frequency of smoking, and a 4.7-fold greater frequency of psychosocial and environmental problems in the attempters than in the control subjects. The independent association of these factors with increased suicide risk persisted after adjusting for the effect of other factors.

CONCLUSIONS

Psychopathologic behavior, psychosocial factors, and smoking are independently associated with increased risk for serious suicide attempts.

Attempted and completed suicide in adolescence

Suicide is the third leading cause of death in adolescence, and medically serious suicide attempts occur in approximately 3% of adolescents. This review examines a number of risk factors that contribute to suicidal behavior. A prior suicide attempt is one of the best predictors of both a repeat attempt and eventual completed suicide. Depression, disruptive behavior disorders, and substance-use disorders also place adolescents at high risk for suicidal behavior, with comorbidity further increasing risk. Research on families indicates that suicidal behavior is transmitted through families. Groups at high risk for suicidal behavior include gay, lesbian, and bisexual youths, incarcerated adolescents, and homeless/runaway teens. Although abnormalities in the serotonergic system have not been consistently linked to suicidal behavior, genetic and neurobiologic studies suggest that impulsive aggression may be the mechanism through which decreased serotonergic activity is related to suicidal behavior. Findings from prevention and intervention studies are modest and indicate the need for substantially more theory-driven treatment research.

Suicidal ideation among Viennese high school students

OBJECTIVE

Suicidality spans a spectrum ranging from suicidal thoughts to suicidal acts, and suicidal ideation is more prevalent in youth populations, suggesting important developmental issues. We assessed the prevalence of lifetime suicidal ideation and associated psychosocial factors among Viennese high school students.

METHOD

An anonymous self-report survey assessing demographic characteristics and the major psychiatric risk factors of teenage suicide was completed by students at three Viennese high schools (n = 214; mean age 15.4 years).

RESULTS

Eighty-one (37.9%) high school students reported having had suicidal thoughts at some point in their lives, girls significantly more often than boys (48.5% vs. 29.1%, P = 0.004). Furthermore, lifetime suicidal ideation in Viennese high school students was associated with living in broken-home families, cigarette smoking, substance problems (alcohol/drugs), self-reported depression, and high school type (the highest prevalence was in grammar school). After adjusting for confounders, we found that female gender, substance problems, school type and cigarette smoking were significantly associated with lifetime suicidal ideation in Viennese high school students.

CONCLUSIONS

The psychosocial factors associated with adolescent suicidal ideation require attention in the contexts of suicide prevention and mental health promotion.

Screening for suicide risk in the pediatric emergency and acute care setting

PURPOSE OF REVIEW

This paper reviews epidemiology, psychiatric comorbidities, risk factors, warning signs, screening measures, and issues related to screening for suicide risk in the pediatric emergency department and acute care settings.

RECENT FINDINGS

For the first time in over a decade, rates of adolescent suicide are increasing. A recent review found physician gatekeeper training to be one of only two effective prevention strategies. Limited methods exist to assess for suicide risk in pediatric acute care settings that are able to meet the demands and challenges presented in time-limited medical settings.

SUMMARY

Suicide is the third leading cause of death in adolescents. Although a prior suicide attempt is the single most important risk factor, affective, cognitive, family and peer factors also affect risk of completed suicide. Practitioners in the acute care and emergency department setting are well positioned to identify, assess, and appropriately refer these adolescents and their families. Screening instruments in this setting need to be accurate, brief, and relevant to patients, families, and providers. We propose a two-question algorithm that targets imminent risk for a suicide attempt. This type of screening also needs to be accompanied by hospital or community-based support systems for further assessment, intervention and follow-up.

Coping mechanisms, stressful events and suicidal behavior among youth admitted to juvenile justice and child welfare services

This study examines the relationship between coping mechanisms and suicide attempts among 84 adolescents in the Quebec youth residential services. A new measure based on in-depth interviews is used to identify coping mechanisms. The suicidal youths used fewer adequate coping mechanisms than nonsuicidal youths when faced with comparable stressful events. Negative cognitive reframing, anger, and blaming others were more frequently reported by the suicidal youths. Contrary to certain theoretical conceptions, coping mechanisms were not stable and varied according to the context of the suicidal crisis. These findings indicate the usefulness of this approach to measure coping mechanisms and support the importance of programs aimed at developing coping skills for suicide prevention.

An Analysis of Parent-Female Adolescent Relationships in Female Adolescent Suicides

This study analyzed Turkish female adolescent-family relations, which is believed to be one of the significant factors in female adolescents' suicide attempts, from a multidimensional perspective. The Parent-Adolescent Relationship Inventory, a multidimensional evaluation tool based on the behavioral family-system approach was used as a research tool. The inventory consists of the concepts and techniques of behavioral theory, family system theory, and cognitive theory in parent-adolescent' problems and conflicts. Based on these theories, the parent-adolescent relations inventory (PARQ), involves three main dimensions: problem solving and communication skills, cognitive/internalized beliefs, and functions and structures in family systems. There are two forms of the inventory, the adolescent form and the parent form. Only the adolescent form of PARQ, including 284 items, was used in this research. The inventory also consists of 16 subscales. It was adapted into Turkish by Eryüksel (1996) . The subjects of the study were 52 female adolescents who had attempted suicide and were taken to the Emergency Department of The Faculty of Medicine in Çukurova University, and 52 normal female adolescents from two different secondary schools at the southern province in Turkey. The age range of the clinical and normal groups were 14–18 ([Formula: see text] = 16). The results of the study revealed that the general stress level of female adolescents who attempted suicide is higher than those of normal groups. The examination of family structures of these female adolescents made it clear that mothers were the mediator between fathers and adolescents. It was also observed that both mothers and fathers shared many somatic concerns.

Adolescent suicidal behavior: associations with preadolescent physical abuse and selected risk and protective factors

OBJECTIVES

To determine whether preadolescent physical abuse raises the risk of adolescent suicidal behavior, to examine potential mediators and moderators of the relationship between preadolescent abuse and adolescent suicidality, and to examine whether distal (preadolescent) risk factors add to proximal (adolescent) factors in predicting suicidality.

METHOD

Seventy-five physically abused preadolescents on the New York City Maltreatment Register and 78 controls were studied at ages 10.5 and 16.5 years. Adolescent suicidal ideation and attempts and hypothesized risk and protective factors were assessed by self-report, parent interview, and teacher ratings. Data were analyzed by logistic regression.

RESULTS

Preadolescent physical abuse was a robust, largely unmediated, independent predictor of adolescent suicidality. Only adolescent internalizing problems mediated the relationship. No risk factors moderated the relationship. Adolescent attachment to parents and internalizing problems contributed independently to the prediction of suicidality risk in abused and control subjects. No preadolescent risk or protective factors added to the predictions beyond risk deriving from preadolescent abuse.

CONCLUSIONS

The association between preadolescent physical abuse and adolescent suicidality is largely unmediated and unmoderated by well-documented risk factors for suicidality. Therefore, comprehensive interventions to reduce abusive parenting must begin when families enter the child protection system, along with therapeutic interventions with the children and adolescents themselves.

An evaluation of crisis hotline outcomes. Part 2: Suicidal callers

In this study we evaluated the effectiveness of telephone crisis services/hotlines, examining proximal outcomes as measured by changes in callers' suicide state from the beginning to the end of their calls to eight centers in the U.S. and again within 3 weeks of their calls. Between March 2003 and July 2004, 1,085 suicide callers were assessed during their calls and 380 (35.0%) participated in the follow-up assessment. Several key findings emerged. Seriously suicidal individuals reached out to telephone crisis services. Significant decreases in suicidality were found during the course of the telephone session, with continuing decreases in hopelessness and psychological pain in the following weeks. A caller's intent to die at the end of the call was the most potent predictor of subsequent suicidality. The need to heighten outreach strategies and improve referrals is highlighted.

Texas Children's Medication Algorithm Project: update from Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder

OBJECTIVE

To revise and update consensus guidelines for medication treatment algorithms for childhood major depressive disorder based on new scientific evidence and expert clinical consensus when evidence is lacking.

METHOD

A consensus conference was held January 13-14, 2005, that included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review, update, and incorporate the most current data to inform and recommend specific pharmacological approaches and clinical guidance for treatment of major depressive disorder in children and adolescents.

RESULTS

Consensually agreed on medication algorithms for major depression (with and without psychosis) and comorbid attention-deficit disorders were updated. These revised algorithms also incorporated approaches to address issues of suicidality, aggression, and irritability. Stages 1, 2, and 3 of the algorithm consist of selective serotonin reuptake inhibitor and norepinephrine serotonin reuptake inhibitor medications whose use is supported by controlled, acute clinical trials and clinical experience. Recent studies provide support that selective serotonin reuptake inhibitors in addition to fluoxetine are still encouraged as first-line interventions. The need for additional assessments, precautions, and monitoring is emphasized, as well as continuation and maintenance treatment.

CONCLUSIONS

Evidence and expert clinical consensus support the use of selected antidepressants in the treatment of depression in youths. The use of the recommended antidepressant medications requires appropriate monitoring of suicidality and potential adverse effects and consideration of other evidence-based treatment alternatives such as cognitive behavioral therapies.

Suicide risk factors in children and adolescents with bipolar disorder

Suicidal behavior in children and adolescents with bipolar disorder is a major public health problem that remains understudied. Most research on suicidal behavior in bipolar disorder has been conducted in older adolescents and adults and is limited by retrospective design. Although preliminary research suggests that the early onset of bipolar disorder is associated with increased suicide risk, few studies have prospectively examined the effects of prior suicidal behavior, clinical course, comorbid psychiatric disorders, familial suicidality, and psychosocial factors on suicidal behavior in bipolar youths. More systematic research is needed to better understand suicidal behavior in bipolar children and adolescents. Increased knowledge of the risk factors that contribute to suicidal behavior should lead to better prevention and treatment.

Psychiatric illness, socioeconomic status, and marital status in people committing suicide: a matched case-sibling-control study

STUDY OBJECTIVE

Suicides cluster in both families and persons with psychiatric disorders and socioeconomic disadvantages. This study compares these factors between suicide cases, their siblings, and population based controls in an attempt to evaluate both the familial and the individual element of these factors.

DESIGN

Nested case-control study. Information on causes of death, psychiatric admission, marital status, children, and socioeconomic factors was obtained from routine registers.

SETTING

Denmark.

PARTICIPANTS

985 suicide cases, 1104 sex-age (+/-3 years) matched siblings, and 16 619 controls.

MAIN RESULTS

The suicide rate ratios obtained from the case-sibling and the case-control analysis, respectively, were of similar magnitude. For example, in the case-sibling analysis the adjusted suicide rate ratios associated with discharge from a psychiatric hospital within the previous 365 days, being unemployed the previous year, having a postgraduate degree and being single were 42.13 (95% CI 17.75 to 100.02), 1.78 (1.35 to 2.36), 0.51 (0.21 to 1.26), and 2.69 (1.91 to 3.79), respectively. The corresponding rate ratios obtained from the case-control analysis were 47.91 (35.41 to 64.83), 1.76 (1.49 to 2.08), 0.45 (0.26 to 0.76), and 2.39 (1.87 to 3.07). Moreover, the analogous ratios when comparing siblings and controls were 1.98 (1.08 to 3.63), 1.22 (1.06 to 1.41), 0.65 (0.44 to 0.95), and 0.89 (0.75 to 1.06).

CONCLUSIONS

People who commit suicide deviate similarly from siblings and controls in exposure to hospitalised psychiatric disorders and socioeconomic disadvantages, although these factors contribute to the familial aggregation of suicides.

Risk of adverse behavioral effects with pediatric use of antidepressants

OBJECTIVES

This article reviews evidence that led the Food and Drug Administration to issue a "black box" warning about the risk of "suicidality" (suicidal thoughts and behavior) in children and adolescents during treatment with antidepressants.

RESULTS

Re-analysis of data from randomized clinical trials of antidepressants in the pediatric population revealed a significantly greater overall (all drugs across all indications) risk ratio for drug 1.95 (95% Cl, 1.28-2.98) compared to placebo in this sample of approximately 4,000 subjects.

DISCUSSION

The essential message of the "black box" is to remind prescribers and consumers about the importance of monitoring closely for adverse behavioral changes during the initiation of (or changes in) antidepressant therapy. Possible mechanisms that might account for this phenomenon, particularly the so-called activation syndrome, are discussed.

CONCLUSION

Empirical studies are needed to identify the precursors of suicidality and to predict which individuals are most susceptible to adverse behavioral side effects of antidepressants.

Psychopharmacologic treatment of pediatric major depressive disorder

RATIONALE

The role of pharmacotherapy in the treatment of major depressive disorder (MDD) in youth has received much attention in recent years due to concerns of efficacy and safety of the antidepressants for the treatment of MDD in youth.

OBJECTIVES

This review describes the existing published and unpublished literature regarding the efficacy and short-term safety of the antidepressants and decision-making process required for the use of these medications for youth with MDD. In addition, current continuation and maintenance treatments are discussed.

RESULTS

In general, nine depressed youth must be treated with an antidepressant to obtain one clinical response above that achieved with placebo. To date, fluoxetine has showed the most consistent positive treatment effects. Depressed youth had also acutely responded to other antidepressants, but the response to placebo has also been high. Overall, the antidepressants are well tolerated, but 1-3 children and adolescents of 100 taking antidepressants showed onset or worsening of suicidal ideation and, more rarely, suicide attempts.

CONCLUSIONS

There is a positive risk-benefit ratio for the use of antidepressants in the acute treatment of depressed youth. First-line antidepressant treatment with-or without-specific types of psychotherapy is indicated for youth with MDD of at least moderate severity. All youth taking antidepressants must be closely monitored for suicidality and medication side effects. Many youth will likely require psychotherapy or additional medication treatments to address comorbid disorders. Treatments to prevent relapses and recurrences require further study.