Child and adolescent suicide: epidemiology, risk factors, and approaches to prevention

Animal models of suicide-trait-related behaviors

Although antidepressants are moderately effective in treating major depressive disorder (MDD), concerns have arisen that selective serotonin-reuptake inhibitors (SSRIs) are associated with suicidal thinking and behavior, especially in children, adolescents and young adults. Almost no experimental research in model systems has considered the mechanisms by which SSRIs might be associated with this potential side effect in some susceptible individuals. Suicide is a complex behavior and impossible to fully reproduce in an animal model. However, by investigating traits that show strong cross-species parallels in addition to associations with suicide in humans, animal models might elucidate the mechanisms by which SSRIs are associated with suicidal thinking and behavior. Traits linked with suicide in humans that can be successfully modeled in rodents include aggression, impulsivity, irritability and hopelessness/helplessness. Modeling these relevant traits in animals can help to clarify the impact of SSRIs on these traits, suggesting avenues for reducing suicide risk in this vulnerable population.

Disruption of orbitofrontal cortex laterality in offspring from multiplex alcohol dependence families

BACKGROUND

Increased susceptibility for developing alcohol dependence (AD) might be related to structural differences in brain circuits that influence the salience of rewards and/or modify the efficiency of information processing. The role of the orbitofrontal cortex (OFC) in regulating emotional processing is increasingly being recognized along with its association with impulsive behavior.

METHODS

Magnetic resonance imaging was used to measure the OFC in 107 high- and low-risk offspring (mean age 17.6 +/- 4.69 years) from either multiplex AD families or control families. Region of interest measures including segmented values were obtained by reliable raters using BRAINS2 software. Statistical analyses were adjusted for intracranial volume, age, socioeconomic status (SES), IQ, and handedness. The Multidimensional Personality Questionnaire (MPQ) was administered to determine scale scores for Control. Genotyping was performed for the serotonin transporter (5-HTT) gene and the brain-derived neurotrophic factor (BDNF) gene.

RESULTS

High-risk offspring from multiplex for AD families showed decreased right/left OFC volumes in comparison with control subjects. Smaller volume in the right hemisphere was significantly associated with variation in the 5-HTT and BDNF genes. White matter (WM) ratios showed a positive correlation with MPQ Control scale scores, indicating that reduced OFC WM is related to greater impulsivity.

CONCLUSIONS

Offspring from multiplex families for AD manifest genetic susceptibility by exhibiting disruption in the laterality of the OFC volume that is related to greater impulsivity (lower Control scale scores). This disruption in OFC laterality is related to variation in genes associated with neuronal growth.

Psychiatric comorbidity more common among adolescent females with CD/ODD than among males

Clinicians and researchers have been increasingly concerned on conduct problems among adolescent females. Yet, most research on the issue has been conducted among males. The aim of this study was to characterize conduct disorder (CD) among adolescent females in comparison with males. Family background, symptoms and severity of CD, and psychiatric comorbidity were assessed among Finnish 12-18-year-old females (n=40) with conduct disorder/oppositional defiant disorder (CD/ODD) compared with males (n=37). Data were collected via structured interviews with the subjects and interviews with parents. Lifetime and current Axis I diagnoses (DSM-IV) were assessed using the Structured Clinical Interview (SCID-I) interview. No gender differences were found in the number of CD symptoms or aggressive symptoms. Family adversities, comorbid major depression, anxiety disorders and substance use disorders as well as suicidality were more common, while reading disorder was less common among girls compared with boys. The varied problems and comorbid disorders among females with CD/ODD are important to recognize.

Detecting suicidality among adolescent outpatients: evaluation of trained clinicians' suicidality assessment against a structured diagnostic assessment made by trained raters

BACKGROUND

Accurate assessment of suicidality is of major importance. We aimed to evaluate trained clinicians' ability to assess suicidality against a structured assessment made by trained raters.

METHOD

Treating clinicians classified 218 adolescent psychiatric outpatients suffering from a depressive mood disorder into three classes: 1-no suicidal ideation, 2-suicidal ideation, no suicidal acts, 3-suicidal or self-harming acts. This classification was compared with a classification with identical content derived from the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-PL) made by trained raters. The convergence was assessed by kappa- and weighted kappa tests.

RESULTS

The clinicians' classification to class 1 (no suicidal ideation) was 85%, class 2 (suicidal ideation) 50%, and class 3 (suicidal acts) 10% concurrent with the K-SADS evaluation (gamma2 = 37.1, df 4, p = 0.000). Weighted kappa for the agreement of the measures was 0.335 (CI = 0.198-0.471, p < 0.0001). The clinicians under-detected suicidal and self-harm acts, but over-detected suicidal ideation.

CONCLUSION

There was only a modest agreement between the trained clinicians' suicidality evaluation and the K-SADS evaluation, especially concerning suicidal or self-harming acts. We suggest a wider use of structured scales in clinical and research settings to improve reliable detection of adolescents with suicidality.

Hyperactivity-inattention symptoms in childhood and suicidal behaviors in adolescence: the Youth Gazel Cohort

OBJECTIVE

Although a link has been suggested between attention deficit/hyperactivity disorder (ADHD) and completed suicide, little is known about the association with suicidal behaviors in community settings. This study addresses the relationship between childhood hyperactivity-inattention symptoms (HI-s) and subsequent suicidal behaviors.

METHOD

Nine hundred sixteen subjects aged 7-18 were recruited from the general population and surveyed in 1991 and 1999. Parent and adolescent self-reports provided psychopathology and suicidal behavior pattern measures. Multivariate modeling was used to evaluate the effects of childhood HI-s and other risk factors on adolescent suicidal behaviors.

RESULTS

In males, HI-s independently accounted for the risk of lifetime suicide plans/attempts (OR=3.25, P = 0.02) and adolescent 12-month prevalence rates of suicide plans/attempts (OR=5.46, P = 0.03). In females, HI-s did not independently heighten the likelihood of suicidal behaviors.

CONCLUSION

This survey suggests a possible specific link between HI-s and suicide plans/attempts in males.

Adolescent alcohol involvement and suicide attempts: toward the development of a conceptual framework

The present article provides a conceptual framework of the relation between alcohol involvement (A) and suicide attempts (S). This framework can be broadly construed to reflect two dimensions: directionality (direction of causality; A-->S, S-->A, or a spurious relation) and temporality (distinguishing between proximal and distal effects of both behaviors). We review and evaluate the evidence on the association between A and S among adolescents using this conceptual framework as a guide. The extant data suggest that this relation is complex and not fully understood. Further, it seems unlikely that a single approach will be found to determine direction of causality, and the specification and validation of hypothesized mechanisms will involve a variety of different types of evidence. Suggestions for additional research using informative designs are discussed.

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.

Attempted suicide and associated risk factors among youth in urban Japan

BACKGROUND

Suicide is a major social and health issue in Japan. We assessed prevalence of attempted suicide and explored individual, interpersonal, behavioral, and psychological risk factors associated with attempted suicide in a general community sample of youth in a metropolitan Japanese city.

METHOD

Survey of 2,095 participants age between 15 and 24 who were recruited using street-intercept techniques.

RESULTS

Overall, 6% of males and 11% of females reported a prior suicide attempt. For males, attempted suicide was independently associated with experience of school bullying, being homosexual or bisexual, history of drug use, experience of unwanted sex, history of a diagnosed sexually transmitted infection, and low self-esteem. For females, attempted suicide was independently associated with being younger (ages 15-19 compared to 20-24), experience of school bullying, history of drug use, and history of smoking.

CONCLUSION

Prevention intervention programs for youth in Japan are necessary to achieve national aims to reduce attempted suicides and suicide mortality.

Risk factors for suicide in Taiwanese college students

OBJECTIVE

The authors investigated the personality characteristics, psychopathology, parenting style, and family function among Taiwanese college students with high, moderate, and low suicidal risks.

PARTICIPANTS

The sample included 2,919 first-year college students (1,414 men, 1,505 women) from a university in Taipei, Taiwan.

METHODS

A self-administered questionnaire assessed domains covering demographics, personality, psychopathology, frequency of substance use, parenting style, family functioning, and suicidal behaviors. The authors used mixed models for data analysis.

RESULTS

The authors observed a positive linear trend between increased suicidal tendency and levels of neuroticism, harm avoidance, novelty seeking, psychopathology, and parenting styles of low affection, overprotection, and authoritarian controlling. Use of tobacco and alcohol and impaired family adaptation and cohesion were associated with high and moderate suicidal risks.

CONCLUSIONS

Personality, psychopathology, substance use, and familial factors are important correlates of suicidal risks among college students in Taiwan. Optimal suicide prevention strategies in the college setting should incorporate the multiple facets of suicidal risks.

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.

Differences in the clinical characteristics of adolescent depressive disorders

Our objective was to analyze differences in clinical characteristics and comorbidity between different types of adolescent depressive disorders. A sample of 218 consecutive adolescent (ages 13-19 years) psychiatric outpatients with depressive disorders was interviewed for DSM-IV Axis I and Axis II diagnoses. We obtained data by interviewing the adolescents themselves and collecting additional background information from the clinical records. Lifetime age of onset for depression, current episode duration, frequency of suicidal behavior, psychosocial impairment, and the number of current comorbid psychiatric disorders varied between adolescent depressive disorder categories. The type of co-occurring disorder was mainly consistent across depressive disorders. Minor depression and dysthymia (DY) presented as milder depressions, whereas bipolar depression (BPD) and double depression [DD; i.e., DY with superimposed major depressive disorder (MDD)] appeared as especially severe conditions. Only earlier lifetime onset distinguished recurrent MDD from first-episode MDD, and newly emergent MDD appeared to be as impairing as recurrent MDD. Adolescent depressive disorder categories differ in many clinically relevant aspects, with most differences reflecting a continuum of depression severity. Identification of bipolarity and the subgroup with DD seems especially warranted. First episode MDD should be considered as severe a disorder as recurring MDD.

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.

Pediatric poisonings in southeast of Turkey: epidemiological and clinical aspects

Current detailed information about the causes, management, and clinical course of acute childhood poisonings in Turkey is scarce. Therefore, we have conducted a descriptive study of children presenting with acute poisoning to the pediatric emergency department of Dicle University Hospital throughout an 8-month period. Two hundred unselected children with poisoning were evaluated in terms of clinical, epidemiological and socioeconomic aspects. The mean age of patients was 5.7 ± 4.0 years. The majority of the patients ( n = 108, 54%) were aged from 13 months to 4 years ( P < 0.05). In majority of patients (66.5%, n = 133), poisonings were accidental. Intentional poisonings accounted for 3.5% ( n = 7) and food poisoning accounted for 30% ( n = 60) of all cases. The families had more than three children in 129 (97%) of accidentally poisoned and in seven (100%) of intentionally poisoned patients, six were girls and one was a boy. The parents of most patients were uneducated. Furthermore, more than two third of families had low level of income. In all, 171 patients (85.5%) were discharged after an observation period of 24 h. Four patients died. In conclusion, factors such as low educational level of parents, presence of more than three children in the family, and low income increase the incidence of childhood poisonings. The low educational level of girls increases the incidence of intentional poisoning.

Suicidal behaviours in a population-based sample of French youth

OBJECTIVES

To estimate the prevalence of suicidal ideation and behaviours in a large, representative sample of French youth and to evaluate age and sex correlates.

METHOD

We surveyed a large (n = 1106) cohort of French adolescents and young adults, aged 15 to 26 years and diversified throughout France, using a mailed-in self-report questionnaire.

RESULTS

Lifetime prevalence rates for suicidal ideation, plans, and attempts were 47.2%, 14.8%, and 5.7%, respectively. Rates for female youth were higher than for male youth across the entire spectrum of suicide-related outcomes. Rates generally increased between the ages of 15 and 20 years and decreased after age 21.

CONCLUSIONS

The findings suggest that suicidal thoughts and behaviours are widespread phenomena among adolescents and constitute a major public health issue.

Psychological autopsy studies: the role of alcohol use in adolescent and young adult suicides

Alcohol abusers seem to be prone to both suicide attempts and completions. The relationship between alcohol abuse and suicide in adolescence is complex.

OBJECTIVES

To examine the role of alcohol abuse and dependence in adolescent suicide in psychological autopsy studies.

METHOD

A search in the National Library of Medicine (NLM) PubMed database using "adolescents" and "all child: 0-18 years" as the search terms for age and "psychological autopsy" as the search term for title or abstract.

RESULTS

Forty articles met the selection criteria and each one is described. There was a high prevalence of alcohol abuse detected in the studies (range 21.42% to 43.47% in samples aged under 20 years). Alcohol misuse was present in suicides in the form of chronic abuse, acute abuse and dependence.

CONCLUSIONS

Alcohol abuse and dependence is highly prevalent among adolescent suicides. In many studies, alcohol consumption is analyzed in combination with drug abuse. Further studies are necessary to clarify the prevalence of chronic and acute alcohol abuse in order to identify specific high-risk population groups and design antisuicidal interventions for them. Both acute and chronic alcohol use should be evaluated when assessing suicide risk in adolescents.

Minor depression in adolescence: phenomenology and clinical correlates

BACKGROUND

Depressions that fail to meet the diagnostic criteria for major depressive disorder (MDD) may be underdiagnosed and undertreated in adolescent population. Traditionally, they are not considered as serious conditions and the phenomenological nature and clinical correlates of these disorders are largely unknown. In the present study, we used a large, representative and age-standardized sample of adolescents to examine the phenomenology and clinical correlates of minor depression, a poorly understood condition included in the category of Depressive Disorder Not Otherwise Specified in Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revised (DSM-IV-TR).

METHODS

909 girls and 945 boys, with mean age of 14, were interviewed by professionals using the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA).

RESULTS

Although clearly milder condition than MDD, minor depression was associated with marked suicidal thoughts, plans and attempts, recurrences and a high degree of comorbidity. At this early age, despite that 14% of adolescents under 15 had suffered from depressive conditions with severe clinical implications, most of them failing to meet the diagnostic threshold for MDD, only 1.7% had received any psychiatric treatment. 40% of depressive adolescents who had attempted suicide had no contact with mental health services.

LIMITATIONS

Analyzed in a cross-sectional setting, no conclusions about long-term implications could be made.

CONCLUSIONS

The results highlight the clinical and public health significance of non-MDD depressions, e.g. minor depression, which need to be more carefully identified and treated at early age.

Improvement in cognitive and psychosocial functioning and self image among adolescent inpatient suicide attempters

BACKGROUND

Psychiatric treatment of suicidal youths is often difficult and non-compliance in treatment is a significant problem. This prospective study compared characteristics and changes in cognitive functioning, self image and psychosocial functioning among 13 to 18 year-old adolescent psychiatric inpatients with suicide attempts (n = 16) and with no suicidality (n = 39)

METHODS

The two-group pre-post test prospective study design included assessments by a psychiatrist, a psychologist and medical staff members as well as self-rated measures. DSM-III-R diagnoses were assigned using the SCID and thereafter transformed to DSM-IV diagnoses. Staff members assessed psychosocial functioning using the Global Assessment Scale (GAS). Cognitive performance was assessed using the Wechsler Adult Intelligence Scale, while the Offer Self-Image Questionnaire (OSIQ) was used to assess the subjects' self-image. ANCOVA with repeated measures was used to test changes from entry to discharge among the suicide attempters and non suicidal patients. Logistic regression modeling was used to assess variables associated with an improvement of 10 points or more in the GAS score.

RESULTS

Among suicide attempter patients, psychosocial functioning, cognitive performance and both the psychological self and body-image improved during treatment and their treatment compliance and outcome were as good as that of the non-suicidal patients. Suicidal ideation and hopelessness declined, and psychosocial functioning improved. Changes in verbal cognitive performance were more pronounced among the suicide attempters. Having an improved body-image associated with a higher probability of improvement in psychosocial functioning while higher GAS score at entry was associated with lower probability of functional improvement in both patient groups.

CONCLUSION

These findings illustrate that a multimodal treatment program seems to improve psychosocial functioning and self-image among severely disordered suicidal adolescent inpatients. There were no changes in familial relationships, possibly indicating a need for more intensive family interventions when treating suicidal youths. Multimodal inpatient treatment including an individual therapeutic relationship seems recommendable for severely impaired psychiatric inpatients tailored to the suicidal adolescent's needs.

Death and suicide among former child and adolescent psychiatric patients

BACKGROUND

Increased mortality rates among previous child and adolescent psychiatry (CAP) patients have been found in Scandinavian studies up to the 1980s. The suicide risk in this group has been estimated to be almost five times higher than expected. This article addresses two questions: Do Swedish CAP patients continue to risk premature death and what kind of information related to psychiatric symptoms and/or behavior problems can predict later suicide?

METHODS

Hospital files, Sweden's census databases (including immigration and emigration) and administrative databases (including the Swedish Hospital Discharge register and the Persons Convicted of Offences register), and the Cause of Death register were examined to determine the mortality rate in a group of 1,400 former CAP inpatients and outpatients over a period of 12-33 years. Observed and expected numbers of deceased were calculated with the prospective method and the standardized mortality ratio (SMR) method. The relative risk or the risk ratio (RR) is presented with 95% confidence intervals (CIs). Significance level tests were made using two-by-two tables and chi-square tests. The Cox proportional-hazards regression model was used for survival analysis.

RESULTS

Twenty-four males and 14 females died. Compared with the general population, the standardized mortality ratio in this group of CAP patients was significantly higher in both sexes. Behavioral problems, school problems, and co-morbid alcohol or drug abuse and criminality (including alcohol-related crimes) were found to be important predictors. Thirty-two deaths were attributed to suicide, intoxication, drug overdose, or accident; one patient died of an alcohol abuse-related disorder, and five patients died of natural causes. Suicide was the most common cause of death, but only 2 of these 19 cases were initially admitted for attempted suicide.

CONCLUSION

We suggest that suicide and death prevention among CAP patients may not be a psychiatric issue per se but a future function of society's juvenile social-welfare investments and juvenile-delinquency prevention programs.

Gender differences in life stressors associated with child and adolescent suicides in Singapore from 1995 to 2003

AIMS

This study explored gender differences in life stressors of children and adolescents who died by suicide. Three main classes of life stressors have been identified by previous research to be significant risk factors for suicide in children and adolescents: interpersonal/relationship problems, family problems, and academic/school problems.

METHODS

The sample consisted of 156 (89 males and 67 females) completed child and adolescent suicides in Singapore from 1995 to 2003. The age of these individuals ranged from 10 to 19 years with a mean age of 16.49 (SD = 2.59).

RESULTS

Significantly more females were found to have had interpersonal/ relationship problems as recent life stressors compared with males. No gender differences were found for the other two life stressors, family problems and academic/school problems. In addition, among the three life stressors studied, only interpersonal/relationship problems emerged as a significant predictor of female child and adolescent suicide.

CONCLUSIONS

Consistent with previous research literature, these findings contribute to a growing literature documenting the relatively larger impact of relational life stressors on child and adolescent female suicidality. Implications for suicide intervention and prevention, especially among young females, were discussed.

US suicide rates by age group, 1970-2002: an examination of recent trends

US suicide rates have declined in recent years, reversing earlier trends. We examined suicide rates among 4 age groups from 1970 to 2002 and the factors that may have contributed to the decline. We paid particular attention to newer anti-depressants because of recent concerns and controversy about a possible association with suicidal behaviors. These trends warrant more extensive analysis of suicide rates among specific subgroups, including consideration of additional variables that may influence rates differentially. The relative contributions of depression diagnosis and treatment, postsuicide attempt care, and other contextual factors (e.g., overall economic conditions) also deserve attention. If the decline is associated with contextual factors, clarifying these associations will better inform public policy decisions and contribute to more effective interventions for preventing suicide.

Characteristics of adolescent suicide attempters admitted to an acute psychiatric ward in Taiwan

BACKGROUND

To investigate the characteristics of adolescent suicide attempters in Taiwan, compare with Western reports and provide reference for suicide preventive interventions in adolescence.

METHODS

During a 3-year period, the charts of 109 adolescent psychiatric inpatients were retrospectively reviewed. Twenty-eight adolescents admitted to an acute psychiatric ward as a result of recent suicide attempts were investigated to unravel factors related to suicide. Fifty-five adolescents with at least 1 suicide attempt recently or in the past were analyzed for risk factors of suicidal behavior compared to others.

RESULTS

Of the 109 adolescents admitted, 28 (25.6%) patients had been admitted due to recent suicide attempt. The most common diagnosis was depressive disorder (50%), followed by bipolar disorder (14.3%), schizophrenia (14.3%), and finally adjustment disorder (10.7%). There were significantly more girls than boys who attempted suicide. Suicide attempts increased with age, but this trend was not statistically significant. The most common precipitating factors were school stress (46%), parent-child conflict (25%), and psychopathology (25%) including feeling of hopelessness and psychotic symptoms. Adolescents with substance abuse or panic symptoms comprised a higher risk group for suicide. After discharge, 34.9% (38/109) of patients were lost to follow-up, and 15.5% (11/71) of the follow-up patients continued to manifest suicidal behavior.

CONCLUSION

Our study confirms some previous Western reports that adolescents with depressive disorders commonly manifest suicide attempts. There are, however, some cultural differences in risk factors. School-related problems play an important role in Taiwan among the adolescent suicides, and prior suicide attempts predict future suicidal behavior. Enhancing school-based screening for adolescents with suicide risk and transferring them to psychiatric professionals for intervention is important. We should focus suicide prevention resources mainly on the adolescent population with psychiatric illness, prior suicide attempts, and with high risk factors.

Teenage suicide cluster formation and contagion: implications for primary care

BACKGROUND

We have previously studied unintentional as well as intentional injury deaths among teenagers living in the four northernmost counties, forming approximately 55% of Sweden with 908,000 inhabitants in 1991. During this work, we found what we suspected to be a suicide cluster among teenagers and we also suspected contagion since there were links between these cases. In this present study, we investigate the occurrence of suicide clustering among teenagers, analyze cluster definitions, and suggest preventive measures.

METHODS

A retrospective study of teenager suicides autopsied at the Department of Forensic Medicine in Umeå, Sweden, during 1981 through 2000. Police reports, autopsy protocols, and medical records were studied in all cases, and the police officers that conducted the investigation at the scene were interviewed in all cluster cases. Parents of the suicide victims of the first cluster were also interviewed. Two aggregations of teenager suicides were detected and evaluated as possible suicide clusters using the US Centers for Disease Control definition of a suicide cluster.

RESULTS

Two clusters including six teenagers were confirmed, and contagion was established within each cluster.

CONCLUSION

The general practitioner is identified as a key person in the aftermath of a teenage suicide since the general practitioner often meet the family, friends of the deceased, and other acquaintances early in the process after a suicide. This makes the general practitioner suitable to initiate contacts with others involved in the well-being of the young, in order to prevent suicide cluster formation and para-suicidal activities.

Adolescent suicide and suicidal behavior

This review examines the descriptive epidemiology, and risk and protective factors for youth suicide and suicidal behavior. A model of youth suicidal behavior is articulated, whereby suicidal behavior ensues as a result of an interaction of socio-cultural, developmental, psychiatric, psychological, and family-environmental factors. On the basis of this review, clinical and public health approaches to the reduction in youth suicide and recommendations for further research will be discussed.

Suicidal behaviour in adolescents: associations with parental marital status and perceived parent-adolescent relationship

BACKGROUND

Because equivocal findings exist with regard to the relationship between adolescents' suicidal behaviour and parental marital status, the aim of this study was to investigate this relationship and in particular the effect of the perceived parent-adolescent relationship on this association, taking into account the role of gender.

METHOD

For this purpose, self-report surveys were administered to a representative school-based sample of 2707 adolescents in Antwerp (Belgium).

RESULTS

1) Boys living in a single parent family reported more suicidal ideations and self-harming behaviour than boys living in an intact family or in a remarried family; 2) Girls living in a remarried family reported more suicidal ideations and self-harming behaviour than girls living in an intact or in a single parent family; 3) Even after controlling for the levels of perceived parent-adolescent relationship, these associations remained significant.

LIMITATIONS

The cross-sectional design, the retrospective assessment of suicidality and changes in family structure, the lack of external information and the assessment of the parent-adolescent relationship for both parents together, may have influenced the findings.

CONCLUSIONS

When assessing risk factors for adolescent suicidality, marital status of the parents may bear clinical importance. In contrast to other studies, the perceived parent-adolescent relationship did not alter this association, a finding that needs further study.

Suicidal tendencies and attitude towards freedom to choose suicide among Lithuanian schoolchildren: results from three cross-sectional studies in 1994, 1998, and 2002

BACKGROUND

Suicidal behaviour is increasingly becoming a phenomenon associated with young people and an important public health issue in Lithuania. However, there are very few studies evaluating impact of young peoples' attitudes towards suicide to their suicidal behaviour. A better understanding of the relations among the variables associated with suicidal ideation and threats in the normal population of adolescents may eventually result in a better understanding of the more serious forms of adolescent suicidal behaviour. The aim of the present study was to evaluate prevalence of suicidal tendencies among Lithuanian schoolchildren and to estimate its association with an attitude towards suicide in 1994-2002.

METHODS

Three country representative samples of schoolchildren, aged 11, 13 and 15, were surveyed in 1994 (n = 5,428), 1998 (n = 4,513), and 2002 (n = 5,645) anonymously in conformity with the methodology of the World Health Organization Cross--National study on Health Behaviour in School-aged Children (HBSC).

RESULTS

About one third of respondents reported about suicidal ideation, plans or attempts to commit suicide. In the study period of eight years, the percentage of adolescents who reported sometime suicidal ideation decreased but the percentage of adolescents who declared serious suicidal behaviour remained on the same high level (8.1%, 9.8% and 8.4% correspondingly in 1994, 1998 and 2002). Moreover, the number of suicidal attempts changed from 1.0% in 1994 to 1.8% in the year 1998 and to 1,7% in the year 2002. The schoolchildren's attitude towards suicide became more agreeable: 36.6%, 41.9% and 62.5% of respondents, correspondingly in 1994, 1998 and 2002, answered that they agree with a person's freedom to make a choice between life and suicide. A multiple logistic regression analysis with low level of suicidality and high level of suicidality versus non suicidal behaviour as dependent variables for gender, age, year of the survey and attitude towards freedom to choose suicide as independent variables approved a significant association between studied covariates over the entire study period.

CONCLUSION

Suicidal tendencies are quite frequent among Lithuanian adolescents. An increasing number of schoolchildren are expressing an agreeable attitude towards suicide. The approving attitude towards suicide among adolescents correlates with suicidal ideation and behaviour.

Psychopathological distress predicts suicidal ideation and self-harm in adolescent eating disorder outpatients

OBJECTIVE

This study evaluated the differences in suicidal behaviour between adolescent anorexia nervosa (AN) and bulimia nervosa (BN), and the association of age, menarche timing, duration of eating disorder (ED), depression and general psychopathological symptoms (GSI) with suicidal behaviour in adolescent ED.

METHODS

The study group comprised 57 adolescent outpatients (girls) attending for assessment because of eating disorders. Suicidal ideation, deliberate self-harm and suicidal attempts were assessed in self-report questionnaires.

RESULTS

In both ED groups, one adolescent had attempted suicide before assessment. Suicidal ideation and/or deliberate self-harm were reported in over half of the cases. Bulimics had significantly more suicidal ideation and deliberate self-harm than anorectics. In multivariate analysis, BN and depression predicted suicidal ideation, but only GSI persisted as predicting deliberate self-harm.

CONCLUSIONS

Suicidal behaviour is common in adolescent ED. Type of ED (BN), depression and higher GSI are strongly associated with suicidal ideation and deliberate self-harm. Our results point to the need to evaluate psychopathological symptoms in adolescent ED, especially in BN, in the initial assessment to prevent severe suicidal behaviour.

Suicidality in adjustment disorder--clinical characteristics of adolescent outpatients

OBJECTIVE

Although a remarkable proportion of adolescents suffering from adjustment disorder (AD) are suicidal, few studies have documented the characteristics of suicidal AD patients. We examined background, psychopathology and treatment-related factors among suicidal adolescent AD outpatients.

METHOD

Data on 302 consecutively referred psychiatric outpatient adolescents, aged 12-22 years, were collected. DSM-III-R diagnoses were assigned at the end of treatment based on all available data. Of the patients 89 received a diagnosis of AD, 25% of whom showed suicide attempts, suicidal threats or ideation.

RESULTS

Compared with non-suicidal AD patients, suicidal AD patients were characterized by previous psychiatric treatment (OR = 6.1), poor psychosocial functioning at treatment entry (OR = 16.2), suicide as a stressor (OR = 33.3), dysphoric mood (OR = 6.9) and psychomotor restlessness (OR = 3.7).

CONCLUSIONS

Common risk factors for suicidality in major psychiatric disorders characterized suicidal AD patients. Psychiatric assessment of AD patients should include careful monitoring of both symptomatology and exposure to suicide of significant others.

Selective serotonin reuptake inhibitor antidepressants and the risk of suicide: a controlled forensic database study of 14,857 suicides

OBJECTIVE

To test the hypothesis that selective serotonin reuptake inhibitor (SSRI) antidepressants may have a suicide emergent effect, particularly in children and adolescents.

METHOD

Detections of different antidepressants in the forensic toxicological screening of 14 857 suicides were compared with those in 26,422 cases of deaths by accident or natural causes in Sweden 1992-2000.

RESULTS

There were 3411 detections of antidepressants in the suicides and 1538 in the controls. SSRIs had lower odds ratios than the other antidepressants. In the 52 suicides under 15 years, no SSRIs were detected. In 15-19-year age group, SSRIs had lower relative risk in suicides compared with non-SSRIs.

CONCLUSION

The hypothesis that treatment of depressed individuals with SSRIs leads to an increased risk of suicide was not supported by this analysis of the total suicidal outcome of the nationwide use of SSRIs in Sweden over a period of 9 years, either in adults or in children or adolescents.

Medicolegal Childhood Deaths in Adana, Turkey

The objective of this study is to determine the characteristics of and changes in the medicolegal childhood deaths that occurred in the provincial center of Adana, and to contribute to the establishment of a database for the development of national and international policies. The study is a retrospective research examining the 1,110 cases in the age group 0 to 18, which were specified as medicolegal deaths in the provincial center of Adana-Turkey between the years 2000-2004. The cases were examined according to age, sex, causes of deaths, the origins and scenes of occurrence. Among all the deaths, 523 cases (47.2%) were seen in the age group of 0-6 years. Accidents account for 900 cases (81.1%), and blunt traumas (594 cases) represent the most common cause of deaths. The share of traffic accidents in total blunt traumas was found to be 441 cases (74.2%). And 270 (24.3%) of all medicolegal deaths occurred as a result of household accidents. The present study has also indicated that the home and surroundings represent the highest-risk areas. As a conclusion, setting up childhood injury prevention committees and providing training programs for parents will be effective for the prevention of childhood injuries and deaths.

Childhood suicide: a major issue in pediatric health care

Although prevention of youth suicide is a major aim in most countries, it often is not taken into account that younger children also are capable of killing themselves. Evidence suggests that the suicide rate among children has increased dramatically and that risk factors for suicide must be evaluated when dealing with children in primary and secondary care. Adverse life events in combination with other factors, such as depression, may lead to suicide. This article aims at stimulating further discussion among those involved in pediatric health care. Epidemiological data, an overview of risk factors, and the authors' reflections on the topic are provided.

Altering the course of neurodevelopment: a framework for understanding the enduring effects of psychotropic drugs

Childhood is a time filled with wondrous changes, as brain plasticity permits experiences to shape the immature brain to meet the demands of the environment. Change occurs at various levels--from neuroanatomy, including within a given region and its connectivity to other regions, to the function of neurotransmitter systems and their reactivity to pharmacological agents in the short- and long-term. The nature and degree to which drug exposure influences the final adult topography is influenced greatly by the maturational phase of these critical factors. Moreover, evidence is slowly emerging that suggests that the long-term effects of drug exposure are delayed and expressed once the vulnerable system reaches maturation (i.e., typically during adulthood). This phenomenon is known as neuronal imprinting and occurs when the effects of drug exposure outlast the drug itself. Thus, understanding the persistent effects critically depends on the window of observation. Embracing this concept should influence how we conduct preclinical assessments of developmental drug exposure, and ultimately how we conduct clinical assessments of drug efficacy, effectiveness, and safety for the treatment of childhood psychiatric disorders. In this article, we present a model to provide a heuristic framework for making predictions about imprinted effects of childhood drug exposure. We then review epidemiological data on attention deficit hyperactivity disorder (ADHD) and childhood depression, prescription practices, and what is known regarding the long-term consequences of drug exposure in these populations. We conclude with a discussion of the current status of preclinical studies on juvenile stimulant exposure.

Psychosocial wellbeing and psychiatric care in the European Communities: analysis of macro indicators

BACKGROUND

This paper reports the findings of an analytical comparison of several macro indicators collected routinely from institutional sources in Europe.

METHODS

We carried out a review of macro indicators capable of providing a synthetic description of mental health status and the availability of psychiatric care in European countries. These were collected routinely from sources such as WHO, OECD, EUROSTAT, and IMS. The evaluation of temporal trends in each nation permits subsequent comparisons between countries.

RESULTS

In all European countries, a decreased trend of suicides was observed in the period 1980-2000, with the exception of Ireland and (partially) of Spain. In Ireland, the increased trend was particularly strong, with a high risk in young and adult males. Portugal and Greece had respectively the highest and the lowest rates of undetermined causes of death. Most countries that were high consumers of alcohol in the initial period of observation had a rate above the national mean until 1980, after which consumption decreased. Most nations that were low consumers in 1960 had rates below the mean until 1980,when the rates progressively increased. However, a general decrease of alcohol-related deaths was apparent in all countries. Mortality associated with mental disorder increased, most clearly during the mid 1980s. The number of psychiatrists per 100,000 inhabitants ranged from 3.6 in Spain to 17.5 in Finland; of child psychiatrists, from 0.9 in Germany to 5.1 in Portugal. Psychiatric beds ranged from 0.4 per 1,000 inhabitants in Italy and Spain to 1.3 in Ireland. Nine countries showed a trend towards a reduction in psychiatric beds, whilst in a further five countries no change was observed. Rates of long-stay patients varied from 9.5 in the UK to 84 in Belgium, with a generally decreasing trend. The use of outpatient facilities differed markedly between countries, although there was a general increase over time. Official data were scarce in relation to the sale of psychotropic drugs. IMS data indicated increasing consumption in all European countries for antidepressant and antipsychotic medication.

CONCLUSIONS

The official data resources available for European countries seem to indicate some discrepancies, probably relating to methods of recording. Better co-ordination in the collection of data about mental health status in the European Union and an improvement of the quality in available services is needed.