Suicide prevention:Providing Sanctuary for Adolescents in

Crisis

Nancy Rappaport, MDHarvard Medical School

www.academicwebpages.com/nr

Mood Disorders

Case Histories

Disturbing Statistics

Fig. 1

0

5

10

15

1980 1986 1988 1990 1992 1994 1996

Rate per 100,000

adolescents

10-14 years old

15-19 years old

Fig 1: Developmental and temporal trends in rates of adolescent suicide. Data from Maguire & Pastore (1999).

Statistics (ctd.)

Fig. 1.2

05

101520

1950 1970 1990 1992 1994 1996Rate per 100,000

adolescents

Male (15-19 yrs)

Female (15-19yrs)

Fig 1.2: Developmental trends since 1950 in suicide rates for 15-19 yr old adolescents, by gender. Maguire & Pastore (1999).

• For young people 15-24 yrs old, suicide is the third leading cause of death, behind accidental injury and homicide – 2,000 adolescents 15-19 commit suicide each year

• Persons under age 25 accounted for 15% of all suicides in 1997

• Within schools this statistic translates to (in a district of 8,000 students) one suicide a year

• Firearms are the most common method for completed suicides, followed by ingestions leading to overdose, and hanging

• 65% of completed suicides use handguns. The increase in the rates of youth suicide (and the number of deaths by suicide) over the past four decades is largely related to the use of firearms as a method of destruction

• Substance abuse/dependence is the probable reason that adolescence attempts are more lethal

• There are 400 suicide attempts by teenage boys for every completed suicide in males

• Four thousand suicide attempts per every death in females

• Who uses the most effective method – Girls or Boys?

• The Center for Disease Control (CDC) has tracked by school survey since 1991 every two years 12,000 to 16,000 students.

• Approximately 20% of students have had suicidal ideation; 10% have made a suicide attempt in a 12-month period; 1-3% of teenagers will receive medical attention for an attempt

• .01% will be successful• Ideation is almost always episodic

Profile of Children with Completed Suicides

• Immature problem solving that translates into more impulsive behavior

• Less able to tolerate frustration (adult data shows decreased serotonin)

• Unable to plan future actions

• Aggressive or violent outbursts

• Difficulty making decisions

• Less able to assess situations realistically than non-suicidal children

• Loss of parent before the age of 12

• History of parental abuse

• Early onset of suicidal behavior (prepubertal) predicts suicidal behavior in adolescents

• Although suicides are rare in children age 12 and under, suicide attempts are NOT rare in bipolar children age 12 and under (20%)

• Usually these children are difficult to treat and there is considerable controversy about the criteria as they are referred to as “rapid cyclers and often have mood lability, mood swings, affective storms, irritability and aggressiveness, periodic agitation, explosiveness and severe temper tantrums which can also be in response to trauma and family discord,” (Papolos 1999).

Psychological Autopsies

• Shaffer studied large numbers of completed suicides at an average age of 16 (170 psychological suicide autopsies) in an ethnically diverse population in 1984-86 interviewing multiple informants with community control subjects.

• More than 90% of subjects who committed suicide met criteria for at least one major psychiatric diagnosis

• Half of these subjects had psychiatric disorder for at least two years

• Link between psychopathology and suicide

Organized plan, intent, preparation

• One in four adolescents that completed suicides show evidence of planning

• According to Shaffer the time-honored clinical inquiry about planning is a poor measure of serious intent

Important Implications

• Need for thorough diagnostic interview

• Never discount a threat especially in the context of affective or substance abuse disorders

• Importance of aggressive intervention in first-episode affective illness

• The most common diagnostic groups were mood disorders (52% major depression), disruptive disorders and substance abuse

• A child with a mood disorder is four to five times more likely to attempt suicide than a child without a mood disorder

Completer Profile

• Evenly distributed by the SES, evenly distributed by educated vs. uneducated, Western states highest, 60% of firearms

• 50% of completers were never in therapy

• 75% of completers communicated thoughts about their suicide aloud to several people months before dying (“natural screeners”)

• Suicide awareness programs

• Screening

• First step of recognition

Strategies for Suicide Prevention

SUICIDAL IDEATION

ACTIVE DISORDERe.g., Mood disorder,

substance abuse, anxiety

#2 STRESS AVOIDANCE/ TOLERANCE

#1 FIND & TREAT

#3 CRISIS SERVICES

#4 MEDIA GUIDELINES & POSTVENTION

#5 METHODCONTROL

STRESS EVENTe.g., In trouble with

law/school; loss; humiliation

SURVIVAL

ACUTE MOOD CHANGE

e.g., Anxiety-dread, hopelessness, anger

SUICIDE

SOCIALINHIBITION

MENTAL STATESlowed down

Strong taboo;

vailable support;

presence of others;

difficult to access method

i.e.

UNDERLYING TRAIT

Impulsive, intense, serotonin abnormality

SOCIALRecent example, weak

taboo, isolation

MENTAL STATEAgitation

Method Availability/ Familiarity

FACILITATION

1

2

Adapted from Shaffer & Greenberg, 2002

Types of Depression

• Major Depression Usually begins in the late teens, but has been diagnosed in children as young as four

• Dysthymia Chronic, mild depression. Starts in childhood and can last decades

• Bipolar disorder Older teens cycle between mania and depression. Younger teens can experience both symptoms at once

• Clinical vignettes

SIGECAPS

Sleep - too little or too much

lose Interest or pleasure

feelings of Guilt or worthlessness

decreased Energy

decreased Concentration

change in Appetite

Psychomotor agitation or retardation

Suicidal ideation

“I don’t care.”

“Depression is the mother of anger”

• Irritability• Duration of

symptoms• Vague,

nonspecific physical complaints

• Rate of depression varies; with age, the rate of the disorder increases

• .3% preschoolers

• 1-2% of elementary age boys and girls, 1:1 ratio

• 5% of adolescents with a 2:1 ratio of girls to boys

Risk Factors

• Unresolved grief

• Childhood trauma

• Learned feelings of helplessness (negative & hopeless)

• Anxiety disorder

Reprinted with permission

Stress and Protection in Different Family Contexts

• High levels of conflict• “Child is expendable”• Inordinate shame or guilt• Noble self-sacrifice• Deflection away from other conflicts• “Stress clusters”• Impulsivity and aggression

Stress Protection (ctd.)• Ask the family and the patient about how they

communicate and see if the patient can identify who she/he relies on when stressed

• Assess the family’s capacity to monitor and maintain sufficient watch over the adolescent

• Winnicott: “Why not tell him that you know that when he steals he is not wanting the things that he steals but he is looking for something that he has a right to; that he is making a claim on his mother and father because he feels deprived of their love.”

NYT, March25,2005

Medications

• SSRI more effective than placebo

Serotonin

• Distributed widely in the body

• Discharged by neurons in the brain

• Regulation of mood

• Regulation of sleep

Medications

• SSRI• Prozac• Zoloft• Celexa• Luvox (anxiety)• Effexor• Wellbutrin• Serzone & Trazadone

“How long should a doctor treat depression with medication?”

Suicide Risk and Antidepressants: An Update

• Controlled trials of antidepressants in children and adolescents

• Of 15 placebo-controlled trials of ADs for depression in children, only three found a statistically significant benefit.

• FDA self-reported

… these trials are not without bias however …

New Analysis Disputes Antidepressant, Suicide Link

• The sicker you are, the more likely you are to get medication (these kids are not included in the studies).

• There was a financial incentive to drug companies to do a study, regardless of whether they showed a difference between placebo and drug

Wakeup call

• On average you have to treat 140 patients with antidepressant to create a drug induced suicidality in 1 patient

• Do the drugs themselves increase the risk of the suicide attempt?

Take home message

• Newer antidepressants can lead to a sense of agitation in children

• Small percentage can lead to suicidal ideation or non-lethal attempts at self harm

• ADs are effective for children with anxiety disorders and only Prozac has been shown to benefit kids with depression

New Study by Valuck

• Published in December 2004 CNS Drugs• Analyzed claims data from 24,000+ adolescents

diagnosed with major depressive disorder• There was no outside funding• Valuck looked at the association between

diagnosis, subsequent treatment patterns, and suicide attempt.

Suicidal Ideation vs Suicide

• The FDA studies that were reviewed had no actual suicides in any of the clinical trials which have now included close to 5000 subjects

Wait, by Galway KinnellWait, for now.Distrust everything, if you have to.But trust the hours.Haven't theycarried you everywhere, up to now?Personal events will become interesting again.Hair will become interesting.Pain will become interesting.Buds that open out of season will become lovely again.Second-hand gloves will become lovely again,their memories are what give them the need for other hands. And thedesolation of lovers is the same: that enormous emptinesscarved out of such tiny beings as we areasks to be filled; the needfor the new love is faithfulness to the old.

Wait.Don't go too early.You're tired. But everyone's tired.But no one is tired enough.Only wait a while and listen.Music of hair,Music of pain,music of looms weaving all our loves again.Be there to hear it, it will be the only time,most of all to hear,the flute of your whole existence,rehearsed by the sorrows, play itself into total exhaustion