Comorbid substance use reduces the health care contacts of suicide attempters with schizophrenia spectrum or mood disorders

Utilization of health care services has been found to differ between psychiatric disorders. However, the pattern of health care contacts among suicide attempters with mental disorders is not known. This study systematically investigated the pattern of health care contacts among suicide attempters with schizophrenia spectrum versus mood disorders with or without comorbid substance use disorders both before and after attempted suicide. All consecutive medically treated suicide attempters in Helsinki from January 15, 1997, to January 14, 1998, were identified (n = 1,198). Data were gathered on all their health care contacts within the 12 months before and after the index attempt. Whereas the clear majority of all suicide attempters with schizophrenia spectrum or mood disorders had a treatment contact during the 30 days following the attempt, half of those with pure substance use disorders were without any contact with health care. Comorbid substance use made treatment less likely after attempted suicide among both psychiatric disorder groups; those with schizophrenia spectrum and comorbid substance use disorders were seven times more often left without aftercare recommendation than those without substance use comorbidity. Comorbid substance use disorders among suicide attempters with schizophrenia spectrum disorders decrease the likelihood of active aftercare, despite high suicide risk.     

Elderly suicide attempters with depression are often diagnosed only after the attempt

OBJECTIVE: No previous study has comprehensively investigated the pattern of health care contacts among elderly subjects attempting suicide. The present study compared elderly suicide attempters with younger attempters, before and after attempted suicide, in terms of health care contacts, clinical diagnoses of mental disorders, and characteristics predicting lack of treatment contact after the index attempt. METHODS: All consecutive 1198 suicide attempters treated in hospital emergency rooms in Helsinki, Finland, from 15.1.1997 to 14.1.1998 were identified and divided into two age groups: (1) elderly suicide attempters aged 60 years or more (n = 81) and (2) suicide attempters aged under 60 years (n = 1117). RESULTS: During the final 12 months before the attempt, the majority of elderly suicide attempters had a contact with primary health care, but their mood disorders were likely to have remained undiagnosed before the index attempt. In primary health care, only 4% had been diagnosed with a mood disorder before the attempt, but 57% after (p < 0.001). After the suicide attempt, most elderly suicide attempters were referred for aftercare, two thirds having contact with psychiatric care. CONCLUSIONS: For purposes of preventing suicidal behaviour, screening for depression, plus further education on recognition, diagnosis and treatment of mood disorders among the elderly in primary health care setting are needed.     

Attempted suicide and psychiatric consultation.

This study investigated the differences in clinical characteristics between suicide attempters referred or not referred to psychiatric consultation after a suicide attempt and factors affecting such referral to psychiatric aftercare after attempted suicide. All 1198 consecutive suicide attempters treated in hospital emergency rooms in Helsinki during a 12-month period were identified. Data were gathered on any psychiatric consultation after the attempt and on all health care contacts 1 year before and after the index attempt. We found that half of the suicide attempters who were not referred to psychiatric consultation were without any aftercare recommendation and treatment contact soon after their attempt. Factors predicting referral to psychiatric consultation were age, psychotic disorder, lack of substance use disorder and, most strongly, the hospital where the suicide attempt was treated. Although the characteristics of a patient attempting suicide do play a role in determining whether a psychiatric consultation will take place or not, the most important factor is the consultation practices of the particular hospital. This in turn influences the probability of adequate aftercare.     

Determinants of psychiatric hospitalization after attempted suicide

OBJECTIVE: This study investigated the characteristics of suicide attempters referred to psychiatric hospitals and the factors affecting such referral. METHOD: All 1198 consecutive suicide attempters treated in general hospital emergency rooms in Helsinki during a 12-month period were identified. Data on all health care contacts 1 year before the index attempt and on referrals to psychiatric hospitals after the attempt were gathered. RESULTS: We found that a quarter of patients were referred to psychiatric hospitals as inpatients after index suicide attempts. Factors predicting referral to psychiatric hospitals, compared to nonreferral, were older age, psychotic disorder, mood disorder, lack of alcohol consumption preceding the attempt, somatic illness, suicide attempt on a weekday, previous psychiatric treatment, psychiatric consultation and the hospital treating the suicide attempt. CONCLUSION: Although the clinical characteristics of patients attempting suicide are a major determinant of whether they are subsequently referred to psychiatric hospitals, the treatment practices of emergency room hospitals also influence treatment decisions.     

Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors

Background. Adolescents in many countries show high rates of suicide attempts and repetitions of attempts as a common feature. Attempted suicide is the best predictor of future suicide. Repetition of attempts further increases the risk of suicide. The present study sought to identify patterns and risk factors for repetition of attempts in older teenagers. Methods. Data were collected by uniform procedures in a longitudinal follow-up study in seven European centres participating in the WHO/EURO Multicentre Study on Suicidal Behaviour. Information on attempted suicide in the 15–19-year age group during the period 1989–1995 was analysed. Results. A total of 1,720 attempts by 1,264 individuals over a mean follow-up period of 204 weeks (SD 108.9) were recorded. When life-table analysis was performed, 24 % of the individuals who had previously attempted suicide made another attempt within one year after the index attempt, compared with 6.8 % of the “first-evers”, with no major gender difference. Cox regression analysis revealed that previous attempted suicide (OR 3.3, 95 % CI 2.4–4.4) and use of “hard” methods (OR 1.5, 95 % CI 1.1–2.1) were both significantly associated with repetition of attempted suicide. Stepwise Cox regression analysis showed that a history of previous attempted suicide was the most important independent predictor of repetition (OR 3.2, 95 % CI 2.4–4.4). Conclusion. For young suicide attempters, follow-up and adequate aftercare are very important if repetition and risk of suicide are to be reduced. This applies particularly to those who have already made more than one attempt. Accepted: 19 February 2001     

Aftercare of depressed inpatients

Background: In contrast to acute treatment, delivery of aftercare to depressed patients has not been well studied. Poor care may contribute to poor outcomes for treated depression. Methods: One hundred and two patients discharged from hospital with unipolar depression were followed up 18 months later and were interviewed in detail regarding aftercare and treatment received. Unmet needs were assessed on the community version of the MRC Needs for Care Assessment. Results: In the first month after discharge approximately 70 % of subjects received contacts with mental health services and in the first 3 months over 80 % received at least one contact. About 40 % were in contact with mental health services at 18 months. Needs assessment found comparatively low unmet needs, reaching highest levels (around 25 % in any 6-month period) for medication. Two-thirds of unmet needs for medication and psychotherapy were due to patient refusal or non-compliance. Aftercare levels were higher in those with more previous admissions and were unrelated to presence of personality disorder. Conclusions: There were some deficiencies in service aftercare for depressed patients in a British NHS setting, although unmet need was not high. Some aftercare failures reflect patient reluctance to receive further treatment, representing a challenge to overcome in patients entitled to autonomous choices. Accepted: 27 September 2002 Correspondence to R. Ramana     

Treatment received by alcohol-dependent suicide attempters

The purpose of this study was to examine the clinical features of alcohol-dependent suicide attempters and the treatment they received before and after the index attempt. A total of 47 subjects with current DSM-III-R alcohol dependence were identified from a systematic sample of 114 suicide attempters in Helsinki. All of them were comprehensively interviewed after the attempt, and the treatment they had received was established from psychiatric and other health-care records and follow-up interviews. Most had a history of psychiatric (83%) or substance abuse (83%) treatment. During the final month before the attempt, half of the subjects (51%) had been treated by health care services; 11% had received disulfiram-treatment and 6% had received psychotherapy. Subjects complied with recommended aftercare more often when they had been actively referred. After 1 month, 64% were being treated by health care services. However, only 14% were receiving disulfiram-treatment and 9% were receiving psychotherapy. These findings suggest that the quality and activity of treatment offered to suicide attempters with alcohol dependence should be improved.     

Excess mortality of suicide attempters

  Background: Excessive mortality of suicide attempters has emerged from many follow-up studies. Completed suicide is the main cause of excess deaths, but the increased risk of deaths from other unnatural and natural causes is also of major public health concern. We lack follow-up studies of the different causes of death in cohorts of suicide attempters. The present study aimed to determine the mortality by suicide and other causes of death and to investigate risk factors. Methods: This mean 5.3-year follow-up study was based on an unselected cohort of suicide attempts by both violent and non-violent methods, treated in hospitals in a well-defined urban catchment area in Helsinki. In total, 2782 patients aged 15 years and over admitted to the emergency rooms after suicide attempt between 1989 and 1996 were included in the follow-up analysis. Standardised mortality ratios (SMR) for suicide, disease, accident, homicide, and undetermined death were calculated. Results: Mortality from all causes was 15 times higher than that expected among men and nine times higher in women. SMRs in men were 5402 (95% CI 4339–6412) for suicide, 2480 (95% CI 925–4835) for homicide, and 11,139 (95% CI 6884–16,680) for undetermined cause, and for women 7682 (95% CI 5423–9585), 3763 (95% CI 52–5880) and 15,681 (95% CI 6894-22,294), respectively. Fifteen percent of all suicide attempters died during the average 5.3-year follow-up of the index attempt. Deaths from suicide accounted for 37% of all excess deaths in men and 44% in women. The mortality ratio was highest during the 1st follow-up year. The total number of lost years of life among the 413 suicide attempters who died during follow-up was 13,883. The risk factors for all causes of death were male sex, single, retirement, drug overdose as a method, an index attempt not involving alcohol, and a repeated attempt. Conclusion: A suicide attempt indicates a severe risk of premature death, and suicide is the main cause of excess deaths. However, it appears that concentrating efficient treatment only on the most suicidal patients could prevent no more than two of five premature deaths. More effort is therefore needed to prevent the excess mortality of suicide attempters by also addressing causes of death other than suicide. Accepted: 27 October 2000     

Telephone contact with patients in the year after a suicide attempt: does it affect treatment attendance and outcome? A randomised controlled study.

Ambivalence to treatment and repeated suicidal behaviour are well-known problems in suicide attempters. A randomised controlled study was performed to investigate the influence of repeated telephone contacts on treatment attendance, repetition of suicidal behaviour and mental health the year after a suicide attempt. SUBJECTS AND METHODS: One month after their suicide attempt 216 patients were randomised to either two telephone interventions in addition to treatment as usual, or no such intervention during the subsequent year. The interventions included motivational support to attend and/or to stay in treatment. At 1 month and again after 12 months the following measurements were used: GSI (SCL-90), GAF and SSI. RESULTS: At follow-up treatment attendance was high and did not differ between the randomised groups. Among those with an initial treatment contact other than psychiatric, more patients in the intervention group had such contact at follow-up. The randomised groups did not differ in repetition of suicide attempts during follow-up or in improvement in GSI (SCL-90), GAF and SSI. In individuals with no initial treatment the intervention group improved more in certain psychological symptom dimensions (SCL-90). CONCLUSION: Telephone interventions seem to have an effect on patients who at their suicide attempt had other treatment than psychiatric and in those with no treatment.     

Sex differences in risk factors for suicide after attempted suicide

Abstract.Aim: This study aims to investigate suicide risk factors after attempted suicide and whether and how these risk factors differ between the sexes.Method: A total of 1052 suicide attempters admitted to the Medical Emergency Inpatient Unit, Lund University Hospital, Sweden were followed up concerning suicide and death from other causes after a median period of 6 years and 5 months. In all, 50 persons committed suicide during follow-up. At the index suicide attempt, socio-demographic data and information about clinical characteristics were gathered in a standardised manner. Risk factors were identified among these data using survival analyses for the whole sample and for each sex separately.Result: Men had a higher frequency of suicide and a greater overall mortality than women. Cox regressions showed that suicide attempt(s) prior to the index attempt and the use of a violent method for the index attempt were risk factors for men only, whereas older age and a high suicidal intent (Beck SIS score) were female ones. Major depression was a risk factor for both sexes.Conclusion: More attention probably needs to be paid to the importance of gender in assessment of suicide risk and treatment of suicide attempters.     

Deliberate self-poisoning: treatment follow-up of repeaters and nonrepeaters.

Since 1986 psychiatrists and social workers of the Lund Suicide Research Center have investigated subjects admitted to the medical intensive care unit after a suicide attempt. Fifty-nine of 79 deliberate self-poisoners were interviewed 12 months after a suicide attempt. Twenty-one had previously been interviewed 6 months after the index suicide attempt. We obtained minor information on 8 subjects. Two patients had committed suicide. Sixteen subjects (27%) of those who were interviewed showed repeated suicidal behavior (repeaters) during the 1-year follow-up, and their psychiatric diagnoses at the index attempt were most commonly alcohol abuse and dysthymia (DSM-III, Axis I). Compared with nonrepeaters, repeaters had more often made previous suicide attempts, their index attempt was less serious and they were more often in psychiatric treatment at index. At follow-up, repeaters more often than nonrepeaters expressed the need for professional mental health support. Two-thirds of the patients were in treatment at follow-up. About half had remained in continuous treatment and most in psychiatric care for more than 1 year. Repeated self-poisoning occurred despite ongoing treatment. In view of the fact that numerous suicide attempters obviously remain in treatment for several years, we suggest further development and evaluation of long-term treatment strategies.     

Contacts of suicide attempters with GPs prior to the event: a comparison between Stockholm and Bern

The aim of this study was to investigate patterns of contact made with GPs by subjects in two cities prior to attempting suicide, in order to determine whether differences in the health care systems could be a possible factor influencing the help-seeking behaviour of people experiencing suicidal crises. Structured interviews were conducted with suicide attempters from geographically defined catchment areas in two countries with private and national health care systems, respectively. The subjects were suicide attempters, admitted consecutively, aged ≥15 years and living either in Stockholm (n=202) or in Bern (n=66). Patients living in Bern had seen their GPs more regularly and more frequently throughout the year. There was an increase in the number of visits to the GP prior to the suicide attempt in both cities, but it was greater in Stockholm than in Bern. However, in Stockholm fewer patients who saw their GP in the week before the attempt talked about their suicidal thoughts. The differences in help-seeking behaviour between the two patient samples may be related to the higher number of practising GPs and a more personal and consistent patient-doctor relationship in Bern. It is possible that the private medical care system in Switzerland lowers the threshold enabling patients to talk to their GP about their suicidal plans. The results suggest that in both cities there is scope for improving communication of the suicidal patient with his or her doctor.     

Stroke and mental health care: a record linkage study

Background Stroke is associated with psychiatric morbidity but little is known about mental health care use in stroke patients. Method A probability record linkage study was conducted linking stroke cases admitted to a teaching hospital serving a catchment area between 1987 and 1995 with records from a psychiatric case register covering the same area. Results Stroke patients had a more than twofold increased risk of contact with mental health care than individuals in the general population (yearly prevalences of respectively 88 and 39 per 1000; risk ratio 2.24; 95 % CI 2.04–2.45). One-third of all stroke admissions had had mental health care before and more than half had had mental health care after the stroke. In the year of admission for stroke, the probability of receiving mental health care was highest, while in the more remote years the risk was lower. Conclusion Stroke is associated with an increased probability of contact with mental health services. The pattern of mental health care of a stroke patient is different from that of other mental health patients: more episodic and concentrated around the time of admission for stroke. Accepted: 19 September 2001     

Accessibility and pathways to psychiatric care in a community-based mental health system

Background The careful analysis of pathways to specialist mental health care, within the context of community-based services, is important because it allows a detailed understanding of the inter-relationship between the component parts of the whole system of care. Moreover, it permits a comparison of service functioning to made over time, and is one way to operationalise the measurement of accessibility to services. The aims of this study are to describe: (i) the pathways followed by patients with new episodes of care to community-based mental health services, (ii) the time intervals from onset of the problem to first contact with services, and then to onward referral to specialist care (accessibility), and (iii) to explore the short-term costs associated with different pathways. Methods Using data from the South-Verona Psychiatric Case Register, all new patients referred to any of the facilities which are part of the South-Verona Community Psychiatric Service (CPS) over a 6-month period (November 1999 – May 2000) were eligible to enter the study. Patients were interviewed by telephone using the Italian translation of the WHO Encounter Form. The costs of care provided in the 3 months following the index contact were assessed for all patients. Results The most common route to mental health services is via a GP (40 %), followed by a referral from a hospital doctor (26 %) and self-referral (23 %). The median interval from onset to direct contact with the South-Verona CPS (12 weeks) was shorter than the intervals from onset to direct contact with other service providers (the median interval for contact with GPs and hospital doctors was 24 weeks). The intervals varied considerably from 1 week (for attempted suicide), to 1.5 years (for disturbed behaviour). The results of backward regression modelling revealed a significant relationship between patients' characteristics and community costs or total psychiatric costs (44 % and 53 % of the variance explained respectively). Conclusion When the results are compared with a directly comparable earlier study in South-Verona, it is apparent that between 1991 and 1999 an increasing proportion of patients with insomnia and somatic disorders presented first to GPs, while a decreasing proportion of patients over the years sought care directly from specialist care. An increase in the role of local GPs as gatekeepers has, therefore, emerged. A prompt assessment by the South-Verona CPS of the patients' presenting problems was also confirmed, and this can be explained by the ‘drop-in’ approach at the Mental Health Centre, where patients can seek specialist care directly, without previously attending GPs. This method of measuring time intervals along pathways is proposed as a way to operationalise accessibility to services in future. Accepted: 16 July 2001     

Healthcare use before and after suicide attempt in refugees and Swedish-born individuals

Purpose

There is a lack of research on whether healthcare use before and after a suicide attempt differs between refugees and the host population. We aimed to investigate if the patterns of specialised (inpatient and specialised outpatient) psychiatric and somatic healthcare use, 3 years before and after a suicide attempt, differ between refugees and the Swedish-born individuals in Sweden. Additionally, we aimed to explore if specialised healthcare use differed among refugee suicide attempters according to their sex, age, education or receipt of disability pension.

Methods

All refugees and Swedish-born individuals, 20–64 years of age, treated for suicide attempt in specialised healthcare during 2004–2013 (n = 85,771 suicide attempters, of which 4.5% refugees) were followed 3 years before and after (Y − 3 to Y + 3) the index suicide attempt (t0) regarding their specialised healthcare use. Annual adjusted prevalence with 95% confidence intervals (CIs) of specialised healthcare use were assessed by generalized estimating equations (GEE). Additionally, in analyses among the refugees, GEE models were stratified by sex, age, educational level and disability pension.

Results

Compared to Swedish-born, refugees had lower prevalence rates of psychiatric and somatic healthcare use during the observation period. During Y + 1, 25% (95% CI 23–28%) refugees and 30% (95% CI 29–30%) Swedish-born used inpatient psychiatric healthcare. Among refugees, a higher specialised healthcare use was observed in disability pension recipients than non-recipients.

Conclusion

Refugees used less specialised healthcare, before and after a suicide attempt, relative to the Swedish-born. Strengthened cultural competence among healthcare professionals and better health literacy among the refugees may improve healthcare access in refugees.

     

Attempted suicide predicts suicide risk in schizophrenia spectrum psychosis

Background: People with schizophrenia have an increased risk of suicide and attempted suicide is suggested to be an important risk factor. Aim: Our objective was to assess the cumulative survival, predictive values and odds ratios of attempted suicide for suicide in a long-term cohort of patients with schizophrenia spectrum psychosis with and without previous attempted suicide. Method: Inpatients (n=224) hospitalized with schizophrenia spectrum psychosis were followed for a mean of 25 years. All patients were followed up for causes of death. Information on suicide attempt before the end of the observation period was retrieved from medical records. Results: Eight percent died by suicide during the follow-up. Eighteen percent of suicide attempters died by suicide. Two percent of non-attempters died by suicide. There was a strong association between previous suicide attempt and suicide in men and women. Odds ratio for attempters vs. non-attempters was 10. Suicide risk was almost three times higher in male than female suicide attempters. Conclusion: Previous attempted suicide is an important risk factor for suicide in both men and women with schizophrenia spectrum psychosis, particularly in male suicide attempters. The suicide risk remains high over a long period. Continuous assessment of risk factors and appropriate treatment are crucial for this patient group to prevent suicide.     

Life events preceding suicide by young people

Background Life events are often reported to precede suicide. This paper aims to determine the frequency, timing and type of life events preceding suicide by young people and those with and without a mental illness. Method Informants, usually family members, were interviewed for a sample of young (less than 35 years) suicides. Information was recorded on events occurring in the 6 months before death. Equivalent information was obtained for living controls who had been matched for age and gender and obtained through the general practices of the suicides. Results Suicide was associated with life events in the previous 3 months, and particularly in the previous week. Specifically, interpersonal and forensic (being arrested, charged or sentenced) events distinguished suicides and controls. The number of life events in the different time periods under study did not distinguish suicides with and without severe mental illness, although more suicides without a severe mental illness had a reported life event in the week before their death. Conclusions Adverse life events frequently precede suicide in young people with and without severe mental illness. However, recent life events may have a lesser causal role in those with severe mental illness. Clinical and health promotion measures to improve the way that young people cope with interpersonal problems and other crises may be an important part of any suicide prevention strategy. Accepted: 15 November 2001     

Thinking life is not worth living. A population survey of Great Britain

Background“Saving lives: our healthier nation” includes a target to reduce the death rate from suicide. Thoughts of suicide and feeling life is not worth living might be the first step in a pathway that can end in completed suicide. This study aims to identify factors associated with feeling life is not worth living amongst the household population of Great Britain, and to assess the strength of these associations after taking account of an individual's level of psychiatric morbidity. Methods The 1993 OPCS National Psychiatric Morbidity Surveys of Great Britain assessed psychiatric morbidity using the Revised Clinical Interview Schedule amongst a stratified, clustered probability sample of 9830 subjects representative of the British private household population aged 16–64. Results Of the sample 0.8 % (95 % CI 0.6 %–1 %) had thoughts of suicide in the week before interview and 3.1 % (95 % CI 2.7 %–3.5 %) reported thoughts of life not worth living in the week before interview. Psychiatric morbidity was most strongly associated with such thoughts. Ethnicity, marital status and low social support were strongly associated with such thoughts after adjusting for age, sex and psychiatric morbidity. Conclusions Reducing psychiatric morbidity in the population as a whole might also decrease the frequency of suicidal thoughts. Policies which improve social support at a population level might also have a large impact on prevalence of suicidal thoughts. Accepted: 14 March 2002     

Schizophrenia and substance misuse problems: a comparison between patients with and without significant carer contact

Aim Many researchers and clinicians in the mental health field have given much attention over the last few years to patients with co-morbid problems of schizophrenia and substance use. This population is becoming a focus of attention for all service providers owing to the suggested increase in numbers of patients with these dual diagnoses and the observed negative effects on patients and costs to services. The advantages for providing family interventions in schizophrenia are now well established and increasingly these interventions are being evaluated for families of dual diagnosis patients. Many dually diagnosed patients do not, however, have a great deal of contact with a carer/relative. This paper looks at whether differences exist between patients with a dual diagnosis that have carer contact and those who do not have carer contact in terms of their illness history and type of substance use. For the purpose of this article ‘carer’ refers to an individual who is an informal carer or relative with whom the client has weekly contact of 10h. Many of these carers provide the client with emotional, physical and material support. Method The identification process for both ‘carer contact’ and ‘no carer contact’ patients was conducted through the screening of the hospital's care programme approach (CPA) lists and through contact with care co-ordinators and consultants. Case notes of all patients identified were screened and information on demographic data, duration of illness, admissions and substance use was collected. Results Results indicated that the ‘no carer contact’ group was older and had significantly more days in hospital at last admission. Conclusions It is possible that as patients get older their contact with significant others decreases, i. e. loss of contact with key relatives is due to age rather than severity of substance use. Furthermore, patients' reduced contact results in them having longer stays in hospital possibly because they will not receive additional support when discharged. Accepted: 16 July 2001     

Major depressive episode and health care use among adolescents and young adults

Objective: The aim was to analyze how major depressive episode (MDE), chronic illness and their co-existence are associated with health care use in young people. Method: As part of the Finnish Health Care Survey 1996, a random sample of 942 15 to 24-year-olds was interviewed. DS M-III-R MDE over the previous 12 months was assessed using the University of Michigan Composite Diagnostic Interview Short Form (UM-CIDI SF). Results: Of the study population, 43.7% (n=439) reported recent use of services for physical illness, the highest proportion being among respondents with both MDE and chronic illness (73.9 %). In multivariable logistic regression analysis, disabling chronic illness (OR 2.59; 95% CI 1.51, 4.45) was related to treatment use for physical causes while MDE alone (OR 1.56; 95% CI 0.95, 2.58) or accompanied with chronic illness (OR 2.47; 95% CI 0.99, 6.14) showed borderline associations. In all, 1.5% (n=14) of the respondents reported recent health care use for any mental health problems. Of the 68 subjects with MDE, 51.5% (n=35) were estimated to be in need of treatment while 20.6% (n=14) had actually sought care for depression during the preceding year. Psychosocial impairment showed borderline association with treatment use (OR 3.77; 95% CI 0.97, 14.7). Only two subjects (14 %) reported recent use of antidepressant medication. Conclusions: MDE in adolescents and young adults is undertreated. An tidepressant medication was seldom used in Finland in 1996. Young people suffering from both MDE and chronic illness are likely to use services other than psychiatric services, and systematic screening for depressive symptoms in these treatment settings is recommended. Accepted: 21 January 2003 Correspondence to Dr. Linnea Haarasilta