The role of the pediatrician in preventing suicide in adolescents with alcohol use disorders

Worldwide, suicide is among the top five causes of mortality in the 15- to 19- year age group. Pediatricians and primary care providers are in a distinctive position to help prevent suicide in adolescents. According to the Guidelines for Adolescent Preventive Services, all adolescents should have at least an annual preventive services visit, which should address both the biomedical and psychosocial aspects of health. Suicide prevention may best be accomplished by detection and management of specific risk factors, rather than by attempting to recognize those youth who are considered most likely to commit suicide. Alcohol use has been regarded as an important risk factor for adolescent suicidal behavior and the diagnosis of an alcohol use disorder indicates an elevated risk for adolescent suicide. Although the causal relationship between alcohol use and suicide remains unknown, a clear and strong relationship exists. Pediatricians and other health care providers should be skilled to recognize risk factors for adolescent suicide, including alcohol and drug misuse, depression, major loss, and recent suicides within a community. The relative frequency of suicidal behavior among adolescents suffering from alcohol use disorders and its distressing effects on individuals, families and society merits further research and development of prevention strategies in general pediatric settings.     

Adolescent depression and suicide risk: association with sex and drug behavior

BACKGROUND: Depression is common among adolescents, and suicide is the third leading cause of death among 15- to 19-year-olds. Although both health problems have been associated with drug use and early sexual intercourse, the relationship has not been systematically studied in a nationally representative sample. METHODS: Sixteen patterns of combined sex and drug use behaviors were obtained using cluster analysis of responses to Wave I of the National Longitudinal Study of Adolescent Health conducted from September 1994 through December 1995. Bivariate and multivariate analyses tested correlations between behavior patterns and current depression, serious suicidal ideation, and previous suicide attempt, controlling for gender, race/ethnicity, Hispanic ethnicity, family structure, and parent education. RESULTS: Compared to youth who abstain from risk behaviors, involvement in any drinking, smoking, and/or sexual activity was associated with significantly increased odds of depression, suicidal ideation, and suicide attempts. Odds ratios were highest among youth who engaged in illegal drug use. There were few differences between boys and girls who abstain from sex and drug behaviors. Girls were less likely than boys to engage in high-risk behaviors, but those who did tended to be more vulnerable to depression, suicidal ideation, and suicide attempt. CONCLUSIONS: Teens engaging in risk behaviors are at increased odds for depression, suicidal ideation, and suicide attempts. Although causal direction has not been established, involvement in any sex or drug use is cause for concern, and should be a clinical indication for mental health screening for girls; both boys and girls should be screened if engaging in any marijuana or illegal drug use.     

Suicide attempts and physical fighting among high school students--United States, 2001

Violence is a major cause of morbidity and mortality, particularly among youths. In the United States, homicide and suicide are the second and third leading causes of death, respectively, for persons aged 13-19 years. Although suicide commonly is associated with anxiety, depression, and social withdrawal, research suggests a link between violent behaviors directed at oneself (i.e., suicidal behaviors) and violent behaviors directed at others among adolescents. Certain students who engage in extreme forms of violence, such as school shootings, exhibit suicidal ideation or behavior before or during the attack. However, suicidal behavior also might be associated with involvement in less extreme forms of violent behaviors, such as physical fighting, which might be a risk factor for more severe forms of violence. To characterize any potential association between suicide attempts and fighting, CDC analyzed self-reported 2001 data from a nationally representative sample of high school students in the United States. The results of that analysis indicated that students who reported attempting suicide during the preceding 12 months were nearly four times more likely also to have reported fighting than those who reported not attempting suicide. Prevention programs that seek to reduce both suicidal and violent behaviors are needed. Because prevalence of this association was determined to be highest in the 9th grade, these efforts might be most effective if implemented before students reach high school.     

Genetic Contribution to Suicidal Behaviors and Associated Risk Factors among Adolescents in the U.S.

This paper examines genetic contribution to suicidal behaviors and other risk factors associated with suicidal behavior among adolescents in the U.S. Using adolescent twin data in the National Longitudinal Study of Adolescent Health (N=1448), we compared concordance in suicidal ideation and attempt among monozygotic (MZ) and dizygotic (DZ) twins. Heritability of risk factors for suicidal behaviors also was examined using Pearson correlation and mixed-model analyses. A trend of higher concordance in suicidal ideation and attempt was found among MZ than DZ twins but the difference was not statistically significant by the stringent test of bootstrapping analysis. Evidence of heritability was found for several suicide risk factors. The percentage of variance explained by heritability was larger among female twins for depression, aggression, and quantity of cigarettes smoked in comparison to heritability estimates for male twins. However, estimated heritability was larger among male than female twins for alcohol use and binge drinking. Heritability influence was negligible among both sexes for other drug use. Risk factors for suicidal behaviors among adolescents may be heritable. Gender differences found in the heritability of some suicide risk factors suggest these genetic contributions are gender specific. Future research examining potential interactions between expression of genetic influence and particular environmental contexts may enhance prevention and intervention efforts.     

Longitudinal Associations Between Types of Childhood Trauma and Suicidal Behavior Among Substance Users: A Cohort Study

Objectives. We examined the longitudinal associations between different types and severities of childhood trauma and suicide attempts among illicit drug users.Methods. Data came from 2 prospective cohort studies of illicit drug users in Vancouver, Canada, in 2005 to 2010. We used recurrent event proportional means models to estimate adjusted and weighted associations between types and severities of childhood maltreatment and suicide attempts.Results. Of 1634 participants, 411 (25.2%) reported a history of suicidal behavior at baseline. Over 5 years, 80 (4.9%) participants reported 97 suicide attempts, a rate of 2.6 per 100 person-years. Severe to extreme levels of sexual abuse (adjusted hazard ratio [AHR] = 2.5; 95% confidence interval [CI] = 1.4, 4.4), physical abuse (AHR = 2.0; 95% CI = 1.1, 3.8), and emotional abuse (AHR = 3.5; 95% CI = 1.4, 8.7) predicted suicide attempts. Severe forms of physical and emotional neglect were not significantly associated with an increased risk of suicidal behavior.Conclusions. Severe sexual, physical, and emotional childhood abuse confer substantial risk of repeated suicidal behavior in adulthood. Illicit drug users require intensive secondary suicide prevention efforts, particularly among those with a history of childhood trauma.The global burden of suicide is considerable and is the tenth leading cause of death worldwide, with annual mortality estimated at 14.5 deaths per 100 000.1 Suicide is a major and preventable public health problem among young people aged 15 to 24 years in Canada (second leading cause of death2) and the United States (third leading cause of death3). Each year, approximately 1 million adults in the United States attempt suicide, resulting in 35 000 deaths and more than 320 000 emergency department visits.4 The societal, financial, and public health burdens associated with suicide are therefore substantial.The epidemiology of suicide is multifactorial and complex.1 The 2012 National Strategy for Suicide Prevention identifies several groups at particularly high risk of suicide in the United States, including individuals with a past history of suicidal behavior, members of the armed forces and veterans, American Indians/Alaska Natives, men in midlife, and individuals in justice and child welfare settings.5 Of public health concern in Canada, suicide rates among Aboriginal Peoples are 2 to 3 times that observed in the nonaboriginal population.6,7 A large body of literature has also demonstrated high rates of suicidal behavior among lesbian, gay, bisexual, and transgender populations.8–10People who use illicit drugs are particularly vulnerable to suicidal ideation and behavior, and suicide is a leading cause of death in drug-using populations.11,12 Furthermore, the relationship between substance abuse and increased suicide risk has been well established.13,14 A growing body of research has examined various correlates of suicide attempts among drug users. In treatment-seeking samples of drug and alcohol abusers, major depressive disorder and other psychiatric conditions (e.g., borderline personality disorder, anxiety, agoraphobia) have been associated with a history of suicide attempts.15–20 Furthermore, markers of social disadvantage and marginalization, such as unemployment and homelessness, are associated with a heightened risk of suicide and are common among drug users.11 Specific typologies of drug use have also been linked to a greater likelihood of attempting suicide, including longer durations of substance use,18,21 polysubstance use,20,22 and injection methamphetamine use.23In recent years, childhood maltreatment has emerged as a consistent correlate of suicidal ideation and behavior among drug users.19,24,25 These studies provide preliminary evidence that childhood abuse and neglect are important determinants of suicide in drug-using populations. However, it is unclear whether certain types of childhood maltreatment are more strongly associated with suicidal behavior than others. The majority of studies to date have examined suicide and early traumatic experiences among clinical samples, which may be subject to selection bias if being in treatment is a common effect of both exposure (i.e., childhood maltreatment) and other, unmeasured factors that may cause suicidal behavior (e.g., genetic or familial susceptibility to psychiatric disorders such as depression). To our knowledge no studies have prospectively examined suicidal behavior in a community-recruited cohort of drug users. Drug-using cohorts are particularly well suited to examining the relationship between childhood maltreatment and recurrent suicidal behavior because of their high rates of suicide. We used recurrent event survival models to determine the longitudinal associations between exposure to different types and severities of childhood trauma and suicide attempts, measured prospectively in a cohort of drug users in Vancouver, British Columbia.     

Ethnicity and the relationship between adolescent alcohol use and suicidal behavior

Adolescent suicide is the 3rd leading cause of death in the United States and alcohol consumption is estimated to cause adolescent males to be up to 17 times more likely to attempt suicide, and females three times more likely to attempt suicide. Suicide and suicide attempt rates vary across different ethnicities. Also, associated psychopathology, stressors and substance use differ across ethnic groups in adolescents. In an exhaustive review of the literature, we found that depressed Asian-American youth were four times more likely to display suicidal behavior when compared to other Asian youths with other diagnoses; and depressed African-American females were more likely to report suicidal ideation than male adolescents. We also found that Asian-Americans who experience high parental conflict are 30 times more likely to engage in suicidal behavior when compared to Asian-American youths with low parental conflict. African-American adolescents are 6.4 times more likely to attempt suicide as a result of parental conflict. With respect to alcohol use and dependence, Caucasian adolescents were twice as likely as the African American victims to have used alcohol before committing suicide. Alcohol use among adolescents was associated with increased suicidal behavior. Cultural differences in alcohol consumption may account for disparities, however future research is needed to further examine cultural trends in suicidal behavior and alcoholism.     

安徽省部分职业院校青少年网络欺凌与自杀相关行为的关联性研究

目的 了解安徽省青少年网络欺凌的流行现状,分析网络欺凌与自杀相关行为的关联,为网络欺凌和自杀相关行为的干预提供科学依据。方法 采用分层整群抽样方法选取安徽省5所职业院校,对共计10 574名在校学生进行问卷调查,了解其网络欺凌和自杀相关心理行为的情况,分析网络欺凌与自杀相关行为的关联性。结果 本研究收回有效问卷10 158份,研究对象中网络欺凌的总检出率为3.3%,自杀意念、自杀计划和自杀未遂的检出率分别是5.6%、3.5%和1.8%。Logistic回归分析结果显示,无论男女,遭受网络欺凌是自杀意念、自杀计划和自杀未遂的危险因素（均有P<0.05）。结论 青少年遭受网络欺凌现象普遍,这与青少年自杀相关行为存在相关性,应予以重视。     

Emotional Suppression Mediates the Relation Between Adverse Life Events and Adolescent Suicide: Implications for Prevention

Suicidal ideation substantially increases the odds of future suicide attempts, and suicide is the second leading cause of death among adolescents. A history of adverse life events has been linked with future suicidal ideation and attempts, although studies examining potential mediating variables have been scarce. One probable mediating mechanism is how the individual copes with adverse life events. For example, certain coping strategies appear to be more problematic than others in increasing future psychopathology, and emotional suppression in particular has been associated with poor mental health outcomes in adults and children. However, no studies to date have examined the potential mediating role of emotional suppression in the relation between adverse life events and suicidal thoughts/behavior in adolescence. The goal of the current study was to examine emotional suppression as a mediator in the relation between childhood adversity and future suicidal thoughts/behaviors in youth. A total of 625 participants, aged 14–19 years, seeking ER services were administered measures assessing adverse life events, coping strategies, suicidal ideation in the last 2 weeks, and suicide attempts in the last month. The results suggest that emotional suppression mediates the relation between adversity and both (1) suicidal thoughts and (2) suicide attempts above and beyond demographic variables and depressive symptoms. This study has important implications for interventions aimed at preventing suicidal thoughts and behavior in adolescents with histories of adversity.     

淮北市中学生自伤与自杀行为关系分析

目的了解中学生自伤与自杀心理行为的流行状况及其相互关系,为实施干预措施提供依据。方法采取整群方便抽样方法,对安徽省淮北市6所中学2 707名中学生的自伤和自杀行为进行问卷调查。结果 2 707名中学生最近1 a内自伤行为的总报告率为35.2%,62.4%的自伤行为者具有反复性(≥3次),排名前3位的自伤行为分别为故意打自己(19.0%)、故意掐伤自己(15.7%)、故意拽头发(12.2%);自杀行为总报告率为16.8%,32.5%的自杀行为者具有反复性(≥3次),自杀意念、自杀计划、自杀未遂报告率分别为16.2%,7.4%,3.1%。女生总自伤行为、自杀意念、自杀计划的报告率均高于男生,差异均有统计学意义(P值均<0.05),初中生自杀意念、自杀计划、自杀未遂报告率均高于高中生,差异均有统计学意义(P值均<0.01)。有自伤行为的中学生自杀行为报告率明显高于无自伤行为者(P值均<0.01),有自伤行为中学生的自杀意念、自杀计划及自杀未遂风险分别是无自伤行为者的5.571,7.735,8.020倍。结论自伤是青少年自杀行为的危险因素。应及早对青少年实施综合性干预措施,预防自杀行为的发生。     

Impulsive-aggressive traits and suicidal adolescents and young adults with alcoholism

Suicidal behavior and alcohol use disorders among adolescents and young adults are serious public health problems. In the study of suicidal behavior among young people with alcoholism, it has been shown that aggression and impulsivity are higher among those who attempted suicide. Impulsivity has been related to suicidal and self-destructive behaviors within different psychiatric conditions, i.e. alcohol and substance use disorders, mood disorders, conduct disorder, impulse control disorders, antisocial personality disorder, and borderline personality disorder. The term impulsivity has been used to define different constructs such as (1) personality trait or cognitive style in which disinhibition is the core characteristic, (2) a tendency to act immediately in response to external or internal stimuli, and (3) a group of psychiatric disorders with behavioral dyscontrol. Among adolescents suicidal behavior is transmitted in families independently of psychiatric conditions, but not independently of impulsivity/aggression. Two causal links between impulsiveness and alcoholism have been proposed: (1) adolescents who develop alcoholism possess higher premorbid levels of impulsiveness than those who do not develop alcoholism, and (2) levels of impulsiveness differentiate both populations only after the development of alcoholism, with higher levels of impulsiveness among those adolescents who developed alcoholism. Cognitive behavioral techniques have shown promising results in the treatment of adolescents with alcohol and substance use disorder and suicidality. The relative frequency of suicidal behavior among adolescents and young adults suffering from alcoholism and its subsequent devastating effects on individuals, families and society merits further research and development of prevention strategies.     

Drug Use, Sexual Activity, and Suicidal Behavior in U.S. High School Students

ABSTRACT: Data from the 1990 Youth Risk Behavior Survey were used to examine the interrelationship of drug use, sexual activity, and suicidal behavior in U.S. high school students. Findings indicated adolescents who engaged in substance use and/or sexual activity were more likely to experience suicide ideation and behavior than those who abstained from such activities. Data analysis revealed a significant and positive relationship between cocaine use and severity of outcomes of suicide attempts. Marijuana use and alcohol use were related to suicide behavior, but these relationships were not as strong as those noted for cocaine use. The study also revealed a positive relationship between frequency of sexual activity and attempted suicide, but could not determine whether such sexual activity was coerced, forced, or voluntary in nature.     

抑郁障碍青少年自杀行为预测因素研究进展

近年来,青少年自杀行为的发生率逐年升高,成为威胁青少年身心健康乃至生命的严重公共卫生问题。抑郁障碍青少年是自杀行为发生的高危人群。研究从影响抑郁障碍青少年自杀行为的个人心理因素、家庭因素以及学校和社会因素3个方面进行综述,为青少年自杀行为的有效预防提供科学依据。     

Sexual Behavior and Drug Use Among Asian and Latino Adolescents: Association with Immigrant Status

This paper contributes new evidence on the association between immigrant status and health by describing and attempting to explain patterns of co-occurring sex and drug use behaviors among Asian and Latino adolescents in the United States. Nine patterns of sex and drug use behaviors were identified from a cluster analysis of data from 3,924 Asian and Latino youth (grades 7–12) who participated in the National Longitudinal Study of Adolescent Health (Add Health). The relationship between immigrant status and risk cluster membership was evaluated with multinomial logistic regression. Compared to foreign-born youth, U.S. born Asian and Latino adolescents were more likely to engage in sex and drug risk behaviors. Family and residential characteristics associated with immigrant status partly accounted for this finding. The results indicate that among Asian and Latino adolescents, assimilation to U.S. risk behavior norms occurs rapidly and is evident by the second generation.     

Adolescent Alcohol Use,Suicidal Ideation,and Suicide Attempts

PurposeTo examine the association between self-reported alcohol use and suicide attempts among adolescents who did and did not report suicidal ideation during the past year.MethodsScreening data from 31,953 students attending schools in the United States that implemented the Signs of Suicide (SOS) program in 2001–2002 were used in this analysis. Two types of alcohol use were investigated: heavy episodic drinking, and drinking while down. Self-reported suicide attempts were regressed on suicidal ideation and both measures of alcohol use, controlling for participants’ levels of depressive symptoms, and demographic characteristics.ResultsLogistic regression analyses indicated that both drinking while down and heavy episodic drinking were significantly associated with self-reported suicide attempts. Analyses examining the conditional association of alcohol use and suicidal ideation with self-reported suicide attempts revealed that drinking while down was associated with significantly greater risk of suicide attempt among those not reporting suicidal ideation in the past year. Heavy episodic drinking was associated with increased risk of suicide attempt equally among those who did and did not report suicidal ideation.ConclusionsThis study identified the use of alcohol while sad or depressed as a marker for suicidal behavior in adolescents who did not report ideating prior to an attempt, and hence, may not be detected by current strategies for assessing suicide risk. Findings from this study should provide further impetus for alcohol screening among clinicians beyond that motivated by concerns about alcohol and substance use.     

Alcohol and adolescent suicide

Adolescent suicide is a major public health problem. In this review, the authors discuss different aspects of the relation between alcohol abuse and suicidal behavior in adolescents, including epidemiology, role of family history, comorbidity, gender differences, neurobiology, treatment, and prevention. In the general population, about 2,000 adolescents in the United States die by suicide each year. Suicide continually ranks as the second or third leading cause of death of persons between the ages of 15 and 34 years old. The suicide rate in young people has more than doubled during the period from 1956 to 1993. This increasing suicide rate has been blamed on the increase of adolescent alcohol abuse. Availability of alcohol and guns at home may contribute to suicide risk in adolescents. Comorbid psychopathology, which is common among adolescent alcohol abusers, substantially increases risk for suicide completions and attempts. Depressed adolescents may use alcohol to self-medicate depressive symptoms. Alcohol abuse and suicidal behavior in adolescents and in adults has been found to have biochemical, genetic, and psychological correlates. Ideally, treatment of adolescents who receive a diagnosis of an alcohol use disorder and co-occurring suicidality should follow an integrated protocol that addresses both conditions. Future studies of psychological and neurobiological mechanisms of suicidality in adolescents with alcohol and/or substance abuse are merited.