Suicidal behavior and hypothalamic-pituitary-adrenocortical axis indices in child psychiatric inpatients

Studies of adults have reported associations between suicidal behavior and hypothalamic-pituitary-adrenocortical (HPA) axis functioning, but these associations were inconsistent. Very few studies of prepubertal children evaluating these relations exist. This study of 49 prepubertal psychiatric inpatients evaluates associations between suicidal behavior and predexamethasone and postdexamethasone plasma cortisol levels shortly after hospital admission and 7 weeks later. Results suggest that associations between suicidal behavior and plasma cortisol levels are independent of diagnosis. Covariation of predexamethasone and postdexamethasone plasma cortisol levels with major depression was associated with severity of suicidal behavior. Implications of these results for childhood suicidal risk are discussed.     

Suicidal behavior in child psychiatric inpatients and outpatients and in nonpatients

One hundred one child psychiatric outpatients were assessed using a standard battery of measures to identify factors associated with suicidal behavior. Data on these outpatients were compared to those for psychiatric inpatients and nonpatients previously studied. The frequency of suicidal behavior among the outpatients (24.8%) was less than for a comparable group of inpatients (78.5%) but more than for a comparable group of nonpatients (12%). Four variables--recent general psychopathology, preoccupation with death, and recent and past depression--were significantly associated with suicidal behavior in the three groups of children.     

Adverse childhood experiences and suicidal behavior of adolescent psychiatric inpatients

The present study examines the association of adverse childhood experiences (ACEs) to suicidal behavior and mortality in 508 Finnish adolescents (aged 12–17 years) who required acute psychiatric hospitalization between April 2001 and March 2006. The Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL) and the European Addiction Severity Index (EuropASI) were used to obtain information about ACEs, adolescents’ suicidal behavior and psychiatric diagnoses. The cases of death were obtained from Statistics Finland. The results of our study indicated that, among girls, exposure to sexual abuse statistically significantly increased the risk of non-suicidal self-injury (NSSI) (OR, 1.8; 95 % CI, 1.0–3.2) and suicide attempts (OR, 2.3; 95 % CI, 1.0–4.5). The cumulative number of ACEs was also associated with an increased risk of NSSI (OR, 1.2; 95 % CI, 1.0- 1.4) and suicide attempts (OR, 1.2; 95 % CI, 1.0–1.4) in girls. Among all deceased adolescents, ACEs were most notable among those who had died due to accidents and injuries. Gender differences in the types of ACEs were noted and discussed.     

Addiction and suicidal behavior in acute psychiatric inpatients

Objective

This study aims to evaluate the relationship of alcohol/drug use and effect severities to the degree of suicidality in acutely admitted psychiatric patients. Both degree of substance dependency and degree of substance-induced syndrome were analyzed. In addition, length of stay, involuntary status, and against medical advice discharge status were determined as they related to these variables.

Methods

Structured clinical admissions and discharge ratings were gathered from 10?667 consecutive, single-case individual records, from an urban acute care county psychiatric hospital.

Results

Data indicate that of the most severely suicidal group, 56% had substance abuse or dependence, 40% were rated as having half or more of their admission syndrome substance induced, and most had nonpsychotic diagnoses. There was an inverse relationship between degree of substance problem and length of stay. Although these patients more commonly left against medical advice, and were readmitted more frequently, they were less likely to be involuntarily committed.

Conclusions

A large, potentially lethal, and highly expensive subgroup of patients has been characterized, which might be called the “New Revolving Door acute psychiatric inpatient.” This group, which uses the most expensive level of care in the mental health system but is substantially addiction related, poses special challenges for inpatient psychiatric units, addiction treatment providers, and health care planners.     

Suicide in adolescent psychiatric inpatients: incidence and predictive factors

Of 1969 previous adolescent psychiatric inpatients, 1792 (91%) were traced after a mean follow-up period of 15 years. Thirty-five patients, 1.7% of the females and 2.2% of the males, had committed suicide, corresponding to a yearly suicide rate of 145/100,000 for males and 110/100,000 for females. This represents a 6-fold increase for males and a 19-fold increase for females compared with the suicide rate for 15- to 29-year-old males and females in the general population. There was seasonality in violent but not in nonviolent suicides. The patients who had committed suicide were compared with matched patients from the same sample who stayed alive. The suicide group had more depressive symptoms, more learning difficulties, poorer self esteem, were more help-rejecting, and had more immature defense mechanisms. They lacked parental support and were more often verbally abused by their parents. They had more frequently experienced serious losses in early childhood and had a higher score on enduring stressors on Axis IV in DSM-III-R. They more often came from urban areas and received poorer follow-up after discharge from hospital. Eight of these discriminating factors were combined into a predictive model for the lifetime risk of suicide in adolescent psychiatric inpatients. The model had strong predictive power, classifying 84% of the population correctly.     

Adolescence-limited versus life-course-persistent criminal behaviour in adolescent psychiatric inpatients

 A nation-wide sample of 1072 Norwegian adolescent psychiatric inpatients were followed up 15–33 (mean 23.8) years after hospitalisation, by record linkage to the National Register of Criminality. Defining criminal behaviour as entry into the criminal registry, 481 patients (45%) had an adolescent criminal debut, entering the registry before the age of 21. Of these, 130 (27%) had no criminal record after the age of 21 and were consequently considered as adolescence-limited criminal offenders, as opposed to the remaining 351 (73%) individuals who continued their criminal behaviour beyond the age of 21 and were considered as life-course-persistent criminal offenders. On the basis of hospital records, all patients were rediagnosed according to DSM-IV and scored on factors hypothesised to have predictive power as to persistence of criminal behaviour. We found that 79.6% of the male, and 58.8% of the female adolescent delinquents went on to life-course-persistent criminality. In females, intravenous use of illegal drugs, and being discharged from the hospital elsewhere than to the family home, were strong and independent predictors of life-course-persistent criminal behaviour. In males, the following were significant and independent predictors of life-course-persistent criminality: a high number of conduct disorder criteria fulfilled, comorbidity of psychoactive substance use disorder, and having attended correctional school. Accepted: 8 March 1999     

Suicidal behavior among inner-city Hispanic adolescent females

Suicidal behavior is disproportionately frequent among inner-city Hispanic adolescent girls. In an attempt to generate a multifactorial set of hypotheses to explain this behavior, 33 such subjects consecutively admitted for suicidal behavior and 15 demographically identical nonsuicidal subjects were assessed by means of a structured interview. Mothers of all subjects were also assessed. Attempts were nearly always impulsive and nonlethal, though often with a stated wish to die. Nearly all were overdoses, and were precipitated by conflicts with mother or boyfriend. Mothers could usually identify the precipitants. Attempters' parents were less often born in the U.S., their mothers seemed medically less healthy, and their extended families were more often supported by public assistance, and had a higher incidence of criminal and psychiatric problems. School performance was poorer among attempters, who had suffered more and earlier losses, especially of biologic fathers, with whom fewer had ongoing relationships. They more often had boyfriends, had begun sexual activity, had recently lost friends, and expressed a mistrustful stance toward friendships. Similarly, their mothers had fewer friends and more often expressed a mistrustful stance. Relationships with mothers seemed more intense, desperate, and even violent, and attempters were much more often parentified, i.e., mothering their mothers. Although both groups often assumed caretaking roles in their families, attempters were more negatively described by themselves and by their mothers. While knowledge of suicidal models was common in both groups, attempters' mothers knew of even more models than did their daughters or the nonsuicidal subjects or their mothers. Notably, more attempters' mothers had themselves made attempts. Families of most attempters were usually mobilized by the attempt. These findings permit the construction of a putative profile of risk factors that can be tested more rigorously.     

Changes in suicidal behavior in child psychiatric inpatients

This study of 49 preadolescent psychiatric inpatients, aged 6-12 years, evaluated changes from the time of admission to 7 weeks later in ratings of suicidal behavior, assaultive behavior, depression, hopelessness, and global functioning. Standard research instruments were used to measure these variables. There were significant decreases in suicidal behavior, assaultiveness, and depression and a significant increase in global assessment during the 7 weeks of hospitalization. Severity of suicidal behavior and severity of assaultive behavior at admission predicted a subsequent change in level of suicidal behavior. Furthermore, severity of suicidal behavior at admission was the best indicator of a change in severity of suicidal behavior.     

Sadistic personality disorder and comorbid mental illness in adolescent psychiatric inpatients

Sadistic personality disorder (SPD) is a controversial diagnosis proposed in the DSM-III-R, but not included in the DSM-IV. Few studies have focused on this disorder in adolescents. This article describes the results of a study that sought to determine the presence of sadistic personality characteristics in psychiatrically hospitalized adolescents and of comorbid Axis I or personality disorder patterns in those youth with SPD or SPD traits. Fifty-six adolescents were assessed for sadistic and other personality disorders with the Structured Interview for DSM-III-R Personality Disorders-Revised (SIDP-R). Axis I disorders were assessed using the Diagnostic Interview for Children and Adolescents, Adolescent Version (DICA-R-A) and portions of the Schedule for Affective Disorders and Schizophrenia for School Age Children, Epidemiologic (K-SADS-E). The youth were divided into those with SPD and SPD traits, the Sadistic Group (n = 18), and the Nonsadistic Group (n = 38). A significant proportion of the adolescents in this study met full DSM criteria for SPD (14%). The Sadistic Group (32%) had significantly more Axis I and personality pathology than did the Nonsadistic Group. However, all but one in the Sadistic Group met criteria for other personality disorders, confounding the interpretation of these findings and consistent with adult literature studies. Subjects with sadistic personality characteristics were identified in this adolescent inpatient sample, and they had more extensive Axis I and II psychopathology than the comparison group. The validity of this disorder in younger populations requires further study. Future studies should also explore the impact that the mandatory use of the pleasure/gratification criterion has on the validity of the SPD diagnosis and whether the requisite presence of this criterion decreases the overlap currently noted between SPD and other Axis II diagnoses.     

Need for systematic screening for IGD in adolescent psychiatric inpatients

Psychiatric comorbidities are frequent in adolescents with internet gaming disorder (IGD). In contrast, the proportion of IGD among adolescents hospitalized for a psychiatric disorder has not been documented yet. In addition, parental ratings of IGD could be useful for diagnosis, but very few data exist on this issue. The objectives of this study were to: (1) assess the prevalence of IGD among adolescent psychiatric inpatients, using the Ten-Item Internet Gaming Disorder Test (IGDT-10), and (2) assess the parental version developed for this study (IGDT-10-P). A total of 102 patients, aged from 12 to 17 years old, were included from four psychiatric units of the French region Auvergne-Rhône-Alpes, during a 6-month inclusion period. Adolescents completed the IGDT-10 while one of their parents completed the IGDT-10-P. The inclusion rate among the eligible population was 57.95%. The prevalence of IGD in the sample, based on the IGDT-10 and IGDT-10-P, was 6.00% and 12.79%, respectively. Psychometric features of the IGDT-10-P indicated excellent internal consistency, a good model fit to the one factor model in confirmatory factor analysis, a strong correlation with gaming time, and a moderate correlation with the IGDT-10. Our results support the need for a systematic screening of IGD among adolescents hospitalized for a psychiatric disorder. Future studies should aim to confirm and explain the prevalence gap between self- and parent-reported criteria.     

Suicidal behavior of adolescent girls: profile and meaning

In the last two decades the incidence of adolescent suicides has been very high (though it has been on the decrease in the U.S.A. over the last four years), giving rise to a multitude of empirical and theoretical studies. The extensive knowledge that has accumulated regarding adolescent suicidal behavior has led to a more differentiated attitude. Many studies try to clarify specific needs, motivations and the conceptualization of death and suicide in various adolescent subgroups (minorities, females, homosexuals), thereby enabling more specific and exact methods of evaluation, prevention and intervention. Adolescent girls' suicidal behavior is different in many aspects from boys' suicidal behavior: Girls mortality rate from suicide is a 3-5 times lower rate than boys, but their attempted suicide rate is four to hundreds time higher. Girls suicide mainly by drugs and their suicide is mainly in reaction to interpersonal difficulties. Their motivation is often a cry for help. The comorbidity of suicide and depression is much higher for adolescent girls than boys. These differences generate a different understanding and separate treatment strategies. Two theoretical approaches that may explain the profile which characterizes suicidal girls will be presented. One has a psychological developmental context, and the other a social cultural context. Implications for specific prevention measures include legal action on pack sizes of analgesics, compulsory registration of attempted suicide and more gender specific treatment and prevention programs.     

Legal issues in the treatment of adolescent psychiatric inpatients.

When planning a specialized adolescent treatment unit for a regional state mental hospital in North Carolina, staff of the child psychiatry training program explored several critical legal issues surrounding the admission, treatment, and discharge of minors, as well as issues of confidentiality. Through a question-and-answer format they conclude that, to help avoid conditions that could result in successful litigation against the hospital, parents, adolescents, and staff must have a documented, mutual agreement to and understanding of the techniques, procedures, and limitations of the treatment program. Such documentation could be provided through a signed treatment contract.     

Clinical correlates of cannabis use among adolescent psychiatric inpatients

ObjectivesThis study sought to determine the clinical correlates of adolescents with cannabis use and no additional drug use (CU) compared to adolescents with no drug use (NDU) among a group of adolescent psychiatric inpatients in Israel.MethodsTwo hundred and thirty-six patients consecutively admitted to an adolescent inpatient unit at a university-affiliated mental health center in Israel during a 3-year period were screened. Individuals with polydrug use were excluded from the study.ResultsPrevalence of cannabis use was 13%. In the CU group, 39% were diagnosed with attention deficit and disruptive behavior disorders compared with 16% in the NDU group. Antipsychotics were the most common medications prescribed in both groups. Mood stabilizers were more frequently prescribed to CU than to NDU patients (39% vs 16%, respectively). A higher prevalence of alcohol abuse and criminal behaviors was found among CU compared to NDU patients (61% and 39% vs 6% and 4%, respectively).ConclusionsThe high prevalence of disruptive behaviors and frequent treatment with antipsychotics and mood stabilizers in the CU group may be related to the strong association between externalizing behavior and cannabis use and the non-specific pharmacological treatment of disruptive behaviors. Formal screening for cannabis use should be considered in psychiatric facilities. Specifically, adolescents with disruptive behaviors could benefit from early interventions, before and after cannabis initiation.     

Characteristics of assaultive behavior among psychiatric inpatients

OBJECTIVE: The purpose of this study was to assess the extent to which psychosis, disordered impulse control, and psychopathy contribute to assaults among psychiatric inpatients. METHODS: The authors used a semistructured interview to elicit reasons for assaults from assailants and their victims on an inpatient research ward. Video monitoring provided supplemental information to confirm participants' identities and activities before and during the assault. RESULTS: Consensus clinical ratings indicated that approximately 20 percent of the assaults in this sample were directly related to positive psychotic symptoms. Factor analysis revealed two psychosis-related factors, one related to positive psychotic symptoms and the other to psychotic confusion and disorganization, as well as a third factor that differentiated impulsive from psychopathic assaults. CONCLUSIONS: Information obtained from interviews with assailants can reveal the underlying causes of specific assaults. This information is potentially useful in the selection of rational antiaggressive treatment strategies.     

A catch-up study of former child and adolescent psychiatric inpatients: psychiatric status in adulthood

BACKGROUND: The purpose of this study was to reassess former child and adolescent psychiatric patients as adults with regard to their further development. METHODS: We used a 'catch-up' design. A former child and adolescent psychiatric patient cohort and controls (matched for sex and age) were assessed as adults with standardized instruments (Schedules for Clinical Assessment in Neuropsychiatry, International Personality Disorder Examination, biography, psychiatric history, Global Assessment Scale, Satisfaction with Life Scale). RESULTS: We assessed 164 former patients and 80 controls. The mean catch-up period was 13.2 years, and the subjects had a mean age of 24.8 years. Thirty-nine percent of the former patients and 25% of the controls fulfilled criteria for an ICD-10 diagnosis (present state) at catch-up, with a clear excess of personality disorders in the former patient group (13 vs. 3%). Using a survival analysis we estimated that 38% of the former patients and 10% of the controls would undergo psychiatric treatment between the ages of 18 and 31 years. CONCLUSIONS: Most former child and adolescent psychiatric patients did not come into contact with psychiatric treatment facilities again in their twenties, although they had a higher risk for a psychiatric disorder than controls. Nevertheless, the risk of later developing a personality disorder according to ICD-10 seems to be markedly raised for former child and adolescent psychiatric patients.