Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients

The characteristics of adolescent suicide victims (n = 27) were compared with those of a group at high risk for suicide, suicidal psychiatric inpatients (n = 56) who had either seriously considered (n = 18) or actually attempted (n = 38) suicide. The suicide victims and suicidal inpatients showed similarly high rates of affective disorder and family histories of affective disorder, antisocial disorder, and suicide, suggesting that among adolescents there is a continuum of suicidality from ideation to completion. However, four putative risk factors were more prevalent among the suicide victims: (1) diagnosis of bipolar disorder; (2) affective disorder with comorbidity; (3) lack of previous mental health treatment; and (4) availability of firearms in the homes, which taken together accurately classified 81.9% of cases. In addition, suicide completers showed higher suicidal intent than did suicide attempters. These findings suggest a profile of psychiatric patients at high risk for suicide, and the proper identification and treatment of such patients may prevent suicide in high-risk clinical populations.     

Outcomes of suicidal behaviors

Research issues associated with outcomes of suicidal behavior include: the appropriate length of time to follow subjects is at least two years, psychiatric controls without a history of suicide attempt are a recommended comparison group, quantitation of traits such as aggression or impulsivity is desirable. Clinical issues include the following: the diathesis for suicide is a trait, the most universal risk factor across groups is the presence of depression, yet under-treatment, such as inadequate dosing of antidepressants and high rates of drop-out from psychotherapy, is a major problem. Other issues include that treatment must take a lifelong perspective, there is an ongoing need for psychoeducation of practitioners and the public, outreach to institutions such as schools, hospitals and jails is needed, when a child or adolescent exhibits suicidal behavior, parents should be screened for psychiatric illness, there is an urgent need to remedy barriers to treatment including insurance coverage obstacles, long wait-lists, and fragmentation of mental healthcare. Improvements should include a focus on step-down treatments and the integration of primary care and mental healthcare. Establishing a national registry of serious suicidal behavior to aid research, and clinical trials of treatments for suicidal behavior is important. Subpopulations for study include children, adolescents, the elderly, institutionalized persons, community samples (as distinct from clinical samples), persons with a family history of suicide (for genetic linkage studies), attempters versus completers, single versus multiple attempters and persons who drop out of treatment.     

12-Month and Lifetime Prevalence of Suicide Attempts Among Black Adolescents in the National Survey of American Life

ObjectiveProvide nationally representative data on the prevalence and psychiatric correlates of suicidal ideation and attempts among African American and Caribbean black adolescents in the United States.MethodData on nonfatal suicidal behavior among 1,170 African American and Caribbean black adolescents aged 13 to 17 years are from the National Survey of American Life-Adolescent, a nationally representative household survey of adults with an attached adolescent sample conducted between February 2001 and June 2003.ResultsNationwide black adolescents reported having a lifetime prevalence of 7.5% for suicidal ideation and 2.7% for attempts. The 12-month prevalence of suicidal ideation and attempt was 3.2% and 1.4%, respectively. Among all respondents, 4% of black American adolescents and 7% of female subjects were projected to attempt suicide by age 17 years. African American adolescents were approximately five times more likely than Caribbean black adolescents to attempt suicide. Almost half of the National Survey of American Life-Adolescent respondents who reported a suicide attempt had never met criteria for any of the DSM-IV disorders by the time of their attempts.ConclusionsClinicians should be trained to screen for suicidal behavior, even among those without DSM-IV disorders, when treating black adolescents, particularly female subjects. In addition, preventive efforts should consider ethnic differences in suicide risk and targeting nonclinical settings.     

Impaired Self-Regulation and Suicidal Behavior Among Adolescent and Young Adult Psychiatric Inpatients

The aim of this study was to examine the correlates of suicidal behavior among 64 adolescents (ages 13-17 years) and 62 young adults (ages 18-35 years) within a psychiatric inpatient setting. We investigated the influence of impairment in general self-regulation, including specific behavioral dysregulation, on suicidal behavior within these two groups. Results suggested that suicidal adolescents and young adults experienced similar degrees of overall disruption in self-regulation. However, compared to their young adult counterparts, suicidal adolescents were characterized by more self-injurious and self-mutilative behaviors, as well as greater outward expression of anger. Results indicated that adolescent attempters were particularly prone to self-harm behavior. These findings suggest that specific psychopathology associated with suicidal behavior may differ across these developmental stages.     

Psychosocial and psychiatric characteristics of suicide completers with psychiatric treatment before death: a psychological autopsy study of 76 cases

Aim: The present study was conducted to examine differences in psychosocial and psychiatric characteristics between suicide completers with and without a history of psychiatric treatment within the year before death, using a psychological autopsy method. Methods: A semi‐structured interview was administered by a psychiatrist and other mental health professionals for the closest bereaved of 76 suicide completers. Results: Suicide completers with a history of psychiatric treatment (n = 38) were significantly younger than those without (n = 38) (P < 0.01), and a significantly higher proportion of cases in the treatment group were estimated to be suffering from schizophrenia. Further, in 57.9% of the treatment group, the fatal suicidal behavior involved overdose with prescribed psychotropic drugs. In addition, female suicide completers in the treatment group were more likely to have a history of self‐harm or non‐fatal suicidal behavior. Conclusion: Many suicide completers who received psychiatric treatment were young adults. It was common for suicide completers to overdose on prescribed drugs as a supplementary means of suicide, and many experienced self‐harming behavior before death. In addition, a higher proportion of the treatment cases suffered from schizophrenia.     

Suicide in adolescents with disruptive disorders.

OBJECTIVE: To determine the psychiatric risk factors for suicide in adolescents with disruptive disorders. METHOD: Fifty-nine adolescent suicide completers and 18 community controls, both having a probable or definite current DSM-III diagnosis of disruptive disorders, were compared. RESULTS: Adolescents with disruptive disorders who committed suicide had higher rates of current substance abuse, past suicide attempt, family history of substance abuse, and family history of mood disorder than disruptive community controls. CONCLUSIONS: Disruptive adolescents appear to be at risk for completed suicide when comorbid substance abuse and past history of suicide attempt are present. The risk increases if the adolescents have a past history of physical abuse and if they have parents with substance abuse and mood disorders. Clinicians should be aware of these risk factors and implement active interventions to prevent suicide. Treatment should focus on treating not only the adolescents, but also their family members. The findings of this study also highlight the need for future research in the prevention of suicide in adolescents with disruptive disorders and comorbid substance abuse.     

The relationship between adolescent suicidal behavior and life events in childhood and adolescence.

OBJECTIVE: Although the relationship between experience of problematic life events and adolescent suicidal behavior has frequently been recognized during the past decade, few studies of life events have been initiated that discriminated between adolescent suicide attempters and depressed adolescents. Therefore, the authors compared adolescent suicide attempters with both depressed and nondepressed adolescents who never attempted suicide with respect to life events that happened in two periods: childhood (defined as the period up to age 12 years) and adolescence (age 12 and older). METHOD: Using a semistructured interview, the authors gathered life event data about childhood and adolescence from three groups of adolescents: 48 suicide attempters, 66 depressed adolescents who had never made a suicide attempt, and 43 nondepressed adolescents who had never made a suicide attempt. RESULTS: The group of adolescents who attempted suicide differed from both of the other groups in that they had experienced more turmoil in their families, starting in childhood and not stabilizing during adolescence. During adolescence, they were more often sexually abused. During the last year before the attempt, further social instability, such as changes in residence and having to repeat a class, occurred. CONCLUSIONS: For suicidal adolescents, the suicide attempt seems embedded not just in the problems every adolescent has to deal with but in greater turmoil in their families, rooted in childhood and not stabilizing during adolescence, in combination with traumatic events during adolescence and social instability in the year preceding the attempt.     

Fatal and Non-Fatal Suicidal Behavior in Israeli Adolescent Males

The objective of this study is examine the similarities and differences between adolescent suicide completers, adolescents with non-fatal suicidal symptoms, and non-suicidal psychiatric controls in an epidemiologic sample. Using the central Israeli military medical registry, 214 18–21 year old males from the same national service cohort were identified, consisting of 43 consecutive completed suicides and 171 consecutive central psychiatric clinic outpatients presenting with near-fatal suicide attempts, serious suicide attempts, para-suicidal gestures, threats, ideation, or other non-suicidal complaints. Systematic pre-induction and service data were available for all subjects, with detailed postmortem inquest data for suicides. Systematic clinical data, including the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS), Hamilton Depression Scale, and Eysenck Personality Inventory were obtained on all clinic subjects. Major depression was present in half of completers, near-lethal attempters, and ideators, but absent in the other clinic groups, whose commonest diagnosis was adjustment disorder. Depression scores increased across groups with increasing intent; ideators also had high scores. Completers and near-lethal attempters had higher I.Q. and medical fitness ratings and were in more demanding assignments than other groups. Prior attempts were commonest in completers, near-lethal attempters, and gesturers. Disciplinary history, ethnicity, family intactness, immigrant status, and Eysenck Personality Inventory scores did not differentiate the groups. The findings may not be generalizable to female adolescents or to other countries or time periods. The findings thus point to contrasts, as well as similarities, between groups of adolescents with different types of suicidal symptoms.     

Fatal and non-fatal suicidal behavior in Israeli adolescent males

The objective of this study is examine the similarities and differences between adolescent suicide completers, adolescents with non-fatal suicidal symptoms, and non-suicidal psychiatric controls in an epidemiologic sample. Using the central Israeli military medical registry, 214 18-21 year old males from the same national service cohort were identified, consisting of 43 consecutive completed suicides and 171 consecutive central psychiatric clinic outpatients presenting with near-fatal suicide attempts, serious suicide attempts, para-suicidal gestures, threats, ideation, or other non-suicidal complaints. Systematic pre-induction and service data were available for all subjects, with detailed postmortem inquest data for suicides. Systematic clinical data, including the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS), Hamilton Depression Scale, and Eysenck Personality Inventory were obtained on all clinic subjects. Major depression was present in half of completers, near-lethal attempters, and ideators, but absent in the other clinic groups, whose commonest diagnosis was adjustment disorder. Depression scores increased across groups with increasing intent; ideators also had high scores. Completers and near-lethal attempters had higher I.Q. and medical fitness ratings and were in more demanding assignments than other groups. Prior attempts were commonest in completers, near-lethal attempters, and gesturers. Disciplinary history, ethnicity, family intactness, immigrant status, and Eysenck Personality Inventory scores did not differentiate the groups. The findings may not be generalizable to female adolescents or to other countries or time periods. The findings thus point to contrasts, as well as similarities, between groups of adolescents with different types of suicidal symptoms.     

Gender differences in suicide attempts from adolescence to young adulthood

OBJECTIVE: To examine associations of age, gender, and psychosocial factors during adolescence with risk of suicide attempt between ages 19 and 23 years. METHOD: Initial assessments were conducted with 1,709 adolescents (aged 14-18) in western Oregon between 1987 and 1989. One year later, 1,507 participants returned for a second assessment. A subset of participants (n = 941; 57.2% women) had a third diagnostic assessment after turning 24 (between 1993 and 1999). Information on suicidal behavior, psychosocial risk factors, and lifetime DSM-III-R psychiatric diagnosis was collected at each assessment. RESULTS: The suicide attempt hazard rate for female adolescents was significantly higher than for male adolescents (Wilcoxon chi 2(1)[n = 941] = 12.69, p < .001). By age 19, the attempt hazard rate for female adolescents dropped to a level comparable with that of male adolescents. Disappearance of the gender difference for suicide attempts by young adulthood was not paralleled by a decrease in the gender difference for major depression. Adolescent suicidal behavior predicted suicide attempt during young adulthood for female, but not male, participants. Adolescent psychosocial risk factors for suicide attempt during young adulthood were identified separately for girls and boys. CONCLUSIONS: Unlike depression, the elevated incidence rate of suicide attempts by adolescent girls is not maintained into young adulthood. Screening and prevention implications are discussed.     

Gender role in adolescent suicidal behavior: observations and therapeutic implications

We analyzed the relative seriousness of suicide attempts by boys based on 430 hospitalized suicide attempters ages 13 to 19 years. A comparison by sex of adolescent suicide attempters with a school population of non-suicidal adolescents of the same age group shows greater differences in the areas of school failure, psychosomatic and distress-related symptoms and substance abuse between suicidal and non-suicidal boys than between suicidal and non-suicidal girls. These findings suggest that compared with non-suicidal boys and girls, suicidal boys show more deviant behavior than girls. The question then arises as to whether there are differences in the treatment received by male and female suicide attempters. On hospital admission, more boys than girls are sent to psychiatric wards, and boys are proposed follow-up care more frequently than girls. On the other hand, boys and girls are not treated differently with respect to psychiatric consultations during hospitalization or coordination with outside physicians (family doctor, school doctor, other physicians) and the social services. These findings could serve as the basis for the development of specific treatment plans to meet the needs of suicidal boys.     

Suicidal behavior and self-disclosure in adolescent psychiatric inpatients

The inability to communicate feelings and thoughts to people close to oneself may be an important risk factor for suicidal behavior. This inability has been operationalized in the concept of self-disclosure. The purpose of this article was to evaluate the correlation of self-disclosure with suicidal behavior in adolescents. Eighty consecutive admissions to an adolescent psychiatric inpatient unit were evaluated. Thirty-four were suicide attempters, 18 were suicidal ideators, and 18 were nonsuicidal. Assessment measures included the Child Suicide Potential Scale, the Suicide Intent Scale, the Suicide Ideation Scale, and the Self-Disclosure Scale. The results show that low self-disclosure levels are associated with suicidal thinking, suicide attempts, and suicidal attitudes. Thus, low self-disclosure may well be a risk factor worthy of further evaluation in the attempt to understand adolescent suicidal behavior.     

Psychosocial profile of suicide ideators, attempters and completers in India

The study aims to determine the psychological profile of suicide ideators, attempters and completers in a tertiary care teaching hospital. A total of 260 suicidal ideators, 58 attempters and 55 completers were studied. The majority of ideators, attempters and completers were 26-35 years of age, males (except attempters who were predominantly females), married, literate up to high school, employed (ideators) or housewives (attempters and completers). The suicide ideators, attempters and completers who had a past history of attempt were 6.9%, 24.1% and 18.2% respectively. Family history of attempted suicide or completed suicide was also common among patients suffering from depression. In suicidal ideators, mixed anxiety and depressive disorder was the most common psychiatric diagnosis followed by major depression and schizophrenia. Among suicide attempters, adjustment disorder with depression was the most common diagnosis. The most common method of suicide attempt was organophosphorus compound intake whereas in suicide completers, the most common method in use was hanging. The patients with suicidal ideation or attempt need careful evaluation, early intervention and long term follow up.     

Multimethod assessment of suicidality in adolescent psychiatric inpatients: preliminary results

OBJECTIVE: To examine agreement among multiple assessments of adolescent suicidal ideation and suicidal behavior for adolescent psychiatric inpatients, including pencil/paper checklists; structured and unstructured interviews; and adolescent, clinician, and parent reports, and to provide suggestions for the accurate and reliable assessment of suicidality in adolescence. METHOD: Participants included 153 adolescent psychiatric inpatients (54 boys, 99 girls) between the ages of 12 and 17 years. Measurement of suicidal ideation and behavior included common assessment instruments and standard clinical practices, including the Suicidal Ideation Questionnaire, NIMH Diagnostic Interview Schedule for Children, clinician interview, and parent report (Behavior Assessment Scale for Children). RESULTS: Results revealed significantly different rates of suicidality across each instrument and poor to moderate agreement between similar measures of adolescent suicidal ideation and suicidal behavior. Agreement between measures was generally best for boys, for older adolescents, and for assessments relying on a single informant. Reporters were most likely to agree on the presence of suicidality for more severely suicidal adolescents; this finding suggests that agreement in itself may be a useful marker for adolescent suicide. CONCLUSIONS: Results of this preliminary study supported the use of multiple measurement approaches when examining adolescent suicidality, particularly those that rely on clinician judgment and adolescents' own reports. Implications for future research and for clinical practice are also discussed.     

Suicidal behavior among adolescents with conduct disorder--the role of alcohol dependence

Our aim was to investigate the association between alcohol dependence and suicidal behavior among adolescent girls and boys suffering from conduct disorder (CD). The original study sample consisted of 387 adolescents (age 12-17) admitted to psychiatric inpatient care between April 2001 and May 2005. DSM-IV-based psychiatric diagnoses and variables measuring suicidal behavior were obtained from the Schedule for Affective Disorders and Schizophrenia for School Aged Children--Present and Lifetime (K-SADS-PL). Of the total study population, 59 adolescent girls and 82 boys had CD according to DSM-IV criteria. Of all adolescents with CD, 24 (40.7%) girls and 24 (29.3%) boys were suffering from alcohol dependence. Among girls with CD, alcohol dependence increased the risk for suicide attempts up to 3.8-fold (95% CI 1.1-13.4). Among boys with CD, alcohol dependence increased the risk for life-threatening suicide attempt over nine-fold (95% CI 1.2-80.1). In addition, the risk for self-mutilative behavior was as high as 3.9-fold (95% CI 1.1-13.8) among girls and 5.3-fold (95% CI 1.1-26.5) among boys. The results indicate that, among adolescents suffering from CD, the risk of suicidal behavior is considerably increased by co-morbid alcohol dependence, which should therefore be carefully taken into account in clinical work.     

Familial aggregation of suicidal behavior: a family study of male suicide completers from the general population

OBJECTIVE: This study compared suicidality in families of adult male suicide completers and community comparison subjects. METHOD: Two hundred forty-seven relatives of 25 male suicide completers and 171 relatives of 25 matched comparison subjects were assessed for recurrent risk of suicidal and related behaviors. Analyses were performed on a subgroup of relatives of suicide completers with cluster B personality disorders. RESULTS: Relatives of suicide completers were over 10 times more likely than relatives of comparison subjects to attempt or complete suicide after the authors controlled for psychopathology. Relatives of suicide completers were not more likely to exhibit suicidal ideation but had more severe suicidal ideation than relatives of comparison subjects. These findings were stronger for the suicide completers diagnosed with cluster B personality disorders. CONCLUSIONS: Suicide has a familial component independent of psychopathology that may be mediated by a combination of factors, including more severe suicidal ideation and aggressive behavior.     

The association of psychiatric disorders with suicide attempts in a juvenile delinquent sample

The goal of this study was to examine the degree to which psychiatric disorders (current and lifetime) are associated with a history of suicide attempt in a sample of juvenile delinquents. Sixty adolescents in a secure detention facility participated in diagnostic interviews assessing most psychiatric disorders according to DSM-III-R criteria. Although this population appears to have numerous psychiatric problems, suicide attempts were primarily associated with the internalising problems of depression (major depression and dysthymia) and anxiety disorders. Suicide attempt rates were approximately twice as high for adolescents with these disorders compared with adolescents who had not experienced the disorder. Cannabis use disorders were associated with a trend (p = 0.051) for lower lifetime suicidal behaviour. Conduct and oppositional defiant disorders were associated with higher rates of suicide attempts in boys but lower rates of attempts in girls. The co-occurrence of psychiatric disorders did not significantly increase the likelihood of suicide attempt, although the pattern of results was in the predicted direction. Understanding the determinants of suicidal behaviour in detained adolescents has important clinical and theoretical implications. Efforts are clearly needed to treat depression actively in this population. Copyright © 1997 Whurr Publishers Ltd.     

Violence and Substance Use in Adolescents with Increasing Severity of Suicidal Behavior

A theoretical pathway of progression of suicidal behavior, from ideation tocommunicating suicidal intent to suicide attempt was examined by investigating whether adolescents at each stage of the pathway could be differentiated from those at the previous stage by their risk behaviors. Cluster sampling produced a sample of 7,340 high-school students who completed a self-administered questionnaire. Bivariate analyses and multivariate logistic regression models were used to investigate the relationships between stage of severity of suicidal behavior and selected risk behaviors. For females, the more severe the suicidal behaviors exhibited, the more likely that the adolescent had been both a perpetrator and victim of violence. For males, attempting suicide was associated with being a victim and perpetrator of violence. Our findings lend partial support to the continuum of severity hypothesis of suicidal behaviors and suggest that clinicians should be alerted to escalating violent behavior as a potential precursor to suicide attempt.     

Suicide attempts and self-mutilative behavior in a juvenile correctional facility

OBJECTIVE: To determine the lifetime history of suicide attempts in incarcerated youths and psychological factors related to suicidal and self-mutilative behaviors during incarceration. METHOD: A 25% systematic random sample chart review of adolescents admitted to a juvenile correctional facility yielded a sample of 289 adolescents. Seventy-eight of these adolescents were clinically referred for psychiatric assessment. Suicidal behavior was assessed with the Spectrum of Suicidal Behavior Scale and self-mutilation with the Functional Assessment of Self-Mutilation. RESULTS: Of the 289 adolescents, 12.4% reported a prior suicide attempt. Almost 60% of these attempts were made using violent methods (e.g., cutting). Of the 78 clinically referred subjects, 30% reported suicidal ideation/behavior and 30% reported self-mutilative behavior while incarcerated. Suicidal clinically referred adolescents reported more depression, anxiety, and anger than nonsuicidal youths. Adolescents who reported self-mutilative behavior had higher anxiety, anger, and substance use than non-self-mutilative adolescents. CONCLUSIONS: Results suggest that incarcerated adolescents have higher rates of suicide attempts and use more violent methods of attempt than adolescents in the general population. Furthermore, incarcerated clinically referred suicidal and self-mutilative youths report more severe affective symptoms than their nonsuicidal and non-self-mutilative counterparts, suggesting a need for mental health treatment.     

Maternal versus adolescent reports of suicidal behaviors: a nationwide survey in Israel

Community and nationwide surveys on adolescent suicidal behaviors using clinical interviews are not abundant. Rates of self-reported suicide attempts in community samples vary greatly between 1 and 20 %. In general, adolescent and parental agreement in child psychiatry practice is low, and their agreement with regard to suicidal behavior is unknown. The current study assesses the rates of suicidal ideation and behaviors as well as the rate of agreement between adolescents and their mothers in a representative nationwide sample. The survey included a representative and randomized community sample of 14- to 17-year-old adolescents (n = 957), and their mothers who were interviewed using the Development and Well-Being Assessment Inventory (DAWBA). The prevalence of suicidal ideation and self-initiated behaviors was 4.9 and 1.9 %, respectively. The concordance between mothers’ and adolescents’ reporting on ideation was low (7.3 %). There was no concordance between mothers’ and adolescents’ reports of suicidal acts. Adolescents reported self-initiated behaviors nearly three times more frequently than their mothers. Paternal unemployment, care by welfare agencies and having a psychiatric disorder, specifically depression or post-traumatic stress disorder, was associated with a higher risk for both suicidal ideation and attempts. In this nationwide community study, by evaluating information gathered by clinical interviews, it was found that the lifetime rates of suicidal ideation were moderate. The rates of suicide attempts were lower than have been previously reported. The concordance between the reports of adolescents and their mothers was low for ideation and nonexistent for attempts. Thus, clinicians should interview adolescents separately from their mothers regarding their suicidality.