Suicide in mood disordered children and adolescents

This article reviews the risk factors for fatal and nonfatal suicidal behavior in children and adolescents. Numerous empirical studies suggest that mood disorders are among the most important risk factors for youth suicidal behavior. In addition, other psychosocial factors increase risk for youth suicidal behavior independent of mood disorders. Prevention strategies for suicidal behavior should incorporate methods to identify children and adolescents who suffer from major depressive, dysthymic, and bipolar disorders. Such strategies should identify children and adolescents who have a history of suicidal ideation and/or suicide attempts.     

Sleep and youth suicidal behavior: a neglected field

PURPOSE OF REVIEW: Sleep undergoes substantial changes during adolescence and suicide risk begins to increase during this period as well. This review focuses on recent literature on the relationship between sleep and suicidal behavior and proposes directions for future research. RECENT FINDINGS: Adolescent sleep is characterized by widespread sleep restriction, irregular sleep schedules, daytime sleepiness, and elevated risk for sleep disturbances. More research on adolescent sleep and psychosocial impairment, psychiatric disorders, and suicidal behavior has been conducted. Suicidal psychiatric patients had more sleep disturbances including insomnia, hypersomnia, or nightmares than nonsuicidal patients. Shorter rapid eye movement latency and increased rapid eye movement activity have been noted to be a marker of suicidality in psychiatric patients. Epidemiological studies have demonstrated that insomnia, nightmares, and sleep insufficiency are associated with elevated risk for suicide. Although the link between insomnia and suicidal behavior appears to be mediated by depression, existing data suggest an independent predictive role of nightmares in future suicidal behavior. SUMMARY: Sleep loss or disturbances are likely to signal an increased risk of future suicidal action in adolescents. Large-scale prospective studies and neurobiological studies are needed for a better understanding of the complex relationship between sleep, psychopathology, and youth suicidal behavior.     

Atypical antipsychotics and suicide in mood and anxiety disorders

Abstract:  Globally, a million people commit suicide every year, and 10–20 million attempt it. Mood disorders, especially major depressive disorder (MDD) and bipolar disorder, are the most common psychiatric conditions associated with suicide. Primary (psychiatric and physical illness), secondary (psychosocial), and tertiary (demographic) risk factors for suicide have been identified. Comorbid psychiatric illness, particularly anxiety symptoms or disorders, significantly increase the risk of suicidal behavior. Current standard risk assessments and precautions may be of limited value, while assessing the severity of anxiety and agitation may be more effective in identifying patients at risk. Lithium is the medication that has most consistently demonstrated an antisuicidal effect. The effects of antidepressants and conventional antipsychotics on suicide risk are uncertain, but atypical antipsychotics appear promising. Atypical antipsychotics have beneficial effects on depressed mood both in patients with MDD and in patients with bipolar disorder. In addition, data in patients with schizophrenia have demonstrated a significant improvement in the incidence of suicidal behavior with clozapine compared with olanzapine. Electroconvulsive therapy appears to have an acute benefit on suicidality.     

Psychogenic nonepileptic seizures and suicidal behavior on a video/EEG telemetry unit: The need for psychiatric assessment and screening for suicide risk

Patients with epilepsy and psychogenic nonepileptic seizures (PNES) have an increased prevalence of psychiatric illness and risk for suicidal ideation/suicidal behavior/suicide compared with the general population. Recent literature suggests that antiepileptic drugs (AEDs) used to treat epilepsy, pain, and psychiatric disorders increase the risk of suicide and that this increased risk may be AED selective. This case analyzes a suicide attempt on a video/EEG telemetry unit. Specific risk factors associated with increased risk of suicidal behaviors pertinent to this case are reviewed: epilepsy, multiple psychiatric diagnoses including affective disorder, AEDs, PNES, prior medically serious suicide attempt, and suicide attempt within the past month. Specific psychometric rating scales to screen for both psychiatric illness and suicide risk and psychiatric assessment should be integral components of the evaluation and treatment of patients on video/EEG telemetry units.     

Psychogenic nonepileptic seizures and suicidal behavior on a video/EEG telemetry unit: the need for psychiatric assessment and screening for suicide risk

Patients with epilepsy and psychogenic nonepileptic seizures (PNES) have an increased prevalence of psychiatric illness and risk for suicidal ideation/suicidal behavior/suicide compared with the general population. Recent literature suggests that antiepileptic drugs (AEDs) used to treat epilepsy, pain, and psychiatric disorders increase the risk of suicide and that this increased risk may be AED selective. This case analyzes a suicide attempt on a video/EEG telemetry unit. Specific risk factors associated with increased risk of suicidal behaviors pertinent to this case are reviewed: epilepsy, multiple psychiatric diagnoses including affective disorder, AEDs, PNES, prior medically serious suicide attempt, and suicide attempt within the past month. Specific psychometric rating scales to screen for both psychiatric illness and suicide risk and psychiatric assessment should be integral components of the evaluation and treatment of patients on video/EEG telemetry units.     

Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy

Studies of causes of death among people with epilepsy suggest that the lifetime prevalence rate of suicide is elevated. Although not all of the studies have reported an increased risk for suicide, the collective data yield an average rate of approximately 12% among people with epilepsy, compared with 1.1-1.2% in the general population. The increased risk for suicide appears to affect children and adolescents as well as adults. Rates of suicide attempts have also been reported to be elevated among people with epilepsy. A suicide attempt is a significant risk factor for completed suicide. Certain psychiatric disorders, including primary mood disorders, also increase the risk for suicide. Among people with epilepsy, psychiatric comorbidity is common, and rates of mood disorders, particularly major depression, have consistently been reported to be elevated. Other potential risk factors are family issues, physical health, personality, life stress, previous suicidal behavior, and access to firearms. Assessing severity of risk helps to determine the appropriate level of intervention. The suicidality module of the Mini-International Neuropsychiatric Interview is a practical tool to help quantify current suicide risk.     

Risk factors for suicide and attempted suicide among young people

OBJECTIVE: Suicide rates in young people have increased during the past three decades, particularly among young males, and there is increasing public and policy concern about the issue of youth suicide in Australia and New Zealand. This paper summarises current knowledge about risk factors for suicide and suicide attempts in young people. METHOD: Evidence about risk factors for suicidal behaviour in young people was gathered by review of relevant English language articles and other papers, published since the mid-1980s. RESULTS: The international literature yields a generally consistent account of the risk factors and life processes that lead to youth suicide and suicide attempts. Risk factor domains which may contribute to suicidal behaviour include: social and educational disadvantage; childhood and family adversity; psychopathology; individual and personal vulnerabilities; exposure to stressful life events and circumstances; and social, cultural and contextual factors. Frequently, suicidal behaviours in young people appear to be a consequence of adverse life sequences in which multiple risk factors from these domains combine to increase risk of suicidal behaviour. CONCLUSIONS: Current research evidence suggests that the strongest risk factors for youth suicide are mental disorders (in particular, affective disorders, substance use disorders and antisocial behaviours) and a history of psychopathology, indicating that priorities for intervening to reduce youth suicidal behaviours lie with interventions focused upon the improved recognition, treatment and management of young people with mental disorders.     

Suicidal Behaviour in Mood Disorders—Who,When, and Why?

Objective:

About one-half to two-thirds of all suicides are by people who suffer from mood disorders; preventing suicides among those who suffer from them is thus central for suicide prevention. Understanding factors underlying suicide risk is necessary for rational preventive decisions.

Method:

The literature on risk factors for completed and attempted suicide among subjects with depressive and bipolar disorders (BDs) was reviewed.

Results:

Lifetime risk of completed suicide among psychiatric patients with mood disorders is likely between 5% and 6%, with BDs, and possibly somewhat higher risk than patients with major depressive disorder. Longitudinal and psychological autopsy studies indicate suicidal acts usually take place during major depressive episodes (MDEs) or mixed illness episodes. Incidence of suicide attempts is about 20- to 40-fold, compared with euthymia, during these episodes, and duration of these high-risk states is therefore an important determinant of overall risk. Substance use and cluster B personality disorders also markedly increase risk of suicidal acts during mood episodes. Other major risk factors include hopelessness and presence of impulsive–aggressive traits. Both childhood adversity and recent adverse life events are likely to increase risk of suicide attempts, and suicidal acts are predicted by poor perceived social support. Understanding suicidal thinking and decision making is necessary for advancing treatment and prevention.

Conclusion:

Among subjects with mood disorders, suicidal acts usually occur during MDEs or mixed episodes concurrent with comorbid disorders. Nevertheless, illness factors can only in part explain suicidal behaviour. Illness factors, difficulty controlling impulsive and aggressive responses, plus predisposing early exposures and life situations result in a process of suicidal thinking, planning, and acts.     

Diagnosis of childhood and adolescent suicidal behavior: unmet needs for suicide prevention.

This article highlights strategies for diagnosing risk for childhood and adolescent suicidal behavior. Empirical studies identifying risk factors for childhood and adolescent suicidal behavior guided recommendations for suicide risk assessment. Diagnostic assessment involves identification of multiple factors including demographic characteristics, suicidal behavior, psychopathology, interpersonal problems, family discord, family psychopathology, accessibility of lethal suicide methods, exposure to suicide, and protective factors. Interview methods and self-report questionnaires are reliable and valid in identifying suicidal risk but are limited by low base rates of suicide. Identification of risk factors as foci for intervention is important for suicide prevention.     

Genetics of suicide: an overview

Risk for suicide may have heritable contributions. Evidence supporting this hypothesis includes strong and consistent findings from more than 20 controlled family studies indicating nearly 5-fold greater relative risk of suicidal acts among relatives of index cases with suicidal behavior compared to relatives of nonsuicidal controls. Relative risk was greater for completed suicide than for attempts. Contributions of genetic instead of environmental factors are indicated by a higher average concordance for suicidal behavior among co-twins of suicidal identical twins compared to fraternal twins or to relatives of other suicidal subjects, in at least seven studies. Three studies indicate significantly greater suicidal risk, particularly for completed suicide, among biological versus adoptive relatives of suicidal or mentally ill persons adopted early in life. Molecular genetics studies have searched inconclusively for associations of suicidal behavior with genes mainly for proteins required for central serotonergic neurotransmission. Complex interactions of environmental with heritable risk and protective factors for suicide and psychiatric illnesses or vulnerability traits are suspected, but specific intervening mechanisms remain elusive. Familial or genetic risks for psychiatric factors strongly associated with suicide, such as major affective illnesses and alcohol abuse, as well as impulsive or aggressive traits, have not consistently been separated from suicidal risk itself.     

Risk of suicide in mood disorders

Suicide is commonly associated with mood disorders. Risk factors for suicide in mood disorders can be organized according to whether their effect is on the threshold or diathesis for suicidal acts or whether they serve mainly as triggers or precipitants of suicidal acts. Predisposition to suicidal behavior or diathesis is a key element that helps to differentiate patients who are at high risk versus those at lower risk. The objective severity of mood disorders does not identify depressed patients at high risk for suicide attempt. There is a lack of agreement over the suicide risk associated with characteristics of depression such as psychotic features, agitation, or anxiety, or mixed mood states as part of bipolar disorder. Risk factors affecting the diathesis for suicidal behavior include family history of suicide, low cerebrospinal fluid 5-hydroxyindolacetic acid, alcohol and/or substance abuse, cluster B personality disorder, high past impulsivity and aggression, chronic physical illness particularly involving the brain, marital isolation, parental loss before age 11, childhood history of physical and sexual abuse, hopelessness, and not living with a child under age 18. Most common precipitants of suicidal acts in mood disorders include interpersonal losses or conflicts, financial trouble, and job problems. Identification of high risk patients and effective treatment are required for suicide prevention to reduce morbidity and mortality in affective disorders.     

Suicidal Behavior in Juvenile Delinquents: The Role of ADHD and Other Comorbid Psychiatric Disorders

This study evaluated the role of psychiatric morbidity in relation to a history of suicidal behavior, with a particular focus on attention-deficit/hyperactivity disorder (ADHD). Suicidality and psychiatric diagnoses were assessed in 370 incarcerated male juvenile delinquents from Northern Russia using the semi-structured K-SADS-PL psychiatric interview. A lifetime history of suicidal ideation only (24.7?%) and suicidal ideation with suicide attempts (15.7?%) was common. Binary logistic regression analysis was used to assess the role of ADHD and other psychiatric disorders in suicidal ideation and suicide attempts. A history of suicidal ideation and of suicide attempts were associated with higher rates of psychiatric morbidity and with the number of comorbid psychiatric disorders. An ADHD diagnosis was associated with an increased risk for both suicidal ideation and for suicide attempts. The comorbidity of ADHD with drug dependence further increased the risk for suicidal ideation, while ADHD and alcohol dependence comorbidity increased the risk for suicide attempts. Our findings highlight the importance of adequately detecting and treating psychiatric disorders in vulnerable youths, especially when they are comorbid with ADHD.     

Suicidal ideation and attempts in bipolar I and II disorders

OBJECTIVE: Few studies have investigated the prevalence of and risk factors for suicidal ideation and attempts among representative samples of psychiatric patients with bipolar I and II disorders. METHOD: In the Jorvi Bipolar Study (JoBS), psychiatric inpatients and outpatients were screened for bipolar disorders with the Mood Disorder Questionnaire from January 1, 2002, to February 28, 2003. According to Structured Clinical Interviews for DSM-IV Axis I and II Disorders, 191 patients were diagnosed with bipolar disorders (bipolar I, N = 90; bipolar II, N = 101). Suicidal ideation was measured using the Scale for Suicidal Ideation. Prevalence of and risk factors for ideation and attempts were investigated. RESULTS: During the current episode, 39 (20%) of the patients had attempted suicide and 116 (61%) had suicidal ideation; all attempters also reported ideation. During their lifetime, 80% of patients (N = 152) had had suicidal behavior and 51% (N = 98) had attempted suicide. In nominal regression models, severity of depressive episode and hopelessness were independent risk factors for suicidal ideation, and hopelessness, comorbid personality disorder, and previous suicide attempt were independent risk factors for suicide attempts. There were no differences in prevalence of suicidal behavior between bipolar I and II disorder; the risk factors were overlapping but not identical. CONCLUSION: Over their lifetime, the vast majority (80%) of psychiatric patients with bipolar disorders have either suicidal ideation or ideation plus suicide attempts. Depression and hopelessness, comorbidity, and preceding suicidal behavior are key indicators of risk. The prevalence of suicidal behavior in bipolar I and II disorders is similar, but the risk factors for it may differ somewhat between the two.     

Suicide Attempts Among Adolescents with Self-Reported Disabilities

This study examines the relative risk for suicide attempts (SA) among high-school students self-identifying with one or more disability classifications (nine); assesses the extent to which youth with disabilities are disproportionately vulnerable to risk factors that predict suicidal behavior among all adolescents; and explores whether disability status adds to risk for SA after accounting for a comprehensive set of known risk and protective factors for SA. Analyses using Wisconsin’s 2012 Dane County Youth Assessment Survey data found that youth in each disability category were 3–9 times more likely to report suicide attempt(s) relative to peers, and the endorsement of multiple disabilities tripled the risk SA relative to youth reporting a single disability. Some disability sub-groups, including youth reporting autism spectrum disorder, hearing, and vision impairments reported surprisingly high rates of SA. While youth with disabilities reported disproportionate exposure to adversity in every life domain examined, similar to youth reporting SA, disability status added unique risk for suicidal behavior. This suggests that disability may be a ‘fundamental cause’ of suicidal behavior, a question that requires further investigation.     

The risk of assaultive behavior in suicidal patients

This study assessed the occurrence of assaultive behavior in a group of suicidal patients who were in psychiatric hospitals, many for long periods of time. Of the 94 suicidal patients, 42 (45%) patients physically assaulted other persons at least once in the 3 months preceding the survey. Although many patients manifested active psychotic psychopathology at the time of the survey, there were no significant differences between assaultive and non-assaultive suicidal patients in terms of the presence of psychosis. The sex, race, primary psychiatric diagnosis, and length of stay of patients also were not related to the occurrence of assaultive behavior in suicidal patients. Only youth and the presence of seizure disorders were related to increased risk of assaultive behavior in hospitalized suicidal patients. The author compares the findings of this study to his previous study of concurrent assault and suicide just before or at the time of admission to psychiatric hospitals.     

Youth suicide: risk factors, assessment, and treatment of adolescent and young adult suicidal patients

One of the most difficult clinical problems facing the mental health professional is the prediction and prevention of youth suicide. Suicide is currently the third leading cause of death for young people, ages 15 to 24, in the United States. This article presents several models for understanding youth suicidal behavior including psychologic, sociologic, and biomedical explanations. It summarize what is known about risk factors for adolescent and young adult suicide, including psychiatric diagnosis, personality traits, psychosocial factors, associated medical illnesses, biologic correlates, and family history and genetics. Knowledge about these risk factors will be translated into practical considerations for the treatment of adolescent and young adult suicidal patterns, including psychotherapeutic, psychopharmacologic, and environmental interventions.     

Proximal psychiatric risk factors for suicidality in youth: the Great Smoky Mountains Study

CONTEXT: Psychiatric disorder is a major risk factor for suicidality but has poor positive predictive value. OBJECTIVES: To characterize proximal risks for suicidality associated with anxiety, depressive, disruptive behavior, and substance use disorders, and to test whether there are critical combinations of disorders that discriminate at-risk youth independent of severity of psychopathology. DESIGN: The Great Smoky Mountains Study, a representative sample of children and adolescents aged 9 to 16 years from the southeastern United States. Subjects and their parents were interviewed on multiple occasions from 1993 to 2000 about the subjects' recent psychiatric and suicidal history. SETTING: An epidemiological sample of youth. PARTICIPANTS: The sample included 1420 individual subjects with 6676 records across 8 waves of data collection. MAIN OUTCOME MEASURES: Wanting to die, suicidal ideation, suicide plans, or suicide attempt during the past 3 months. RESULTS: Eleven broad psychiatric profiles discriminated suicidal youth. Risk was greatest in association with current depression plus anxiety (specifically GAD [generalized anxiety disorder]) (odds ratio, 468.53) or depression plus a disruptive disorder (primarily ODD [oppositional-defiant disorder]) (odds ratio, 222.94). Unless comorbid, anxiety and substance use disorders were not proximally associated with suicidality. The severity of symptom-related impairment and, in some cases, total symptom load explained risk associated with all psychiatric profiles except depression plus anxiety, specifically GAD (adjusted odds ratio, 50.16). Severity of impairment and poverty defined by federal guidelines for families were both independent risk factors, irrespective of psychiatric profile. Suicidal youth without diagnosable disorders had subthreshold (mostly disruptive) disorders, disabling relationship difficulties, or psychiatric symptoms without associated impairment. CONCLUSIONS: Severity of symptom-related impairment and total symptom load explained most of the risk for suicidality associated with current psychiatric disorders. Only depression plus GAD discriminated at-risk youth independent of severity of psychopathology.     

Management of the depressed, suicidal child or adolescent

Two prominent risk factors for completed suicide and suicidal behavior in adolescents are previous suicide attempts and a diagnosis of a depressive episode. Adolescents with different degrees of suicidal risk and severity are referred or admitted to various clinical settings. Research has yet to identify clearly the treatment of choice for suicidal patients. Regardless, clinical interventions should be based on a thorough suicide risk assessment. Treatment strategies should be multidimensional, targeting suicidal behavior and the underlying psychiatric illness or other personality and environmental risk factors. Because adolescents are referred from one clinical setting to another, continuity of care must be one of mental health practitioners' major concerns. Lack of continuity of care places patients at an elevated risk for additional suicide attempts.     

Epidemiology, risk factors, and psychopharmacological management of suicidal behavior in borderline personality disorder.

Borderline personality disorder (BPD) is a chronic psychiatric condition characterized by a pervasive pattern of instability in affect regulation and impulse control. These maladaptive coping strategies predispose individuals with BPD to suicidal behavior, and this diagnosis increases the risk for completed suicide. Empirical data indicate that adverse life events; a history of childhood trauma; and the presence of comorbid psychiatric conditions, in particular major depressive disorder and substance use disorders; confer an elevated risk of suicidal behavior in patients with BPD. Psychopharmacological interventions, including the use of antidepressants, anti-psychotics, and mood stabilizers, are considered in this review in terms of the evidence for their utility in reducing the risk of suicidal behavior in BPD.     

Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior

OBJECTIVE: Posttraumatic stress disorder (PTSD) increases the risk of suicidal behavior; a major depressive episode also increases the risk for suicidal behavior. The authors' goal was to examine the effect of comorbid PTSD and major depressive episode on suicidal behavior. METHOD: Inpatients with a diagnosis of major depressive episode (N=156) were assessed for PTSD, suicidal behavior, and clinical risk factors for suicidal acts. RESULTS: Patients with comorbid major depressive episode and PTSD were more likely to have attempted suicide, and women with both disorders were more likely to have attempted suicide than men with both disorders. Cluster B personality disorder and PTSD were independently related to history of suicide attempts. CONCLUSIONS: The greater rate of suicide attempts among patients with comorbid PTSD and major depressive episode was not due to differences in substance use, childhood abuse, or cluster B personality disorders.