Childhood Depression and Risk of Suicide: A Preliminary Report of a Longitudinal Study

Childhood Depression and Risk of Suicide: A Preliminary Report of a Longitudinal Study UMA RAO, M.D., MYRNA M. WEISSMAN, PH.D., JACQUELINE A. MARTIN, R.N., M.A., AND ROBERT W. HAMMOND, B.S. Abstract. In the course of locating a sample of 427 adults who were assessed as children or adolescents with either major depressive disorder, mixed anxiety states, or no psychiatric disorder (normal controls), we found seven cases of suicide. Of the original sample, we located 159 of the 204 subjects with major depressive disorder (78%), 37 of the 66 subjects with anxiety disorders (56%), and 85 of the 177 normal controls (48%). All seven suicides occurred exclusively among the 159 children located from the major depressive disorder group, yielding a rate of 4.4% over approximately 10 years. Psychological autopsy was conducted in the seven suicide victims to assess the psychological status since the initial assessment and at the time of death. Although the onset of the first depressive episode in these victims was around puberty, the suicides usually did not occur until late adolescence or early adulthood. At least five of the seven subjects had recurrent depressive symptoms and were clinically depressed at the time of death. These preliminary findings suggest that major depressive disorder in childhood has significant mortality by suicide. J. Am. Acad. Child Adolesc. Psychiatry, 1993,32, 1:21-27. Key Words: major depressive disorder, suicide, childhood.

In contrast to the debates two decades ago, it is now clear from epidemiological and clinical studies that major depressive disorder (MDD) does occur in children and that many cases first occur in adolescence and young adulthood (Christie et aI., 1988). There is some agreement that the symptom patterns in children and· adolescents are similar to those of adults as described in the DSM-II/ (American Accepted March 24, 1992. From the Department of Psychiatry, College of Physicians and Surgeons of Columbia University and New York State Psychiatric Institute. Dr. Rao is an assistant professor in the Department of Psychiatry at the University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic. Dr. Weissman is a professor in the Department of Psychiatry and School of Public Health at the College of Physicians and Surgeons of Columbia University and the director ofClinical Genetic Epidemiology at New York State Psychiatric Institute. Ms. Martin is a Research Associate in the Department of Psychiatry at New York State Psychiatric Institute. Mr. Hammond is a clinical research assistant at Hoechst-Roussel Pharmaceuticals Inc., Somerville, NJ. This work derives directly from the ideas, imagination, and vision of Joaquim Puig-Antich, MD. He undertook a study of depressed children at a time when there was little consensus about its existence or methods for its assessmelJt. He entrusted the second author with theirfollow up. The initial and unexpectedfinding, a high suicide rate among the depressed children grown up, was discovered after his death. The authors would like to thank David Shaffer, M.D., Jennifer Lish, Ph.D., Prudence Fisher, MS., and Virginia Warner, MP.H.,for ·advice on the assessment. This work was supported by a grant from the John D. and Catherine T. MacArthur Foundation Network 1 534209 to David Kupfer, M.D., and by the NIMH Grant 903.JOOIB to the Child Psychiatry Clinical Research Center at the New York State Psychiatric Institute, New York, NY. Dr. Rao was supported by the NIMH Institutional Research Training Grant 5-38501 through the College of Physicians and Surgeons of Columbia University. Reprint requests to Dr. Rao, WPIC, 3811 O'Hara Street, Pittsburgh, PA 15213. 0890-8567/93/3201-o021$03.00/0©1993 by the American Academy of Child and Adolescent Psychiatry.

I. Am. Acad. Child Adolesc. Psychiatry, 32: I,January 1993

Psychiatric Association, 1980; Ryan et aI., 1987; Strober et aI., 1981), and that it is associated with substantial impairment in psychosocial functioning (Puig-Antich et aI., 1985a & b) including substance abuse, school drop-outs, and suicide attempts (Brent et aI., 1990; Fleming and Offord, 1990; Kandel and Davies, 1986). However, it is not certain if these symptoms persist into adulthood. Despite the increasing prevalence of depression in children and adolescents, the associated familial aggregation, and the high risk for suicide attempts, we know little about the continuity between the childhood and adult forms (Klerman and Weissman, 1989). Information on the continuity between the childhood and adult forms of depression requires longitudinal studies of children into adulthood. Ideally, these studies should include (1) systematic psychiatric assessments of subjects both in childhood and in adulthood, (2) follow-up diagnoses conducted blindly with regard to the original childhood diagnoses, (3) at least two control groups assessed at both points, as children and as adults, including (a) normal controls who have no evidence of ever having a psychiatric disorder to determine the natural history, course, and incidence of disorders over time, and (b) a second control group with other psychiatric disorders, but not depression, to determine the specificity of the diagnostic outcome in adulthood. There are no published studies, to date, that meet all these requirements. The study that comes closet to having the ideal design was recently published by Harrington and associates (1990). This study used a "catch-up longitudinal design" to assess adult psychiatric status and social adjustment of depressed children and adolescents compared with individually matched nondepressed psychiatric controls. The sample included 80 child and adolescent psychiatric patients who had a depressive syndrome operationally defined and retrospectively based on their symptoms recorded when they attended a psychiatric clinic. These children were individu2/

RAO ET AL.

ally matched with 80 nondepressive psychiatric controls on demographic variables and nondepressive childhood symptoms using a computer algorithm. Follow-up was done after an average of 18 years from the initial contact. The major findings were that the depressed group was at an increased risk for affective disorders in adult life as well as psychiatric hospitalizations and treatment. They were no more likely than was the control group to have nondepressive adult psychiatric disorders. These [mdings strongly suggested that there was a substantial specificity and continuity in affective disturbance between childhood and adult life. This study, albeit closest to the ideal design, had to rely on retrospective reconstruction from earlier notes for initial diagnoses. There are other longitudinal studies of children and adolescents with major depression that do provide similar findings despite some methodological limitations, including small samples, short follow-up period, absence of diagnostic criteria, and absence of control groups. These studies suggest that the depressive episodes have prolonged course with recurrence (Chess et aI., 1983; Garber et aI., 1988; Kovacs et aI., 1984a, b; Olsen, 1961; Strober and Carlson, 1982; WeIner et aI., 1979), persistence of depressive symptoms into adulthood (Chess et aI., 1983; Garber et aI., 1988; Kandel and Davies, 1986; Poznanski et aI., 1976; WeIner et aI., 1979), increased rates of only affective illness when compared with controls, suggesting specificity of the disorder (Garber et aI., 1988; WeIner et aI., 1979), poor social functioning in adulthood (Garber et aI., 1988; Kandel and Davies, 1986; Olsen, 1961; Poznanski et aI., 1976; WeIner et aI., 1979), and bipolar disorder in the future (Strober and Carlson, 1982; WeIner et aI., 1979). Some studies also have demonstrated increased prevalence of affective disorders among family members (Garber et aI., 1988; King and Pittman, 1970; Strober and Carlson, 1982; WeIner et a!., 1979). The paucity of longitudinal studies of depressed children into adulthood is, in part, because until recently the conventional belief was that depression did not occur in children, and if it did, it was thought to be masked. There were .few instruments for systematic assessment of children and adolescents until the late 1970s. Joaquim Puig-Antich, M.D., was a pioneer in adapting diagnostic assessment for children and conducting comprehensive studies of depressed children. Between 1978 and 1984, he conducted comprehensive clinical and biological studies of children with either MDD, mixed anxiety states, or no psychiatric disorder (normal controls). The sample, now in adulthood, provides a unique opportunity to answer several questions regarding continuity and discontinuity between childhood and adult depression: Are they similar disorders? Are they developmentally linked? Is childhood depression a precursor of adult bipolar and other disorders? How are patterns of continuity or discontinuity affected by comorbidity, familial loading, and abnormalities in psychosocial functioning? The answers may suggest prevention strategies and treatment interventions for depressed children. This article reports our initial findings on suicide during the course of efforts to locate Dr. Puig-Antich's sample in preparation for a follow-up study.

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Method Initial Sample

The sample included 204 child or adolescent patients diagnosed as having a major depressive disorder, 66 as having mixed anxiety disorders (separation anxiety disorder, phobias, obsessive-compulsive disorder, or overanxious disorder), and 177 normal subjects who had no current or past psychiatric history. A fourth group of 30 children with attention deficit disorder or conduct disorder (ADD-CD) were studied initially but are not included here because of the small sample size and unsuccessful efforts to locate the group. The total sample for this study consisted initially of 447 children. Initial Assessments

Patients were accepted for an initial screening at New York State Psychiatric Institute (NYSPI) between 1978 and 1984 if they were between 6 and 17 years old and were reported to appear sad or said they were sad, or presented with suicidal ideation or behavior, school refusal, nervousness, fears, or rituals. Each case was screened for appropriateness dur:ing a 2-week diagnostic evaluation that included the Schedule for Affective Disorder and Schizophrenia for School Age Children (K-SADS) (Chambers et aI., 1985), psychosocial assessment using a semistructured instrument, the Psycho. Social Schedule (PSS) (Lukens et aI., 1983), pediatric examination that included Tanner staging, IQ, and wide range achievement tests. A second KSADS was conducted 10 to 16 days later to assess symptoms for the past week by another physician. The assessments were done independently, and both the child and the parent were interviewed. Adolescents also were administered the K-SADS, Epidemiologic version (K-SADS-E) (Orvaschel et aI., 1982) to assess the nature of any previous episodes of psychiatric disorders. Interrater reliability, test-retest reliability for symptoms and intraclass correlation coefficient reported elsewhere were high (Puig-Antich et aI., 1985a, 1989b). The diagnosis of major depression was made using the unmodified adult Research Diagnostic Criteria (RDC) (Spitzer et aI., 1978). The diagnoses of the various anxiety disorders conformed to the DSM-III criteria. Normal controls were recruited by random sampling of the third, fourth, and fifth grade children at an urban school on the basis of having a student body whose ethnic and socioeconomic characteristics were similar to those of the first half of the depressed sample. Neither the children nor their parents were told that the study was connected with . depression to avoid biased sampling. Two separate groups of interviewers assessed the child and collected the family data. The two groups were kept blind to each other's results. The K-SADS-E was used to interview the child and the parent. At no point were the interviewers certain of the proband having been accepted as normal. Only children who met none of the DSM-III criteria for psychiatric diagnoses during their lifetime were accepted into the normal group. In addition to the above assessments, information on the family history of psychiatric illness was obtained from the J. Am. Acad. Child Adolesc. Psychiatry, 32: 1,January 1993

CHILDHOOD DEPRESSION AND RISK OF SUICIDE

mother, using the Family History Method (FH-RDC) (Andreasen et aI., 1977). Treatment with tricyclic antidepressants and psychosocial interventions, sleep, and neuroendocrine studies were conducted on a subgroup of children and adolescents (Chambers et aI., 1982; PuigAntich et aI., 1981, 1982, 1983, 1984a, b, c, d, and e, 1985a, and b, 1987, 1989a and b; Ryan et aI., 1986, 1987). Follow-Up

Attempts were made to locate the original sample between 1989 and 1991 by using the old addresses of the patients and their neighbors, obtained from the clinic records and from files maintained by credit bureaus and public utilities. Psychological autopsy was conducted on the seven identified suicides. The psychological autopsy was conducted by a child psychiatrist (U.R.). Psychiatric history since the initial assessment and the psychological status at the time of death were assessed using the K-SADS-E (Orvaschel et aI., 1982). Modifications were made to obtain information on the number of depressive episodes, clinical symptoms and treatment during each episode, and the psychological status at the time of death. Psychosocial functioning, during the lifetime and within the last 6 months before death, was obtained by using a modified semistructured interview, the Social Adjustment Inventory for Children and Adolescents (SAICA) (John et aI., 1987). Details of the suicide, including the precipitants of death, the method used, and the physical circumstances were assessed through a semistructured interview, the Completed Suicide Event Interview (Fisher et aI., unpublished). Family history of psychiatric illness was obtained by using the Family History - Epidemiologic Version (FHE) (Lish et aI., unpublished). The FHE is a screening instrument that was modified from the FH-RDC for epidemiological studies. The FHE was modified to obtain information on suicide among family members and friends. Significant family life events also were assessed using a modified version of the Coddington Life Events Questionnaire (Coddington, 1972). A parent was the informant in six cases and an aunt in the seventh case. The interviews were conducted between January and March of 1991 in six cases. The parents of one subject were interviewed within 3 months of death in another study using similar measures. Other informants were sought but consent was not obtained. Information also was obtained from the initial assessments done by Puig-Antich et aI. between 1978 and 1984, the hospital records during and subsequent to the initial evaluation, and the medical examiner's reports.

TABLE

Results

As of January 1991, the research staff had located 159 of the 204 depressed subjects (78%), 37 of the 66 subjects with anxiety disorders (56%), and 85 of the 177 normal controls (48%) (Table 1). Of the 281 subjects located thus far, there have been seven deaths by suicide. All seven suicides occurred exclusively in the depressed group, yielding a rate of 4.4% over 10 years, among the located depressed subjects. Efforts to locate the remaining sample continue. Table 2 describes the characteristics of the seven suicide victims. There were four males and three females. No clear pattern was observed among the seven victims either in the demographic features, subtypes of MDD, comorbid diagnoses, treatment response, or method of suicide. The first depressive episode occurred before or around puberty in each case. The initial assessments by Dr. Puig-Antich were conducted during the late adolescent period in five subjects when they sought treatment. Two subjects were assessed around puberty. The timing of suicide in all but two cases was in late adolescence or early adulthood. Death occurred during the period of study in one subject and the remaining deaths occurred well after the initial assessment. A variety of methods were used, although tricyclic overdose was the most common cause of death (three of seven). Of the remaining four subjects, one died by the use of explosives, one by jumping, one by accidental fire after ingesting gasoline, and one by drowning. Among the three subjects with tricyclic overdose, two were on active treatment at the time of death. One subject saved the medication for almost a year after terminating treatment. Five subjects had met RDC criteria for a major depressive disorder around the time of death, and one of these subjects had psychotic symptoms in addition to depressive symptoms. One subject had depressive symptoms but did not meet criteria for a major depressive disorder. Adequate information was not available to make a diagnosis in one subject. Information obtained from initial assessments, medical records, and interviews with parents indicated that all the subjects had a prolonged course of illness. They were usually isolated with few or no friends and had a history of suicidal ideation and/or attempts. Four subjects initially responded well to tricyclic antidepressants, two subjects showed partial improvement, and one subject showed very minimal improvement with tricyclics. Addition of other drugs, including lithium, did not cause any significant change. Two of the subjects with a poor response to antidepressants later developed psychotic symptoms and were treated with antipsychotic medication with no significant

1. Description of Sample, Percent Located, and Suicide Rate

Diagnostic Group

Total Sample

N Located

% Located

Suicides

Suicide Ratell 00 in Located Sample

Major depression Anxiety disorders Normal controls Total

204 66 177 447

159 37 85 281

78 56 48 65

7 0 0 7

4.4 0.0 0.0 2.5

J. Am. Acad. Child Adolesc. Psychiatry, 32:1, January 1993

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TABLE 2. Characteristics of the Seven Suicides

Case No.

Gender

I 2 3 4

M M M M F F F

5 6 7 Note: MDD

=

Onset First MDD

Age at Initial Assessment

Age at Death

Suicide Method

Provisional Diagnoses at Death

13 14 14 12 10 14

17 17 16 16 II 17 13

26 21 23 18 14 20 14

Explosives Tricyclic OD Jumping Gasoline ingestion Drowning Tricyclic OD Tricyclic OD

MDD MDD MDD, Psychosis Bipolar, depressed Unknown MDD MDD (Possible)

12

major depressive disorder; OD

=

overdose.

improvement. After the initial assessment at NYSPI, at least six subjects had recurrence of depressive symptoms with deterioration in psychosocial functioning. One subject later developed bipolar disorder. A second subject also developed manic symptoms. However, it was not clear whether this was induced by the various substances the subject abused. Five of the subjects had written letters to their parents about the intent of suicide, but the information was received after the death in all cases. All except one subject had a family history of affective illness and/or alcoholism among the first-degree relatives. Two subjects had relatives with a diagnosis of bipolar disorder. There was a history of suicide attempts among the relatives of three subjects. A brief description of each of the seven subjects follows: Subject 1 was a 17-year-old white young man initially assessed in 1980. He had a history of depressive symptoms for 4 years before assessment and had made three previous suicide attempts. He also had a history of alcohol abuse beginning at age 14. His peer relationships were impaired from early childhood. Treatment was started with an antidepressant medication after his initial assessment at NYSPI. He showed significant improvement in his depressive symptoms and school functioning but continued to abuse alcohol. Medication was discontinued in 1981, and he was discharged from the clinic. He did well for a year after discharge but became depressed again by the end of 1982. He started to have occupational difficulties and changed several jobs. He never sought treatment for these problems. His parents were divorced when he was 23, and his condition worsened. A 6-year heterosexual relationship was terminated by his partner one year before death. He became withdrawn and essentially nonfunctional except for brief periods of employment. Six days before death, he took an overdose of tranquilizers and alcohol. On the day of his death, he appeared to be his normal self. He picked up his paycheck and apparently purchased a gun and some explosives. He died at the age of 26 by detonating himself in a vacant house under construction. Family history is significant for alcoholism and depression on both sides of the family. Subject 2 was a 17-year-old white young man who was referred in 1984 by his school counselor with a history of depression for 2 1/2 years and a decline in academic performance. He never had made a suicide attempt but had recurrent thoughts with rehearsed planning. He was quiet and had 24

very few friends from early childhood. Treatment was started with an antidepressant after his initial assessment. He responded positively for 3 years but discontinued his medication in 1987. He became depressed again and dropped out of school, although he was performing well academically. He planned to join the military in 1988 but became anxious as the time approached. He was rejected by a girl friend 2 days before death. A week before joining the military, he took a lethal overdose of the antidepressant medication he had saved. He was 21 years old. Family history was significant for alcoholism in the father and older brother and depression in two siblings, one of whom has been treated with antidepressants. Subject 3 was a 16-year-old black male adolescent who was referred to the clinic in 1983 after a suicide attempt. At the age of 14, he began to show some signs of depression, which worsened progressively until his admission. He was started on an antidepressant after his assessment at NYSPI. Several changes were made in medication because of poor response and/or significant side effects. He did not complete high school and never worked. He developed psychotic symptoms (delusional thinking and hallucinations) in addition to depressive symptoms in 1986 and terminated treatment at NYSPI. Subsequently, he had several hospitalizations for suicide attempts. One month before death, he became very depressed and developed psychotic symptoms. He died at the age of 23 by jumping out of a sixth floor window. Family history is significant for depression and alcoholism in the father. Subject 4 was a 16-year-old white male adolescent referred in 1983 for depressive symptoms and poor school performance of 4 years' duration. He was in treatment for 3 years before that with poor response to several medications. He was started on antidepressant medication after assessment at NYSPI. Several changes were made because of poor response to treatment. He had cyclic changes in mood along with psychotic symptoms and was hospitalized for more than a year. Difficulties continued after discharge. Two weeks before death, he became increasingly depressed and did not respond to lithium and antidepressants. He expressed hopelessness about his condition several times and ingested gasoline while his parents were away. He was later discovered alive. However, as he was being removed from the scene, the fumes from the gasoline he had ingested were l. Am. Acad. Child Ado/esc. Psychiatry, 32:1,January 1993

CHILDHOOD DEPRESSION AND RISK OF SUICIDE

ignited by a furnace pilot light. He became engulfed in flames and subsequently died. He died at the age of 18 years. The subject was adopted at 4 months of age. The natural father was thought to have been treated for bipolar disorder. No psychiatric problems were known in the adoptive family. Subject 5 was an ll-year-old black girl referred in 1980 because of behavior problems at school, temper tantrums at home, impaired peer relationships, and suicidal threats. On evaluation, she had symptoms of behavior problems and depression with onset at the age of 10. She was started on an antidepressant medication after assessment and had good response. Since the age of 5 years, she had lived with her maternal grandmother after her mother's death. There were significant difficulties between her and her grandmother with frequent running away from home. She was placed in a residential school in 1983. Information was obtained from a great aunt who saw her on weekends. She could not swim but went into the deep end of a swimming pool and drowned at age 14. Autopsy report could not be obtained in this case because of the nonavailability of her legal guardian. Her mother had behavior problems from the age of 8, was dependent on alcohol, and was killed by her boyfriend at the age of 23. Her maternal uncle had been incarcerated on charges of narcotic trafficking and weapon shooting. Along with substance abuse, two maternal aunts had behavior problems from childhood, one of the aunts had several psychiatric hospitalizations. Subjects 6 was a 17-year-old white young woman who was referred in 1980 by· her psychologist who had been treating her for 3 years, because of worsening depression, decline in academic performance, and dropping out of school. She was started on an antidepressant. There was some improvement in depressive symptoms, but she continued to have problems with family and peers. She began to abuse alcohol and several drugs. She never attained any gainful employment. After her father's death in 1982, her symptoms worsened. She developed some manic symptoms subsequent to her assessment at NYSPI. However, no formal diagnosis was made. She made several suicide attempts (sometimes making serious attempts) before and after her initial assessment at NYSPI. One attempt, insulin overdose, resulted in a coma and some memory deficits. Two months before death, she had an abortion and terminated the relationship with her boyfriend. She became more isolated and died by overdosing on her antidepressant. She was 20 years old at the time. Family history is significant for depressive illness in the father. Both parents were holocaust survivors and several members of the family died in the holocaust, making it difficult to obtain adequate family history. Two seconddegree relatives were given a diagnosis of bipolar disorder and were on lithium therapy. Subject 7 was a 13-year-old white girl referred in 1979 with depressive symptoms and school refusal for 2 years. Symptoms worsened after parental separation and change in school. She was started on an antidepressant with a good response. Attempts were made in 1980 to decrease her medication resulting in recurrence of symptoms. Medication was reinstituted. Her mood improved, and she became more inJ. Am. Acad. Child Adolesc. Psychiatry, 32:1, January 1993

volved socially. She continued to have problems with school attendance, although there was mild improvement. One year after initial assessment, at age 14, she died by an overdose of her antidepressant medication. There was no known psychiatric illness among any family members. Discussion

The major finding in this study is the high rate of suicide in subjects with early onset MDD when compared with subjects with early onset anxiety disorders or normal controls. Although the first onset of depression often was around puberty or earlier, the suicides occurred in late adolescence or early adulthood. The association between child or adolescent onset depression and suicide has been noted by other investigators. WeIner and his associates (1979) conducted an 8- to lO-year follow-up of 77 adolescent psychiatric inpatients and found that four of the 28 subjects with affective disorder died of suicide, yielding a rate of 14.3% over 10 years. Harrington and associates (1990) assessed a sample of 80 children and adolescents with a diagnosis of major depressive disorder an average of 18 years after the initial contact and discovered two suicides, yielding a rate of 2.5% over 18 years. The discrepant rates of suicide in these two studies and the currently reported study may be as a result of varying degrees of severity of the disorder. WeIner's study had an inpatient sample, whereas the sample in both Harrington's study and the present investigation were predominantly from outpatient populations. Follow-up studies of adults with major depression also have shown increased risk of suicide associated with affective disorders. A lifetime incidence of 15% (3 or 4 times higher than that of the other psychiatric disorders and 30 times higher than the general population rate) has been reported (Guze and Robins, 1970; Miles, 1977). The relative risk for suicide in affective disorders is found to be higher during the early period of follow-up, and the rate drops during the succeeding years, probably suggesting an adjustment to their depressed status (Fawcett et aI., 1987; Guze and Robins, 1970; Roy, 1982; Tsuang, 1978). Most deaths in the reported sample occurred well after the initial assessment. Suicide in children, adolescents, and young adults is rare despite recently increasing rates. The subjects in the present investigation are still young adults, and most have not passed through the risk period (25 to 40 years) typically found in adult studies. Only longitudinal studies of children and adolescents with major depression can empirically answer whether this group continues to have a risk of recurrent episodes of depression with increased morbidity and suicide into later adulthood. Suicide by tricyclic overdose was the most common method in our sample (three of seven cases, 43%). Shaffer and Gould (personal communication) assessed the psychological status and the method of suicide in 170 consecutive suicides in New York. They found that the most common methods were through hanging (36%) and gunshots (29%). Only 8% died by means of ingestion. There is a suggestion that treatment with tricyclic antidepressants may be a poten25

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tial hazard for suicide in adolescents and requires close supervision for compliance and suicidal ideation. The findings of this study should be interpreted with certain limitations. We have not located the full original sample, resulting in an oversampling of the depressed group. However, similar efforts to find cases of suicide were made for all groups. We have little knowledge of the outcome in the ADD-CD sample, a group at high risk for suicide. The information obtained for the interval period and the psychological status at the time of death were done several years after death, leading to a possible retrospective recall bias. Effort was made to corroborate the information from hospital records. The provisional diagnoses at the time of death were not made blind to the original diagnoses of the subjects, probably leading to an overdiagnosis of MOD. Finally, we have only two control groups (anxiety disorders and normal controls). We are not certain whether the high suicide risk is specific to early onset depression. Other investigators have found high rates of suicide in subjects with early onset schizophrenia (Kupferman et aI., 1988; Weiner et aI., 1979) and in adult subjects with schizophrenia (Miles, 1977; Tsuang, 1978). The unique feature of this study is that these subjects were assessed as children with standardized instruments that provided detailed information before death. The findings suggest that early onset depression is associated with mortality by suicide in late adolescence or early adulthood. If an investigation were conducted to determine the rate of suicide in affective disorders by taking a sample of adult subjects, these subjects would have been lost for follow-up, possibly leading to an underestimation of the suicide rate in this population. In conclusion, we have described seven cases of completed suicide over a lO-year period in a sample of 157 subjects initially diagnosed and treated for MOD as children or adolescents. No cases of suicide were found in a control sample of children diagnosed as having an anxiety disorder or in the normal subjects. These findings suggestthat MOD in children and adolescents is associated with increased risk for suicide and that this risk may be specific to MOD. These are preliminary findings, and we plan a comprehensive assessment of the full. sample.

References American Psychiatric Association (1980), Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-I1/). Washington, DC: American Psychiatric Association. Andreasen, N. c., Endicott, J., Spitzer, R. L. & Winokur, G. (1977), The family history method using diagnostic criteria. Arch. Gen. Psychiatry, 34:1229-1235. Brent, D. A., Kolko, D. J., Allen, M. J. & Brown, R. V. (1990), Suicidality in affectively disordered adolescent inpatients. J. Am Acad. Child Adolesc. Psychiatry, 29:586-593. Chambers, W. J., Puig-Antich, J., Tabrizi, M. A. & Davies, M. (1982), Psychotic symptoms in prepubertal major depressive disorder. Arch. Gen. Psychiatry, 39:921-927. Chambers, W. J., Puig-Antich, J., Hirsch, M., Paez, P., Ambrosini, P., Tabrizi, M. & Davies, M. (1985), The assessment of affective disorders in children and adolescents by semi-structured interview. Arch. Gen. Psychiatry, 42:692-702. Chess, S., Thomas, A. & Hassibi, M. (1983), Depression in childhood and adolescence: a prospective study of six cases. J. Nerv. Ment. Dis., 171:411-420.

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From Pediatrics The Occurrence of High Levels of Acute Behavioral Distress in Children and Adolescents Undergoing Routine Venipunctures G. Bennett Humphrey, M.D., Ph.D., Chris M. 1. Boon, M.A., G.F.E. Chiquit van Linden van den Heuvell, M.A., and Harry B. M. van de Wiel, Ph.D. Abstract. While there is no question that children dislike needles, there are very little data available on the occurrence of high levels of distress experienced by children undergoing routine venipunctures. To provide some insight into this problem, trained observers evaluated distress in 223 different children and adolescents undergoing this procedure. An observational distress scale of 1 to 5 was dev~loped; I = calm, 2 = timid/nervous, 3 = serious distress, but still under control,4 = serious distress with loss of control, and 5 = panic. We observed a strong relation between distress and. age but not between distress and gender. During the actual venipuncture, half the subjects (113/223) were scored as having high levels of distress (3 or more). Our subjects were also grouped into three age ranges: toddlers; 2 1/2 to 6 years, N = 70; preadolescents; 7 to 12 years, N = 55; and adolescents, 12 years and older, N = 98. The percent of subjects experiencing high levels of distress for each group were: 83%, 51 %, and 29%, respectively. We conclude that for venipunctures: 1) high levels of distress are common, and 2) age and not gender correlates with distress. Other correlations are discussed. Toddlers and pre-adolescents should be targets for new interventions to reduce distress. Pediatrics 1992;90:87-91.

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