Correlates of the Medical Lethality of Suicide Attempts in Children and Adolescents

Correlates of the Medical Lethality of Suicide Attempts in Children and Adolescents DA VID A. BRENT, M.D. Abstract. The relationship between the medical lethality of suicidal behavior and demographic. psychiatric. social. and familial/environmental variables was examined in chart review of a consecutive series of youthful suicideattempters presenting in a Children's Hospital over a 5-year period. Correlatesof the lethality of suicidal behavior included male sex. diagnoses of affective disorder and substance abuse. high suicidal intent. and the ingestion of a psychotropic agent. Patients who made medically lethal attempts appeared to have characteristics which converge with those who have completed suicide. The availability of a lethal agent may be the most significant determinant of the lethality of impulsive attempts. whereas suicidal intent and severity of psychopathology may make the most important contributions to the lethalityof attempts by hopeless. dysphoricindividuals. The implications of these findings for the prediction and prevention of suicide in children and adolescents are discussed. 1. Amer. Acad. Child Ado!. Psychiat., 1987.26, I :87-89. Key Words: suicideattempts, intent. lethality. hopelessness. Youngman, 1963, 1968). In addition to the support of this previous work, the study of the lethality of suicidal behavior is warranted' because this parameter is observable, easily objectified, can be elucidated independent of informant cooperation, and most important, represents the ultimate determinant of the success of the suicide attempt. Although these results are promising, generalization to younger populations is difficult, insofar as only a few of these studies focused on children and adolescents (Garfinkel et al., 1982; Otto, 1972; Robbins and Alessi, 1985). This paper will examine the relationship of the medical lethality of a suicide attempt to other descriptors of the attempt as well as to the demographic, psychiatric, and familial/environmental variables in a consecutive series of suicide attempters seen at Children's Hospital of Pittsburgh. In addition, these correlates of the lethality of suicidal behavior will be: (I) assessed in subgroups deemed to be at high and low risk for suicide and (2) compared with known risk factors for completed suicide.

Suicidal behavior is one of the most common psychiatric emergencies in children and adolescents (Mattsson et al., 1969; Shafii et al., 1979). The study of this problem has become more critical in recent years in the context of a dramatic rise in the rate of both attempted and completed suicide among youths (ShafTer and Fisher, 1981; Weissman, 1974; Wexler et aI., 1978). In spite of the increased attention devoted to this vexing trend, the study of factors predictive of completed suicide is inherently limited in several ways. First, because suicide is so rare an event, even among a high-risk population, any prospective study must encompass a very large number of subjects to be followed over a long period of time (Otto, 1972; Pokorny, 1983). Second, although psychological autopsies of completed suicide are of considerable value, most proponents of such an approach acknowledge the possibility of considerable bias resulting from such procedures (Barraclough et al., 1974; Robins et aI., 1959). An alternative approach to augment these other methods is the intensive study of suicidal individuals who have made attempts which most closely resemble those of completers, but through medical resuscitation or chance circumstances have survived. Previous studies of individuals who have engaged in dangerous but nonlethal behavior have shown that they do have some characteristics in common with those persons who complete suicide (Garfinkel et aI., 1982; Goldney, 1981; Henderson et al., 1977; Pallis and Sainsbury, 1976; Robbins and Alessi, 1985). In fact, survivors of medically dangerous suicide attempts are at higher risk to complete suicide than are survivors of less dangerous attempts (Motto, 1965; Otto, 1972; Pierce, 1981; Rosen, 1970; Tuckman and

Method

The charts of 131 consecutive suicide attempts by 126 patients seen at Children's Hospital of Pittsburgh (CHP), 1978-1983 were reviewed by the author. All suicide attempters who presented at the emergency room at CHP were routinely admitted to a pediatric service for 48 hours, during which time psychiatric and social service consultations were obtained. The author was the psychiatric consultant for 21 of these patients. Sample Characteristics. Sample characteristics abstracted from the chart are summarized in Table I. Subjects were primarily white, female, and made suicide attempts of low lethality. Measures. The Risk Rescue Rating (RR) was utilized to assess the medical lethality of the suicide attempt. The scale has two components-"risk," which measures the actual dangerousness of the attempt, and "rescue," which examines the circumstances of the attempt that would either facilitate or impede rescue. This measure of lethality was chosen in favor of others such as "level of consciousness" (Birthnell and Alarcon, 1971, 1977; Williams et aI., 1977) or "intensity of treatment required" (Goldney and Pilowsky, 1980) because only the RR considers the context in which the attempt has taken place. Also, the RR has been utilized in previous studies

Received Julv 8, IY85: accepted NOI'. 4, IY85. From the Weslem Psvchiatric Institute and Clinic, 3811 O'Hara SI .. Pittsburgh, PA 15113. Reprint requests 10 Dr. Brent. Some ottlu: results in this paper lI'ere presented at a Poster Session at the 30lh Scicntilic MeelinK or the American Academy or Child Psvchiatrv. October. IY83, San Francisco, Califomia. 'The assistuncc ofDrs. Evelvn Bromct, DUI'iJ Kolko, Maria Kovacs, and Helen Orvaschcl in the conception and revision ofthis manuscript is KraIefitlly acknowledged. Rich Ulrich, M.S.. provided statistical consultation. Ms. Ellen l.ipshit: and Ms. Susan Pietrusinski helped obtain the medical records. This work lI'as supported ill pari bv NIMI/ Training grant 1 T3MI/ 15oY-Oo and a Clinical Invcstigutor Award 10 the author (/ K08 MIIO0581-01),

OlNO-X567/X7/2601-0087$02.00/0 (CI 1987 by the AmericanAcademy of Child and Adolescent Psychiatry, 87

BRENT

88 TABLE 1. Characteristics of the Study Sample Category

Variable Age

Race

Frequency

7-12 1:1-1,'1 16-18

23 76 31

Wh~e

~

Other

42

Ma~

37

Female

94

Professional Manager Semiprofessional Other white collar Skilled lahor Semiskilled labor Unskilled labor Unemployed

10 17 21 19 2;' 11 8 20

Marital status of parents

Married Married, one stepparrent Single parent Foster parents or group home

;':1 20 4:1 12

Method of attempt

Firearms Hanging Laceration Overdose

Sex

Occupation of head of household"

Distribution of riskrescue rating

2,'1-29 :10-:14 3;'-:19 40-44

:10 14 20 18

45-49

23

,'10-,'14

1:1 10 3

;';,-,59 6~M n

2 4 124

Hollingshead and Redlich (19;'8).

of adolescent (Garfinkel et al., 1982) and young adult (Goldney, 1981) suicide atternpters. The RR was designed to be utilized for chart reviews, and has high internal consistency, interrater reliability and both discriminant and construct validity (Weisman and Worden, 1972). Suicidal intent was assessed by use of the Beck Suicidal Intent Scale (SIS) (Beck et al., 1974). Since this scale was not designed to be utilized as an instrument for chart review, interrater reliability was tested on a subset of charts and found to be adequate (r = 0.73, df> 9, p < 0.01). Measures of hopelessness and suicidal intent after the attempt were coded as dichotomous variables. Hopelessness was noted to be present if, on mental status examination, the patient described pessimism about the future. Suicidal intent after an attempt was noted to be present if the patient showed a persistent wish to die. Social adjustment was assessed in three areas-school, peers, and family, and rated on a three point scale in each area, based upon anchor points utilized to assess social functioning (Axis V) in DSM-I1I. Interrater reliability for these measures were adequate (r values range from 0.64 to 1.00, p values < 0.05-0.0 I).

Psychiatric diagnoses were recorded in the chart as DSMII or DSM-III diagnoses; DSM-II diagnoses were recorded as their equivalent DSM-I1I categories for purposes of comparison. A subset of these patients was referred for inpatient psychiatric hospitalization, and a comparison of the diagnoses of the consulting psychiatrist at CHP with the discharge diagnoses of the inpatient hospital showed an acceptable rate of concordance (r = 0.76, df > 21, p < 0.01). Adequate data were present for all variables, with the exception of family history of psychiatric disorder and suicidal behavior, where in many cases information was not recorded. Statistical tests employed include Pearson's correlation coefficient, Student's r-test, the chi-square (x~) statistic, analyses of variance and covariance, and multiple linear regression. All statistical tests are two-tailed. Results Significant correlates of the medical lethality of suicidal behavior in this sample included male sex (t = 2.87, df = 129, p = 0.005), diagnosis of affective disorder, particularly in combination with substance abuse (I" = 3.41, df = 7,123, p = 0.03) and family history of affective disorder (I" = 3.98, df = 3,83, p = 0.0 I) (Table 2). In addition, the medical lethality was correlated with suicidal intent both prior to (r = 0.51, P < 0.000 I) and subsequent to the suicide attempt (t = 2.57, df = 123, p = 0.0 I), as well as with degree of planning (I" = 5.89, df> 2,127, p = 0.004), and use of a psychotropic agent (60% of which were antidepressants) as the agent of the attempt (I" = 10.41, df> 2, 117, P = 0.000 I). The association between the use of a psychotropic agent and the medical lethality of suicidal behavior has been reported previously (Goldney, 1981). However, in contradistinction to Goldney's report on a sample of young adult female atternpters, only 6% of the present series of children and adolescents overdosed on their own medication. The relationship between class of agent and the medical lethality of the attempt remained robust, even after covarying out the effects of other possibly mediating variables (e.g., parental medical or psychiatric illness, chronic medical or psychiatric illness in the child, stress at home, suicidal intent; F = 9.65, df> 2, 117; n = 0.0001). The medical lethality of suicide attempts was not associated with other demographic (age, race, social class), social (school function, peer and family relations), or family/environmental variables (abuse, inter-parental or parent-child discord, parental illness, or number and type of stressful life events). Regression of demographic variables and those variables shown to be significantly associated with RR on univariate analyses revealed that 37% of the variance could be explained by sex, class of agent, and most importantly, suicidal intent. The sample was then dichotomized on the presence or absence of hopelessness. Hopelessness was chosen because of its prognostic value in the prediction of future suicidal attempts and completions (Beck et al., 1975b, 1985; Pierce, 1981). In this sample, hopelessness was unrelated to age, race, sex, medical lethality or class of agent ingested. However, hopelessness was related to suicidal intent (r = 0.43, df = 121, P < 0.0001), to diagnosis of affective disorder (x~ = 35.92, df = 6, p < 0.000 I), and degree of planning (r = 0.74, df> 121, p < 0.000 I). Therefore, dichotomization of the sample on

89

MEDICAL LETHALITY OF SUICIDE ATTEMPTS

TABLE 2. Significant correlates of medical lethality Category

Variable Sex

Male Female Marital status of parents Married Stepfamily Single parent Out-of-home Psychiatric diagnoses Affective disorder Affective/conduct disorder Affective/substance abuse Conduct disorder Conduct/substance abuse Adjustment disorder Other Continued suicidal intent No Yes Family history of psychiat ric illness None Affective disorder Antisocial personality Alcohol/drug abuse Expectation of lethal outcome No Uncertain Certain Degree of planning None Some «24 hr) A great deal (>24 hr) Class of agent (ingestions only) Over-the-counter Nonpsychotropic prescriptions Psychotropic

Frequency

Mean RR ± SE

37 94

4~3.R6 ± 11.16 :3R.42 ± 9.19

56 20 43 12

42.06 ± 10.RO 34.83 ± 9.66 ~38.97 ± 9.11 42.27 ± 7.16

26 9 13 R 15 32 2R

37.f>1 42.17 47.54 37.94 41.02 :35.RR :39.20

9R 27

± 10'<)6 44.20 ± 9.2f>

If)

:39.11 ± R.20 4:3.20 ± 9.~30 :31.16 ± 5.19 :36.67 ± 10.04

p Value 0.005

0.03

± ± ± ± ± ± ±

10.5:3 6.76 8.79 9.21 9.54 10.65 11.~37

0.01 ~3H.66

0.01

:36 4 32

0.0001 :37.:30 ± 9.72 41.69 ± 8.H6 48.29 ± 9.27

76 ~17

17

0.004

H

:37.97 ± lO.1~3 4:l..'if> ± 7.96 46.26 ± 12.12

59 2R ~ 3:3

36.01 ± 7.R3 41.03 ± 10.32 45.0R ± 10.:37

87

as

0.0001

TABLE 3. Regression Analyses of Medical Lethality

Significance

Beta ± s.s.

Partial Correlation

= 1:11)*

Suicidal intent Class of agent Sex

0.50 ± O.OH -O.2R ± O.OR -0.14 ± 0.07

0.4:3 -0.26 -0.14

.'i.99 -3.6.'i 1.9R

«l.OOOl 0.0004 0.0.'i

Non-hopeless (N = 7H)**

Class of agent Suicidal intent

-0.41 ± 0.11 0.:32 ± O.lO

-0.:37

-:1.7~3

o.a:

:3.l7

0.0004 0.002

Hopeless (N = 45)***

Suicidal intent Hace Affect ive disorder Sex Substance abuse

O..'i6 -0.29 0.26 -0.2:1 0.21

Subject 1'001 Total (N

Variable

± ± ± ± ±

O.lO O.OH (UO 0.09 0.09

0.44 -0.27 0.20 -0.20 O.lR

(p)

5.4:3 -3.:39 2.f>4 -2.49 2.25

<0.0001 0.002 0.02 0.02 0.03

* R" = 0.:37; ** IF = 0.27; *** H" = 0.76.

this variable yielded a hopeless. affectively disordered group who made planned attempts of high intent, and a nonhopeless group whose attempts were impulsive and of variable intent. The regression equations fit to the two subsamples are decidedly distinct (Table 3). In the group that did not report hopelessness, 27% of the variance in the RR was accounted for (I-' = 7.79. dl> 2. 75. {J < 0.0001), with 18% of the variance explained by the class of agent and the remaining

9% associated with suicidal intent. In the group that endorsed hopelessness. 76% of the variance in the RR was explained (I-' = 16.80, df= 7. 37, {J < 0.0001) by the following variables: sex, race. suicidal intent, and diagnoses of affective disorder and substance abuse. Discussion

This study is subject to two main limitations. First. there are difficulties inherent in data gathered from chart review-

90

BRENT

particularly in the assessment of more subtle variables such as social adaptation and family interaction. Some of our negative findings with respect to the relationship between these variables and the medical lethality of the attempts may have been due to this limitation. Second, the investigator assessed both medical lethality and other variables, which might have resulted in an overestimate of the strength of some of these relationships. While the reliability of these results is buttressed by the demonstration of interrater reliability for a subset of measures in the chart reviews, the findings of this study should be viewed as more appropriate for hypothesis generation than for hypothesis testing. This study is consistent with other work correlating the lethality of suicide attempts in children and adolescents with such factors as male sex, suicidal intent, depression, and family history of affective disorder (Garfinkel et al., 1982). Such variables are also associated with the greatest risk of completed suicide (Otto, 1972; Shaffer, 1974; Weiner et al., 1979). These findings support the view that suicide attempters that are especially lethal represent a subgroup whose characteristics converge with those of suicide com pieters. Multivariate analyses revealed the association between intent and RR as the most consistent and significant relationship between lethality and any response variable. Because the content of the "rescue" subscale of the RR overlaps with the SIS, both the univariate and multivariate analyses were repeated utilizing just the "risk" subscale as the dependent variable, without substantial changes in the findings. Therefore, the role of suicidal intent as a determinant of the medical lethality of the attempt appears robust, and is not simply an artifact of some common items between the two scales. While the relationship between medical lethality and intent may have been inflated due to the investigator filling out both scales, Beck et al. (1975a), utilizing a scale similar to the "risk" subscalc, found a correlation between lethality and intent (r = 0.19, P < 0.00 I), similar to the correlation in the present study between "risk" and intent (r = 0.30, df = 129, p< 0.0001).

The subdivision of this sample by hopelessness seemed to separate subjects into a non-hopeless group of adjustment and conduct disorders who made unplanned attempts of variable intent, and a group of hopeless, affectively disturbed patients who made planned attempts of high suicidal intent. Similar groupings have been demonstrated empirically in samples of adult suicide attempters (Goldney, 1981, 1982; Henderson et al., 1977; Paykel and Rassaby, 1978). The RR for the hopeless group appeared to be very much a function of known risk factors for completed suicide (e.g., substance abuse, affective disorder, high intent, male sex, white race) (Otto, 1972; Shaffer, 1974; Weiner et al., 1979). In contrast, the type of agent ingested by the non-hopeless group was actually a more important determinant of RR than suicidal intent. This is consistent with the report that impulsive suicide attempters are more likely to overdose on pills that are easily accessible to them (Williams et al., 1977). While the role of the availability of lethal agents in attempted and completed suicide is controversial (Maxwell, 1984; McClure, 1984), there is support for the viewpoint that availability in and of itself poses a risk factor for completed suicide. For example, restriction of the quantity of sedative

prescnptions in Australia (Goldney and Katsikitis, 1983), diminution of the toxicity of domestic gas in Great Britain (Brown, 1979; Kreitman, 1976), and strictness of handgun control in the United States (Boyd, 1983; Lester and Murrell, 1980, 1982) have been related to lower suicide rates both specific to a given method, as well as overall. These findings have implications for further investigation into the prediction and prevention of suicide in adolescents. Prediction of suicide may be quite difficult for the nonhopeless group, given that a low amount of the variance of RR is explained by psychosocial variables, and that what variance is explained is primarily a function of agent. Prevention of suicide in this group may rest primarily upon public health measures aimed at the restriction of availability of lethal agents (Boyd, 1983; Goldney and Katsikitis, 1983; Jones, 1977; Lester and Murrell, 1980, 1982; Robin and Freeman-Browne, 1968). In contrast to the situation among the non-hopeless, impulsive group, prediction of suicide may be attainable for the hopeless attempters, for whom the RR was intimately related to the severity and range of psychopathology. Secondary prevention of suicide in this group should be directed towards the amelioration of underlying psychopathology. Further research is warranted to confirm and extend these results. References Barraclough. B.. Bunch. J.. Nelson. B. & Sainsbury. P. (1974), A hundred cases of suicide: clinical aspects. Brit. 1. Psvchiat.• 125:355-373. . Beck. A., Schuyler. R. & Herman. J. (1974). Development of suicidal intent scales, In: The Prediction ofSuicide, ed. A. Beck, H. Resnick & D. Lettieri. Bowie, Md.: Charles Press, pp. 45-58. - - Beck, R. & Kovacs. M. (1975a), Classification of suicidal behaviors; I. Quantifying intent and medical lethality. A mer. J. Psvchiat., I32:285-2l!7. - - Kovacs M. & Weissman. A. (1975b). Hopelessness and suicidal behavior: an overview. 1. A mer. Med. Assn.. 234:1146-1149. - - Steer. R.. Kovacs. M. & Garrison. B. (1985), Hopelessness and eventual suicide: a ten-year prospective study of patients hospitalized with suicidal ideation. A mer. 1. Psvchiat., 142:559-563. Birthnell, J. & Alarcon, J. (1971). Depression and attempted suicide. Brit. 1. Psvchiat.. 118:289-296. - - - - (1977), The motivational and emotional state of 91 cases of attempted suicide. Brit. 1. Mcd. Psycho!.• 44:45-52. Boyd, J. (1983), The increasing rate of suicide by firearms. New Eng .J. su«. 308:872-874. Brown, J. (1979), Suicide in Britain: more attempts, fewer deaths. lessons for public policy. Arch. Gen. Psychiat., 36: 1119-1124. Garfinkel, 8., Froese, A. & Hood, J. (1982), Suicide attempts in children and adolescents. A mer. 1. Psvchiat.. 139:1257-1261. Goldncy, R. (1981), Attempted suicide' in young women: correlates of lethality. Brit. 1. Psvchiat., 139:382-390. - - (1982), Locus of control in young women who have attempted suicide. 1. Ncrv. Mell/. o«. 170:198-20 I. - - & Katsikitis. M. (1983), Cohort analysis of suicide rates in Australia. Arch. (jell. Psvchiat.. 40:71-74. - - & Pilowsky. I. (198(l). Depression in young women who have attempted suicide. Austral. New Z. 1. Psvchiat., 14:203-211. Henderson, A.. Hartigan, J.. Davidson, J.: et al. (1977), A typology of parasuicide. Brit. 1. Psvchiat., 131:631-641. Hollingshead. A. & Redlich, F. (1958). Socia! Class and Mental 111111'.1.1: A Community Study. New York: John Wiley & Sons. Jones. D. (1977). Self-poisoning with drugs: the past 20 years in Sheffield. Brit ..vtcd. 1., 1:28-29. Kreitman, N. (1976), The coal gas story: United Kingdom suicide rates, 1960-1971. Brit. 1. Prcv. Med.. 30:86-93.

MEDICAL LETHALITY OF SUICIDE ATIEMPTS Lester. D. & Murrell. M. (1980). The influence of gun control laws on suicidal behavior. A mer. 1. Psvchiat.. 137:121-122. - - - - (1982). The preventive effect of strict gun control laws on suicidal behavior. A mer. J. l'svchiat .• 137:121-122. Mattsson. A.. Seese. L. & Hawkins, J. (1969). Suicidal behavior as a child psychiatric emergency. Arch. Gen. Psvchiat., 20: 100-109. Maxwell. S. (1984). Suicide by firearms (letter). Nell' Eng. J. Med.. 310:46-47. McClure. G. (1984). Trends in the suicide rate for England and Wales. 1975-1980. Brit. 1. Psvchiat .. 144:119-126. Motto. J. (1965). Suicide attempts-a longitudinal view. Arch. (/1'11. Psvchiat.. 13:516-520. Otto. U. (1972). Suicidal acts by children and adoleseents. Acta. Psychiat. Scand. Suppl., 233. Pallis. D. & Sainsbury. P. (1976). The value of assessing intent in attempted suicide. Psychol. Mcd.. 6:487-492. Paykel, E. & Rassaby. E. (1978). Classification of suicide attempters by cluster analysis. Brit. .J. Psvchiat .. 133:45-52. Pierce. D. (1981). The predictive validation of a suicide intent scale: a five year follow-up. Brit. 1. Psychiat.. 139:391-396. Pokorny. A. (1983). Prediction of suicide in psychiatric patients. Report of a prospective study. Arch. (/1'11. Psychiat .. 40:249-257. Robbins. D. R. & Alessi. N. E. (1985). Depressive symptoms and suicidal behavior in adolescents. A mer. 1. Psvchiat., 142:588-592. Robin. A. & Freeman-Browne. D. (1968). Drugs left at home by psychiatric inpatients. Brit. Med. 1.. 3:424-425. Robins. E.. Murphy. G .. Wilkinson. R.. et al. (1959). Some clinical

91

considerations in the prevention of suicide based on a study of 134 successful suicides. Amcr. 1. Public Illth., 49:888-898. Rosen. D. (1970). The serious suicide attempt: epidemiological and follow-up study of 11116 patients. Amer. 1. Psvchiat.. 127:764-770. Shafii, H .. Whittinghill. R. & Healy. M. (1979). The pediatric-psychiatric model for emergencies in child psychiatry: a study of 994 cases. Amer. 1. Psvchiat.. 136:1600-1601. Shaffer, D. (1974). Suicide in childhood and early adolescence. J. Child Psvchol. Psvchiat., 15:275-291. - - & Fisher. P. (1911 I). The epidemiology of suicide in children and young adoleseents. This Journal. 20:545-565. Tuckman. J. & Youngman. W. (1963). Identifying suicide risk groups among attempted suicides. Public lllth. Rep.• 78:763-766. - - - - (19611). A seale for assessing suicidal risk of attempted suicides. 1. Clin. Psycho!.. 24: 17-19. Weisman. A. & Worden. W. (1972). Risk-rescue rating in suicide assessment. Arch. Gen. Psvchiat .. 26:553-560. Weissman. M. (1974). The epidemiology of suicide attempts. 19601971. Arch. Gen. Psychiat .. 30:737-746. Weiner. A.. Weiner. Z. & Fishman. R. (1979). Psychiatric adolescent inpatients: eight to ten-year follow-up. Arch. Gen. Psychiat., 36:6911-700. Wexler. L.. Weissman. M. & Kasl, S. (1978). Suicide attempts 19701975: updating a United States study and comparisons with international trends. Brit. .J. Psvchiat.. 132: IllO-185. Williams. C. Sale. I. & Wignall. A. (1977). Correlates of impulsive suicidal behaviors. Nell' Z. Mcd. J.. 85:323-325.