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Secular trends in psychiatric diagnoses of suicide victims
127
Journal of Affective Dworders, 21 (1991) 127-132 0 1991 Elsevier Science Publishers B.V. 0165-0327/91/$03.50 ADONIS 0165032791000676
JAD 00780
Secular trends in psychiatric Gabrielle
A. Carlson
‘, Charles
diagnoses
L. Rich I, Patricia
Grayson
of suicide victims 1 and
Richard
’ Department of Psychiatry and Behuoioral Science. State Unruersity of New York at St0n.v Brook, Stony and ’ Department
of Psychrat~,
Brook.
C. Fowler NY
I
’
1794, U.S.A.
lJnluersit,v of California. San Diego. CA. U.S.A.
(Received 16 July 1990) (Accepted 29 October 1990)
Summary
Post-mortem psychiatric diagnoses are compared in two cohorts of male suicides from St. Louis (1956-1957) (Robins, 1981) and San Diego (1981-1982) (Rich et al., 1986). Similar structured interviews and diagnostic criteria had been used in both assessments. Substance/alcohol abuse has remained the major diagnosis in suicides under age 60. Rates of depressive disorder alone have decreased overall, due mostly to decreased rates in the elderly. Thus, depression occurs more frequently in younger ages. Comorbid depression and substance/alcohol abuse has also increased in younger ages. Implications in terms of the so-called ‘cohort effect’ are discussed.
Key words:
Suicide
victims;
Psychiatric
diagnosis;
Introduction It is well known that suicides rarely occur in the absence of diagnosable mental illness, especially depression, alcoholism, and schizophrenia, and that rates of suicide have substantially increased in adolescents and young adults since 1960 (Murphy and Wetzel, 1990; Shaffer et al., 1988). On the one hand, the finding that rates of depression seem to be increasing in progressively younger populations (Klerman, 1988) might tempt
Address for correspondence: Dr. G.A. Carlson, Department of Psychiatry and Behavioral Science, Putnam Hall, State University of New York at Stony Brook, Stony Brook, NY 11794-8790, U.S.A.
Substance/
alcohol
abuse;
Depression
one to conclude that this explains the rise in suicides among young people. On the other hand, recent systematic interview data reveal that substance abuse rather than depression is the more prevalent diagnosis in suicide victims under age 30; by contrast, major depression is the more common diagnosis in the over 30 population (Rich et al., 1986). The purpose of this study was to explore the secular trends in diagnosis of suicide victims at different ages over the past 25 years in an attempt to elucidate the relationships between psychopathology and changing rates of suicide. Specifically, we tested whether the prominence of a particular diagnosis at particular developmental intervals from youth to old age has changed over the 25-year interval.
128
Methods
Systematic data were obtained by Robins (1981) on 134 suicides in 195661957 in St. Louis and by Rich et al. (1986) in 1981-1982 in San Diego. These data sets have a number of important similarities that enabled us to examine diagnoses over time. Each included consecutive suicides in areas with both urban and suburban populations, namely the cities and counties of St. Louis and San Diego, respectively. Each city had a population of about 900,000 at the time with similar age, sex and minority distributions (Bureau of the Census, 1952, 1982). The time frames were similar (1 year for the St. Louis study, 10 months for the consecutive suicides in the San Diego study). Both used structured interviews of informants who knew the victims and obtained data from informants in all but 11% of cases in the earlier study and 8% in the later study. The background psychosocial, diagnostic, and specific suicide information elicited during the interview was similar in part because the interview schedule for the later study was modeled after that used in the St. Louis study. Most importantly, the diagnostic criteria were very similar. The Washington University (or Feighner) criteria (Feighner et al., 1972) were applied in Robins’ study. The DSM-III criteria (American Psychiatric Association, 1980) were used in the San Diego study. One difference between them is that the former requires a duration of depressive symptoms of 1 month rather than 2 weeks. The criteria for alcohol abuse were similar, however. Another important difference involves the listing of codiagnoses in DSM-III whereas under the Feighner criteria, diagnosis of either depression or alcoholism, not both, was given. It was thus necessary to reread the vignettes in Robins’ monograph to try to determine whether comorbidity, in fact, existed. This was done separately by two authors (G.A.C. and C.L.R.) with independent agreement initially reached on all but one case. This case was also easily resolved. For this report, comorbidity was defined as major depression with significant co-occurrence of alcohol or drug use, or conversely, alcohol abuse with the significant co-occurrence of depressive symptomatology. Of 45 men who had met criteria for affective disorder, 13 were reclassified as having comorbid depression.
Of the 29 males with alcoholism or drug abuse, eight were reclassified as comorbid. Suicides were divided by 20-year time spans to investigate when between the ages of 20 and 80 significant shifts in diagnostic rates occurred. This interval was selected to correspond roughly to the developmental shifts of youth. adulthood, middle age and senescence. For this report. data are presented only for males because in the Robins study there were too few females in some age groups for analytic purposes. Chi-square analysis with Yates’ correction was used for comparisons of rates of specific psychiatric disorders in the two samples stratified by age. Results
The population rates by age group have not changed as remarkably as the suicide rates by age. Comparing St. Louis (1950 census) and San Diego (1980 census) reveals percent distributions for males as follows: 30% and 34% for those aged 20 or less, 32% and 37% for those aged 21-40, 26% and 18% for those aged 41-60 and 12% and 11% for those aged 61 and over. By contrast, suicides are very underrepresented in the youngest age group (none in the St. Louis sample and 6% in the San Diego sample). Thereafter, a decided shift occurs with 21% of the St. Louis sample vs. 48% of the San Diego sample aged 21-40, 37% and 27% respectively in the middle-aged sample, and an overrepresentation of elderly suicides in the St. Louis sample (42%) but not the San Diego sample (19%). Overall, the frequency with which affective disorder alone is diagnosed in male suicide victims dropped significantly in the 25 years between studies (32% vs. 14.7%, x2 = 10.52, P = 0.001) while comorbid depression increased somewhat (20.3% vs. 29.4%, x2 = 3.29, P < 0.1). There was no change in rates of substance abuse (22% vs. 23.8%). There are two ways to examine the relationship of age cohort and diagnosis. One way is to inspect the types of diagnoses occurring in a particular age group in the first cohort and compare them with the second, as is illustrated in Table 1 and graphically represented in Fig. 1. The second way is to survey the entire cohort to determine if
129
Affective Substance
Comorbld abuse
dllIl.m
Affect ‘Other
,ve Substance
Dlagnosls
Comorbld abuse
iii Affecttve Substance
‘Other’
Dlagnosls Fig. 1. Comparison
of suicides
within
‘Other’
Dlagnosss
J
Affective Substance
Comorb;d abdse
Comorbld abuse
‘Other’
Dlagnosls each age group between 1956 and 1982. Significant group (x2 = 10.09. P < 0.02).
difference
observed
for the 61-X0+
age
particular diagnoses are more likely in one age group or another and then to see if the pattern changes in the second cohort. See Table 2 and Fig.
cant differences in the relative rates of any of the diagnoses between the two studies. This is true for middle-aged people (aged 41-60) as well. In fact
2.
major depression as the primary diagnosis among suicide victims is notable only among the elderly
Inspection first of diagnoses in specific age groups reveals that in 1957, none of the suicide victims was under 20 years of age. Thus, the presence of suicides aged 13-20 in the San Diego study indeed reflects the increased rate of suicide among young people. Diagnoses in this later sample have been reported elsewhere (Rich et al., 1990) and include youngsters with conduct/ substance abuse disorders and those with adjustment disorders whose psychopathology reflects subsyndromal but chronic maladaptation. In the next age group, adults aged 21-40, alcohol and drugs have consistently played the most prominent role in suicides and there are no signifi-
in the St. Louis study. The distribution of diagnoses between the two studies is significantly different only among the elderly (x2 with Yates’ correction = 10.09, P < 0.02) largely because of the decreased rates of depression and increased rates of ‘other’ diagnoses. (In these instances, ‘other’ includes people with organic brain syndromes and those on whom data were insufficient to make diagnoses.) Comparison of the diagnoses across each cohort reveals the relationship between age and diagnosis between time periods and only one significant difference
emerges.
Comorbid
depression
and al-
130
TABLE
1
COMPARISON OF GROUP MALES
SUICIDES
Age cohort O-20
21-40
St. Louis (1957). n = 103 n(S) 0
WITHIN
EACH
41-60
61-801
22 (21.4)
38 (36.9)
43 (41.7)
_
3 (13.6)
7 (18.4)
23 (53.4)
_
8 (36.4) 4 (18.2) 7 (31.8)
13 (34.2) 10 (26.3) 8 (21.0)
2 (4.6) 7 (16.2) 11 (25.6)
Sun Diego (IPRZ), n = 143 n (S) 9 (6.2) 68 (47.6)
39 (27.3)
27 (18.9)
6 (8.8)
9 (23.1)
5 (18.5)
20 (29.4) 24 (35.3) 18 (26.5)
10 (25.6) 12 (30.8) 8 (20.5)
1 (3.7) 3 (11.1) 18 (66.7)
Affective Substance/ alcohol abuse Comorbid Other
Affective Substance/ alcohol abuse Comorbid Other
l(ll.1)
3 (33.3) 3 (33.3) 2 (22.2)
Significance
NS
NS
P
21-40 Age
41-60
group
cohol/substance abuse is most frequent among the adults in the San Diego study and is clearly playing a more significant role than it did 25 years earlier (x2 = 9.0, P < 0.05with Yates’ correction). Although overall rates of depression alone occurring in suicides have decreased, there is also a definite shift in the frequency with which depression is occurring at younger ages. Thus, in 1957, of those suicide victims whose diagnosis was major depression, 69.7% were over age 61. In 1982, 76.2% were under age 61. This just misses statistical significance.
Discussion
One of the limitations of the study has to do with comparing case vignettes derived from structured interviews with structured interviews themselves. This is less of a problem in the precisely defined areas of affective disorder and substance abuse alone. The reason that a less conservative definition of comorbidity was used was to mini-
,$ = 10.09 P < 0.02 Yates’ correction -.-son
O-20
AGE
DIego
--o--St
LOUIS
/
61-80
age group
(year)
0
40
-L u 5
20
(year)
P 0 Age
Fig. 2. Comparison
group
of diagnosis
distribution
41-60 Age
(year)
across each cohort.
Distribution
of comorbidity
group
changed
61.80
(year)
(x2 = 10.09, P < 0.02).
131 TABLE
2
COMPARISON
OF DIAGNOSES
ACROSS
Age cohort O-20 Affective St. Louis San Diego
AGE COHORTS
21-40
- MALES
41-60
61-80+
n
Significance
1 (4.8)
3 (9.1) 6 (28.6)
7 (21.2) 9 (42.9)
23 (69.7) 5 (23.8)
33 21
abuse _ 3 (8.8)
8 (34.9) 20 (58.8)
13 (56.5) 10 (29.4)
2 (8.7) 1 (1.9)
23 34
Comorbid St. Louis San Diego
_ 3 (7.1)
4 (19.0) 24 (57.1)
10 (47.6) 12 (28.5)
l(33.3) 3 (7.1)
21 42
Other St. Louis San Diego
2 (4.3)
7 (26.9) 18 (39.1)
8 (30.8) 8 (17.4)
11 (42.3) 18 (39.1)
26 46
Substance/alcohol St. Louis San Diego
Results
are given as absolute
numbers
and, in parentheses,
NS
,yz = 9.0 P i 0.05 Yates’ correction
NS
percentages.
mize the likelihood of overlooking comorbidity at a time it was not acknowledged in the St. Louis study. While there are likely to be many cultural differences between St. Louis and San Diego accounting for diagnostic differences, demographic differences, in fact, are minimal. Age, gender, race and death due to homicide were similar (Bureau of the Census, 1952,1982; Federal Bureau of Investigation, 1956, 1982). A third limitation may be the possibility
x2 = 7.6 P < 0.06 Yates’ correction
that,
age 20 or less. This is not remarkably different from the San Diego data where 6% of total suicides were age 20 or less compared to the total population where 34% were age 20 or less. In other words, although there has been a significant rate of increase in adolescent in question, adolescents underrepresented
suicide over the 25 years have remained equally
compared
to their general
popu-
lation frequency. With respect to specific findings, it appears the frequency with which major depression occurs specifically
in
label the suicides of young people, especially adolescents, hence there were no suicides under the age of 24 in the St. Louis study and nine in the
dramatically
between
San Diego study under age 21. (This represents a statistically significant difference by Fisher’s Exact Test, P < 0.01.)Shaffer and Fisher (1981) have found, however, that relatively speaking, few accidents are really misidentified suicides. Given
although when one examines the 1982 cohort, it is clear that the major depression that is occurring
in the 195Os, the coroner
was more likely to mis-
the usual method of suicide by gunshot or hanging in young men, it is unlikely that adolescent male suicides, had they occurred in 1956-1957, would have been missed though there is no way of ruling that out. Comparing percent suicide victims by age with total suicide population by age reveals a less startling contrast, however. In St. Louis, 0% of the total suicide population was age 20 or less compared to a total population where 30% were
elderly
suicides
1957
and
has 1982.
dropped There
has
not been a compensatory increase in rates of major depression alone occurring in younger age groups
in suicides is occurring at younger that substance abuse, be it alcohol,
ages. The fact other drugs or
both, has remained the major diagnostic culprit for the past 25 years suggests that different psychiatric phenomena may be accounting for suicide in younger vs. older people. The cohort effect reported in the ECA studies (Klerman, 1988), then, is evident here more in comorbid depression which has decidedly val studied.
increased
in the 25-year
inter-
These findings may appear to be at variance with what has been reported to be the declining
132
age of onset of depressive disorder in recent decades. We feel there is a plausible explanation. In an elegant study comparing rates of mild, moderate and severe depression in Lundby, Sweden between 1947-1957 and 195771972, Hagnell and colleagues (1982) made an interesting observation. Rates of severe depression (which implied an impairment of reality testing) have remained relatively constant across the decades 1947- 1972 from ages lo-80 + with the exception of a drop in rates of depression in 60-69-year-olds in the 1957-1972 sample. In contrast. rates of mild and moderate depression not only increase with age starting at ages 20-29, the cumulative probability of depression more than doubled between the first and second survey and between the 30- and 50-year age groups the cumulative probability of depression more than tripled. One might hypothesize that mild and moderate depressions are more stress-related, more sensitive to the sociocultural changes that have taken place since World War II and more likely to include depressions which co-occur with other psychiatric disorders (i.e., comorbid depression). Since these depressions appear to be less responsive to electroconvulsive therapy and possibly antidepressant medication, the strategies that have helped primary depressions may be less effective in the treatment of suicidal depressions of young people. References American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. American Psychiatrlc Association. Washington. DC.
Bureau of the Census (1952) 1950 Population Census Report. Vol. III, 47. U.S. Government Printmg Office. Washington, DC. p. 21. Bureau of the Census (1982) 1980 Crnsus of Population Characteristics of the Population. Vol. 1. 6. U.S. Government Printing Office. Washington, DC, p. 649. Federal Bureau of Investigation (1956) Uniform Crime Reports for the United States 1956, Vol. XXVII, No. 1. U.S. Government Printing Office, Washington, D.C. p. 19. Federal Bureau of Investigation (1981) Uniform Crime Reports for the United States 1980. U.S. Government Printing Office, Washmgton, DC, p. 62. Feighner. J.P.. Robins, E., Cue. S.B.. Woodruff. R.A., Winokur, G. and Munoz, R. (1972) Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiatry 26. 57-63. Hagnell. 0.. Lanke, J.. Rorsman, B. and Ojeqo. L.. (1989) Are we entering an age of melancholy? Depressive illness in a prospective epidemiologic study over 25 years: the Lundby study, Sweden. Psychol. Med. 12, 279-289. Klerman, G.L. (1988) The current age of youthful melancholia Br. J. Psychiatry 152. 4-14. Murphy. G.E. and Wetzel, R.D. (1990) The lifetime risk of suicide in alcoholism. Arch. Gen. Psychiatry 47. 383-392. Rich, C.L.. Young, D. and Fowler, R.C. (1986) San Diego suicide study young vs old subjects. Arch. Gem Psychiatry 43, 577-582. Rich. C.L., Sherman. M. and Fowler, R.C. (1990) San Diego suicide study the adolescents. Adolescence (in press). Robins, E. (1981) The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide. Oxford University Press, Oxford. Shaffer, D. and Fisher. P. (1981) The epidemiology of suicide in children and young adolescents. J. Acad. Child Psychiatry 20, 545-565. Shaffer, D., Garland, A., Gould. M.. Fisher, P. and Trautman, P. (1988) Preventing teenage suicide a critical review. J. Am. Acad. Child Adolesc. Psychiatry 27, 675-687.
Journal of Affective Dworders, 21 (1991) 127-132 0 1991 Elsevier Science Publishers B.V. 0165-0327/91/$03.50 ADONIS 0165032791000676
JAD 00780
Secular trends in psychiatric Gabrielle
A. Carlson
‘, Charles
diagnoses
L. Rich I, Patricia
Grayson
of suicide victims 1 and
Richard
’ Department of Psychiatry and Behuoioral Science. State Unruersity of New York at St0n.v Brook, Stony and ’ Department
of Psychrat~,
Brook.
C. Fowler NY
I
’
1794, U.S.A.
lJnluersit,v of California. San Diego. CA. U.S.A.
(Received 16 July 1990) (Accepted 29 October 1990)
Summary
Post-mortem psychiatric diagnoses are compared in two cohorts of male suicides from St. Louis (1956-1957) (Robins, 1981) and San Diego (1981-1982) (Rich et al., 1986). Similar structured interviews and diagnostic criteria had been used in both assessments. Substance/alcohol abuse has remained the major diagnosis in suicides under age 60. Rates of depressive disorder alone have decreased overall, due mostly to decreased rates in the elderly. Thus, depression occurs more frequently in younger ages. Comorbid depression and substance/alcohol abuse has also increased in younger ages. Implications in terms of the so-called ‘cohort effect’ are discussed.
Key words:
Suicide
victims;
Psychiatric
diagnosis;
Introduction It is well known that suicides rarely occur in the absence of diagnosable mental illness, especially depression, alcoholism, and schizophrenia, and that rates of suicide have substantially increased in adolescents and young adults since 1960 (Murphy and Wetzel, 1990; Shaffer et al., 1988). On the one hand, the finding that rates of depression seem to be increasing in progressively younger populations (Klerman, 1988) might tempt
Address for correspondence: Dr. G.A. Carlson, Department of Psychiatry and Behavioral Science, Putnam Hall, State University of New York at Stony Brook, Stony Brook, NY 11794-8790, U.S.A.
Substance/
alcohol
abuse;
Depression
one to conclude that this explains the rise in suicides among young people. On the other hand, recent systematic interview data reveal that substance abuse rather than depression is the more prevalent diagnosis in suicide victims under age 30; by contrast, major depression is the more common diagnosis in the over 30 population (Rich et al., 1986). The purpose of this study was to explore the secular trends in diagnosis of suicide victims at different ages over the past 25 years in an attempt to elucidate the relationships between psychopathology and changing rates of suicide. Specifically, we tested whether the prominence of a particular diagnosis at particular developmental intervals from youth to old age has changed over the 25-year interval.
128
Methods
Systematic data were obtained by Robins (1981) on 134 suicides in 195661957 in St. Louis and by Rich et al. (1986) in 1981-1982 in San Diego. These data sets have a number of important similarities that enabled us to examine diagnoses over time. Each included consecutive suicides in areas with both urban and suburban populations, namely the cities and counties of St. Louis and San Diego, respectively. Each city had a population of about 900,000 at the time with similar age, sex and minority distributions (Bureau of the Census, 1952, 1982). The time frames were similar (1 year for the St. Louis study, 10 months for the consecutive suicides in the San Diego study). Both used structured interviews of informants who knew the victims and obtained data from informants in all but 11% of cases in the earlier study and 8% in the later study. The background psychosocial, diagnostic, and specific suicide information elicited during the interview was similar in part because the interview schedule for the later study was modeled after that used in the St. Louis study. Most importantly, the diagnostic criteria were very similar. The Washington University (or Feighner) criteria (Feighner et al., 1972) were applied in Robins’ study. The DSM-III criteria (American Psychiatric Association, 1980) were used in the San Diego study. One difference between them is that the former requires a duration of depressive symptoms of 1 month rather than 2 weeks. The criteria for alcohol abuse were similar, however. Another important difference involves the listing of codiagnoses in DSM-III whereas under the Feighner criteria, diagnosis of either depression or alcoholism, not both, was given. It was thus necessary to reread the vignettes in Robins’ monograph to try to determine whether comorbidity, in fact, existed. This was done separately by two authors (G.A.C. and C.L.R.) with independent agreement initially reached on all but one case. This case was also easily resolved. For this report, comorbidity was defined as major depression with significant co-occurrence of alcohol or drug use, or conversely, alcohol abuse with the significant co-occurrence of depressive symptomatology. Of 45 men who had met criteria for affective disorder, 13 were reclassified as having comorbid depression.
Of the 29 males with alcoholism or drug abuse, eight were reclassified as comorbid. Suicides were divided by 20-year time spans to investigate when between the ages of 20 and 80 significant shifts in diagnostic rates occurred. This interval was selected to correspond roughly to the developmental shifts of youth. adulthood, middle age and senescence. For this report. data are presented only for males because in the Robins study there were too few females in some age groups for analytic purposes. Chi-square analysis with Yates’ correction was used for comparisons of rates of specific psychiatric disorders in the two samples stratified by age. Results
The population rates by age group have not changed as remarkably as the suicide rates by age. Comparing St. Louis (1950 census) and San Diego (1980 census) reveals percent distributions for males as follows: 30% and 34% for those aged 20 or less, 32% and 37% for those aged 21-40, 26% and 18% for those aged 41-60 and 12% and 11% for those aged 61 and over. By contrast, suicides are very underrepresented in the youngest age group (none in the St. Louis sample and 6% in the San Diego sample). Thereafter, a decided shift occurs with 21% of the St. Louis sample vs. 48% of the San Diego sample aged 21-40, 37% and 27% respectively in the middle-aged sample, and an overrepresentation of elderly suicides in the St. Louis sample (42%) but not the San Diego sample (19%). Overall, the frequency with which affective disorder alone is diagnosed in male suicide victims dropped significantly in the 25 years between studies (32% vs. 14.7%, x2 = 10.52, P = 0.001) while comorbid depression increased somewhat (20.3% vs. 29.4%, x2 = 3.29, P < 0.1). There was no change in rates of substance abuse (22% vs. 23.8%). There are two ways to examine the relationship of age cohort and diagnosis. One way is to inspect the types of diagnoses occurring in a particular age group in the first cohort and compare them with the second, as is illustrated in Table 1 and graphically represented in Fig. 1. The second way is to survey the entire cohort to determine if
129
Affective Substance
Comorbld abuse
dllIl.m
Affect ‘Other
,ve Substance
Dlagnosls
Comorbld abuse
iii Affecttve Substance
‘Other’
Dlagnosls Fig. 1. Comparison
of suicides
within
‘Other’
Dlagnosss
J
Affective Substance
Comorb;d abdse
Comorbld abuse
‘Other’
Dlagnosls each age group between 1956 and 1982. Significant group (x2 = 10.09. P < 0.02).
difference
observed
for the 61-X0+
age
particular diagnoses are more likely in one age group or another and then to see if the pattern changes in the second cohort. See Table 2 and Fig.
cant differences in the relative rates of any of the diagnoses between the two studies. This is true for middle-aged people (aged 41-60) as well. In fact
2.
major depression as the primary diagnosis among suicide victims is notable only among the elderly
Inspection first of diagnoses in specific age groups reveals that in 1957, none of the suicide victims was under 20 years of age. Thus, the presence of suicides aged 13-20 in the San Diego study indeed reflects the increased rate of suicide among young people. Diagnoses in this later sample have been reported elsewhere (Rich et al., 1990) and include youngsters with conduct/ substance abuse disorders and those with adjustment disorders whose psychopathology reflects subsyndromal but chronic maladaptation. In the next age group, adults aged 21-40, alcohol and drugs have consistently played the most prominent role in suicides and there are no signifi-
in the St. Louis study. The distribution of diagnoses between the two studies is significantly different only among the elderly (x2 with Yates’ correction = 10.09, P < 0.02) largely because of the decreased rates of depression and increased rates of ‘other’ diagnoses. (In these instances, ‘other’ includes people with organic brain syndromes and those on whom data were insufficient to make diagnoses.) Comparison of the diagnoses across each cohort reveals the relationship between age and diagnosis between time periods and only one significant difference
emerges.
Comorbid
depression
and al-
130
TABLE
1
COMPARISON OF GROUP MALES
SUICIDES
Age cohort O-20
21-40
St. Louis (1957). n = 103 n(S) 0
WITHIN
EACH
41-60
61-801
22 (21.4)
38 (36.9)
43 (41.7)
_
3 (13.6)
7 (18.4)
23 (53.4)
_
8 (36.4) 4 (18.2) 7 (31.8)
13 (34.2) 10 (26.3) 8 (21.0)
2 (4.6) 7 (16.2) 11 (25.6)
Sun Diego (IPRZ), n = 143 n (S) 9 (6.2) 68 (47.6)
39 (27.3)
27 (18.9)
6 (8.8)
9 (23.1)
5 (18.5)
20 (29.4) 24 (35.3) 18 (26.5)
10 (25.6) 12 (30.8) 8 (20.5)
1 (3.7) 3 (11.1) 18 (66.7)
Affective Substance/ alcohol abuse Comorbid Other
Affective Substance/ alcohol abuse Comorbid Other
l(ll.1)
3 (33.3) 3 (33.3) 2 (22.2)
Significance
NS
NS
P
21-40 Age
41-60
group
cohol/substance abuse is most frequent among the adults in the San Diego study and is clearly playing a more significant role than it did 25 years earlier (x2 = 9.0, P < 0.05with Yates’ correction). Although overall rates of depression alone occurring in suicides have decreased, there is also a definite shift in the frequency with which depression is occurring at younger ages. Thus, in 1957, of those suicide victims whose diagnosis was major depression, 69.7% were over age 61. In 1982, 76.2% were under age 61. This just misses statistical significance.
Discussion
One of the limitations of the study has to do with comparing case vignettes derived from structured interviews with structured interviews themselves. This is less of a problem in the precisely defined areas of affective disorder and substance abuse alone. The reason that a less conservative definition of comorbidity was used was to mini-
,$ = 10.09 P < 0.02 Yates’ correction -.-son
O-20
AGE
DIego
--o--St
LOUIS
/
61-80
age group
(year)
0
40
-L u 5
20
(year)
P 0 Age
Fig. 2. Comparison
group
of diagnosis
distribution
41-60 Age
(year)
across each cohort.
Distribution
of comorbidity
group
changed
61.80
(year)
(x2 = 10.09, P < 0.02).
131 TABLE
2
COMPARISON
OF DIAGNOSES
ACROSS
Age cohort O-20 Affective St. Louis San Diego
AGE COHORTS
21-40
- MALES
41-60
61-80+
n
Significance
1 (4.8)
3 (9.1) 6 (28.6)
7 (21.2) 9 (42.9)
23 (69.7) 5 (23.8)
33 21
abuse _ 3 (8.8)
8 (34.9) 20 (58.8)
13 (56.5) 10 (29.4)
2 (8.7) 1 (1.9)
23 34
Comorbid St. Louis San Diego
_ 3 (7.1)
4 (19.0) 24 (57.1)
10 (47.6) 12 (28.5)
l(33.3) 3 (7.1)
21 42
Other St. Louis San Diego
2 (4.3)
7 (26.9) 18 (39.1)
8 (30.8) 8 (17.4)
11 (42.3) 18 (39.1)
26 46
Substance/alcohol St. Louis San Diego
Results
are given as absolute
numbers
and, in parentheses,
NS
,yz = 9.0 P i 0.05 Yates’ correction
NS
percentages.
mize the likelihood of overlooking comorbidity at a time it was not acknowledged in the St. Louis study. While there are likely to be many cultural differences between St. Louis and San Diego accounting for diagnostic differences, demographic differences, in fact, are minimal. Age, gender, race and death due to homicide were similar (Bureau of the Census, 1952,1982; Federal Bureau of Investigation, 1956, 1982). A third limitation may be the possibility
x2 = 7.6 P < 0.06 Yates’ correction
that,
age 20 or less. This is not remarkably different from the San Diego data where 6% of total suicides were age 20 or less compared to the total population where 34% were age 20 or less. In other words, although there has been a significant rate of increase in adolescent in question, adolescents underrepresented
suicide over the 25 years have remained equally
compared
to their general
popu-
lation frequency. With respect to specific findings, it appears the frequency with which major depression occurs specifically
in
label the suicides of young people, especially adolescents, hence there were no suicides under the age of 24 in the St. Louis study and nine in the
dramatically
between
San Diego study under age 21. (This represents a statistically significant difference by Fisher’s Exact Test, P < 0.01.)Shaffer and Fisher (1981) have found, however, that relatively speaking, few accidents are really misidentified suicides. Given
although when one examines the 1982 cohort, it is clear that the major depression that is occurring
in the 195Os, the coroner
was more likely to mis-
the usual method of suicide by gunshot or hanging in young men, it is unlikely that adolescent male suicides, had they occurred in 1956-1957, would have been missed though there is no way of ruling that out. Comparing percent suicide victims by age with total suicide population by age reveals a less startling contrast, however. In St. Louis, 0% of the total suicide population was age 20 or less compared to a total population where 30% were
elderly
suicides
1957
and
has 1982.
dropped There
has
not been a compensatory increase in rates of major depression alone occurring in younger age groups
in suicides is occurring at younger that substance abuse, be it alcohol,
ages. The fact other drugs or
both, has remained the major diagnostic culprit for the past 25 years suggests that different psychiatric phenomena may be accounting for suicide in younger vs. older people. The cohort effect reported in the ECA studies (Klerman, 1988), then, is evident here more in comorbid depression which has decidedly val studied.
increased
in the 25-year
inter-
These findings may appear to be at variance with what has been reported to be the declining
132
age of onset of depressive disorder in recent decades. We feel there is a plausible explanation. In an elegant study comparing rates of mild, moderate and severe depression in Lundby, Sweden between 1947-1957 and 195771972, Hagnell and colleagues (1982) made an interesting observation. Rates of severe depression (which implied an impairment of reality testing) have remained relatively constant across the decades 1947- 1972 from ages lo-80 + with the exception of a drop in rates of depression in 60-69-year-olds in the 1957-1972 sample. In contrast. rates of mild and moderate depression not only increase with age starting at ages 20-29, the cumulative probability of depression more than doubled between the first and second survey and between the 30- and 50-year age groups the cumulative probability of depression more than tripled. One might hypothesize that mild and moderate depressions are more stress-related, more sensitive to the sociocultural changes that have taken place since World War II and more likely to include depressions which co-occur with other psychiatric disorders (i.e., comorbid depression). Since these depressions appear to be less responsive to electroconvulsive therapy and possibly antidepressant medication, the strategies that have helped primary depressions may be less effective in the treatment of suicidal depressions of young people. References American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. American Psychiatrlc Association. Washington. DC.
Bureau of the Census (1952) 1950 Population Census Report. Vol. III, 47. U.S. Government Printmg Office. Washington, DC. p. 21. Bureau of the Census (1982) 1980 Crnsus of Population Characteristics of the Population. Vol. 1. 6. U.S. Government Printing Office. Washington, DC, p. 649. Federal Bureau of Investigation (1956) Uniform Crime Reports for the United States 1956, Vol. XXVII, No. 1. U.S. Government Printing Office, Washington, D.C. p. 19. Federal Bureau of Investigation (1981) Uniform Crime Reports for the United States 1980. U.S. Government Printing Office, Washmgton, DC, p. 62. Feighner. J.P.. Robins, E., Cue. S.B.. Woodruff. R.A., Winokur, G. and Munoz, R. (1972) Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiatry 26. 57-63. Hagnell. 0.. Lanke, J.. Rorsman, B. and Ojeqo. L.. (1989) Are we entering an age of melancholy? Depressive illness in a prospective epidemiologic study over 25 years: the Lundby study, Sweden. Psychol. Med. 12, 279-289. Klerman, G.L. (1988) The current age of youthful melancholia Br. J. Psychiatry 152. 4-14. Murphy. G.E. and Wetzel, R.D. (1990) The lifetime risk of suicide in alcoholism. Arch. Gen. Psychiatry 47. 383-392. Rich, C.L.. Young, D. and Fowler, R.C. (1986) San Diego suicide study young vs old subjects. Arch. Gem Psychiatry 43, 577-582. Rich. C.L., Sherman. M. and Fowler, R.C. (1990) San Diego suicide study the adolescents. Adolescence (in press). Robins, E. (1981) The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide. Oxford University Press, Oxford. Shaffer, D. and Fisher. P. (1981) The epidemiology of suicide in children and young adolescents. J. Acad. Child Psychiatry 20, 545-565. Shaffer, D., Garland, A., Gould. M.. Fisher, P. and Trautman, P. (1988) Preventing teenage suicide a critical review. J. Am. Acad. Child Adolesc. Psychiatry 27, 675-687.