Suicidal Behaviors and Childhood-Onset Depressive Disorders: A Longitudinal Investigation

Suicidal Behaviors and Childhood-Onset Depressive Disorders: A Longitudinal Investigation MARIA KOVACS, PH.D., DAVID GOLDSTON, PH.D.,

AND

CONSTANTINE GATSONIS, PH.D.

Abstract. In this longitudinal study, the rates and correlates of suicidal ideation and suicide attempts were determined among outpatient youths with depressive disorders and youths with other psychiatric disorders. At study entry, about 66% of the subjects evidenced suicidal ideation and 9% already attempted suicide. The rate of ideation remained fairly stable over time, whereas the rate of attempts reached 24% by the average age of 17 years. Major depressive and dysthymic disorders were associated with significantly higher rates of suicidal behaviors than were adjustment disorder with depressed mood and nondepressive disorders. In the presence of affective disorders, comorbid conduct and/or substance use disorders further increased the risk of suicide attempts. J. Am. Acad. Child Adolesc. Psychiatry, 1993, 32, 1:8-20. Key Words: suicidal behaviors, depression in children and adolescents.

Over the past 10 years, increasing information has become available regarding the prevalence and correlates of suicidal behaviors among juveniles (for reviews, see Crumley, 1990; Davidson and Linnoila, 1989; Low and Andrews, 1990; Shaffer et aI., 1988; Spirito et aI., 1989). One of the themes in this body of literature is that suicidal ideation is far more frequent than suicide attempts and that suicide attempts are considerably more frequent than completed suicide, suggesting that these behaviors characterize overlapping but nonidentical populations. An association also has been consistently reported between suicidal behaviors and psychiatric disturbance in general and between suicidality and depressive symptoms or disorders in particular. Additionally, certain demographic features have been thought to increase the risk for suicidal behavior in this age group. However, for a variety of reasons, it is difficult to synthesize and interpret the data on the incidence and prevalence of suicidal behaviors. It also is not clear what factors may affect the relationship between suicidal behaviors and demographic variables and whether some psychiatric conditions may interact with one another to alter the risk of suicidality. The difficulties in interpretation derive in part from the dissimilar populations that have been examined, the frequent reliance on nonstandardized assessments, the scarcity of systemati-

Accepted March 24, 1992. Dr. Kovacs is with the Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine. Dr. Goldston is with the Department of Psychiatry and Behavioral Medicine, Bowman Gray School of Medicine of Wake Forest University. Dr. Gatsonis is with the Department of Health Care Policy, Harvard Medical School. Preparation of this paper was supported by Grant MH-33990 from the National Institute of Mental Health, Health and Human Services Administration and a grant from the W. T. Grant Foundation. Dr. Goldston was supported in part by a Bowman Gray School of Medicine Venture Grant and a Faculty Scholar Award from the W. T. Grant Foundation. Appreciation is expressed for the statistical and data analytic contributions of Lydia Voti, M.S., and Phoebe Lucy Parrone, M.S. Reprint requests to Dr. Kovacs, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15213. 0890-8567/93/320l-0008$03.00/0© 1993 by the American Academy of Child and Adolescent Psychiatry.

8

cally and carefully diagnosed samples, and the relative lack of longitudinal studies. It is particularly notable that outpatients have received little research attention although they represent the vast majority of referrals in child psychiatry. Much of what is known about suicidal behaviors in childhood is based on crosssectional studies of psychiatric inpatients, suicide comp1eters, and youths presenting in emergency rooms. The extent to which findings from such select groups may be generalized to other samples is not known. This problem is compounded by the fact that only a few studies of clinical populations have employed standardized psychiatric evaluations, and most of those focused on mixed inpatient-outpatient samples. There are some indications, however, that suicidal behaviors may be relatively frequent among juveniles, even in ambulatory settings. Standardized clinical assessments of mostly outpatient samples of youths have revealed that up to about 60% have suicidal ideation and up to about 20% have made suicide attempts (Carlson and Cantwell, 1982; ,Myers et aI., 1991; Pfeffer et aI., 1986; Ryan et aI., 1987). However, rates tend to differ as a function of the time intervals under consideration and the diagnostic, age, and inpatient-outpatient composition of the samples. Regardless of the population, suicidal behaviors have been consistently associated with depressive symptoms or disorders (for a review, see Kovacs and PUig-Antich, 1989). More specifically, suicidal youngsters have high rates of depression (e.g., Brent et aI., 1988; Carlson and Cantwell, 1982; Kosky et aI., 1990; Robbins and Alessi, 1985), those with depressive disorders have high rates of suicidal ideation and attempts (e.g., Myers et aI., 1991; Ryan et aI., 1987), and suicide victims often have a history of unipolar or bipolar depressive disorder (Brent et aI., 1988; Hoberman and Garfinkel, 1988). An association between suicidality and depression also has been documented in general child psychiatric samples and community surveys (e.g., Brent et aI., 1986; Garrison et aI., 1991b; Kashani et aI., 1989; Pfeffer et aI., 1986, 1988, 1991; Smith and Crawford, 1986; Velez and Cohen, 1988). However, scant information exists on the risk for suicidal behaviors posed by major depressive J. Am. Acad. Child Adolesc. Psychiatry, 32: I,January 1993

SUICIDAL BEHAVIORS

disorders as compared with dysthymic disorders and mild forms of depressive conditions. Conduct and substance use disorders also have been considered as psychiatric risk factors for attempted and completed suicide, in part because these conditions are associated with impulsive behavior. In some samples, up to one third of suicide attempters had antisocial behavior or substance abuse (Spirito et aI., 1989), with possibly higher rates among older adolescents (Crumley, 1990). Likewise, a notable portion of completed suicides have histories of substance abuse or antisocial behavior (Brent et aI., 1988; Hoberman and Garfinkel, 1988; Shafii et aI., 1985). However, the foregoing findings have not been consistently replicated (e.g., Robbins and Alessi, 1985); in fact, socialized conduct disorder has been described as a "protective" factor against ideation and attempts (Garrison et aI., 1991 b). Therefore, the data are equivocal regarding the role of "externalizing disorders" in suicidal behaviors (e.g., Apter et al., 1988; Levy and Deykin, 1989; Pfeffer et aI., 1991). Given the equivocal findings, it is important to note that youths with major depressive or dysthymic disorders frequently have comorbid conduct and/or substance abuse disorders (Kovacs et aI., 1988; Myers et aI., 1991; PUig-Antich, 1982). Possibly, therefore, "externalizing" disorders may serve as aggravating conditions rather than primary risk factors for suicidal behaviors. From among demographic factors, gender and age may affect the likelihood of suicidal behaviors (for reviews, see Low and Andrews, 1990; Shaffer et aI., 1988; Spirito et aI., 1989). More specifically, boys outnumber girls among those who complete suicide, whereas girls usually outnumber boys among those who attempt suicide. However, studies of suicidal ideation have yielded contradictory findings with regard to the importance of gender (e.g., Garrison et aI., 1991a, b; Harkavy Friedman et aI., 1987). A further complication is that gender may interact with diagnosis to alter the risk of suicidality. For example, in two studies of young patients with major depressive disorder, there were no compelling differences between boys and girls in rates of suicidal behaviors or extent of suicidality (Myers et aI., 1991; Ryan et aI., 1987). Likewise, in a,study of adolescent college students, there were. no gender differences in rates of ideation or attempt in the presence of major depression (Levy and Deykin, 1989). The differential rates of suicidal behaviors as a function of age suggest that these behaviors may be developmentally mediated. Namely, teenagers tend to have higher rates of both attempted and completed suicide than do children (e.g., Catlson and Cantwell, 1982; Kosky et aI., 1990; Shaffer et aI., 1988; Spinto et aI., 1989), and rates of suicidal ideation apparently increase with age (e.g., Carlson et aI., 1987; Kosky et aI., 1986, 1990). Furthermore, age and gender may be interacting risk factors. For example, in two recent epidemiological studies, boys and girls had similar rates of attempted suicide up to their mid-adolescence, whereas gender differences emerged after the age of 14 (Garrison et aI., 1991b; Joffe et aI., 1988). Finally, the findings are equivocal concerning the role of other demographic or background factors in suicidality, including socioeconomic staJ. Am. Acad. Child Adolesc. Psychiatry, 32: 1,January 1993

tus, race, family composition, or a history of familial psychiatric illness and suicidal behavior (e.g., Dubow et aI., 1989; Garfinkel et aI., 1982; Kosky, 1983; Pfeffer et aI., 1991; Smith and Crawford, 1986). Although recent research efforts have contributed to a better understanding of the problem of suicidality among youths, several issues require further attention. For example, more information is needed about the prevalence of suicidal ideation and attempts among systematically diagnosed child psychiatric outpatients. The data also are scant regarding temporal changes in the rates of suicidal behaviors in any particular sample. Additionally, the relationship between suicidal behaviors and demographic factors such as age has not been verified longitudinally. Moreover, the temporal association between suicide attempts and episodes of depressive or other disorders has not been clearly established. In the present investigation, therefore, the rates and correlates of suicidal behaviors were examined among depressed and nondepressed child psychiatric outpatients who have been participating in a longitudinal follow-up study. More specifically, the first major goal was to determine the prevalence of suicidal ideation and suicide attempts at three points in time and to assess whether the rates differed for the index diagnoses of major depressive disorder, dysthymic disorder, adjustment disorder with depressed mood, and nondepressive disorder. To illustrate temporal trends, "initial lifetime" rates of suicidal behaviors, established at the time of study entry, were contrasted with the rates over the followup and with "summary life-time" rates, incorporating all information. In light of the literature, the effects of gender, race, socioeconomic status, family composition, as well as parental history of suicide attempts and psychiatric hospitalization (as a surrogate for major psychiatric illness) also were considered. Focusing on cases who had a history of depressive illness, the second major goal was to determine the cumulative probability and age-specific risk of suicide attempts among them. The third major goal was to describe the temporal association between psychiatric disorder and suicide attempts; that is, to determine what proportion of attempts occur during illness episodes and how attempts are distributed across various diagnoses. A related goal was to estimate the risk (or odds) of a suicide attempt as a function of a lifetime history of depressive disorders and conduct and/or substance use disorders. Method Subjects

Children and their families were recruited primarily from among sequentially referred cases to the child psychiatry outpatient service of The University of Pittsburgh School of Medicine and the general medical clinic of the affiliated Children's Hospital of Pittsburgh; a few cases were accessed through other avenues. As described in detail elsewhere (Kovacs et aI., 1984a, b), subjects were recruited in two phases and their index diagnoses were determined by the research staff. To be considered for the study, a child had to meet these criteria: 8 to 13 years old, not mentally retarded, no evidence of major systemic illness, ambulatory

9

KOVACS ET AL.

status, living with parent(s) or legal guardian(s), and residing within commuting distance of Greater Pittsburgh. Signed consents were obtained from parent(s) and children for an initial 5-year follow-up and, upon its completion, for further follow-up intervals. Families received a monetary reimbursement at each assessment. The study population includes two samples, defined by research study entry (index) diagnoses, determined at intake or during the first 6 months of diagnostic verification. The depressed sample (n = 142) consists of 60 children with major depressive disorder (MDD), 32 with major depression superimposed on dysthymic disorder (MDDIDD), 23 with dysthymic ,disorder (DD), and 19 who had adjustment disorder with depressed mood (ADDM). The remaining eight cases were diagnosed with bipolar disorder at study entry and are not included in the present analysis. The psychiatric comparison sample (n = 49) includes children with no current or past depressive disorders at study entry. Based on their acute presenting complaints, the most frequent primary diagnoses were conduct disorders (35%), adjustment disorders other than ADDM (20%), "V-codes" signifying family or parent-child conflict (14%) or academic problems (8%), and attention deficit disorder (10%); other conditions, such as enuresis, encopresis, or specific developmental disorders accounted for the rest. The sociodemographic characteristics of the 134 depressed and 49 comparison cases are summarized in Table 1. Portions of the depressed sample have been characterized in previous publications. As noted, both samples had high rates of comorbid Axis I and Axis II psychiatric disorders at study entry (Kovacs et aI., 1984a, b, 1988, 1989; Kovacs and Gatsonis, 1989). Altogether 78% of the depressed children had comorbid diagnoses (not including V-codes), with anxiety, attention deficit, and conduct disorders being the most frequent. Of the comparison cases, 43% had multiple diagnoses, with attention deficit disorder and functional enuresis or encopresis being the most prevalent comorbid diagnoses. TABLE

1. Sociodemographic Characteristics of Samples at Intake

Variable Gender, male Age, mean years 8-9 years 10-11 years 12-13 years Race, white Intact family of origin Head of household's socioeconomic statusa I (highest) II III

IV V Employed head of household a

10

Depressed Sample (n = 134)

Comparison Sample (n = 49)

47% 11.2 years 20% 46% 34% 62% 28%

76% 10.6 years 41% 37% 22% 63% 33%

4% 7% 22% 40% 28%

4% 8% 33% 39% 16%

57%

76%

Based on Hollingshead's (1957) index.

Cases were recruited sequentially, as they became available, over the period of April 1978 through March 1987. Before completing the first 5-year phase of the project, 14 depressed and three comparison cases dropped out. One comparison and eight depressed cases were lost because of moves. An additional 12 depressed and 12 comparison cases completed their initial 5 years of participation and declined further follow-up. Follow-up Interval

For the present analyses, the data were restricted to information collected to September 1, 1990. Because the samples were recruited over a span of 9 years, the cases had variable lengths of follow-up. The longitudinal data for the depressed cases still active and those who completed the study spanned up to 12 years (M = 6.6 years, SD = 2.3 years). For depressed cases who dropped out or were lost, the average follow-up was 1.0 year (SD = 0.9 year). For control subjects . (active or completed), the follow-up interval spanned up to 12 years (M = 8.9 years, SD = 2.1 years); for the controls who were dropouts or were lost, the average follow-up was 1.4 years (SD = 1.5 years). Assessment Procedures

The protocol stipulated four evaluations for the depressed cohort in the first year of the study (intake, and two-, six-, and 12-month follow-ups) and semiannual interviews in later years. Because of logistical problems (canceled appointments, staff shortage, families moving away), the actual time intervals between assessments varied across the cases. The comparison group had the same assessment schedule initially, later was followed via alternating brief phone contacts and regular face-to-face assessments about every 6 to 8 months (because of staff shortage), and more recently was returned to a schedule similar to that for the depressed subjects. The research evaluations were multifaceted and included a semistructured psychiatric interview and demographic data collection. Family psychiatric history was obtained by trained and independent interviewers who were kept blind to the proband's diagnostic status. Mothers were the primary respondents, and were assessed by means of the Schedule for Affective Disorders and Schizophrenia-Lifetime version (SADS-L) and diagnosed via the Research Diagnostic Criteria (RDC) (Endicott and Spitzer, 1978; Spitzer et aI., 1978). Because less than one third of the proband had intact families, paternal psychiatric history was typically diagnosed by family history (FH)-RDC (Andreasen et aI., 1977) with mothers as informants. Two indices of family psychiatric disturbance were used in the present analyses, positive lifetime history of parental (maternal and/or paternal) suicide attempt and psychiatric hospitalization. Psychiatric Evaluations and Diagnosis of Proband

At each clinical assessment, the parent was first interviewed alone about the child, and the child then was interviewed separately by the same researcher. These evaluations were conducted with the semistructured, symptom-oriented Interview Schedule for Children (ISC) and its addenda. The l. Am. Acad. Child Adolesc. Psychiatry, 32:1, January 1993

SUICIDAL BEHAVIORS

interviewers were mental-health professionals (M.A., M.S.W., or Ph.D. level) who were individually and extensively trained in supervised research interviews and were fully affiliated with the project. At each assessment, diagnoses were based on the clinician's final single ratings of each symptom based on data supplied by both the parent and the child. Clinical history and other information, as needed, also were taken into account. Only symptom ratings meeting operational criteria for clinical severity were used in assigning a diagnosis. The reliability of the symptom ratings has been reported (Kovacs, 1985). The assessments were reviewed routinely by the research clinicians, and final diagnoses were assigned by consensus. All diagnoses conformed to DSM-III (American Psychiatric Association, 1980) 'criteria, with the further provision that at least three pertinent symptoms be present for a diagnosis of adjustment disorder. For history and onset and offset (recovery) dates of disorders, parental report was relied on most heavily, particularly with younger subjects. If an onset or offset date could not be determined, an attempt was made to delimit an interval during which the problems emerged or remitted, respectively (e.g., "around age 7 or 8"). The date in question was then operationally set at the midpoint of the delineated interval. The onset of a disorder was dated to the time when, according to all indicators, the child had the full syndromatic picture. Prodromal and subclinical presentations were not sufficient to assign an onset date. Offset, or recovery, was operationally defined as: (a) the absence of the relevant symptoms or, at most, one remaining clinically significant symptom and few if any subclinical symptoms of the pertinent syndrome, and (b) the maintenance of the foregoing state for a minimum of a 2-month inter.val. If the subject recovered from a episode but on follow-up was again found to have become symptomatic in 2 months or less, he or she was designated as still in the previous episode of the illness. For more detail, see Kovacs at aI., (1984a, b, 1988, 1989). Assessment of Suicidal Behavior

Suicidal behaviors also were assessed with the ISC via specific items regarding suicidal ideation, frequency of suicide attempts, the contemplated or actual method(s) of attempt, and related constructs. As with all other ISC items, the items that concern suicidal behaviors consist of standardized questions (e.g., "Have you ever thought about killing yourself?" "Has that been on your mind?" "Have you ever done anything to kill yourself?") and corresponding predefined rating scales. The child and the parent are asked the same .questions about the child in individually conducted interviews. The final ratings represent the clinician's overall weighing of the information obtained. Using definitions proposed by a special National Institute of Mental Health (NIMH) Task Force (Resnik and Hathorne, 1973), a suicide attempt is defined in the ISC as a "willful, self-inflicted, life threatening act," that has the potential, no matter how remote, of resulting in physical injury or harm, the act being associated with some psychological intent to end one's life. Suicidal ideation is defined specifically and narrowly as thoughts, ideas, ruminations, or fantasies about one's suicide J. Am. A cad. Child Ado/esc. Psychiatry, 32: 1, January 1993

or overt verbal threats to kill oneself. The foregoing definitions are reflected in the specific ISC questions. Attempts that were prevented before they were executed (interrupted attempts) are considered to be suicidal ideation rather than suicide attempts. During the (initial) intake interview, the ISC was used to establish whether the child had ever experienced suicidal ideation or had attempted suicide up to and including the day of the assessment. Then, at each follow-up assessment, a determination was made as to whether the child had experienced ideation and attempted suicide since the last evaluation. An interrater trial of 46 cases had been conducted involving conjoint interviews, with an observer independently rating the ISC items. Interrater agreement on presence or absence of suicidal ideation (computed as Cohen's Kappa (K» was 0.95; the coefficient was 1.00 for presence or absence of suicide attempts (M. Kovacs, unpublished data, University of Pittsburgh, 1981). Results Suicidal Behaviors at Study Entry (Initial Lifetime Rates)

The rates of suicidal behaviors at study entry reflect lifetime rates up to that point (referred to as "initial lifetime"). When they entered t4e study, 58% of the children had a history of suicidal ideation (SI), as shown in Table 2, and for the majority of those (76%), the most recent episode of ideation was in the previous 6 months. Altogether 9% of the youths had a history of suicide attempts (SA) when they entered the study, and for most of them (75%) the attempt also occurred in the previous 6 months. Youths who had MDD, those with MDDIDD, and those with DD had similar rates of suicidal ideation and suicide attempts (X 2 = 0.49, df = 2, p = 0.78; X2 = 0.96, df = 2, p = 0.62, respectively) (Table 2). These three index diagnostic groups were therefore combined into one category, henceforth called the "affective disorders" group. Correlates of Sf. Univariate analyses of the preselected clinical and demographic attributes revealed that children with SI differed from the others only in terms of psychiatric diagnoses at intake (X 2 = 11.24, df = 2, P = 0.004) and racial distribution (X 2 = 5.17, df = 1, P = 0.02). Children with an affective disorder (major depression and/or dysthymia) had the highest rate of SI, the nonaffective controls had the lowest rate, and youths with ADDM had a rate of SI intermediate to these two groups (Table 2). The likelihood of ideation was 2.5 times higher in the presence of affective disorder compared with its absence (odds ratio (OR) = 2.57,95% confidence interval (CI) 1.39,4.76). Furthermore, 62.3% of white children compared with 37.7% of the nonwhite children had a history of SI. However, children with SI and the rest of the children did not significantly differ in terms of gender distribution (X 2 = 1.81, df = 1, P = 0.18), mean age at study entry (t = 0.26, df = 181, P = 0.80), socioeconomic status (SES) dichotomized (X2 = 0.10, df = 1, P = 0.75), living in an intact family (X 2 = 2.75, df = 1, P = 0.10), and parental history of psychiatric hospitalization or SA (X 2 = 0.01, df 1, P = 0.91; X2 = 0.13, df = 1, p = 0.72, respectively). 11

KOVACS ET AL. TABLE

2. Prevalence of Suicidal Ideation (SI) and Suicide Attempts (SA) as a Function of Index Diagnosis and Time of Assessmenf Assessment Period Follow-upb

Intake Index Diagnostic Group . Major depressive disorder Major depressive and dysthymic disorder Dysthymic disorder Adjustment disorder with depressed mood Nonaffective disorder All Cases

% SI

% SA

60

65

17

32 23

72

19 49 183

58 39 58 (107)

N

(N)

65

Lifetime'

% SI

%SA

% S1

%SA

58

74

28

85

37

13 9

32 23

66 78

25 17

81 87

28 26

5 0

18 48 179

50 40 62 (110)

6 8 18 (33)

68 51 74 (136)

11

9 (17)

N

8 24 (43)

Percents rounded to the nearest whole. Up to the last interview analyzed, but excluding intake. Cases may also have had the behavior at intake or only during follow-up. Reduced N owing to cases with only intake interviews. C "Summary lifetime," computed as "ever," Le., at intake or during follow-up or both. a

b

To assess the significance of all the clinical and demographic variables together and to check for interaction effects among them, stepwise multivariate logistic regression models were also applied. The results were entirely consistent with the outcome of the univariate analyses and revealed only that diagnostic group and race were significantly related to SI. Correlates ofSA. Suicide attempts were also differentially distributed across the index diagnostic groups (Fisher's exact test = 9.28, df = 2, p = 0.01). Children with affective disorders at intake had the highest rate of SA (14%), youths with ADDM had a lower rate (5%), and none of the controls had attempted suicide (Table 2). A suicide attempt was about 11 times more likely among the cases with affective disorder than among the rest of the youths (OR = 10.83, 95% CI 1.40, 83.64). Age was the only demographic variable that distinguished the children who had and those who had not attempted suicide (t (181) = 3.85, p < 0.0005). Those with a history of SA were older at study entry than the rest (M = 12.45 years, SE = .37 years, M = 10.93 years, SE = 1.55 years, respectively). However, there were no significant betweengroups differences with regard to gender (X 2 = 2.83, df = 1, P = 0.10), race (X 2 = 0.10, df = 1, p = 0.76), SES dichotomized (X 2 = 0.00, df = 1, P = 0.98), living in an intact family (X2 = 0.00, df = 1, P = 0.97), parental history of psychiatric hospitalization (X 2 = 0.00, df = 1, P = 0.40) or parental SA (X2 = 0.07, df = I, p = 0.79). The results of stepwise multivariate logistic regression analyses were again entirely consistent with the foregoing findings and revealed significant effects only for diagnostic group and age at intake. Suicidal Behaviors Over the Follow-up

A subject was considered to have evidenced suicidal behavior during the follow-up if, on any of the interviews subsequent to (but excluding) intake, ideation and/or attempt were rated as present. Recall that each follow-up interview covered the time interval since the previous assessment, yielding a continuous record of symptomatology over time. The findings indicate that the rate of SI remained rela12

tively stable from intake through the last follow-up; in contrast, the rate of attempts doubled as compared with the rate at intake (Table 2). Altogether 62% of the children with follow-up data (110/179) experienced ideation during the interim, and 18% (n = 33) made SAs. However, the figures in Table 2 may be underestimates of the "true" rates over time because of the variable lengths of observation for different patients. Similar to the earlier findings, MDD, MDD/ DD, and DD were associated with similar rates of ideation (X 2 = 1.22, df = 2, p = 0.54) and SA over the follow-up (X 2 = 0.92, df = 2, p = 0.63). Therefore, the three index diagnostic groups were again combined into one "affective disorder" category. Correlates of SI. Suicidal ideation remained more prevalent among the cases who entered the study with affective disorders (72.6%) than among those with ADDM or nondepressive disorders, as shown in Table 2 (X 2 = 16.58, df = 2, p = 0.0003). According to the results of univariate analyses, a significant relationship between gender and suicidal ideation emerged over the follow-up (X 2 = 9.23, df = 1, p = 0.002); a larger proportion of girls (74%) than boys (52%) experienced SI. In contrast, youths with and those without SI did not differ with regard to racial distribution (X 2 = 1.44, df = 1, p = 0.23), SES dichotomized (X2 = 1.68, df = 1, P = 0.20), intact family at study entry (X 2 = 0.67, df = 1, p = 0.41), and parental history of SA or psychiatric hospitalization (X 2 = 0.29, df = 1, P = 0.60; and X2 = 1.31, df = 1, p = 0.26, respectively). The results of stepwise multiple logistic regression analyses were similar although not identical to the results of the univariate contrasts. Namely, SES also emerged as a significant correlate of ideation (p = 0.02) in addition to index diagnostic grouping and gender. Children with lower socioeconomic background were 2.4 times more likely to experience SI than were their higher SES counterparts of the same gender and index diagnosis (95% CI 1.12, 4.93). Correlates of SA. Rates of SA continued to differ across index diagnostic groups (X 2 = 8.27, df = 2, p = 0.02). Children who entered the study with affective disorders had J.Am.Acad. Child Adolesc. Psychiatry, 32: 1, January 1993

SUICIDAL BEHAVIORS

= .34) and .34 (SD test, p = 0.94).

higher rates of SA during the follow-up than did the other youths (Table 2). Univariate analyses also revealed that a significant association between gender and suicide attempt emerged overtime (X 2 = 5.87, df = 1, P = 0.02); disproportionately more girls (26%) than boys (12%) attempted suicide over the observation period. However, the attempters did not differ from the rest in racial distribution (X 2 = 0.37, df = 1, p = 0.54), SES dichotomized (X 2 = 0.65, df = 1, P = 0.42), intact family at intake (X 2 = 0.11, df = 1, P = 0.75), and history of parental SA (X 2 = 0.46, df = 1, p = 0.50) or psychiatric hospitalization (X 2 = 1.29, df = 1, P = 0.26). The results of stepwise multivariate regression analyses were consistent with the foregoing findings. Gender effects over the follow-up. One possible explanation of the gender effects on suicidal behavior over the follow-up (but not at intake) is that boys and girls were observed for different time periods. This hypothesis was not supported by the data. Depressed boys and girls had similar lengths of follow-up, on average (t = 0.42, df = 132, P = 0.67); likewise, control boys and girls did not differ in average follow-up duration (t = 0.91, df = 47, P = 0.37). Another possible explanation is that the diagnostic factor that most influenced rates of SI and SA (presence of depressive disorder) was more characteristic of girls than of boys. This hypothesis was tested by computing the proportion of days a youth was in an episode of affective disorder (MDD and/or DD) during study observation and then comparing the mean proportions for boys and girls. When the entire study population was examined, it was found that girls spent more time in a major depressive or dysthymic disorder than did boys, with proportions of .30 (SD = .34) and .20 (SD = .30), respectively (KruskalWallis test, p = 0.03). However, the latter finding can be primarily attributed to the facts that the control group had an overrepresentation of boys (Table 1) and that the controls were free of affective disorders at intake and remained generally so over the follow-up. When the analyses included only cases who had a depressive disorder (MDD and/or DD) over study observation (n = 122), time spent in a depression did not differ for girls and boys, with proportions of .36 (SD TABLE

=

.32), respectively (Kruskal-Wallis

Summary Lifetime Rates of Suicidal Behaviors an,d Characteristics of First Suicide Attempts The summary lifetime history of suicidal behavior for each case also was determined up to the date of his or her last interview used in the analysis. For those with only intake interviews, "initial lifetime" data were used. At the cutoff point for the analyses, the mean age of the study population was 17.4 years (range 9.1 to 25.7 years). By the time of their late teens, 74% (n = 136) of the 183 youths had a history of SI and 24% (n = 43) had made SAs (Table 2). There were no known completed suicides. Children with an index diagnosis of affective disorder had higher lifetime rates of ideation (85%) than did those with ADDM (68%) or a nonaffective disorder (51 %). By their late teens, a striking 32% (37/115) of the children who entered the study with major depression and/or dysthymia had attempted suicide, as compared with 11 % of those whose index diagnosis was ADDM and 8% of those with nonaffective disorders. Table 3 presents the characteristics of the 43 youths' first lifetime suicide attempts by index diagnostic group. The earliest record of an attempt was at age 8.3 years. Substance ingestion was the most common method of attempt, followed by self-laceration. Infrequently used methods (not listed in Table 3) included hanging (7.0% or three subjects), suffocation or strangulation not involving hanging (2.3% or one subject), and attempted drowning (2.3% or one subject). None of the youths used firearms or explosives, and only three of them employed multiple (two) methods in connection with their first SA. Most attempts had minor medical consequences; only 14.0% of the SAs reportedly required ambulatory medical care (e.g., sutures, gastric lavage), and 23.3% required inpatient hospitalization. At the cutoff date used in the analyses, the 43 attempters made 88 attempts. The average number of attempts was 2.05 (range 1 to 8); 21 children had one SA, and only four of the 22 children with repeat attempts had four or more SAs.

3. Characteristics of First Suicide Attempts (SA)

Age at SA (years) Mean

Range

Most Frequent Methods b

22

13.5

9.0-16.7

Substance ingestion (64%) Stabbing/cutting (18%)

Major depressive and dysthymic disorder

9

[3.2

11.4-17.1

Substance ingestion (50%) Stabbing/cutting (38%)

Dysthymic disorder

6

13.9

[2.4-16.9

Substance ingestion (7 [%) Stabbing/cutting (29%)

Adjustment disorder with depressed mood

2

12.2

8.3-[6.2

Substance ingestion (50%) Jump in front of car (50%)

Nonaffective disorder

4

15.4

13.4-17.9

Substance ingestion (50%) Stabbing/cutting (25%) Gas inhalation (25%)

Index Diagnostic Group Major depressive disorder

a b

Number of cases with at least one SA. Three of the 43 attempters employed two methods.

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

13

KOVACS ET AL.

Children with more than one attempt and those with only one did not significantly differ in gender (X 2 = 0.04, df = 1, p = 0.85)~ race (X 2 = 1.43, df = 1, p = 0.23), SES dichotomized (X 2 = 0.66, df = 1, p = 0.42), or with respect to living in an intact family at study entry (X 2 = 0.19, df = 1, p = 0.67).

Time-Dependent and Age-Dependent Risk of Suicide Attempt among Cases with Affective (Depressive) Disorders Longitudinal analyses, including the Kaplan-Meier method (Kalbfleisch and Prentice, 1980), were used to model both the cumulative probability of a first suicide attempt as a function of time and age, and the effects of demographic variables on this outcome. By taking into account each subject's actual observation interval, these approaches yield a more accurate estimate of the risk of attempted suicide than did the summary lifetime prevalence computed previously. The start point in the analyses was each child's sixth birthday; the end point was the date of the first SA or the date of the last observation point if there was no attempt. As documented later, most SAs occurred during episodes of major depressive and/or dysthymic disorders. Hence, the analyses were restricted to those 122 cases who had a history of such an affective disorder. This included 114 children who entered the study with major depression and/or dysthymia (one subject was deleted because her SA could not be dated), three children whose index diagnosis was ADDM but developed MDD over the followup, and five controls who developed MDD or DD over the follow-up. The cumulative probability of a first attempt in this group is 0.38 by age 17. After age 17, the risk of SA apparently levels off (Fig. 1). That is, if each of these cases with a history of major depressive and/or dysthymic disorders was observed through age 17, 38% would be expected to have made a suicide attempt. The data, organized by yearly life060

1

~ 1 046

!

0.40

:i ~

:g

0.36

'5

V>

;j

0.30

"".~

0.25

u: c

o

.~

0.20

'"

j ~

,6 0.

1

0.10

U

0.05

10

12

W

18

w

18

22

Chronologie Age (in years) Nil rl8k: 122

121

112

98

67

41

21

I. The cumulative probability of first suicide attempt among patients with affective (depressive) disorders.

FIG.

14

table intervals (Dixon et aI., 1990) clearly showed that age 13 to 14 years is a high-risk period for a first attempt. However, the probability estimates are less reliable after age 20 because of the small number of cases remaining in the analysis. Using these longitudinal data, Cox multivariate regression (Kalbfleisch and Prentice, 1980) was used to assess whether clinical and demographic factors had an effect on the risk of a first attempt. The clinical and demographic variables were age-at-onset of first depression (MDD or DD), gender, race, and SES. None of these variables exerted a discernable effect on the time-to-first suicide attempt (Global X2 = 4.15, df = 4, p = 0.39). Some youths attempted suicide on multiple occasions, an occurrence that cannot be accommodated in survival analytic models. Therefore, an alternative strategy was employed to examine further the relationship of age and suicide attempt. Using the above noted 122 cases, the number of cases who attempted suicide during each specified age period was divided by the number of patients actually under observation during that age. The observation period started at intake. The resultant age-specific rates confirm that during ages 13 and 14, a comparatively high proportion of patients attempt suicide (Table 4). Furthermore, partly as a function of repeat attempts, the proportion of patients attempting suicide during age 15 is also high.

Suicide Attempts and Type of Psychiatric Disorder Two further issues were investigated regarding attempted suicide and psychiatric diagnosis. First, for the 43 attempters, the proportion of attempts that took place within or outside episodes of illness was determined as well as the relationship between attempts and particular diagnostic classes. Toward this aim, the date of each attempt made by a subject was mapped against the onset and offset dates of that subject's DSM-1l1 diagnoses over time. Affective disorders, conduct disorders, and substance use disorders were the diagnoses of major interest, regardless of the presence or absence of other comorbid conditions. If a given attempt occurred within an episode other than affective, conduct, or substance use disorder, then the' 'other" disorder was used to classify the case diagnostically. One case whose SA could not be dated was deleted from this analysis, leaving 87 SA made by 42 youths. Because the resultant estimates are biased (because of multiple attempts by some subjects), the findings are presented only descriptively. Second, the relative lifetime risk of an attempt posed by selected disorders was determined. Using the entire study population (n = 183), cases were categorized based on "summary lifetime" history of affective disorder (MDD and/or DD, including cases who developed bipolar depressive episodes over the follow-up), MDD (unipolar or bipolar), conduct/oppositional and/or substance use disorder, and combinations of the foregoing. Then, odds ratio for SA were computed as a function of various diagnoses. Timing ofsuicide attempts and psychiatric disorders. Suicide attempts practically never occurred when children were free of psychiatric illness. All but one of the 87 attempts took place during an episode of diagnosable mental disorder. l. Am. Acad. Child Adolesc. Psychiatry, 32:1,January 1993

SUICIDAL BEHAVIORS TABLE

Age, Years 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

4. Proportion of Patients with Affective (Depressive) Disorders Who Had Suicide Attempts (SA) as a Function of Chronological Age (N = 122)" Number of Subjects Observed at the Given Age 14 26 54 76 91 110 104 91 77

65 48 36 21 13 6 1

Number of Subjects with at Least One SA

Proportion of Subjects with SA at the Given Age

0 1 1 4 3 13 13 10 7 4 1 2 0 0 0 0

0 .04 .02 .05 .03 .12 .13 .11 .09 .06 .02 .06 0 0 0 0

" One subject was deleted from the analysis because date of her SA could not be ascertained. For this Table, observation period starts at study intake; SAs before that point are not included.

Furthermore, depression, broadly defined, was found to be the most prominent psychiatric context for a suicide attempt. Specifically, 50 of all 87 SAs (57.5%) occurred during episodes of major depressive or dysthymic disorder. A further 14 attempts occurred during episodes of major depressive or dysthymic disorder and comorbid conduct/ substance use disorder. Only 12.6% (11 of 87) of all attempts were made within episodes of conduct/substance use disorder in the absence of affective disorders. However, at the time four of these 11 SA, adjustment disorder with depressed mood was also present. From among the 12 remaining suicide attempts, four occurred during episodes of adjustment disorder with depressed mood (4.6%), another four during episodes of bipolar disorder, mixed type, one (1.2%) during an episode of organic affective (depressive) disorder, and one attempt, each, occurred in the context of a personality disorder, an attention deficit disorder, and a period of family stress assigned a "V-code" and not attributable to a mental disorder. A broad categorical definition of depression would include those DSM-III diagnoses that have prominent depressive features, namely, major depressive and dysthymic disorders, adjustment disorder with depressed mood, and organic affective (depressive) disorder. Using this categorization, it was found that 73 of the 87 attempts (83.9%) occurred during episodes of psychiatric disturbance with "depressive" components. Risk of suicide attempts by selected diagnoses. Table 5 presents the unadjusted odds ratio for SAs in the entire study population as a function of particular lifetime diagnostic histories. Note that the relative risks are directly comparable only when they are derived for the same sample or subsampIe of persons; otherwise, the figures are best interpreted as suggestive of trends. The likelihood of a suicide attempt was about four- to l. Am. Acad. Child Adolesc. Psychiatry, 32:1, January 1993

five-fold higher for children with a history of major depression specifically, or affective disorder more generally (MDD and/or DD), as compared with children who did not have affective disorders but had other disorders (Table 5). A history of "externalizing" disorder increased the odds of an attempt by a factor of two, as compared with a history of all other disorders. However, the odds ratio of 2.07 associated with the presence of conduct/substance use disorder is misleading because a portion of children with externalizing disorders also had affective disorders. Removing the cases with this particular comorbidity revealed that conduct/substance use disorder as compared with other disorders was not associated with an elevated risk of SA (Table 5). On the other hand, among youths with a history of major depression specifically or affective disorder more generally, the presence of comorbid conduct/substance use disorders increased the risk of an SA approximately threefold. Partly because different sample sizes were used for the various computations, the data in Table 5 do not allow a direct comparison of the relative risks for an SA posed by noncomorbid affective and conduct/substance disorders, as compared with their comorbid presentation. However, the percentages of suicide attempters by diagnostic histories suggest that conduct/substance use disorders are risk factors mostly in the presence of affective illness. Of the children with a history of "externalizing" disorders but no affective disorders, 10% made suicide attempts. Of the children with a lifetime history of major depression and/or dysthymia but no conduct/substance abuse, 22% attempted suicide. And of those with a history of both categories of disorders, 45% attempted suicide. Discussion

The purpose of the present investigation was to determine the rates, characteristics, and correlates of suicidal ideation 15

KOYACS ET AL. TABLE

5. Likelihood of Suicide Attempt as a Function of Lifetime History of Selected Disorders

Positive Lifetime History of Specified Disorder Affective disorder (versus any other disorder) Comorbid affective and conduct/substance use disorder (vs either or any other disorder) Major depressive disorder (vs any other disorder) Conduct/substance use disorder (vs any other disorder) Conduct/substance use disorder without comorbid affective D/o (vs any other disorder) Comorbid affective and conduct/substance use disorder (vs affective disorder but no conduct/substance use disorder) Comorbid affective and conduct/substance use disorder (vs neither disorder) Comorbid majordepressive and conduct/substance use disorder (vs neither disorder) Comorbid major depressive and conduct/substance use disorder (vs MOD but no conduct/substance use disorder) a

N

183

4.92

1.82,

13.27

183 183 183

4.19 3.79 2.07

2.01, 1.64, 1.04,

8.72 8.76 4.14

136

.51

0.14,

1.85

123

2.80

1.27,

6.17

77

11.31

2.41,

53.06

80

9.64

2.56,

36.3

110

2.68

1.17,

6.14

Computed as ad/bc.

and attempts among outpatient school-age children and adolescents who had depressive disorders and outpatient peers who had other psychiatric disorders. Suicidal ideation was defined specifically as thoughts of wanting to kill oneself and suicide attempts were defined as overt acts intended to kill oneself. At study entry, the subjects were 11 years old, on average. They were repeatedly assessed longitudinally for up to 12 years, with a mean follow-up duration of 6 to 9 years. At the cutoff point for the data analyses, average age of the youths was 17 years old. The major findings from this longitudinal study are as follows. First, SI was found to be quite frequent, already characterizing about two thirds of the children when they entered the study, and this rate remained remarkably stable over the years. In contrast, about one of ten youngsters had a suicide attempt by study entry, and this rate increased twofold over the subsequent 6 to 9 years. Second, the DSMIII diagnoses of MDD and/or DD were associated with similar and high rates of suicidal behaviors, both initially and over time. In comparison, suicidal behaviors were much less frequent among children who had adjustment disorder with depressed mood and were the least common among youths with nondepressive disorders. Third, suicide attempts almost never occurred when youngsters were free of psychiatric illness. Moreover, 84% of the attempts took place in the context of depression, broadly defmed. Examination of the temporal relationship between suicide attempts and type of psychiatric disorder revealed that suicide attempts were made most often (74%) during episodes of depressive and/or dysthymic disorders, and were relatively infrequent during episodes of conduct/substance use disorders (in the absence of concurrent mood disorder). A lifetime history of affective disorder increased the odds of a suicide attempt about fivefold, as compared with a history of all other diagnoses. Among youths with a history of affective disorders, comorbid conduct/substance use disorder further increased the odds of a suicide attempt by about a factor of three. In contrast, conduct/substance use disorder that was not accom-

16

95% Confidence IntervallMantelHaenszel Test

Odds Ratio for Suicide Attempt"

panied by affective disorder did not appreciably alter the odds of an SA occurring. Fourth, at the onset of the study, suicidal behaviors and family and demographic factors (except race) were not associated with one another. However, with time, girls had higher rates of suicidal ideation and attempts than did boys, and lower SES became a risk factor for suicidal ideation. And finally, the adolescent years were found to represent a high-risk developmental period for attempted suicide (regardless of other factors), but the risk declined markedly after age 17. Prevalence of Suicidal Behaviors The consistently high rates of suicidal ideation in the present study, both at intake and over the follow-up, suggest that psychiatric outpatient status and thoughts of suicide are associated with one another. Psychiatric outpatient status also represents a risk factor for attempted suicide at any given point in time, although the magnitude of that risk appears to be developmentally or temporally mediated. It is notable that recently Garrison et aI., (1991a) also found the prevalence of suicidal ideation in a school-based population to be remarkably stable over a 3-year interval. Therefore, thoughts of suicide also may represent a temporally stable cognitive attribute among juveniles. Partly as a function of the time intervals that were assessed in the present study, the rates of ideation and attempts were higher than were the 6-month prevalence rates among outpatients, reported by Pfeffer et al. (1986). Compared with the present study, their sample contained fewer children with depressive disorders, and their subjects were younger, on average. The findings further suggest that suicidal ideation and attempts are not interchangeable as indices of suicidality. In the present population, the ratio of ideation to attempt was 6 to 1 at the average age of 11; it shifted to a ratio of 3 to lover the course of the follow-up. Thus, with other factors held constant, between 16% and 30% of clinically referred youths who thought about killing themselves actually attempted it. In addition, more than 50% of the youths who J. Am. Acad. Child Adolesc. Psychiatry, 32:1, January 1993

SUICIDAL BEHAVIORS

attempted suicide made another suicide attempt. Similar rates of repetition have been reported by others (Gispert et aI., 1987; Kotila and Lonnqvist, 1988; Pfeffer et aI., 1991), along with lower rates as well (Goldacre and Hawton, 1985). Psychiatric Diagnoses and Suicidal Behaviors

The index diagnoses of MDD, DD, and' 'double depression" were associated with relatively high and comparable rates of suicidal ideation and attempts. These results dovetail with previous reports of similarities between major depressive and dysthymic disorders in initial presenting features and predictive validity (Kovacs et aI., 1984a, b; Kovacs and Gatsonis, 1989). The data also parallel a recent finding by Pfeffer et aI. (1991) that major depression and dysthymia represent comparable risk factors for SA among psychiatrically referred youths. By their late teens, 85% of the youngsters who entered the present study with major depression and/or dysthymia had a lifetime history of SI and 32% had attempted suicide, with a .38 cumulative probability of a first suicide attempt by age 17. The close association between affective illness and suicidality in the present population therefore mirrors findings by others (e.g., Brent et aI., 1986, 1988; Levy and Deykin, 1989; Myers et aI., 1991; Ryan et aI., 1987). The index diagnoses of MDD, MDDIDD, and DD, determined at study entry, were associated not only with suicidal behaviors at intake but also with high rates of suicidal behaviors over the follow-up. This finding probably reflects the fact that major depression and dysthymia portend later affective disorders. Namely, in this very same population, it has been documented that MDD is associated with a high rate of recurrence and that dysthymia not only has a protracted course but is also a risk factor for eventual MDD (Kovacs et aI., 1984b; Kovacs and Gatsonis, 1989). The high prevalence of suicidal ideation and attempts in the presence of affective disorders is not merely an artifact of DSM-III criteria. That is, in addition to dysphoric mood, suicidal behavior is one of eight defining symptoms of MDD, of which only four are needed for the diagnosis. Suicidal ideation is one of 13 symptoms that define dysthymic disorder in the DSM-IlI, of which only three are needed (in addition to negative mood) for a diagnosis. On the basis of chance, one would expect lower rates of suicidal behavior than the rates found for both diagnostic groups. In addition, SAs among dysthymic youths cannot be explained by DSMIII criteria because an SA is not a defining symptom of that disorder. The data regarding the diagnostic category of ADDM shed some light on the question as to whether fewer and less persistent symptoms than those characteristic of major depressive or dysthymic disorders increase the risk of suicidality. ADDM was associated with rates of ideation and attempts intermediate to the rates that characterized the affective disorders and the nondepressive disorders, suggesting that even a few depressive symptoms may increase the risk for suicidal behavior. The latter conclusion is supported by the finding that depressive features were present J. Am. Acad. Child Adolesc. Psychiatry, 32:1, January 1993

during the vast majority of psychiatric episodes when an SA took place. Consistent with recent reports of relative risks (Levy and Deykin, 1989; Pfeffer et aI., 1991; Velez and Cohen, 1988), the summary lifetime psychiatric histories confirmed that an affective disorder was the primary diagnostic risk factor for attempted suicide. Additionally, the risk of attempted suicide was higher among youth with both "externalizing" and affective disorders than among youths who had affective disorders but no conduct/substance use disorders. Among juveniles who have major depression or dysthymia, conduct disorders tend- to develop concurrently with or subsequent to the affective disorder (Kovacs et aI., 1988). Therefore, in such instances, both conduct problems and suicidal behaviors could represent "complications" of the mood disturbance. Using a phenomenologic approach, comparatively few suicide attempts were detected during conduct and substance use disorders in the absence of comorbid affective disorders. The odds ratios for SAs, based on summary lifetime psychiatric histories, appeared to reconfirm that, in the present outpatient population, "pure" externalizing disorders constitute a relatively weak risk factor for suicide attempts. Such a possibility may partly account for the discrepant findings in the literature regarding the risk of suicidality posed by these disorders (e.g., Garrison et aI., 1991b; Levy and Deykin, 1989). There has been scant recent speculation as to the psychological mechanism that may be involved in the suicidal acts of youths with affective and conduct or substance use disorders. As an explanatory construct, hopelessness has received inconsistent support (e.g., Asarnow et aI., 1987; Kazdin et aI., 1983; Myers, et aI., 1991; Rotheram-Borus and Trautman, 1988). However, the role of hopelessness in suicidal behavior may be developmentally mediated because the requisite personal and historical time perspective generally does not develop until adolescence (for a review, see Wessman and Gorman, 1977). Impulsivity also has been proposed as a mediating factor, particularly among youngsters with "externalizing" disorders and substance abuse (e.g., Kotila and Lonnqvist, 1988; Spirito, et aI., 1989). However, it has not been satisfactorily explained why poor impulse control should lead to suicidal as opposed to other behaviors. The ubiquitous presence of dysphoric mood around the time of a suicide attempt, detected in the current study, suggests another possible explanation. The mediating variable in the suicidal acts of children and young adolescents could be a limited ability to regulate or tolerate intense negative affect or emotional distress. Viewed from this perspective, suicidal acts among youngsters could represent one way to eliminate or lessen intolerable negative mood states. The findings also indicate that suicidal acts during childhood and adolescence are not' 'normal" developmental phenomena but are almost always symptomatic of diagnosable psychiatric disturbance. Although the youths in the present study had been clinically referred, there were periods of time when no disorders were present. For example, children who entered the study with MDD spent 38% of the days under observation free of any significant DSM-III Axis I 17

KOVACS ET AL.

diagnoses; those with dysthymia were free of salient Axis I disorders for 37% of the time under observation (M. Kovacs, unpublished data, University of Pittsburgh, 1991). Given these symptom-free intervals, it is notable that suicide attempts almost never occurred when cases were free of diagnosable disorders. In a similar vein, more than 90% of inpatient suicidal youths as well as suicide completers in a study by Brent et aI. (1988) had a psychiatric disorder at the time of their "suicidal episode." Demographic Factors and Suicidal Behavior Gender and age are the two demographic factors that have been repeatedly, although not consistently, linked to rates of suicidal behaviors. Inconsistent findings may reflect that gender, age, and diagnostic composition of a sample interact with one another. For example, at the average age of 11, there were no significant gender differences in initial lifetime rates of SI or SA in the present study. The effects of gender became pronounced only as youths entered mid- and late-adolescence. Cross-sectional epidemiologic studies of community and school-based populations have revealed similar trends in suicide attempts, suggesting that gender effects probably emerge after midadolescence or age 14 (Garrison et aI., 1991b; Joffe et aI., 1988). Furthermore, gender and diagnostic status apparently do interact to alter the risk of suicidality. In the present investigation, when only cases with major affective disorder were examined, neither the frequency of attempts nor the cumulative probability of the first attempt revealed any statistically significant gender effects. Likewise, Ryan et aI. (1987) reported no statistically significant differences in rates of ideation and attempt among boys and girls with major depressive disorder. Myers et aI. (1991) also reported that gender did not predict suicidality among juveniles with MDD. Therefore, in diagnostically heterogenous clinical samples and community based surveys of adolescents, gender effects on rates of SA could be artifactual, reflecting that girls spend more time in states of depression than do boys. Age 13 was found to be the modal age for the first suicide attempt; ages 13 and 14 were "peak" periods for attempts; and substance ingestion was the most common method, paralleling findings by others (e.g., Angle et aI., 1983; Velez and Cohen, 1988). However, the rate of SA decreased markedly after late adolescence. Although this finding was unexpected, similar trends have been reported by others. For example, in a follow-up study of previously hospitalized youngsters, Angle et aI. (1983) found an "abrupt decline" of SA after age 18. Likewise, in their community based epidemiologic study, Velez and Cohen (1988) found that after mid to late puberty, the age-specific risk of attempted suicide declined. The decreased rate of SA with the onset of young adulthood may be interpreted as supporting the above proposed hypothesis concerning one psychological mechanism of attempted suicide. Possibly, as children mature, they develop better tolerance for dysphoric mood states and more diverse coping resources. Concomitantly, they may be less likely to resort to attempted suicide during states of despondency. In the present study, suicidal behaviors were not found to

18

be related to family intactness or selected aspects of parental psychiatric history. The findings regarding race and SES were inconsistent. Race and SI were associated only at intake, and SES was found to be related to SI in only one analysis, when other factors were controlled. Previous reports regarding a link between suicidality and SES or race among youths also have been inconsistent, making interpretation difficult (e.g., Dubow et aI., 1989; Garrison et aI., 1991b; Pfeffer et aI., 1991; Velez and Cohen, 1988). Furthermore, the presence or absence of an association between suicidal behavior among youths and familial psychiatric history seems to be partly a function of the population studied. For example, when psychiatric control or comparison groups are used, as in the present study, familial psychopathology does not typically differentiate suicidal and nonsuicidal youths (e.g., Carlson and Cantwell, 1982; Kosky, 1983; Myers et aI., 1991). Recommendations for Future Studies The existing literature on suicidal behaviors in children and adolescents is difficult to integrate because of substantial differences in methodologies and reporting practices across studies. In particular, there has been a general lack of precision in the clinical assessment of suicidal behaviors, a frequent absence of operational definitions, and an occasional failure to specify altogether how the target behaviors were defined. In some studies, a question such as "Did you ever hurt yourself?" has been considered as equivalent to a direct inquiry about suicidal behaviors. In other studies, a presumptive bias is evident in labeling an attempt with a "nonserious" medical consequence as a "gesture." Thereby, outcome is confounded with intent, and categories of suicidal behaviors across different studies are not directly comparable. During the 1970s, considerable work was accomplished on the assessment and definition of suicidal behaviors among adults. For example, a special NIMH panel recommended that suicidal behaviors be classified as either suicide ideation, attempts, or completion; each of these, in turn, also would be rated on several dimensions, such as lethality, intent, and mitigating circumstances (Resnik and Hathorne, 1973). Concomitantly, standardized assessment instruments were developed, versions of which have been applied in investigations of youths (e.g., Brent, 1987; Garfinkel et aI., 1982). Additional methodologic developments and definitional consensus in the study of suicidal behaviors among juveniles should generate a more consistent body of knowledge. In conjunction with increased methodologic precision, there is need for further studies of suicidal behaviors among large outpatient populations. Although the present investigation focused on outpatients, the sample contained an overrepresentation of youths with MDD and/or DD, thereby yielding probably higher rates of suicidal behaviors than in general clinic samples. Future investigations should focus on diagnostically representative juvenile outpatient populations to estimate the clinic base rates of suicidal behaviors. Finally, repeated assessment and longitudinal studies of atrisk children and adolescents are also needed. Admittedly, J. Am. Acad. Chi/dAdolesc. Psychiatry, 32: 1, January 1993

SUICIDAL BEHAVIORS

such studies may preclude the totally blind assessment of suicidal behaviors. However, repeated assessments are likely to increase the accuracy of the reporting about the target behaviors, partly because of the time intervals between assessments. As a result, such investigations may better confirm and delineate temporal trends or recurrent periods of high risk and examine the covariation of purported risk factors for suicidal behavior over time. References American Psychiatric Association (1980), Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, (DSM-lII). 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. Angle, C. R., O'Brien, T. P. & McIntire, M. S. (1983), Adolescent selfpoisoning: a nine-year follow up. Dev. Behav. Pediatr., 4:83-87. Apter, A, Bleich, A, Plutchik, R., Mendelsohn, S. & Tyano, S. (1988), Suicidal behavior, depression, and conduct disorder in hospitalized adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 27:696-699. Asarnow, J. R., Carlson, G. A & Guthrie, D. (1987), Coping strategies, self-perceptions, hopelessness, and perceived family environments in depressed and suicidal children. J. Consult. Clin. Psycho/., 55:361-366. Brent, D. A. (1987), Correlates of the medical lethality of suicide attempts in children and adolescents. J. Am. Acad. Child Adolesc., Psychiatry, 26:87-89. Brent, D. A., Kalas, R., Edelbrock, c., Costello, A. J., Dulcan, M. K. & Conover, N. (1986), Psychopathology and its relationship to suicidal ideation in childhood and adolescence. J. Am. Acad. Child Psychiatry, 25:666-673. Brent, D. A, Perper, J. A., Goldstein, C. E., Kolko, D. J., Allan, M. J., Allman, C. J. & Zelenak, J. P. (1988), Risk factors for adolescent suicide. Arch. Gen. Psychiatry, 45:581-588. Carlson, G. A. & Cantwell, D. P. (1982), Suicidal behavior and depression in children and adolescents. J. Am. Acad. Child Psychiatry, 21 :361-368. Carlson, G. A., Asarnow, J. R. & Orbach, I. (1987), Developmental aspects of suicidal behavior in children: I. J. Am. Acad. Child Adolesc. Psychiatry, 26: 186-192. Crumley, F. E. (1990), Substance abuse and adolescent suicidal behavior. JAMA, 263:3051-3056. Davidson L. & Linnoila, M., (eds.) (1989), Report of the Secretary's Task Force on Youth Suicide. Volume 2: Risk Factors for Youth Suicide. (DHHS Publication No. ADM 89-1622). Washington, DC: U.S. Government Printing Office. Dixon, W. J., Brown, M. B., Engelman, L. & Jennirch, R. I., (eds.) (1990), BMDP Statistical Software Manua/. Berkeley: University of California Press. Dubow, E. E, Kausch, D. E, Blum, M. C., Reed, J. & Bush, E. (1989), Correlates of suicidal ideation and attempts in a community sample of junior high and high school students. J. Clin. Child Psycho/., 18:158-166. Endicott, J. & Spitzer, R. L. (1978), A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch. Gen. Psychiatry, 35:837-844. Garfinkel, B. D., Froese, A. & Hood, J. (1982), Suicide attempts in children and adolescents. Am. J. Psychiatry, 139:1257-1261. Garrison, C. Z., Addy, C. L., Jackson, K. L., McKeown, R. E. & Waller, J. L. (199la), A longitudinal study of suicidal ideation in young adolescents. J. Am. Acad. ChildAdolesc. Psychiatry, 30:597603. Garrison, C. Z., Jackson, K. L., Addy, C. L., McKeown, R. E., & Waller, J. L. (1991b), Suicidal behaviors in young adolescents. Am. J. Epidemio/., 133:1005-1014. Gispert, M., Davis, M. S., Marsh, L. & Wheeler, K. (1987), Predictive factors in repeated suicide attempts by adolescents. Hosp. Community Psychiatry, 38:390-393.

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From Pediatrics Are Poor Families Satisfied with the Medical Care their Children Receive? Corey, M.A., Howard E. Freeman, Ph.D., and Martin F. Shapiro, M.D., Ph.D.

David L. Wood, M.D., M.P.H., eluis

Abstract. While access to care has been shown'to be worse for poor populations, few studies have examined the quality of care received by the poor vs the nonpoor. Furthermore, serious concerns have been raised about the impact of costcontainment efforts on the quality of health care for both the poor and nonpoor. The authors examine the interpersonal quality of medical care received by children from poor and nonpoor families by assessing parental satisfaction with physician-patient communication in a telephone survey of a nationally representative sample of households containing 2182 children and adolescents 17 years or younger. The majority of parents were satisfied with many aspects of their interactions with physicians. However, poor families were more likely to be not completely satisfied with the medical care their children received at their last health visit than nonpoor families (27% vs 12%, P < .001). With regard to specific aspects of the physician-patient communication, poor families were more likely to be not satisfied with the physician's provision of information about the illness (40% vs 21 %, P < .001); the physician's discussion of examination findings (21 % vs 9%, P < .001); and the opportunity provided by the physician to express their concerns (12% vs 6%, P < .00l). Logistic regression demonstrated that poor patients were approximately twice as likely to be not satisfied with the medical encounter and with various aspects of their communication with the physician. It is concluded that the parents of poor children are less satisfied with their care. Both policy and educational inventions may be needed to address this problem. Pediatrics 1992;90:66-70.

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J. Am. Acad. Child Adolese. Psychiatry, 32: I, January 1993