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Suicide in adolescence: some comments on epidemiology and prevention
Journal of Adolescence I98Z, 5, 3 5 5 - 3 6 6
S u i c i d e in a d o l e s c e n c e : s o m e c o m m e n t s o n epidemiology and prevention* FRANCOIS LADAME t AND OLIVIER JEANNERET++ INTRODUCTION Completed suicide and attempted suicide are the concern of adolescents' physicians not only because this form of pathology first manifests itself at this age, but they are also of paramount importance from at least three additional points of view: (a) at a time when the crude death rate is low, suicide as the second or third cause of death must b e regarded as a major public health problem; (b) even though it is the end point of a process rarely perceived as such either by the family, the peer group, or the family physician, with or without a fatal outcome, it is to some extent preventable; (c) whether attempted or completed it is a tragedy which leaves scars, when it is fatal, it leaves guilt feelings in other family members with sometimes long-lasting unconscious hostility between them. When non-fatal, it leaves psychological sequellae in the patient himself, contrasting with feelings of relief and a minimizing attitude in family members and friends, which the family physician is often tempted to support. In this short report we intend to draw attention to four points: first, the complementarity of both epidemiological and clinical approaches; second, the complexity of the natural history of each case, due to the actual overlapping of many psychogenic and sociogenic factors; third, the relatively weak predictive power of each identified risk factor, contrasting with a relatively common sequential chain of events preceding the suicidal act; fourth, the huge investment of energy, professional skills, time and money inherent in any preventive programme. All of these factors, though not necessarily specific to adolescents, are particularly relevant for this age group. * Revised and updated version of a contribution to a round table on "Psycho-social needs of adolescents and available services" at the 16th Convention of the International Pediatric Association, Barcelona, 8-I3 September z98o. 1" Chief, Adolescent Psychiatric Unit, Department of Psychiatry, University of Geneva, I6--z8 Bd. St.-Georges, Iazx Geneva 4, Switzerland. ++Professor and Head, Department of Social and Preventive Medicine, Medical School, University of Geneva, Switzerland. ox4o--xo7J/8a/o4o35$ +
]"
$o3.ooio
9 198z The Associationfor the Psychiatric Study of Adolescents 355
356
F. LADAME AND O. JEANNERET
~,Ve do not intend to enter into the present general controversial discussion among specialists about the nature and components of tile "suicide syndrome" but refer those interested to the recent collection of relevant papers edited by Farmer and Hirsch (198o). E P I D E M I O L O G I C A L APPROACH Let us try to answer as simply as possible some basic questions often asked by physicians as well as by lay persons including the adolescents themselves. ( I ) Do adolescents die more of ten f r o m suicide than adults? T h e answer is no. Data from Switzerland for example show* (Table I) that mortality rates are three times higher over 25 years of age than under, the ratio between young: old being higher in males (c. I ;3) than in females (c. 1:4)"
Table x. Deaths by suicide : absolute numbers and rate per xoo,ooo, Switzerland, x978
Males Age group (years)
N
5--24
x66
Females
R
N 56
886 Io52 --
-
R
-
x x "7
X9"2
3"o
32"7 x515
I4"3 --
x:3
N
I293
463 34"3
Ratio 5-24 ~>25
R
222
407 46"3
All ages
N
5"9
17"2
> 25
R
Ratio Males: females males:females
2"2 --
2"3
24"x --
I:4
x:3
--
m
N = Absolute number; R = rate per ioo,ooo (Source : WHO Statistics, x98o).
(2) Do adolescent males die more often from suicide than adolescent females? Here the answer is yes. I n the same table, the sex ratio (last column on the right) is 3"o in younger people, and, as a matter of fact is higher than in adults (2.2). A m o n g the European countries, the sex ratio is the highest in H u n g a r y (3.6) and the lowest in Italy (I.4) in this age group, according to a W H O study (I975). * A country where death rates from suicide in adolescence are higher than, for example, in Australia or in the U.S.A. (Jeanneret, x981), possibly because there are less legal, psychosocial or life insurance related reasons for underreporting than in many other countries.
SUICIDE I N ADOLESCENCE
357
(3) h~ regard to attempted suicides, what is their frequency (htcidence) hz adolescents compared to adnlts? All data are estimates since there is no compulsory reporting in any country. The conventional indicator is here the case fatality rate (i.e. the number of deaths divided by the total number of cases (completed suicides + attempted suicides)). Estimates from many reports give a tenfold difference between young people and adults, this rate jumping from about i/ioo in the former to about i/IO in the latter. Let us keep in mind, as a rule of thumb, this proportion of one completed suicide for lOO attempted suicides which is of prime importance in terms of preventive strategy as we will see later on. (4) Do adolescent males attempt suicide more often than females? The answer is no! In fact it is just the contrary: many more girls are hospitalized for suicide than boys; this is observed in all reports on "suicidal morbidity" (see Farmer, 198o; Sainsbury, Jenkins and Levey, 198o). Nevertheless, the increasing use of pharmaceuticals by boys instead of more readily fatal means like firearms or hanging, could contribute to decrease this sex differential in the future. (5) Are there time trends for both attempted and completed suicides hz this age group? Again statistics on attempted suicides are scarce, but any increase in crude numbers has to be reconsidered in terms of rates, since the last lO-2O years have been characterized, as everybody knows, by an increase in the actual number of adolescents in all western countries*. The best estimates of morbidity come from hospital statistics sometimes available at the national level. In England and Wales, in the past 20 years for instance, there has been an increase of such cases, especially in the younger age groups (Farmer, 198o) . Recent increases in rates for completed suicides have been observed in most countries and in all age groups, except in the United Kingdom where the only age-sex group showing an increase is the group of females aged 15-24 (Sainsbury et al., 198o). In Switzerland (Fig. I), the mortality rates are increasing in the same two large age groups as in Table I : less than 24 years and more than 25 years of age. Note the parallel trends in adult females' and adolescent males' rates. (6) IVhat about repeaters? Follow up studies of attempted suicide in all ages are now more numerous and more accurate in terms of epidemiological criteria (Katschnig, 198o). In a very well known French study focused on adolescents (Davidson, Choquet and * Placed as t h e d e n o m i n a t o r in b o t h m o r b i d i t y (incidence) a n d mortality rates.
F. LADAME AND O. JEANNERET
358 50
/ ~ Q~:)''O
45
(>25 ye~s)
40
35 0
oo
o
30
B 25 o = r 20
(-25ye0rs) ( 5 - 2 4 ye0rs)
r
Q:
15 I0
o
0
~
o
5
o._..__.___._~~O~o__.__.o_o_o~OlO..o/ce.o
0
I
I
~
I
~
I
~? (5-24
years)
I I I I I I I I
"1966 '-1970 . 7,. . 7. 3 72
75, '7 7, 74 76 78
Yeor
Figure x. Time trend in suicide. Rate (xoo,ooo) by sex in younger and in older People (Switzerland I95I-I978--W.H.O. Statistics, x98o). Facy, x976 ) the global incidence of repeats is 3 ~ per cent, but such a rate includes large differences according to the risk factors. Even a rough dichotomie classification of three risk factors increases the repeater risk from 13 per cent to 6z per cent (Table z). Adding the "history of character problems" as a risk factor has little effect as the risk is almost the same with (6z per cent) and without it (6o per cent). Other recent surveys on attempters and repeaters, which use statistical tools like cluster analysis (Katschnig, Sint and Fuchs-Robertin, 198o; Paykel, x98o ) have thrown light on the main correlates and causal factors to be taken into consideration. Table 2. Repeater rate accordhzg to the presence or absence of three risk factors (after Davidson et al., z976) Risk factor Pronounced depressive symptoms History of character problems Dissatisfaction in intra-family relationships Repeater rate (%)
+ + + 62
+ -+ 60
--+ 13
S U I C I D E IN A D O L E S C E N C E
359
(7) What becomes of suicidal adolescents? In the absence of a control group, the finding of attempted suicide in the history of adult psychiatric patients is not a proof of any causal relationship or even of a statistically significant correlation. Only cohort studies are known to suggest causal relationships, but, for obvious reasons, they are very rare. In Sweden, Otto (i972) has shown, in a follow-up study of zo-i 5 years, that the risk is higher in terms of mortality and morbidity (both mental and somatic) in adults who were formerly adolescent attempters than in a control group of non-attempters. This study is of prime importance in the perspective of secondary prevention of suicidal attempts in adolescence, as we shall see below. (8) Should the physician be concerned in practice with the discovery of suicidal thoughts hz an adolescent patient under care for some other reason? Recent large scale interview surveys have shown that these thoughts are very common in normal adolescents at some stage of their development and thus confirm the experience of clinicians. In Fig. 2 these thoughts are nevertheless localized at the bottom of an iceberg, because most of the adolescents do not
Pseudo-occ|dents
2 }~
,y2_
Attempted suicide
~ . ~ . . .
Figure 2. Adolescent suicide: the iceberg paradigm.
~
Visibility
36o
I'. L A D A M E A N D O. J E A N N E R E T
mention them spontaneously. An extensive study in France by Stork (I977) dealing with both younger and older students as well as young soldiers has shown the trivial character of such thoughts. According to this author, in these phantasies, death is viewed not so much as final self-destruction but as an alternative solution to frustrations met in the daily life or is linked with transient personality changes. In preventive work with adolescents it is therefore useful to give them the opportunity to elaborate these thoughts by asking them frankly about them. This last comment brings us into the second part of this paper, focused on prevention. COMMENTS ON PREVENTION It is easier to discuss objectives and means of prevention by considering levels of prevention. For the sake of this discussion, we select only two: primary and secondary levels.
Primary prevention At this level we should recognize a real risk in some adolescents who have suicidal thoughts and who may be about to put their thoughts into action. Early detection of adolescents who could attempt suicide should be focused on three areas: (x) Identification of depressive illness as differentiated from depressive ups and downs inherent to adolescent development. (z) Evaluation of signs of alienation, evidenced in adolescence by a change in usual habits, such as estrangement from other adolescents, family, peer groups, and]or academic or professional ties as well as the loss of a boy- or girlfriend. (3) Perception of mounting anxiety that is often overwhelming and an t/ncontainable distress within days or even hours preceding a suicide attempt.
Adolescent depression One of the main difficulties about adolescent depression is to distinguish (Fig. 3) (a) what belongs to a normal developmental process, (b) what is the sign of ongoing eonflictual pathology, determined by internalized conflicts of adolescence and (c) what means an actual depressive illness which is a consequence of earlier developmental defects (Ladame, F., in press). Symptoms are considered no more than warning signals that require, from ease to case, a thorough evaluation of personality organization. We should also
36x
SUICIDE IN ADOLESCENCE Normal developmental process
Conflictuol pathology during
Developmental pathology prior to
adolescence
adolescence
Figure 3. Main causal factors of depression in adolescence. remember that the clinical signs of adolescent depression are variable, evolving with the different stages of adolescence and usually dissimilar to the clinical picture seen in adult psychiatry. Early evidence of depression may be no more than an incapacity to concentrate on school work. Somatic complaints are common features: fatigue, insomnia, headaches, backaches, and gastroenterological problems. In the younger adolescent, depression is often masked by behavioural problems and in the older group by compulsive promiscuity, an inability to be alone, and great restlessness. We can also observe that accidentproneness may be a warning signal to be taken seriously as may be the occurrence of phobic, obsessional and conversion symptoms. (These latter are rarely indicators of mere neurotic personality disorders during adolescence.)
Social alienation Significant determinants can often be traced chronologically through the social history of the adolescent suicide attempter (Fig. 4)- Our own research (Fischer and Ladame, i979) on presuicidal itineraries has shown that the majority of these adolescents have undergone separations within the family: death of a parent, divorce, separations, running away, etc., significantly from tile age of x2. And, yet more importantly, for most of them, these events are only repeats of past traumatic separations in which peculiar family functioning is evident. For instance we are often confronted with situations of role
F. LADAME AND O. JEANNERET
362
Repeated failures
Separations within the family
1
Inversion of the parent/child roles ('parentification' of the adolescent)
Relegation to lower class, school or occupation
1
Flight into the adult world
Desperate efforts in order to'overflcat'
1
Dissolution of the last tentative emotional links (often with a significant adult)
1 Acute overwhelming anxiety
1
Suicidal act
Figure 4- Observed sequential chain of events in attempted and completed suicide in adolescence. reversal in which the adolescent becomes the parental child. Two thirds of these adolescents fail at school or work and are relegated to less satisfying occupations. In the remaining cases we note problems leading to changes in class or instability in occupational training. The final point in this trajectory is to drop out completely. We have also noticed in some adolescents what we can call a kind of premature flight into the adult world: escaping normal peer or group relationships they establish a special and privileged heterosexual relationship with an adult which usually breaks down quickly and irremediably. About a year before an adolescent's suicide attempt we often observe a makeshift effort to redirect an unstable and deteriorating situation. At this
SUICIDE IN ADOLESCENCE
363
point he desperately tries to find a buoy; however, because it is only a superficial investment there is only a negative outcome which leads to the only remaining solution--the suicide attempt. When these events are obvious they are easily perceived by any professional. When they are discrete or hidden-they are beyond recognition even by an expert.
Overwhehning anxiety The third and last focus of attention is hzcreashtg anxiety just before the
acting out of a suicidal gesture. This final stage is characterized by a cataclysmic, overwhelming anxiety, described as panic and fear of a breakdown. This terrible fear is linked to specific internal defence mechanisms (Ladame, F., I98I ). At this juncture only outside help may afford temporary relief. The practical question is to know who should or can ascertain presuicidal behaviour states. Primary suicide prevention is, in fact, a task involving everyone and therefore always complicated by risks. The medical profession must certainly be alert to, or at least aware of, these risks as so many suicidal adolescents present physical functional complaints in the weeks or months preceding their suicide attempt and seek out the family doctor or a pediatrician. It may be time-consuming to carry out an in-depth interview, but it is more important than a conventional history. If necessary we should not then hesitate to speak overtly with the young about suicide and suicide intentions conveying empathetie understanding and going beyond our personal or emotional attitude in relation to suicide.
Secondary prevention Secondary prevention should not aim merely at alleviating the direct consequences of a suicidal gesture and preventing future attempts. Secondary prevention is little use if it is limited to short-term action, without taking into consideration the long-term handicap for the future of the young suicide attempter (Fig. 5). The immediate consequences of a first suicide attempt for an adolescent rarely incurs serious medical problems. The behaviour of many youngsters, chiefly among the younger group, may be improved after acting-out episodes and this prevents or avoids investigation of their internal, psychic state. The fact that everyone concerned (the adolescent himself, his family, and his doctor) ardently hopes that everything is now all right can be very counterproductive. The study by Otto (I972) showed that beyond the immediate prognosis, serious consequences do bear upon the psychological, psychosomatic and
F. LADAME AND O. JEANNERET
364
A morerelevantmodelJ
J Convenhonolmodel J
Suicide-prone adolescent
Suicide-prone adolescent
I ...............(Primary preventJon) Death
9
................ (Primary prevent,on)
Death J
l
~
.............. ~eccndary prevent,on) Repeated
SUicid~toff erupts
Increased mar tclhty, morbidlty
and psycho-socialhandicaps in later life
Figure 5. Conventional model vs. a more relevant model of the roles of secondary prevention in adolescent suicide. psychosocial future of adolescents who have attempted suicide, once they have reached adulthood. The suicidal act is a breakdown of the whole organization of the personality. All medical and social resources should be mobilized to lighten the burden of psychosocial distress or disability to facilitate the on-going developmental processes of adolescence. This entails giving up any arbitrary splitting between psychological and sociological factors and the acknowledgement of their intimate interdependency. If we expect the adolescent's suicidal behaviour to improve and the long-term prognosis to be favourable something must change in his mind, his life style and his familial and social environment. Hospitalization is rarely indicated beyond the necessary time for strictly medical measures and psychosocial evaluation. We do not consider psychiatric hospitalization desirable for adolescents within this context. Generally hospitalization in a psychiatric ward is short-term; it offers no guarantee about the duration of expected change and is therefore not a safeguard for the future (Barter, Swaback and Todd, i968; McIntire et al., z977). Ideally, an adolescent who has attempted suicide should be treated with long-term, intensive psychotherapy, this being the only means of achieving a change in the internal organization of the personality and tapping the developmental potential. Short-term psychotherapy or crisis intervention ostensibly resolves immediate problems but this is only temporary. Individual intensive psychotherapy requires the patient's positive motivation as well as support
SUICIDE IN ADOLESCENCE
365
from the parents. This form of treatment produces personality change only after a certain lapse of time (Ladamc, I981). However,somethingmust change as well in the adolescent'sdirect environmentif the suicidal bchaviouris to be modified. In this context the family approachmay sometimesbc hclphll. Unfortunately, however, the families of suicidal adolescents often lack empathy with their child's needs and are very rarely motivated to undertake therapy aimed at modifying family dynamics. In our own research with 4 ~ families in which an adolescent child had attempted suicide (Snakkers, Ladame and Nardini, x98o; Snakkers, Nardini and Ladame, x98I), only one family asked for treatment and began therapy, This might suggest negative implications concerning therapeutic programmes limited only to family therapy techniques! Work in the adolescent's environment should not in any event be limited to the family. It is absolutely necessary to preserve existing and meaningful social relationships and re-establish those which have disappeared. This may necessitate direct contact or even forming a network with teachers, employers, other professionals, as well as close friends and acquaintances. Peer relationships are of paramount importance and contacts with organized groups of young people must be facilitated.
CONCLUSIONS (I) Whcn dealing with at risk individual adolcscents, is primary prevention actually realistic ? Why not rathcr plan it as a sct of non-specific mcasures dealing with thc cducational, psychological and societal conditions which influencc the maturational processes from childhood to adolcscence? (2) Suicidc case fatality ratc is known to be low in adolescence, lower than in any othcr age group. The impact of secondary prcvention is therefore a major one, at least potentially. Its targetshould not be limited to the prevention of further suicides; it should also focus on adolescent suicides attempters at risk of becoming adults exposed to incrcased mortality and morbidity as well as to psycho-socially handicapping conditions. (3) Adolescent suicide attempters (and, afortiori, repeaters) need not only immcdiate help but also longer trcatments. This is a tremendous challenge for mcntal health scrvices: inventive, creative as well as rcalistic resources arc badly needed[ (4) Adolescents' physicians in practice as well as family physicians and pediatricians interestcd in adolescence arc all faced with a v c r y difficult task in charge of a case of attcmptcd suicide and need the support of all manner of mental health spccialists in their preventivc and curative tasks.
366
F. LADAtME AND O. JEANNERET REFERENCES
Barter, J. T., Swaback, D. O. and Todd, D. (i968). Adolescent suicide attempts. A follow-up study of hospitalized patients. Archives of General Psychiatry x9, 523527. Davidson, F., Choquet, IM. and Facy, F. (1976). La notion de risque dans le domaine du suicide de l'adolescent. Revue d'Epiddmiologlqtte et de Santd Publique, 24, 283300.
Farmer, R. T. D. (I98O). T h e relationship between suicide and parasuicide. In The Suicide S)'ndrome, Farmer, R. T . D. and Hirsch, S. R. (Eds.), pp. I9-37. London: Croom Helm. Farmer, R. T. D. and Hirsch, S. R. (Eds) (198o). The Suicide Syndrome, 268pp. London: Croom Helm. Fischer, W. and Ladame, F. (x979). Premiers r6sultats de recherches sur les tentatives de suicide des adolescents: l'itin~raire pr~suicidaire. AIddecine sociale et prd~'entire 24, 49-52. Jeanneret, O. (in press), ltlortality and morbidity in Adolescence. Revised version of a document prepared for the "Second National Conference of the Australian Association for Adolescent Health", Sydney, I o - I I December, 1981. Katschnig, H. (x98o). Measuring life stress: a comparison of two methods. In The Suicide Syndronle, Farmer, R. T. D. and Hirsch, S. R. (Eds), pp. I16-123. London: Cr'oom Helm. Katschnig, H., Sint, P. and Fuchs-Robetin, G. (198o). Suicide and parasuicide: identification of high- and low-risk groups by cluster analysis. In Tire Suicide Syndrome, Farmer, R. T. D. and Hirsch, S. R. (Eds), pp. x54-166. London: Croom Helm. Ladame, F. (I98I). Les Tentatives de Suicide des Adolescents. Paris: Masson. Ladame, F. (in press) Les perturbations des processus de maturation et leur effet sur le comportement et la sant6. In Les Adolescents et Leur Santd, Jeanneret, O., Deschamps, J. P., Manciaux, M. and Sand, E. A. (Eds). Paris: Flammarion. tX'IcIntire, M. S., Angle, C. R., Wikoff, R. L. and Schlicht, M. L. (1977). Recurrent adolescent suicidal behavior. Pediatrics 6o, 6o5-6o8. Otto, U. (I972). Suicidal acts by children and adolescents: a follow-up study. Aeta Psychiatrica Scandinavica Suppl. 233. Paykel, E. S. (198o). A classification of suicide attempters by cluster analysis. In Tire Suicide Syndrome, Farmer, R. T. D. and Hirsch, S. R. (Eds), pp. I44-~53. London: Croom Helm. Sainsbury, P., Jenkins, J. and Levey, A. (198o). T h e social correlates of suicide in Europe. In The Suicide Syndrome, Farmer, R. T. D. and Hirsch, S. R. (Eds), pP. 38-53. London: Croom Helm. Snakkers, J., Ladame, F. and Nardini, D. (x98o). La famille peut-elle emp~cher l'adolescent de se suicider ? Neuropsychiatrie de rEnfance et de l'Adolescence 28, 393-398 . Snakkers, H., Nardini, D. and Ladame, F. (in press). Evolution individuelle et ~volution familiale apr~s une tentative de suicide d'adolesccnt. Proceedings of the XIth International Conference for Suicide Prevention, Paris, x98x. Paris: Pergamon Press. Stork, J. (x977)- Echelle d'6valuation de risque suicidaire. Psychlatrie de l'Enfant zo, 493-52o. W.H.O. (I975). Le Suicide et les Tentatives de Suicide, 143 pp. (Texte 6tabli par Eileen M. Brooke). Gen~ve: O.t'kLS. (Cahiers de sant6 publique, 58.)
S u i c i d e in a d o l e s c e n c e : s o m e c o m m e n t s o n epidemiology and prevention* FRANCOIS LADAME t AND OLIVIER JEANNERET++ INTRODUCTION Completed suicide and attempted suicide are the concern of adolescents' physicians not only because this form of pathology first manifests itself at this age, but they are also of paramount importance from at least three additional points of view: (a) at a time when the crude death rate is low, suicide as the second or third cause of death must b e regarded as a major public health problem; (b) even though it is the end point of a process rarely perceived as such either by the family, the peer group, or the family physician, with or without a fatal outcome, it is to some extent preventable; (c) whether attempted or completed it is a tragedy which leaves scars, when it is fatal, it leaves guilt feelings in other family members with sometimes long-lasting unconscious hostility between them. When non-fatal, it leaves psychological sequellae in the patient himself, contrasting with feelings of relief and a minimizing attitude in family members and friends, which the family physician is often tempted to support. In this short report we intend to draw attention to four points: first, the complementarity of both epidemiological and clinical approaches; second, the complexity of the natural history of each case, due to the actual overlapping of many psychogenic and sociogenic factors; third, the relatively weak predictive power of each identified risk factor, contrasting with a relatively common sequential chain of events preceding the suicidal act; fourth, the huge investment of energy, professional skills, time and money inherent in any preventive programme. All of these factors, though not necessarily specific to adolescents, are particularly relevant for this age group. * Revised and updated version of a contribution to a round table on "Psycho-social needs of adolescents and available services" at the 16th Convention of the International Pediatric Association, Barcelona, 8-I3 September z98o. 1" Chief, Adolescent Psychiatric Unit, Department of Psychiatry, University of Geneva, I6--z8 Bd. St.-Georges, Iazx Geneva 4, Switzerland. ++Professor and Head, Department of Social and Preventive Medicine, Medical School, University of Geneva, Switzerland. ox4o--xo7J/8a/o4o35$ +
]"
$o3.ooio
9 198z The Associationfor the Psychiatric Study of Adolescents 355
356
F. LADAME AND O. JEANNERET
~,Ve do not intend to enter into the present general controversial discussion among specialists about the nature and components of tile "suicide syndrome" but refer those interested to the recent collection of relevant papers edited by Farmer and Hirsch (198o). E P I D E M I O L O G I C A L APPROACH Let us try to answer as simply as possible some basic questions often asked by physicians as well as by lay persons including the adolescents themselves. ( I ) Do adolescents die more of ten f r o m suicide than adults? T h e answer is no. Data from Switzerland for example show* (Table I) that mortality rates are three times higher over 25 years of age than under, the ratio between young: old being higher in males (c. I ;3) than in females (c. 1:4)"
Table x. Deaths by suicide : absolute numbers and rate per xoo,ooo, Switzerland, x978
Males Age group (years)
N
5--24
x66
Females
R
N 56
886 Io52 --
-
R
-
x x "7
X9"2
3"o
32"7 x515
I4"3 --
x:3
N
I293
463 34"3
Ratio 5-24 ~>25
R
222
407 46"3
All ages
N
5"9
17"2
> 25
R
Ratio Males: females males:females
2"2 --
2"3
24"x --
I:4
x:3
--
m
N = Absolute number; R = rate per ioo,ooo (Source : WHO Statistics, x98o).
(2) Do adolescent males die more often from suicide than adolescent females? Here the answer is yes. I n the same table, the sex ratio (last column on the right) is 3"o in younger people, and, as a matter of fact is higher than in adults (2.2). A m o n g the European countries, the sex ratio is the highest in H u n g a r y (3.6) and the lowest in Italy (I.4) in this age group, according to a W H O study (I975). * A country where death rates from suicide in adolescence are higher than, for example, in Australia or in the U.S.A. (Jeanneret, x981), possibly because there are less legal, psychosocial or life insurance related reasons for underreporting than in many other countries.
SUICIDE I N ADOLESCENCE
357
(3) h~ regard to attempted suicides, what is their frequency (htcidence) hz adolescents compared to adnlts? All data are estimates since there is no compulsory reporting in any country. The conventional indicator is here the case fatality rate (i.e. the number of deaths divided by the total number of cases (completed suicides + attempted suicides)). Estimates from many reports give a tenfold difference between young people and adults, this rate jumping from about i/ioo in the former to about i/IO in the latter. Let us keep in mind, as a rule of thumb, this proportion of one completed suicide for lOO attempted suicides which is of prime importance in terms of preventive strategy as we will see later on. (4) Do adolescent males attempt suicide more often than females? The answer is no! In fact it is just the contrary: many more girls are hospitalized for suicide than boys; this is observed in all reports on "suicidal morbidity" (see Farmer, 198o; Sainsbury, Jenkins and Levey, 198o). Nevertheless, the increasing use of pharmaceuticals by boys instead of more readily fatal means like firearms or hanging, could contribute to decrease this sex differential in the future. (5) Are there time trends for both attempted and completed suicides hz this age group? Again statistics on attempted suicides are scarce, but any increase in crude numbers has to be reconsidered in terms of rates, since the last lO-2O years have been characterized, as everybody knows, by an increase in the actual number of adolescents in all western countries*. The best estimates of morbidity come from hospital statistics sometimes available at the national level. In England and Wales, in the past 20 years for instance, there has been an increase of such cases, especially in the younger age groups (Farmer, 198o) . Recent increases in rates for completed suicides have been observed in most countries and in all age groups, except in the United Kingdom where the only age-sex group showing an increase is the group of females aged 15-24 (Sainsbury et al., 198o). In Switzerland (Fig. I), the mortality rates are increasing in the same two large age groups as in Table I : less than 24 years and more than 25 years of age. Note the parallel trends in adult females' and adolescent males' rates. (6) IVhat about repeaters? Follow up studies of attempted suicide in all ages are now more numerous and more accurate in terms of epidemiological criteria (Katschnig, 198o). In a very well known French study focused on adolescents (Davidson, Choquet and * Placed as t h e d e n o m i n a t o r in b o t h m o r b i d i t y (incidence) a n d mortality rates.
F. LADAME AND O. JEANNERET
358 50
/ ~ Q~:)''O
45
(>25 ye~s)
40
35 0
oo
o
30
B 25 o = r 20
(-25ye0rs) ( 5 - 2 4 ye0rs)
r
Q:
15 I0
o
0
~
o
5
o._..__.___._~~O~o__.__.o_o_o~OlO..o/ce.o
0
I
I
~
I
~
I
~? (5-24
years)
I I I I I I I I
"1966 '-1970 . 7,. . 7. 3 72
75, '7 7, 74 76 78
Yeor
Figure x. Time trend in suicide. Rate (xoo,ooo) by sex in younger and in older People (Switzerland I95I-I978--W.H.O. Statistics, x98o). Facy, x976 ) the global incidence of repeats is 3 ~ per cent, but such a rate includes large differences according to the risk factors. Even a rough dichotomie classification of three risk factors increases the repeater risk from 13 per cent to 6z per cent (Table z). Adding the "history of character problems" as a risk factor has little effect as the risk is almost the same with (6z per cent) and without it (6o per cent). Other recent surveys on attempters and repeaters, which use statistical tools like cluster analysis (Katschnig, Sint and Fuchs-Robertin, 198o; Paykel, x98o ) have thrown light on the main correlates and causal factors to be taken into consideration. Table 2. Repeater rate accordhzg to the presence or absence of three risk factors (after Davidson et al., z976) Risk factor Pronounced depressive symptoms History of character problems Dissatisfaction in intra-family relationships Repeater rate (%)
+ + + 62
+ -+ 60
--+ 13
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(7) What becomes of suicidal adolescents? In the absence of a control group, the finding of attempted suicide in the history of adult psychiatric patients is not a proof of any causal relationship or even of a statistically significant correlation. Only cohort studies are known to suggest causal relationships, but, for obvious reasons, they are very rare. In Sweden, Otto (i972) has shown, in a follow-up study of zo-i 5 years, that the risk is higher in terms of mortality and morbidity (both mental and somatic) in adults who were formerly adolescent attempters than in a control group of non-attempters. This study is of prime importance in the perspective of secondary prevention of suicidal attempts in adolescence, as we shall see below. (8) Should the physician be concerned in practice with the discovery of suicidal thoughts hz an adolescent patient under care for some other reason? Recent large scale interview surveys have shown that these thoughts are very common in normal adolescents at some stage of their development and thus confirm the experience of clinicians. In Fig. 2 these thoughts are nevertheless localized at the bottom of an iceberg, because most of the adolescents do not
Pseudo-occ|dents
2 }~
,y2_
Attempted suicide
~ . ~ . . .
Figure 2. Adolescent suicide: the iceberg paradigm.
~
Visibility
36o
I'. L A D A M E A N D O. J E A N N E R E T
mention them spontaneously. An extensive study in France by Stork (I977) dealing with both younger and older students as well as young soldiers has shown the trivial character of such thoughts. According to this author, in these phantasies, death is viewed not so much as final self-destruction but as an alternative solution to frustrations met in the daily life or is linked with transient personality changes. In preventive work with adolescents it is therefore useful to give them the opportunity to elaborate these thoughts by asking them frankly about them. This last comment brings us into the second part of this paper, focused on prevention. COMMENTS ON PREVENTION It is easier to discuss objectives and means of prevention by considering levels of prevention. For the sake of this discussion, we select only two: primary and secondary levels.
Primary prevention At this level we should recognize a real risk in some adolescents who have suicidal thoughts and who may be about to put their thoughts into action. Early detection of adolescents who could attempt suicide should be focused on three areas: (x) Identification of depressive illness as differentiated from depressive ups and downs inherent to adolescent development. (z) Evaluation of signs of alienation, evidenced in adolescence by a change in usual habits, such as estrangement from other adolescents, family, peer groups, and]or academic or professional ties as well as the loss of a boy- or girlfriend. (3) Perception of mounting anxiety that is often overwhelming and an t/ncontainable distress within days or even hours preceding a suicide attempt.
Adolescent depression One of the main difficulties about adolescent depression is to distinguish (Fig. 3) (a) what belongs to a normal developmental process, (b) what is the sign of ongoing eonflictual pathology, determined by internalized conflicts of adolescence and (c) what means an actual depressive illness which is a consequence of earlier developmental defects (Ladame, F., in press). Symptoms are considered no more than warning signals that require, from ease to case, a thorough evaluation of personality organization. We should also
36x
SUICIDE IN ADOLESCENCE Normal developmental process
Conflictuol pathology during
Developmental pathology prior to
adolescence
adolescence
Figure 3. Main causal factors of depression in adolescence. remember that the clinical signs of adolescent depression are variable, evolving with the different stages of adolescence and usually dissimilar to the clinical picture seen in adult psychiatry. Early evidence of depression may be no more than an incapacity to concentrate on school work. Somatic complaints are common features: fatigue, insomnia, headaches, backaches, and gastroenterological problems. In the younger adolescent, depression is often masked by behavioural problems and in the older group by compulsive promiscuity, an inability to be alone, and great restlessness. We can also observe that accidentproneness may be a warning signal to be taken seriously as may be the occurrence of phobic, obsessional and conversion symptoms. (These latter are rarely indicators of mere neurotic personality disorders during adolescence.)
Social alienation Significant determinants can often be traced chronologically through the social history of the adolescent suicide attempter (Fig. 4)- Our own research (Fischer and Ladame, i979) on presuicidal itineraries has shown that the majority of these adolescents have undergone separations within the family: death of a parent, divorce, separations, running away, etc., significantly from tile age of x2. And, yet more importantly, for most of them, these events are only repeats of past traumatic separations in which peculiar family functioning is evident. For instance we are often confronted with situations of role
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Repeated failures
Separations within the family
1
Inversion of the parent/child roles ('parentification' of the adolescent)
Relegation to lower class, school or occupation
1
Flight into the adult world
Desperate efforts in order to'overflcat'
1
Dissolution of the last tentative emotional links (often with a significant adult)
1 Acute overwhelming anxiety
1
Suicidal act
Figure 4- Observed sequential chain of events in attempted and completed suicide in adolescence. reversal in which the adolescent becomes the parental child. Two thirds of these adolescents fail at school or work and are relegated to less satisfying occupations. In the remaining cases we note problems leading to changes in class or instability in occupational training. The final point in this trajectory is to drop out completely. We have also noticed in some adolescents what we can call a kind of premature flight into the adult world: escaping normal peer or group relationships they establish a special and privileged heterosexual relationship with an adult which usually breaks down quickly and irremediably. About a year before an adolescent's suicide attempt we often observe a makeshift effort to redirect an unstable and deteriorating situation. At this
SUICIDE IN ADOLESCENCE
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point he desperately tries to find a buoy; however, because it is only a superficial investment there is only a negative outcome which leads to the only remaining solution--the suicide attempt. When these events are obvious they are easily perceived by any professional. When they are discrete or hidden-they are beyond recognition even by an expert.
Overwhehning anxiety The third and last focus of attention is hzcreashtg anxiety just before the
acting out of a suicidal gesture. This final stage is characterized by a cataclysmic, overwhelming anxiety, described as panic and fear of a breakdown. This terrible fear is linked to specific internal defence mechanisms (Ladame, F., I98I ). At this juncture only outside help may afford temporary relief. The practical question is to know who should or can ascertain presuicidal behaviour states. Primary suicide prevention is, in fact, a task involving everyone and therefore always complicated by risks. The medical profession must certainly be alert to, or at least aware of, these risks as so many suicidal adolescents present physical functional complaints in the weeks or months preceding their suicide attempt and seek out the family doctor or a pediatrician. It may be time-consuming to carry out an in-depth interview, but it is more important than a conventional history. If necessary we should not then hesitate to speak overtly with the young about suicide and suicide intentions conveying empathetie understanding and going beyond our personal or emotional attitude in relation to suicide.
Secondary prevention Secondary prevention should not aim merely at alleviating the direct consequences of a suicidal gesture and preventing future attempts. Secondary prevention is little use if it is limited to short-term action, without taking into consideration the long-term handicap for the future of the young suicide attempter (Fig. 5). The immediate consequences of a first suicide attempt for an adolescent rarely incurs serious medical problems. The behaviour of many youngsters, chiefly among the younger group, may be improved after acting-out episodes and this prevents or avoids investigation of their internal, psychic state. The fact that everyone concerned (the adolescent himself, his family, and his doctor) ardently hopes that everything is now all right can be very counterproductive. The study by Otto (I972) showed that beyond the immediate prognosis, serious consequences do bear upon the psychological, psychosomatic and
F. LADAME AND O. JEANNERET
364
A morerelevantmodelJ
J Convenhonolmodel J
Suicide-prone adolescent
Suicide-prone adolescent
I ...............(Primary preventJon) Death
9
................ (Primary prevent,on)
Death J
l
~
.............. ~eccndary prevent,on) Repeated
SUicid~toff erupts
Increased mar tclhty, morbidlty
and psycho-socialhandicaps in later life
Figure 5. Conventional model vs. a more relevant model of the roles of secondary prevention in adolescent suicide. psychosocial future of adolescents who have attempted suicide, once they have reached adulthood. The suicidal act is a breakdown of the whole organization of the personality. All medical and social resources should be mobilized to lighten the burden of psychosocial distress or disability to facilitate the on-going developmental processes of adolescence. This entails giving up any arbitrary splitting between psychological and sociological factors and the acknowledgement of their intimate interdependency. If we expect the adolescent's suicidal behaviour to improve and the long-term prognosis to be favourable something must change in his mind, his life style and his familial and social environment. Hospitalization is rarely indicated beyond the necessary time for strictly medical measures and psychosocial evaluation. We do not consider psychiatric hospitalization desirable for adolescents within this context. Generally hospitalization in a psychiatric ward is short-term; it offers no guarantee about the duration of expected change and is therefore not a safeguard for the future (Barter, Swaback and Todd, i968; McIntire et al., z977). Ideally, an adolescent who has attempted suicide should be treated with long-term, intensive psychotherapy, this being the only means of achieving a change in the internal organization of the personality and tapping the developmental potential. Short-term psychotherapy or crisis intervention ostensibly resolves immediate problems but this is only temporary. Individual intensive psychotherapy requires the patient's positive motivation as well as support
SUICIDE IN ADOLESCENCE
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from the parents. This form of treatment produces personality change only after a certain lapse of time (Ladamc, I981). However,somethingmust change as well in the adolescent'sdirect environmentif the suicidal bchaviouris to be modified. In this context the family approachmay sometimesbc hclphll. Unfortunately, however, the families of suicidal adolescents often lack empathy with their child's needs and are very rarely motivated to undertake therapy aimed at modifying family dynamics. In our own research with 4 ~ families in which an adolescent child had attempted suicide (Snakkers, Ladame and Nardini, x98o; Snakkers, Nardini and Ladame, x98I), only one family asked for treatment and began therapy, This might suggest negative implications concerning therapeutic programmes limited only to family therapy techniques! Work in the adolescent's environment should not in any event be limited to the family. It is absolutely necessary to preserve existing and meaningful social relationships and re-establish those which have disappeared. This may necessitate direct contact or even forming a network with teachers, employers, other professionals, as well as close friends and acquaintances. Peer relationships are of paramount importance and contacts with organized groups of young people must be facilitated.
CONCLUSIONS (I) Whcn dealing with at risk individual adolcscents, is primary prevention actually realistic ? Why not rathcr plan it as a sct of non-specific mcasures dealing with thc cducational, psychological and societal conditions which influencc the maturational processes from childhood to adolcscence? (2) Suicidc case fatality ratc is known to be low in adolescence, lower than in any othcr age group. The impact of secondary prcvention is therefore a major one, at least potentially. Its targetshould not be limited to the prevention of further suicides; it should also focus on adolescent suicides attempters at risk of becoming adults exposed to incrcased mortality and morbidity as well as to psycho-socially handicapping conditions. (3) Adolescent suicide attempters (and, afortiori, repeaters) need not only immcdiate help but also longer trcatments. This is a tremendous challenge for mcntal health scrvices: inventive, creative as well as rcalistic resources arc badly needed[ (4) Adolescents' physicians in practice as well as family physicians and pediatricians interestcd in adolescence arc all faced with a v c r y difficult task in charge of a case of attcmptcd suicide and need the support of all manner of mental health spccialists in their preventivc and curative tasks.
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F. LADAtME AND O. JEANNERET REFERENCES
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