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Suicide prevention in adolescence: An overview of current trends
JOURNAL
OF ADOLESCENT
HEALTH
1992;13:40&408
CONFERENCE PROCEEDINGS
Suicide Prevention in Adolescence: An Overview of Current Trends FRANGOIS
LADAME,
M.D.
In recent years, there has been a progressive tendency in the literature toward minimizing the controversy around the existence or not of psychopathologic features by adolescent suicide attempters (l-4). The main question concerns the nature of this pathology (its unity or diversity).
Associated Psychic Disorders Considering depression as the general motive of suicide would be an oversimplification, as depression is a universal affect, which suicide is not. Two of three young suicide attempters fit into the restricted diagnosis of “depressive disease” or DSMIII’s criteria for a “major depressive episode (5,6)” Depressive symptoms are a good predictor of suicidal ideas (7), but suicidal ideation doesn’t suffice to predict a risk of suicide. In France, for instance, Choquet (8) has shown that fewer than 20% of those who think about suicide make suicide attempts! In an effort to better understand this, interest is now focused on amorbidity, i.e., the association of depression with another diagnosis (9), as well as either on a short-term course of depression (10) or with recurrent brief depressions (11). Among these other diagnoses are the anxiety disorders (1,12). Recently, Johnson et al. (13), investigating a sample population 18 years and older, have concluded that suicide attempts are associated with panic disorders and that the risks are comparable with those of major Fromthe UniversityofGenevaSchoolofMedicineandthe Adolescent OutpntientUnit, ServiceM&w-Ptiagogique, Geneva, Switzerland. Address reprintrequests to: FrangoisLadame. M.D., 16-18, Boubard St. ceorgff, P.O.B. 50, 1211 Gentbe 8, Switzerland. This papet MS presented at the 5th Congress of the international Association fir Adolescent Health, Iuly 36, 1992, Montreux, SwitZl?rland. Manuscriptaccepted[anuary 31.1992. 406 1~139xl92/$5.00
depression, Aggression and violence are other important variables influencing suicidality (14,15). The burden of psychiatric disorders is also reflected by the studies on personalitydisortfcrsor mental functioning. More than 60% of a group of 40 suicide attempters aged 12-20 years, fit into the diagnostic categories of borderline or narcissistic disorders (16). When assessed according to M. and E. Laufer’s criteria (17) these youngsters present a “developmental deadlock.” Using DSM-III’s axis II, Crumley (5) observes a similar proportion of personality disorders. Even psychotic disorders which have long been considered as a negligible factor in teenage suicide, were found by Kotila & L,iinnqvist (18) in 10% of the boys and 5% of the girls during the clinical examination following a suicide attempt. Biology Until now the biologic correlates of suicide have all been identified in adult studies. The finding upon which there seems to be general agreement is the low concentration of 5-HIAA, a serotonin metabolite in the cerebrospinal fluid. This marker might be helpful in the future to predict the prognosis of a suicide attempt (19). Considering the absence of any study of this kind (as far as we know) in adolescent patients, probably for understandable ethical reasons, their implications for prevention strategies are yet unknown.
Environmental Factors and Life Events The classic controversy between sociogenesis and psychogenesis belongs now to the past (12) owing to the assumption that internal and external determinants are inseparable. Recent epidemiologic re-
Q Society for Adolescent Medicine, 1992 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
July 1992
search fully acknowledges the contribution of psychopathology (1,20), which does not exclude external factors as coparticipants either in the facilitation or in the inhibition of suicidal behavior. Farmer and Creed (21) have concluded that life events did not explain self-poisoning in a group of patients aged 17-35 years. In teenagers, the precipitants of suicidal behavior are often common, unavoidable stresses of this period of development (1). This statement confirms our observations concerning depressive adolescents (22): “. . . events are not significant by themselves but according to the kind of reaction they elicit, in the direction either of a nhmmap mern significant &.1 I-1‘0_ or __ _-I_ r~“.-Gti’-yFLU,“U.” This indi_ cates the importance of the adolescent’s ability to use adaptive resources (“coping devices” or transformational capabilities of the psychic apparatus). A very important and probably currently underestimated category of events are incest and sexual abuse (4). Psychuanalytic Research Laufer and Laufer (17) have been among the first psychoanalysts to have assessed and treated adolescents who have attempted suicide. Through psychoanalytic understanding we see the hatred and violence directed against the body, while the selfdestructive behavior is aimed primarily at the dimination of the mature male or female sexual body. In fantasy, a cleavage would allow to preserve the image of the idealized body which is the prepubertal body encompassed with all the ideas of the “perfection” of the infantile past. These observations have been largely confirmed by those who have had psychoanalytic experience with young suicidal patients (16). For these authors, treatment of young suicide attempters, must address these conscious and unconscious determinants of suicidal behavior. Follow-Up Studies Some studies relate the suicide rate in former adolescent attempters and global adaptation as adults in those who haven’t died. The repetition rate fluctuates between 14% and 40%. According to Davidson and Philippe (20) the repetition rate of suicide attempts in the group aged 15-24 years is 37%. The risk of repetition in a short interval is particularly high in young people. Otto’s demonstration (23), in 1972, of excessive mortality and of poor psychosocial outcome of Swedish adolescents who had &tempted suicide lo-
SUICIDEPREVENTION:AN OVERVIEW
407
15 years earlier has b&n more or less confirmed by others. Recently, at the end of a 5-year follow-up period in the Helsinki area, Kotila and Lonnqvist (2) have observed that the mean mortality rate for suicide and violent death was 20-fold in former suicide attempters, compared with the mortality for suicide and violent death among the 15-19 year olds as a whole in Finland during the same period. The poorer outcome and higher risk of subsequent suicide of young male adolescents attempting suicide deserves special attention. In Kotila and Liinnqvist’s research (18), the risk ratio for suicide during the 5-year follow-up was about four times higher for boys than for giris and the risk ratio for violent death about seven times as high. Very interestingly, beyond the first 5-year follow-up, Kotila (personal communication) notes a decline in the suicide rate but a rise in chronic depressive pathology. This currently ongoing observation stresses the necessity for a sufficiently long follow-up if the aim is to encompass all the varieties of outcome and functioning of these adolescents once they are adults.
Impact of Treatment Once we have acknowledged the part played by psychopathology in adolescent suicides or suicide attempters, we still have to prove that we are n.ow able to have a positive effect upon the outcome. The impact of treatment both on further suicidal@ and on psychopathology in adolescents who have tried to kill themselves has not been studied systematically over a reasonable period of time with either a comparative group or a comparison of different types of treatment, nor a consideration of the different types of disorders. A few studies have been done on adult attempters (see Shaffer et al. (1) for a critical review). The prognosis (with respect to suicidality) seems to be better in those who receive psychiatric treatment. A recent follow-up study on psychiatric inpatient adolescents (24), which doesn’t address itself specifically to the issue of suicide, shows that the results after 7 years were better for patients whose treatment at the unit had lasted for more than 3 months and had included psychotherapy. This form of treatment should continue on an outpatient basis.
References 1. Shaffer D,
Garland A, Gould M, et al. Preventing teenage suicide: A criticalreview. J Am Acad Child Adolesc Psychiatry 1988;27:675-87. 2. Kotila L, Ldnnqvist J. Suicide and violent death among ad-
408
3.
4.
5. 6.
7.
8.
9.
10.
11.
12.
LADAME
olescent suicide attempters. Acta Pschiatr Stand 1989;79:45359. Brent DA, Kerr MM, Goldstein C, et al. An outbreak of suicide and suicidal behavior in a high school. J Am Acad Child Adolesc Psychiatry 1989;28:918-24. Ladame F. Le suicide chez I’enfant et I’adolescent. Approche clinique. In: Trait& de Psychiatric de I’Enfant et de I’Adolescent, Lebovici S, Diatkine R, Soul6 M, eds. nouveIle edition en 4 vol. Paris: PUF (sous presse). CrumIey FE. Adolescent suicide attempts. JAMA 1979; 241:2404-7. Clarkin JF, Friedman, MD, Hurt SW. Affective and character pathology of suicidal adolescent and young adult inpatients. J Clin Psychiatry 1984;45:19-22. Kandel DB. EpidCmiologie et facteurs de risque des idees ’ ‘d*;*n* t’adnlosren** sii;ct U,&.”.*bnv SC@, .I..“._ _ . .. . Q? _ dspressif, consommation de drogues et problemes de comportement. In: Tentatives de Suicide B I’Adolescence. Paris: Centre International de I’Enfance, 1989;137-65. Choquet M. Le phenomene “suicide” parmi les adolescents en France: Approche epidemiologique. In: Tentatives de Suicide a I’Adolescence. Paris: Centre International de I’Enfance, 1989:51-65. Brent DA, Kolko DJ, Allan MJ. Suicidality in affectively disordered adolescent inpatients. J Am Acad Child Adolesc Psy1940; chiatry 29586-93. Davis AT. Short-term course of depression following attempted suicide: A preliminary report. Acta Psychiatr Stand 1990;81:345-51. Montgomery SA, Montgomery D, Baldwin D, et al. The duration, nature and recurrence rate of brief depressions. Prog Neuropsychopharmacol Biol Psychiatry 1990;14:729-35. Ladame F. Les tentatives de suicide des adolescents. Paris: Masson, 1981.
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
13. Johnson J, Weissman MM, IUennan GL. Panic disorder, comorbidity and suicide attempts. Arch Gen Psychiatry 1990; 42805-B. 14. Ladame F. Le traitement des adolescents suicidants et le probleme du contre-transfert. Adolescence (Paris) 1986;4:243-5. 15. Apter A, Bleich A, Plutchii R, et al. Suicidal behavior, depression, and conduct disorder in hospitalized adolescents. J Am Acad Child Adolesc Psychiatry 1988;27:696-9. 16. Ladame F. Les tentatives de suicide des adolescents: Pourquoi? Comment? In: Caglar H, Ladame F, Raimbault G, et al., eds. Adolescence et Suicide. Paris: ESF 1989:17-35. 17. Laufer M, Laufer E. Adolescence and developmental breakdown. A psychoanalytic view. New Haven: Yale University press, 1984. 18. Kotila L, Lonnqvist J. Adolescent suicide attempts: Sex dif(dwn*ps predicting suicide. Acta Psychiatr Stand i988; .*.-..-_ 77~264-70. 19. Asberg M, Nordstrom P, Traskman-Bendz L, et al. Cerebrospinal fluid studies in suicide. Ann NY Acad Sci 1987;487: 243-4. 20. Davidson F, Philippe A. Suicide et tentatives de suicide aujourd’hui. Etude CpidCmiologique. Paris: Inserm-Doin, 1986. 21. Farmer R, Creed F. Life events and hostility in self-poisoning. Br J Psychiatry 1989;154:390-5. 22. Ladame F, Fischer W. Relations et sociabilite de I’Adolescent depressif. In: Tentatives de suicide B I’Adolescence. Paris: Centre International de I’Enfance, 1989185-92. 23. Otto 0. Suicidal acts by children and adolescents. Acta Psychiatr Stand 1972 [Suppl] :233. 24. Pelkonen M. Inpatient psychiatric adolescents function better than expected after discharge. A follow-up study. Acta Psychiatr Stand 1990;81:317-21.
OF ADOLESCENT
HEALTH
1992;13:40&408
CONFERENCE PROCEEDINGS
Suicide Prevention in Adolescence: An Overview of Current Trends FRANGOIS
LADAME,
M.D.
In recent years, there has been a progressive tendency in the literature toward minimizing the controversy around the existence or not of psychopathologic features by adolescent suicide attempters (l-4). The main question concerns the nature of this pathology (its unity or diversity).
Associated Psychic Disorders Considering depression as the general motive of suicide would be an oversimplification, as depression is a universal affect, which suicide is not. Two of three young suicide attempters fit into the restricted diagnosis of “depressive disease” or DSMIII’s criteria for a “major depressive episode (5,6)” Depressive symptoms are a good predictor of suicidal ideas (7), but suicidal ideation doesn’t suffice to predict a risk of suicide. In France, for instance, Choquet (8) has shown that fewer than 20% of those who think about suicide make suicide attempts! In an effort to better understand this, interest is now focused on amorbidity, i.e., the association of depression with another diagnosis (9), as well as either on a short-term course of depression (10) or with recurrent brief depressions (11). Among these other diagnoses are the anxiety disorders (1,12). Recently, Johnson et al. (13), investigating a sample population 18 years and older, have concluded that suicide attempts are associated with panic disorders and that the risks are comparable with those of major Fromthe UniversityofGenevaSchoolofMedicineandthe Adolescent OutpntientUnit, ServiceM&w-Ptiagogique, Geneva, Switzerland. Address reprintrequests to: FrangoisLadame. M.D., 16-18, Boubard St. ceorgff, P.O.B. 50, 1211 Gentbe 8, Switzerland. This papet MS presented at the 5th Congress of the international Association fir Adolescent Health, Iuly 36, 1992, Montreux, SwitZl?rland. Manuscriptaccepted[anuary 31.1992. 406 1~139xl92/$5.00
depression, Aggression and violence are other important variables influencing suicidality (14,15). The burden of psychiatric disorders is also reflected by the studies on personalitydisortfcrsor mental functioning. More than 60% of a group of 40 suicide attempters aged 12-20 years, fit into the diagnostic categories of borderline or narcissistic disorders (16). When assessed according to M. and E. Laufer’s criteria (17) these youngsters present a “developmental deadlock.” Using DSM-III’s axis II, Crumley (5) observes a similar proportion of personality disorders. Even psychotic disorders which have long been considered as a negligible factor in teenage suicide, were found by Kotila & L,iinnqvist (18) in 10% of the boys and 5% of the girls during the clinical examination following a suicide attempt. Biology Until now the biologic correlates of suicide have all been identified in adult studies. The finding upon which there seems to be general agreement is the low concentration of 5-HIAA, a serotonin metabolite in the cerebrospinal fluid. This marker might be helpful in the future to predict the prognosis of a suicide attempt (19). Considering the absence of any study of this kind (as far as we know) in adolescent patients, probably for understandable ethical reasons, their implications for prevention strategies are yet unknown.
Environmental Factors and Life Events The classic controversy between sociogenesis and psychogenesis belongs now to the past (12) owing to the assumption that internal and external determinants are inseparable. Recent epidemiologic re-
Q Society for Adolescent Medicine, 1992 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
July 1992
search fully acknowledges the contribution of psychopathology (1,20), which does not exclude external factors as coparticipants either in the facilitation or in the inhibition of suicidal behavior. Farmer and Creed (21) have concluded that life events did not explain self-poisoning in a group of patients aged 17-35 years. In teenagers, the precipitants of suicidal behavior are often common, unavoidable stresses of this period of development (1). This statement confirms our observations concerning depressive adolescents (22): “. . . events are not significant by themselves but according to the kind of reaction they elicit, in the direction either of a nhmmap mern significant &.1 I-1‘0_ or __ _-I_ r~“.-Gti’-yFLU,“U.” This indi_ cates the importance of the adolescent’s ability to use adaptive resources (“coping devices” or transformational capabilities of the psychic apparatus). A very important and probably currently underestimated category of events are incest and sexual abuse (4). Psychuanalytic Research Laufer and Laufer (17) have been among the first psychoanalysts to have assessed and treated adolescents who have attempted suicide. Through psychoanalytic understanding we see the hatred and violence directed against the body, while the selfdestructive behavior is aimed primarily at the dimination of the mature male or female sexual body. In fantasy, a cleavage would allow to preserve the image of the idealized body which is the prepubertal body encompassed with all the ideas of the “perfection” of the infantile past. These observations have been largely confirmed by those who have had psychoanalytic experience with young suicidal patients (16). For these authors, treatment of young suicide attempters, must address these conscious and unconscious determinants of suicidal behavior. Follow-Up Studies Some studies relate the suicide rate in former adolescent attempters and global adaptation as adults in those who haven’t died. The repetition rate fluctuates between 14% and 40%. According to Davidson and Philippe (20) the repetition rate of suicide attempts in the group aged 15-24 years is 37%. The risk of repetition in a short interval is particularly high in young people. Otto’s demonstration (23), in 1972, of excessive mortality and of poor psychosocial outcome of Swedish adolescents who had &tempted suicide lo-
SUICIDEPREVENTION:AN OVERVIEW
407
15 years earlier has b&n more or less confirmed by others. Recently, at the end of a 5-year follow-up period in the Helsinki area, Kotila and Lonnqvist (2) have observed that the mean mortality rate for suicide and violent death was 20-fold in former suicide attempters, compared with the mortality for suicide and violent death among the 15-19 year olds as a whole in Finland during the same period. The poorer outcome and higher risk of subsequent suicide of young male adolescents attempting suicide deserves special attention. In Kotila and Liinnqvist’s research (18), the risk ratio for suicide during the 5-year follow-up was about four times higher for boys than for giris and the risk ratio for violent death about seven times as high. Very interestingly, beyond the first 5-year follow-up, Kotila (personal communication) notes a decline in the suicide rate but a rise in chronic depressive pathology. This currently ongoing observation stresses the necessity for a sufficiently long follow-up if the aim is to encompass all the varieties of outcome and functioning of these adolescents once they are adults.
Impact of Treatment Once we have acknowledged the part played by psychopathology in adolescent suicides or suicide attempters, we still have to prove that we are n.ow able to have a positive effect upon the outcome. The impact of treatment both on further suicidal@ and on psychopathology in adolescents who have tried to kill themselves has not been studied systematically over a reasonable period of time with either a comparative group or a comparison of different types of treatment, nor a consideration of the different types of disorders. A few studies have been done on adult attempters (see Shaffer et al. (1) for a critical review). The prognosis (with respect to suicidality) seems to be better in those who receive psychiatric treatment. A recent follow-up study on psychiatric inpatient adolescents (24), which doesn’t address itself specifically to the issue of suicide, shows that the results after 7 years were better for patients whose treatment at the unit had lasted for more than 3 months and had included psychotherapy. This form of treatment should continue on an outpatient basis.
References 1. Shaffer D,
Garland A, Gould M, et al. Preventing teenage suicide: A criticalreview. J Am Acad Child Adolesc Psychiatry 1988;27:675-87. 2. Kotila L, Ldnnqvist J. Suicide and violent death among ad-
408
3.
4.
5. 6.
7.
8.
9.
10.
11.
12.
LADAME
olescent suicide attempters. Acta Pschiatr Stand 1989;79:45359. Brent DA, Kerr MM, Goldstein C, et al. An outbreak of suicide and suicidal behavior in a high school. J Am Acad Child Adolesc Psychiatry 1989;28:918-24. Ladame F. Le suicide chez I’enfant et I’adolescent. Approche clinique. In: Trait& de Psychiatric de I’Enfant et de I’Adolescent, Lebovici S, Diatkine R, Soul6 M, eds. nouveIle edition en 4 vol. Paris: PUF (sous presse). CrumIey FE. Adolescent suicide attempts. JAMA 1979; 241:2404-7. Clarkin JF, Friedman, MD, Hurt SW. Affective and character pathology of suicidal adolescent and young adult inpatients. J Clin Psychiatry 1984;45:19-22. Kandel DB. EpidCmiologie et facteurs de risque des idees ’ ‘d*;*n* t’adnlosren** sii;ct U,&.”.*bnv SC@, .I..“._ _ . .. . Q? _ dspressif, consommation de drogues et problemes de comportement. In: Tentatives de Suicide B I’Adolescence. Paris: Centre International de I’Enfance, 1989;137-65. Choquet M. Le phenomene “suicide” parmi les adolescents en France: Approche epidemiologique. In: Tentatives de Suicide a I’Adolescence. Paris: Centre International de I’Enfance, 1989:51-65. Brent DA, Kolko DJ, Allan MJ. Suicidality in affectively disordered adolescent inpatients. J Am Acad Child Adolesc Psy1940; chiatry 29586-93. Davis AT. Short-term course of depression following attempted suicide: A preliminary report. Acta Psychiatr Stand 1990;81:345-51. Montgomery SA, Montgomery D, Baldwin D, et al. The duration, nature and recurrence rate of brief depressions. Prog Neuropsychopharmacol Biol Psychiatry 1990;14:729-35. Ladame F. Les tentatives de suicide des adolescents. Paris: Masson, 1981.
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
13. Johnson J, Weissman MM, IUennan GL. Panic disorder, comorbidity and suicide attempts. Arch Gen Psychiatry 1990; 42805-B. 14. Ladame F. Le traitement des adolescents suicidants et le probleme du contre-transfert. Adolescence (Paris) 1986;4:243-5. 15. Apter A, Bleich A, Plutchii R, et al. Suicidal behavior, depression, and conduct disorder in hospitalized adolescents. J Am Acad Child Adolesc Psychiatry 1988;27:696-9. 16. Ladame F. Les tentatives de suicide des adolescents: Pourquoi? Comment? In: Caglar H, Ladame F, Raimbault G, et al., eds. Adolescence et Suicide. Paris: ESF 1989:17-35. 17. Laufer M, Laufer E. Adolescence and developmental breakdown. A psychoanalytic view. New Haven: Yale University press, 1984. 18. Kotila L, Lonnqvist J. Adolescent suicide attempts: Sex dif(dwn*ps predicting suicide. Acta Psychiatr Stand i988; .*.-..-_ 77~264-70. 19. Asberg M, Nordstrom P, Traskman-Bendz L, et al. Cerebrospinal fluid studies in suicide. Ann NY Acad Sci 1987;487: 243-4. 20. Davidson F, Philippe A. Suicide et tentatives de suicide aujourd’hui. Etude CpidCmiologique. Paris: Inserm-Doin, 1986. 21. Farmer R, Creed F. Life events and hostility in self-poisoning. Br J Psychiatry 1989;154:390-5. 22. Ladame F, Fischer W. Relations et sociabilite de I’Adolescent depressif. In: Tentatives de suicide B I’Adolescence. Paris: Centre International de I’Enfance, 1989185-92. 23. Otto 0. Suicidal acts by children and adolescents. Acta Psychiatr Stand 1972 [Suppl] :233. 24. Pelkonen M. Inpatient psychiatric adolescents function better than expected after discharge. A follow-up study. Acta Psychiatr Stand 1990;81:317-21.