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Youth Suicide

Youth Suicide . Hatim Omar, M.D. Professor, Pediatrics & ObGyn. Director, Adolescent Medicine & Young Parent Program Department of Pediatrics University of Kentucky Email: haomar2@uky.edu.

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Youth Suicide

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  1. Youth Suicide Hatim Omar, M.D. Professor, Pediatrics & Ob\Gyn. Director, Adolescent Medicine & Young Parent Program Department of Pediatrics University of Kentucky Email: haomar2@uky.edu

  2. One million deaths annually from suicide: "global" mortality rate 16 per 100,000, one death every 40 seconds. • Suicide one of three leading causes of death 15-44 years • Suicide attempts 20 x > completed suicide. • Suicide 2% of the total global burden of disease. • Youth highest risk in 30% of developed and developing countries. • 90% Mental disorders (depression, substance abuse) • Complex socio-cultural factors • Socioeconomic crisis (loss of loved one, employment, honor).

  3. Leading Causes of Violent Death Worldwide Source: WHO, Violence and Health, Report of the Secretariat, November 2001

  4. Rates

  5. X Every 17 minutes someone in this country dies as the result of suicide On an average day 87 people die from suicide and another 1,850 attempt suicide Suicide took the lives of 31,665 Americans in 2002 Over 765,000 Americans attempt suicide each year There were 1.7 times as many suicides as homicides in 2000 Twice as many people die from suicide than HIV/AIDS • Info from • Suicide Awareness Voices of Education • Centers for Disease Control • Journal of AMA The rate of youth suicide has tripled since the 1950s 95% of suicides occur at the peak of a depressive episode

  6. Other Facts • More females attempt suicide • At least 4 times as many males die from suicide • Most common means is firearms for both males and females (57%) • Ages 15-24 suicide is 3rd leading cause of death • Ages 10-14 suicide is 4th leading cause of death

  7. DID YOU KNOW…… More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease combined

  8. Percentage of High School Students Who Made a Suicide Plan,* 1991 - 2003 * During the 12 months preceding the survey 1 Significant linear decrease, p < .05 National Youth Risk Behavior Surveys, 1991 - 2003

  9. Percentage of High School Students Who Actually Attempted Suicide,* 1991 - 2003 * One or more times during the 12 months preceding the survey 1 No change over time National Youth Risk Behavior Surveys, 1991 - 2003

  10. Suicide Rates by Race/EthnicityAges 15 to 19, 1997 • Asian/Pacific Islander: 5.0 per 100,000 • African American: 7.1 • Hispanic: 7.9 • White, non-Hispanic: 10.2 • American Indian/Alsaka Native: 20.5 National Adolescent Health Information Center

  11. Suicide Rates

  12. Youth Suicide • Why do they do it? • Failure to handle problems because of: -Frustration -Hopelessness -Compulsive decisions -No place to go, No one to talk to -Mental health problem (untreated)

  13. ‘Causes’ of Suicide • Multiple factors build to ‘threshold’ • Sadness, hopelessness, despair, depression • Pain and hurt, feeling different, unwanted • Bullying, abuse, anger, rage • Cry for help , unheard, frustration • ‘trigger incident’ – row, failed exam .. • Availability of method (gun, drugs etc)

  14. Most common stressors leading to youth suicide, KY Fight with Parent 20% End of a relationship 12% Fight with a significant other 8% Financial problems 10% Recent move, social isolation 7% Legal problems 6% Family Problems 6% Academic problems 5% Substance abuse 4% Homosexuality 3% Recent abuse 4% Other stressors 15%

  15. Adolescent Depression and Suicide Myths • Adolescence is inevitably a time of “Storm and Stress” • Moodiness is normal in adolescents • Adolescents must rebel and reject the values of their parents • Adolescents cannot experience a true “clinical” depression • Their egos and brain development are immature • Suicide attempts are manipulative and “only for show” • Asking about suicide plans plants the idea

  16. Adolescent Depression and SuicideFacts • Within any year, at least 8% of teens experience significant depression • Most will not seek or receive treatment • 1 in 5 teens report having had at least one episode of depression w/o having treatment Many teens contemplate suicide: • 19% have thought of suicide (3 million) • 2 million make plans to carry it out • 400,000 attempts requiring medical attention • ~5,000 successfully complete suicide

  17. Adolescent Depression and SuicideFacts • High family concordance • First degree relatives of adol w/ MDD have elevated rates of alcohol abuse and MDD, but not anxiety disorders or personality disorders • First degree relatives of adolescents with anxiety disorders do not have elevated rates of MDD (Harrington, 2001)

  18. Adolescent Depression and SuicideFacts • Strong developmental trends • Before puberty, m-f ratio is equal; by mid-teens f > m • Rates of suicide and depression increase w/ age • Depression in teen yrs assoc w/ > adult risks • But, depression in younger childhood not • Higher rates of co-morbid diagnoses in teen yrs • Pre-puberty, depression assoc w/ family disturbance (Harrington, 2001)

  19. Suicide Assessment:Risk Factors • Distal or Predisposing Factors • E.g., psychopathology • Proximal or Acute Risk Factors • E.g., loss • Protective Factors • E.g., close social network (Brent, 2001; Harrington, 2001; Kleespies & Dettmer, 2000; Miller & Glinski, 2000)

  20. Suicide Assessment: Predisposing Risk Factors Co-morbid Disorders (Frequency in Clinic Samples of Depressed Teens) -40% - 70% depressed teens have a comorbid disorder • 20% - 30% have two or more comorbid disorders • Most frequent • Dysthymia (30% - 80%) • Conduct problems or ADHD (10% - 80%) • Substance use disorder (20% - 30%) • Anxiety Disorders (9% - 55%)

  21. Suicide Assessment:Predisposing Risk Factors • Psychiatric disorders assoc w/ suicide • Mood • Depression most freq disorder assoc w/ suicide • More freq among female than male completed suicides • Conduct • May have higher levels of suicide attempts than those w/ MDD, although they report less depression • More freq among males • Substance abuse • 35% significant blood alcohol levels at autopsy • 38% consumed alcohol w/in 6 hrs of attempt • As high as 50% have histories of substance abuse • More frequent among males

  22. Suicide Assessment:Predisposing Risk Factors • Psychiatric disorders assoc w/ suicide Personality disorders and styles • Borderline Personality Disorder • Impulsive personality style • Anxiety • May not be important risk factor once controlling for depression • Some suggestions separation anxiety may increase risk • Brent et al. (1998) found coexisting anxiety disorder predicted continuing depression after treatment (Brent, 2001; Groholt et al., 2000; Harrington, 2001; King et al., 2001; Koplin & Agethen, 2002; McKewon et al., 1998; Miller & Glinski, 2000)

  23. Suicide Assessment: Predisposing Risk Factors • History of Previous Attempts • Strongest predictor of future attempts • 10–15% repeat w/in 6 mos; 20% w/in 2 yrs • However, 60 – 70% of attemptors have made no previous attempt • Explore, as well, other types of self-harm • Associated w/ personality disorder, which is independent predictor

  24. Suicide Assessment: Acute Risk Factors • Level of Intention • Presence of a plan • Suicidal ideation • Not always reported • Pre-attempt behaviors • Notes, giving possessions away, saying good-bye’s • Conception of death • Talking about death, seeing death as a solution, viewing death as a better place • Lethality of means • Note: Younger teens may misjudge lethality

  25. Suicide Assessment: Acute Risk Factors Availability of Means • Especially firearms • Most frequently used method among completers, male and female • When firearms in home, suicide completion risk is 5x greater

  26. Suicide Assessment: Acute Risk Factors • Current Emotional State • Level of depression • Hopelessness • Strong predictor of lethality • Associated w/ repeat attempts if not addressed • “Altered state of mind” (Harrington, 2001) • Rage

  27. Suicide Assessment: Acute Risk Factors • Precipitating Factors • Most often interpersonal • Loss • Death of significant other • Conflict in important relationships • > 16 yrs w/ friends (e.g., romantic break-up) • < 16 yrs w/ family • Abuse or victimization • Ongoing and teen not protected • Secrets

  28. Suicide Assessment: Acute Risk Factors • Precipitating Factors • Suicide among friends • Both a loss • May legitimize suicide as a solution • Loss of function • Increased risk among teens with chronic diseases/conditions when there is functional impairment • Legal, school problems • Particularly important in teens w/ CD

  29. Suicide Assessment: Protective Factors • Family cohesion (McKeown, et al., 1998) • Emotional supportiveness • Capacity to form relationships (Harrington, 2001) • Reasons for living • Children, parents, spiritual beliefs Competencies • E.g., High grade point averages in boys (Wagman, Browsky, Ireland, & Resnick, 2001)

  30. Reasons for Suicide Attempts:Summary • Intrapersonal reasons (e.g., feelings) more common reason with interpersonal precipitants • Manipulation of others: not a frequent reason, though others often attribute manipulative motives to teen • Anger and depression frequently found in teen attempts • Anger is related to the seriousness of the teen’s motivation (Boergers, et al., 1998)

  31. Adolescent Depression ModelsCognitive - Behavioral • Emphasizes internal cognitions that in turn, affect behavior and emotions • Multiple determinants • Negative cognitions • Stressful events • Risk factors • “Immunities” • High self-esteem • Coping skills • Plentitude of positive activities and events (Clarke, et al., 2002. STEADY Project) http://www.kpchr.org/acwd

  32. Cognitive – Behavioral Treatment Emphasis is on: • Monitoring emotions • Identifying precipitating events • Challenging cognitions • Catastrophic thinking • Unrealistic expectations or assumptions • Replacing these w/ more adaptive thoughts

  33. Cognitive – Behavioral Treatment Behavioral component can include: • Increasing positive events • Remedying skill deficits • Social skills training • Conflict resolution • Academic supports • Relaxation training

  34. Cognitive – Behavioral Treatment • Emphasis is on maladaptive thinking or cognitive styles • Typically, thinking is • Global • “Why can’t I do anything right?” • “Everything in my life is a disaster!” • Personal • “People will think I’m a loser.” • “That was a stupid thing to say.” • Permanent • “I’ll never have a boyfriend.” • “I always say the wrong thing.”

  35. Do Treatments for DepressionLower Suicide Risk in Teens? • Very few controlled studies of treatments directly targeting suicide • Many studies of treatment for depression either exclude suicidal individuals or do not include a measure of suicidality in outcomes • Treatment attrition rates are high among adolescent suicide attempters • Suicide behavior must be targeted specifically, not only indirectly by treating depression (Miller & Glinski, 2000)

  36. Facets of TreatmentTargeting Risk for Suicide Address Immediate Affective Needs • Counteract hopelessness – Set small, clear goals • Teach recognition of internal states and responses Address Precipitating Event • Counteract distorted perceptions • Teach others ways of communicating Family Involvement • Educate about depression and suicide • Teach communication/problem resolution • Participate in making plan • Treat parental psychopathology (Brent, 2001)

  37. Mood Disorders: Depression • Most frequent psychological disorder in adolescence • Adolescence is typically thought of as a period of heightened emotionality • Freud: “Sturm and Drang” • Storm and Stress • Clinical depression is more than moodiness or sensitivity

  38. Depression: Major Depressive Disorder MOOD • Depressed (or irritable) mood*** • Sad, tearful, flat, empty • In children/adol may be irritable mood • Diminished interest in almost all daily activities*** THINKING & ATTITUDE • Feeling worthless, excessive or inappropriate guilt • Difficulties w/ concentration, indecisiveness • Recurrent thoughts of death or suicide

  39. Depression: Major Depressive Disorder PHYSICAL CHANGES • Appetite change, weight loss (5% w/in one month) • Or failure to make expected gains in growing child • Sleep disturbance • insomnia, sleeping too much • Psychomotor agitation or retardation • Fatigue or loss of energy

  40. Depression: Major Depressive Disorder • Symptoms occur nearly every day and/or for most of the day • Have been present for at least 2 weeks • Represent change from previous functioning • Not attributable to a medical condition, e.g., hypothyroidism • Not due to a substance (prescribed or illicit) • Not due to “normal” bereavement

  41. Major Depressive Disorder:Overview: Epidemiology • Depression is twice as likely in adult women • In pre-adolescent children, rates are equal (2.6% in 6-11 yo) • Rates for females begin to rise between 13-15 and increase dramatically between 15-18 (Hankin et al., 1998)

  42. Major Depressive Disorder:Overview Age of Onset • Most adults report 1st episode b/w 15 - 19 • Prospective studies find earlier onset, usually b/w 14 - 15 yrs • Most have had sub-clinical episodes of depression before • 7% - 14% have a major episode < 15 yrs • Earlier age of onset predicts a more serious illness and > likelihood of recurrence

  43. Major Depressive Disorder:Overview Outcomes • Average episode lasts 5 - 6 months • May be a bimodal distribution w/ half having a relatively short first episode (2 mos) and half much longer • When severe enough for referral for treatment, episodes often last longer (as long as 12 mos) • ~75% recover with a year, and 90%+ within 2 yrs

  44. Major Depressive Disorder:Overview: Recurrence Rates of Recurrence • Cumulative rates • 1 yr 25% • 2 yrs 40% • 5 yrs 70% • Many (20% - 40%) will develop Bipolar disorder within 5 yrs • Many will have a chronic, relapsing disorder

  45. Depression: Treatment Modality Overview

  46. Role of the Primary Care Physician • Screening, Identification, and Diagnosis • Education of patient, parents, and others • Treatment • Referral when appropriate

  47. When interviewing patient & parents, focus on family psychiatric history • Adolescents with MDD: • have a family history of mood disorders in 50-80% of cases • have a high familial aggregation of depression, alcoholism, anxiety, and other diagnoses in first and second degree relatives • More likely to have a friend or a relative who has attempted or committed suicide

  48. Suicide Prevention

  49. Develop and Test Prevention Strategies Identify Risk and Protective Factors Define the Problem The Public Health Approach to Prevention5 Ensure Widespread Adoption

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