Jeff Bridge

Personality Disorder, Tendency to Impulsive Violence, and Suicidal Behavior in Adolescents

Inpatient suicide attempters (n = 37) were compared with never-suicidal psychiatric controls (n = 29) with respect to prevalence and severity of personality disorder, history of aggression and assaultive behavior, and other measures of impulsive violence. Attempters, compared with controls, were more likely to show evidence of personality disorder or trait, particularly those of the borderline type. Attempters showed greater number of borderline symptoms than did controls, even after removing the item relating to suicidality. There were no differences between the groups with respect to lifetime history of aggression, history of assaultive behavior, or self-report measures of a tendency to impulsive aggression. Those attempters with personality disorder were much more likely to have made a previous attempt. The apparently high prevalence of personality disorder among adolescent inpatient suicide attempters indicates that the social impairment associated with personality disorder be viewed as an important aspect of treatment.

Long-Term Impact of Exposure to Suicide: A Three-Year Controlled Follow-up

OBJECTIVEnTo determine the long-term impact of exposure to suicide on the friends of adolescent suicide victims.nnnMETHODnOne hundred sixty-six friends of suicide victims and unexposed community controls were followed up at periodic intervals up to 3 years after the suicide, using the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Epidemiologic and Present Episode versions, to assess current and incident psychopathology.nnnRESULTSnThe incidence of suicide attempts was comparable between groups over the entire follow-up period, despite higher rates of baseline and incident psychopathology in the exposed group. An increased incidence of depression and anxiety was found in friends that was most marked in the first 6 months of follow-up. An increased incidence of posttraumatic stress disorder (PTSD) in those exposed was seen in the early as well as the later periods of follow-up. Those exposed youths who knew the suicide plans of the suicide victim were at the greatest risk for incident depression and PTSD over the entire course of follow-up.nnnCONCLUSIONnExposure to suicide does not result in an increased risk of suicidal behavior among friends and acquaintances, but it has a relatively long impact in terms of increased incidence of depression, anxiety, and PTSD.

Suicide in Adolescents With Disruptive Disorders

OBJECTIVEnTo determine the psychiatric risk factors for suicide in adolescents with disruptive disorders.nnnMETHODnFifty-nine adolescent suicide completers and 18 community controls, both having a probable or definite current DSM-III diagnosis of disruptive disorders, were compared.nnnRESULTSnAdolescents with disruptive disorders who committed suicide had higher rates of current substance abuse, past suicide attempt, family history of substance abuse, and family history of mood disorder than disruptive community controls.nnnCONCLUSIONSnDisruptive adolescents appear to be at risk for completed suicide when comorbid substance abuse and past history of suicide attempt are present. The risk increases if the adolescents have a past history of physical abuse and if they have parents with substance abuse and mood disorders. Clinicians should be aware of these risk factors and implement active interventions to prevent suicide. Treatment should focus on treating not only the adolescents, but also their family members. The findings of this study also highlight the need for future research in the prevention of suicide in adolescents with disruptive disorders and comorbid substance abuse.

Screen for child anxiety‐related emotional disorders (SCARED): Convergent and divergent validity

The purpose of this study was to examine the Screen for Child Anxiety‐Related Emotional Disorders’ (SCARED) divergent and convergent validity and its ability to identify anxious children. The SCARED, the Child Behaviour Checklist (CBCL), and the State‐Trait Anxiety Inventory for Children (STAIC) were administered to children, adolescents (n = 295), and their parents attending an outpatient mood and anxiety disorders clinic. DSM‐IIIR/IV diagnoses were made using a semistructured interview (n = 130) or a symptom checklist (n = 165). The Multi‐Trait Multi‐Method Matrix was used to assess construct validity, and Receiver Operating Curve analysis was used to assess the sensitivity and specificity of the SCARED, CBCL, and STAIC. The SCARED correlated significantly better with the CBCL’s internalizing factors than with the externalizing factors. In addition, parent and child forms of the SCARED correlated significantly with the trait and state subscales of the STAIC. Children with an anxiety disorder scored significantly higher on the SCARED than children with depression only or disruptive disorders only (P < 0.05), thus demonstrating the discriminant validity of the SCARED. The SCARED is a reliable and valid screening tool for clinically referred children and adolescents with anxiety disorders. Depression and Anxiety 12:85–91, 2000.

Compliance With Recommendations to Remove Firearms in Families Participating in a Clinical Trial for Adolescent Depression

OBJECTIVEnTo assess the rate and correlates of compliance with clinicians recommendations to remove firearms from the homes of depressed adolescents participating in a clinical trial.nnnMETHODnThe parents of 106 adolescents with major depression who participated in a randomized psychotherapy clinical trial were asked systematically about firearms in the home. Those who answered affirmatively were given information about the suicide risk conveyed by guns in the home and urged to remove them. The rates of gun removal and acquisition were assessed at the end of the treatment and over the subsequent 2-year naturalistic follow-up.nnnRESULTSnOf those who had guns at intake, 26.9% reported removing them by the end of the acute trial. Retention was associated with urban origin, marital dissatisfaction, and paternal psychopathology. Of those who did not have guns at intake, 17.1% reported acquiring them over 2-year follow-up. Living in a 2-parent household and marital dissatisfaction were associated with gun acquisition.nnnCONCLUSIONSnFamilies of depressed adolescents may frequently be noncompliant with recommendations to remove guns from the home despite compliance with other aspects of treatment. More efficacious interventions to reduce access to guns in the homes of at-risk youths are needed.

Screening, Triage, and Referral of Patients Who Report Suicidal Thought During a Primary Care Visit

OBJECTIVE: Suicidal youths are rarely identified in primary care settings. We describe here a care process that includes a computerized screen, colocated social workers, and a coordinated suicide-prevention team at a specialty mental health unit. PATIENTS AND METHODS: Patients were 1547 youths aged 11 to 20 years seen in an urban primary care system during 2005 and 2006. We performed an observational study of services provided to youths who screened positive for suicidal ideation on a computerized behavioral health screen during visits to pediatric primary care clinics. Data included clinical records, provider notes, and patients responses to the screen. RESULTS: A total of 209 (14%) youths reported suicidal thought in the previous month. Suicidal thought was more common among girls, younger youths, substance users, depressed youths, youths who carried weapons, and those who had been in fights; 87% reported at least 1 other serious behavioral health problem. Social workers were able to triage 205 (98%) youths. Triage occurred on the visit day for 193 youths (94%). Mental health evaluations were recommended for 152 (74%) of the triaged youths. Of the 109 subjects referred to a clinic with records accessible for review, 71 (65%) received a mental health service within 6 months. CONCLUSIONS: Pediatric primary care is a feasible setting in which to screen for suicidal youths and link them with mental health services. Youths who visit primary care clinics are willing to disclose suicidal ideation on a computerized screen. Youths who screen positive for suicide have many associated behavioral health needs. The use of information technology, colocated physician extenders, and a coordinated team on the mental health side can facilitate rapid, personal contact between the family and mental health service providers, and has the potential to overcome barriers to care for youths with suicidal ideation in the primary care setting.

Familial Aggregation of Adolescent Personality Disorders

OBJECTIVEnA family study of DSM-III-R personality disorders was conducted in the families of 66 clinically referred adolescents to examine the validity of personality disorder diagnoses in adolescents.nnnMETHODnSemistructured interviews of Axis I and II disorders, including the Structured Clinical Interview for DSM-III-R Personality Disorders, were used to directly interview 66 clinically referred adolescents and their adult first-degree family members, combining family study and family history data.nnnRESULTSnThe relatives of adolescents with avoidant personality disorder had an increased prevalence of avoidant and cluster A (schizoid, schizotypal, and paranoid) personality disorders. The relatives of adolescents with borderline personality disorder demonstrated increased rates of borderline and avoidant personality disorders, even after adjusting for comorbidity.nnnCONCLUSIONSnThe results of this study support the validity of Axis II diagnoses, particularly avoidant and borderline disorders, in adolescents.

Subsyndromal depression in adolescents after a brief psychotherapy trial: course and outcome

INTRODUCTIONnSubsyndromal depression has been associated with an increased risk of the development of major depressive disorder (MDD). Since treatment trials of adolescent MDD often result in subsyndromal depression as the outcome, the long-term course of these youth would be useful to understand.nnnMETHODSn107 adolescents with MDD participated in a clinical psychotherapy trial, of whom 99 were followed up for two years after acute treatment. Those with subsyndromal depression (2-3 symptoms) at the end of acute treatment were compared to those who were well (< or =1 symptom) and those who were still depressed (> or =4 symptoms) on presentation at intake, the end of treatment, and over the two-year follow-up.nnnRESULTSnOf the 99 youth, at the end of acute treatment 26 were well, 18 were subsyndromal, and 55 were still depressed. A substantial proportion of the subsyndromally depressed youth were functionally impaired (38%), and showed a protracted time to recovery. The risk of recurrence was similar to those who were without depression at the end of acute treatment (46% vs. 44%). Recurrence was predicted by depressive symptom severity and family difficulties at the end of acute treatment.nnnLIMITATIONSnA large proportion of the subsyndromal groups received open treatment that may have altered their course. Also, this was a referred sample, rather than an epidemiological one.nnnCONCLUSIONSnIn clinical samples treated with psychotherapy, subsyndromal depression poses a significant risk for functional impairment and protracted recovery. Depressive recurrence may be prevented by targeting reduction of symptom severity and of family difficulties.

National Surveys of Child Mental Health: A Measure of Childrenʼs Services or Service Vagaries?

Kelly J. Kelleher, MD, Jeff Bridge, PhD In this issue of the Journal, Ghandour et al1 report on data from the 2007 National Survey of Children’s Health to identify geographic differences and similarities in rates of parent-reported mental health diagnoses and treatment services. They note that there is a marked geographic variation in diagnostic rates and conditions, but that service receipt is low and relatively uniform across states. As with most national survey reports, there are predictable concerns and strengths associated with this research methodology. For the former, the necessary reliance on a small number of parent-reported items means that there is little depth to both diagnostic and treatment information and uncertain validity of retrospective reports of lifetime mental health conditions. Previous studies would suggest that parents are reliable reporters for yes/no types of questions and general service sector information, but they may struggle with specificity and quantification of services use.2,3 On the other hand, we have few studies that can document national variation and inform our ability to address policy differences among states. In total, national reports like this on a periodic basis are essential components to our research armamentarium because we can communicate the results to diverse audiences and stakeholders. The overall conclusions are consistent with smaller studies and likely to be reliable with regard to trends. Future studies would do well to pay careful attention to changes in federal and state-level policies that are likely to influence trends in service utilization for pediatric mental health conditions. As the authors suggest, it is possible that mental health parity laws enacted in a few states before 2007 facilitated children’s access to mental health services for both diagnoses and treatment. It is tempting to speculate about the potential impact of federal parity in coverage of mental health conditions on treatment rates of US children and adolescents. The most important question to ask with such a report is not whether we agree with the rough estimates from individual states, but rather, what are the implications of such numbers? Specifically, do the study results reflect accurately the psychiatric epidemiology of mental health conditions in children and adolescents and their service systems? With respect to prevalence estimates, the answer is almost certainly, “no.” Every study of primary care, schools, community samples, foster care, and juvenile justice notes high rates of undetected mental health problems and disorders.4–6 Thus, parent-reported diagnoses should be considered more a marker of service performance in detection and a floor number for true prevalence. This study serves a similar role as a marker for treatment prevalence. Burns et al7 note that parents report school use of psychologists for educational assessment and special education as a treatment often, and such numbers constitute a large portion of all parent-reported services, whereas primary care services and other mental health care provided in the medical setting may not be seen as mental health services by parents. Still, the fact that there is such national uniformity in service reporting underscores the scarcity of mental health care that exists in every US community. In summary, the findings of Ghandour et al1 that the prevalence of mental health conditions in US youths varied markedly by state of residence, while receipt of mental health treatment was more strongly related to socioeconomic and health-related factors, should not be used to support the notion that specific state estimates of prevalence or treatment will be useful for planning purposes. Although national surveys provide helpful information to buttress our advocacy arguments, detection and access problems remain major public health challenges untouched by our best efforts to date.