Joshua A. Perper

Psychiatric risk factors for adolescent suicide: a case-control study

OBJECTIVE The objective of this study was to determine the psychiatric risk factors for adolescent suicide. METHOD Sixty-seven adolescent suicide victims were compared with 67 demographically matched community controls. Psychiatric disorder was assessed in suicide victims using a psychological autopsy protocol and in controls using similar semistructured psychiatric interviews. Risk factors were quantified by use of the odds ratio (OR), that is, the relative frequency of the occurrence of a given condition in the suicides compared with the controls. RESULTS The most significant psychiatric risk factors associated with adolescent suicide were major depression (OR = 27.0), bipolar mixed state (OR = 9.0), substance abuse (OR = 8.5), and conduct disorder (OR = 6.0). Substance abuse was a more significant risk factor when comorbid with affective illness than when alone (OR = 17.0 versus 3.3). The majority of depressed suicide victims had a primary affective disorder (82%). A significant minority (31%) of depressed suicide victims had been depressed less than 3 months. Previous suicide attempts, suicidal ideation, and homicidal ideation also were associated with adolescent suicide. CONCLUSIONS The development of effective treatments for youth who fit the above-noted risk profiles should be given high priority.

Familial risk factors for adolescent suicide: a case‐control study

Sixty‐seven adolescent suicide victims and 67 demographically matched living controls were compared as to family constellation, familial stressors and familial loading for psychopathology. Suicide victims were less likely to have lived with both biological parents, were more likely to be exposed to stressors such as parent‐child discord, physical abuse and residential instability and showed greater familial loading for depression and substance abuse. Multivariate analyses showed that family history of both depression and substance abuse and lifetime history of parent‐child discord were most closely associated with adolescent suicide. Children who are the offspring of parents with depression or substance abuse should be psychiatrically screened. Family interventions to decrease discord may also be helpful in decreasing the risk of adolescent suicide.

Personality Disorder, Personality Traits, Impulsive Violence, and Completed Suicide in Adolescents

OBJECTIVE This study was designed to assess the association between personality disorders, personality traits, impulsive violence, and suicide. METHOD Personality disorders and traits in 43 adolescent suicide victims and 43 community controls were assessed from the parents, using semistructured interviews and self-report forms. RESULTS Probable or definite personality disorders were more common in suicide victims than in controls, particularly Cluster B (impulsive-dramatic) and C type (avoidant-dependent) disorders. Suicide victims also showed greater scores on lifetime aggression, even after controlling for differences in psychopathology between suicides and controls. CONCLUSIONS Personality disorders and the tendency to engage in impulsive violence are critical risk factors for completed suicide.

Unexpected, unexplained death in epileptic patients

Thirty-seven cases of unexpected, unexplained death in epileptic patients were recorded by the Allegheny County Coroners Office during the years 1969 through 1973. In no case was there anatomic or chemical evidence at autopsy sufficient to explain death. All patients had a duration of epilepsy greater than a year. All but two had less than one seizure per month. Blood levels of anticonvulsants at autopsy revealed only three patients with therapeutic levels of the drugs. Almost 50 percent of the cases studied had no demonstrable anticonvulsant. It is suggested that inadequate levels of anticonvulsant drugs are a significant factor associated with unexpected, unexplained death in epileptic patients.

Risk factors for completed suicide among adolescents with a lifetime history of substance abuse: a case-control study

The risk factors for suicide in adolescents with substance abuse were assessed by comparing 23 adolescent suicide victims and 12 community controls with a lifetime history of definite or probable DSM‐III substance abuse. Suicide victims were more likely than controls to show the following risk factors: active substance abuse, comorbid major depression, suicidal ideation within the past week, family history of depression and substance abuse, legal problems and presence of a handgun in the home. Recommendations for the identification and prevention of suicide among substance‐abusing youth on the basis of these findings are presented.

Suicide in Adolescents with No Apparent Psychopathology

OBJECTIVE To delineate the characteristics of adolescent suicide victims with no apparent psychiatric disorder. METHOD Seven adolescent suicide victims with no apparent disorder were compared with 60 suicide victims with definite or probable psychiatric disorder, and with 38 community controls with no psychiatric disorder. RESULTS Suicide victims without psychiatric disorder, compared with the remainder of suicides showed lower rates of past psychiatric treatment, previous suicide attempt, family history of affective illness, total life stressors over the previous 12 months, and a greater prevalence of the availability of a loaded gun in the home. The seven suicide victims compared with the 38 psychiatrically normal community controls, showed a higher rate of familial psychiatric disorder, past suicidal ideation or behavior, legal or disciplinary problems in the past year, and firearms in the home, particularly those that were loaded. CONCLUSION Even suicide victims without apparent psychiatric disorder still show some evidence of psychiatric risk factors compared with community controls. However, prevention of suicide in this group is probably best achieved by restriction of the availability of firearms, particularly loaded ones. The clinician should pay particular attention to suicidal risk in youth who are confronting legal or serious disciplinary crises and should take suicidal ideation seriously even in the absence of clear psychopathology.

Suicide in affectively ill adolescents: a case-control study.

Sixty-three adolescent suicide victims with a history of affective illness were compared to 23 adolescent community controls with a lifetime history of affective illness, using a case-control design. Suicide victims were more likely to have had major depression, comorbid substance abuse, a past suicide attempt, family history of major depression, treatment with a tricyclic antidepressant, history of legal problems, and a handgun available in the home. There was a non-significant trend for bipolar depression to convey a higher risk for completed suicide than unipolar depression. Recommendations for the prevention of suicide among those with early onset affective illness are discussed in light of these findings.

Psychiatric sequelae to the loss of an adolescent peer to suicide

OBJECTIVE This study was designed to learn whether friends and acquaintances of suicide victims were at increased risk for depression, post-traumatic stress disorder, and suicidal behavior after exposure to suicide. METHOD The social networks of 26 adolescent suicide victims, consisting of 146 adolescents, were interviewed 7 months after the death of the suicide victim and compared with 146 matched, unexposed controls. RESULTS The rates of these disorders that had onset after exposure were elevated in the exposed group vs. controls: major depression, post-traumatic stress disorder, suicidal ideation with a plan or an attempt, but not suicidal attempts. Almost all of those exposed youth who developed new-onset suicidality did so in the context of a new-onset depressive episode. The majority of these new-onset depressive disorders began within 1 month of exposure. CONCLUSION Postvention programs not only should focus on the prevention of imitation of suicidal behavior, but also should provide longer term follow-up for potentially bereaved and depressed youth exposed to suicide.

Posttraumatic stress disorder in peers of adolescent suicide victims: predisposing factors and phenomenology

OBJECTIVE To examine the factors predisposing to posttraumatic stress disorder (PTSD) in peers of adolescent suicide victims. METHOD One hundred forty-six adolescents who were the friends of 26 suicide victims were studied. Five percent (n = 8) developed PTSD after exposure to suicide. These 8 subjects with PTSD were compared to the remainder of the exposed subjects (n = 138). RESULTS Subjects with PTSD were more likely than those without PTSD to have had a history of substance abuse, agoraphobia, and suicide attempts. Subjects who developed PTSD were more likely to have developed a new-onset depression, to have more severe grief, and to have been closer to the suicide victim. Subjects with PTSD tended to have more severe exposure to suicide and came from discordant households with a history of disruptions in key relationships. The 8 subjects who developed PTSD were compared to 38 subjects who developed new-onset depression but not PTSD. Those with PTSD were more likely to have had past substance abuse, prior suicide attempts, family history of panic disorder, a history of parent-child disruption, and a history of loss. Symptoms of intrusive visual images, hypervigilance, and avoidance of reminders discriminated subjects who had PTSD from new-onset depressives without PTSD. CONCLUSIONS PTSD is an expectable outcome in youth exposed to suicide. Further work is required to differentiate symptoms of depression from PTSD.

The validity of diagnoses obtained through the psychological autopsy procedure in adolescent suicide victims: use of family history

A test of validity of the psychiatric diagnoses obtained by the psychological autopsy procedure is described in a consecutive series of 67 adolescent suicide victims. Family history of mental illness in first‐degree relatives of subjects was obtained blind to subject diagnosis using the family history method. It was hypothesized that subjects with a given diagnosis, compared with subjects without this diagnosis, would show an increased rate of this disorder among first‐degree relatives. This hypothesis was supported insofar as specific associations between subject diagnosis and familial rates of illness were demonstrated for major depression, bipolar illness, conduct and antisocial disorder and substance abuse. These results provide further support for the validity of diagnoses obtained through the psychological autopsy procedure.