Mirjami Pelkonen

Child and adolescent suicide: epidemiology, risk factors, and approaches to prevention

Suicide is rare in childhood and early adolescence, and becomes more frequent with increasing age. The latest mean worldwide annual rates of suicide per 100 000 were 0.5 for females and 0.9 for males among 5–14-year-olds, and 12.0 for females and 14.2 for males among 15–24-year-olds, respectively. In most countries, males outnumber females in youth suicide statistics. Although the rates vary between countries, suicide is one of the commonest causes of death among young people. Due to the growing risk for suicide with increasing age, adolescents are the main target of suicide prevention. Reportedly, less than half of young people who have committed suicide had received psychiatric care, and thus broad prevention strategies are needed in healthcare and social services. Primary care clinicians are key professionals in recognizing youth at risk for suicide.This article reviews recent population-based psychological autopsy studies of youth suicides and selected follow-up studies of clinical populations and suicide attempters, analyzing risk factors for youth suicides. As youth suicides are rare, research on risk factors for youth suicidal ideation and attempted suicide is also briefly reviewed.The relationship between psychiatric disorders and adolescent suicide is now well established. Mood disorders, substance abuse and prior suicide attempts are strongly related with youth suicides. Factors related to family adversity, social alienation and precipitating problems also contribute to the risk of suicide. The main target of effective prevention of youth suicide is to reduce suicide risk factors. Recognition and effective treatment of psychiatric disorders, e.g. depression, are essential in preventing child and adolescent suicides. Research on the treatment of diagnosed depressive disorders and of those with suicidal behavior is reviewed.In the treatment of youth depression, psychosocial treatments have proved to be useful and efficacious. Although studies on the effectiveness of selective serotonin reuptake inhibitors are limited in number, evidence supports their use as first-line antidepressant medication in youth depression. Available evidence suggests that various treatment modalities are useful in the treatment of suicidal youths, e.g. cognitive behavioral therapy and specialized emergency room interventions. Much of the decrease in suicide ideation and suicide attempts seems to be attributable to nonspecific elements in treatment. For high-risk youth, providing continuity of care is a challenge, since they are often noncompliant and commonly drop out or terminate their treatment prematurely. Developing efficacious treatments for suicidal children and adolescents would offer better possibilities to prevent suicides.

Associations between peer victimization, self-reported depression and social phobia among adolescents: the role of comorbidity.

Associations of peer victimization with adolescent depression and social phobia (SP), while controlling for comorbidity between them, have not been sufficiently explored in earlier research. A total of 3156 Finnish adolescents aged 15-16 years participated in a survey study. Self-reported peer victimization, as well as self-reported depression (Beck Depression Inventory), SP (Social Phobia Inventory), and selected background variables were assessed. Frequency of overt and covert peer victimization was examined among four groups: (1) adolescents with depression non-comorbid with SP (DEP), (2) those with SP non-comorbid with depression (SP), (3) those with both SP and depression (SP+DEP), and (4) controls, with neither. A logistic regression analysis controlling for confounding familial (family moving, parental unemployment), and psychopathology (delinquency, aggressiveness, general anxiety) covariates was conducted to confirm the associations between peer victimization and the four groups. Among boys the comorbid SP+DEP group reported the highest rates of both overt and covert victimization, these being significantly higher than among both DEP and SP groups. Among girls covert victimization was again most frequent in the SP+DEP group, but overt victimization was not more frequent in the comorbid group than it was in the DEP and SP groups. In the logistic regression analysis depression without SP did not maintain an independent association with either type of victimization. Instead, SP without depression with ORs from 2.8 to 4.3, and SP comorbid with depression, with ORs between 3.2 and 11.4 had independent associations with peer victimization. In conclusion, overt and covert peer victimization seem to be associated with SP, rather than depression, among adolescents.

Age and gender differences in social anxiety symptoms during adolescence: The Social Phobia Inventory (SPIN) as a measure

The aim of the present study was to examine age and gender differences in social anxiety symptoms during adolescence, and to investigate the psychometrics of the Social Phobia Inventory (SPIN) among adolescents. The SPIN was administered to a large general population sample (n=5252) of Finnish adolescents aged 12-16 years. Age and gender trends in scores and internal consistency and factorial composition of the SPIN were examined in this sample. The test-retest reliability of the SPIN was examined in a smaller sample of adolescents (n=802). Results showed that girls scored higher than boys on the SPIN full scale and three subscales across the whole age range. Eighth graders (14- to 15-year-olds) scored higher than seventh and ninth graders on the full scale, for boys the differences were significant. Good test-retest reliability (r=0.81), and internal consistency (alpha=0.89) were found for the SPIN. An exploratory factor analysis (EFA) performed on a random half (n=2625) of the population sample yielded a one-factor model accounting for 38% of the variance between items. This one-factor model, plus an alternative three-factor model, were examined in the holdout half of the population sample (n=2627) by means of a confirmatory factor analysis (CFA). Some support was gained for both factor structures. Our results indicate that symptoms of social phobia may increase in mid-adolescence. The SPIN appears to be a reliable self-report instrument among adolescents.

Factors Associated With Early Dropout From Adolescent Psychiatric Outpatient Treatment

OBJECTIVE To examine background factors, psychopathology, and psychosocial impairment among adolescents complying with or dropping out early from outpatient psychiatric treatment. METHOD Family background, psychiatric history, and other data were collected prospectively on 143 male and 154 female outpatients aged 12 to 22 years. DSM-II-R psychiatric diagnoses were assessed at the end of treatment. RESULTS Fifty-three adolescents (17.8%) attended 1 or 2 treatment appointments, and 33 of them (11.1% of 297) then dropped out; 50.5% of the total attended 3 to 13, and 31.6% attended 14 or more appointments. Low parental socioeconomic status was more common among the early dropouts than the other patient groups (88%, 69%, 63%, respectively). The early dropouts had had more problems with the law than the adolescents attending 14 or more appointments (18%, 6%), but less suicidal behavior (24%, 56%, respectively). Among the early dropouts, mood disorders were less common (21%, 49%), especially major depression (0%, 20%), and substance abuse was more common (9%, 0%) than among patients attending 14 or more appointments. CONCLUSIONS Low parental socioeconomic status, not having mood disorder, not having psychotropic medication, and having substance abuse were associated with early dropout of adolescents from outpatient psychiatric treatment.

Suicidal ideation, deliberate self-harm behaviour and suicide attempts among adolescent outpatients with depressive mood disorders and comorbid axis I disorders

ObjectiveWe aimed to analyse and compare prevalence and associated clinical features of suicidal ideation, self-harm behaviour with no suicidal intent and suicide attempts among adolescent outpatients with depressive mood disorders with or without comorbidity.MethodA sample of 218 consecutive adolescent outpatients aged 13–19 years with depressive mood disorders was interviewed using K-SADS-PL for DSM-IV Axis I diagnoses. They filled out self-report questionnaires assessing depressive and anxiety symptoms. Suicidal behaviour was assessed by K-SADS-PL suicidality items.ResultsHalf of the subjects reported suicidal ideation or behaviour. There was no difference in prevalence of suicidal behaviour between non-comorbid and comorbid mood disorder groups. Multivariate logistic regression analyses produced the following associations: (1) suicidal ideation with self-reported depressive symptoms and poor psychosocial functioning, (2) deliberate self-harm behaviour with younger age and poor psychosocial functioning, and (3) suicide attempts with self-reported depressive symptoms and poor psychosocial functioning. ConclusionsDepressed mood disorders, whether comorbid or not, are associated with suicidal ideation and suicide attempts. Diagnostic assessment should be supplemented by self-report methods when assessing suicidal behaviour in depressed adolescents.

Depressed adolescents as young adults - Predictors of suicide attempt and non-suicidal self-injury during an 8-year follow-up

BACKGROUND Clinically derived follow-up studies examining the predictors of suicide attempts (SA) and non-suicidal self-injury (NSSI) among adolescents are scarce. The aims were to study SA and NSSI as predictors of future NSSI and SA, and to study the role of other risk and protective factors, especially alcohol use, and perceived social support from family and peers during a 1-year follow-up and between the 1-year and 8-year follow-ups among consecutively referred depressed adolescent outpatients. METHODS The Adolescent Depression Study (ADS) is a longitudinal study of depressed adolescent outpatients (mean age at baseline 16.5 years, 81.8% females). The subjects of the present study (n=139, 63.8% of the original study population) were assessed at baseline, at 1-year and 8-year follow-ups using semi-structured diagnostic interviews (K-SADS-PL) for DSM-IV diagnoses, and structured self-report scales for clinical risk factors. RESULTS In multivariate comparisons, SAs were predicted both in the 1-year follow-up and in the period between the 1- and 8-year follow-ups by alcohol use and low perceived peer support. NSSI in the 1-year of follow-up was predicted by baseline NSSI, younger age and alcohol use, whereas the only significant predictor for NSSI between the 1- and 8-year follow-ups was NSSI. LIMITATIONS A large majority of the sample were females, limiting the possibility to analyze gender differences. CONCLUSIONS Among depressed outpatients NSSI is a strong predictor of suicidal behavior, and other factors beyond depression, such as alcohol use and availability of social support, must also be addressed to prevent the recurrence of suicidal behavior.

Current comorbidity among consecutive adolescent psychiatric outpatients with DSM-IV mood disorders

ObjectiveTo compare selected characteristics (age, sex, age of onset for depression, impairment, severity of depression, somatic comorbidity, and treatment status) of adolescents with currently comorbid and non-comorbid depression.MethodA sample of 218 consecutive adolescent (13–19 years) psychiatric outpatients with depressive disorders, and 200 age- and sex-matched school-attending controls were interviewed for DSM-IV Axis I and Axis II diagnoses.ResultsCurrent comorbidity, most commonly with anxiety disorders, was equally frequent (>70%) in outpatients and depressed controls. Younger age (OR 0.20; 95% CI 0.08, 0.51) and male gender (OR 0.02; 95% CI 0.09, 0.55) were associated with concurrent disruptive disorders. Current comorbidity with substance use disorders (SUD) was independent of age (OR 1.13; 95% CI 0.51, 2.49) and sex (OR 0.51; 95% CI 0.22, 1.17). Personality disorders associated with older age (OR 2.06; 95% CI 1.10, 3.86). In multivariable logistic regression analysis, impairment (GAF ≤60) was associated with current comorbidity (OR 3.13; 95% CI 1.53, 6.45), while severity of depression and lifetime age of onset for depression were not.ConclusionsAdolescent depression presents with age- and sex-dependent patterns of multiple co-occurring problem areas. While many clinical characteristics of adolescent depression are not affected by comorbidity, comorbidity associates with increased impairment.

Psychometric properties and clinical utility of the Scale for Suicidal Ideation (SSI) in adolescents

BackgroundAccurate assessment of suicidality is of major importance in both clinical and research settings. The Scale for Suicidal Ideation (SSI) is a well-established clinician-rating scale but its suitability to adolescents has not been studied. The aim of this study was to evaluate the reliability and validity, and to test an appropriate cutoff threshold for the SSI in a depressed adolescent outpatient population and controls.Methods218 adolescent psychiatric outpatient clinic patients suffering from depressive disorders and 200 age- and sex-matched school-attending controls were evaluated by the SSI for presence and severity of suicidal ideation. Internal consistency, discriminative-, concurrent-, and construct validity as well as the screening properties of the SSI were evaluated.ResultsCronbachs α for the whole SSI was 0.95. The SSI total score differentiated patients and controls, and increased statistically significantly in classes with increasing severity of suicidality derived from the suicidality items of the K-SADS-PL diagnostic interview. Varimax-rotated principal component analysis of the SSI items yielded three theoretically coherent factors suggesting construct validity. Area under the receiver operating characteristic (ROC) curve was 0.84 for the whole sample and 0.80 for the patient sample. The optimal cutoff threshold for the SSI total score was 3/4 yielding sensitivity of 75% and specificity of 88.9% in this population.ConclusionsSSI appears to be a reliable and a valid measure of suicidal ideation for depressed adolescents.

Suicidality in adjustment disorder--clinical characteristics of adolescent outpatients.

ObjectiveAlthough a remarkable proportion of adolescents suffering from adjustment disorder (AD) are suicidal, few studies have documented the characteristics of suicidal AD patients. We examined background, psychopathology and treatment-related factors among suicidal adolescent AD outpatients.MethodData on 302 consecutively referred psychiatric outpatient adolescents, aged 12–22 years, were collected. DSM-III-R diagnoses were assigned at the end of treatment based on all available data. Of the patients 89 received a diagnosis of AD, 25% of whom showed suicide attempts, suicidal threats or ideation.ResultsCompared with non-suicidal AD patients, suicidal AD patients were characterized by previous psychiatric treatment (OR=6.1), poor psychosocial functioning at treatment entry (OR=16.2), suicide as a stressor (OR=33.3), dysphoric mood (OR=6.9) and psychomotor restlessness (OR=3.7).ConclusionsCommon risk factors for suicidality in major psychiatric disorders characterized suicidal AD patients. Psychiatric assessment of AD patients should include careful monitoring of both symptomatology and exposure to suicide of significant others.

Factors associated with deliberate self-harm behaviour among depressed adolescent outpatients

This study examined whether depressed adolescent outpatients with deliberate self-harm behaviour (DSH) differed from non-suicidal depressed adolescent outpatients in depressive and anxiety symptoms, alcohol use, perceived social support and number of negative life-events. Depressed adolescent outpatients (n=155) aged 13-19 years were interviewed using K-SADS-PL for DSM-IV Axis I diagnoses and completed self-report questionnaires. Suicidal behaviour was assessed by K-SADS-PL suicidality items. Depressed adolescents with DSH were younger, perceived less support from the family, had more severe depressive symptoms and used more alcohol than non-suicidal depressed adolescents. Adolescents with DSH and suicidal ideation or suicide attempts had more depressive and anxiety symptoms than adolescents with DSH only. Adolescents with severe internalizing distress symptoms are at risk not only for DSH, but also additional suicidal behaviour. Family interventions may be needed in the treatment of depressed adolescents with DSH.