Presentation on theme: "Associate Medical Director DMH"— Presentation transcript:
1 Associate Medical Director DMH Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal BehaviorLaine Young-Walker, M.D.Associate Medical Director DMHAssociate Training Director of Child and Adolescent Psychiatry Fellowship Program at University of Missouri-Columbia
2 Historical Review• Until late 1950’s literature on suicide was confined to case reviews• In the late 1950’s there was the first systematic psychological autopsy study done at Washington University (St. Louis)These studies gave evidence for the importance of psychiatric disorder as the proximal cause of most suicides
3 Historical Review• The 1960’s started a period of increasing suicides in young males• By early 1980’s the suicide rate in white, male teenagers had more than doubled• A task force of clinical and research experts convened by the US Dept of Health and Human Services to develop policies to reduce the rates of youth suicide
4 Historical Review• There is substantial information on the characteristics of suicide victims• There is less information about child and adolescent attempters• There is little systematic evidence-based knowledge about the optimal treatment of the suicidal child or adolescent• The suggestions by the PP are based on experience and clinician observations due to the lack of substantial research
5 Suicide Epidemiology• 1997 suicide mortality rate for y/o’s was 1.6 per 100,000• 1997 suicide mortality rate for y/o’s was 9.5 per 100,000 (boys 15.2 per 100,000; girls 3.4 per 100,000)• 1997 suicide mortality rate for y/o’s was 13.6 per 100,000
6 Suicide Epidemiology1) What ranking does suicide have as a cause of death in teens?2) Who attempts suicide more frequently (males or females)??3) Who commits suicide more frequently (males or females)??
7 Suicide Epidemiology• 2000 adolescents (13-19) commit suicide each year• Suicide is the 3rd leading cause of death in teens• The ratio of male to female suicide in: young children is 3:1fifteen to nineteen year olds is 4.5:1twenty to twenty-four year olds is 6:1
8 Suicide Epidemiology • Males are more likely to commit suicide • Females are more likely to attempt suicide
9 Suicide Epidemiology• Between early 1960’s and late 1980’s the suicide rate among year old males increased threefold• What do you think are reasons for this increase?
10 Suicide Epidemiology• Suggested reasons for increase in suicidal behavior among teenage boys are increased availability of firearms and increased substance use• Loaded guns were risk factors for the small number of suicides without diagnosed psychopathology
11 Suicide Epidemiology• Teen suicide rates among whites reached a peak in 1987 and has since declined• The African-American male suicide rate increased dramatically after 1986, but since 1994 it has declined• What are your thoughts about the reason for the decline in rates??
12 Suicide Epidemiology• Potential reasons for decline in suicide rates includelowered substance and alcohol use rates among the young (CDC, 1998)greatly increased prescribing of antidepressants to depressed individuals (largest increase in children/adolescent/young adults)
13 Suicide Epidemiology1) Where do you think the highest rates of suicide are found (geographically)?2) What is the most common method used for suicide completion?
14 Suicide Epidemiology• Suicide rates are highest in western states and Alaska• Firearms are the most common method by which Americans of all ages, ethnicities, and genders commit suicide• The methods used to commit suicide show great geographic variation (may reflect availability)• Ingestions account for 16% of year old female suicides but only 2% of suicides in males of that age
15 Suicide Epidemiology (Clinical Characteristics) • Completed suicide occurs most commonly in older adolescents• 90% of adolescent suicides occur in people with pre-existing psychiatric disorder• Most common forms of psychiatric disorder in completed suicidesMood disorder (in boys often co morbid with conduct d/o or substance abuse)Substance and/or alcohol abuse
16 Suicide Epidemiology (clinical characteristics) • Many children and adolescents who committed suicide were irritable, impulsive, volatile, and prone to outbursts of aggression• Most adolescent suicides appear to be impulsive• Suicide is often preceded by a stressful eventTrouble at school or with lawRuptured relationship with boy/girl friendFight with friends
17 Suicide Epidemiology (clinical characteristics) • It appears that suicide can be precipitated (in a presumably already suicidal youth) by exposure to news of another’s suicide or by reading about/viewing suicide portrayed in a romantic light• One third of people who complete suicide have made a prior attempt (prior attempts more common in girls and in suicide where there is a mood disorder at the time of death)• Suicide pacts are very uncommon in young people
18 Suicide EpidemiologyWhat are some risk factors?
20 Suicide Epidemiology (risk factors) • Psychiatric DisordersControlled studies of completed suicide suggest similar risk factors for boys and girls but marked difference in their relative importanceGirls the most significant risk factor is the presence of major depression and the next is prior suicide attemptFor boys the most potent predictor is previous suicide attempt (increases risk over 30 fold) and the next is depression, substance abuse and disruptive behavior
21 Suicide Epidemiology (risk factors) • Psychiatric Disorders (cont)Disruptive disorders common in male teens who commit suicideDisruptive disorder is commonly co morbid with mood, anxiety, substance abuse diagnosisThere is a greater risk for suicide in patients with schizophrenia
22 Suicide Epidemiology (risk factors) • Psychosocial StressorsStressful life events often precede suicide and or an attemptThe stressor is rarely sufficient to cause suicideThe importance is that it can be a precipitating factor in youth already at risk due to their psychiatric conditionControlled studies indicate low levels of communication between parent and children may be a significant risk factor
23 Suicide Epidemiology (risk factors) • Cultural FactorsSince 1987 the difference in rates between young African Americans and whites have narrowedRate in AA and other minority males has increased rapidly, while rate in whites has been steady or declinedWhat do you think could be causes of the increase in AA and minority males??
24 Suicide Epidemiology (risk factors) • Cultural FactorsTheories for the increase in AA suicide ratesIncreased access to firearmsWeakened social support systems and weaker sense of group adherenceIncreased secularism in AA youth
25 Suicide Epidemiology (risk factors) • Facilitating FactorsMaladaptive attributes and coping stylesParental psychopathologySocial-psychological factorsHIV-positive diagnosis and AIDS
26 Suicide Epidemiology (risk factors) • Facilitating Factors (cont)Maladaptive attributional and coping stylesHopelessness is repeatedly found to be associated with suicidalityBiological factors is common in adult suicides (dysregulation of serotonergic system)For Adolescents a preliminary small sample study found ¾ adolescent suicide attempters had CSF 5-HIAA concentrations that would indicate severe suicide risk in adults
27 Suicide Epidemiology (risk factors) • Facilitating Factors (cont)Parental psychopathologyFamily history of suicidal behaviorParental depressionParental substance abuse
28 Suicide Epidemiology (risk factors) • Facilitating Factors (cont)Social-psychological factorsSuicide can be facilitated in vulnerable teens by exposure to real or fictional accounts of suicide (including media coverage)Suicide clusters are 3 or more suicides that cluster in a particular locale in a three-month period (presumed to be related to imitation and usually involve adolescents or young adults)Suicide clusters account for 1-5% of US teen suicides (small percentage)
29 Suicide Epidemiology (risk factors) • Facilitating Factors (cont)HIV-positive diagnosis and AIDSIt has been suggested that HIV infection increases the risk of suicide and suicidal behavior in adolescents and young-adult youth
30 Non-Lethal Suicidal Behavior Epidemiology • Suicidal attempts—any behavior intended to end the child’s or adolescent’s life• Parasuicide—nonfatal suicidal acts by ingestion, with non-lethal intent• Each year 2 million US adolescents attempt suicide• Each year almost 700,000 seek medical attention for their attempt
31 Non-Lethal Suicidal Behavior Epidemiology • Suicide attempts in adolescence are twice as common in females as males• Suicide ideation is very common among high school students¼ females and 1/6 males have seriously considered suicide in a twelve-month periodHispanic students of both sexes were more likely than whites or African Americans to have seriously considered suicide, made a plan, attempted suicide or made an attempt requiring medical attentionReason for higher rate in Hispanic youth is unknown
32 Non-Lethal Suicidal Behavior Clinical Presentation • Spectrum of severity ranges from suicidal ideation, suicide threats and attempts, to completed suicide
33 Non-Lethal Suicidal Behavior Clinical Presentation • Suicidal ideationThoughts about wishing to kill one’s self; making plans; thoughts about the impact of one’s suicide on othersNot all children appreciate suicide may result in irreversible death (this should not influence the clinician in judging seriousness of the ideation)
34 Non-Lethal Suicidal Behavior Clinical Presentation • Suicide threatsUtterances made to others that indicate an intent to commit suicideMay be accompanied by actionsIn young child the most commonly this is a threat to jump out of a window, run into traffic, or to stab himself/herself
35 Non-Lethal Suicidal Behavior Clinical Presentation • Methods of attemptWhat is the most common method of attempt??
36 Non-Lethal Suicidal Behavior Clinical Presentation • Methods of attemptMajority are by ingestionsMost commonly OTC analgesicsPrevalence of superficial cutting and hanging is not knownLess common methods includeHangingJumping from heightStabbingDrowning
37 Non-Lethal Suicidal Behavior Clinical Presentation • Methods of attempt (cont)The choice of attempt and completion method largely determined by opportunityThe following are predictive of further suicide-attempt behavior and ultimate death by suicideRepeated attemptsAttempts by unusual methods (other than ingestion or superficial laceration)Medically serious attempts
38 Non-Lethal Suicidal Behavior Risk Factors • Risk factors for attempts in both genders are mood or anxiety disorders or substance abuse• Diagnoses with increased risk for suicidal ideation or attemptPanic attacks in girlsDisruptive behavior in boys• It is likely that serious family disturbances increase the risk for attempted suicideThis is inferred from high incidence of suicide in abused childrenThe clinician should assess past/present suicidal ideation or behavior in cases where abuse is suspected
39 Non-Lethal Suicidal Behavior Risk Factors • There is no evidence that minority sexual orientation (homosexuality)is more common in completed teen suicides than in controls• There is strong evidence that gay, lesbian, and bisexual youth of both sexes are more likely to experience suicidal ideation and attemptsuicideThere are a higher number of risk factorsHigh rates of drug/alcohol abuseMore likely to be bullied or victimized at school
40 Non-Lethal Suicidal Behavior Risk Factors • There are differences between how persons who complete and attempt suicide present• For attempted suicideMost evidence from emergency roomsMost commonly y/o female who has taken small or medium sized overdose of a readily available medication (OTC or family members meds)Usually impulsiveOccurs in context of dispute with family or boyfriend/girlfriend
41 Non-Lethal Suicidal Behavior Risk Factors • Attempted suicide (continued)Recently information has been collected from community based studiesIndicate suicide attempt rate in boys is higher in community than in patients presenting to the ER• There have been few risk factor comparisons between completed and attempted suicides
42 Non-Lethal Suicidal Behavior Natural History • Early onset suicidal behavior in prepuberty predicts suicidal behavior in adolescents• Early onset MDD is associated with suicidal behavior in adolescents
43 Non-Lethal Suicidal Behavior Developmental Features • The younger the child the less complex and more easily available are methods used to enact suicidal impulses• Social adjustment problems of young suicide attempters is mainly due to disturbed relationships within the family
44 Non-Lethal Suicidal Behavior Developmental Features • Social adjustment problems of adolescents is mainly peer related conflicts• The ages of onset of psychiatric symptoms and disorders that increase risk for suicidal behavior in adolescents are more common in older adolescentsMDD, substance abuse, BAD, schizophrenia, personality d/o
45 AssessmentWhat is included in the assessment of suicide??
46 Assessment• Requires evaluation of the suicidal behavior and determination of risk for death or repetition• Also requires evaluation of underlying diagnosis or promoting factors
47 Assessment • In assessing the attempt, determine Type of method employed (more unusual=worse prognosis)Potential medical lethality (not always reliable predictor)Degree of planning involvedDegree to which chance of intervention or discovery was minimizedAvailability of firearms or lethal meds should be ascertained and recommended for removal
48 Assessment • Assess the person with suicide ideas Question whether the child/adolescent is contemplating or has attempted suicide without anyone knowingEvaluating presence and degree of intent is complicatedOne approach is to evaluate motivating feelingsEx: wish to gain attention, to effect change in interpersonal relationships, to rejoin a dead relative, to avoid an intolerable situation, to get revenge
49 AssessmentWhat are the risk factors for repeat suicide attempt or completed suicide??
50 Assessment• Risk factors for repeat suicide attempt or completed suicideMale genderIncreasing ageLiving alone (homeless, runaway, isolated)Previous attempts with method other than ingestion or superficial cutting and took steps to avoid detection
51 Assessment • Assessment of underlying conditions Conditions that lead to suicidal behaviorPsychiatric diagnosis (depression, mania, hypomania, mixed states, rapid cycling, substances)Social or environmental factors (isolation, anger, stress)Cognitive distortions (hopelessness)Inappropriate coping styles (impulsivity, catastrophizing)History of family psychopathologyFamily discord or other life-event stresses involving interpersonal relationship problems
52 Assessment• Gather information from multiple sources and by varied developmentally sensitive techniquesInterviews, play and behavior observation, rating scales• Children/adolescents are more likely to tell of suicidal ideation and actions than their parents
53 Treatment1) So what do you do when you have a patient who is expressing suicidal ideations??2) How do you proceed?
54 Treatment • Safety considerations is of over-riding importance • Treatment should be provided within a ‘wrap around’ service delivery system (includes impatient, short and long term outpatient, and emergency intervention)
55 Treatment • Acute management Hospitalize if condition makes behavior unpredictableExamples of mental status features predictive of short term difficultyInability to form alliance with clinicianLack of truthfulness or inability to discuss/regulate emotion and behaviorPsychosisIntoxication from drugs or alcoholMultiple prior serious suicide attempts
56 Treatment • Acute management Diagnostic features indicating need for hospitalizationMDD with psychotic featuresRapid cycling with irritability and impulsive behaviorPsychosis with command hallucinationsAlcohol or substance abuseSocial factors affecting decision to hospitalizeLack of sufficient environmental support to help stabilize the individual
57 Treatment •Emergency or Crisis Service Intervention Never discharge from ER without caretaker verifying the patient’s accountDiscuss making firearms and/or lethal meds inaccessibleLimiting access to alcohol or other potentially dis-inhibiting substances should be discussedArrange follow-up appointment
58 Treatment • Partial hospitalization and outpatient Partial hospitalization is a good alternative if the child/adolescent is disturbed but containable in a supportive home or other residential settingOutpatient is used when the child/adolescent is not likely to act on suicidal impulses, there is sufficient support at home, and someone can take action if the patients mood deteriorates
59 Treatment • Psychotherapy Aims to decrease intolerable feelings and thoughtsRe-orient the cognitive and emotional perspectives of the suicidal patient
60 Treatment • Types of Psychotherapy CBT—shown to be effective in adults; efficacy in adolescents not yet examinedInterpersonal—suicidal behavior in children/adolescents is frequently associated with interpersonal conflict; treatment of this may reduce suicidal riskThis therapy addresses interpersonal problems (loss, role disputes, role transitions, and interpersonal deficits)
61 Treatment • Types of Psychotherapy (continued) DBT (dialectical-behavior therapy)--reduces suicidality in adults with BPD. Recently a modified and manualized form of this has been used with suicidal adolescents. Research suggests it is acceptable for teens and reduces hospitalizationPsychodynamic—no studies address efficacyFamily therapy—may decrease problems of family discord
62 Treatment • Psychopharmacological intervention Lithium reduces suicide recurrence in adultsSSRI’s reduce suicidal ideation in adultsStudies not conducted in children/adolescentsIn fact in last decade case reports of patients developing suicidal preoccupations has arisenMonitor youth for increased agitation or suicidality
64 Prevention • Community based suicide prevention Crisis Hotlines Research limited; failed to show impact on suicideMethod restriction (ex: reduce firearm access)No evidence for significant impactIndirect case finding through educationIneffective mode of case findingDirect case findingAn excellent and cost-effective way to identify possibly at risk children and adolescentsMedia counseling