DMH Suicide Prevention Presentation

8/3/2019 DMH Suicide Prevention Presentation

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Suicide prevention:Providing

Sanctuary for Adolescents inCrisis

Nancy Rappaport, MD

Harvard Medical School

www.academicwebpages.com/nr

http://www.academicwebpages.com/nr

http://www.academicwebpages.com/nr



Mood Disorders



Case Histories



Disturbing Statistics

Fig. 1

0

5

10

15

1 9 8 0

1 9 8 6

1 9 8 8

1 9 9 0

1 9 9 2

1 9 9 4

1 9 9 6

R a t e

p e r 1 0 0 ,

0 0 0

a d o l e s c e n t s

10-14 years o ld

15-19 years o ld

Fig 1: Developmental and temporal trends in rates of

adolescent suicide. Data from Maguire & Pastore (1999).





Statistics (ctd.)

Fig. 1.2

0

5

10

15

20

1 9 5 0

1 9 7 0

1 9 9 0

1 9 9 2

1 9 9 4

1 9 9 6

R a

t e p e r 1 0 0 , 0

0 0

a d o l e s c e n t s

Male (15-19 yrs)

Female (15-19

yrs)

Fig 1.2: Developmental trends since 1950 in suicide rates for

15-19 yr old adolescents, by gender. Maguire & Pastore (1999).



• For young people 15-24 yrs old, suicide isthe third leading cause of death, behindaccidental injury and homicide – 2,000adolescents 15-19 commit suicide each year

• Persons under age 25 accounted for 15% of all suicides in 1997

• Within schools this statistic translates to (in

a district of 8,000 students) one suicide ayear



• Firearms are the most common method for completed

suicides, followed by ingestions leading to overdose, and

hanging

• 65% of completed suicides use handguns. The increase in

the rates of youth suicide (and the number of deaths by

suicide) over the past four decades is largely related to theuse of firearms as a method of destruction

• Substance abuse/dependence is the probable reason that

adolescence attempts are more lethal



• There are 400 suicide attempts by teenage

boys for every completed suicide in males

• Four thousand suicide attempts per everydeath in females

• Who uses the most effective method – Girls

or Boys?



• The Center for Disease Control (CDC) has

tracked by school survey since 1991 everytwo years 12,000 to 16,000 students.

• Approximately 20% of students have had

suicidal ideation; 10% have made a suicideattempt in a 12-month period; 1-3% of teenagers will receive medical attention for an attempt

• .01% will be successful

• Ideation is almost always episodic



Profile of Children with Completed

Suicides• Immature problem solving that translates into more

impulsive behavior

• Less able to tolerate frustration (adult data shows

decreased serotonin)

• Unable to plan future actions

• Aggressive or violent outbursts

• Difficulty making decisions• Less able to assess situations realistically than non-suicidal

children



• Loss of parent before theage of 12

• History of parental abuse



• Early onset of suicidal behavior (prepubertal)

predicts suicidal behavior in

adolescents



• Although suicides are rare in

children age 12 and under, suicide

attempts are NOT rare in bipolar children age 12 and under (20%)



• Usually these children are difficult to treat

and there is considerable controversy about

the criteria as they are referred to as “rapid

cyclers and often have mood lability, mood

swings, affective storms, irritability andaggressiveness, periodic agitation,

explosiveness and severe temper tantrums

which can also be in response to trauma andfamily discord,” (Papolos 1999).



Psychological Autopsies

• Shaffer studied large numbers of completed

suicides at an average age of 16 (170

psychological suicide autopsies) in anethnically diverse population in 1984-86

interviewing multiple informants with

community control subjects.



• More than 90% of subjects whocommitted suicide met criteria for at

least one major psychiatric diagnosis

• Half of these subjects had psychiatricdisorder for at least two years

• Link between psychopathology and

suicide



Organized plan, intent,

preparation

• One in four adolescents that completed

suicides show evidence of planning• According to Shaffer the time-honored

clinical inquiry about planning is a poor

measure of serious intent



Important Implications

• Need for thorough diagnostic interview

• Never discount a threat especially in the

context of affective or substance abusedisorders

• Importance of aggressive intervention in

first-episode affective illness



• The most common diagnostic groups were

mood disorders (52% major depression),

disruptive disorders and substance abuse

• A child with a mood disorder is four to five

times more likely to attempt suicide than a

child without a mood disorder



Completer Profile

• Evenly distributed by the SES, evenly

distributed by educated vs. uneducated,

Western states highest, 60% of firearms• 50% of completers were never in therapy

• 75% of completers communicated thoughts

about their suicide aloud to several peoplemonths before dying (“natural screeners”)



• Suicide awareness programs

• Screening• First step of recognition

Strategies for Suicide Prevention



SUICIDAL

IDEATION

ACTIVE DISORDER

e.g., Mood disorder,

substance abuse, anxiety#2 STRESS

AVOIDANCE/

TOLERANCE

#1 FIND &

TREAT

#3 CRISIS

SERVICES

#4 MEDIA

GUIDELINES &

POSTVENTION

#5 METHOD

CONTROL

STRESS EVENT

e.g., In trouble with

law/school; loss;

humiliation

SURVIVAL

ACUTE MOOD

CHANGE

e.g., Anxiety-dread,

hopelessness, anger

SUICIDE

SOCIAL INHIBITION

MENTAL STATESlowed down

Strong

taboo;vailable

support;

presence of

others;

difficult to

accessmethod

i.e.

UNDERLYING

TRAIT Impulsive, intense,

serotonin abnormality

SOCIAL

Recent example, weak taboo, isolation

MENTAL STATEAgitation

Method Availability/

Familiarity

FACILITATION

1

2

Adapted from Shaffer & Greenberg, 2002



Types of Depression

• Major Depression Usually begins in the late

teens, but has been diagnosed in children as young as four

• Dysthymia Chronic, mild depression. Starts inchildhood and can last decades

• Bipolar disorder Older teens cycle between

mania and depression. Younger teens can experience both

symptoms at once

• Clinical vignettes



SIGECAPS

Sleep - too little or too much

lose Interest or pleasure

feelings of Guilt or worthlessness

decreased Energy

decreased Concentration

change in A ppetite

Psychomotor agitation or retardation

Suicidal ideation



“I don’t care.”



“Depression is the mother of

anger”

• Irritability

• Duration of symptoms

• Vague,

nonspecific physicalcomplaints



• Rate of depression varies; with age, the rateof the disorder increases

• .3% preschoolers

• 1-2% of elementary age boys and girls, 1:1ratio

• 5% of adolescents with a 2:1 ratio of girls to

boys



Risk Factors

• Unresolved grief

• Childhood trauma

• Learned feelings of helplessness (negative

& hopeless)

• Anxiety disorder



Reprinted with permission



Stress and Protection in Different

Family Contexts• High levels of conflict

• “Child is expendable”

• Inordinate shame or guilt• Noble self-sacrifice

• Deflection away from other conflicts

• “Stress clusters”

• Impulsivity and aggression



Stress Protection (ctd.)

• Ask the family and the patient about how theycommunicate and see if the patient can identify whoshe/he relies on when stressed

• Assess the family’s capacity to monitor and maintainsufficient watch over the adolescent

• Winnicott: “Why not tell him that you know that whenhe steals he is not wanting the things that he steals buthe is looking for something that he has a right to; thathe is making a claim on his mother and father becausehe feels deprived of their love.”





NYT, March25,2005



Medications

• SSRI more effective than placebo



Serotonin

• Distributed widely in the body

• Discharged by neurons in the brain

• Regulation of mood

• Regulation of sleep



Medications

• SSRI

• Prozac

• Zoloft• Celexa

• Luvox (anxiety)

• Effexor • Wellbutrin

• Serzone & Trazadone



“How long should a doctor treat

depression with medication?”



Suicide Risk and

Antidepressants: An Update• Controlled trials of antidepressants in

children and adolescents

• Of 15 placebo-controlled trials of ADs for depression in children, only three found astatistically significant benefit.

• FDA self-reported

… these trials are not without bias however …



New Analysis Disputes

Antidepressant, Suicide Link • The sicker you are, the more likely you are

to get medication (these kids are not

included in the studies).• There was a financial incentive to drug

companies to do a study, regardless of

whether they showed a difference between placebo and drug



Wakeup call

• On average you have to treat 140 patients

with antidepressant to create a drug induced

suicidality in 1 patient• Do the drugs themselves increase the risk of

the suicide attempt?



Take home message

• Newer antidepressants can lead to a sense of

agitation in children

• Small percentage can lead to suicidalideation or non-lethal attempts at self harm

• ADs are effective for children with anxiety

disorders and only Prozac has been shownto benefit kids with depression



New Study by Valuck

• Published in December 2004 CNS Drugs

• Analyzed claims data from 24,000+ adolescentsdiagnosed with major depressive disorder

• There was no outside funding

• Valuck looked at the association betweendiagnosis, subsequent treatment patterns, and

suicide attempt.





Suicidal Ideation vs Suicide

• The FDA studies that were reviewed had no

actual suicides in any of the clinical trials

which have now included close to 5000subjects



Wait, by Galway Kinnell

Wait, for now.Distrust everything, if you have to.

But trust the hours.Haven't theycarried you everywhere, up to now?Personal events will become interesting again.Hair will become interesting.Pain will become interesting.Buds that open out of season will become lovely again.Second-hand gloves will become lovely again,their memories are what give them the need for other hands. And the

desolation of lovers is the same: that enormous emptinesscarved out of such tiny beings as we areasks to be filled; the needfor the new love is faithfulness to the old.

Wait.Don't go too early.You're tired. But everyone's tired.But no one is tired enough.Only wait a while and listen.Music of hair,Music of pain,music of looms weaving all our loves again.Be there to hear it, it will be the only time,most of all to hear,the flute of your whole existence,rehearsed by the sorrows, play itself into total exhaustion



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