February 2, 20049:00 A.M.

Washington, D.C.

David Shaffer, F.R.C.P., F.R.C.Psych.Columbia University/New York State Psychiatric Institute

1051 Riverside Drive, New York, NY 10032

SUICIDE AND RELATED PROBLEMS

IN ADOLESCENCE

FOOD AND DRUG ADMINISTRATIONFDA Meeting

1EPIDEMIOLOGY

CAUSE # OF DEATHSAccidents 6646Homicide 1899Suicide 1611Cancer 732Heart Disease 347Congenital Anomalies 255Chronic Lower

Respiratory Disease 74Stroke 68Influenza and Pneumonia 66Blood Poisoning 57

Anderson & Smith 2003

1599

C.E14

LEADING CAUSES OF DEATH IN 15- TO 19-YEAR-OLDS

— U N I T E D S T A T E S, 2001 —

Firearms 55 37 52 62 37 57

Hanging/Suffocation 35 40 36 19 15 18

Ingestion 3 13 5 7 31 12

CO poisoning 2 2 2 5 6 5

Jumping froma Height 2 3 2 2 3 2

Cutting .4 0 .3 1 1 1

Other 3 5 3 4 7 5

5–19 Years ≥ 20 YearsM F ALL M F ALL

(N=1,595) (N=333) (N=1,928) (N= 22,016) (N=5,399) (N=27,415)

CDC Wonder 2003 (11/13)

SUICIDE METHODS: CHILDREN AND OTHERS

— % O F A L L S U I C I D E S, U N I T E D S T A T E S, 2000 —

Age

C.E1.XX

SUICIDE RATES BY RACE PER 100,000 LIVING POPULATION— U N I T E D S T A T E S , A L L A G E S, 2001 —

Ra

te p

er

100,

000

CDC 2003 (WISQARS)

0

5

10

15

20

25

30

35

40

45

50

55

60

65

Black Females

Black Males

White Females

White Males

Ra

te p

er

100,

000

AgeC.E3

SUICIDE RATES DURING ADOLESCENCE

— U N I T E D S T A T E S , A G E S 10–24, 2001 —

CDC 2003 (WISQARS)

0

5

10

15

20

25

30

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Black Females

Black Males

White Females

White Males

1 Russian Federation 1997–1998 34.52 New Zealand 1997–1998 33.23 Kazakhstan 1998–1999 30.74 Estonia 1998–1999 28.85 Lithuania 1998–1999 28.56 Finland 1997–1998 24.27 Latvia 1998–1999 22.18 Belarus 1998–1999 21.49 Canada 1996–1997 19.1

10 Austria 1999–2000 18.611 Ukraine 1999–2000 18.612 Croatia 1998–1999 17.713 Australia 1997–1998 17.514 Ireland 1996–1997 16.015 Switzerland 1995–1996 15.2

16 USA 1997–1998 14.917 Belgium 1994–1995 14.6

TEEN SUICIDE RATES IN COUNTRIES WITH EFFECTIVE REPORTING

— M A L E S A G E 15–19 —

COUNTRY* YEARS RATE**18 Poland 1995–1996 14.419 Norway 1996–1997 14.020 Hungary 1999–2000 12.221 Bulgaria 1997–1998 11.922 Czech Republic 1998–1999 11.523 Germany 1998–1999 9.524 Sweden 1995–1996 9.425 Denmark 1995–1996 8.726 France 1997–1998 7.627 Japan 1996–1997 6.828 Romania 1998–1999 6.629 United Kingdom 1998–1999 6.330 Netherlands 1998–1999 5.931 Italy 1996–1997 5.232 Spain 1997–1998 4.933 China (selected

urban and rural) 1997–1998 3.934 Greece 1997–1998 2.3

COUNTRY* YEARS RATE**

Pelkunen & Marttunen 2003; *available from WHO 3/5/2003; **2-year average per 100,000 population

1 New Zealand 1997–1998 17.12 Kazakhstan 1998–1999 10.33 Lithuania 1998–1999 10.34 Russian Federation 1997–1998 8.55 Estonia 1998–1999 7.66 Norway 1996–1997 7.07 China (selected

urban and rural) 1997–1998 6.48 Latvia 1998–1999 5.99 Belarus 1998–1999 5.6

10 Finland 1997–1998 5.611 Australia 1997–1998 5.412 Switzerland 1995–1996 5.413 Croatia 1998–1999 5.314 Austria 1999–2000 4.915 Canada 1996–1997 4.916 Ireland 1996–1997 4.817 Ukraine 1999–2000 4.6

TEEN SUICIDE RATES IN COUNTRIES WITH EFFECTIVE REPORTING

— F E M A L E S A G E 15–19 —

COUNTRY* YEARS RATE**18 Bulgaria 1997–1998 4.519 Belgium 1994–1995 3.520 Sweden 1995–1996 3.421 Romania 1998–1999 3.3

22 USA 1997–1998 3.223 Czech Republic 1998–1999 3.124 Hungary 1999–2000 3.125 France 1997–1998 2.926 Japan 1996–1997 2.927 Netherlands 1998–1999 2.928 Poland 1995–1996 2.929 Germany 1998–1999 2.830 Denmark 1995–1996 2.031 United Kingdom 1998–1999 2.032 Spain 1997–1998 1.633 Italy 1996–1997 1.534 Greece 1997–1998 0.5

COUNTRY* YEARS RATE**

Pelkunen & Marttunen 2003; *available from WHO 3/5/2003; **2-year average per 100,000 population

Ideation 19.0% 3.8 million

Attempt 8.8% 1.8 million

Attempt received 2.6% 520,000medical attention

SUICIDE (age 15–19)* .008% 1,611

* Anderson 2002; Grunbaum et al. 2002 (YRBS), U.S. Census 2000 C.E15.XX

FREQUENCY OF SUICIDAL IDEATION AND ATTEMPTS

— U.S. HIGH-SCHOOL STUDENTS, AGE 15–19, YRBS ——

(2001, N=13,601)

RATE N

1 53%

2 or 3 30%

4 or More 17%

Similar findings in patient studies 1 attempt increases risk of another 15-fold

TEEN ATTEMPTERS

ATTEMPTS PER YEAR(2001, YRBS, N=13,601)

Barter et al. 1968, Brent 1993, CDC 2002 (YRBS 2001 Codebook), Goldacre & Hawton 1985, Goldston et al. 1999, Hawton et al. 1982, Hulten 2001, Kotila 1992, Lewinsohn et al. 1994, McIntire et al. 1977, Spirito 1992, Spirito et al. 2003, Wichstrom 2000 SA42.XX

TEEN IDEATORS

EPISODES OF IDEATION* PER YEAR

(N=981)

Reifman & Windle 1995; *“How often have you thought about killing yourself?”; past year, N=698; last 6 months, N=283)

1 45%

2 24%

3 or More 31%

SI19.XX

HOW ARE SUICIDAL ADOLESCENTS EXCLUDED

FROM PSYCHOPHARM STUDIES?STUDY EXCLUSION CRITERIASertraline “previous attempt or

(Wagner et al. 2003) posing significantsuicidal risk”

Fluoxetine “serious suicidal risk”(Emslie et al. 2002)

Fluoxetine not specified(Emslie et al. 1997)

Paroxetine “current ideation with intent or(Keller et al. 2001) specific plan OR history of

attempts by drug overdose”

Citalopram not specified(Wagner et al. 2001)

SI22.XX

Year

C.E16.XX

20TH-CENTURY - CHANGES IN YOUTH SUICIDE RATES

— U N I T E D S T A T E S , A G E S 15–24 —

Rat

e p

er10

0,00

0

Anderson 2002, CDC Wonder 2003, USDHEW 1956, Vital Statistics U.S. 1954–1978

0

2

4

6

8

10

12

14

16

18

20

22

24

26

Females

Males

2CAUSES OF SUICIDE

LOCATION N YEARS %

Israel 43 mid-1980s 90%

*New York 120 1984–1986 90%

Finland 53 1987–1988 94%

*Pittsburgh 140 1984–1994 82%

PSYCHIATRIC DISORDER IN ADOLESCENT SUICIDE

— P S Y C H O L O G I C A L - A U T O P S Y S T U D I E S —

C.D6.XXApter 1993, Shaffer 1996, Marttunen 1991, Brent 1999; *case-control studies

MALE FEMALE(N=213) (N=46)

Depression 50% 69%

Antisocial 43% 24%

Substance Abuse 38% 17%

Anxiety 19% 48%

66% of 16- to 19-Year-Old Male Suicides Have Substance/Alcohol Abuse

MOST COMMON DIAGNOSES IN TEEN SUICIDESS

Brent et al. 1999, Shaffer et al. 1996 C.D8.XX

SUICIDALITY IN DEPRESSED CHILDREN AND TEENS

Andrews & Lewinsohn 1992, Fombonne et al. 2001, Haavisto et al. 2003, Kovacs et al. 1993, Larson & Ivarsson 1998, Ryan et al. 1987, Weissman et al. 1999, Wichstrom 2000

At Time of Diagnosis

STUDIES SUBJECTS IDEATION ATTEMPT

6 1265 60% 30%

During Follow-Up

STUDIES SUBJECTS IDEATION ATTEMPT

3 466 ? 24%

DE21.XX

OTHER FACTORS THAT PREDISPOSE TO SUICIDE

2004 January

Imitation

Biological abnormalities that ?predispose to impulsive response to stress

A family history of suicide

C.MO1.XX

STRESS EVENTe.g. Trouble with Law/School

LossHumiliation

ACUTE MOOD CHANGEe.g. Anxiety – Dread

HopelessnessAnger

ACTIVE DISORDERe.g. Mood Disorder

Substance AbuseAlcohol Abuse

(Hopelessness)COGNITIVE SET

HOW SUICIDES OCCUR— P A T H W A Y S T O A N D F R O M I D E A T I O N —

SURVIVAL

FACILITATION

SOCIALReligiosityAvailable SupportDifficult Access

to MethodConsider Effect on Others

SUICIDE

Slowed Down

MENTAL STATEMETHOD AVAILABILITY/

COMPETENCE

UNDERLYING “IMPULSIVE” TRAIT

Recent ExampleWeak TabooBeing Alone

SOCIAL

SUICIDALIDEATION

INHIBITION

MENTAL STATEAgitation

IMPACT OF ALCOHOL

3CHANGING RATES

Year

C.E16.XX

20TH-CENTURY - CHANGES IN YOUTH SUICIDE RATES

— U N I T E D S T A T E S , A G E S 15–24 —

Rat

e p

er10

0,00

0

Anderson 2002, CDC Wonder 2003, USDHEW 1956, Vital Statistics U.S. 1954–1978

0

2

4

6

8

10

12

14

16

18

20

22

24

26

Females

Males

Declining Rates Australia Austria* Canada England & Wales France Germany* Hong Kong Ireland Italy

TEEN SUICIDE RATES IN INDUSTRIALIZED NATIONS

— M A L E S 15–24, 1988–2001 —

Japan New Zealand Spain Switzerland*

Stable/Rising Rates Scotland

World Health Organization 2003; *decline started before 1988

Economic ProsperityBUT • Rates also decline in high-youth-

unemployment countries• relationship between SES and suicide

not strong

Less drug and alcohol abuseBUT • use and abuse rates have not changed

POSSIBLE REASONS FOR DECLINING SUICIDE RATES 1

[DR13.XX]

Reduced firearm availabilityBUT

• proportion of suicides by firearm unchanged

• declines noted in countries with very few firearm suicides

POSSIBLE REASONS FOR DECLINING SUICIDE RATES 2

[DR13.XX]

More psychotherapeutic treatmentBUT • psychotherapy has declined

More psychopharmacologic treatment

Better recognition of adolescent depression

Some combination of the above

POSSIBLE REASONS FOR DECLINING SUICIDE RATES 3

[DR13.XX]

4TREATMENT

CONSIDERATIONS

EFFECTIVE TREATMENT OF SUICIDE ATTEMPTERS

— M E T A - A N A L Y S I S O F 2 3 R C T s —

Outcome = Repeated Attempts

PSYCHOTHERAPYDBT (adult borderlines)

MEDICATIONFlupenthixol (Navane) in multiple attempts

Lithium in bipolar

Clozaril in schizophrenia

Meltzer et al 2003, Montgomery & Montgomery 1982, Tondo & Baldessarini 2000 C.Rx3

AdultsSTUDY RECENT TREATMENTUlster 30%United Kingdom 56%

Canada 50%

TeensSTUDY RECENT TREATMENTFinland 23%Pittsburgh 15%New York City 21%Norway 7%

TEENS WHO SUICIDE RECEIVE LESS

TREATMENT THAN ADULTS

C.Rx18.XX

Marttunen et al. 1992 Brent et al. 1993, Shaffer et al. 1996, Groholt et al. 1997, Foster et al. 1997, Appleby et al. 1999, Lesage et al. 1994

Prescribed antidepressants 24%

Antidepressants found at autopsy 0%

DEPRESSED TEENS WHO COMMIT SUICIDE DO NOT TAKE THEIR MEDICATIONS

— U T A H Y O U T H S U I C I D E S T U D Y, N = 49 —

Gray et al. 2003 DR30.XX

SUICIDALITY DURING THE TREATMENT OF TEEN DEPRESSION

Cautions & Considerations -1

2004 February

Ideation and attempts are common in depressed teens and recur frequently.

Teens often conceal ideation and attempts unless asked about them directly.Self report facilitates disclosure.

Event Reports may be influenced by mode of elicitation. They are not used with a glossary, misclassification can occur.

SUICIDALITY DURING THE TREATMENT OF TEEN DEPRESSION

Cautions & Considerations -2

2004 February

“Self harm” is a heterogeneous descriptor - not all types of self harm are associated with suicidal intent.

There have been no direct studies -with frequent and careful measurements -examining whether SSRI’s increase, decrease or have no effect on suicidal ideation and behavior.

SUICIDALITY DURING THE TREATMENT OF TEEN DEPRESSION

Cautions & Considerations -3

2004 February

After increasing for 35 years teen suicide rates have been declining consistently in many countries.

During this period there has been a marked increase in exposure of teens to SSRI antidepressants.

These trends could be related. We do not - currently - have a better explanation for the turnabout of a condition that led to the death of tens of thousands of young people.