Transcript DMH Suicide Prevention Presentation

Suicide prevention:Providing
Sanctuary for Adolescents in
Crisis
Nancy Rappaport, MD
Harvard Medical School
www.academicwebpages.com/nr
Mood Disorders
Case Histories
Disturbing Statistics
Fig 1: Developmental and temporal trends in rates of
adolescent suicide. Data from Maguire & Pastore (1999).
15
10
10-14 year s old
5
15-19 year s old
19
96
19
94
19
92
19
90
19
88
19
86
0
19
80
Rate per 100,000
adolescents
Fig. 1
Statistics (ctd.)
Fig 1.2: Developmental trends since 1950 in suicide rates for
15-19 yr old adolescents, by gender. Maguire & Pastore (1999).
20
15
10
5
0
Male (15-19 yrs)
19
96
19
94
19
92
19
90
Female (15-19
yrs)
19
70
19
50
Rate per 100,000
adolescents
Fig. 1.2
• For young people 15-24 yrs old, suicide is
the third leading cause of death, behind
accidental injury and homicide – 2,000
adolescents 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 a
year
• 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 the
use 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 every
death in females
• Who uses the most effective method – Girls
or Boys?
• The Center for Disease Control (CDC) has
tracked by school survey since 1991 every
two years 12,000 to 16,000 students.
• Approximately 20% of students have had
suicidal ideation; 10% have made a suicide
attempt 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 the
age 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 and
aggressiveness, periodic agitation,
explosiveness and severe temper tantrums
which can also be in response to trauma and
family discord,” (Papolos 1999).
Psychological Autopsies
• Shaffer studied large numbers of completed
suicides at an average age of 16 (170
psychological suicide autopsies) in an
ethnically diverse population in 1984-86
interviewing multiple informants with
community control subjects.
• More than 90% of subjects who
committed suicide met criteria for at
least one major psychiatric diagnosis
• Half of these subjects had psychiatric
disorder 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 abuse
disorders
• 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 people
months before dying (“natural screeners”)
Strategies for Suicide Prevention
• Suicide awareness programs
• Screening
• First step of recognition
#1 FIND &
TREAT
ACTIVE DISORDER
e.g., Mood disorder,
substance abuse, anxiety
STRESS EVENT
e.g., In trouble with
law/school; loss;
humiliation
ACUTE MOOD
CHANGE
e.g., Anxiety-dread,
hopelessness, anger
1 INHIBITION
SOCIAL
i.e.
MENTAL STATE
Slowed down
SURVIVAL
Adapted from Shaffer & Greenberg, 2002
SUICIDAL
IDEATION
2
FACILITATION
UNDERLYING
TRAIT
Impulsive, intense,
serotonin abnormality
Strong
taboo;
vailable
support;
presence of
others;
difficult to
access
method
#2 STRESS
AVOIDANCE/
TOLERANCE
#3 CRISIS
SERVICES
#4 MEDIA
GUIDELINES &
POSTVENTION
SOCIAL
Recent example, weak
taboo, isolation
MENTAL STATE
#5 METHOD
CONTROL
Agitation
Method Availability/
Familiarity
SUICIDE
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 in
childhood 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 Appetite
Psychomotor agitation or retardation
Suicidal ideation
“I don’t care.”
“Depression is the mother of
anger”
• Irritability
• Duration of
symptoms
• Vague,
nonspecific
physical
complaints
• Rate of depression varies; with age, the rate
of the disorder increases
• .3% preschoolers
• 1-2% of elementary age boys and girls, 1:1
ratio
• 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
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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 they
communicate and see if the patient can identify who
she/he relies on when stressed
• Assess the family’s capacity to monitor and maintain
sufficient watch over the adolescent
• Winnicott: “Why not tell him that you know that when
he steals he is not wanting the things that he steals but
he is looking for something that he has a right to; that
he is making a claim on his mother and father because
he feels deprived of their love.”
NYT, March25,2005
Medications
• SSRI more effective than
placebo
Serotonin
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•
•
•
Distributed widely in the body
Discharged by neurons in the brain
Regulation of mood
Regulation of sleep
Medications
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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 a
statistically 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 suicidal
ideation or non-lethal attempts at self harm
• ADs are effective for children with anxiety
disorders and only Prozac has been shown
to benefit kids with depression
New Study by Valuck
• Published in December 2004 CNS Drugs
• Analyzed claims data from 24,000+ adolescents
diagnosed with major depressive disorder
• There was no outside funding
• Valuck looked at the association between
diagnosis, 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 5000
subjects
Wait, by Galway Kinnell
Wait, for now.
Distrust everything, if you have to.
But trust the hours.
Haven't they
carried 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 emptiness
carved out of such tiny beings as we are
asks to be filled; the need
for 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