Youth Depression & Suicide

Transcription

1 Youth Depression & Suicide Hatim Omar, M.D. Professor, Pediatrics & Ob\Gyn. Chief, Division of Adolescent Medicine & Young Parent Program Department of Pediatrics University of Kentucky

2 DISCLOSURE I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity

3 Objectives Epidemiology of youth suicide Contributing factors Overview of mood disorders with focus on depression Treatment options Prevention

4 One million deaths annually from suicide: "global" mortality rate 16 per 100,000, one death every 40 seconds. Suicide one of three leading causes of death years Suicide attempts 20 x > completed suicide. Suicide 2% of the total global burden of disease. Youth highest risk in 30% of developed and developing countries. 90% Mental disorders (depression, substance abuse) Complex socio-cultural factors Socioeconomic crisis (loss of loved one, employment, honor).

5 Leading Causes of Violent Death Worldwide Armed Conflict 20% Homicide 30% Suicide 50% Source: WHO, Violence and Health, Report of the Secretariat, November 2001

6 Demographics of suicide Third-leading cause of death years of age Males: unintentional injury 11,827; homicide 4765; suicide 3498; neoplasms 1035; heart disease 770 Females: unintentional injury 3926; suicide 714; homicide 701; neoplasms 682 Rates suicide plans and attempts greater females than males; males more likely to complete (more likely choose lethal method) Suicide rate highest in white males; Hispanics most likely to have suicide attempt

7 Rates

8

9 DID YOU KNOW More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease combined

10 Suicidal behaviors, YRBS, 2007 Male Female Felt sad or hopeless 21.2% 35.8% Seriously considered attempt 10.3% 18.7% Made suicide plan 9.2% 13.4% Attempted suicide 4.6% 9.3% Suicide attempt treated MD/nurse 1.5% 2.4%

11 Prevalence and Demographics of College and University Suicide Suicide among college/university students overall appears to be less frequent than among an age-matched non-student population (7.5/100,000 vs. 15/100,000, Silverman, 1997). Estimated suicide deaths per year = 1,088 Suicide is the second leading cause of death among the college/university population (vs. the third leading cause among all youth 15-24). 75% of university suicides involve males. Suicide rate appears higher among graduate students, especially women.

12 Risk factors for suicide Psychiatric disorders Previous suicide attempt History of abuse Family history of suicidal behavior or mood disorder Proximal factors Access to means Substance use Social stress (loss/conflict; isolation; sexual orientation; hopelessness/helplessness)

13 Causes of Suicide Multiple factors build to threshold Sadness, hopelessness, despair, depression Pain and hurt, feeling different, unwanted Bullying, abuse, anger, rage Cry for help, unheard, frustration trigger incident row, failed exam.. Availability of method (gun, drugs etc)

14 Most common stressors leading to youth suicide (Kentucky, Omar 2001) Fight with parents (20%) End of relationship (12%) Financial problems (10%) Fight with sig other (8%) Recent move, social isolation (7%) Legal problems (6%) Family problems (6%) Academic problems (5%) Substance abuse (4%) Recent abuse (4%) Sexual orientation (3%)

15 Adolescent Depression and Suicide Myths Adolescence is inevitably a time of Storm and Stress Moodiness is normal in adolescents Adolescents must rebel and reject the values of their parents Adolescents cannot experience a true clinical depression Their egos and brain development are immature Suicide attempts are manipulative and only for show Asking about suicide plans plants the idea

16 Adolescent Depression and Suicide Facts Strong developmental trends Before puberty, m-f ratio is equal; by mid-teens f > m Rates of suicide and depression increase w/ age Depression in teen yrs assoc w/ > adult risks But, depression in younger childhood not Higher rates of co-morbid diagnoses in teen yrs Pre-puberty, depression assoc w/ family disturbance (Harrington, 2001)

17 Suicide Assessment: Predisposing Risk Factors Co-morbid Disorders (Frequency in Clinic Samples of Depressed Teens) -40% - 70% depressed teens have a comorbid disorder 20% - 30% have two or more comorbid disorders Most frequent Dysthymia (30% - 80%) Conduct problems or ADHD (10% - 80%) Substance use disorder (20% - 30%) Anxiety Disorders (9% - 55%)

18 Suicide Assessment: Predisposing Risk Factors Psychiatric disorders assoc w/ suicide Mood Depression most freq disorder assoc w/ suicide More freq among female than male completed suicides Conduct May have higher levels of suicide attempts than those w/ MDD, although they report less depression More freq among males Substance abuse 35% significant blood alcohol levels at autopsy 38% consumed alcohol w/in 6 hrs of attempt As high as 50% have histories of substance abuse More frequent among males

19 Suicide Assessment: Predisposing Risk Factors Psychiatric disorders assoc w/ suicide Personality disorders and styles Borderline Personality Disorder Impulsive personality style Anxiety May not be important risk factor once controlling for depression Some suggestions separation anxiety may increase risk Brent et al. (1998) found coexisting anxiety disorder predicted continuing depression after treatment (Brent, 2001; Groholt et al., 2000; Harrington, 2001; King et al., 2001; Koplin & Agethen, 2002; McKewon et al., 1998; Miller & Glinski, 2000)

20 Suicide Assessment: Predisposing Risk Factors History of Previous Attempts Strongest predictor of future attempts 10 15% repeat w/in 6 mos; 20% w/in 2 yrs However, 60 70% of attemptors have made no previous attempt Explore, as well, other types of self-harm Associated w/ personality disorder, which is independent predictor

21 Suicide Assessment: Acute Risk Factors Level of Intention Presence of a plan Suicidal ideation Not always reported Pre-attempt behaviors Notes, giving possessions away, saying good-bye s Conception of death Talking about death, seeing death as a solution, viewing death as a better place Lethality of means Note: Younger teens may misjudge lethality

22 Suicide Assessment: Acute Risk Factors Availability of Means Especially firearms Most frequently used method among completers, male and female When firearms in home, suicide completion risk is 5x greater

23 Suicide Assessment: Acute Risk Factors Current Emotional State Level of depression Hopelessness Strong predictor of lethality Associated w/ repeat attempts if not addressed Altered state of mind (Harrington, 2001) Rage

24 Suicide Assessment: Acute Risk Factors Precipitating Factors Most often interpersonal Loss Death of significant other Conflict in important relationships > 16 yrs w/ friends (e.g., romantic break-up) < 16 yrs w/ family Abuse or victimization Ongoing and teen not protected Secrets

25 Suicide Assessment: Acute Risk Factors Precipitating Factors Suicide among friends Both a loss May legitimize suicide as a solution Loss of function Increased risk among teens with chronic diseases/conditions when there is functional impairment Legal, school problems Particularly important in teens w/ CD

26 Reasons for Suicide Attempts: Summary Intrapersonal reasons (e.g., feelings) more common reason with interpersonal precipitants Manipulation of others: not a frequent reason, though others often attribute manipulative motives to teen Anger and depression frequently found in teen attempts Anger is related to the seriousness of the teen s motivation (Boergers, et al., 1998)

27 Do Treatments for Depression Lower Suicide Risk in Teens? Very few controlled studies of treatments directly targeting suicide Many studies of treatment for depression either exclude suicidal individuals or do not include a measure of suicidality in outcomes Treatment attrition rates are high among adolescent suicide attempters Suicide behavior must be targeted specifically, not only indirectly by treating depression (Miller & Glinski, 2000)

28 Major Depression Treatment Acute Phase (Symptom Response) Placebo % Antidepressant % Psychotherapies % Maintenance Phase (Relapse Prevention) Placebo 15-45% Antidepressant %

29 Major Depressive Disorder: Overview: Epidemiology Depression is twice as likely in adult women In pre-adolescent children, rates are equal (2.6% in 6-11 yo) Rates for females begin to rise between and increase dramatically between Yrs Boys Girls (Hankin et al., 1998) % overall

30 Bullying Behavior Definitions Historical emphasis on: 1) physical bullying 2) verbal taunting Current recognition of differing forms of bullying behavior (i.e. gender and ethnic differences)

31 Asking about suicide Previous suicide attempts Recent serious suicidal preoccupation Depression Alcohol/ substance use History of witnessing domestic violence, or victim of violence Access to fire arms

32 Is path warm? : key warning signs Ideation (talk of wish to harm self) Substance abuse Purposelessness (no reason for living; burden) Anxiety (restlessness; insomnia) Trapped (no way out) Hopelessness (lack of value; others not caring) Withdrawal Anger Recklessness Mood changes (shifts from typical mood)

33 How imminent? Odds of suicide? Provider must make clinical decision if risk is imminent (within 48 hours), or short term Issue of risk resolution; odds ratios: Discharge from psych unit past week: 280x Discharge from psych unit past year: 35-50x Prior attempt: 22x Firearm available: 5x Substance abuse: 7x Greatest risk after discharge: mood disorder, brief stay, limited resources

34 Antidepressants and suicide risk October 2004: FDA mandates placement of Black Label warning that antidepressants increase risk of suicidal ideation and behavior in children and teens FDA advisory committee reviewed the literature on 24 short-term placebo-controlled trials, 4400 children and adolescents; increased risk of suicidal thoughts or behaviors (RR 1.95), risk greatest weeks after initiation Amer Coll Neuropsychopharmacology: 15 trials, 2000 patients: no completed suicides (same rate suicidal ideation or behavior)

35 Recommendations for initiation of antidepressants in adolescents Face-to-face contact weekly during initial 4 wks Contact every 2 weeks next 4 weeks Contact every 12 weeks (first face-to-face, then by phone if appropriate) Patients & families be aware of emergence of irritability, worsening depression, suicidal ideation Gibbons 2007: rate of suicide ages in US rose (1 st rise in 10 years); Netherlands, suicide rate rose 49% , SSRI prescriptions decreased 22%

36 Patients with history of multiple suicide attempts as high-risk group Greater likelihood of co-morbidity or personality disorder Younger age at first attempt Lower lethality in first attempt More impulsive More likely associated with substance abuse Greater symptom severity Anxiety, depression, hopelessness, anger, suicidal ideation More frequent history of trauma, abuse Lower threshold for triggering crisis, longer crisis duration

37 Self-injurious behaviors and suicidal behaviors Paul 02: self-injuring distinct from suicidal behavior in intent, bodily harm, methods Common psychopathologic features of eating disorders and self-injurious behaviors (traumatic experience, greater dissociation) 130/376 ever injured themselves, 80/376 self-injurious behaviors preceding 6 months (typically cutting or scratching)

38 Role of the Primary Care Physician Screening, Identification, and Diagnosis (1. What do you do for fun? 2. Tel me something good about yourself 3. What do you want to do when you grow up? 4. Are you mostly happy or not?) Education of patient, parents, and others Treatment Referral when appropriate

39 Suicide Prevention

40 Teens have a lot to offer! An often underutilized asset!