adolescents Characteristics of out-patient with suicidal tendencies Helsinki, Finland

Transcription

1 Acta Psychiatr Scand 1997: 95: Printed in UK - all rights reserved Characteristics of out-patient with suicidal tendencies Copyright 0 Munksgaard 1997 ACTA PSYCHIATRICA SCANDINAVICA ISSN X adolescents Pelkonen M, Marttunen M, Pulkkinen E, Laippala F', Aro H. Characteristics of out-patient adolescents with suicidal tendencies. Acta Psychiatr Scand 1997: 95: Munksgaard Suicidal adolescent out-patients were compared with non-suicidal subjects with respect to background factors, psychopathology and treatment received. Data for suicidal ideation, suicide attempts, psychiatric diagnoses (DSM-111- R) and other patient-related factors were collected prospectively during treatment of 122 male and 138 female out-patients aged years. In total, 42% of subjects displayed suicidal tendencies, and 18% had attempted suicide. According to polychotomous regression, mood disorder, previous psychiatric treatment and low level of psychosocial functioning at treatment entry were associated with suicide attempts and with suicidal ideation for both sexes. Suicidal patients were more often receiving psychotropic medication and had more total appointments (mean number 15 vs. 9) than non-suicidal patients. Suicidal and non-suicidal patients kept their scheduled appointments to the same extent (66% vs. 65%). Treatments which meet the needs of disordered suicidal adolescents need to be developed. I M. Pelkonen'. M. Marttunen*, E. Pulkkinen3, P. Laippala'A, H. Are'** 'Tampere School of Public Health, University of Tampere, 'Department of Mental Health, National Public Health Institute. Helsinki, 3Adolescent Psychiatric Unit, Kellokoski Hospital, Kellokoski and 4Tampere University Hospital, Tampere, Finland Key words: adolescence; suicidality; depression Hillevi Aro, Department of Mental Health, National Public Health Institute, Mannerheimintie 166, FIN Helsinki, Finland Accepted for publication May 18, 1996 Introduction Suicidal ideation and suicide attempts are reportedly common among adolescent out-patients ( 1), and in follow-up studies suicidality has been reported to be associated with subsequent suicidal behaviour (2), completed suicides and other mortality (3, 4). In studies of completed adolescent suicides it has been found that a substantial proportion of the victims have had previous suicidal ideation and suicide attempts (5-8). Suicidal ideation and suicide attempts are associated with a broad range of psychopathology, especially depressive disorders (1, 9, lo), and also with impaired psychosocial adjustment (11). The high level of psychiatric disturbance and adverse long-term outcomes associated with adolescent suicidality suggests a considerable need for psychiatric treatment of these adolescents. However, in outpatient settings the high level of non-compliance complicates both treatment and efforts to evaluate and develop new ways to help these high-risk young people (12). Our knowledge of the detailed characteristics of out-patient adolescents with suicidal tendencies and their treatmenth,adolescent psychiatric settings is far from complete. The aim of the present study was to determine the frequencies of suicidal ideation and suicide attempts among adolescent out-patients and to characterize suicidal adolescents compared to nonsuicidal adolescents in terms of the patients' background factors, psychopathology, psychosocial impairment, and treatment received. Material and methods The subjects of this study were adolescents aged years (122 male and 138 female subjects) who were referred for their first treatment at the out-patient adolescent psychiatric clinic of Kerava during a 5-year period from 1990 to 1994, and who had completed the index treatment by 31 December During the study period a total of 302 adolescents were referred to the clinic for the first time, of whom 23 male and 19 female patients were excluded from the analyses of the present study because their treatment continued after 31 December The catchment area of the adolescent psychiatric out-patient clinic includes the towns of Vantaa and Kerava, with approximately

2 Characteristics of suicidal adolescents inhabitants (about 15% adolescents) in an urban and suburban area in Southern Finland close to Helsinki, the capital of Finland. The clinic offers eclectic psychiatric treatment, including individual psychotherapy, family consultations and psychotropic medication when appropriate. At the time of referral, the male subjects were somewhat older than the females (mean age of males, 16.9 years, range years; mean age of females, 16.2 years, range years; t=2.32, df = 258, P = 0.021). The data were collected prospectively in two stages. Data on family-related characteristics and the adolescents previous psychiatric treatment, current life situation, previous and current suicidal ideation and suicide attempts and the referring person were collected, and the level of the adolescents psychosocial functioning was assessed by means of the Global Assessment Scale (GAS) (13) during the first two appointments. At the end of the treatment the following data were collected: number of individual and family appointments scheduled and kept, duration of treatment, psychotropic medication, suicidal ideation and suicide attempts during the treatment, level of psychosocial functioning, and information about recommended after-care. The final psychiatric diagnoses according to the DSM-111-R criteria (14) were assigned at the end of the treatment. Multiple diagnoses on DSM-111-R Axes I and I1 were permitted. According to the classification, adjustment disorder with depressed mood was not included under mood disorders. The metacategory depressive syndrome includes mood disorders and adjustment disorder with depressed mood. The socio-economic status (SES) of the adolescents families was based on the occupation of the parent considered to be the guardian of the adolescent (15). SES was classified as high (1-3) when the guardian was a self-employed worker or uppergrade employee, and low (4-9) when the guardian was a lower-grade employee or manual worker. Parental support during the year preceding the treatment was considered to be weakened if there was evidence of parental alcohol abuse, severe parental psychiatric illness, parental attempted or completed suicide or parental violence (16). Subjects with previous or current suicide attempts, suicide threats or suicidal ideation were coded as suicidal (10). Adolescents were categorized as having had problems with the law if they had been arrested, charged with or convicted of an offence. Statistical analyses The group comparisons were analysed by means of the Chi-square test with Yates correction, Fisher s exact test, and Student s two-tailed t-test when appropriate. Logistic regression (17) was used to select variables associated with the dependent variable (suicidality). The fit of the model was measured by goodness-of-fit Chi-square test. When analysing the response with more than two classes, we used polychotomous regression (18). Statistical analyses were performed using SPSS (19) and BMDP Statistical Software (20) on a SUNKJNIX mainframe computer. Results Of the 260 study subjects, 110 patients (42%) were classified as being suicidal, representing 47 of 122 males (39%) and 63 of 138 females (46%). Of all the adolescents, 64 individuals (25%) displayed only suicidal ideation or threats, and 46 subjects (18%) had made at least one suicide attempt either before or during the treatment. Suicidal and non-suicidal adolescents did not differ with regard to familial characteristics (Table l), and no statistically significant age differences between suicidal and non-suicidal subjects were found (mean age 16.7 years, range years vs. mean age 16.4 years, range years, respectively). Suicidal adolescents more often had a history of previous psychiatric treatments, and were referred for treatment by a health care professional more often than non-suicidal adolescents (Table 1). For both male and female subjects, mood disorders, and specifically major depression, were more common and adjustment disorders were less common among suicidal than non-suicidal adolescents (Table 2). Of the adolescents with only suicidal ideation, 32 of 64 subjects (%YO), and 28 of 46 subjects (61%) with suicide attempts had a mood disorder. statistically significant difference in the frequency of antisocial disorders (conduct disorder and antisocial personality disorder combined) was found (7 of 110 (6%) among suicidal and 11 of 150 (7%) among non-suicidal adolescents). The suicidal adolescents were more severely impaired than the non-suicidal adolescents (mean GAS score at first appointment, 4.4 for suicidal subjects vs. 5.2 for non-suicidal subjects, t=6.3, df=258, P<O.OOl; mean GAS score at last appointment, 5.0 for suicidal subjects vs. 5.6 for nonsuicidal subjects, t=4.8, df=258, P<O.OOl). Treatment-related factors The mean length of the index treatment was 220 days (range days, median days) for the suicidal subjects and 167 days (range days, median days) for the non-suicidal subjects 101

3 ~~ ~~ Pelkonen et al. Table 1 Familial and individual characteristics of suicidal and non-suicidal adolescents Suicidal adolescents Nan-suicidal adolescents Males (1) Females (2) Total 43) Males (4) Females (5) Total (6) (n=47) (n=63) (n=110) (n=75) (n=75) (n=150) P-value ~ ~ _ n % n % n % n % n % n % 1vs.4 2vs5 3vs6 Family-related factors Parental divorce NS NS NS Death of parent NS NS NS Living at home NS NS NS Weakened parental support NS NS NS Low SES NS NS NS Individual characteristics At school NS NS Taken into foster care NS NS NS Problems with the law NS NS NS Any previous psychiatric care NS Previous out-patient care only NS NS Out-patient care in adolescence NS In-patient care in adolescence Referring person was a health care professional * Statistically significant differences at P<0.05; NS, non-significant. Table 2. Clinical characteristics of suicidal and non-suicidal adolescents Suicidal adolescents Nan-suicidal adolescents Males (1) Females (2) Total (3) Males (4) Females (5) Total (6) (n=47) (n=63) (n=110) (n=75) (n=75) (n=150) P-value _ ~ ~ _ n % n % n % n % n % n % 1vs.4 2vs.5 3vs.6 Psychiatric diagnoses Depressive syndromeb Mood disorders Major depression Adjustment disorders Disruptive disorders NS NS NS Personality disorders NS NS NS Substance use disorders NS NS NS Psychotropic medication Recommendation for admission to psychiatric hospital Mean Mean Mean Mean Mean Mean Total number of appointments kept NS Total number of scheduled appointments Family appointments kept NS NS NS Family appointments scheduled NS NS NS Individual appointments kept Individual appointments scheduled Statistically significant differences at P<0.05; NS, non-significant. Includes mood disorders and adjustment disorder with depressed mood (t=-2.1, df=258, P=0.034). Suicidal adolescents were more often receiving psychotropic medication, more often had a recommendation for admission to psychiatric hospital after treatment, and had more total and individual appointments than nonsuicidal adolescents (Table 2). Suicidal adolescents 102

4 Characteristics of suicidal adolescents kept 66% and non-suicidal adolescents kept 65% of their scheduled appointments. The treatment included individual appointments for virtually all adolescents (104 of 110 (95%) suicidal subjects vs. 137 of 150 (91%) non-suicidal subjects). Family members were involved in the treatment for 40 of 110 (36%) suicidal subjects and 66 of 150 (44%) non-suicidal subjects. Of the suicidal adolescents, 45% (vs. 51% of non-suicidal subjects) had individual appointments but no family appointments or psychotropic medication during the treatment period. Adolescents with mood disorders When suicidal (n = 60) and non-suicidal (n = 29) adolescents with mood disorders were compared, it was found that suicidal adolescents had more often had previous psychiatric impatient treatment (8 of 60 (13%) vs. 0 of 29 cases, respectively; Fisher s exact test, P=0.049), were receiving psychotropic medication (16.of 60 (27%) vs. 2 of 29 (7%) cases, respectively; x2=4.7, df=l, P=0.03) and more often received a recommendation for admission to psychiatric hospital after treatment (14 of 60 (23%) vs. 0 of 29 cases, respectively; Fisher s exact test, P=0.004). The suicidal adolescents with mood disorders also had a lower level of psychosocial functioning at treatment entry than the nonsuicidal adolescents with mood disorders (mean GAS score for suicidal adolescents, 4.3 vs. 5.1 for non-suicidal adolescents; tz3.8, df=87, P<O.OOl), and also at the last appointment (mean GAS score for suicidal subjects, 4.8 vs. 5.5 for non-suicidal subjects; t=2.8, df=87, P=0.006). Of those adolescents who had a mood disorder, 40% (24 of 60) of suicidal and 41 YO (12 of 29) of non-suicidal subjects had at least one coexistent psychiatric diagnosis. Multivariate analyses In the stepwise logistic regression the most significant predictors associated with suicidality (having suicidal ideation or suicide attempts) (with 95% CI) were as follows: diagnosis of a mood disorder (OR=5.87, 95% CI ), previous in-patient treatment during adolescence (OR=5.53, 95% CI ), recommendation for admission to psychiatric hospital (OR=4.31, 95% CI ), low level of psychosocial functioning at treatment entry (OR=3.46, 95% CI ) and female sex (OR=2.61, 95% CI ) (goodness-of-fit x2=5.95, df=8, P=0.653). Further multivariate analyses were performed for both sexes separately, and the impact of a strong predictor of diagnosis of a mood disorder was controlled. According to the polychotomous regression (Tables 3 and 4), having a diagnosis of mood disorder, previous psychiatric treatment and a low level of psychosocial functioning at treatment entry were associated with suicide attempts (with the highest odds in all variables) and with suicidal ideation (with lower odds than for suicide attempts) for both sexes. Among male adolescents, but not among females, adding the variables weakened parental support, parental divorce, problems with the law and being referred by a health care professional established the most statistically significant model. When age was controlled in the multivariate analyses, the results remained unchanged. Discussion The relatively high prevalence (42%) of any suicidality and the finding that almost 20% of adolescent out-patients had made a suicide attempt are consistent with previous research results (1, 9). In agreement with previous studies of clinical populations (9, 21), we found that suicidal tendencies were more common among female than male adolescents, although the difference only reached the level of statistical significance in multivariate analyses. Interestingly, in the present study, in contrast to the study by Stiffman et al. (9), associations between familial characteristics and adolescents suicidality reached the level of statistical significance only in multivariate analyses and only among the male adolescents. A gender difference consistent with that found in our study was also reported by Aro (22), who found that male subjects were more vulnerable to long-term parental discord than females in a follow-up study of an adolescent population. However, in previous research, diverse interactions between parental distress and adolescents psychopathology among males and females have been reported (23-25). On the other hand, Kovacs et al. (1) reported that associations between familial psychopathology and adolescents suicidality are obscured when psychiatric control groups are used. Our findings that suicidal adolescents were characterized by high levels of previous psychiatric treatment and current poor levels of psychosocial functioning are consistent with previous research on suicide attempters (26), and with studies comparing suicidal and non-suicidal adolescents in clinical populations (1, 2, 9, 10, 27, 28) and in the general population (11, 29). According to Stanley and Barter (30), suicide attempters did not differ from other emotionally disturbed in-patients with regard to previous or current social adjustment, possibly due to severe psychosocial impairment among all of those adolescents. Previous severe 103

5 ~~ Pelkonen et al. Table 3. Summary of polychotomous regression: significant predictors associated with suicidal ideation and suicide attempts among male adolescents (n= 122) Outcome nsuicidal vs. Having suicidal ideation Making suicide attempts Predictor Mood disorders Poor GAS (score of 1-4) at treatment entry Previous in-patient care during adolescence Previous in-patient care during adolescence Mood disorders Poor GAS (score of 1-4) at treatment entry 95% confidence Coefficient SE Odds ratio limits a Goodness-of-fit xz= , df = 168, P=O.89. Table 4. Summary of polychotomous regression: significant predictors associated with suicidal ideation and suicide attempts among female adolescents In= 138) Outcome Predictor 95% confidence Coefficient SE Odds ratio limits nsuicidal vs. Having suicidal ideation Mood disorders Poor GAS (score of 1-4) at treatment entry Previous out-patient care Making suicide attempts Mood disorders Poor GAS (score of 1-4) at treatment entry Previous out-patient care Goodness-of-fit x =93.49, df = 104, P=0.76. psychosocial impairment was reported to be associated with male mortality in a follow-up study of former adolescent out-patients (4), among former male suicide attempters (26), and also among female suicide victims in a population-based psychological autopsy study of completed adolescent suicides (31). 104

6 Characteristics of suicidal adolescents As previously reported among referred children and pre-adolescents (32), adolescent out-patients (1,9,10,27) and adolescent in-patients (33), mood disorders were associated with suicidal ideation and suicide attempts in the present study. The high prevalence of suicidality among adolescents with mood disorders is consistent with the findings of previous research (34), and suggests that asking about suicidal thoughts and attempts should be an essential element of the assessment of mooddisordered adolescents. In contrast to the results of Lewinsohn et al. (35) for adolescents in the general population, mood-disordered suicidal and non-suicidal adolescents in the present study population did not differ with regard to psychiatric comorbidity. In previous research (1, 33), mood disorders with non-affective comorbidity have been associated with suicidality among referred youths. The low frequency of substance use disorders, disruptive disorders and antisocial disorders probably explains their -lack of association with suicidality, a finding which differs from that of previous studies (9). The rarity of substance use disorders and conduct disorders in the present study population reflects the organization of Finnish adolescent health care, whereby young people with alcohol and drug problems and problems with the law are not usually referred to adolescent psychiatric services but to services for substance abusers. However, in the present study, having problems with the law was associated with suicidality among the male adolescents in multivariate analyses, possibly suggesting weak or indirect associations. Kovacs et al. (1) also reported that conduct disorders and substance abuse constituted a relatively weak risk of suicidality among out-patient adolescents. Furthermore, it is possible that the antisocial symptomatology among many adolescents in this study population was not severe enough to fulfil the relatively strict DSM- III-R diagnostic criteria for conduct disorder or antisocial personality disorder. The importance of such subthreshold antisocial behaviour has been previously stressed in a study of adolescent completed suicides (36). In the present study, adolescents who had made suicide attempts showed somewhat higher rates of the same risk factors than those with suicidal ideation only. This result supports the view that suicidal ideation and suicide attempts can be conceptualized as milder and more severe manifestations of the same phenomenon (2, 5, 32). Consistent with this, in a population-based study, Fergusson and Lynskey (37) reported that suicide attempters had higher rates of psychopathology and long-term familial distress than subjects with suicidal ideation. On the other hand, Carlson and Cantwell (38) reported that depression was associated with suicidal ideation but not with suicide attempts among referred children and adolescents. In clinical populations, the generally high level of psychopathology may obscure the differences between subjects with suicidal ideation and suicide attempters that are found in studies where subjects are drawn from the general population. The finding that suicidal adolescents, especially those with mood disorders, were on psychotropic medication and received a recommendation for admission to psychiatric hospital after the index treatment more often than non-suicidal adolescents, is consistent with previous research (3, 33). The longer duration of treatment and higher number of scheduled and kept appointments among suicidal compared to non-suicidal adolescents suggests that special emphasis was placed on the treatment of those suicidal individuals. Interestingly, suicidal adolescents did not miss more appointments than non-suicidal adolescents, although previous studies have reported higher rates of non-compliance, ranging from 41% to 77% among suicidal adolescents (12,39,40), than that found in the present study (34%). Nevertheless, about one-third of scheduled appointments were not kept, which suggests that vigorous tracking procedures for all non-compliant adolescent out-patients are needed. Special emphasis should be placed on the development of services which meet the needs of these disordered adolescents. Further research should address the effects of different treatments offered for suicidal adolescents, and it seems that multimodal, yet more specific, treatments need to be developed for these high-risk young people. One of the strengths of this study is the fact that it involves a relatively large consecutively referred adolescent out-patient population. Data were collected prospectively and patient-related factors were carefully assessed. The Global Assessment Scale (13), which is also a global and reliable measure of changes in psychosocial functioning among adolescents (41), was used. Suicidality was precisely defined so as to include only unambiguous suicidal ideation, suicide threats and suicide attempts. This methodological decision and the subjects possible under-reporting of suicidal tendencies may have resulted in an underestimation of the prevalence of suicidality. A diagnostic classification with clear diagnostic criteria (DSM- III-R) was used to assess the clinical psychiatric diagnoses. However, the results obtained for this clinical study population, in which adolescents were mostly from urban or suburban areas, cannot be directly extrapolated to non-clinical populations. 105

7 Pelkonen et al. Acknowledgements This study was supported financially by the Academy of Finland, the Yrjo Jahnsson Foundation and the Finnish Adolescent Psychiatric Association. References 1. KOVACS M, GOLDSTON D, GATSONIS C. Suicidal behaviors and childhood-onset depressive disorders: a longitudinal investigation. J Am Acad Child Adolesc Psychiatry 1993: 32: PFEFFER CR, KLERMAN GL, HURT SW, KAKUMA T, PESKIN JR, SIEFKER CA. Suicidal children grow up: rates and psychosocial risk factors for suicide attempts during follow-up. J Am Acad Child Adolesc Psychiatry 1993: 32: RAO U, WEISSMAN MM, MARTIN JA, HAMMOND RW. Childhood depression and risk of suicide: a preliminary report of a longitudinal study. J Am Acad Child Adolesc Psychiatry 1993: 32: PELKONEN M, MARTTUNEN M, PULKKINEN E, KOIVISTO A-M, LAIPPALA P, ARO H. Excess mortality among former adolescent male out-patients. Acta Psychiatr Scand 1996: 94: BRENT DA, PERPER JA, GOLDSTEIN CE et al. Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 1988: 45: MARTTUNEN MJ, ARO HM, HENRIKSSON MM, LONNQVIST JK. Mental disorders in adolescent suicide. DSM-111-R Axes I and I1 diagnoses among 13 to 19 year olds in Finland. Arch Gen Psychiatry 1991: 48: SHAFII M, CARRIGAN S, WHIITINGHILL JR, DERRICK A. Psychological autopsy of completed suicide in children and adolescents. Am J Psychiatry 1985: SHAFFER D, GOULD M, FISHER P et al. Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry 1996: 53: STIWMAN AR, EARLS F, ROBINS LN, POWELL J. The relationship between adolescent depression and suicide attempts. Adv Adolesc Ment Health 1988: 3: PFEFFER CR, PLUTCHIK R, MIZRUCHI MS, LIPKINS R. Suicidal behavior in child psychiatric inpatients and outpatients and nonpatients. Am J Psychiatry 1986: 143: PLJIG-ANTICH J, KAUFMAN J, RYAN ND et al. The psychosocial functioning and family environment of depressed adolescents. J Am Acad Child Adolesc Psychiatry 1993: PIACENTINI J, ROTHERAM-BORUS MJ, GILLIS JR et al. Demographic predictors of treatment attendance among adolescent suicide attempters. J Consult Clin Psycho1 1995: 63: ENDICOTT J, SPITZERL, FLEW JL, COHEN J. The Global Assessment Scale. Arch Gen Psychiatry 1976: 33: American Psychiatric Association. Diagnostic and statistical manual of mental disorders, revised 3rd edn. Washington, DC: American Psychiatric Association, Central Statistical Office of Finland. Classification of occupations Helsinki: Central Statistical Office of Finland, MARTTUNEN MJ, ARO HM, HENRIKSSON MM, L~NNQVIST JK. Psychosocial stressors more common in adolescent suicides with alcohol abuse compared with depressive adolescent suicides. J Am Acad Child Adolesc Psychiatry : FLEISS JL, WILLIAMS JBW, DUBRO AF. The logistic regression analysis of psychiatric data. J Psychiatr Res 1986: MORAN MA, ENGELMAN L, FITZGERALD G, LYNCH B. Polychotomous stepwise logistic regression. In: DIXON WJ et al., ed. BMDP statistical software manual. Vol. 2. Berkeley: University of California Press, NORUSIS MJ. SPSS for Windows. Advanced statistics Release 6.0. Chicago: SPSS Inc., DIXON WJ, BROWN MB, ENGELMAN L, JENNRICH RI. BMDP statistical software manual. Vol. 2. Berkeley: University of California Press, OTTO U. Suicidal acts by children and adolescents. A followup study. Acta Psychiatr Scand 1972: (Suppl. 233): ARO H. Stress, development and psychosomatic symptoms in adolescence: a comparison of the sexes. Psychiatr Fenn 1989: 20: ARO HM, RANTANEN PK. Parental loss and adolescent development. In: CHILAND C, YOUNG JG, ed. New approaches to mental health from birth to adolescence. In: The child in the family. Vol. 9. The Yearbook of the International Association for Child and Adolescent Psychiatry and Allied Disciplines. New Haven: Yale University Press, 1992: RU~TER M. Relationships between mental disorders in childhood and adulthood. Acta Psychiatr Scand 1995: 91: ARO H. Risk and protective factors in depression: a developmental perspective. Acta Psychiatr Scand 1994: 89 (SUPPI. 377): KOTILA L, LONNQVIST J. Adolescent suicide attempts: sex differences predicting suicide. Acta Psychiatr Scand 1988: 77: RYAN ND, PUIG-ANTICH J, AMBROSINI P et al. The clinical picture of major depression in children and adolescents. Arch Gen Psychiatry 1987: 44: BIEDERMAN J, FARAONE S, MICK E, LELON E. Psychiatric comorbidity among referred juveniles with major depression: fact or artifact? J Am Acad Child Adolesc Psychiatry 1995: 34: LEWINSOHN PM, ROHDE F', SEELEY JR. Psychosocial characteristics of adolescents with a history of suicide attempt. J Am Acad Child Adolesc Psychiatry 1993: 32: STANLEY EJ, BARTER JT. Adolescent suicidal behavior. Am J Orthopsychiatry 1970: MAR~UNEN MJ, HENRIKSSON MM, ARO HM, HEIKKINEN ME, ISOMETSA ET, LONNQVIST JK. Suicide among female adolescents: characteristics and comparison with males in age group 13 to 22 years. J Am Acad Child Adolesc Psychiatry 1995: 34: , KOSKY R, SILBURN S, ZUBRICK SR. Are children and adolescents who have suicidal thoughts different from those who attempt suicide? J Nerv Ment Dis : BRENT DA, KOLKO DJ, WARTELLA ME et al. Adolescent psychiatric inpatients' risk of suicide attempt at 6-month follow-up. J Am Acad Child Adolesc Psychiatry 1993: 32: MYERS K, MCCAYLEY E, CALDERON R, 'I~EDER R. The 3- year longitudinal course of suicidality and predictive factors for subsequent suicidality in youths with major depressive disorder. J Am Acad Child Adolesc Psychiatry 1991: 30: LEWINSOHN PM, ROHDE F', SEELEY JR. Adolescent psychopathology The clinical consequences of comorbidity. J Am Acad Child Adolesc Psychiatry 1995: 34: MARTTUNEN MJ, ARO HM, HENRIKSSON MM, LONNQVIST JK. Antisocial behaviour in adolescent suicide. Acta Psychiatr Scand : FERGUSON DM, LYNSKEY MT. Childhood circumstances, adolescent adjustment, and suicide attempts in a New Zealand birth cohort. J Am Acad Child Adolesc Psychiatry 1995:

8 Characteristics of suicidal adolescents 38. CARLSON GA, CANTWELL DP. Suicidal behavior and depression in children and adolescents. J Am Acad Child Psychiatry 1982: 21: MATTSON A, SEESE L, HAWKINS J. Suicidal behavior as a child psychiatric emergency. Arch Gen Psychiatry 1969: 20: BZAUTMAN PD, STEWART N, MONSHIMA. Are adolescent suicide attempters noncompliant with outpatient care? J Am Acad Child Adolesc Psychiatry 1993: 32: PELKONEN M. Inpatient psychiatric adolescents function better than expected after discharge. A follow-up study. Acta Psychiatr Scand 1990: 81: