DMH Suicide Prevention Presentation
Transcript of 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
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Mood Disorders
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Case Histories
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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).
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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).
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• 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
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• 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
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• 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?
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• 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
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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
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• Loss of parent before theage of 12
• History of parental abuse
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• Early onset of suicidal behavior (prepubertal)
predicts suicidal behavior in
adolescents
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• Although suicides are rare in
children age 12 and under, suicide
attempts are NOT rare in bipolar children age 12 and under (20%)
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• 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).
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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.
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• 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
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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
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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
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• 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
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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”)
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• Suicide awareness programs
• Screening• First step of recognition
Strategies for Suicide Prevention
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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
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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
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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
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“I don’t care.”
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“Depression is the mother of
anger”
• Irritability
• Duration of symptoms
• Vague,
nonspecific physicalcomplaints
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• 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
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Risk Factors
• Unresolved grief
• Childhood trauma
• Learned feelings of helplessness (negative
& hopeless)
• Anxiety disorder
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Reprinted with permission
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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
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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.”
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NYT, March25,2005
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Medications
• SSRI more effective than placebo
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Serotonin
• Distributed widely in the body
• Discharged by neurons in the brain
• Regulation of mood
• Regulation of sleep
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Medications
• SSRI
• Prozac
• Zoloft• Celexa
• Luvox (anxiety)
• Effexor • Wellbutrin
• Serzone & Trazadone
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“How long should a doctor treat
depression with medication?”
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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 …
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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
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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?
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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
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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.
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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
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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