Adolescent Suicidal Behavior

1. Adolescent Suicidal Behavior Evaluation and Treatment Considerations Gabriel Kaplan, M.D. Bennett Silver, M.D.

2. Conference Agenda Dr. Gabriel Kaplan • Epidemiology Dr. Bennett Silver • Psychopathology Dr. Gabriel Kaplan • Risk Assessment  • Pharmacological Approach Dr. Bennett Silver • Psychosocial Approach and Prevention Programs

3. Bennett Silver, MD ACADEMIC CREDENTIALS • Board Certified Adult Psychiatrist • American Board of Psychiatry and Neurology, INC • Child Psychiatrist • Mt. Sinai School of Medicine Trained Specialist • Director of Residency Training • Bergen Regional Medical Center • Three decades of clinical work with suicidal patients PUBLICATIONS/PRESENTATIONS • Editor, • Child and Adolescent Psychiatry Alerts national newsletter • Editor, • Psychiatry Drug Alerts national newsletter • Presentations to physicians, school personnel, professional associations, parent groups, on the topic of suicide

4. Gabriel Kaplan, MD ACADEMIC CREDENTIALS • Board Certified Child Psychiatrist, American Board of Psychiatry and Neurology, INC • Distinguished Fellow, American Psychiatric Association • Clinical Associate Professor of Psychiatry, University of Medicine and Dentistry of New Jersey PUBLICATIONS/RESEARCH/SYMPOSIA • Kaplan G. • Co-Investigator. New York Hospital Research Grant Follow-up Suicidal Adolescents. 1986-1988 • Pfeffer C., Newcorn J.H., Kaplan G., et al. • Suicidal Behavior in Adolescent Psychiatric Inpatients. J American Academy of Child Adolesc Psychiatry. 1988; 27:357-361 • Pfeffer, C., Newcorn J.H., Kaplan G., et al. • Subtypes of Suicidal and Assaultive Behaviors in Adolescents J Child Psychology and Psychiatry, 1989; 1:151-163 • Kaplan, G., Oquendo, M., Escobar, J., and Marin, H. • Assessment and Management of Depression Symposium 2006 APA • Kaplan, G., Oquendo, M., Escobar, J., and Marin, H. • Assessment and Management of Suicidal Behavior across the Life Cycle Symposium 2007 APA • Greydanus D. and Kaplan G. • Strategies to Improve Medication Adherence in Youths: Approaches During the Active to Maintenance Transition. Psychiatric Times pp 14-16 July, 2012 • Kaplan G. • What is New in Adolescent Psychiatry?  A Literature Review and Clinical Implications Adolescent Medicine: State of Art Reviews (AM:STARs). Spring 2013 (in Press)

5. Epidemiology Gabriel Kaplan, MD

6. Definitions Goldsmith SK, Pellmar TC, Kleinman AM, et al. Reducing Suicide: A National Imperative. Washington, D.C.: National Academy Press; 2002.

7. Trends in Suicide Rates Ages 10 Years and Older, by Sex, 1991–2009 Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/

8. Rates have increased since 2004 • Influence of internet social networks • High suicide among young U.S. troops • Higher rates of untreated depression in the wake of recent “black box” warnings on antidepressants—a possible unintended consequence of the medication warnings, required by the FDA in 2004

9. Percentage of Suicides Ages 10 Years and Older, by Sex and Mechanism, 2005–2009 Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/

10. Leading Causes of Death by Age

11. Youth Risk Behavior Surveillance System (YRBSS) • The YRBSS was developed by the Centers for Disease Control (CDC ) in 1990 to monitor priority health risk behaviors that contribute markedly to the leading causes of death, disability, and social problems among youth and adults in the United States • The YRBSS includes national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th through 12th grade students. These surveys are conducted every two years, usually during the spring semester.

12. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

13. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

14. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

15. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

16. H S Students Considering, Planning, or Attempting Suicide in Past 12 Months 2009 Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/

17. Suicide Rates Ages 10–24 Years, by Race/Ethnicity and Sex, 2005–2009 Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/

18. Risk Assessment Gabriel Kaplan, MD

19. Common school suicidal situations • A note is found • A student overhears another student • A student confides in a guidance counselor • A student threatens during school day • A parent confides in a teacher/counselor • A teacher discovers student’s self mutilation • A student “does not look well” and is asked • Student is absent, parents confide • Routine suicide school screening • A student who is bullied expresses suicide ideas

20. Risk Factors • History of depression or other mental illness • Psychiatric disorder is present in up to 80-90% of adolescent suicide victims and attempters • Most common psychiatric conditions are mood, anxiety, conduct, and substance abuse disorders. • History of previous suicide attempts • Family history of suicide • Stressful life event or loss • Easy access to lethal methods • Exposure to the suicidal behavior of others • Incarceration • Bullying (victims and perpetrators) • Hopelessness/guilt

21. What to do? • A plausible suspicion must be assessed immediately • A usually happy go lucky 7 year old crying “I want to die” because another student took a toy away does not need an emergent evaluation. • Keep in mind risk factors/age discussed here • While rare, every suicide is “one too many” • Thus, when in doubt, err on the side of caution and refer a.s.a.p.

22. Evaluation • Adolescent suicidal behavior is a medical emergency that must be assessed by highly qualified professionals: • Child Psychiatrist, • Psychiatrist, • Non-MD with training and experience in the assessment of suicidal behavior • If an adolescent actively threatens suicide, an assessment must be conducted asap in the Emergency Room setting

23. Expert evaluation • Comprehensive psychiatric examination • Includes medical history • Patient, family, teacher input required • Evaluation focused on determining potential risk and disposition • May include rating scales

24. Expert will assess • Presence of mental illness • Large majority of patients who suicide suffer from mental illness • All psychiatrically ill adolescents are high risk • Presence of aggravating circumstances • Loss, bullying, substance abuse • Suicide continuum stage

25. Suicide Continuum Passive Death Wish Suicidal Ideation without method Suicidal Ideation with method Attempt Completion Self-Injurious behavior with unclear intent

26. Focused assessment of continuum • It is vital to assess what the adolescent is thinking • In order to determine strengths and weaknesses, difficult questions must be asked centered on degree of desire to die • Questions must be very specific. Trying to assess suicidality without asking about death is like trying to determine appendicitis without asking “does it hurt here?” • There is ample evidence that asking about suicide does not “put” ideas in any adolescent’s mind

27. Examples of Suicide Continuum • Passive death wish • I wish God took me away • Ideation without method • I feel bad and have thought about killing myself • Ideation with a method • I am thinking about shooting myself

28. Attempt vs. Gesture • SUICIDE GESTURE: • Self-injury in which there is unclear intent to die but instead an intent to give the appearance of a suicide attempt in order to communicate with others(Nock & Kessler Journal of Abnormal Psychology 2006, Vol. 115, No. 3, 616 – 623) • SUICIDE ATTEMPT: • Potentially self-injurious behavior with a nonfatal outcome, for which there is evidence (either implicit or explicit) that the person intended at some level to kill self (Goldsmith SK, Pellmar TC, Kleinman AM, et al. Reducing Suicide: A National Imperative. Washington, D.C.: National Academy Press; 2002). • There is evidence that these two groups differ but there is also evidence that those who engage in suicide gestures also carry a higher risk of completion. • Those who “gesture” must be taken seriously

29. High Risk • 16 year old male • Abuses alcohol • Treated for bipolar disorder • History of suicidal ideas • Recent loss of mother due to medical illness • Father is a hunter • Broke up with GF and stated he wants to kill self

30. Medium Risk • 17 year old female • History of self mutilation without intent to die • Family history of completed suicide • Doing poorly in school, ostracized by peers • Attends therapy regularly • Has good relationship with parents • During an argument with peer in school was overheard voicing wish to die

31. Low Risk • 9 year old male • Parents recently separated • Stays with grandmother very often • Doing well in school and liked by peers • No family history of psychiatric problems • After watching a movie showing a suicide, told grandmother nobody likes him and he wishes to die

32. Risk And Disposition • High Risk • Inpatient treatment • If condition relapses, next time discharge to structured setting, possibly a therapeutic day school • Medium Risk • If new condition, Partial Care Program • If condition is chronic, structured setting advisable, possibly a therapeutic day school • Minimal Risk • Traditional Outpatient Treatment

33. Psychopathology of Suicide Bennett Silver, MD

34. How it Happens Alex was a 17 year old high school senior. He was a warm, sensitive, quiet young man; a high honor roll student and a gifted young writer. He had been accepted to an excellent college, and a promising, successful future seemed assured. Yet one late afternoon in April, upon returning home from work, his horrified mother discovered him on the floor of his bedroom. Alex had killed himself with a gunshot to the head. How is it possible that this young man, who seemed to have everything to live for, would take his own life?

35. Why it Happens In order to understand why tragedies like this occur, we must understand the psychopathology from which it stems.

36. Suicide as a Symptom • Suicide is to the psychiatrist as cancer is to the internist • The psychiatrist may provide optimal care, yet the patient may die by suicide nonetheless • Suicide is best viewed as a symptom of an underlying disease rather than a disease per se • The underlying disease is usually some type of depression, or another psychiatric disorder and therefore is highly treatable

37. Causes of Depression • Depression has no single cause. Genetics/Biology definitely play a role (family history) • The environment: stressful situations, abuse, family issues, physical illness, loss, romantic breakups, conflict over sexual orientation • Anxiety and behavior problems increase chances for depression • Predisposing personality traits: perfectionism, inhibition, isolation, supersensitive • Drug and alcohol dependency • Head injuries (e.g., football, soccer, car accidents), lead to disinhibition, depression and suicide • Sometimes no clear triggering event A bio-psycho-social model provides the best understanding of depression

38. Biological Theories About Suicide • Genetic factors predispose to suicide – clusters of families with both mood disorders & suicides and clusters with mood disorders without suicide, indicates independent inheritance of mood disorders and suicidal behavior • Biological theories about suicide linked to studies of depression-the mental state most often underlying suicide • Deficiency of neurotransmitters like norepinephrine/ serotonin at critical sites in brain resulting in depression • Many studies indicate a lower level of serotonin in brains of those who suicided and in cerebrospinal fluid of depressed individuals who have attempted suicide than in depressed patients who are not suicidal

39. Low Brain Serotonin, Impulsivity and Suicide • More violent suicide attempters/completers(guns, jumping) lower levels of serotonin than those using less violent means (e.g., pills) • Studies have found decreased serotonin levels for gamblers/fire-setters/impulsive individuals, compared to control populations • This non-specificity links lower serotonin levels with poor impulse control which increases suicidal behavior. • Alcohol lowers serotonin at same sites in brain as seen in depressed patients. Alcohol is a disinhibiter that increases impulsivity and greatly increases risk of suicide in depressed patients. • One third of adolescents who suicide are legally intoxicated at the time of death

40. Biopsychosocial Theories • Stress plays a role in development of depression, addiction and other psychiatric disorders • Corticotrophin releasing factor (CRF), a key brain hormone in the stress response, is implicated in the physiology of both depression & Substance use disorders (SUDs) • Elevated CRF concentrations found in the brains of suicide victims • Early life stress (physical/sexual abuse/neglect) and chronic stress cause sustained elevations of CRF, causing long term damage to brain pathways (neuroadaptation) which increases susceptibility to depression and substance use • This provides the biological underpinnings of the well-established relationship between early life adversity and depression, suicide and SUDs in adolescents and adults

41. Suicidal Behavior • More than 90% of all completed suicides in adolescents (and adults) are individuals with psychiatric disorders: • Mood Disorders (most common): Major Depression, Bipolar Dis • Schizophrenia • Alcoholism • Drug Dependence • Conduct Disorders • Borderline Personality Disorder • Panic Disorder • Substance Abuse Disorders and Anxiety Disorders appear more important as cofactors rather than primary in themselves. Co-existent high anxiety, panic, or substance use, accompanying major depressive disorder or schizophrenia markedly increase suicide risk

42. The Suicidal Crisis • Often, a crisis situation, what one author called a “state of perturbation,” occurs in a vulnerable adolescent with a psychiatric disorder and that crisis converts a state of potential risk into an actual suicidal act • The most common precipitating events are break-ups, episodes of perceived humiliation, academic or extracurricular failures, school disciplinary/legal problems, or sexual assaults

43. Mood Disorders and Completed Suicide60-70% of suicide victims were suffering from a significant clinical depression at the time of their deaths

44. Some Facts About Bipolar Disorder • Prevalence in America of approx 1% to 4% • Equally in men and women • 60% onset before age 20 • 10%-15% of adolescents with recurrent major depression go on to develop Bipolar Disorder • Residual symptoms between episodes common, and 60% experience chronic interpersonal and school difficulties between episodes • Strong genetic influence-one of most familial psychiatric disorders

45. Characterized by Recurrent Mood Episodes • Major Depressive Episode • Manic Episode • Mixed Episode • Hypomanic Episode

46. Manic Episode • Distinct period of persistently elevated, expansive, or irritable mood –causes marked impairment in functioning • During period of mood disturbance at least 3 of the following: • Inflated self-esteem or grandiosity • Decreased need for sleep • More talkative, pressured speech • Flight of ideas or racing thoughts • Distractibility • Increased in goal-directed activity (social, school work, sexual) or psychomotor agitation • Excessive involvement in activities with high potential for negative consequences (e.g., buying sprees, sexual indiscretions)

47. Mixed and Hypomanic Episodes • During a Mixed Episode manic and depressive symptoms may occur simultaneously or in quick succession. • During a Hypomanic Episode, symptoms same as during Manic Episode, but less severe - do not cause marked impairment in functioning.

48. Suicide Risk in Bipolar Disorder and Major Depression

49. Other Factors That Increase Suicidal Acts in Depressed and Bipolar Patients • Severity of depression • Age of onset (younger age) • Severity of ideation • Number of prior attempts • Stable levels of hopelessness • Transition points: first week of hospitalization, incarceration, bereavement, victimization/abuse

50. Comorbid Substance Abuse • Prevalence of comorbid substance abuse in bipolar I and bipolar II disorder is as high as 61% and 48% respectively • This is greater than the prevalence of substance abuse seen with any other psychiatric conditions, including schizophrenia, panic disorder, dysthymia and unipolar depression • Comorbid substance use increases the risk for suicide in mood disorders