Primary Care Recognition and Management of Suicidal Behavior in Juveniles

1. Primary Care Recognition and Management of Suicidal Behavior in Juveniles Jeffrey I. Hunt, MD Alpert Medical School of Brown University

2. The Scope of the Problem • 3rd leading cause of death among 10-14 and 15-19 year olds. (Anderson, 2002) • 1 out of 5 teenagers in the US seriously considers suicide. (Grunbaum et al., 2002) • 1600 US teenagers die by suicide each year.

3. Rates of Suicidal Behaviors • Youth risk behavior study (YRBS) conducted by CDC indicated: • 19% of HS students contemplate suicide • 15% made specific plans • 8.8% attempted suicide • 2.6% made medically significant attempts • Overall, decrease in youth suicides in past decade. (JAACAP April, 2003)

4. The Challenge for Primary Care • Many suicidal young people seek medical care in the month preceding their suicidal behavior, fewer than half of doctors reported that they routinely screen for suicide risk (Pfaff, 1999; Frankenfield, 2000) • Need for training • 72% of 600 family physicians and pediatricians in NC had prescribed an SSRI but only 8% had adequate training and only 16% said they were comfortable treating depression (Voelker, 1999) • Educational approaches for primary care MDs have led to reductions in suicide rate in adult studies (Rutz, 1992)

5. Clinical Characteristics of Teens Who Commit Suicide • Most Common Diagnoses • Mood Disorder 60% • Antisocial Disorder 50% • Substance Abuse 35% • Anxiety Disorder 27% Gould et al., 1996

6. Clinical Features of Suicide Attempt vs. Completed Suicide • Completers more likely than attempters: • have bipolar disorder • have firearm in the home • have high suicidal intent • have dual diagnosis of mood and non-mood disorder Brent et al, 1993; Gould et al., 1996

7. Onset of Any Psychiatric Symptoms Before a Suicide • Time before death • > 12 months 63% • 3-12 months 13% • < 3months 4% Shaffer et al., 1996

8. Most suicides preceded by a stressful event • disciplinary crisis • relationship problem • humiliation • contagion Gould et al., 1996

9. Onset of Ideation Before a Teen’s Suicide Attempt(N=29) • < 30 minutes 69% • 39-119 minutes 24% • > 2 hours 7% Negron et al., 1997

10. SuicideFacts • Age • Uncommon in childhood, early adolescents. • Increases markedly in late teens to 20’s. • Gender • Suicide attempts more common among females • Completed suicides 5X more among males. • Firearm and strangulation in males vs. OD in females.

11. Suicide Facts • Ethnicity • More common among Caucasians than African-Americans. • Highest among native Americans and lowest among Asians/ Pacific- Islanders. • Motivation and Intent • Expression of extreme distress • 2/3 attempt suicide for reasons other than to die. • Result of an impulsive act, desire to influence others, gain attention and escape a noxious situation.

12. Suicide Facts • Highest in western states and Alaska • Firearms most common method • rural: firearms • urban: jumping from a height • suburban: asphyxiation by CO • Ingestions in 15-24 year olds: 16% of female suicides, 2% of male suicides

13. Risk Factors • Psycho-pathology • 90% of youth suicides have at least one major psychiatric disorder. (Beautrais, 2001) • Depression, substance abuse and aggressive or disruptive behaviors very common. • 49% – 64% of all adolescent suicide victims have depressive disorders. • 10% - 15% of all patients with bipolar disorder commit suicide.

14. Risk Factors • Immediate Risk elevated by severe anxiety or agitation • Prior suicide attempt is a strong predictor of completed suicide. • Serotonin function abnormalities. • Reduced serotonin metabolites in the brain and CSF of suicide victims.

15. Risk Factors • Family factors • Parental psycho-pathology particularly depression and substance abuse. • Family history of suicide. • Parental conflicts / divorce. • Parent – child relationship

16. Risk Factors • Socio-environmental factors. • Life stressors (interpersonal losses). • Physical / Sexual abuse. • School / Work problems. • Lack of meaningful peer relationships. • Access to firearms. • Chronic / Multiple physical illness.

17. Protective Factors • Family cohesion • Religiosity • Ability to form therapeutic alliance

18. Secular Trends • Suicide rate declining • Possible reasons: • Increase in prescriptions of antidepressants • firearm legislation • Firm conclusions not possible

19. Suicide Risk Assessment • One of the most complex, difficult and challenging clinical tasks in psychiatry • Forecasting the weather as metaphor for suicide risk assessment (Simon, 1992) • suicide risk is time driven assessments • short term assessments more accurate • Like a weather forecast suicide risk assessments need to be updated frequently

20. Suicide Risk Assessment • Needs to be systematic • Checklists helpful but not sufficient • “Contracting for safety” does not eliminate need for risk assessment • Documentation of clinical decision making is important

21. Assessment of Suicidal Behavior • Assessment of the Attempt • type of method • potential lethality • degree of planning involved • degree of chance of intervention • previous suicide attempts • pervasive suicidal ideation • availability of firearms or lethal medications • motivating feelings

22. Assessment of Underlying Conditions • Psychiatric diagnoses • Social/environmental factors • Cognitive distortions • Coping style • History of family psychopathology • Family discord or other life event stresses

23. Acute Management • Identify all risk factors • Identify resources that potentially reduce risk • If risk outweighs available resources consider increased level of care

24. Gender: All males over age 12 Mental State: Depression, psychosis, hopelessness, social withdrawal, persisting SI, Intoxication Nature of Attempt: Potentially lethal attempt Past History: previous suicide attempts and/or history of volatile and unpredictable behavior Home Background: absence of caring or responsible setting Factors Indicating Hospitalization Shaffer et al., 2000

25. Minimum Steps to Take Before Discharge from Office or ED • Always talk to the parent or caregiver to corroborate the adolescent’s history and to establish treatment alliance and plan to maintain safety • Secure any firearms and medication • Concrete and precise follow-up appointment with emergency telephone numbers • No-suicide contract (helpful but not sufficient) Shaffer, et al., 2000

26. Treatment: Inpatient & Partial Hospitalization • No evidence that exposure to other suicidal psychiatric inpatients increases the risk of suicidal behavior • Stabilize mood • Address environmental stresses • Address clearly dysfunctional family patterns or parental psychiatric illness

27. Treatment Approaches • Problem oriented • Cognitive Behavior Therapy • Dialectical Behavior Therapy • Medication • Family Therapy • Group Therapy

28. Crisis Services Educational approaches Case Finding Professional education Suicide Prevention

29. Community-Based Suicide Prevention • Crisis hot lines • little research fails to show impact • Method restriction • gun-security laws little impact • raised minimum drinking age significant impact • Indirect case finding through education • fails to increase help-seeking behavior and activates SI in previously suicidal adolescents

30. Community-Based Suicide Prevention • Direct case finding • cost-effective and highly sensitive • screening in a non-threatening way at risk youth in high schools, detention centers, etc. • www.teenscreen.org • Media Counseling • CDC and AFSP guidelines regarding risk of prominent coverage of youth suicide • Training • educating primary care providers regarding identification and treatment of mood disorders

31. Legal Issues in Suicide • Assessment versus prediction • No standard of exists for the prediction of suicide • standard exists requiring adequate assessment of suicide • Courts analyze suicide cases to determine whether suicide was foreseeable • Contemporaneous documentation of suicide risk assessment is vital

32. Team approach • Know the mental health clinicians with whom you are working • Establish regular means of communicating about your mutual patients • Identify with the patient and parents who is to be first point of contact • Document discussions with collaborators

33. Summary • Suicidal behavior in adolescents is very common • Primary care clinicians often have contact with suicidal adolescents prior to them making attempts • Systematic and timely risk assessments can reduce morbidity and mortality