# Presentation: 790744

## SUICIDE AND RELATED PROBLEMS IN ADOLESCENCE

***David Shaffer, F.R.C.P., F.R.C.Psych.*****Columbia University/New York State Psychiatric Institute**
**1051 Riverside Drive, New York, NY 10032**

**SUICIDE AND ****RELATED PROBLEMS ****IN ADOLESCENCE**

**FOOD AND DRUG ADMINISTRATION**
***FDA Meeting***

## 1EPIDEMIOLOGY

## LEADING CAUSES OF DEATH IN 15- TO 19-YEAR-OLDS— U N I T E D   S T A T E S,  2001 —

**Accidents****	****6646**
**Homicide****	****1899**
**Suicide****	****1611**
**Cancer****	****732**
**Heart Disease****	****347**
**Congenital Anomalies****	****255**
**Chronic Lower ****Respiratory Disease****	****74**
**Stroke****	****68**
**Influenza and Pneumonia****	****66**
**Blood Poisoning****	****57**

**Anderson & Smith 2003**

**1599**

**C.E14**

**LEADING CAUSES OF DEATH ****IN 15- TO 19-YEAR-OLDS****— U N I T E D   S T A T E S,  2001 —**

## SUICIDE METHODS: CHILDREN AND OTHERS— %   O F   A L L   S U I C I D E S,  U N I T E D   S T A T E S,  2000 —

**Hanging/****Suffocation****	****35****	****40****	****36****	****19****	****15****	****18**
**Ingestion****	****3****	****13****	****5****	****7****	****31****	****12**
**CO poisoning****	****2****	****2****	****2****	****5****	****6****	****5**
**Jumping from****a Height****	****2****	****3****	****2****	****2****	****3****	****2**
**Cutting****	****.4****	****0****	****.3****	****1****	****1****	****1**
**Other****	****3****	****5****	****3****	****4****	****7****	****5**

***	******	******5–19 Years******	******	******	******≥ 20 Years***
**	****M****	****F****	****ALL****	****M****	****F****	****ALL*****	******(N=1,595)******	******(N=333)******	******(N=1,928)******	******(N= 22,016)******	******(N=5,399)******	******(N=27,415)***

**CDC Wonder 2003 (11/13)**

**SUICIDE METHODS: ****CHILDREN AND OTHERS****— %   O F   A L L   S U I C I D E S,  U N I T E D   S T A T E S,  2000 —**

## SUICIDE RATES BY RACE PER 100,000 LIVING POPULATION— U N I T E D   S T A T E S ,   A L L   A G E S, 2001 —

**C.E1.XX**

**SUICIDE RATES BY RACE PER ****100,000 LIVING POPULATION****— U N I T E D   S T A T E S ,   A L L   A G E S, 2001 —**

**Rate per****100,000**

**CDC 2003 (WISQARS)**

## SUICIDE RATES DURING ADOLESCENCE— U N I T E D   S T A T E S ,   A G E S  10–24, 2001 —

**Age**

**C.E3**

**SUICIDE RATES ****DURING ADOLESCENCE****— U N I T E D   S T A T E S ,   A G E S  10–24, 2001 —**

**CDC 2003 (WISQARS)**

## TEEN SUICIDE RATES IN COUNTRIES WITH EFFECTIVE REPORTING— M A L E S   A G E   15–19 —

**	****2****	****New Zealand****	****1997–1998****	****33.2**
**	****3****	****Kazakhstan****	****1998–1999****	****30.7**
**	****4****	****Estonia****	****1998–1999****	****28.8**
**	****5****	****Lithuania****	****1998–1999****	****28.5**
**	****6****	****Finland****	****1997–1998****	****24.2**
**	****7****	****Latvia****	****1998–1999****	****22.1**
**	****8****	****Belarus****	****1998–1999****	****21.4**
**	****9****	****Canada****	****1996–1997****	****19.1**
**	****10****	****Austria****	****1999–2000****	****18.6**
**	****11****	****Ukraine****	****1999–2000****	****18.6**
**	****12****	****Croatia****	****1998–1999****	****17.7**
**	****13****	****Australia****	****1997–1998****	****17.5**
**	****14****	****Ireland****	****1996–1997****	****16.0**
**	****15****	****Switzerland****	****1995–1996****	****15.2**
**	****16****	****USA****	****1997–1998****	****14.9**
**	****17****	****Belgium****	****1994–1995****	****14.6**

**TEEN SUICIDE RATES IN COUNTRIES WITH EFFECTIVE REPORTING****— M A L E S   A G E   15–19 —**

**COUNTRY*********	****YEARS****	****RATE********

**	****18****	****Poland****	****1995–1996****	****14.4**
**	****19****	****Norway****	****1996–1997****	****14.0**
**	****20****	****Hungary****	****1999–2000****	****12.2**
**	****21****	****Bulgaria****	****1997–1998****	****11.9****	****22****	****Czech Republic****	****1998–1999****	****11.5**
**	****23****	****Germany****	****1998–1999****	****9.5**
**	****24****	****Sweden****	****1995–1996****	****9.4**
**	****25****	****Denmark****	****1995–1996****	****8.7**
**	****26****	****France****	****1997–1998****	****7.6**
**	****27****	****Japan****	****1996–1997****	****6.8**
**	****28****	****Romania****	****1998–1999****	****6.6**
**	****29****	****United Kingdom****	****1998–1999****	****6.3**
**	****30****	****Netherlands****	****1998–1999****	****5.9**
**	****31****	****Italy****	****1996–1997****	****5.2**
**	****32****	****Spain****	****1997–1998****	****4.9**
**	****33****	****China *****(selected ******	******	******urban and rural)*****	****1997–1998****	****3.9**
**	****34****	****Greece****	****1997–1998****	****2.3**

**COUNTRY*********	****YEARS****	****RATE********

**Pelkunen & Marttunen 2003; *available from WHO 3/5/2003; **2-year average per 100,000 population**

## TEEN SUICIDE RATES IN COUNTRIES WITH EFFECTIVE REPORTING— F E M A L E S   A G E   15–19 —

**	****2****	****Kazakhstan****	****1998–1999****	****10.3**
**	****3****	****Lithuania****	****1998–1999****	****10.3**
**	****4****	****Russian Federation****	****1997–1998****	****8.5**
**	****5****	****Estonia****	****1998–1999****	****7.6**
**	****6****	****Norway****	****1996–1997****	****7.0**
**	****7****	****China *****(selected ******	******	******urban and rural)*****	****1997–1998****	****6.4**
**	****8****	****Latvia****	****1998–1999****	****5.9**
**	****9****	****Belarus****	****1998–1999****	****5.6**
**	****10****	****Finland****	****1997–1998****	****5.6**
**	****11****	****Australia****	****1997–1998****	****5.4**
**	****12****	****Switzerland****	****1995–1996****	****5.4**
**	****13****	****Croatia****	****1998–1999****	****5.3**
**	****14****	****Austria****	****1999–2000****	****4.9**
**	****15****	****Canada****	****1996–1997****	****4.9**
**	****16****	****Ireland****	****1996–1997****	****4.8**
**	****17****	****Ukraine****	****1999–2000****	****4.6**

**TEEN SUICIDE RATES IN COUNTRIES WITH EFFECTIVE REPORTING****— F E M A L E S   A G E   15–19 —**

**COUNTRY*********	****YEARS****	****RATE********

**	****18****	****Bulgaria****	****1997–1998****	****4.5**
**	****19****	****Belgium****	****1994–1995****	****3.5**
**	****20****	****Sweden****	****1995–1996****	****3.4**
**	****21****	****Romania****	****1998–1999****	****3.3**
**	****22****	****USA****	****1997–1998****	****3.2**
**	****23****	****Czech Republic****	****1998–1999****	****3.1**
**	****24****	****Hungary****	****1999–2000****	****3.1**
**	****25****	****France****	****1997–1998****	****2.9**
**	****26****	****Japan****	****1996–1997****	****2.9**
**	****27****	****Netherlands****	****1998–1999****	****2.9**
**	****28****	****Poland****	****1995–1996****	****2.9**
**	****29****	****Germany****	****1998–1999****	****2.8**
**	****30****	****Denmark****	****1995–1996****	****2.0**
**	****31****	****United Kingdom****	****1998–1999****	****2.0**
**	****32****	****Spain****	****1997–1998****	****1.6**
**	****33****	****Italy****	****1996–1997****	****1.5**
**	****34****	****Greece****	****1997–1998****	****0.5**

**COUNTRY*********	****YEARS****	****RATE********

**Pelkunen & Marttunen 2003; *available from WHO 3/5/2003; **2-year average per 100,000 population**

## FREQUENCY OF SUICIDAL IDEATION AND ATTEMPTS— U.S. HIGH-SCHOOL STUDENTS, AGE 15–19, YRBS ——(2001, N=13,601)

**Attempt****	****8.8%****	****1.8 million**
**Attempt received****	****2.6%****	****520,000****medical attention**
**SUICIDE (age 15–19)*****	****.008%****	****1,611**

*** Anderson 2002; Grunbaum et al. 2002 (YRBS), U.S. Census 2000**

**C.E15.XX**

**FREQUENCY OF SUICIDAL IDEATION AND ATTEMPTS****— U.S. HIGH-SCHOOL STUDENTS, AGE 15–19, YRBS ——*****(2001, N=13,601)***

_**	**_**RATE****	****N**

## TEEN ATTEMPTERS ATTEMPTS PER YEAR(2001, YRBS, N=13,601)

**	****2 or 3****	****30%**
**	****4 or More ****	****17%**
***Similar findings in patient studies***
***1 attempt increases risk of another 15-fold***

**TEEN ATTEMPTERS**** ****ATTEMPTS PER YEAR*****(2001, YRBS, N=13,601)***

**Barter et al. 1968, Brent 1993, CDC 2002 (YRBS 2001 Codebook), Goldacre & Hawton 1985, Goldston et al. 1999, Hawton et al. 1982, Hulten 2001, Kotila 1992, Lewinsohn et al. 1994, McIntire et al. 1977, Spirito 1992, Spirito et al. 2003, Wichstrom 2000**

**SA42.XX**

## EPISODES OF IDEATION* PER YEAR

**EPISODES OF ****IDEATION********* PER YEAR**
***(N=981)***

**Reifman & Windle 1995; *“How often have you thought about killing yourself?”; past year, N=698; last 6 months, N=283)**

**1****	****45%**
**2****	****24%**
**3 or More****	****31%**

**SI19.XX**

## HOW ARE SUICIDAL ADOLESCENTS EXCLUDED FROM PSYCHOPHARM STUDIES?

**STUDY****	****EXCLUSION CRITERIA**
***Sertraline******	*****“previous attempt or*****(Wagner et al. 2003)*****	****posing significant****	****suicidal risk”**
***Fluoxetine*****	****“serious suicidal risk”*****(Emslie et al. 2002)***
***Fluoxetine******	****** *****not specified*****(Emslie et al. 1997)***
***Paroxetine*****	****“current ideation with intent or*****(Keller et al. 2001)*****	****specific plan OR history of****	****attempts by drug overdose”**
***Citalopram******	*****not specified*****(Wagner et al. 2001)***

**SI22.XX**

## 20TH-CENTURY - CHANGES IN YOUTH SUICIDE RATES— U N I T E D   S T A T E S ,  A G E S   15–24 —

**C.E16.XX**

**20TH-CENTURY - CHANGES IN YOUTH SUICIDE RATES****— U N I T E D   S T A T E S ,  A G E S   15–24 —**

**Rate per****100,000**

**Anderson 2002, CDC Wonder 2003, USDHEW 1956, Vital Statistics U.S. 1954–1978**

## 2CAUSES OF SUICIDE

## PSYCHIATRIC DISORDER IN ADOLESCENT SUICIDE— P S Y C H O L O G I C A L - A U T O P S Y   S T U D I E S —

**Israel****	****43****	****mid-1980s****	****90%**
***New York****	****120****	****1984–1986 ****	****90%**
**Finland****	****53****	****1987–1988****	****94%**
***Pittsburgh****	****140****	****1984–1994****	****82%**

**PSYCHIATRIC DISORDER ****IN ADOLESCENT SUICIDE****— P S Y C H O L O G I C A L - A U T O P S Y   S T U D I E S —**

**C.D6.XX**

**Apter 1993, Shaffer 1996, Marttunen 1991, Brent 1999; *case-control studies**

## MOST COMMON  DIAGNOSES IN TEEN SUICIDESS

***	******	******(N=213)******	******(N=46)***
**Depression ****	****50% ****	****69%**
**Antisocial ****	****43% ****	****24%**
**Substance Abuse****	****38%****	****17%**
**Anxiety ****	****19%****	****48%**
***66% of 16- to 19-Year-Old Male Suicides Have Substance/Alcohol Abuse***

**MOST COMMON  ****DIAGNOSES IN TEEN SUICIDESS**

**Brent et al. 1999, Shaffer et al. 1996**

**C.D8.XX**

## SUICIDALITY IN DEPRESSED CHILDREN AND TEENS

**Andrews & Lewinsohn 1992, Fombonne et al. 2001, Haavisto et al. 2003, Kovacs et al. 1993, Larson & Ivarsson 1998, Ryan et al. 1987, Weissman et al. 1999, Wichstrom 2000**

**	*****At Time of Diagnosis***
**STUDIES ****	**** SUBJECTS ****	**** IDEATION****	****ATTEMPT**
**	****6****	****1265****	****60%****	****30%****	**
***During Follow-Up***
**STUDIES ****	**** SUBJECTS ****	**** IDEATION****	****ATTEMPT**
**	****3****	****466****	****?****	****24%**

**DE21.XX**

## OTHER FACTORS THAT PREDISPOSE TO SUICIDE

**2004 January**

**Imitation **
**Biological abnormalities that ?predispose to impulsive response to stress**
**A family history of suicide**

## HOW SUICIDES OCCUR— P A T H W A Y S   T O   A N D   F R O M   I D E A T I O N —

**HOW SUICIDES OCCUR****— P A T H W A Y S   T O   A N D   F R O M   I D E A T I O N —**

## 3CHANGING RATES

## 20TH-CENTURY - CHANGES IN YOUTH SUICIDE RATES — U N I T E D   S T A T E S ,  A G E S   15–24 —

**C.E16.XX**

**20TH-CENTURY - CHANGES IN YOUTH SUICIDE RATES ****— U N I T E D   S T A T E S ,  A G E S   15–24 —**

**Rate per****100,000**

**Anderson 2002, CDC Wonder 2003, USDHEW 1956, Vital Statistics U.S. 1954–1978**

## TEEN SUICIDE RATES IN INDUSTRIALIZED NATIONS— M A L E S   15–24,   1988–2001 —

**Australia**
**Austria***
**Canada**
**England & Wales**
**France**
**Germany***
**Hong Kong**
**Ireland**
**Italy**

**TEEN SUICIDE RATES IN INDUSTRIALIZED NATIONS****— M A L E S   15–24,   1988–2001 —**

**Japan**
**New Zealand**
**Spain**
**Switzerland***
***Stable/Rising Rates***
**Scotland**

**World Health Organization 2003; *decline started before 1988**

## POSSIBLE REASONS FOR DECLINING SUICIDE RATES 1

***	******BUT****** ***
***Rates also decline in high-youth-unemployment countries***
***relationship between SES and suicide not strong***
**Less drug and alcohol abuse**
***	******BUT****** ***
***use and abuse rates have not changed***

**POSSIBLE REASONS FOR DECLINING SUICIDE RATES 1**

**[DR13.XX]**

## POSSIBLE REASONS FOR DECLINING SUICIDE RATES 2

***	******BUT****** ***
***proportion of suicides by firearm unchanged***
***declines noted in countries with very few firearm suicides***

**POSSIBLE REASONS FOR DECLINING SUICIDE RATES 2**

**[DR13.XX]**

## POSSIBLE REASONS FOR DECLINING SUICIDE RATES 3

***	******BUT****** ***
***psychotherapy has declined***
**More psychopharmacologic treatment**
**Better recognition of adolescent depression**
**Some combination of the above**

**POSSIBLE REASONS FOR DECLINING SUICIDE RATES 3**

**[DR13.XX]**

## 4TREATMENT CONSIDERATIONS

## EFFECTIVE TREATMENT OF SUICIDE ATTEMPTERS— M E T A - A N A L Y S I S   O F   2 3   R C T s —Outcome = Repeated Attempts

**PSYCHOTHERAPY**
***DBT***** (adult borderlines)**
**MEDICATION**
***Flupenthixol (Navane)***** in multiple attempts**
**Lithium in bipolar**
**Clozaril in schizophrenia**

**Meltzer et al 2003, Montgomery & Montgomery 1982, Tondo & Baldessarini 2000**

**C.Rx3**

## TEENS WHO SUICIDE RECEIVE LESS TREATMENT THAN ADULTS

**STUDY****	****RECENT TREATMENT**
**Ulster****	****30%**
**United Kingdom****	****56%**
**Canada****	****50%***** ***
***Teens***
**STUDY****	****RECENT TREATMENT**
**Finland****	****23%**
**Pittsburgh****	****15%**
**New York City****	****21%**
**Norway****	****7%**

**TEENS WHO ****SUICIDE RECEIVE LESS TREATMENT THAN ADULTS**

**C.Rx18.XX**

**Marttunen et al. 1992 ****Brent et al. 1993, Shaffer et al. 1996, Groholt et al. 1997, Foster et al. 1997, Appleby et al. 1999, Lesage et al. 1994**

## DEPRESSED TEENS WHO COMMIT SUICIDE DO NOT TAKE THEIR MEDICATIONS— U T A H   Y O U T H   S U I C I D E   S T U D Y,   N = 49 —

**Antidepressants ****found at autopsy****	****0%**

**DEPRESSED TEENS WHO ****COMMIT SUICIDE DO NOT ****TAKE THEIR MEDICATIONS****— U T A H   Y O U T H   S U I C I D E   S T U D Y,   N = 49 —**

**Gray et al. 2003**

**DR30.XX**

## SUICIDALITY DURING THE TREATMENT OF TEEN DEPRESSION

**Cautions & Considerations -1**

**2004 February**

**Ideation and attempts are common in depressed teens and recur frequently. **
**Teens often conceal ideation and attempts unless asked about them directly.Self report facilitates disclosure.**
**Event Reports may be influenced by mode of elicitation. They are not used with a glossary, misclassification can occur.**

## SUICIDALITY DURING THE TREATMENT OF TEEN DEPRESSION

**Cautions & Considerations -2**

**2004 February**

**“****Self harm” is a heterogeneous descriptor - not all types of self harm are associated with suicidal intent.**
**There have been no direct studies -with frequent and careful measurements -examining whether SSRI’s increase, decrease or have no effect on suicidal ideation and behavior.**

## SUICIDALITY DURING THE TREATMENT OF TEEN DEPRESSION

**Cautions & Considerations -3**

**2004 February**

**After *****increasing***** for 35 years teen suicide rates have been *****declining***** consistently in **_**many**_** countries. **
**During this period there has been a marked **_***increase***_** in exposure of teens to SSRI antidepressants. **
**These trends *****could***** be related. We do not - currently - have a better explanation for the turnabout of a condition that led to the death of tens of thousands of young people.**