Clinical assessment versus research methods in the assessment of suicidal behavior

Youth suicidal behavior: assessment and intervention

In this article, the authors review the research on risk assessment of suicidal adolescents and describe the small body of randomized-clinical-treatment trials for this population. Research has yielded a fairly consistent set of direct and indirect risk factors for suicidal behavior in adolescents. The authors describe a variety of measures commonly used to assess these risk factors. Treatment studies targeting suicide are sparse for all ages. In the adult literature, evidence suggests clozapine, depot flupenthixol, lithium, and dialectical behavior therapy (DBT) are significantly more effective in decreasing suicidal behavior than placebo or Treatment as Usual. For adolescents, it is difficult to draw conclusions about treatment efficacy. In general, control conditions are just as effective at reducing suicidal behavior as experimental conditions. While some novel interventions for suicidal adolescents are described, there is a desperate need for more research to be conducted in order to advance this burgeoning field.

Factors associated with repeat suicide attempts among adolescents

OBJECTIVE

To determine potential risk factors associated with repeat suicide attempts among adolescents.

METHOD

Retrospective medical record review of all patients aged 13-20 years who presented to the emergency department at an inner city tertiary hospital after attempted suicide between 1994 and 1996. Subjects were identified using the International Classification of Diseases (ICD-9) codes E950.0 to E959.9 for attempted suicide. Study variables included demographic parameters, chronic medical conditions/illnesses, psychiatric and substance abuse disorders, history of sexual abuse and previous and subsequent suicide attempts. Variables univariately associated with repetition at p < 0.25 were entered into a multiple regression analysis.

RESULTS

Eighty seven per cent of patients presented with a drug overdose. Seventy-six per cent of all subjects attempted suicide in the context of a dispute or relationship break-up. At least one psychiatric disorder was present in 76% of subjects at the index attempt. The most frequently diagnosed disorders were depression (45.5%) and drug (34%) and alcohol abuse (27%). Variables predicting repetition within 12 months were drug (OR = 3.891, p = 0.02) and alcohol abuse (OR = 3.56, p = 0.05), non-affective psychotic disorders (OR = 3.81, p = 0.04), and chronic medical conditions/illness (OR = 3.29, p = 0.03). A history of sexual abuse was almost significant (OR = 3.03, p = 0.06).

CONCLUSIONS

Adolescents most likely to re-attempt suicide with 12 months present with either substance abuse, non-affective psychotic disorders, chronic medical conditions, or a history of sexual abuse. All adolescents with a possible suicide attempt should receive a comprehensive mental health and psychosocial assessment. Closer scrutiny of the role of chronic illnesses and sexual abuse in both future research and clinical management is urged. A broad based, multidisciplinary intervention approach is recommended.

Surveillance of suicidal behavior in Kitsap County, Washington: a retrospective study

Suicide is a major source of preventable morbidity and mortality in Kitsap County, Washington State. This article describes a study of suicidal behavior to identify risk groups in order to design intervention strategies. A retrospective study was conducted by reviewing the charts of individuals exhibiting suicidal behavior who had presented to the county's only civilian hospital emergency department over a 7 month period. Frequencies were calculated to identify at-risk populations and determine risk factors. One hundred forty-five charts were reviewed. Subjects were mostly female (69%), and ages ranged from 10 to 80 years with 73% between 15 and 44 years. Two-thirds of the subjects were not working. More than half had previously exhibited suicidal behavior and more than 75% had previous mental health encounter(s). Most admissions (67.6%) occurred between 4:00 p.m. and 4:00 a.m. The core public health functions of assessment, policy development, and assurance provided the framework for this community to explore the finding that suicide was a major source of preventable morbidity and mortality. Community-based intervention strategies have been developed in an effort to reach the Healthy People 2000 objective of reducing suicide deaths to no more than 10.5 per 100,000 residents.

A clinical-psychological approach to suicidal behavior in depression from Moscow

This contribution strives to familiarize Western readers with the theoretical concept of suicidal behavior which was developed at the Department of Suicidology of Moscow Psychiatric Research Institute and has been in use there for the last two decades. In describing this approach the paper concentrates on what differentiates it from traditional Western management without making value judgments about either approach. Such an account of the concept and its development will hopefully afford the reader an opportunity to arrive at his or her own conclusions regarding its clinical value.

Pharmacotherapy of affectively ill suicidal patients

The development of psychopharmacologic strategies for ameliorating the symptoms associated with major psychiatric disorders is relatively recent in the history of medicine. Regarding depression, the past 30 years have seen the advent of several clinically therapeutic antidepressant medication classes. With the advent of these newer and safer antidepressants, more primary care practitioners are prescribing these drugs, and as a result, more people are being prescribed antidepressant medication than ever before. This article reviews this psychopharmacologic revolution that has emerged as a consequence of a greater understanding of the neurochemical perturbations underlying major affective disorders.

Validity of DSM-III-R diagnosis by psychological autopsy: a comparison with clinician ante-mortem diagnosis

Psychological autopsies are an important research tool in establishing risk factors associated with suicide. We report the results of a validity study comparing psychological autopsy-generated DSM-III-R diagnoses in suicides and non-suicides with chart diagnoses generated by clinicians who had treated the subjects prior to death. The Structured Clinical Interview for DSM-III-R Disorders (SCID-P) and the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) were used to make independent post-mortem diagnoses. Comparison of research diagnoses with clinician ante-mortem diagnoses generated kappa coefficients of 0.85 for Axis I diagnoses and 0.65 for Axis II conditions. These kappa coefficients compare favourably with direct patient interview reliability studies. This provides evidence for the validity of the psychological autopsy as a method of determining psychiatric diagnosis.