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An NIMH report published in 2000 estimated that 8
million American children and adolescents suffer from serious behavioral,
emotional and cognitive disorders. Suicide is currently the third
leading cause of death among 15-to-24-year olds.
To find successful interventions, NIH supports nationwide programs
in universities and research hospitals, among them the Western
Psychiatric Institute and Clinic in Pittsburgh. That's where Dr.
David A. Brent, professor of psychiatry, pediatrics and epidemiology,
has been continuously funded by NIMH since 1985. He spoke on "Suicidal
Risk in Adolescents: Assessment and Treatment," at the Great Teachers
lecture series Feb. 8 in Lipsett Amphitheater.
|Dr. David A. Brent
"Having some thought of wanting to die is quite common in adolescents," Brent
began, "at around 20 percent. As you get ideation with a plan,
or with intent, that is much less common."
For medically serious suicide attempts, the prevalence is about
1-2 percent. Girls are about twice as likely to attempt as boys,
and of those who attempt, between 15 and 30 percent will repeat
within a year. "This is concerning because suicidal behavior is
the most significant risk factor for completed suicide," Brent
said, "with a 10- to 60-fold increase in risk."
Yet there is good news. "I would like to see this on the cover
of the New York Times," Brent declared. "The suicide rate among
adolescents has been declining for about a decade." We don't yet
know why. People who are interested in anti-depressants think the
decrease reflects increased sales, he noted, and people interested
in gun control have correlated the decrease with that.
"If you only have time to look at one assessment factor," he said, "the
most important is the nature of the suicidality, because that's
what drives the risk: specifically, the degree to which the person
has intent to kill himself or herself at that moment."
To assess ideation, the clinician should progress from less specific
questions ("Have you ever thought you'd be better off dead?") to
more specific ("Do you have a plan?").
Other important dimensions of ideation are frequency and intensity, "but
the fact that somebody has suicidal ideation only occasionally
is not that reassuring, because it's really the 'worst point' that's
the most dangerous. Somebody can impulsively act on a suicidal
urge; that's really what you need to target."
Brent recalled a teenager "who had saved up 90 pills, overdosed,
and then claimed it was an accident. So look at what people do
rather than at their own report — including, interestingly
enough, whether they've communicated intent to someone."
Brent described a variety of risk factors for suicidal behavior,
among them psychological characteristics such as hopelessness;
aggression and impulsivity; a social skills deficit; and homosexuality/
bisexuality. He was careful to clarify that "homosexuality and
bisexuality are not synonymous with pathology, but the response
of society is deviant. There's so much stigma. Victimization, rejection
and bullying place these kids at a much higher risk of suicidal
||Dr. David Brent of Western
Psychiatric Institute and Clinic in Pittsburgh presents recent
clinical and research findings on teen suicide risk.
Family and environmental factors such as discord, abuse and neglect
are also significant. "If you could eliminate sexual abuse," Brent
stated, "you could eliminate about one-fifth of suicidal behavior." In
collaboration with colleagues at Columbia, Brent is engaged in
an ongoing study indicating how suicidal behavior runs in families.
He stressed that this is not accounted for by mood disorders alone,
but also because of the familial transmission of impulsive aggression,
probably related to genetic factors. "While this could take years
to prove," said Brent, "from a clinical point of view we know that
it's a significant factor."
Brent emphasized how adolescents' risky behaviors can be offset
by a few core processes: having dinner with your kids every night;
being involved in their activities; seeing that kids have a connection
with schools and protecting them from "deviant peer groups."
"The relationship between mood disorders and suicide is intimate,
though it is not the only risk factor," Brent continued. Depression
increases the risk for suicidal behavior 10- to 50-fold; 80 percent
of attempters and 60 percent of completers are depressed. Some
studies suggest that improved treatment of depression reduces suicidality;
others show reduction in suicide with use of selective serotonin
reuptake inhibitors (SSRIs).
On the other hand, Brent noted, such treatment may not reduce
suicidal risk, since the most suicidal individuals are excluded
from clinical trials of depression.
"It's a curious finding," he said, "that suicidal behavior and
mood don't move entirely in concert. Suicidality is multifactorial."
There are very few studies on treatment of suicidal youth, and
the ones that have been done are not that promising. "This one
is kind of humbling," said Brent. "The most powerful effect came
in a study using follow-up postcards sent to teens and saying things
like 'I'm concerned about you,' which shows how nonspecific factors
may be the most potent."
He also noted areas that haven't been sufficiently looked at "but
should be, such as lithium as protection against suicide."
What do you do with somebody who's suicidal? There are a few important
considerations: a safety plan; case management to determine appropriate
level of care, and to ensure return for treatment; analysis of
the attempt; focus on cognition and the most relevant factors leading
to the attempt; a relapse prevention session, including role-playing
to access crucial skills.
"We teach them a simple emotional regulation technique to identify
at what point they're so hot they're going to lose control, but
can still turn back; we try to work out with them and the family
permission for this kid to walk out of the room to cool off.
"Ultimately, we want these kids and their parents to know everything
we know about depression and suicidal behavior, which unfortunately
isn't all that much. Transparency is a good thing. I will never
put somebody on a medication per se. I'll say these are the benefits,
these are the risks, but it's up to you. Not that you don't sometimes
have to hospitalize people, but over the long run, you want people
to take responsibility and control over their own illness." Common
sense advice includes exercising, engaging in enjoyable activities
and getting enough sleep.
Asked whether talking with kids about suicide increases incidence,
Brent cited a recent study that proved it doesn't.
"Here is the main issue in somebody who is suicidal," he said. "Simultaneously
these kids have two wishes." He turned both palms up, side-by-side,
and rhythmically moved them up and down, as if hefting two objects
of equal weight. "They have a wish to die and a wish to live. The
two are in balance, and we have to find how to strengthen the balance
in the direction of life."