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SUICIDE AND RELATED PROBLEMS IN ADOLESCENCE

FOOD AND DRUG ADMINISTRATION FDA Meeting. SUICIDE AND RELATED PROBLEMS IN ADOLESCENCE. February 2, 2004 9:00 A.M. Washington, D.C. David Shaffer, F.R.C.P., F.R.C.Psych. Columbia University/New York State Psychiatric Institute 1051 Riverside Drive, New York, NY 10032. 1 EPIDEMIOLOGY.

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SUICIDE AND RELATED PROBLEMS IN ADOLESCENCE

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  1. FOOD AND DRUG ADMINISTRATION FDA Meeting SUICIDE AND RELATED PROBLEMS IN ADOLESCENCE February 2, 20049:00 A.M.Washington, D.C. David Shaffer, F.R.C.P., F.R.C.Psych.Columbia University/New York State Psychiatric Institute 1051 Riverside Drive, New York, NY 10032

  2. 1EPIDEMIOLOGY

  3. LEADING CAUSES OF DEATH IN 15- TO 19-YEAR-OLDS— U N I T E D S T A T E S, 2001 — CAUSE # OF DEATHS 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 1599 Anderson & Smith 2003 C.E14

  4. 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 — 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) Firearms 55 37 52 62 37 57 Hanging/Suffocation 35 40 36 19 15 18 Ingestion 3 13 5 7 31 12 CO poisoning 2 2 2 5 6 5 Jumping froma Height 2 3 2 2 3 2 Cutting .4 0 .3 1 1 1 Other 3 5 3 4 7 5 CDC Wonder 2003 (11/13)

  5. 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 per100,000 Age CDC 2003 (WISQARS) C.E1.XX

  6. SUICIDE RATES DURING ADOLESCENCE— U N I T E D S T A T E S , A G E S 10–24, 2001 — Rate per100,000 Age CDC 2003 (WISQARS) C.E3

  7. TEEN SUICIDE RATES IN COUNTRIES WITH EFFECTIVE REPORTING— M A L E S A G E 15–19 — COUNTRY* YEARS RATE** COUNTRY* YEARS RATE** 1 Russian Federation 1997–1998 34.5 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 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 Pelkunen & Marttunen 2003; *available from WHO 3/5/2003; **2-year average per 100,000 population

  8. TEEN SUICIDE RATES IN COUNTRIES WITH EFFECTIVE REPORTING— F E M A L E S A G E 15–19 — COUNTRY* YEARS RATE** COUNTRY* YEARS RATE** 1 New Zealand 1997–1998 17.1 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 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 Pelkunen & Marttunen 2003; *available from WHO 3/5/2003; **2-year average per 100,000 population

  9. FREQUENCY OF SUICIDAL IDEATION AND ATTEMPTS— U.S. HIGH-SCHOOL STUDENTS, AGE 15–19, YRBS ——(2001, N=13,601) RATE N Ideation 19.0% 3.8 million Attempt 8.8% 1.8 million Attempt received 2.6% 520,000medical attention SUICIDE (age 15–19)* .008% 1,611 * Anderson 2002; Grunbaum et al. 2002 (YRBS), U.S. Census 2000 C.E15.XX

  10. TEEN ATTEMPTERSATTEMPTS PER YEAR(2001, YRBS, N=13,601) • 1 53% • 2 or 3 30% • 4 or More 17% • Similar findings in patient studies • 1 attempt increases risk of another 15-fold 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

  11. TEEN IDEATORS EPISODES OF IDEATION* PER YEAR (N=981) 1 45% 2 24% 3 or More 31% Reifman & Windle 1995; *“How often have you thought about killing yourself?”; past year, N=698; last 6 months, N=283) SI19.XX

  12. 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

  13. 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 per100,000 Year Anderson 2002, CDC Wonder 2003, USDHEW 1956, Vital Statistics U.S. 1954–1978 C.E16.XX

  14. 2CAUSES OF SUICIDE

  15. 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 — LOCATIONN YEARS % Israel 43 mid-1980s 90% *New York 120 1984–1986 90% Finland 53 1987–1988 94% *Pittsburgh 140 1984–1994 82% Apter 1993, Shaffer 1996, Marttunen 1991, Brent 1999; *case-control studies C.D6.XX

  16. MOST COMMON DIAGNOSES IN TEEN SUICIDESS MALE FEMALE (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 Brent et al. 1999, Shaffer et al. 1996 C.D8.XX

  17. SUICIDALITY IN DEPRESSED CHILDREN AND TEENS At Time of Diagnosis STUDIES SUBJECTS IDEATION ATTEMPT 6 1265 60% 30% During Follow-Up STUDIES SUBJECTS IDEATION ATTEMPT 3 466 ? 24% 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 DE21.XX

  18. OTHER FACTORS THAT PREDISPOSE TO SUICIDE • Imitation • Biological abnormalities that ?predispose to impulsive response to stress • A family history of suicide 2004 January

  19. 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 — COGNITIVE SET SUICIDALIDEATION (Hopelessness) ACTIVE DISORDER e.g. Mood DisorderSubstance AbuseAlcohol Abuse INHIBITION FACILITATION UNDERLYING “IMPULSIVE” TRAIT SOCIAL Religiosity Available Support Difficult Accessto Method Consider Effect on Others STRESS EVENT e.g. Trouble with Law/School Loss Humiliation IMPACT OF ALCOHOL SOCIAL Recent Example Weak Taboo Being Alone ACUTE MOOD CHANGE MENTAL STATE e.g. Anxiety – DreadHopelessnessAnger METHOD AVAILABILITY/COMPETENCE Slowed Down MENTAL STATE Agitation SURVIVAL SUICIDE C.MO1.XX

  20. 3CHANGING RATES

  21. 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 per100,000 Year Anderson 2002, CDC Wonder 2003, USDHEW 1956, Vital Statistics U.S. 1954–1978 C.E16.XX

  22. TEEN SUICIDE RATES IN INDUSTRIALIZED NATIONS— M A L E S 15–24, 1988–2001 — • Declining Rates • Australia • Austria* • Canada • England & Wales • France • Germany* • Hong Kong • Ireland • Italy • Japan • New Zealand • Spain • Switzerland* • Stable/Rising Rates • Scotland World Health Organization 2003; *decline started before 1988

  23. POSSIBLE REASONS FOR DECLINING SUICIDE RATES 1 • Economic Prosperity • 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 [DR13.XX]

  24. POSSIBLE REASONS FOR DECLINING SUICIDE RATES 2 • Reduced firearm availability • BUT • proportion of suicides by firearm unchanged • declines noted in countries with very few firearm suicides [DR13.XX]

  25. POSSIBLE REASONS FOR DECLINING SUICIDE RATES 3 • More psychotherapeutic treatment • BUT • psychotherapy has declined • More psychopharmacologic treatment • Better recognition of adolescent depression • Some combination of the above [DR13.XX]

  26. 4TREATMENT CONSIDERATIONS

  27. 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

  28. TEENS WHO SUICIDE RECEIVE LESS TREATMENT THAN ADULTS 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% 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 C.Rx18.XX

  29. 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 — Prescribed antidepressants 24% Antidepressants found at autopsy 0% Gray et al. 2003 DR30.XX

  30. SUICIDALITY DURING THE TREATMENT OF TEEN DEPRESSION Cautions & Considerations -1 • 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. 2004 February

  31. SUICIDALITY DURING THE TREATMENT OF TEEN DEPRESSION Cautions & Considerations -2 • “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. 2004 February

  32. SUICIDALITY DURING THE TREATMENT OF TEEN DEPRESSION Cautions & Considerations -3 • 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. 2004 February

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