Suicidal Children Grow Up: Psychiatric Treatment during Follow-up Period CYNTHIA R. PFEFFER, M.D., JOAN R. PESKIN, M.A.,
AND
CAROL A. SIEFKER, M.A.
Abstract. This study compares the treatment course during a 6- to 8-year follow-up period of 53 suicidal preadolescent and young adolescent psychiatric inpatients with those of 16 nonsuicidal psychiatric inpatients and 64 non patients selected from a community. The three groups of subjects were matched on demographic characteristics. All 69 patients and 10 (15.6%) nonpatients received treatment during follow-up. Treatment course during follow-up for suicidal patients was significantly longer, earlier, and more intensive than for the nonpatient controls. Fifty-five percent of 20 subjects who attempted suicide during follow-up were in treatment at the time of the suicide attempt. J. Am. Acad. Child Adolesc. Psychiatry, 1992, 31, 4:679-685. Key Words: suicidal children, follow-up treatment. Although research has focused on youth suicidal behavior, little information exists about the outcome of children who report suicidal behavior at a young age. This study is part of a longitudinal investigation of suicidal preadolescents and young adolescents and has an overall purpose of studying the natural course of suicidal youth (Pfeffer et aI., 1986, 1988a, 1991; unpublished manuscript). This report compares outcome, as measured by treatment course during a 6- to 8-year follow-up period, of suicidal and nonsuicidal preadolescent and young adolescent psychiatric nonpatients and a group of preadolescent and young adolescent nonpatients. This is a naturalistic study in that none of the children were assigned to treatment by the investigators. One purpose of this study is to determine if psychological impairment, estimated by treatment utilization during a follow-up period, is greater for suicidal preadolescents and young adolescents than for nonsuicidal youngsters. Although early intervention is considered to be important for prevention of youth suicidal behavior (Alcohol, Drug Abuse, and Mental Health Administration, 1989; Brent et aI., 1990; Pfeffer, 1986; Pfeffer et aI., 1988b; Shaffer et aI., 1988), there are no systematic controlled treatment studies of the efficacy of treatment for suicidal children or adolescents and there is relatively little information about treatments used by suicidal youth. Retrospective reports of suicidal youth (Shaffer et aI., 1988; Shafii et aI., 1985) suggest that adolescents who commit suicide have histories of more frequent mental health service visits than nonsuicidal adolescents. However, when compared with adolescent psychiatric inpatient suicide attempters, adolescents who
Accepted July l7, 1991. Dr. Pfeffer is Professor of Psychiatry, Cornell University Medical College, and Chief Child Psychiatry Inpatient Unit, New York
Hospital-Westchester Division. Ms. Peskin and Ms. Siefker are Research Associates, New York Hospital-Westchester Division. This study was supported by USPHS grant MN 142120, 1987 to 1990, from the National Institute of Mental Health. The authors wish to thank Tatsuyuki Kakuma, Ph.D., Biostatistician at New York Hospital-Westchester Division for statistical advice. Correspondence and reprint requests to Dr. Pfeffer, New York Hospital-Westchester Division, 21 Bloomingdale Road, White Plains, New York 10605. 0890-8567/92/31 04-0679$03.00/0© 1992 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 31 :4, July 1992
committed suicide had less psychiatric treatment in their lifetimes (Brent et aI., 1988). For example, the low utilization of mental health services by youth suicide victims is illustrated by one study (Brent et aI., 1988) that reported that only 7.4% of 27 adolescent suicide victims were in psychiatric treatment at the time of their deaths. Other reports (Garfinkel et aI., 1982) suggest that adolescent suicide attempters who were treated in general emergency room services had histories of more frequent utilization of mental health services than nonsuicidal adolescents who were treated for medical problems in general emergency room settings. Despite utilization of psychiatric treatment by suicidal youth, studies (Pfeffer et aI., 1988b; Shaffer et aI., 1988) suggest that youth suicide attempters are more noncompliant with treatment recommendations than nonsuicidal youth. One study (Trautman et aI., 1987) suggested that noncompliance with outpatient psychiatric treatment by adolescent suicide attempters may be associated with the finding that the parents of the suicide attempters had an untreated psychiatric illness. There are only a few follow-up studies of suicidal youth that document treatment during follow-up. Angle et a1. (1983) reported that 47% of 15 psychiatrically hospitalized adolescent suicide attempters, who were interviewed in a 9-year follow-up study, attributed benefits to moving out of the parents' home and into a more supportive environment. An 18-month follow-up study of suicidal preadolescent psychiatric inpatients (Cohen-Sandler et a\., 1982) suggested that one consequence of hospital treatment of children's suicidal behavior is "long term removal from the parental home" (p. 400). In that study, only 44% of suicidal inpatients, compared with 70% of nonsuicidal inpatients, returned home after hospitalization. Asarnow and colleagues (1988) studied rates of rehospitalization of depressed versus schizophrenic preadolescent psychiatric inpatients during a 6-year follow-up period. Within 2 years after the index psychiatric hospitalization, 50% of the 28 depressed inpatients in that study were rehospitalized primarily because of suicidal behavior or intensification of depression. The present study will identify whether psychiatric treatment during a 6- to 8-year follow-up period of suicidal preadolescents and young adolescents occurs earlier, is more intensive, and is longer than treatment of nonsuicidal pread679
PFEFFER ET AL.
olescents and young adolescents. This information may point out important issues useful for developing effective techniques to prevent youth suicidal behavior. Methods Sample
One hundred thirty-three subjects, who were described previously (Pfeffer et aI., 1991, unpublished manuscript), were included in this study. They are a subsample of 106 psychiatric inpatients and 101 nonpatients who were initially studied from 1979 to 1982 (Pfeffer et aI., 1986). These 133 subjects were included in this study because they were willing to be interviewed again, and they provided written informed consent. There were no significant differences in age, gender, social status (Hollingshead and Redlich, 1958), race or ethnicity, religion, suicidal behavior, or diagnoses for these 133 subjects and the 74 subjects who were not interviewed again in this 6- to 8-year follow-up (Pfeffer et aI., unpublished manuscript). The 133 subjects included 53 preadolescents and young adolescents who reported suicidal ideation or attempts within 6 months of an initial psychiatric hospitalization and who were considered to be at risk for future suicidal behavior. The suicidal subjects were compared with 16 preadolescents and young adolescents who reported no history of suicidal ideas or acts within 6 months of an initial psychiatric hospitalization and 64 nonpatients who were selected from the community by stratified random sampling to match the demographic features of the inpatients. The nonpatients had no history of psychiatric treatment and were not in classes for the emotionally disturbed or neurologically handicapped (Pfeffer et aI., 1986). The proportion of subjects from each of the initial groups (84 suicidal patients, 22 nonsuicidal patients, and 101 nonpatients) who were not interviewed again was similar (X 2 = 0.8, df = 2, p < 0.680). The characteristics of the subjects have been described previously (Pfeffer et aI., 1991; unpublished manuscript) and will be described briefly in this report. The demographic distributions were similar for the 53 suicidal patients, 16 nonsuicidal patients, and 64 nonpatient controls. The 133 subjects were predominantly white (72.2%), male (72.9%), middle social status (52.6%), and Catholic (60.2%). Their mean age at the initial assessment in 1979 through 1982 was 10.5 ± 1.8 years (range 4.6 to 14.7 years). All 69 patients and 42 (65.6%) nonpatients had a psychiatric disorder at the initial assessment. There were significantly more DSM-III psychiatric disorders among the suicidal patients (4.1 ± 2.1 disorders) and nonsuicidal patients (3.3 ± 1.5 disorders) compared with the nonpatient controls (1.7 ± 2.0 disorders) (F = 23.1, df = 2, p < 0.0001). Among the suicidal and nonsuicidal patients, the most prevalent DSM-III disorders were disruptive and developmental disorders (Table 1). Mood disorder was significantly more prevalent among the suicidal patients (56.6%) than the nonsuicidal patients (12.5%) (X 2 = 9.6, df = 1, p = 0.003). The most prevalent DSM-III disorders among the nonpatients were disruptive and anxiety disorders (Table 1). At the 6- to 8-year follow-up, no deaths were reported 680
among the 207 subjects initially studied. A National Death Index search (National Center for Health Statistics, 1990b) was used to determine that none of the unlocated subjects had died. Among the 133 subjects interviewed again, significantly more suicidal patients (26.4%) than nonpatients (6.3%) reported at least one suicide attempt during the follOW-Up period (X 2 = 10.1, df = 2, p < 0.006) (Pfeffer et aI., 1991; Unpublished manuscript). Twelve and one-half percent of the nonsuicidal patients reported at least one suicide attempt in the follow-up period. Fifty-one (96.2%) suicidal patients, 16 (100%) nonsuicidal patients, and 43 (67.2%) nonpatients had at least one DSM-III-R psychiatric disorder at some time during the 6- to 8-year follow-up period (Pfeffer et aI., 1991a). Assessment Procedures
The research assessments, which were described previously (Pfeffer et aI., 1991; Unpublished manuscript), involved separate semistructured interviews of the subjects and their parents conducted by highly trained master or Ph.D. level psychologists. Interrater reliability was high for all variables evaluated (Pfeffer et aI., 1991; Unpublished manuscript). The Spectrum of Suicidal Behavior Scale (Pfeffer et aI., 1986, 1991; Unpublished manuscript) was used to obtain retrospective information about the subjects' suicidal ideation and acts during the follow-up period. Modifications of the Kiddie Schedule of Affective Disorders and Schizophrenia-Present Episode (Chambers et aI., 1985) and Epidemiological Version (Orvaschel et aI., 1982) were used to rate presence of psychiatric symptoms and behaviors of the subjects in accordance with DSM-III-R criteria. These ratings were used to identify DSM-III-R psychiatric disorders during the 6- to 8-year follow-up period. Information about type, onset, and duration of psychiatric treatment of the subjects during the 6- to 8-year followup period was obtained from multiple sources including subjects, parents, treatment facilities, and schools. All information was reviewed separately by two research assistants, and a best estimate rating was made about the treatment course for each subject. Statistical Analyses
Statistical analyses included chi square tests or Fisher's exact test for categorical variables such as frequency of types of treatment and analysis of variance for continuous variables such as duration of treatment. Survival analysis using the life table method (Kalbfleisch and Prentice, 1980) with yearly intervals was used to identify the cumulative probability of time until the first treatment after the initial assessment. This analysis enabled the inclusion of data about subjects who did not have treatment during the 6- to 8-year follow-up period and the inclusion of data about subjects who dropped out before a treatment was used. The first treatment after the initial assessment was used as an outcome to identify whether any group of subjects had an earlier onset of treatment in the follow-up period. Differences in survival distributions between groups of subjects were evaluated with the Log Rank test, which identified differences over the entire follow-up period. The Wilcoxon test, which J. Am. Acad. Child Adolesc. Psychiatry, 31:4, July 1992
SUICIDAL CHILDREN: TREATMENT DURING FOLLOW-UP TABLE
SI Disorder N Mood 30 Disruptive 26 Anxiety 7 Schizophrenic 8 Other 15 Developmental 24 Note: SI = Suicidal Inpatients, NI " SI > NI at p < 0.05 "SI > NC at p < 0.05. 'NI > NC atp < 0.05.
1. DSM-IlI Psychiatric Disorders at Initial Assessment NI NC
% 56.6",b 49.1 b
N
2 11 13.2 2 15.1 b 2 28.3 3 45.3" 6 = Nonsuicida1 Inpatients, NC
assessed data more extensively in the earlier phase of the follow-up period, was also applied. Because results of these tests were identical, only results of the Log Rank test were presented.
Results Treatment during the Follow-up Period Table 2 shows the types of psychiatric treatment received by the subjects at some time during the 6- to 8-year followup period (X follow-up period = 7.16 ± 1.0 years). All 69 patients compared to 10 (15.6%) nonpatient controls used at least one mental health service at some time in the followup period that included psychiatric hospitalization, residential treatment, day hospital, or outpatient treatment. Multiple treatments were used during the fallow-up period. The average number of treatment services used by the suicidal (X = 1.8 ± 0.8) and nonsuicidal patients (1.9 ± 0.9) was significantly greater than that for the nonpatient controls (X = 0.2 ± 0.7) (F = 72.6, df = 2,130, p < 0.0001). In general, significantly more suicidal patients used each type of psychiatric treatment during the follow-up period than nonpatient controls. For example, 71.7% of the suicidal patients were treated away from home in psychiatric hospitals and/or residential treatment centers during some phase of the followup period. Although the most frequently used intervention for the nonpatient controls was outpatient treatment, significantly more suicidal patients than nonpatient controls used this type of intervention. Over 62% of the suicidal patients, but very few nonpatient controls (3.1 %), were treated with psychotropic medication such as lithium, antidepressants, or major tranquilizers.
Duration of Treatment Table 3 shows the average number of years of treatment during the follow-up period for treated subjects. These data represent the total number of years spent in a specific treatment during the follow-up period regardless of whether treatments were used at one time or recurrently. Suicidal patients spent the longest time in residential treatment for an average of approximately 4 years. Nonpatient controls spent the longest time in day hospital or outpatient treatment with an average of 1.7 ± 1.9 years and 1.0 ± 0.9 years, respectively. The longest prescribed medications for the suicidal patients were major tranquilizers. In general, when J. Am. Acad. Child Adolesc. Psychiatry, 3 I :4, July 1992
%
N
12.5 10 17 68.8' 12.5 18 12.5' 1 18.8 9 37.5 11 = Nonpatient Controls.
%
15.6 26.6 28.1 1.6 14.1 17.2
X2 (eif
= 2)
25.6 12.1 4.7 7.4 3.7 11.1
P
0.0001 0.002 0.095 0.024 0.157 0.004
treatments were used, there were no significant differences in duration of treatments for the groups of subjects. The lack of statistical differences may be due to the low number of subjects who were compared.
Time until First Treatment during the Follow-up Period All patients were referred to treatment after hospitalization at the initial assessment. As shown in Table 4, suicidal patients compared with nonpatient controls had significantly earlier first experiences with each type of treatment, such as away from home in a psychiatric hospital or a residential treatment program, psychiatric day hospital or outpatient service, and psychotropic medication. An appreciable number of suicidal patients compared with only a few nonpatient controls received a variety of treatments in the first year of follow-up (Table 4). When medication was prescribed, the most frequent first medications for the 31 suicidal patients who received medication in the follow-up period were major tranquilizers (58%), antidepressants (29%), and stimulants (22.6%). The one control subject who received medication during the follow-up period was treated with lithium for a bipolar disorder.
Clinical Features of Subjects and Treatment during Follow-up Among the 20 subjects who reported at least one suicide attempt in the follow-up period, 11 (55%) were in treatment at the time of the first suicide attempt in the follow-up period. Seven (35%) of these subjects were in a psychiatric hospital or in residential treatment, and four (20%) were treated in a day hospital or outpatient facility at the time of the first suicide attempt in the follow-up period. There was no significant association between having a history of a suicide attempt at the initial assessment and being in psychiatric treatment at the time of the first suicide attempt in the follow-up period. Two (22.2%) subjects with a history of a suicide attempt at the initial assessment were not in treatment at the time of the first suicide attempt in the followup period. When psychiatric hospitalization was used, eight (22.9%) subjects reported a suicide attempt just before the first psychiatric hospitalization in the follow-up period. There was no significant difference between the three groups of subjects (25 suicidal patients, eight nonsuicidal patients, and
681
PFEFFER ET AL.
TABLE 2. Psychiatric Treatments during Follow-up Period SI (N
=
NI (N
53)
=
NC (N
16)
=
64)
Psychiatric Treatment
N
%
N
%
N
%
X2 (df = 2)
p
Any mental health service Away from home Psychiatric hospital Residential treatment Living at home Day hospital Outpatient treatment" Judicial service Any medication" Stimulants Lithium Antidepressants Minor tranquilizers Major tranquilizers Other medication d
53 38 25 31 35 14 27 5 33 9 8 10 3 22 14
100.0" 71.7" 47.2" 58.5" 66.0" 26.4" 50.9" 9.4 62.3" 17.0" 15.1" 18.9" 5.7 41.5" 26.4"
16 14 8 II 8 5 6 I 12 3 2 2 1 10 5
100.eY' 87.5 b 50.eY' 68.8b 50.eY' 31.Jh 37.5 6.2 7.5eY' 18.8 b 12.5 12.5 6.2 62.5 b 31.2b
10 2 2 I 10 2 10 5 2 0 1 0 0 0 I
15.6 3.1 3.1 1.6 15.6 3.1 15.5 7.8 3.1 0.0 1.6 0.0 0.0 0.0 1.6
98.0 73.1 34.3 54.0 31.5 15.! 16.8 0.2 56.9 12.3 7.4 12.8 3.8 42.0 17.8
0.0001 0.0001 0.0001 0.0001 0.0001 0.001 0.0001 0.905 0.0001 0.0002 0.02 0.002 0.150 0.0001 0.0001
Note: SI = Suicidal Inpatients, NI = Nonsuicidal Inpatients, NC = Nonpatients Controls. " Significant group differences at p < 0.05, SI > NC. b Significant group differences at p < 0.05, NI > NC. C Treatment of at least 2 weeks' duration. d Includes anticonvulsants, antiparkinsonians, sedatives, and antihypertensives.
TABLE 3. Total Duration (Years) of Psychiatric Treatmentfor Treated Subjects during Follow-up Period Psychiatric Treatment" A way from home Psychiatric hospital Residential treatment Day hospital Outpatient treatment Stimulants Lithium Antidepressants Minor tranquilizers Major tranquilizers
SI (N
= 53) X ± SD
NI (N
N
= 16) X ± SD
NC (N
N
3.9 0.9 4.1 2.3 2.4 1.7 1.7 1.8 1.2 2.5
14 8 II 5 6 3 2 2 I 10
3.6 0.4 4.2 2.7 3.8 h 0.7 0.6 1.5 3.5 2.6
2 2 1 2 10 0 I
38 25 31 14 27 9 8 10 3 22
2.8 1.0 2.4 1.9 2.1 1.9
1.3 1.8 0.9 2.5
3.1 0.2 3.0 2.4 3.9 0.5 0.6 0.7 0.0 2.5
N
a 0 0
= X±
SD
F
df
p
0.3 0.2 0.1 1.7 1.0
0.2 0.3 0.0 1.9 0.9
1.61 1.16 1.22 0.20 3.17 0.85 0.89 0.06 4.84 0.02
2,51 2,37 2,40 2,18 2,40 1,10 2,8 1,10 1,2 1,20
0.21 0.35 0.31 0.82 0.05 0.38 0.45 0.81 0.16 0.89
10)
0.5 0.5
Note: SI = Suicidal Inpatients; NI = Nonsuicidal Inpatients; NC = Nonpatient Controls. "Outpatient or medication treatment was of at least 2 weeks' duration each. /> Significant group differences at p < 0.05, NI > NC.
two nonpatient controls) in the number of subjects who reported suicide attempts at the time of the first psychiatric hospitalization in the follow-up period (X2 = 1.3, df = 2, p < 0.522). Among the 35 subjects who had a first psychiatric hospitalization in the follow-up period, psychiatric disorders present at the time of hospital admission were disruptive (77%), mood (60%), anxiety (46%), substance abuse (20%), other (20%), developmental (14%), and schizophrenic (9%). There were no significant differences between the three groups of subjects for psychiatric disorders such as mood (X 2 = 1.5, df = 2, p < 0.467), disruptive (X 2 = 0.6, df = 2, p < 0.729), schizophrenic (X 2 = 1.3, df = 2, P < 0.519), other (X2 = 1.0, df = 2, p < 0.597), and developmental (X 2 = 2.2, df = 2, p < 0.331) at the time of the first psychiatric hospitalization in the follow-up period.
Discussion This prospective longitudinal study is distinct among the
682
few follow-up studies of suicidal children and adolescents (Angle, 1983; Barter et aI., 1968; Cohen-Sandler et aI., 1982; Hawton et aI., 1982) because it not only describes infonnation_about the naturalistic treatment course during yearly intervals of follow-up but also compares interventions during a 6- to 8-year follow-up period for suicidal psychiatrically hospitalized preadolescents and young adolescents with those of no~suicidal controls. The suicidal psychiatric patients in this stu~y had a significantly different treatment course during the fb.!low-up period than preadolescents and young adolescents who were selected from the community. Specifically, all suIG.idal patients, compared with 15.6% nonpatient controls, we\~ treated during the follow-up period and especially in settings that provided extensive environmental structure and intensive social support, often on a daily basis. Treatment during the follow-up period OCCUlTed earlier and was longer for the suicidal patients than the nonpatient controls. In addition, the suicidal patients were J. Am. Acad. Child Adolesc. Psychiatry, 31 :4, July 1992
SUICIDAL CHILDREN: TREATMENT DURING FOLLOW-UP TABLE
4. Comparison of Suicidal Patients, Nonsuicidal Patients, and Nonpatient Controls for First Treatment in the Follow-up Period Differences between Groups for Treatment in Follow-up Period
Treatment in First Year of Follow-up Period SI
NC
NI
Treatment
N
%
N
%
N
%
Log rank X2
P
Away from home
31
58.5
12
75.0
a
0.0
66.3" 70.7/'
Psychiatric hospitalization
17
32.1
3
[8.8
a
0.0
Day hospital or outpatient service
37
50.9
7
43.8
2
3.1
0.0001 0.0001 0.23 0.0001 0.0001 0.92 0.000 [
Psychotropic medication
23
4304
9
56.3
a
0.0
104'3304" 30.7/' 0.0' 34.9" 10.91> 1.2" 50.2" 51.61> 0.9'
O.OOO[ 0.27 0.0001 0.0001 0.34
" Suicidal patients (SI) compared with nonpatient controls (NC), df = I. b Nonsuicida[ patients (NI) compared with nonpatient controls (NC), df = 1. , Suicidal patients (SI) compared with nonsuicidal patients (NI), df = I.
treated during follow-up with significantly more psychotropic medications than the nonpatient controls. These results suggest that psychological impairment, when it was estimated by utilization of intensive treatment during the 6to 8-year follow-up period, is greater for the suicidal children who were treated in a psychiatric hospital than for the nonpatient controls.
Limitations Evaluation of the efficacy of treatment for diminishing psychiatric symptoms or disorders during the follow-up period was beyond the scope of this study because interventions during the follow-up period were not controlled by the investigators. Treatment was classified by type of treatment setting, but this study did not describe modalities of treatment such as individual, family, or group interventions. The generalizability of this study for youth suicidal behavior is limited primarily because the suicidal subjects were initially psychiatrically hospitalized, a treatment that is infrequently used by preadolescents and young adolescents. Nonsuicidal psychiatric inpatients were included in this study in an effort to identify whether suicidal children have a distinct treatment course during follow-up when the level of psychiatric disturbance at the time of initial assessment was controlled. In general, there were no differences in treatment courses during the follow-up period for the suicidal and nonsuicidal psychiatric patients. However, because only 16 nonsuicidal psychiatric patients were studied, this relatively low number of nonsuicidal patients may have affected the ability to detect moderate to small differences between these two groups of patients.
Implications for Clinical Practice and Research An important aspect of this study is that it provided information about the naturalistic clinical practices of treatment for suicidal child psychiatric inpatients. This information has important implications for understanding health care delivery for these patients. The suicidal preadolescents in J. Am. Acad. Child Adolesc. Psychiatry, 31:4, July 1992
this study used a continuum of psychiatric services during the 6- to 8-year follow-up period with approximately 47% using psychiatric hospitalization, 59% using residential treatment, 26% using day hospitalization, and 51 % using outpatient treatment. Suicidal patients used significantly more types of treatment services during the follow-up period than the nonpatient controls. The findings that treatment for suicidal patients during the follow-up period was often multimodal emphasizes the importance of organizing treatment networks that provide efficient referrals between sufficiently available evaluation and treatment services, such as community programs located in schools and recreational settings, psychiatric emergency and outpatient services, day hospitals, psychiatric hospitals, and residential treatment programs. The need for controlled studies to identify efficacy of treatment modalities to reduce suicidal risk, especially among youngsters with mood and disruptive disorders, is highlighted by the results that among the 20 subjects who reported a first suicide attempt in the follow-up period, 55% were in treatment at the time of the suicide attempt, and rehospitalization during the follow-up period was required to treat predominantly suicidal behavior, mood disorders, and disruptive disorders. This study documented a high rate of treatment away from home in residential programs or psychiatric hospitals for the suicidal patients to improve not only the psychopathology of the youngsters but also the social support and predictability of interpersonal relationships that may have been lacking within the home situation. This finding is similar to other studies of suicidal psychiatric inpatients (Angle et al., 1983; Cohen-Sandler et al., 1982). One implication is that there is a need to develop and study the effectiveness of family oriented interventions, such as family therapy or parent counseling, which are aimed at improving family interactions and social support. A previous report (Pfeffer et al., Unpublished manuscript) suggested that approximately 72% of suicidal psychiatric
683
PFEFFER ET AL.
patients had a mood disorder at some time in the 6- to 8year follow-up period. As reported in the present study, only 19% of the suicidal patients were treated with antidepressants in the follow-up period. The disparity in number of suicidal youngsters with mood disorders and number of suicidal youngsters treated with antidepressants may imply that clinicians infrequently use antidepressants for depressed suicidal preadolescents and young adolescents. Although clinicians may be cautious about prescribing medication to suicidal children, the prescribing practices identified in this study may have been influenced by the results of research that have demonstrated only modest superiority of antidepressant medication over placebo for depressed children and adolescents (Geller et aI., 1989; Preskorn et aI., 1982; PuigAntich et aI., 1987; Ryan et aI., 1988). When antidepressants were prescribed for the suicidal subjects in this study, however, clinicians used antidepressant medication on average 1.8 years during the follow-up period; a duration of treatment that represented multiple short-term treatment trials rather than continuous usage of these medications. Antidepressant treatment studies in depressed children and adolescents have many methodological limitations, including short-term treatment designs (Kaplan, 1990; Lapierre and Raval, 1989). In view of the results of recent controlled treatment studies with depressed adults suggesting the benefits of long-term antidepressant treatment (Frank et aI., 1990), controlled studies using long-term treatment designs may elucidate the efficacy of antidepressant medication in preventing relapse of depression or suicidal tendencies in children and adolescents. Finally, the lack of suicides among the suicidal subjects may be attributed to treatment effects. These subjects were identified early in their lives to be at risk for suicidal behavior, and they were treated intensively for many years. Another explanation is that these subjects have not fully passed through the high risk age period for youth suicide which includes 15- to 24-year-olds (National Center for Health Statistics, 1990a). This issue may be evaluated if these subjects are followed for a more extended time, especially as they traverse the high-risk age period for youth suicide.
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Adolesc. Psychiatry, 18:679-692. - - - - - - - - (1980), Suicidal behavior in latency-age children. An empirical study: an outpatient population. J. Am. Acad. Child Adolesc. Psychiatry, 19:703-710. - - Plutchik, R., Mizruchi, M. S. & Lipkins, R. (1986), Suicidal behavior in child psychiatric inpatients and outpatients and in nonpatients. Am. J. Psychiatry, 143:733-738. - - Lipkins, R., Plutchik, R. & Mizruchi, M. S. (l988a), Normal children at risk for suicidal behavior: a two-year follow-up study.
J. Am. Acad. Child Adolesc. Psychiatry, 27:34--41. --Newcorn, J., Kaplan, G., Mizruchi, M. S. & Plutchik, R. (l988b), Suicidal behavior in adolescent psychiatric inpatients. J. Am. Acad.
Child Adolesc. Psychiatry, 27:357-361. - - Klerman, G. L., Hurt, S. W., Lesser, M., Peskin, J. R. & Siefker, C. A. (1991), Suicidal children grow up: demographic and clinical risk factors for adolescent suicide attempts. J. Am. Acad. Child
Adolesc. Psychiatry, 30:609-616. Preskorn, S. H., Weller, E. B., & Weller, R. A. (1982), Depression in children: relationship between plasma imipramine levels and response. J. Clin. Psychiatry, 43:450-453. Puig-Antich, J., Perel, J. M., Leepatkin, W. et al. (1987), Imipramine in prepubertal major depressive disorder. Arch. Gen. Psychiatry, 44:81-89. Ryan, N. D., Puig-Antich, J., Rabinovich, H. et al. (1988), MAOIs in adolescent major depression unresponsive to tricyclic antidepressants. J. Am. Acad. Child Adolesc. Psychiatry, 27:755-758.
J. Am. A cad. Child Adolesc. Psychiatry, 31 :4, July 1992
SUICIDAL CHILDREN: TREATMENT DURING FOLLOW-UP
Shaffer, D., Garland, A., Gould, M., Fisher, P. & Trautman, P. (1988), Preventing teenage suicide: A critical review. J. Am. Acad. Child Adolesc. Psychiatry, 27:675-687. Shafii, M., Carrigan, S., Whittinghill, 1. R. & Derrick, A. (1985), Psychological autopsy of completed suicide in children and adoles-
J. Am. A cad. Child Adolesc. Psychiatry, 3/:4, July 1992
cents. Am. J. Psychiatry, 142:1061-1064. Trautman, P. D., Levin, M. A. & Krauskopf, M. A. (1987), Home visits with non-compliant adolescent suicide attempters. Proceedings of the 34th Annual Meeting of the American Academy of Child and Adolescent Psychiatry, Washington, DC.
685
AND
CAROL A. SIEFKER, M.A.
Abstract. This study compares the treatment course during a 6- to 8-year follow-up period of 53 suicidal preadolescent and young adolescent psychiatric inpatients with those of 16 nonsuicidal psychiatric inpatients and 64 non patients selected from a community. The three groups of subjects were matched on demographic characteristics. All 69 patients and 10 (15.6%) nonpatients received treatment during follow-up. Treatment course during follow-up for suicidal patients was significantly longer, earlier, and more intensive than for the nonpatient controls. Fifty-five percent of 20 subjects who attempted suicide during follow-up were in treatment at the time of the suicide attempt. J. Am. Acad. Child Adolesc. Psychiatry, 1992, 31, 4:679-685. Key Words: suicidal children, follow-up treatment. Although research has focused on youth suicidal behavior, little information exists about the outcome of children who report suicidal behavior at a young age. This study is part of a longitudinal investigation of suicidal preadolescents and young adolescents and has an overall purpose of studying the natural course of suicidal youth (Pfeffer et aI., 1986, 1988a, 1991; unpublished manuscript). This report compares outcome, as measured by treatment course during a 6- to 8-year follow-up period, of suicidal and nonsuicidal preadolescent and young adolescent psychiatric nonpatients and a group of preadolescent and young adolescent nonpatients. This is a naturalistic study in that none of the children were assigned to treatment by the investigators. One purpose of this study is to determine if psychological impairment, estimated by treatment utilization during a follow-up period, is greater for suicidal preadolescents and young adolescents than for nonsuicidal youngsters. Although early intervention is considered to be important for prevention of youth suicidal behavior (Alcohol, Drug Abuse, and Mental Health Administration, 1989; Brent et aI., 1990; Pfeffer, 1986; Pfeffer et aI., 1988b; Shaffer et aI., 1988), there are no systematic controlled treatment studies of the efficacy of treatment for suicidal children or adolescents and there is relatively little information about treatments used by suicidal youth. Retrospective reports of suicidal youth (Shaffer et aI., 1988; Shafii et aI., 1985) suggest that adolescents who commit suicide have histories of more frequent mental health service visits than nonsuicidal adolescents. However, when compared with adolescent psychiatric inpatient suicide attempters, adolescents who
Accepted July l7, 1991. Dr. Pfeffer is Professor of Psychiatry, Cornell University Medical College, and Chief Child Psychiatry Inpatient Unit, New York
Hospital-Westchester Division. Ms. Peskin and Ms. Siefker are Research Associates, New York Hospital-Westchester Division. This study was supported by USPHS grant MN 142120, 1987 to 1990, from the National Institute of Mental Health. The authors wish to thank Tatsuyuki Kakuma, Ph.D., Biostatistician at New York Hospital-Westchester Division for statistical advice. Correspondence and reprint requests to Dr. Pfeffer, New York Hospital-Westchester Division, 21 Bloomingdale Road, White Plains, New York 10605. 0890-8567/92/31 04-0679$03.00/0© 1992 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 31 :4, July 1992
committed suicide had less psychiatric treatment in their lifetimes (Brent et aI., 1988). For example, the low utilization of mental health services by youth suicide victims is illustrated by one study (Brent et aI., 1988) that reported that only 7.4% of 27 adolescent suicide victims were in psychiatric treatment at the time of their deaths. Other reports (Garfinkel et aI., 1982) suggest that adolescent suicide attempters who were treated in general emergency room services had histories of more frequent utilization of mental health services than nonsuicidal adolescents who were treated for medical problems in general emergency room settings. Despite utilization of psychiatric treatment by suicidal youth, studies (Pfeffer et aI., 1988b; Shaffer et aI., 1988) suggest that youth suicide attempters are more noncompliant with treatment recommendations than nonsuicidal youth. One study (Trautman et aI., 1987) suggested that noncompliance with outpatient psychiatric treatment by adolescent suicide attempters may be associated with the finding that the parents of the suicide attempters had an untreated psychiatric illness. There are only a few follow-up studies of suicidal youth that document treatment during follow-up. Angle et a1. (1983) reported that 47% of 15 psychiatrically hospitalized adolescent suicide attempters, who were interviewed in a 9-year follow-up study, attributed benefits to moving out of the parents' home and into a more supportive environment. An 18-month follow-up study of suicidal preadolescent psychiatric inpatients (Cohen-Sandler et a\., 1982) suggested that one consequence of hospital treatment of children's suicidal behavior is "long term removal from the parental home" (p. 400). In that study, only 44% of suicidal inpatients, compared with 70% of nonsuicidal inpatients, returned home after hospitalization. Asarnow and colleagues (1988) studied rates of rehospitalization of depressed versus schizophrenic preadolescent psychiatric inpatients during a 6-year follow-up period. Within 2 years after the index psychiatric hospitalization, 50% of the 28 depressed inpatients in that study were rehospitalized primarily because of suicidal behavior or intensification of depression. The present study will identify whether psychiatric treatment during a 6- to 8-year follow-up period of suicidal preadolescents and young adolescents occurs earlier, is more intensive, and is longer than treatment of nonsuicidal pread679
PFEFFER ET AL.
olescents and young adolescents. This information may point out important issues useful for developing effective techniques to prevent youth suicidal behavior. Methods Sample
One hundred thirty-three subjects, who were described previously (Pfeffer et aI., 1991, unpublished manuscript), were included in this study. They are a subsample of 106 psychiatric inpatients and 101 nonpatients who were initially studied from 1979 to 1982 (Pfeffer et aI., 1986). These 133 subjects were included in this study because they were willing to be interviewed again, and they provided written informed consent. There were no significant differences in age, gender, social status (Hollingshead and Redlich, 1958), race or ethnicity, religion, suicidal behavior, or diagnoses for these 133 subjects and the 74 subjects who were not interviewed again in this 6- to 8-year follow-up (Pfeffer et aI., unpublished manuscript). The 133 subjects included 53 preadolescents and young adolescents who reported suicidal ideation or attempts within 6 months of an initial psychiatric hospitalization and who were considered to be at risk for future suicidal behavior. The suicidal subjects were compared with 16 preadolescents and young adolescents who reported no history of suicidal ideas or acts within 6 months of an initial psychiatric hospitalization and 64 nonpatients who were selected from the community by stratified random sampling to match the demographic features of the inpatients. The nonpatients had no history of psychiatric treatment and were not in classes for the emotionally disturbed or neurologically handicapped (Pfeffer et aI., 1986). The proportion of subjects from each of the initial groups (84 suicidal patients, 22 nonsuicidal patients, and 101 nonpatients) who were not interviewed again was similar (X 2 = 0.8, df = 2, p < 0.680). The characteristics of the subjects have been described previously (Pfeffer et aI., 1991; unpublished manuscript) and will be described briefly in this report. The demographic distributions were similar for the 53 suicidal patients, 16 nonsuicidal patients, and 64 nonpatient controls. The 133 subjects were predominantly white (72.2%), male (72.9%), middle social status (52.6%), and Catholic (60.2%). Their mean age at the initial assessment in 1979 through 1982 was 10.5 ± 1.8 years (range 4.6 to 14.7 years). All 69 patients and 42 (65.6%) nonpatients had a psychiatric disorder at the initial assessment. There were significantly more DSM-III psychiatric disorders among the suicidal patients (4.1 ± 2.1 disorders) and nonsuicidal patients (3.3 ± 1.5 disorders) compared with the nonpatient controls (1.7 ± 2.0 disorders) (F = 23.1, df = 2, p < 0.0001). Among the suicidal and nonsuicidal patients, the most prevalent DSM-III disorders were disruptive and developmental disorders (Table 1). Mood disorder was significantly more prevalent among the suicidal patients (56.6%) than the nonsuicidal patients (12.5%) (X 2 = 9.6, df = 1, p = 0.003). The most prevalent DSM-III disorders among the nonpatients were disruptive and anxiety disorders (Table 1). At the 6- to 8-year follow-up, no deaths were reported 680
among the 207 subjects initially studied. A National Death Index search (National Center for Health Statistics, 1990b) was used to determine that none of the unlocated subjects had died. Among the 133 subjects interviewed again, significantly more suicidal patients (26.4%) than nonpatients (6.3%) reported at least one suicide attempt during the follOW-Up period (X 2 = 10.1, df = 2, p < 0.006) (Pfeffer et aI., 1991; Unpublished manuscript). Twelve and one-half percent of the nonsuicidal patients reported at least one suicide attempt in the follow-up period. Fifty-one (96.2%) suicidal patients, 16 (100%) nonsuicidal patients, and 43 (67.2%) nonpatients had at least one DSM-III-R psychiatric disorder at some time during the 6- to 8-year follow-up period (Pfeffer et aI., 1991a). Assessment Procedures
The research assessments, which were described previously (Pfeffer et aI., 1991; Unpublished manuscript), involved separate semistructured interviews of the subjects and their parents conducted by highly trained master or Ph.D. level psychologists. Interrater reliability was high for all variables evaluated (Pfeffer et aI., 1991; Unpublished manuscript). The Spectrum of Suicidal Behavior Scale (Pfeffer et aI., 1986, 1991; Unpublished manuscript) was used to obtain retrospective information about the subjects' suicidal ideation and acts during the follow-up period. Modifications of the Kiddie Schedule of Affective Disorders and Schizophrenia-Present Episode (Chambers et aI., 1985) and Epidemiological Version (Orvaschel et aI., 1982) were used to rate presence of psychiatric symptoms and behaviors of the subjects in accordance with DSM-III-R criteria. These ratings were used to identify DSM-III-R psychiatric disorders during the 6- to 8-year follow-up period. Information about type, onset, and duration of psychiatric treatment of the subjects during the 6- to 8-year followup period was obtained from multiple sources including subjects, parents, treatment facilities, and schools. All information was reviewed separately by two research assistants, and a best estimate rating was made about the treatment course for each subject. Statistical Analyses
Statistical analyses included chi square tests or Fisher's exact test for categorical variables such as frequency of types of treatment and analysis of variance for continuous variables such as duration of treatment. Survival analysis using the life table method (Kalbfleisch and Prentice, 1980) with yearly intervals was used to identify the cumulative probability of time until the first treatment after the initial assessment. This analysis enabled the inclusion of data about subjects who did not have treatment during the 6- to 8-year follow-up period and the inclusion of data about subjects who dropped out before a treatment was used. The first treatment after the initial assessment was used as an outcome to identify whether any group of subjects had an earlier onset of treatment in the follow-up period. Differences in survival distributions between groups of subjects were evaluated with the Log Rank test, which identified differences over the entire follow-up period. The Wilcoxon test, which J. Am. Acad. Child Adolesc. Psychiatry, 31:4, July 1992
SUICIDAL CHILDREN: TREATMENT DURING FOLLOW-UP TABLE
SI Disorder N Mood 30 Disruptive 26 Anxiety 7 Schizophrenic 8 Other 15 Developmental 24 Note: SI = Suicidal Inpatients, NI " SI > NI at p < 0.05 "SI > NC at p < 0.05. 'NI > NC atp < 0.05.
1. DSM-IlI Psychiatric Disorders at Initial Assessment NI NC
% 56.6",b 49.1 b
N
2 11 13.2 2 15.1 b 2 28.3 3 45.3" 6 = Nonsuicida1 Inpatients, NC
assessed data more extensively in the earlier phase of the follow-up period, was also applied. Because results of these tests were identical, only results of the Log Rank test were presented.
Results Treatment during the Follow-up Period Table 2 shows the types of psychiatric treatment received by the subjects at some time during the 6- to 8-year followup period (X follow-up period = 7.16 ± 1.0 years). All 69 patients compared to 10 (15.6%) nonpatient controls used at least one mental health service at some time in the followup period that included psychiatric hospitalization, residential treatment, day hospital, or outpatient treatment. Multiple treatments were used during the fallow-up period. The average number of treatment services used by the suicidal (X = 1.8 ± 0.8) and nonsuicidal patients (1.9 ± 0.9) was significantly greater than that for the nonpatient controls (X = 0.2 ± 0.7) (F = 72.6, df = 2,130, p < 0.0001). In general, significantly more suicidal patients used each type of psychiatric treatment during the follow-up period than nonpatient controls. For example, 71.7% of the suicidal patients were treated away from home in psychiatric hospitals and/or residential treatment centers during some phase of the followup period. Although the most frequently used intervention for the nonpatient controls was outpatient treatment, significantly more suicidal patients than nonpatient controls used this type of intervention. Over 62% of the suicidal patients, but very few nonpatient controls (3.1 %), were treated with psychotropic medication such as lithium, antidepressants, or major tranquilizers.
Duration of Treatment Table 3 shows the average number of years of treatment during the follow-up period for treated subjects. These data represent the total number of years spent in a specific treatment during the follow-up period regardless of whether treatments were used at one time or recurrently. Suicidal patients spent the longest time in residential treatment for an average of approximately 4 years. Nonpatient controls spent the longest time in day hospital or outpatient treatment with an average of 1.7 ± 1.9 years and 1.0 ± 0.9 years, respectively. The longest prescribed medications for the suicidal patients were major tranquilizers. In general, when J. Am. Acad. Child Adolesc. Psychiatry, 3 I :4, July 1992
%
N
12.5 10 17 68.8' 12.5 18 12.5' 1 18.8 9 37.5 11 = Nonpatient Controls.
%
15.6 26.6 28.1 1.6 14.1 17.2
X2 (eif
= 2)
25.6 12.1 4.7 7.4 3.7 11.1
P
0.0001 0.002 0.095 0.024 0.157 0.004
treatments were used, there were no significant differences in duration of treatments for the groups of subjects. The lack of statistical differences may be due to the low number of subjects who were compared.
Time until First Treatment during the Follow-up Period All patients were referred to treatment after hospitalization at the initial assessment. As shown in Table 4, suicidal patients compared with nonpatient controls had significantly earlier first experiences with each type of treatment, such as away from home in a psychiatric hospital or a residential treatment program, psychiatric day hospital or outpatient service, and psychotropic medication. An appreciable number of suicidal patients compared with only a few nonpatient controls received a variety of treatments in the first year of follow-up (Table 4). When medication was prescribed, the most frequent first medications for the 31 suicidal patients who received medication in the follow-up period were major tranquilizers (58%), antidepressants (29%), and stimulants (22.6%). The one control subject who received medication during the follow-up period was treated with lithium for a bipolar disorder.
Clinical Features of Subjects and Treatment during Follow-up Among the 20 subjects who reported at least one suicide attempt in the follow-up period, 11 (55%) were in treatment at the time of the first suicide attempt in the follow-up period. Seven (35%) of these subjects were in a psychiatric hospital or in residential treatment, and four (20%) were treated in a day hospital or outpatient facility at the time of the first suicide attempt in the follow-up period. There was no significant association between having a history of a suicide attempt at the initial assessment and being in psychiatric treatment at the time of the first suicide attempt in the follow-up period. Two (22.2%) subjects with a history of a suicide attempt at the initial assessment were not in treatment at the time of the first suicide attempt in the followup period. When psychiatric hospitalization was used, eight (22.9%) subjects reported a suicide attempt just before the first psychiatric hospitalization in the follow-up period. There was no significant difference between the three groups of subjects (25 suicidal patients, eight nonsuicidal patients, and
681
PFEFFER ET AL.
TABLE 2. Psychiatric Treatments during Follow-up Period SI (N
=
NI (N
53)
=
NC (N
16)
=
64)
Psychiatric Treatment
N
%
N
%
N
%
X2 (df = 2)
p
Any mental health service Away from home Psychiatric hospital Residential treatment Living at home Day hospital Outpatient treatment" Judicial service Any medication" Stimulants Lithium Antidepressants Minor tranquilizers Major tranquilizers Other medication d
53 38 25 31 35 14 27 5 33 9 8 10 3 22 14
100.0" 71.7" 47.2" 58.5" 66.0" 26.4" 50.9" 9.4 62.3" 17.0" 15.1" 18.9" 5.7 41.5" 26.4"
16 14 8 II 8 5 6 I 12 3 2 2 1 10 5
100.eY' 87.5 b 50.eY' 68.8b 50.eY' 31.Jh 37.5 6.2 7.5eY' 18.8 b 12.5 12.5 6.2 62.5 b 31.2b
10 2 2 I 10 2 10 5 2 0 1 0 0 0 I
15.6 3.1 3.1 1.6 15.6 3.1 15.5 7.8 3.1 0.0 1.6 0.0 0.0 0.0 1.6
98.0 73.1 34.3 54.0 31.5 15.! 16.8 0.2 56.9 12.3 7.4 12.8 3.8 42.0 17.8
0.0001 0.0001 0.0001 0.0001 0.0001 0.001 0.0001 0.905 0.0001 0.0002 0.02 0.002 0.150 0.0001 0.0001
Note: SI = Suicidal Inpatients, NI = Nonsuicidal Inpatients, NC = Nonpatients Controls. " Significant group differences at p < 0.05, SI > NC. b Significant group differences at p < 0.05, NI > NC. C Treatment of at least 2 weeks' duration. d Includes anticonvulsants, antiparkinsonians, sedatives, and antihypertensives.
TABLE 3. Total Duration (Years) of Psychiatric Treatmentfor Treated Subjects during Follow-up Period Psychiatric Treatment" A way from home Psychiatric hospital Residential treatment Day hospital Outpatient treatment Stimulants Lithium Antidepressants Minor tranquilizers Major tranquilizers
SI (N
= 53) X ± SD
NI (N
N
= 16) X ± SD
NC (N
N
3.9 0.9 4.1 2.3 2.4 1.7 1.7 1.8 1.2 2.5
14 8 II 5 6 3 2 2 I 10
3.6 0.4 4.2 2.7 3.8 h 0.7 0.6 1.5 3.5 2.6
2 2 1 2 10 0 I
38 25 31 14 27 9 8 10 3 22
2.8 1.0 2.4 1.9 2.1 1.9
1.3 1.8 0.9 2.5
3.1 0.2 3.0 2.4 3.9 0.5 0.6 0.7 0.0 2.5
N
a 0 0
= X±
SD
F
df
p
0.3 0.2 0.1 1.7 1.0
0.2 0.3 0.0 1.9 0.9
1.61 1.16 1.22 0.20 3.17 0.85 0.89 0.06 4.84 0.02
2,51 2,37 2,40 2,18 2,40 1,10 2,8 1,10 1,2 1,20
0.21 0.35 0.31 0.82 0.05 0.38 0.45 0.81 0.16 0.89
10)
0.5 0.5
Note: SI = Suicidal Inpatients; NI = Nonsuicidal Inpatients; NC = Nonpatient Controls. "Outpatient or medication treatment was of at least 2 weeks' duration each. /> Significant group differences at p < 0.05, NI > NC.
two nonpatient controls) in the number of subjects who reported suicide attempts at the time of the first psychiatric hospitalization in the follow-up period (X2 = 1.3, df = 2, p < 0.522). Among the 35 subjects who had a first psychiatric hospitalization in the follow-up period, psychiatric disorders present at the time of hospital admission were disruptive (77%), mood (60%), anxiety (46%), substance abuse (20%), other (20%), developmental (14%), and schizophrenic (9%). There were no significant differences between the three groups of subjects for psychiatric disorders such as mood (X 2 = 1.5, df = 2, p < 0.467), disruptive (X 2 = 0.6, df = 2, p < 0.729), schizophrenic (X 2 = 1.3, df = 2, P < 0.519), other (X2 = 1.0, df = 2, p < 0.597), and developmental (X 2 = 2.2, df = 2, p < 0.331) at the time of the first psychiatric hospitalization in the follow-up period.
Discussion This prospective longitudinal study is distinct among the
682
few follow-up studies of suicidal children and adolescents (Angle, 1983; Barter et aI., 1968; Cohen-Sandler et aI., 1982; Hawton et aI., 1982) because it not only describes infonnation_about the naturalistic treatment course during yearly intervals of follow-up but also compares interventions during a 6- to 8-year follow-up period for suicidal psychiatrically hospitalized preadolescents and young adolescents with those of no~suicidal controls. The suicidal psychiatric patients in this stu~y had a significantly different treatment course during the fb.!low-up period than preadolescents and young adolescents who were selected from the community. Specifically, all suIG.idal patients, compared with 15.6% nonpatient controls, we\~ treated during the follow-up period and especially in settings that provided extensive environmental structure and intensive social support, often on a daily basis. Treatment during the follow-up period OCCUlTed earlier and was longer for the suicidal patients than the nonpatient controls. In addition, the suicidal patients were J. Am. Acad. Child Adolesc. Psychiatry, 31 :4, July 1992
SUICIDAL CHILDREN: TREATMENT DURING FOLLOW-UP TABLE
4. Comparison of Suicidal Patients, Nonsuicidal Patients, and Nonpatient Controls for First Treatment in the Follow-up Period Differences between Groups for Treatment in Follow-up Period
Treatment in First Year of Follow-up Period SI
NC
NI
Treatment
N
%
N
%
N
%
Log rank X2
P
Away from home
31
58.5
12
75.0
a
0.0
66.3" 70.7/'
Psychiatric hospitalization
17
32.1
3
[8.8
a
0.0
Day hospital or outpatient service
37
50.9
7
43.8
2
3.1
0.0001 0.0001 0.23 0.0001 0.0001 0.92 0.000 [
Psychotropic medication
23
4304
9
56.3
a
0.0
104'3304" 30.7/' 0.0' 34.9" 10.91> 1.2" 50.2" 51.61> 0.9'
O.OOO[ 0.27 0.0001 0.0001 0.34
" Suicidal patients (SI) compared with nonpatient controls (NC), df = I. b Nonsuicida[ patients (NI) compared with nonpatient controls (NC), df = 1. , Suicidal patients (SI) compared with nonsuicidal patients (NI), df = I.
treated during follow-up with significantly more psychotropic medications than the nonpatient controls. These results suggest that psychological impairment, when it was estimated by utilization of intensive treatment during the 6to 8-year follow-up period, is greater for the suicidal children who were treated in a psychiatric hospital than for the nonpatient controls.
Limitations Evaluation of the efficacy of treatment for diminishing psychiatric symptoms or disorders during the follow-up period was beyond the scope of this study because interventions during the follow-up period were not controlled by the investigators. Treatment was classified by type of treatment setting, but this study did not describe modalities of treatment such as individual, family, or group interventions. The generalizability of this study for youth suicidal behavior is limited primarily because the suicidal subjects were initially psychiatrically hospitalized, a treatment that is infrequently used by preadolescents and young adolescents. Nonsuicidal psychiatric inpatients were included in this study in an effort to identify whether suicidal children have a distinct treatment course during follow-up when the level of psychiatric disturbance at the time of initial assessment was controlled. In general, there were no differences in treatment courses during the follow-up period for the suicidal and nonsuicidal psychiatric patients. However, because only 16 nonsuicidal psychiatric patients were studied, this relatively low number of nonsuicidal patients may have affected the ability to detect moderate to small differences between these two groups of patients.
Implications for Clinical Practice and Research An important aspect of this study is that it provided information about the naturalistic clinical practices of treatment for suicidal child psychiatric inpatients. This information has important implications for understanding health care delivery for these patients. The suicidal preadolescents in J. Am. Acad. Child Adolesc. Psychiatry, 31:4, July 1992
this study used a continuum of psychiatric services during the 6- to 8-year follow-up period with approximately 47% using psychiatric hospitalization, 59% using residential treatment, 26% using day hospitalization, and 51 % using outpatient treatment. Suicidal patients used significantly more types of treatment services during the follow-up period than the nonpatient controls. The findings that treatment for suicidal patients during the follow-up period was often multimodal emphasizes the importance of organizing treatment networks that provide efficient referrals between sufficiently available evaluation and treatment services, such as community programs located in schools and recreational settings, psychiatric emergency and outpatient services, day hospitals, psychiatric hospitals, and residential treatment programs. The need for controlled studies to identify efficacy of treatment modalities to reduce suicidal risk, especially among youngsters with mood and disruptive disorders, is highlighted by the results that among the 20 subjects who reported a first suicide attempt in the follow-up period, 55% were in treatment at the time of the suicide attempt, and rehospitalization during the follow-up period was required to treat predominantly suicidal behavior, mood disorders, and disruptive disorders. This study documented a high rate of treatment away from home in residential programs or psychiatric hospitals for the suicidal patients to improve not only the psychopathology of the youngsters but also the social support and predictability of interpersonal relationships that may have been lacking within the home situation. This finding is similar to other studies of suicidal psychiatric inpatients (Angle et al., 1983; Cohen-Sandler et al., 1982). One implication is that there is a need to develop and study the effectiveness of family oriented interventions, such as family therapy or parent counseling, which are aimed at improving family interactions and social support. A previous report (Pfeffer et al., Unpublished manuscript) suggested that approximately 72% of suicidal psychiatric
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PFEFFER ET AL.
patients had a mood disorder at some time in the 6- to 8year follow-up period. As reported in the present study, only 19% of the suicidal patients were treated with antidepressants in the follow-up period. The disparity in number of suicidal youngsters with mood disorders and number of suicidal youngsters treated with antidepressants may imply that clinicians infrequently use antidepressants for depressed suicidal preadolescents and young adolescents. Although clinicians may be cautious about prescribing medication to suicidal children, the prescribing practices identified in this study may have been influenced by the results of research that have demonstrated only modest superiority of antidepressant medication over placebo for depressed children and adolescents (Geller et aI., 1989; Preskorn et aI., 1982; PuigAntich et aI., 1987; Ryan et aI., 1988). When antidepressants were prescribed for the suicidal subjects in this study, however, clinicians used antidepressant medication on average 1.8 years during the follow-up period; a duration of treatment that represented multiple short-term treatment trials rather than continuous usage of these medications. Antidepressant treatment studies in depressed children and adolescents have many methodological limitations, including short-term treatment designs (Kaplan, 1990; Lapierre and Raval, 1989). In view of the results of recent controlled treatment studies with depressed adults suggesting the benefits of long-term antidepressant treatment (Frank et aI., 1990), controlled studies using long-term treatment designs may elucidate the efficacy of antidepressant medication in preventing relapse of depression or suicidal tendencies in children and adolescents. Finally, the lack of suicides among the suicidal subjects may be attributed to treatment effects. These subjects were identified early in their lives to be at risk for suicidal behavior, and they were treated intensively for many years. Another explanation is that these subjects have not fully passed through the high risk age period for youth suicide which includes 15- to 24-year-olds (National Center for Health Statistics, 1990a). This issue may be evaluated if these subjects are followed for a more extended time, especially as they traverse the high-risk age period for youth suicide.
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