Iris Publishers - Current Trends in Clinical & Medical Sciences (CTCMS)
Suicides and Suicide attempts among Child and Adolescent Psychiatric Inpatients in Iran
Authored by Saeed Shoja Shafti
Suicide
is rare in childhood and early adolescence and becomes more frequent with
increasing age. The latest mean worldwide annual rates of suicide per 100 000
were 0.5 for females and 0.9 for males among 5-14-year-olds, and 12.0 for
females and 14.2 for males among 15-24-year-olds, respectively. In most
countries, males outnumber females in youth suicide statistics. Although the
rates vary between countries, suicide is one of the commonest causes of death
among young people. Due to the growing risk for suicide with increasing age,
adolescents are the main target of suicide prevention. Reportedly, less than
half of young people who have committed suicide had received psychiatric care,
and thus broad prevention strategies are needed in healthcare and social services.
Primary care clinicians are key professionals in recognizing youth at risk for
suicide [2]. In ten years follow up of eighty-eight subjects with
adolescent-onset psychotic disorders, mainly schizophrenia and affective
disorders, 4.5% of subjects had died from suicide while another 25% of the
subjects had attempted suicide [3].
In
the context of suicide, there is a growing body of evidence showing that
exposure to early-life maltreatment can affect molecular mechanisms involved in
the regulation of behavior through methylation and histone modification,
supposed to induce behavioral deviations during the early development, and
possibly later in life, affect genes involved in crucial neural processes. This
mechanism is called epigenetics. Childhood abuse and other detrimental
environmental factors seem to target the epigenetic regulation of genes
involved in the synthesis of neurotrophic factors and neurotransmission [4]. On
the other hand, some scholars believe that People with first episode psychosis
(FEP) are at increased risk of premature death, suicide [5].
According
to the findings of a study, the rate of attempted suicide among young people
undergoing treatment for first episode psychosis was around 12%. Of these 72.6%
attempted suicide on one occasion. 85.3% of attempts occurred when patients
were treated as outpatients and were in regular contact with the service.
77.6%of suicide attempts tended to be impulsive triggered by interpersonal
conflict or distress due to psychotic symptoms. Two thirds involved
self-poisoning, usually by overdose of prescribed medications. All inpatient
suicide attempts were by hanging or strangulation [6].
So,
Individuals with a first episode of psychotic illness are known to be at high
risk of suicide, yet little is understood about the timing of risk in this
critical period. Suicide risk was highest in the first month of treatment,
decreasing rapidly over the next 6 months and declining slightly thereafter
[7]. In this regard, longer duration of untreated psychosis, greater symptoms
of depression, and positive symptoms of psychosis were found to increase the
odds of experiencing suicidal ideation in first episode psychosis [8]. While
according to some studies depressive symptoms during the index psychotic
episode and comorbidity with stimulant abuse at baseline were relevant
predictive factors for suicidal behavior during the first years of first
affective and non-affective psychotic episodes [9], more depressive symptoms,
higher insight, and negative beliefs about psychosis increase the risk for
suicidality in FEP [10].
Impulsive
behavior such as self-harm, as well as having a family history of severe mental
disorder or substance use, have been stated as important risk factors for
suicide in FEP [11,12]. Furthermore, low levels of cholesterol have been
described in suicide behavior including among those individuals who have an
increased tendency for impulsivity [13,14]. While, as a kind of psychological
explanation, some scholars believe that young men in the early stages of their
treatment are seeking to find meaning for frightening, intrusive experiences
with origins which often precede psychosis, and these experiences invade
personal identity, interactions and recovery [15], some suggests that
personality characters, specifically, passive-dependent traits can be a
predictor of first suicide attempts FEP [16]
On
the other hand, no general agreement regarding higher prevalence of suicide in
FEP is so far achievable. For example, while researchers like Nordentoft et al.
[17], Bornheimer LA [8], Fedyszyn et al. [7], and Cohen et al. [18] have stated
that FEP is a particularly high-risk period for suicide, with a risk as high as
10-60% during the first year of treatment, other scholars like Preti et al.
[19], Pompili et al. [20], Crumlish et al. [21], and Addington et al. [22] have
expected a lower risk or stated that suicide rates are difficult to measure in
FEP patients, even in carefully defined samples. In the present study, suicides
and suicide attempts among child and adolescent psychiatric in-patients, during
the last five years, in Razi psychiatric hospital, as the largest national
psychiatric hospital in Iran and region, has been evaluated to assess the
general profile of suicidal behavior among native child and adolescent
psychiatric inpatients, and comparing first admission with recurrent admission
patients.
Methods
Child
and adolescent section of the Razi psychiatric hospital was the field of the
present assessment. For valuation, all inpatients with suicidal behavior
(successful suicide and attempted suicide, in total), during the last sixty
months, had been included in the current retrospective study.
Statistical
analyses
Difference
of suicidal behavior between first admission and recurrent admission patients,
had been analyzed by ‘comparison of proportions’. Statistical significance as
well, had been defined as p value ≤0.05. MedCalc Statistical Software version
15.2 was used as statistical software tool for analysis.
Results
As
said by the results, among 748 child and adolescent psychiatric patients
hospitalized in razi psychiatric hospital, during a sixty months period
(2013-2018), 14 suicide attempts, without any successful one, had been recorded
by the security board of hospital (Table 1). Six of suicide subjects were male
and 8 of them were female, with no significant difference about quantity (Table
2). The most frequent mental illness was bipolar I disorder (50%), which was
significantly more prevalent among female patients (z=2.72, p<0.007, CI 95%:0.19,
1.23), followed by conduct disorder (42.85%), and substance abuse disorder
(7.14%). In this regard, no significant difference was evident among
psychiatric disorders (Table 3). Moreover, no significant difference was
evident between the first admission and recurrent admission child and
adolescent inpatients, totally (p<0.44) and separately (Table 3). The annual
incidences of suicidal behavior in both groups were comparable, and they were
around 0.21% and 0.16%, in first admission and recurrent admission psychiatric
inpatients, respectively (Table 1).
Discussion
Suicidal behavior is the most common reason for an emergency
evaluation in adolescents. Despite the minimal risk for a complete suicide in a
child less than 12 years of age, suicidal ideation or behavior in a child of
any age must be carefully evaluated, with particular attention to the
psychiatric status of the child and the ability of the family or the guardians
to provide the appropriate supervision. The assessment must determine the
circumstances of the suicidal ideation or behavior, its lethality, and the
persistence of the suicidal intention. An evaluation of the family’s
sensitivity, supportiveness, and competence must be done to assess their
ability to monitor the child’s suicidal potential [23].
Also, the most important risk factors for late school-age
children and adolescents, as established by scientific research in this domain
were: mental disorders, previous suicide attempts, specific personality
characteristics, genetic loading and family processes in combination with
triggering psychosocial stressors, exposure to inspiring models and
availability of means of committing suicide [24]. In addition, violent method
and mental disorder increase the 1-year suicide risk in young male self-harm
patients. Further, violent method increases suicide risk within 1 year in all
age and gender groups except the youngest females. Repeated self-harm may
increase the long-term risk more in young patients. These aspects should be
accounted for in clinical suicide risk assessment [25]. So, clinicians should
consider the substantially increased risk of suicide among self-harm patients
with psychotic disorders [26].
As suicide is a relatively rare event in psychotic
disorders, general population-based prevention strategies may have more impact
in this vulnerable group as well as the wider population [27,28]. While the
immediate post-discharge period is a time of marked risk, rates of suicide
remain high for many years after discharge and patients admitted because of
suicidal ideas or behaviors and those in the first months after discharge
should be a focus of concern [29]. Back to our discussion and according to the
findings of the present study, the most common principal diagnoses among the
suicide subjects were bipolar disorder and conduct disorder, which was somewhat
similar to the findings of Pelkonen et al. [2], since there was no subject with
diagnosis of schizophrenia and a remarkable number with diagnosis of conduct
disorder in our study, which was not evident in the above survey.
Also, our results were in harmony with the conclusions of
Berkol et al. [30] with respect to higher prevalence of female gender in
bipolar patients with suicide attempts. Also, in keeping with the results,
while the annual incidences of suicidal behavior in both groups were comparable,
they were lower than assessments of Jarbin et al. [3] and Fedyszyn et al. [6],
and higher than approximations of Li et al. [31], which could be stemmed from
cultural, instrumental, diagnostic and methodical differences. Also, in
accordance with the outcomes of the present assessment, no significant
difference was evident between the first admission and recurrent admission
inpatients, totally and separately, particularly with respect to psychotic
disorders.
Such an outcome is clearly incongruous with the findings of
Nordentoft et al. [17], Bornheimer LA [8], Fedyszyn et al. [7], and Cohen et
al. [18] who have stated that first episode psychosis is a particularly
high-risk period for suicide and first-episode psychotic disorder , in general,
has seemed to be a high-risk population for suicidal behavior during the first
year of treatment. On the other hand, our findings are compatible with the
stances of Preti et al. [19], Pompili et al. [20], Crumlish et al. [21], and
Addington et al. [22], who have estimated a lower risk or indicated that
suicide rates are difficult to measure in FEP patients, and there is relatively
little specific information about the risk of suicide at illness onset or
retrospectively concerning the untreated psychotic period. Anyhow, disregard to
outcomes of the present study and its similarities or differences with
comparable studies, elements of an inclusive prevention policy can be grouped
under five items: securing the hospital environment, optimization of the care
of the patients at suicidal risk, training of the medical teams in the
detection of the risk and in the care of the suicidal subjects, involvement of
the families in the care and implementation of post-event procedures following
a completed suicide or an attempt [32].
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