Researchers conducted a retrospective cohort study of over 17,000 adult HMO members who attended a primary care clinic and completed a confidential questionnaire about childhood abuse and family dysfunction, suicide attempts and other health-related issues. Subjects for the study (9,367 females; 7,970 males) attended the San Diego-based clinic between 1995 and 1996, or in 1997.

Outcomes were measured by comparing self-reports of suicide attempts to the number of adverse childhood events (ACEs), which included emotional, physical or sexual abuse; family substance abuse, mental illness, and incarceration; and parental domestic violence, separation, or divorce.

The study revealed that the number of ACEs dramatically increased the risk of suicide attempts among this cohort. The study found that the lifetime prevalence of having at least one suicide attempt was 3.8 percent, and that having ACEs in any category increased the likelihood of a suicide attempt two to five-fold. A strong, graded relationship between the ACE score and suicide attempts during childhood/adolescence and adulthood (p<.001) was identified by the investigators.

When compared with individuals reporting no ACEs, the adjusted odds ratio of suicide attempts among individuals with at least seven ACEs was 31.1 percent. However, after adjusting for illicit drug use, depressed affect and self-reported alcoholism, the investigators observed a reduction in the strength of the relationship between ACEs and suicide attempts.

The authors conclude, "The unusually high estimates we obtained for the [attributable risk factors] suggest that such experiences largely influence suicide attempts throughout the lifespan. Thus, recognition that adverse childhood experiences are common and frequently take place as multiple events may be the first step in preventing their occurrence; identifying and treating persons who have been affected by such experiences may have substantial value in our evolving efforts to prevent suicide."

A second article by Alan J. Zametkin, M.D., and colleagues reports on the suicide of a 16-year-old female.

The authors contemplate the magnitude of the loss and how this case underscores the need to identify and treat at-risk adolescents, and the difficulty in predicting or preventing adolescent suicide - the third leading cause of death among young people between the ages of 15 and 24.

There are a number of specific risk factors for suicide, such as previous attempt, major depressive disorder and other mood disorders, as well as several less-specific factors, including dramatic personality changes or psychosocial stressors such as a disciplinary crisis. The authors comment on current evidence, with specific attention paid to the body of research on behavioral interventions and prevention programs for adolescents - none of which has consistently succeeded in reducing subsequent attempts in adolescents who have previously tried to commit suicide. And, while the introduction of pharmacotherapy has helped to alleviate symptoms of depression in some patients, there is no direct evidence that the use of medications significantly lowers suicide rates in adolescent attempters.

Despite the paucity of data on adolescent suicide, the authors state that physicians should familiarize themselves with the symptoms of depression and risk factors for adolescent suicide, paying particularly close attention to those recently hospitalized for suicidal behavior. Other recommendations include screening for substance abuse, conduct disorder and poor school performance, and inquiring about lethal means in the household (such as firearms).

The authors conclude, "If health care providers vigilantly screen for the constellation of factors that lead teenagers to commit suicide, then this rare but tragic behavior will be reduced."

As depression is a chronic and recurring medical illness, some patients may require years of follow-up treatment. The authors encourage physicians faced with a denial for treatment by an insurer to review the recommendations outlined in the American Academy of Child and Adolescent Psychiatry practice parameters (Shaffer D et al., 2001).

Dube SR, Anda RF, Felitti VJ, et al.: Childhood abuse, household dysfunction and the risk of attempted suicide throughout the lifespan. Journal of the American Medical Association 2001; 3089-3096. Correspondence to: Ms. Dube, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Adult and Community Health, 4770 Buford Hwy NE, MS K-45, Atlanta, GA 30341-3717; e-mail: skd7@cdc.gov.

Zametkin AJ, Alter MR, Yemini T: Suicide in teenagers: Assessment, management and prevention. Journal of the American Medical Association 2001; 286: 3120-3125. Correspondence to: Dr. Zametkin, National Institute of Mental Health, 3N238, Bldg. 10, 9000 Rockville Pike, Bethesda, MD 20892; e-mail: zametkin@mail.nih.gov.

Reference:
Shaffer D, Pfeffer CR, Work Group on Quality Issues: Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. Journal of the American Academy of Child and Adolescent Psychiatry 2001; 40 (supp): 24S-51S.