Tentative de suicide des adolescents: accueil, evaluation, orientation [Suicide attempt: encounter, evaluation, orientation].

Le suicide et les tentatives de suicide des adolescents sont des enjeux de santé publique majeurs. En s'appuyant sur le modèle de soins développé à Genève, nous décrivons les différents temps nécessaires pour accueillir, évaluer et orienter un adolescent pris dans un mouvement suicidaire. Un temps d'accueil et d'évaluation pédiatrique, puis un temps d'évaluation psychiatrique et enfin un temps d'orientation à l'issue duquel est proposée une prise en charge spécifique. En fonction des caractéristiques cliniques du jeune (impulsivité, symptomatologie anxio-dépressive...), de sa capacité d'engagement dans les soins et de la qualité des liens du réseau, la prise en charge sera soit ambulatoire intensive, soit hospitalière. Suicide and suicide attempts of adolescents are major public health issues. Based on a model of care developed in Geneva, we describe the conditions necessary to evaluate and guide a teenager trapped in a suicidal behavior. First of all, there must be some time dedicated to pediatric assessement followed by a psychiatric evaluation and finally, the adolescent can be oriented toward specific treatment. Depending on the clinical characteristics of the young adolescent and according to his willingness to engage himself in intensive follow-up (impulsivity, anxious?--depressive symptomatology...), cares will be given either as outpatient with close monitoring or inpatient.

Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first-episode psychosis

OBJECTIVES: Studies investigating suicidal behaviour in psychosis rarely focus on incidence cohorts of first-episode patients. This is important, because patients who refuse study participation have higher rates of comorbid substance use disorders and longer duration of untreated psychosis as well as worse course illness, variables potentially linked to higher prevalence of suicidal behaviour. The aims of the present study were therefore to examine the prevalence and predictors of suicide and suicide attempt before and during the first 18-24 months of treatment. METHOD: A retrospective file audit of 661 patients was carried out. RESULTS: Six patients (0.9%) died by suicide, 93 (14.3%) attempted suicide prior to entry, and 57 (8.7%) did so during treatment. Predictors of suicide attempt were: previous attempt (odds ratio (OR)=45.54, 95% confidence interval (CI)=9.46-219.15), sexual abuse (OR=8.46, 95%CI=1.88-38.03), comorbid polysubstance (OR=13.63, 95%CI=2.58-71.99), greater insight (OR=0.17, 95%CI=0.06-0.49), lower baseline Global Assessment of Functioning Scale and Scale of Occupational and Functional Assessment score (OR=0.96, 95%CI=0.62-0.91; OR=0.98, 95%CI=0.95-0.99), and longer time in treatment (OR=1.05, 95%CI=1.03-1.08). CONCLUSIONS: The prevalence of suicidal behaviour was high, indicating that suicidal behaviour in incidence populations is higher than in non-epidemiological cohorts of first-episode patients. The rate of repetition of suicide attempt among the sample, however, was lower than expected, suggesting that specialist services can play a role in reducing suicide risk.

The relationship between parental practices and suicidal behaviors in Québec adolescents

Sommaire Cette thèse examine les liens entre la présence de risques suicidaires chez les adolescents et leur perception des pratiques de chacun de leurs parents. L’étude a examiné l’association entre le comportement suicidaire et différents aspects des pratiques parentales incluant l’affection, l’exercice du contrôle comportemental et psychologique ainsi que les conflits entre parent et adolescents. La thèse a également examiné l’effet du statut matrimonial des parents sur le comportement suicidaire chez les jeunes. Le dernier objectif de l’étude a été d’explorer le rôle du sexe de l’adolescent comme facteur de vulnérabilité face au suicide. L’échantillon de l’étude était composé 1096 adolescents Montréalais, âgés de 11 à 18 ans. L’échantillon était également réparti entre filles et garçons, fréquentant deux écoles secondaires de la région de Montréal, dans la province du Québec au Canada. Il y avait deux groupes à l’étude : le groupe suicidaire et le groupe non-suicidaire. Le premier groupe incluait les sujets présentant des idéations suicidaires et ceux ayant fait une ou plusieurs tentatives de suicide. Un questionnaire auto-rapporté fut administré à chaque sujet pour évaluer les dimensions suivantes auprès de la mère et du père : le niveau de proximité affective, le niveau de supervision parentale, le contrôle comportemental et le contrôle psychologique, la tolérance à l’égard des amis, ainsi que la fréquence et l’impact émotionnel des conflits. Une échelle a également évalué la présence éventuelle de comportements suicidaires chez les jeunes. Dans le but de tester l’hypothèse de base de l’étude, une série d’analyses descriptives et une MANCOVA ont été réalisées. L’hypothèse générale de la thèse postulant que les adolescents ayant des risques suicidaires présenteraient des relations plus problématiques avec leurs parents fut confirmée. En contrôlant l’effet de la détresse psychologique des adolescents, les analyses ont mené à la conclusion que, dans les familles biparentales, un faible niveau de proximité affective avec la mère, une fréquence plus élevée de conflits avec la mère, un excès du contrôle psychologique et un plus faible niveau de supervision maternelle, présentaient des liens significatifs avec le comportement suicidaire chez les adolescents. Indépendamment de la structure familiale, les caractéristiques suivantes du père étaient respectivement perçues par l’adolescent comme ayant des liens significatifs avec le comportement suicidaire des adolescents: faible proximité affective, impact émotionnel et fréquence élevée des conflits ainsi que le manque de supervision. Ces résultats ont été interprétés à la lumière des théories de la socialisation qui mettent l’accent sur le rôle central de la qualité des liens affectifs entre parents et adolescents, comme facteur de protection contre les risques suicidaires. Les résultats ont aussi révélé que les filles adolescentes sont plus exposées aux risques suicidaires tels que tentatives et idéations suicidaires. Les conclusions de cette étude soulignent le besoin urgent de recherches plus poussées sur le comportement suicidaire des adolescents et leurs liens avec les facteurs familiaux, en tenant compte du statut matrimonial des parents. La thèse met également l’accent sur la nécessité de mettre en place des programmes de prévention auprès des adolescents présentant des risques suicidaires élevés.

Prevalence and associated factors for suicidal ideation and behaviors in obsessive-compulsive disorder

Introduction: Patients with obsessive-compulsive disorder (OCD) have historically been considered at low risk for suicide, but recent studies are controversial. Objective: To study the prevalence of suicidal thoughts and attempts in OCD patients and to compare those with and without suicidality according to demographic and clinical variables. Methods: Fifty outpatients with primary OCD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) from a Brazilian public university were evaluated. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was used to assess OCD severity, the Beck Depression Inventory to evaluate depressive symptoms and the Alcohol Use Disorders Identification Test to assess alcohol problems. Results: All patients had obsessions and compulsions, 64% a chronic fluctuating course and 62% a minimum Y-BOCS score of 16. Half of the patients presented relevant depressive symptoms, but only three had a history of alcohol problems. Seventy percent reported having already thought that life was not worth living, 56% had wished to be dead, 46% had suicidal ideation, 20% had made suicidal plans, and 10% had already attempted suicide. Current suicidal ideation occurred in 14% of the sample and was significantly associated with a Y-BOCS score ≥16. Previous suicidal thoughts were associated with a Beck Depression Inventory score ≥19. Conclusion: Suicidally has been underestimated in OCD and should be investigated in every patient, so that appropriate preventive measures can be taken.

Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first-episode psychosis

Studies investigating suicidal behaviour in psychosis rarely focus on incidence cohorts of first-episode patients. This is important, because patients who refuse study participation have higher rates of comorbid substance use disorders and longer duration of untreated psychosis as well as worse course illness, variables potentially linked to higher prevalence of suicidal behaviour. The aims of the present study were therefore to examine the prevalence and predictors of suicide and suicide attempt before and during the first 18-24 months of treatment.

Serious suicidal behaviors: socio-demographic and clinical features in a multinational, multicenter sample

BACKGROUND: Declared suicidal intent and physical danger are both considered important components in defining suicidal behaviors (SB). AIMS: 1) To investigate characteristics of serious suicidal behaviors (SSB), defined by either suicidal intent or lethality; 2) To determine any difference in terms of socio-demographic, clinical and/or service usage variables between SSB and non-serious suicidal behaviors (NSSB). METHODS: A total of 2631 contacts for SB were registered in the context of the MONSUE (Monitoring Suicidal Behavior in Europe) study project. Demographic and clinical information were registered. ICD-10 was used for classifying data about psychiatric diagnoses, methods used for SB and injuries reported. Clear intentionality, high-case fatality methods and serious injuries all defined SSB (n = 1169; 44.4%) RESULTS: SSB were more often preceded by a contact with an inpatient (either psychiatric or somatic) rather than an outpatient service. Among those having a previous history of SB, SSB subjects had fewer contacts with health services before the previous attempt. The strongest predictors for SSB appeared to be older age and not professing a religion. CONCLUSION: Many of the known factors contributing to the risk of completed suicide were also present for SSB. Our findings on service usage by suicide attempters show which aspects of mental health services should be strengthened in order to improve suicide prevention.

Suicidal ideation in a European Huntington's disease population.

BACKGROUND Previous studies indicate increased prevalences of suicidal ideation, suicide attempts, and completed suicide in Huntington's disease (HD) compared with the general population. This study investigates correlates and predictors of suicidal ideation in HD. METHODS The study cohort consisted of 2106 HD mutation carriers, all participating in the REGISTRY study of the European Huntington's Disease Network. Of the 1937 participants without suicidal ideation at baseline, 945 had one or more follow-up measurements. Participants were assessed for suicidal ideation by the behavioural subscale of the Unified Huntington's Disease Rating Scale (UHDRS). Correlates of suicidal ideation were analyzed using logistic regression analysis and predictors were analyzed using Cox regression analysis. RESULTS At baseline, 169 (8.0%) mutation carriers endorsed suicidal ideation. Disease duration (odds ratio [OR]=0.96; 95% confidence interval [CI]: 0.9-1.0), anxiety (OR=2.14; 95%CI: 1.4-3.3), aggression (OR=2.41; 95%CI: 1.5-3.8), a previous suicide attempt (OR=3.95; 95%CI: 2.4-6.6), and a depressed mood (OR=13.71; 95%CI: 6.7-28.0) were independently correlated to suicidal ideation at baseline. The 4-year cumulative incidence of suicidal ideation was 9.9%. Longitudinally, the presence of a depressed mood (hazard ratio [HR]=2.05; 95%CI: 1.1-4.0) and use of benzodiazepines (HR=2.44; 95%CI: 1.2-5.0) at baseline were independent predictors of incident suicidal ideation, whereas a previous suicide attempt was not predictive. LIMITATIONS As suicidal ideation was assessed by only one item, and participants were a selection of all HD mutation carriers, the prevalence of suicidal ideation was likely underestimated. CONCLUSIONS Suicidal ideation in HD frequently occurs. Assessment of suicidal ideation is a priority in mutation carriers with a depressed mood and in those using benzodiazepines.

Dissociable patterns of neural activity during response inhibition in depressed adolescents with and without suicidal behavior

Objectives - Impaired attentional control and behavioral control are implicated in adult suicidal behavior. Little is known about the functional integrity of neural circuitry supporting these processes in suicidal behavior in adolescence. Method - Functional magnetic resonance imaging was used in 15 adolescent suicide attempters with a history of major depressive disorder (ATTs), 15 adolescents with a history of depressive disorder but no suicide attempt (NATs), and 14 healthy controls (HCs) during the performance of a well-validated go-no-go response inhibition and motor control task that measures attentional and behavioral control and has been shown to activate prefrontal, anterior cingulate, and parietal cortical circuitries. Questionnaires assessed symptoms and standardized interviews characterized suicide attempts. Results - A 3 group by 2 condition (go-no-go response inhibition versus go motor control blocks) block-design whole-brain analysis (p < .05, corrected) showed that NATs showed greater activity than ATTs in the right anterior cingulate gyrus (p = .008), and that NATs, but not ATTs, showed significantly greater activity than HCs in the left insula (p = .004) to go-no-go response inhibition blocks. Conclusions - Although ATTs did not show differential patterns of neural activity from HCs during the go-no-go response inhibition blocks, ATTs and NATs showed differential activation of the right anterior cingulate gyrus during response inhibition. These findings indicate that suicide attempts during adolescence are not associated with abnormal activity in response inhibition neural circuitry. The differential patterns of activity in response inhibition neural circuitry in ATTs and NATs, however, suggest different neural mechanisms for suicide attempt versus major depressive disorder in general in adolescence that should be a focus of further study.

The role of suicide risk in the decision for psychiatric hospitalization after a suicide attempt

BACKGROUND: Suicide prevention can be improved by knowing which variables physicians take into account when considering hospitalization or discharge of patients who have attempted suicide. AIMS: To test whether suicide risk is an adequate explanatory variable for predicting admission to a psychiatric unit after a suicide attempt. METHODS: Analyses of 840 clinical records of patients who had attempted suicide (66.3% women) at four public general hospitals in Madrid (Spain). RESULTS: 180 (21.4%) patients were admitted to psychiatric units. Logistic regression analyses showed that explanatory variables predicting admission were: male gender; previous psychiatric hospitalization; psychiatric disorder; not having a substance-related disorder; use of a lethal method; delay until discovery of more than one hour; previous attempts; suicidal ideation; high suicidal planning; and lack of verbalization of adequate criticism of the attempt. CONCLUSIONS: Suicide risk appears to be an adequate explanatory variable for predicting the decision to admit a patient to a psychiatric ward after a suicide attempt, although the introduction of other variables improves the model. These results provide additional information regarding factors involved in everyday medical practice in emergency settings.

Self-reported needs for care among persons who have suicidal ideation or who have attempted suicide

This study examined the self-reported needs of suicidal users of mental health services and the extent to which needs were met. Data on 10,641 adults were available from the Australian National Survey of Mental Health and Well-being. In the year before the survey, 245 persons with suicidal ideation used services, 37 of whom had attempted suicide. Suicidal persons reported a range of needs, especially for counseling, medication, and information. More than half of those with suicidal ideation and those who had attempted suicide who reported any needs felt that their needs had not been fully met. Suicidal persons were significantly more likely to perceive that they had needs.

Gender differences in the relationship between depression and suicidal ideation in young adolescents

Objective: This study examined the risk relationship between depressive symptomatology and suicidal ideation for young adolescent males and females. Method: A large cohort of students in their first year of high school completed the Center for Epidemiological Studies Depression Scale (CES-D) and the Adolescent Suicide Questionnaire. The risk relationship between depressive symptomatology and suicidal ideation was modelled using non-parametric kernel-smoothing techniques. Results: Suicidal ideation was more frequently reported by females compared with males which was partly explained by females having higher mean depression scores. At moderate levels of depression females also had a significantly higher risk of suicidal ideation compared with males and this increased risk contributed to the overall higher levels of female ideation. Conclusions: The risk relationship between depressive symptomatology and suicidal ideation is different for young adolescent males and females. The results indicate that moderate levels of depressive symptomatology can be associated with suicidal ideation (especially among young females) and that for these young people a suicide risk assessment is required.

Suicidal ideation and suicide attempts as predictors of mental health service use

Objective: To examine the extent to which suicidal ideation and suicide attempts are predictive of service use. Design and setting: The National Survey of Mental Health and Wellbeing considered service utilisation in relation to self-reported mental health problems. Service utilisation was inquired of in relation to hospital-based care (including both specialist mental health and general care settings), as well as consultations with a range of health professionals (both specialist and non-specialist mental health professionals, including psychiatrists, psychologists and general practitioners) on an outpatient basis. Participants: Secondary analysis of self-report data from 10 641 randomly selected Australian adults who participated in the National Survey of Mental Health and Wellbeing in 1997. The key predictor variables were reported suicidal ideation and suicide attempts over the past 12 months. Main outcome measures: Use of services for mental health problems (past 12 months). Results: When considered in isolation, individuals reporting suicidal ideation were more likely to make use of at least one type of service for mental health problems than non-suicidal individuals (OR, 17.3; 95% Cl, 13.2-22.6), and individuals reporting suicide attempts were even more likely to do so (OR, 32.3; 95% CI, 9.0-115.4). In the case of suicidal ideation, this effect remained significant after controlling for a range of potential confounders. For suicide attempts, the effect of mental health service use was no longer significant after other variables were taken into account. Conclusions: Suicidal individuals are likely to make use of services, and a high proportion of suicides may be preventable through appropriate healthcare system responses.

Timing of Dose Relative to Sexual Intercourse Attempt in Previous Sildenafil Citrate Users Treated with Tadalafil: A Geographical Comparison from a Single Arm, Open-Label Study

Introduction. Previous research has demonstrated that sildenafil citrate users alter dosing-sexual attempt behavior when switched to tadalafil. The impact of geography and culture on sexual behavior with phosphodiesterase type 5 (PDE5) inhibitor treatment has not been fully investigated. Aim. To describe and compare the changes in dosing-sexual attempt behavior with sildenafil citrate vs. tadalafil treatment across four distinct geographies: Asia, Australia/New Zealand (ANZ), Central Eastern Europe/Middle East (CEE/ME), and Latin America (LA). Methods. Data from a single-arm, open-label clinical trial conducted in 21 countries from November 2002 to May 2004 were used in this analysis. Men with erectile dysfunction and a history of >= 6-week prior sildenafil citrate use continued sildenafil citrate treatment for 4 weeks then switched to tadalafil for 8 weeks. Dosing instructions were provided. Main Outcomes Measures. Timing of dose and sexual intercourse was assessed through patient diaries for the final 4 weeks of each treatment period. Results. A total of 2,760 men were enrolled: Asia 15.8%; ANZ 29.4%; CEE/ME 19.7%; LA 35.1%. The median time from dosing to intercourse was significantly increased during tadalafil treatment across all geographical regions; however, the magnitude of increase differed significantly by geography (P < 0.0001). The Asian cohort demonstrated the shortest duration between dosing and sexual intercourse attempts (irrespective of drug), and altered sexual behavior the least upon switching to tadalafil. The ANZ cohort demonstrated the longest duration between dosing and sexual intercourse attempts (irrespective of drug), and altered sexual behavior the most upon switching to tadalafil. Conclusion. Men with a history of established sildenafil citrate use alter their dose-attempt behavior when treated with tadalafil irrespective of geography. However, the extent to which sexual behavior alters is not uniform across geographical regions, suggesting that dosing instructions and duration of drug effectiveness, in combination with personal and cultural preferences, may determine sexual behavior with PDE5 inhibitor use. Rubio-Aurioles E, Glina S, Abdo CHN, Hernandez-Serrano R, Rampazzo C, Sotomayor M, West TM, Gallagher GL, and Lenero E. Timing of dose relative to sexual intercourse attempt in previous sildenafil citrate users treated with tadalafil: A geographical comparison from a single arm, open-label study. J Sex Med 2009;6:2836-2850.

Treatment of suicidal people around the world

Background Suicide is a leading cause of death worldwide; however, little information is available about the treatment of suicidal people, or about barriers to treatment. Aims To examine the receipt of mental health treatment and barriers to care among suicidal people around the world. Method Twenty-one nationally representative samples worldwide (n=55 302; age 18 years and over) from the World Health Organization`s World Mental Health Surveys were interviewed regarding past-year suicidal behaviour and past-year healthcare use. Suicidal respondents who had not used services in the past year were asked why they had not sought care. Results Two-fifths of the suicidal respondents had received treatment (from 17% in low-income countries to 56% in high-income countries), mostly from a general medical practitioner (22%), psychiatrist (15%) or non-psychiatrist (15%). Those who had actually attempted suicide were more likely to receive care. Low perceived need was the most important reason for not seeking help (58%), followed by attitudinal barriers such as the wish to handle the problem alone (40%) and structural barriers such as financial concerns (15%). Only 7% of respondents endorsed stigma as a reason for not seeking treatment. Conclusions Most people with suicide ideation, plans and attempts receive no treatment. This is a consistent and pervasive finding, especially in low-income countries. Improving the receipt of treatment worldwide will have to take into account culture-specific factors that may influence the process of help-seeking.