In This Issue

One of the stronger predictors of suicide is a history of making a previous suicide attempt and yet research into the prediction of suicide among those making suicide attempts has been methodologically restricted. Annette Beautrais reports rates of further suicidal behavior amongst individuals making medically serious suicide attempts, and examines whether suicide and suicide attempt may be predicted from baseline characteristics of the individual and the index suicide attempt. Data are drawn from a 5-year study of 302 individuals making medically serious suicide attempts with information collected by personal interview at baseline, 6, 18, 30, and 60 months after the index attempt. Within 5 years, 6.7% died by suicide and 37% made at least one nonfatal suicide attempt. While only very limited prediction of suicide was possible, almost half of those who made serious suicide attempts made a further fatal or nonfatal attempt within 5 years. These findings imply the need for enhanced follow-up, treatment, and surveillance of all patients making serious suicide attempts. Jennifer Muehlenkamp, the 2003 AAS Student Award winner, and Peter Gutierrez collected data from a community sample of 390 high school students to examine potential differences between adolescents who had attempted suicide and those who engaged in self-injurious behaviors on measures of depression, suicidal ideation, and attitudes toward life and death. 15.9% of the students reported self-injurious behaviors (SIB), with a majority beginning SIB between the ages 13 and 15 years. The most common methods reported included cutting, scratching, self-hitting, punching/kicking, burning, and banging. Analysis showed that all three measures predicted participants' self-harm categorization. In the United States, one of the high-risk groups for suicide are those youth involved with the child welfare and juvenile justice systems. Lambert Farand and colleagues studied adolescents (under 19 years of age) involved with the child welfare and juvenile justice systems in the Province of Quebec (Canada) and found that these adolescents accounted for at least one third of all completed suicides in their age group in 1995 and 1996. In 1996, the Quebec rate of suicide for the 15–19 year age group was 20.7/100,000 (compared to 12/100,000 in the U.S.). The overall suicide risk, standardized for age and sex, was 5 times that of the general adolescent population, while female juvenile delinquents had the highest relative risk of suicide (36.1). Forty percent of the suicides were actively involved with the child welfare and juvenile justice systems at the time of their death. The authors discuss three sets of factors that may account for their findings. Deborah Azrael and her colleagues at the Harvard Injury Control Center report on 153 youth suicides (ages 0–17) in Arizona (1994–1999), distinguishing those who died by firearms and those who died by other means. The largest majority of these youth suicides used firearms (71%). Youths who committed suicide were predominantly male (84%), White (84%), in the 15–17 year old age group (76%), and killed themselves at home (83%). A large majority (75%) had experienced a life crisis and most had expressed suicidal thoughts (51%) or had mental health problems in the past (61%). Of particular note is that 45% of the youths had a chronic medical problem and 59% tested positive for drugs or alcohol at autopsy. White youths were more likely than non-White youths to use a firearm to commit suicide, as were youths who had not experienced a life crisis or expressed suicidal thoughts in the past. The authors suggest a profile of the at-risk youth—one who is characterized by impulsivity and who has access to a firearm. Rémy Barbe et al. report a reanalysis of data from a previously published study comparing three forms of therapy for 107 depressed adolescents, specifically considering the impact of present or past suicidality on pretreatment symptom status and response to treatment. The three modalities are cognitive-behavioral (CBT), systemic-behavioral-family (SBFT), or non-directive-supportive (NST) therapy. Consistent with their predictions, the investigators found that suicidal teens exhibited more indicators of psychopathology at intake and responded less well to treatment, including dropping out of treatment more often. Significantly, suicidality adversely affected treatment response primarily in the group receiving supportive therapy (NST). This study addresses an important issue concerning the treatment of suicidal individuals: Should suicidality be considered merely a symptom of depression and other disorders, that can be expected to resolve as treatment of the primary disorder progresses, or might suicidal patients constitute a qualitatively different group with distinct treatment indications? The authors conclude that hopelessness should be specifically targeted early in treatment, and suicidal depressed adolescents should not receive NST but a specific treatment like CBT. One school-based prevention strategy is to help peers feel comfortable informing a responsible adult that a friend has disclosed to them suicidal ideation or intent. Peers tend not to notify adults about such disclosures. Kalafat and Elias (SLTB 22: 315–321, 1992) found that confidants are less likely to deal with a suicidal disclosure on their own if they have had previous social experience with suicide. Katherine Dunham examined 288 undergraduate psychology students to determine whether young adults' own history of suicidal ideation, gender, social history with suicide, and ambiguity of the disclosure would predict their response to a hypothetical suicidal peer. She found that the confidants' experience with others' attempted or completed suicides increased their likelihood of saying they would tell an authority, whereas their own history of ideation or attempts reduced the likelihood of that response. Dunham suggests that one technique to increase the likelihood of disclosure is to include them in the intervention undertaken by the responsible adult. The 2003 Alexander Gralnick Award was received by Jill Harkavy-Friedman et al. for their work on examining the role of depression in suicidal behavior among 86 individuals with schizophrenia and schizoaffective disorder. They found that 34% reported a history of suicide attempts and tended to have an earlier age of onset of psychosis that nonattempters. Suicidal behavior typically occurred 4.5 years after the onset of psychosis and 7.5 years after the onset of the first major depressive episode for those who had a history of major depression. However, only half of the attempters reported a suicide attempt during an episode of major depression and for half, depression was not a trigger for a suicide attempt. Despite a long history of illness, almost half of those with depression never made a suicide attempt. They conclude that, although depression is a potential stressor for triggering suicidal behavior, individuals with schizophrenia without an episode of depression are still at risk for suicidal behavior. In a related study, Debbie Warman et al. examined a heterogeneous sample of patients who had made suicide attempts and are psychotic (not just those with a schizophreniaspectrum disorder). Patients with psychotic disorders endorsed higher levels of suicide ideation than patients without psychotic disorders. During the follow-up period, patients with psychotic disorders subsequently attempted suicide at a significantly higher rate than patients without psychotic disorders. They detail experimentally that depression and hopelessness do not fully mediate the relationship between psychosis and suicide. It is commonly believed that patients with psychotic disorders kill themselves because they are depressed and hopeless. This study encourages future investigation into this theory, as it details that other variables are important to consider. The clinical implication is that even if we devise treatment for depression, hopelessness, and poor social problem solving, we may be missing some important suicide ideation factor specific for psychotic suicide attempt patients. I would like to draw the reader's attention to the next page where the American Association of Suicidology announces the 2005 annual award competitions. We are particularly proud of our annual student award competition. If you meet the criteria for applying, we strongly encourage you to do so.

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