March 2010
A Prevention Programme for Adolescent Suicide in Italy

Giovanni Migliarese, Claudio Mencacci
Neuroscience Department, AO Fatebenefratelli e Oftalmico, Milan, Italy

Epidemiology of suicide in adolescence
Suicide is actually one of the leading causes of death for adolescents. In recent years no significant decrement in the worldwide rates of young suicide have been observed, although different prevention programmes have been promoted. Although the rates of young suicide vary between countries, worldwide it remains one of the most common causes of death in this age. The mean worldwide annual suicide rate for a population of 100.000 was 12.0 for female and 14.2 for male 15-24 year-olds. The epidemiological trend of suicide rate does not show a reduction comparable to other causes of death for the same age. The latest mean Italian annual rates of suicide per 100.000 were 1.4 for females and 6.6 for males. Suicide represent the third cause of death for male and females aged 15-24 in Italy.

Risk factors in adolescent
Different risk factors for adolescent suicide have been identified. The identification of the risk factors that are associated with adolescent suicide is fundamental to identify a subgroup of subjects to target secondary and tertiary prevention programmes, that are more effective than primary prevention in reducing the number of young suicides, as demonstrated by different studies. The most significant risk factor is a previous suicide attempt. A previous attempt dramatically increases the risk of future death by suicide: about one third of people that commit suicide have a history of previous attempt and almost two-thirds of adolescents who commit suicide have communicated their intention. It has been estimated that a previous suicide attempt increased the risk of death up to 30-fold. Up to 50% of adolescents with a suicide attempt repeat it in the next two years: a “suicidal behaviour” has been suggested to explain these high rates of repetition. Other risk factors for adolescent suicide are psychiatric disorders (mood disorders, conduct/disruptive behavioural disorders), psychological factors, stressful life events and abuses, chronic or debilitating physical disorders. Psychiatric comorbidity has been identified as one of the most common factors associated with a completed suicide in adolescence. Different psychological autopsy studies reported the presence of a mental disorder in up to 80% of adolescent suicides. Studies comparing young suicides with general population controls have estimated that the risk for suicide in young people having a mental disorder ranges from odds ratio 12 to 35.

Use or abuse of different substances are associated with suicide attempt. The association can be defined along two domains: directionality, and temporality. With respect to temporality, the terms proximal and distal correspond to traditional notions of acute and chronic effects: a proximal effect occurs in the hours or minutes after a behaviour and exerts its influence over a correspondingly short time interval while a distal effect reflects an accumulated process, that causes effects after weeks or years. Therefore, suicide attempt can be related to substance abuse by increasing the impulsivity of the subject (proximal effect) or causing an alcohol-induced psychiatric condition associated with suicicide (distal effect).

A subject with a previous suicide attempt present characteristics, such as high levels of impulsivity, psychiatric symptomatology, dysfunctional personality traits, abuse of alcohol or other substances, that could explain the high risk of repetition of the suicidal behaviour and the urgency of a correct treatment.

Problems and controversies in prevention of suicide in adolescent
Despite the fact that a great number of adolescents that commit suicide have a history of mental problems, attempted suicides and suicidal behaviour, it has been reported that only about 20-50% of individuals have received psychiatric care. Moreover, few of these subjects were in psychiatric care at time of completed suicide. Even in adolescents with a prior suicide attempt, only one third received a psychiatric treatment. There are many reasons that could explain the high rates of adolescents that do not receive any psychiatric or psychological treatment. Discontinuity of psychiatric care seems characteristic of adolescent with a previous attempt. Many of the adolescents admitted in the emergency department after a suicide attempt are discharged with the indication to a psychiatric/psychological visit, but rarely fix the appointment when coming back in their context. Some studies suggest that a conventional psychiatric treatment is less effective for young people with suicidal behaviour when compared with specific intervention. Then, the development of a specific intervention is fundamental in the treatment of an adolescent with suicide risk: the target of this intervention must be the recognition of a suicide attempt and its treatment, and the recognition of a mental disorder associated with the suicidal behaviour or ideation. Moreover, a specific prevention programme must include an integrated treatment (psychological and psychiatric treatment), designed specifically for this behaviour, which could reduce the high rates of treatment discontinuation clearly evident in different studies. A specific psychological intervention, targeting aspects that are correlated with the suicidal behaviour is required.

A specific treatment after an adolescent suicide attempt
Fatebenefratelli e Oftalmico Hospital in Milan and the association “L’amico Charly onlus” designed an experimental project for the acute and the long term treatment of the adolescent suicide attempt. This project is completely financed by the Lombardy region and involved different specialists and different structures. The project focused on all the adolescents (13-21 years old) that are accepted in the emergency department of the Fatebenefratelli e Oftalmico Hospital after a suicide attempt. In the emergency department we provide firstly an organic evaluation and secondarily a psychiatric evaluation of all adolescents with suicide attempt. A screening for the presence of drugs of abuse in the urine is a routine procedure. Subsequently, it is proposed to the adolescent to be hospitalized in the Pediatric Department, in a room specifically prepared for these patients and provided with video and security tools. During the hospitalisation a psychologist tests the patient with a battery of scientifically based instruments: tests are targeted to assess the absence or the presence of a concomitant mental disorder and to evaluate the suicidal risk and the impulsivity. Moreover, the adolescent has a daily clinical interview with a psychiatrist and, if necessary, a pharmacological treatment is set up. During the hospitalization some sessions of family intervention are provided to the parents of the adolescent. The hospitalization is fundamental in order to reach some important goals: firstly there is the necessity to resolve the acute crisis and to protect the adolescent to other suicidal behaviours. Secondarily it is important to establish a sufficient therapeutic relationship, based on a clear clinical diagnosis, on the goals that are achievable and on the therapeutic instruments that will be utilized during the treatment. It’s important to define an individualized treatment because a suicide attempt is a behaviour that identifies a heterogeneous group of adolescents, and different treatments based on the underlying pathology should be provided. A good hospitalization permits to increase the rate of outpatient treatment: the passage from inpatient care to outpatient treatment should be driven along a continuum. In order to reduce the risk of dropping out, it’s important to begin an outpatient treatment already in the first week after the discharge from the hospital. The close collaboration between the hospital and the onlus “L’amico Charly” that until 2001 offered an outpatient treatment for adolescents with a suicide attempt or severe suicidal ideation, permits to arrange an appointment with a psychiatrist and a psychologist in the first days after the discharge. Moreover it permits us to monitor if the subject really begins the treatment or does not attend the appointment.

Preliminary Results
During the first two years of the programme, 75 adolescents (mid age 17,3) arrived to the Emergency Department of Fatebenefratelli Hospital with a suicide attempt. Around 20% were positive to drug abuse in urine at the moment of the screening, meaning that the attempted suicide was effectuated in a state of partially altered consciousness. For half of the adolescents this was the first time in which they could have a psychiatric visit and an evaluation of their sufferance. Moreover, 40 adolescents had a history of previous suicide attempts, but only a minority of these had been in psychiatric care. For most of adolescents (83.3%) a diagnosis of mental disturbance has been set: dysfunctional personality traits have been identified in more then 50% of adolescents. High rates of depressive symptoms were present (48%). For 35% of adolescent a comorbidity between personality traits and depressive symptoms has been identified. Barratt Impulsivity Scale showed a high level of impulsivity in these patients, both in total score (69.9) and in subscales (attentional impulsiveness, motor impulsiveness, and non-planning impulsiveness). The values of Barratt Impulsiveness Scale total score showed a distribution shifted to higher value of the curve. Given the sample size we could not find a significant difference from the expected values. To 80% of the adolescent we proposed the hospitalization and specific treatment for their behaviour. More than 90% of adolescents who we proposed this treatment are currently in psychiatric or psychological care, and only 3 patients have dropped out. Only five adolescents have repeated a suicide attempt. No adolescent died through suicide.

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