References

Laederach, J., Fischer, W., Bowen, P., & Ladame, F. (1999). Common risk factors in
adolescent suicide attempters revisited. Crisis: The Journal of Crisis Intervention
and Suicide Prevention, 20(1), 15-22. Retrieved March 27, 2009,
doi:10.1027//0227-5910.20.1.15

<!--Additional Information:
Persistent link to this record (Permalink):
http://ezproxy.library.capella.edu/login?url=http://search.ebscohost.com.library.capella.edu/logi
n.aspx?direct=true&db=pdh&AN=cri-20-1-15&site=ehost-live&scope=site
End of citation-->

Common Risk Factors in Adolescent Suicide Attempters Revisited

By: Jrme Laederach

Werner Fischer
Philippa Bowen
Franois Ladame

Biographical Information for Authors: Jrme Laederach, Philippa Bowen, and

Franois Ladame are with the Units for Adolescents and Young Adults, Department of
Psychiatry, Geneva University Hospitals, 51, Bd. de la Cluse, CH-1205 Geneva,
Switzerland. Werner Fischer is Chief Sociologist, Unit for Sociological Research,
Department of Psychiatry, Geneva University Hospitals. His main research interests are
sociology of health and suicidology.

Acknowledgement: Acknowledgments

This study was funded by the Swiss National Science Foundation (FNRS; grant nos. 32-
321198.91 and 3200-043-084.95 / 2) and the Johann Jacobs Foundation. The
enrollment of the research cohort would not have been feasible without the permanent
support of Pierre-F. Unger, Physician-in-Chief of the Division for Medical and Surgical
Emergencies, Geneva University Hospitals. We would also like to express our
appreciation to Cinzia Borel-Messerli, Esperanza Galan, Caroline Moutia, Teresa Pascual-
Sanchez, Maja Perret-Catipovic, Paula Wagner, Valrie Wahl-Vincent, and Eric Zbinden
for their important contributions to this study.

Correspondence concerning this article should be addressed to: Werner

Fischer, Unit for Sociological Research, Department of Psychiatry, Geneva University
Hospitals, 2 Ch. du Petit-Bel-Air, CH-1225 Chne Bourg Switzerland Phone: +41 22 305-
5753.+41 22 305-5799 Electronic Mail may be sent to: fischer@cmu.unige.ch.
Introduction
In Switzerland, the most recent statistics reveal that suicide has now become the
leading cause of death in young people between the ages of 15 and 29 and that is a
major health problem. In examining predictive factors with regard to suicide, a past
history of suicide attempts (SA) has been shown in a number of studies to increase the
risk, both for future suicide attempts as well as for suicide itself (Granboulan, 1995;
Corbitt et al., 1996). Current statistics regarding SA indicate disturbing levels of suicidal
behavior, although methodological problems and poor reliability of data sources have
raised doubts over the results available to date. Nevertheless, the WHO / Euro
Multicentre Study on Parasuicide established European prevalence rates in youth aged
between 15 and 24 for the years 19891992 of 165.5 per 100,000 for males and 284.4
per 100,000 for females (Bille-Brahe et al., 1993). In Switzerland, a study of 3332 school-
aged adolescents found that 3000 per 100,000 males and 4000 per 100,000 of females
acknowledged a suicide attempt in the previous 12 months (Narring et al., 1994). Given
this high frequency of SA and its known association with completed suicide,
examination of the etiological factors in SA, as well as therapeutic and preventative
strategies, has become an important and challenging priority in public health.

Recent Studies on Risk Factors in Adolescent Suicide Attempts

The following characteristics have emerged as potential risk factors for SA: mental
disorders, previous SA, suicidal behavior among family and acquaintances, poor state of
health, poor social integration, and a past history of sexual abuse.

Mental Disorders

Affective disorder has been found to be strongly correlated with suicide, with recent
studies showing a significant increase in the rate of depression in suicide attempters
when compared to community controls or nonsuicidal adolescents (Brent et al. 1993a,
1994a). Nevertheless, studies show that affective disorder alone is not sufficient, and
that it is the comorbidity between depression and one or more other disorders which is
more significant. For Lewinsohn et al. (1995), the presence of a second disorder
substantially increases the SA rate compared to the rate for those with a single
disorder. In their study the diagnosis with the strongest association with SA was
depressive disorder with substance use, disruptive behavior, or anxiety.

Previous Suicide Attempts

A past history of suicidal behavior has been shown in a number of studies to be a

strong predictor of future suicidal behavior in adolescents (Corbitt et al., 1996, Lewinsohn
et al., 1994). One recent follow-up study examined outcome in teenagers an average of
11.5 years after admission following SA and found that in their overall assessment more
than half were either unchanged or worse (Granboulan et al., 1995). 15 of the 127
subjects had died, only one of them from natural causes, and 31% of subjects made at
least one further suicide attempt.
Suicidal Behavior Among Family and Acquaintances

Suicidal behavior in close contacts probably constitutes another risk factor, though
studies to date have been inconclusive. Brent et al. (1993c, 1994b) described the impact
of adolescent suicide on friends and relatives in several reports. The authors recently
concluded that while exposure to suicide does not result in an increased risk of suicidal
behavior among friends and relatives, there is a relatively pervasive impact in terms of
increased risk of depression, anxiety, and posttraumatic stress disorder (Brent et al.,
1996). These conclusions are consistent with those of Pfeffer et al. (1997).

State of Health

Young people who attempt suicide characteristically have multiple difficulties, with,
among other things, an increase in somatic complaints compared with their nonsuicidal
peers. In a national study, Choquet and Ledoux (1994) found that more than 40% of
suicide attempters (compared with 18% of controls) suffered from at least three
somatic complaints (the checklist included headache, nausea, fatigue, nightmares,
backache, and abdominal pain).

Social Integration

In the WHO / Euro Multicentre Study on Parasuicide (Bille-Brahe et al., 1993) recent
changes of sociodemographic circumstances were emphasized, with the change being
from a stable to an unstable situation. Furthermore, the adolescents who had made a
suicide attempt were more often unemployed. Concerning education and professional
training or activity, Gould et al. (1996) demonstrated obvious signs of poor integration
among 120 adolescents who were the subject of psychological autopsy after committing
suicide.

Sexual Abuse

The link between suffering sexual violence and attempted suicide has recently been
addressed by Silverman et al. (1996) in a longitudinal study examining the long-term
consequences of abuse suffered during childhood or adolescence. Their data show a
particularly elevated level of suicidality among the girls, of whom one-quarter had made
a suicide attempt before the age of 21 years.

In light of the above-mentioned risk factors, the aim of this paper is to describe the
sociodemographic and psychiatric characteristics of adolescent suicide attempters in an
ongoing longitudinal research study in Geneva. This study aims at assessing the impact
of treatment on young adolescent suicide attempters. Research hypotheses specifically
concern the influence of psychiatric treatment on further suicidality as well on the
underlying mental disorders. The 5-year follow-up is still going on, and the results are
not yet available. We therefore limit this report to some characteristics of the research
sample when the 148 adolescent suicide attempters were included in the cohort. At that
stage, we primarily aimed at illustrating, in a strictly descriptive way, similarities and
divergences regarding risk factors between our results and those of the above studies

Subjects and Method

Subjects

The study sample includes 148 adolescents, 15 to 19 years old (mean 17.8 years)
admitted to the emergency unit of a general hospital (Geneva University Hospital) after
a suicide attempt, between October 1, 1992, and September 30, 1996. All cases are
included, i. e., first suicide attempters as well as repeaters. Neither ongoing nor former
psychiatric treatment was an exclusion criteria. A total of 203 adolescents were
admitted during that time. Among them, 148 (119 girls, 29 boys) agreed to participate
in the study and provided analyzable questionnaires; 55 adolescents either refused to
participate or were excluded, mainly for linguistic reasons. Reasons for not participating
in the study included denial of suicidal intention, refusal to cooperate, living outside of
Geneva, or loss of patients during holidays.

Procedure

The initial research interview took place during the short stay in the emergency room of
the Geneva University Hospital (length of stay limited to a maximum of 36 hours). The
clinical investigation was done by an experienced clinician. All patients were informed
that they would be part of a follow-up research project and that they would be
contacted for further interviews. Their legal consent was requested and the appropriate
form signed before the first research interview.

Research Instruments

Initial phase data were collected using the Structured Clinical Interview (SCID) for DSM-
III-R axis I disorders and a psychosocial structured questionnaire. While the SCID is the
main diagnostic instrument, for the investigation of behavioral problems not addressed
by this instrument, the corresponding chapter of the Diagnostic Interview Schedule for
Children (DISC) was used. Both instruments have been internationally used on a large
scale. The SCID was primarily designed for adult patients. We choose it since the
suicidal adolescents of our research cohort will be 20 to 25 years old at the end of the
follow-up.

The structured questionnaire was used to collect data related to:

Sociodemographic data, notably sex and age.

Psychosocial factors, as well as personal and family history, with regard
to medical, psychiatric and social issues. These include the subjective
 state of health of the subject, absence from school or work, whether for
health reasons or not, and sexual abuse.
Personal or family history of suicidality or self destructive behavior.

Statistical Analysis

Psychiatric and sociodemographic characteristics were examined using 2 analysis

(Yates correction), with set at p < .05 (two-tailed).

Results
The results which follow have been systematically controlled in terms of sex. However,
the data for males and females have been combined because, with the exception of
three factors (inactivity for health reasons, suicide attempt of a friend, and sexual
abuse) there were no significant differences between males and females.

Population, Sex Ratio and Age

The cohort of 148 adolescents comprised 119 females (80%) and 29 males (19.6%)
aged between 15 and 19 years, giving a female to male ratio of 4:1. The males and the
females varied in their age distribution, showing two distinct peaks, at 16 years for the
females, and 19 years for the males.

Psychiatric Characteristics

The correlation between psychopathology and SA was strong (see Table 1). With one
exception (0.7%), all the adolescents of this study had a diagnosis on axis I DSM-III-R,
that is, 99.3%. The great majority suffered from an affective disorder (86.5%), most
commonly major depression (69.6%). Less than half of the adolescents (41.2%) had
only one current disorder, that being most frequently a mood disorder (30.4%). The
other individual diagnoses (substance abuse, psychotic disorder, adjustment disorder,
and anxiety disorder) were rarely found. 86 adolescents (58.1%) had two or more
current disorders. This comorbidity was most commonly between an affective disorder
and an anxiety disorder (37.2%).

Prevalence of Psychiatric Diagnoses Among Suicide Attempters

Previous SA

Past suicidality was important. 49 adolescents (46.6%) had already made one (25.0%)
or two or more attempts (21.6%) in the past (see Figure 1).

Figure 1. Previous suicide attempts (SA). No differences between males and females
were significant
SA and Completed Suicide in Family and Acquaintances

As shown in Figure 2, 51 adolescents (34.5%) knew someone who had attempted

suicide, either in their close family (16.2%), extended family (5.4%), or among their
friends (12.8%), the latter association being seen more often in boys than girls (24.1%
versus 10.1%, p < 0.05). As shown in Figure 3, fewer subjects knew someone who had
actually died by suicide (12.8%), but when they did, it was most commonly a friend
(8.1%).

Figure 2. Suicide attempts (SA) in family and acquaintances (at least one). * Difference
between males and females (p < .05)

Figure 3. Suicide in family and acquaintances (at least one). No differences between
males and females were significant

Health

108 adolescents (73.0%) considered they had poor / very poor (26.4%) or average
health (46.6%). Only 40 adolescents (27.0%) perceived themselves as having good or
excellent health at the time of the SA.

Social Integration

With regard to their school or professional situation (see Figure 4), most adolescents in
our cohort were at school (54.1%) or had professional training or were working
(30.4%). Only 12 adolescents (8.1%) were inactive at the time of their suicide attempt.
However, absenteeism was frequent, with 60.2% missing two weeks or more during
the previous year. A considerable number (46.6%) had also taken two or more weeks
leave for health reasons during the previous year, this being more common among
males (51.2%) than females (27.6%).

Figure 4. School and professional situation. No differences between males and females
were significant

Sexual Abuse

27 (18.2%) adolescents, and significantly more females than males (p < .05), had been
confronted with sexual violence (i.e., at least physical contact if not rape or incest).

Discussion
The presence of psychopathology among young suicide attempters at the time of
attempting suicide is confirmed by this study. With only one adolescent not presenting
at least one DSM-III psychiatric diagnosis, this association between psychopathology
and suicide attempt is consistent with that demonstrated by Pfeffer et al. (1991). Our
findings show that psychopathology is no less frequent among suicide attempters than
among adolescents who died by suicide (Shaffer et al., 1996). The diagnosis of mood
disorder, which was present in more than three-quarters of our subjects, predominates,
with an incidence rate very close to that reported by Brent et al. (1993b).

The importance of a comorbid psychopathology, which was present in over half of the
adolescents in our cohort, is also in agreement with the findings of others (Shaffer et al.,
1996; Lewinsohn et al., 1995). The latter studies mention three principal forms of
comorbidity: affective disorders associated with anxiety disorders, with conduct
disorder, or with substance abuse. Among the patients in our study, the main
observation is an association between mood disorder and anxiety disorder, which was
present in a little over one-third of patients. By contrast, the comorbidity between mood
disorder and substance abuse is much less important, only one case in 10.

Several reasons could account for these differences between our results and those of
the authors cited. The lower frequency of the diagnosis of substance abuse could be
the effect of a bias in the recruitment of the adolescents for our cohort. It is possible
that adolescents presenting to emergency services with obvious substance abuse
problems were not signalled for inclusion in the research cohort, even when self-
destructive behavior motivated their hospitalization. The immediately obvious signs of
drug addiction could therefore have led the physicians to put the suicidal aspect in
second place, perhaps not addressing it at all. Being directed towards specific substance
abuse treatments may therefore have contributed to their under-representation in our
cohort.

The total absence of behavioral disorderseither as a sole diagnosis or associated with

another disorderis more intriguing. It is possible that the relatively minor place
devoted to the investigation of this disorder, in comparison with the very significant
weight that the SCID was ascribed, translated into a sort of minimization of this aspect.
One must also note that the instrument itself could contribute to the underestimation of
behavioral disorders. In evaluating several instruments which screen for
psychopathology, Orvaschel (1985) drew attention to certain weaknesses and
characteristics of the DISC, including poor test-retest reliability in children and
adolescents and being subject to great fluctuations between studies (between .28 and
.78). There is also a poor correlation between the diagnosis established by the scale
and standard clinical evaluations, and parent-child agreement is poor and variable
(between .04 and .68). The instrument can, therefore, itself bring about relatively
significant biases and modify the results appreciably.

Although there are some differences between our results and those of other recent
studies, these differences do not detract from the significance of the predominance of
the diagnosis of affective disorders, which is common to all studies of the
psychopathological aspects of suicidal adolescents. However, not all adolescents who
have a depression attempt suicide, and our results confirm the importance of other
potential risk factors.

Firstly, it is clear that a past history of suicidality increases the risk of further suicide
attempts. Close to a half of our cohort acknowledged having already made at least one
prior suicide attempt.

Secondly, our study demonstrates an association between suicide attempts in

adolescents and suicidal behavior among family and friends. Although this is a
controversial issue which tends to be minimized by certain authors (Brent et al., 1996;
Pfeffer et al., 1997), we found that more than one-third of the subjects in our cohort
knew a person among family or friends who had attempted suicide. In addition, one
adolescent in seven had been confronted by a completed suicide in his circle of family
or friends. This association cannot be reduced to a simple cause and effect relationship,
but such a history of suicidality could reflect problems, such as social deviance, somatic
or psychiatric disorder, and family break-up, which favor self-destructive behavior. In
addition, following a suicidal event in the family circle, the risks of depressive and
anxiety disorders increase, as well as the risk of posttraumatic stress disorder, as shown
by Brent et al. (1996).

It should be noted that our sample consisted of adolescents who were hospitalized after
attempting suicide. Hence it is not representative of suicidal adolescents as a whole. We
may assume that our cohort includes a larger proportion of the most severe cases, and
thus presents, among other characteristics, a higher frequency of suicidal behavior in
family members and acquaintances.

Thirdly, poor social integration constitutes an additional risk factor. Although nine out of
ten adolescents say that they participate in some form of educational or professional
training or activity, their true involvement appears to be relative low because of a
significant amount of absenteeism as well as inactivity for health reasons. Our results
are consistent with the observations made in the studies of Bill-Brahe et al. (1993) and
Gould et al. (1996). In addition, their poor integration, which may well worsen after the
first or a new suicide attempt, occurs in the context of a state of health which the large
majority of adolescents judge as either only average, or indeed frankly poor.

Finally, two adolescents in ten (primarily females) mention having been the victim of
sexual abuse with contact, although the nature of the sexual abuse was not established
in a precise way. As with other studies, these results do not differ from known rates of
reported sexual abuse in the general population in this age group (Halprin et al., 1996).

In general, although there have now been a number of studies on adolescents who
attempt suicide, the diversity of methodologies used and the complexity of the problem
make comparison between studies difficult. Few studies have investigated the
relationship between risk factors, or their modification over time. Only follow-up
research, looking at the evolution of family, psychosocial, and psychiatric characteristics
of adolescents who attempt suicide, can provide information about the extent to which
specific characteristics precede or predict future suicide attempts. It will thus be
important to more precisely delineate the links between the suicidal gesture and the
risk factors demonstrated, and especially examining the therapeutic management of
these adolescents to see what repercussions treatment has on their psychopathological
profile and the suicidality itself.

For this reason, the design of our research project includes a 5-year follow-up of the
cohort of 148 suicidal adolescents hospitalized in an emergency room, although the
present paper is limited to describing the initial data of the patients at the time of
enrollment. Two other limitations of the study must be pointed out: First, our sample
only includes adolescents admitted to hospital after attempting suicide. It is therefore
not representative of suicidal adolescents as a whole. Second, a quarter of the suicidal
adolescents who were hospitalized during the enrollment period could not be included
for various reasons (mainly linguistic).

Conclusions
According to others', as well as to our own results, a suicide attempt must be
considered more as a process than as an isolated event. The risk factors revisited in this
study were confirmed, including psychopathology, comorbidity, previous suicide
attempts, suicidal behavior among family and acquaintances, poor state of health, poor
social integration, and a past history of sexual abuse. Although some of these factors
are relatively unimportant in the course of adolescent development and could not be
decisive on their own, this is probably not the case when they are considered together.

References
Bille-Brahe, U, Bjerke, T, Crepet, P, Deleo, D, Haring, C, Hawton, K, Kerkhof, A,
Lnnquist, J, Michel, K, Philippe, A, Pommereau, X, Querejeta, I, Salender-Renberg, E,
Schmidtke, A, Temesvary, B, Wasserman, D, & Sampaio-Faria, J-G (1993). The
WHO/Euro multicentre study on parasuicide. Facts and figures. Copenhagen: WHO /
OMS..

Brent, DA, Johnson, B, Bartle, S, Bridge, J, Rather, C, Matta, J, Connolly, J, &

Constantine, D (1993a). Personality disorder, tendency to impulsive violence, and
suicidal behavior in adolescents. Journal of the American Academy of Child and
Adolescent Psychiatry, 32, 6975.

Brent, DA, Kolko, DJ, Wartella, ME, Boylan, MB, Moritz, G, Baugher, M, & Zelenak, JP
(1993b). Adolescent psychiatric inpatients' risk of suicide attempt at 6-month follow-up.
Journal of the American Academy of Child and Adolescent Psychiatry, 32, 95105.

Brent, DA, Perper, JA, Moritz, G, Allman, C, Liotus, L, Schweers, J, Roth, C, Balch, L, &
Canobbio, R (1993c). Bereavement or depression? The impact of the loss of a friend to
suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 1189
1197.

Brent, DA, Perper, JA, Moritz, G, Baugher, M, Schweers, J, & Roth, C (1994a). Suicide in
affectively ill adolescents: A case-control study. Journal of Affective Disorders, 31, 193
202.

Brent, DA, Perper, JA, Moritz, G, Liotus, L, Schweers, J, Balach, L, & Roth, C (1994b).
Familial risk factors for adolescent suicide: a case-control study. Acta Psychiatrica
Scandinavica, 89, 5258.

Brent, DA, Moritz, G, Bridge, J, Perper, J, & Canobbio, R (1996). Long-term impact of
exposure to suicide: A three-year controlled follow-up. Journal of the American
Academy of Child and Adolescent Psychiatry, 35, 646653.

Choquet, M, & Ledoux, S (1994). Adolescents. Enqute nationale. Paris: Inserm.

Corbitt, EM, Malone, KM, Haas, GL, & Mann, JJ (1996). Suicidal behavior in patients
with major depression and comorbid personality disorders. Journal of Affective
Disorders, 39, 6172.

Gould, MS, Shaffer, D, Fisher, P, Kleinman, M, & Morishima, A (1992). The clinical
prediction of adolescent suicide. In RWMaris, ALBerman, JTMaltsberger, & RI Yufit
(eds)Assessment and prediction of suicide (pp. 130143). New York: Guilford.

Gould, MS, Fisher, P, Parides, M, Flory, M, & Shaffer, D (1996). Psychosocial risk factors
of child and adolescent completed suicide. Archives of General Psychiatry, 53, 1155
1162.

Granboulan, V, Rabain, D, & Basquin, M (1995). The outcome of adolescent suicide

attempts. Acta Psychiatrica Scandinavica, 91, 265270.

Halprin, DS, Bouvier, P, Jaff, D, Mounoud, RL, Pawlak, CH, Laederach, J, Rey, Wicky
H, & Asti, F (1996). Prevalence of child sexual abuse among adolescents in Geneva:
Results of a cross sectional survey. British Medical Journal, 312, 13261329.

Lewinsohn, PM, Rohde, P, & Seeley, JR (1994). Psychosocial risk factors for future
adolescent suicide attempts. Journal of Consulting and Clinical Psychology, 62, 297
305.

Lewinsohn, PM, Rohde, P, & Seeley, JR (1995). Adolescent psychopathology: III. The
clinical consequences of comorbidity. Journal of the American Academy of Child and
Adolescent Psychiatry, 34, 510519.
Narring, F, Tschumper, A, Michaud, P-A, Vanetta, F, Meyer, R, Wydler, H, Vuille, J-C,
Paccaud, F, & Gutzwiller, F (1994). La sant des adolescents en Suisse. Rapport d'une
enqute nationale sur la sant et les styles de vie des 1520 ans. Lausanne: Cah Rech
Doc IUMSP No113a .

Orvaschel, H (1985). Psychiatric interviews suitable for use in research with children
and adolescents. Psychopharmacology Bulletin, 21, 737745.

Pfeffer, CR, Klerman, GL, Hurt, SW, Lesser, M, Peskin, JR, & Siefker, CA (1991). Suicidal
children grow up: demographic and clinical risk factors for adolescent suicide attempts.
Journal of the American Academy of Child and Adolescent Psychiatry, 30, 609616.

Pfeffer, CR, Martins, P, Mann, J, Sunkenberg, M, Ice, A, Damore, JP, Gallo, C, Karpenos,
I, & Jiang, H (1997). Child survivors of suicide: psychosocial characteristics. Journal of
the American Academy of Child and Adolescent Psychiatry, 36, 6574.

Shaffer, D, Gould, MS, Fisher, P, Trautman, P, Moreau, D, Kleinman, M, & Flory, M

(1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General
Psychiatry, 53, 339348.

Silverman, AB, Reinherz, HZ, & Giaconia, RM (1996). The long-term sequelae of child
and adolescent abuse: A longitudinal community study. Child Abuse and Neglect, 20,
709723.

Copyright 1999 Hogrefe & Huber Publishers

This publication is protected by US and international copyright laws and its content may
not be copied without the copyright holders express written permission except for the
print or download capabilities of the retrieval software used for access. This content is
intended solely for the use of the individual user.

Source: Crisis: The Journal of Crisis Intervention and Suicide Prevention. Vol.20 (1) pp.
15-22.
Accession Number: cri-20-1-15 Digital Object Identifier: 10.1027//0227-
5910.20.1.15