Incidence and predictors of suicide attempts in bipolar I and II disorders: A five-year follow-up

Few long-term studies on bipolar disorder (BD) have investigated the incidence and risk factors of suicide attempts (SAs) specifically related to illness phases. We examined the incidence of SAs during different phases of BD in a long-term prospective cohort of bipolar I (BD-I) and bipolar II (BD-II) patients, and risk factors specifically for SAs during major depressive episodes (MDEs). In the Jorvi Bipolar Study (JoBS), 191 BD-I and BD-II patients were followed using life-chart methodology. Prospective information on SAs of 177 patients (92.7%) during different illness phases was available up to 5years. The incidence of SAs and their predictors were investigated using logistic and Poisson regression models. Analyses of risk factors for SAs occurring during MDEs were conducted using two-level random-intercept logistic regression models. During the 5 years of follow-up, 90 SAs per 718 patient-years occurred. The incidence was highest, over 120-fold higher than in euthymia, during mixed states (765/1000 person-years; 95% confidence interval [CI] 461-1269 person-years), and also very high in MDEs, almost 60-fold higher than in euthymia (354/1000 person-years; 95% CI 277-451 person-years). For risk of SAs during MDEs, the duration of MDEs, severity of depression, and cluster C personality disorders were significant predictors. We confirmed in this long-term study that the highest incidences of SAs occur in mixed and major depressive illness phases. The variations in incidence rates between euthymia and illness phases were remarkably large, suggesting that the question "when" rather than "who" may be more relevant for suicide risk in BD. However, risk during MDEs is likely also influenced by personality factors.

Differences in the incidence of suicide attempts during various phases of bipolar disorder (BD), or the relative importance of static versus time-varying risk factors for overall risk for suicide attempts, are unknown. We investigated the incidence of suicide attempts in different phases of BD as a part of the Jorvi Bipolar Study (JoBS), a naturalistic, prospective, 18-month study representing psychiatric in- and outpatients with DSM-IV BD in three Finnish cities. Life charts were used to classify time spent in follow-up in the different phases of illness among the 81 BD I and 95 BD II patients. Compared to the other phases of the illness, the incidence of suicide attempts was 37-fold higher [95% confidence interval (CI) for relative risk (RR): 11.8-120.3] during combined mixed and depressive mixed states, and 18-fold higher (95% CI: 6.5-50.8) during major depressive phases. In Cox's proportional hazards regression models, combined mixed (mixed or depressive mixed) or major depressive phases and prior suicide attempts independently predicted suicide attempts. No other factor significantly modified the risks related to these time-varying risk factors; their population-attributable fraction was 86%. The incidence of suicide attempts varies remarkably between illness phases, with mixed and depressive phases involving the highest risk by time. Time spent in high-risk illness phases is likely the major determinant of overall risk for suicide attempts among BD patients. Studies of suicidal behavior should investigate the role of both static and time-varying risk factors in overall risk; clinically, management of mixed and depressive phases may be crucial in reducing risk.

No previous study has prospectively investigated incidence and risk factors for suicide attempts among primary care patients with depression. In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 patients was screened for depression, and Structured Clinical Interviews for DSM-IV used to diagnose Axis I and II disorders. A total of 137 patients were diagnosed with a DSM-IV depressive disorder. Altogether, 82% of patients completed the 5-year follow-up. Information on timing of suicide attempts, plus major depressive episodes (MDEs) and partial or full remission, or periods of substance abuse were examined with life charts. Incidence of suicide attempts and their stable and time-varying risk factors (phases of depression/substance abuse) were investigated using Cox proportional hazard and Poisson regression models. During the follow-up there were 22 discrete suicide attempts by 14/134 (10.4%) patients. The incidence rates were 0, 5.8 and 107 during full or partial remission or MDEs, or 22.2 and 142 per 1000 patient-years during no or active substance abuse, respectively. In Cox models, current MDE (hazard ratio 33.5, 95% confidence interval 3.6-309.7) was the only significant independent risk factor. Primary care doctors were rarely aware of the suicide attempts. Of the primary care patients with depressive disorders, one-tenth attempted suicide in 5 years. However, risk of suicidal acts was almost exclusively confined to MDEs, with or without concurrent active substance abuse. Suicide prevention among primary care patients with depression should focus on active treatment of major depressive disorder and co-morbid substance use, and awareness of suicide risk.

Whether risk of suicide attempts (SAs) differs between patients with bipolar disorder (BD) and patients with major depressive disorder (MDD) is unclear. We investigated whether cumulative risk differences are due to dissimilarities in time spent in high-risk states, incidence per unit time in high-risk states, or both. Incidence rates for SAs during various illness phases, based on prospective life charts, were compared between patients from the Jorvi Bipolar Study (n = 176; 18 months) and the Vantaa Depression Study (n = 249; five years). Risk factors and their interactions with diagnosis were investigated with Cox proportional hazards models. By 18 months, 19.9% of patients with BD versus 9.5% of patients with MDD had attempted suicide. However, patients with BD spent 4.6% of the time in mixed episodes, and more time in major depressive episodes (MDEs) (35% versus 21%, respectively) and in subthreshold depression (39% versus 31%, respectively) than those with MDD. Compared with full remission, the combined incidence rates of SAs were 5-, 25-, and 65-fold in subthreshold depression, MDEs, and BD mixed states, respectively. Between cohorts, incidence of attempts was not different during comparable symptom states. In Cox models, hazard was elevated during MDEs and subthreshold depression, and among patients with preceding SAs, female patients, those with poor social support, and those aged < 40 years, but was unrelated to BD diagnosis. The observed higher cumulative incidence of SAs among patients with BD than among those with MDD is mostly due to patients with BD spending more time in high-risk illness phases, not to differences in incidence during these phases, or to bipolarity itself. BD mixed phases contribute to differences involving very high incidence, but short duration. Diminishing the time spent in high-risk phases is crucial for prevention.

Prospective long-term studies of risk factors for suicide attempts among patients with major depressive disorder have not investigated the course of illness and state at the time of the act. Therefore, the importance of state factors, particularly time spent in risk states, for overall risk remains unknown. In the Vantaa Depression Study, a longitudinal 5-year evaluation of psychiatric patients with major depressive disorder, prospective information on 249 patients (92.6%) was available. Time spent in depressive states and the timing of suicide attempts were investigated with life charts. During the follow-up assessment period, there were 106 suicide attempts per 1,018 patient-years. The incidence rate per 1,000 patient-years during major depressive episodes was 21-fold (N=332 [95% confidence interval [CI]=258.6-419.2]), and it was fourfold during partial remission (N=62 [95% CI=34.6-92.4]) compared with full remission (N=16 [95% CI=11.2-40.2]). In the Cox proportional hazards model, suicide attempts were predicted by the months spent in a major depressive episode (hazard ratio=7.74 [95% CI=3.40-17.6]) or in partial remission (hazard ratio=4.20 [95% CI=1.71-10.3]), history of suicide attempts (hazard ratio=4.39 [95% CI=1.78-10.8]), age (hazard ratio=0.94 [95% CI=0.91-0.98]), lack of a partner (hazard ratio=2.33 [95% CI=0.97-5.56]), and low perceived social support (hazard ratio=3.57 [95% CI=1.09-11.1]). The adjusted population attributable fraction of the time spent depressed for suicide attempts was 78%. Among patients with major depressive disorder, incidence of suicide attempts varies markedly depending on the level of depression, being highest during major depressive episodes. Although previous attempts and poor social support also indicate risk, the time spent depressed is likely the major factor determining overall long-term risk.

Background Patients with bipolar disorder (BD) differ in their relative predominance of types of episodes, yielding predominant polarity, which has important treatment implications. However, few prospective studies of predominant polarity exist. Methods In the Jorvi Bipolar Study (JoBS), a regionally representative cohort of 191 BD I and BD II in- and outpatients was followed for five years using life-chart methodology. Differences between depressive (DP), manic (MP), and no predominant polarity (NP) groups were examined regarding time ill, incidence of suicide attempts, and comorbidity. Results At baseline, 16% of patients had MP, 36% DP, and 48% NP. During the follow-up the MP group spent significantly more time euthymic, less time in major depressive episodes, and more time in manic states than the DP and NP groups. The MP group had significantly lower incidence of suicide attempts than the DP and NP group, lower prevalence of comorbid anxiety disorders but more psychotic symptoms lifetime and more often (hypo)manic first phase of the illness than the DP group. Classification of predominant polarity was influenced by the timeframe used. Limitations The retrospective counting of former phases is vulnerable to recall bias. Assignment of dominant polarity may necessitate a sufficient number of illness phases. Conclusions Predominant polarity has predictive value in predicting group differences in course of illness, but individual patients’ classification may change over time. Patients with manic polarity may represent a more distinct subgroup than the two others regarding illness course, suicide attempts, and psychiatric comorbidity.

P.3.e.007 Polarity of the first episode and predominant polarity in a cohort of bipolar outpatients

Predominant polarity in bipolar I and II disorders: A five-year follow-up study.

A population-based longitudinal study of risk factors for suicide attempts in major depressive disorder

Few studies have investigated the prevalence of and risk factors for suicidal ideation and attempts among representative samples of psychiatric patients with bipolar I and II disorders. In the Jorvi Bipolar Study (JoBS), psychiatric inpatients and outpatients were screened for bipolar disorders with the Mood Disorder Questionnaire from January 1, 2002, to February 28, 2003. According to Structured Clinical Interviews for DSM-IV Axis I and II Disorders, 191 patients were diagnosed with bipolar disorders (bipolar I, N = 90; bipolar II, N = 101). Suicidal ideation was measured using the Scale for Suicidal Ideation. Prevalence of and risk factors for ideation and attempts were investigated. During the current episode, 39 (20%) of the patients had attempted suicide and 116 (61%) had suicidal ideation; all attempters also reported ideation. During their lifetime, 80% of patients (N = 152) had had suicidal behavior and 51% (N = 98) had attempted suicide. In nominal regression models, severity of depressive episode and hopelessness were independent risk factors for suicidal ideation, and hopelessness, comorbid personality disorder, and previous suicide attempt were independent risk factors for suicide attempts. There were no differences in prevalence of suicidal behavior between bipolar I and II disorder; the risk factors were overlapping but not identical. Over their lifetime, the vast majority (80%) of psychiatric patients with bipolar disorders have either suicidal ideation or ideation plus suicide attempts. Depression and hopelessness, comorbidity, and preceding suicidal behavior are key indicators of risk. The prevalence of suicidal behavior in bipolar I and II disorders is similar, but the risk factors for it may differ somewhat between the two.

Mood disorders (MD) are often associated with a higher incidence of suicidal behavior, especially in adolescent patients. However, the mechanisms by which depression affects suicide attempts in adolescents with MD remain poorly elucidated. Therefore, the purpose of this study was to determine the incidence, risk factors, and clinical correlates of suicide attempts in Chinese adolescent patients with MD, as well as the inter-relationship between depressive symptoms, rumination, and suicide attempts, and the role of rumination in mediating depression and suicide attempts. A total of 331 MD adolescent patients aged 11 ~ 18years were recruited from a psychiatric hospital. Suicide attempts were assessed with the MINI Suicide Scale. Depressed symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9). To assess rumination, we used the 21-item Chinese version of the Ruminative Responses Scale (RRS). Overall, the percentage of suicide attempts among MD adolescents was 51.96%, with a higher percentage of females (58.62%) than males (36.36%). Compared to non-suicide attempters, suicide attempters had higher scores on PHQ-9, RRS, depression-related, brooding, and reflective pondering. Gender and RRS were independently associated with suicide attempts. Rumination played a fully mediating role between depression and suicide attempts. In addition, the mediating effect of depression between rumination and suicide attempts was not significant. The incidence of suicide attempts was higher in MD adolescents than in general adolescents. Gender and rumination were associated with suicide attempts in MD adolescents. Moreover, rumination mediated the correlation between depressive symptoms and suicide attempts, suggesting that rumination may be an important intervention component for clinical staff to prevent suicidal behavior in adolescents with MD.

Utilizing a prospectively designed community sample, we set out to estimate the rate of newly-incident suicidal ideation and attempts (non-fatal suicide behaviour) in a community sample, to evaluate antecedent sociodemographic characteristics and psychiatric disorders, and to assess use of mental health services in relation to non-fatal suicide behaviour. Prospectively-gathered data was utilized from 3481 continuing participants in the 13-year follow-up of the Baltimore sample of the NIMH Epidemiologic Catchment Area survey interviewed in 1981, 1982 and 1993/6. The incidence of suicide attempts was estimated at 148.8 per 100,000 person-years and ideation at 419.9 per 100,000 person-years. Persons in the youngest age group, in the lowest socioeconomic status, and previously married persons were at increased risk for non-fatal suicide behaviour during the follow-up interval. Persons who reported suicidal ideation at baseline were more likely to report having attempted suicide at follow-up (RR = 6.09, 95% CI 2.58-14.36). Psychiatric disorders, especially depression and substance abuse, were associated with new-onset of non-fatal suicidal behaviour. While persons who reported newly-incident suicidal behaviour were more likely to report use of mental health services, few said that suicidal ideation or attempts were the reason for the visits. Suicidal ideation is a common and important antecedent to suicide attempts and deserves more attention in community and general medical settings.

ObjectiveTo investigate the incidence of suicide attempts among adolescents with HIV/AIDS in Liangshan Prefecture, Sichuan Province, as well as the correlation between negative life events, sleep, exercise, drug therapy and suicide attempts.MethodsA total of 180 Yi adolescents aged 11–19 years with HIV/AIDS in a county of Liangshan Prefecture, Sichuan Province, China, were investigated by census. The main outcome indicators included the incidence of suicide attempts and whether negative life events, sleep, exercise, drug therapy and other factors were related to suicide attempts.ResultsWe found that the incidence rate of suicide attempts among Yi adolescents with HIV/AIDS in Liangshan Prefecture was 13.9%. Negative life events were a risk factor for suicide attempts (OR = 1.047, p < 0.001, 95% CI 1.027–1.067). In the factors of negative life events, adaptation was a risk factor for suicide attempts (OR = 1.203, p = 0.026, 95% CI 1.022–1.416), and academic pressure showed a tendency to be a risk factor for suicide attempts (OR = 1.149, p = 0.077, 95% CI 0.985–1.339). However, the punishment factor, interpersonal stress factor and loss factor had no significant correlation with suicide attempts. There was no significant correlation between sleep, exercise, drug therapy and suicide attempts.ConclusionThe proportion of suicide attempts among Yi adolescents with HIV/AIDS in Liangshan Prefecture is high and should be considered. Negative life events are independent risk factors for suicide attempts, and it is necessary to strengthen the screening and early intervention for suicide attempts in HIV/AIDS adolescents with definite negative life events.

Czynniki ryzyka podejmowania prób samobójczych u osób leczonych stacjonarnie z powodu uzależnienia od alkoholu w Polsce

After completing this article, readers should be able to: Most youth occasionally experience the blues, feel sad, or become irritable. Nevertheless, it is important to consider the possibility of a depressive disorder when a depressed or irritable mood is more than temporary, occurs in conjunction with other symptoms, or interferes with daily functioning. Major depressive disorder (MDD) is manifested by a depressed or irritable mood or diminished interest or pleasure that lasts for at least 2 weeks. This is accompanied by changes in cognitive and physical functioning. Dysthymic disorder (DD) is a less severe type of depression that involves chronic symptoms and lasts for at least 1 year. These specific types of depressive disorders are the focus of this article.Depressive disorders can be identified in children of all ages, but they become increasingly prevalent during adolescence. In fact, the peak ages of depressive symptom onset in lifespan studies are 15 to 19 years and 25 to 29 years. The sharpest rise in prevalence occurs among girls during adolescence and early adulthood. Approximately 2% of school-age children and 4% to 6% of adolescents struggle with MDD at any one point in time. Lifetime prevalence rates by late adolescence range between 20% and 25%.Prior to puberty, there is about a 1:1 gender ratio for depressive disorders. After puberty, this shifts to a 2:1 ratio of females to males, which continues throughout adulthood. A combination of hormonal and social changes during puberty may explain the differing rates of depression among males and females.Depression has a complex genetic and environmental basis. Adoption, twin, and family studies all point to the impact of genetic factors, which seem to establish a young person's biologic vulnerability for depression. The onset of a depressive episode, however, often is precipitated by difficult life events or stressful experiences such as a parental divorce, school change, or relationship breakup. Other environmental risk factors include maltreatment (sexual abuse, physical abuse, or neglect). The pathways to depression are complex and variable. Some depressive disorders are more biologic; others are more situational.The symptoms of MDD and DD, as outlined in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV; American Psychiatric Association, 1994), include changes in physical, cognitive, and emotional domains (Tables 1 and 2).In 1996, the World Health Organization ranked depression among the most disabling of all diseases in the world, leading all other disorders in "years lived with disabilities." The reasons for this are apparent when one considers the course of depressive illness. Approximately 70% of youth who have MDD experience another depressive episode within 5 years, and youth who have depressive disorders have a fourfold risk of an adult depressive disorder. Approximately 50% of children and adolescents who have MDD can be expected to have adult recurrences. Early onset and recurrences also have been described as a cause of treatment-resistant depression in later life, leading to multiple episodes that last longer, become more severe, and become more difficult to treat. These tend to be associated with more hospitalizations, job absenteeism, and impaired work performance.Depressive disorders in youth are associated with impaired functioning in several areas of daily living. These include strained family and peer relationships, school attendance difficulties, and academic performance problems. Affected youth often experience suicidal thoughts and are at increased risk for attempted and completed suicide.Early-onset bipolar disorder (BD) often presents as depressive symptoms, which can make it difficult to distinguish between bipolar and unipolar depression. BD is characterized by alternating periods of mania and depression. The inflated self-esteem, excess energy, and poor judgment that characterize a manic phase often result in dangerous activity and substantial social problems. Rapid cycling and mixed symptom states occur in subtypes of BD. Approximately 20% to 40% of children who have MDD eventually develop BD. Some clues to the risk for developing a manic or hypomanic episode include psychosis, psychomotor retardation, or a family history of BD.Another potential diagnostic dilemma occurs when a child or adolescent is abusing alcohol or drugs. Youth are not always forthcoming about such abuse, which may be associated with declining school performance, withdrawal from usual social activities, sleep disturbance, and negative moods. Careful questioning of the youth and parent/guardian is necessary to identify a substance use disorder in youth presenting with depressive symptoms. It can be equally challenging to identify a depressive disorder in youth initially identified for services because of problems related to alcohol or substance abuse.Most children and adolescents who are depressed also have a history of some other psychiatric or alcohol/drug use disorder. For example, 25% to 75% of depressed youth have one or more anxiety disorders, such as separation anxiety disorder or social phobia. Disruptive behavior disorders, such as attention-deficit disorder or oppositional defiant disorder, are also common, and substance abuse or dependence characterizes a significant minority of youth who are depressed. A gender difference exists in patterns of comorbidity. Girls more commonly have comorbid anxiety conditions; boys are more likely to have comorbid conduct disorders or substance use disorders.Children and adolescents rarely seek professional treatment. Thus, parents, teachers, pediatricians, and others who have regular contact with youth play critical roles in recognizing youth who are depressed. Few youth use the word "depressed"; even fewer report to someone that they may be experiencing a clinical depression. Therefore, it is helpful to ask youth about experiences of feeling down, "bad," miserable, bored, or irritated. Signs of clinical depression that often initially are visible to others include withdrawal from activities, decline in school performance, change in sleep patterns, and sadness or irritability.The United States Preventive Services Task Force recently recommended the use of two questions in screening for depression among adults: "Over the past 2 weeks, have you ever felt down, depressed, or hopeless?" and "Have you felt little interest or pleasure in doing things?" The Task Force concluded that evidence is inconclusive regarding the effectiveness of routine screening of children and adolescents, but these two questions may help clinicians detect primary symptoms of depression. More comprehensive screening instruments and diagnostic tools or a referral to a mental health professional should be considered if indicated. The Reynolds Adolescent Depression Inventory (RADS) and the Children's Depression Inventory (CDI) are screening tools used in some school and mental health clinics.Clinical interviews are the cornerstone of a comprehensive assessment and should include, at a minimum, interviews with the youth as well as the parent or guardian. In addition to gathering a complete history of presenting problems (onset, chronicity, severity, prior history of symptoms, and treatment), a full psychiatric interview is conducted to obtain information about possible comorbid conditions. For example, it is critical to ascertain whether psychotic features, disruptive behavior disorders, anxiety disorders, or substance abuse problems are present. Information also is gathered about the youth's medical, developmental, social, and educational histories as well as the family psychiatric history.Important sources of information may include school academic and attendance records; teacher reports; and appropriate biomedical, psychological, or other test findings. Standardized self-report questionnaires may permit youths to answer questions about current symptoms without directly verbalizing the extent of their emotional distress to an adult. This approach sometimes can facilitate honest reporting of the number and severity of depressive symptoms. If noted in a self-report questionnaire, critical items always should be followed up with direct inquiry by the clinician (eg, if a youth reports suicidal ideation).The initial goals of treatment are to ensure the youth's safety and develop an effective therapeutic alliance with the youth and parents. This alliance will facilitate ongoing communication and continuation of care. Consultation with teachers and other caregivers also is important. A focus on patient and family education and a collaborative approach to treatment planning can enhance the youth's adherence to treatment recommendations.Psychoeducation is a key component of the treatment. Beyond this, perspectives on the first line of treatment vary. The choice of whether to begin with psychotherapeutic or psychopharmacologic interventions or a combination depends on depression severity and chronicity, prior history of depressive episodes, likelihood of adherence, previous response to treatment, patient and family motivation for treatment, and availability of resources. Because of the psychological, environmental, and social problems associated with depression and its treatment, pharmacotherapy usually is not sufficient as the sole treatment. Attention to parental mental health and family stress as well as to strategies for helping parents manage the youth's irritability, isolation, or other problems should be included in psychotherapeutic interventions. These systemic concerns affect treatment adherence and ultimate outcomes.Psychoeducation addresses the signs and symptoms of depression; the importance of psychotherapy and psychiatric medication; and common misconceptions about the illness, therapy, or medications. It also is helpful to address the impact that depression has on school, social, and family functioning and the ways in which parents and teachers may aid in recovery. Parent and family education may increase adherence and reduce self-blame. Education of parents can help them identify their own mood disorders and potential treatment needs as well. Education also can reduce blame for symptoms such as irritability and anhedonia that may affect others.Controlled studies have documented the short-term effectiveness of cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) for depressed youth. Both generally are time-limited therapies that involve collaboration or guided discovery between the therapist and adolescent. CBT focuses on self-understanding of negative mood states and on the identification and modification of negative, distorted thought patterns. It also emphasizes problem-solving skills, communication skills, and the development of more adaptive behavior patterns. IPT strives to improve the youth's interpersonal functioning by improving self-understanding, problem-solving, communication, and coping in the realm of relationships. It focuses on a chosen interpersonal problem such as grief, a difficult role transition, an interpersonal conflict or role dispute, social skill deficits, or issues in step-parent families. Although randomized, controlled clinical trials have not been conducted for psychodynamic therapy with depressed youth, this approach may be useful. Family therapy is an important supplement to any of these approaches if difficulties in family communication and support are identified. Goals of family therapy may include improving family affective communication, increasing adaptive behaviors, and changing both interpersonal and family functioning.Selective serotonin reuptake inhibitors (SSRIs) are the antidepressants of choice for youth who require pharmacotherapy (American Academy of Child and Adolescent Psychiatry, 1998). The efficacy of the SSRI fluoxetine in reducing depressive symptom severity in children and adolescents has been demonstrated in two double-blind, randomized, placebo-controlled trials. Paroxetine also has demonstrated efficacy compared with imipramine and placebo in a double-blind, placebo-controlled comparison. Other antidepressant medications are not well studied. Dosing guidelines recommend starting with 10 mg fluoxetine and increasing to 20 mg. The maximum dose is 40 mg to 80 mg. When treating a child younger than 8 years of age, clinicians may want to start with 4 to 8 mg elixir of fluoxetine. However, the efficacy and safety data have been demonstrated only down to age 8 years. If there are problems with insomnia, appetite loss, or restlessness, paroxetine is a more sedating SSRI, and dosing guidelines are identical to those for fluoxetine. SSRIs should be discontinued if symptoms of mania appear. However, youth may benefit from treatment with an SSRI for an extended period before BD develops.An adequate trial of SSRIs is at least 4 to 6 weeks. If no or only minimal improvement is observed, a dose increase should be considered and medication continued for at least 4 to 6 additional weeks. If no improvement has been observed, alternative strategies should be considered, including a referral to a psychiatrist in cases of treatment-resistant depression. Additionally, if the pediatrician is not comfortable in the prescriber role, a psychiatric consultation or referral to a physician experienced in the use of medication is recommended. Frequent medication adjustments are ill-advised, and tapering of medications that have shorter half-lives (eg, paroxetine) is recommended. Obtaining serum levels rarely is necessary unless concerns arise about toxicity or compliance. Studies among adults suggest that the same doses used to treat MDD are efficacious for DD.Tricyclic antidepressants (TCAs) are not considered a first-line treatment for children and adolescents who are depressed, but they may be helpful in treating youth who have comorbid attention-deficit/hyperactivity disorder, enuresis, and narcolepsy as well as for augmentation purposes.In contrast to TCAs and monoamine oxidase inhibitors, SSRIs have a relatively safe adverse effects profile, are easily used (once daily), are suitable for long-term maintenance, and have a low lethality after overdose. Additional information on adverse effects, medication interactions, and the treatment of comorbid conditions is available in reviews of practice recommendations published by the American Academy of Child and Adolescent Psychiatry.ECT can be a useful adjunct for individuals whose depression is severe or life-threatening, who have not responded to other treatments, who cannot take antidepressant medications, and who may have psychotic depression. The decision to use ECT must be made carefully and usually requires the recommendation of more than one psychiatrist as well as a substantial discussion with the child's parent or guardian.Unless there are significant adverse effects, medication should be continued for 6 to 12 months if it is believed to help in the remission of depressive symptoms. The pharmacotherapy should be monitored monthly during this continuation phase. Psychotherapy is helpful during this phase to bolster coping skills and to address antecedents, stressors, and interpersonal conflicts that may have contributed to the onset of depression. Medication adherence also may be improved by psychotherapy.Once the patient's symptoms have remitted for 6 to 12 months, the maintenance phase of treatment may last from 1 year to indefinitely. The goals are to facilitate healthy development and to prevent relapse or recurrence. These may be accomplished through monthly or quarterly visits, depending on the severity and chronicity of the present episode, frequency of previous episodes, comorbid disorders, the patient's motivation, and contextual factors (eg, support systems, family stress, and psychopathology).The presence of comorbid conditions often predicts a poorer response to psychopharmacologic and psychosocial treatments. These conditions, such as anxiety, disruptive behavior, and substance use disorders, often persist after remission of the depressive symptoms and require targeted treatments. Because of time, cost, or the incompatibility of treatments, addressing all conditions simultaneously may be impossible. Hence, the clinician often must prioritize treatment goals and the sequence of interventions.A depressive disorder may be "treatment-resistant" because of an inadequate dosage or duration of medication trial, inadequate duration or "fit" with a particular psychotherapy, poor treatment adherence, complicating comorbidity, undetected BD, chronic or severe life events, misdiagnosis, or mistreatment. Psychopharmacologic strategies to address treatment-resistant depression should be applied systematically in conjunction with family education and support and include optimization, switching, augmentation, or combination. Consultation with a psychiatrist always is advised with treatment-resistant cases.If BD is present or is a possibility, a mood-stabilizing agent (eg, lithium carbonate, valproate, or carbamazepine) may be warranted, especially because antidepressants may induce mania in youths at risk for BD. Approximately 30% to 50% of adults experience modest antidepressant effects with mood stabilizers alone. Antidepressants may be useful adjuncts in such treatments. Psychotic depression may require a combination of antidepressants with antipsychotics or ECT. Neuroleptics should be tapered after psychotic symptoms remit due to the risk of tardive dyskinesia. Atypical antipsychotic medications may be preferred. However, the long-term effects of these medications have not been studied in youth.Suicide is the third leading cause of death among children and adolescents (National Center for Health Statistics, CDC, 2000). The suicide rate for ages 15 to 24 years is 11.1 per 100,000, which is much higher than the rate for youth between the ages of 5 and 14 years (0.8 per 100,000). The suicide rate for males in the 15- to 19-year age group is markedly higher than that for females (Table 3). Rates differ by racial and ethnic group. African-American youth have lower suicide rates than Caucasian youth, with the lowest adolescent suicide rate being that of African-American females. The highest suicide rate is that of Native American males.Although many youth who report suicidal thoughts or attempt suicide do not become suicide victims, these categories overlap substantially. For instance, having frequent thoughts of suicide is the best predictor of suicide attempts, and most youth who attempt suicide report a history of suicidal ideation. Furthermore, greater severity of reported suicidal thoughts increases the likelihood of a suicide attempt within the next year. Approximately 35% to 45% of adolescents who complete suicide have a positive history of suicide attempt. The prevalences of both self-reported suicidal ideation and suicide attempts are higher for adolescent females than for adolescent males (Table 3).Risk factors for completed suicide and suicidal behavior are similar in most respects. There are a few exceptions, however, such as the more specific relationship between availability of firearms and completed suicide. In this section, we review the primary risk factors for completed suicide (Table 4).A history of prior suicidal behavior is the strongest predictor of future suicidal behavior. Nonlethal suicidal gestures or self-inflicted harm, which sometimes are thought to be manipulative or attention-seeking, should not be taken lightly. Youth often can be poor judges of lethality, and what is believed to be a gesture actually may be accompanied by significant suicidal intent. It also may result in substantial physical harm or even suicide because of an error in knowledge or judgment (eg, potential lethality of acetaminophen overdose).Approximately 80% of youth who attempt suicide and 90% of youth suicide victims have histories of identifiable psychiatric or mental disorders. The most common types of psychopathology in these youth are depressive disorders, alcohol or substance abuse, conduct disorder or patterns of aggressive behavior, and anxiety disorders. Increased suicide risk is associated with conditions that often are refractory to treatment or present management problems. These include BD, a chronic depressive disorder comorbid with alcohol or substance abuse, and psychotic presentations.Depressive disorders are linked with increased risk for suicidal ideation, suicide attempts, and completed suicides (Table 5). In fact, suicidal ideation and behavior are common and often unrelenting problems among youth who have depressive disorders. Eighty-five percent of depressed youth report significant suicidal ideation, and 32% of depressed youth report one or more suicide attempts prior to adulthood. Retrospective studies have found that about 50% of adolescent suicides involve the consumption of alcohol, which increases impulsivity, impaired judgment, and mood changes.Environmental or family stress, especially a history of neglect or physical, emotional, or sexual abuse, are considered significant risk factors for suicidal behavior. Interpersonal conflict and loss (eg, fights, break-ups, deaths) also are risk factors. Additionally, hopelessness, impulsivity, aggressive behavior, and agitation are psychological characteristics associated with increased risk for suicidal behavior.Gay, lesbian, and bisexual adolescents are at increased risk for suicidal behavior. Recent general population surveys indicate that of these youth experience suicidal ideation, and have made one or more suicide attempts during the past year. of the risk factors in these youth are the same as those for youth. such as comorbid substance abuse and however, are more common among youth who have a In risk factors such as and are specific to those who negative within risk for anxiety, and suicide increases when a youth someone who suicide. In these at and and and social as well as at identification with the suicidal behavior are recommended. of suicide may suicide are to possible to reduce and to parents and to of youth to such are found more commonly in the of suicide victims than in the of other youth, including those of suicidal youth. The importance of suicidal youth's to firearms is by documented between more and in suicide as or should be from the of suicidal youth or monitored by parents and that if adolescents will suicidal and previous suicidal behavior. questions should address whether children or adolescents they not if they ever have thought about or to if they ever have thought about or to and if they have or such a in It is important to that an adolescent about suicidal thoughts or will not such or or increase the risk for suicidal behavior. inquiry regarding the chronicity, and of such thoughts is Standardized self-report such as the may permit the youth to answer without direct which can facilitate If critical items related to or planning and items significant of chronicity, severity, or always should be followed up with direct Other sources of information include reports from parents, teachers, or others who may have suicidal or such as with the assessment of depressive disorders, a comprehensive that from the youth and parent or is psychiatric or may be necessary for found to be at suicide generally are and and attempts that have significant lethality and that include taken to indicate as well as knowledge and planning and should be taken Furthermore, to safety requires of the child's and caregivers should be advised to especially firearms and medications, from the by young children should not be as For example, when a child it may not be behavior should be carefully for associated mood or other or are used in many The patient is to not to attempt suicide. Furthermore, the patient is to to contact the or other adult if or a suicidal or experiences suicidal intent. on these have the past with an increasing on the as an assessment The may current suicidal intent. It also information about the patient's to and to helpful It is useful to review what positive coping the youth and parent take in the of a suicidal This an for problem-solving and can the of some youth and to or the risk of suicidal behavior. It should be however, that not support the that such prevent they are not for comprehensive for a suicidal youth, suicide risk factors, including suicidal and behaviors, are monitored at of when with suicidal youth next at up on and information to the youth and parent or about easily management and regular patient with guidelines for to in population of suicidal youth is in of primary psychiatric comorbid conditions, the presence of complicating psychosocial and Therefore, the treatment should be on a comprehensive of psychopathology more suicide risk and factors.