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Q Do episodes of suicidal behaviour or thoughts in pre-adolescents and mid-adolescents have the same psychosocial and psychiatric outcomes in early adulthood as enduring or current suicidality?
Prospective cohort study.
Follow up period:
Zurich, Switzerland; 1994–2001.
102 pre-adolescents and adolescents selected from 618 participants the Zurich Adolescent Psychology and Psychopathology Study (ZAPPS; a stratified randomised sample of school children).
Participants were assessed using the Youth or Young Adult Self-Report (YASR) questionnaires at baseline, 3 year follow up, and 7 year follow up. Participants were stratified into risk groups according to the presence of suicidal thoughts or behaviour at pre-adolescence only (n = 21), adolescence only (n = 22), young adulthood only (n = 21), or in both adolescence and young adulthood (n = 17; enduring risk group). A control group of 21 participants with no history of suicidal thoughts or behaviour were age and gender matched to the young adulthood risk group.
Behavioural and emotional problems, and psychiatric diagnoses in young adulthood (7 year follow up). The problem behaviour section of the Young YASR was used to assess behavioural and emotional problems (a higher total score reflects greater problems). The Munich-Composite International Diagnostic Interview (M-CIDI) was used to assess DSM-IV psychiatric diagnoses.
Young adults with current or enduring suicidal thoughts and behaviour had the greatest behavioural and emotional problems (total YASR score: 63.96 enduring risk group v 60.19 young adult risk group v 37.81 adolescent risk group v 31.82 pre-adolescent risk group v 21.34 control group; p⩽0.001). Psychiatric disorders were common in all young adults who had experienced suicidal thoughts and behaviour, but were especially so in those who had pre-adolescent, current or enduring suicidal thoughts and behaviour (AR for any DSM-IV psychiatric disorder: pre-adolescent risk group 92%; adolescent risk group 59%; young adult risk group 86%; enduring risk group 88%; control group 10%; p<0.001). The most common psychiatric disorders were substance abuse (48%), phobias (41%), depressive disorders (35%), and somatoform disorders (21%).
Suicidal thoughts or behaviour from pre-adolescence to young adulthood (whether episodic or enduring) is associated with risk of psychosocial and psychiatric problems in young adults, especially if suicidality occurs before adolescence, in early adulthood, or is enduring.
Steinhausen and Winkler Metzke clearly demonstrate that young people reporting suicidal ideation remain at increased risk in a large number of behavioural domains. This research adds to the evidence from longitudinal studies that suicidal ideation and behaviours, including attempted suicide, are frequently precursors of longer term difficulties.1,6 These difficulties span an array of problems including suicidal behaviour, psychiatric morbidity, mortality from suicide and other causes, and psychosocial problems such as relationship problems, legal charges, imprisonment, and social welfare dependence.
The important issue raised here concerns the types of programme and services required to address the needs of young people with suicidal ideation. These have included family oriented therapies, problem solving training, cognitive behavioural therapy (CBT), dialectical behavioural therapy, pharmacotherapy, and training general practitioners to better recognise and treat suicidality in young people.7,12 However, most of these have not been rigorously evaluated. One exception is the TADS study, a randomised controlled trial (RCT) of 439 adolescents (12–17 years) assigned to one of three treatments: 12 weeks of fluoxetine (10–40 mg/day) or CBT or CBT with fluoxetine. The authors concluded that CBT with fluoxetine offered the most favourable trade-off between benefit and risk for adolescents with major depressive disorder.9
At this stage further experimental work is needed to build on the basic epidemiology in this area and to assess, using RCT methodology, the extent to which a range of interventions in suicidal young people mitigates longer term risk.
For correspondence: Professor Steinhausen, Department of Child and Adolescent Psychiatry, University of Zurich, Neum_nsterallee 9, Postfach, CH-8032 Zurich, Switzerland;
Sources of funding: Swiss National Science Foundation.