Objective. —To identify and quantify the major external (nongenetic) factors that contribute to death in the United States. Data Sources. —Articles published between 1977 and 1993 were identified through MEDLINE searches, reference citations, and expert consultation. Government reports and compilations of vital statistics and surveillance data were also obtained. Study Selection. —Sources selected were those that were often cited and those that indicated a quantitative assessment of the relative contributions of various factors to mortality and morbidity. Data Extraction. —Data used were those for which specific methodological assumptions were stated. A table quantifying the contributions of leading factors was constructed using actual counts, generally accepted estimates, and calculated estimates that were developed by summing various individual estimates and correcting to avoid double counting. For the factors of greatest complexity and uncertainty (diet and activity patterns and toxic agents), a conservative approach was taken by choosing the lower boundaries of the various estimates. Data Synthesis. —The most prominent contributors to mortality in the United States in 1990 were tobacco (an estimated 400000 deaths), diet and activity patterns (300 000), alcohol (100 000), microbial agents (90 000), toxic agents (60 000), firearms (35 000), sexual behavior (30 000), motor vehicles (25 000), and illicit use of drugs (20 000). Socioeconomic status and access to medical care are also important contributors, but difficult to quantify independent of the other factors cited. Because the studies reviewed used different approaches to derive estimates, the stated numbers should be viewed as first approximations. Conclusions. —Approximately half of all deaths that occurred in 1990 could be attributed to the factors identified. Although no attempt was made to further quantify the impact of these factors on morbidity and quality of life, the public health burden they impose is considerable and offers guidance for shaping health policy priorities. (JAMA. 1993;270:2207-2212)

https://jamanetwork.com/journals/JAMA/articlepdf/409171/jama_270_18_038.pdf

Actual causes of death in the United States.

Suicidal behavior is a leading cause of injury and death worldwide. Information about the epidemiology of such behavior is important for policy-making and prevention. The authors reviewed government data on suicide and suicidal behavior and conducted a systematic review of studies on the epidemiology of suicide published from 1997 to 2007. The authors' aims were to examine the prevalence of, trends in, and risk and protective factors for suicidal behavior in the United States and cross-nationally. The data revealed significant cross-national variability in the prevalence of suicidal behavior but consistency in age of onset, transition probabilities, and key risk factors. Suicide is more prevalent among men, whereas nonfatal suicidal behaviors are more prevalent among women and persons who are young, are unmarried, or have a psychiatric disorder. Despite an increase in the treatment of suicidal persons over the past decade, incidence rates of suicidal behavior have remained largely unchanged. Most epidemiologic research on suicidal behavior has focused on patterns and correlates of prevalence. The next generation of studies must examine synergistic effects among modifiable risk and protective factors. New studies must incorporate recent advances in survey methods and clinical assessment. Results should be used in ongoing efforts to decrease the significant loss of life caused by suicidal behavior.

/pdf/suicide-and-suicidal-behavior-41x9ufvkfm.pdf

Suicide and Suicidal Behavior

Objective To qualitatively review the literature of the past decade covering the epidemiology, clinical characteristics, natural course, biology, and other correlates of early-onset major depressive disorder (MDD) and dysthymic disorder (DD). Method A computerized search for articles published during the past 10 years was made and selected studies are presented. Results Early-onset MDD and DD are frequent, recurrent, and familial disorders that tend to continue into adulthood, and they are frequently accompanied by other psychiatric disorders. These disorders are usually associated with poor psychosocial and academic outcome and increased risk for substance abuse, bipolar disorder, and suicide. In addition, DD increases the risk for MDD. There is a secular increase in the prevalence of MDD, and it appears that MDD is occurring at an earlier age in successive cohorts. Several genetic, familial, demographic, psychosocial, cognitive, and biological correlates of onset and course of early-onset depression have been identified. Few studies, however, have examined the combined effects of these correlates. Conclusions Considerable advances have been made in our knowledge of early-onset depression. Nevertheless, further research is needed in understanding the pathogenesis of childhood mood disorders. Toward this end, studies aimed at elucidating mechanisms and interrelationships among the different domains of risk factors are needed.

Childhood and adolescent depression: a review of the past 10 years. Part I.

Objective Attention deficit hyperactivity disorder is a heterogeneous disorder of unknown etiology Little is known about the comorbidity of this disorder with disorders other than conduct Therefore, the authors made a systematic search of the psychiatric and psychological literature for empirical studies dealing with the comorbidity of attention deficit hyperactivity disorder with other disorders Data collection The search terms included hyperactivity, hyperkinesis, attention deficit disorder, and attention deficit hyperactivity disorder, cross-referenced with antisocial disorder (aggression, conduct disorder, antisocial disorder), depression (depression, mania, depressive disorder, bipolar), anxiety (anxiety disorder, anxiety), learning problems (learning, learning disability, academic achievement), substance abuse (alcoholism, drug abuse), mental retardation, and Tourette's disorder Findings The literature supports considerable comorbidity of attention deficit hyperactivity disorder with conduct disorder, oppositional defiant disorder, mood disorders, anxiety disorders, learning disabilities, and other disorders, such as mental retardation, Tourette's syndrome, and borderline personality disorder Conclusions Subgroups of children with attention deficit hyperactivity disorder might be delineated on the basis of the disorder's comorbidity with other disorders These subgroups may have differing risk factors, clinical courses, and pharmacological responses Thus, their proper identification may lead to refinements in preventive and treatment strategies Investigation of these issues should help to clarify the etiology, course, and outcome of attention deficit hyperactivity disorder

Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders.

BACKGROUND: The psychological autopsy method offers the most direct technique currently available for examining the relationship between particular antecedents and suicide. This systematic review aimed to examine the results of studies of suicide that used a psychological autopsy method. METHOD: A computer aided search of MEDLINE, BIDS ISI and PSYCHLIT, supplemented by reports known to the reviewers and reports identified from the reference lists of other retrieved reports. Two investigators systematically and independently examined all reports. Median proportions were determined and population attributable fractions were calculated, where possible, in cases of suicide and controls. RESULTS: One hundred and fifty-four reports were identified, of which 76 met the criteria for inclusion; 54 were case series and 22 were case-control studies. The median proportion of cases with mental disorder was 91% (95 % CI 81-98%) in the case series. In the case-control studies the figure was 90% (88-95%) in the cases and 27% (14-48%) in the controls. Co-morbid mental disorder and substance abuse also preceded suicide in more cases (38%, 19-57%) than controls (6%, 0-13%). The population attributable fraction for mental disorder ranged from 47-74% in the seven studies in which it could be calculated. The effects of particular disorders and sociological variables have been insufficiently studied to draw clear conclusions. CONCLUSIONS: The results indicated that mental disorder was the most strongly associated variable of those that have been studied. Further studies should focus on specific disorders and psychosocial factors. Suicide prevention strategies may be most effective if focused on the treatment of mental disorders. Language: en

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0033291702006943

Psychological autopsy studies of suicide: a systematic review.

• The characteristics of adolescent suicide victims (n = 27) were compared with those of a group at high risk for suicide, suicidal psychiatric inpatients (n = 56) who had either seriously considered (n = 18) or actually attempted (n = 38) suicide. The suicide victims and suicidal inpatients showed similarly high rates of affective disorder and family histories of affective disorder, antisocial disorder, and suicide, suggesting that among adolescents there is a continuum of suicidality from ideation to completion. However, four putative risk factors were more prevalent among the suicide victims: (1) diagnosis of bipolar disorder; (2) affective disorder with comorbidity; (3) lack of previous mental health treatment; and (4) availability of firearms in the homes, which taken together accurately classified 81.9% of cases. In addition, suicide completers showed higher suicidal intent than did suicide attempters. These findings suggest a profile of psychiatric patients at high risk for suicide, and the proper identification and treatment of such patients may prevent suicide in high-risk clinical populations.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/494317/archpsyc_45_6_012.pdf

Risk Factors for Adolescent Suicide: A Comparison of Adolescent Suicide Victims With Suicidal Inpatients

Objective. —The presence of guns in the home, the type of gun, and the method of storage were all hypothesized to be associated with risk for adolescent suicide. Design. —Case-control study. Subjects. —The case group consisted of 47 adolescent suicide victims. The two psychiatric inpatient control groups were 47 suicide attempters and 47 never-suicidal psychiatric controls, frequency-matched to the suicide victims on age, gender, and county of origin. Setting. —The cases were a consecutive community sample, whereas the inpatients were drawn from a university psychiatric hospital. Main Outcome Measure. —Odds of the presence of guns in the home of suicide victims (cases) relative to controls. Results. —Guns were twice as likely to be found in the homes of suicide victims as in the homes of attempters (adjusted odds ratio, 2.1; 95% confidence interval, 1.2 to 3.7) or psychiatric controls (adjusted odds ratio, 2.2; 95% confidence interval, 1.4 to 3.5). Handguns were not associated with suicide to any statistically significantly greater extent than long guns. There was no difference in the methods of storage of firearms among the three groups, so that even guns stored locked, or separate from ammunition, were associated with suicide by firearms. Conclusions. —The availability of guns in the home, independent of firearms type or method of storage, appears to increase the risk for suicide among adolescents. Physicians should make a clear and firm recommendation that firearms be removed from the homes of adolescents judged to be at suicidal risk. ( JAMA . 1991;266:2989-2995)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=393663&pdfFileName=jama_266_21_032.pdf

The presence and accessibility of firearms in the homes of adolescent suicides. A case-control study.

OBJECTIVE\nThe presence of guns in the home, the type of gun, and the method of storage were all hypothesized to be associated with risk for adolescent suicide.\n\n\nDESIGN\nCase-control study.\n\n\nSUBJECTS\nThe case group consisted of 47 adolescent suicide victims. The two psychiatric inpatient control groups were 47 suicide attempters and 47 never-suicidal psychiatric controls, frequency-matched to the suicide victims on age, gender, and county of origin.\n\n\nSETTING\nThe cases were a consecutive community sample, whereas the inpatients were drawn from a university psychiatric hospital.\n\n\nMAIN OUTCOME MEASURE\nOdds of the presence of guns in the home of suicide victims (cases) relative to controls.\n\n\nRESULTS\nGuns were twice as likely to be found in the homes of suicide victims as in the homes of attempters (adjusted odds ratio, 2.1; 95% confidence interval, 1.2 to 3.7) or psychiatric controls (adjusted odds ratio, 2.2; 95% confidence interval, 1.4 to 3.5). Handguns were not associated with suicide to any statistically significantly greater extent than long guns. There was no difference in the methods of storage of firearms among the three groups, so that even guns stored locked, or separate from ammunition, were associated with suicide by firearms.\n\n\nCONCLUSIONS\nThe availability of guns in the home, independent of firearms type or method of storage, appears to increase the risk for suicide among adolescents. Physicians should make a clear and firm recommendation that firearms be removed from the homes of adolescents judged to be at suicidal risk.

The Presence and Accessibility of Firearms in the Homes of Adolescent Suicides

Adolescent inpatients (of whom 48 were admitted for a suicide attempt, 33 were admitted for suicidal ideation, and 53 had no history of clinically significant suicidal ideation or attempt), were interviewed while in the hospital and then followed up 6 months later. Of the 134 patients followed up, 13 (9.7%) had made a suicide attempt. The vast majority of those who attempted suicide had been suicidal while in the hospital (12/13 or 92.3%). Other risk factors for suicidal behavior include major depression at intake, affective disorder with nonaffective comorbidity, a depressive disorder that continued through follow-up, death of a relative, and family financial problems. Suicidal inpatients, particularly those with chronic and recurrent affective illness, are at substantial risk for making a suicide attempt within 6 months of discharge. At follow-up, an even higher proportion showed attempts or suicidal ideation with a plan (N = 36 or 26.8%), with risk factors similar to those noted above. More intense outpatient or partial hospital interventions as a transition from the inpatient environment may be necessary to reduce the rate of recidivism among suicidal adolescents.

Adolescent Psychiatric Inpatients' Risk of Suicide Attempt at 6-Month Follow-up

Methodological issues in the use of the psychological autopsy technique to study adolescent suicide victims were addressed in a study of 27 adolescent completed-suicide victims and a comparison group of 56 suicidal psychiatric inpatients. This report concludes that: (1) parent/parent figure descriptions of suicide victims were unaffected by the presence or severity of affective symptomatology in the informant at the time of the interview: (2) parent reports were unaffected by the time interval between the death and the interview, within a time span of 2 to 6 months: and (3) the asymmetry of informant sources must be considered in the interpretation of odds ratios for psychiatric disorder comparing completers to a live control group. In light of these findings and the convergence of several psychological autopsy studies with each other and with prospective studies, the psychological autopsy is thought to yield reliable and valid results for the study of adolescent suicide.

Janice P. Zelenak

Papers

Risk Factors for Adolescent Suicide: A Comparison of Adolescent Suicide Victims With Suicidal Inpatients

The presence and accessibility of firearms in the homes of adolescent suicides. A case-control study.

The Presence and Accessibility of Firearms in the Homes of Adolescent Suicides

Adolescent Psychiatric Inpatients' Risk of Suicide Attempt at 6-Month Follow-up

The Psychological Autopsy: Methodological Considerations for the Study of Adolescent Suicide