Suicide Behavior in Pediatric Bipolar Disorder

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Suicide Behavior in Pediatric Bipolar Disorder

• Presented by
• Liz Podczerwinski, M3
• February 3, 2009

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Lifetime Suicide Rate in Bipolar Disorder

• 20-65 of bipolar (BP) adults experience onset in
  childhood
• Adults with early illness onset are at higher
  risk for suicidal behavior
• 25-50 of adult BP pt make at least 1 suicide
  attempt
• 8-19 of BP pt will succeed

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Lifetime Suicide Rate in Bipolar Disorder Cont

• High risk pt include those with early-onset BP,
  hx of prior attempts, severe depression, mixed
  episodes, rapid cycling, psychosis, comorbid
  disorders, family hx of suicidal attempts,
  availability of methods, substance use disorder,
  aggressive traits/impulsivity, and exposure to
  stressful events (physical and/or sexual abuse)
• Prompt identification and treatment is critical
  as highest rates occur within 1st 2 years of
  illness

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Lifetime Suicide Rate in Bipolar Disorder Cont

• 44 lifetime attempt rate among adolescents with
  BP spectrum disorders vs. 22 in unipolar (UP)
  depressed teens vs. 1 healthy controls
• BP attempters had more lethal and multiple
  attempts vs. UP attempters
• 47 attempt rate among pediatric BPI with
  episodic pattern of mood symptomatology vs. 15
  attempt rate for pt with chronic illness pattern

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Research Study on Suicidal Behavior in Pediatric
Bipolar Disorder

• Goldstein et al. 2005
• Methods
• 405 BP children and adolescents (ages 7-17)
• Used Course Outcome of Bipolar Youth (COBY)
  multi-site study (U of Pittsburgh, Brown, and
  community programs)
• Participants fulfilled DSM-IV BPI, BPII, or
  BP-NOS
• Participants determined to have primary BP d/o
• Intellectual functioning WNL

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Study Demographics

• 54 male vs. 46 female
• Average age 12.7 yr
• Middle class
• 83 Caucasian, 6 African American, 8
  Bi/multi-racial, 1 Asian, 1 Other
• 58 BPI vs. 7 BPII vs. 35 BP-NOS
• Comorbidities include ADHD (60) ODD (39)

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Study Procedures

• Diagnosis-interviews utilizing DSM-IV K-SADS
• Suicidal acts in worst week in the month
  preceding evaluation
• Most severe past episode
• Lifetime suicidal acts
• Confirmation by child psychiatrist or child
  psychologist

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Definition of Suicide Attempt

• a potentially self-injurious behavior with a
  non-fatal outcome for which there is evidence
  that person intended at some level to kill
  himself/herself.
• OCarroll et al

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Study Results

• 32 endorsed lifetime hx of at least 1 suicide
  attempt characterized by significant seriousness
  and/or lethality
• No significant differences between attempters vs.
  non-attempters in regards to sex, race, SES, or
  living situation
• Attempters were significantly older than
  non-attempters
• 67 of attempters had lifetime h/o frequent
  intense suicidal ideation rated moderate or higher

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Clinical Characteristics of Attempters vs.
Non-Attempters

• Attempters
• H/o psychiatric hospitalizations
• Mixed episodes
• Psychotic features
• Endorsed more lifetime non-suicidal
  self-injurious behavior rated by K-SADS- ex.
  Scratching, cutting, burning
• Greater h/o physical and/or sexual abuse
• BP onset after age 12
• Axis I co-morbidities such as substance use d/o
  and panic d/o (ADHD incurred decreased risk)
• Higher of BPI vs. BP-NOS

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Variables Significantly Predictive of Increased
Risk for Lifetime Attempt

• History of self-injurious behavior
• Psychiatric hospitalizations
• Mixed episodes
• Psychosis

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Study Results Cont

• On Childrens Global Assessment Scale (C-GAS)
  during the worst lifetime period of illness,
  suicide attempters were more impaired than
  non-attempters
• Depression rating on K-SADS-DRS was worse for
  attempters
• No differences in manic episode rating

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Family History of Variables

• Attempters
• More likely to have family history of suicide
  attempt
• Greater likelihood of suicide behavior in
  relatives of attempters
• No differences between attempters and
  non-attempters regarding family h/o MD, mania,
  CD, substance use d/o, suicide completion

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Study Discussion

• Findings consistent w/ adult BP
• Pt with h/o mixed episode, psychotic features,
  substance use d/o, panic d/o, were more likely to
  have attempted suicide
• Impulsivity found w/ ADHD was at a higher in
  non-attempters
• Importance of assessing current and past
  symptomatology (past psychiatric hospitalizations)

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Study Limitations

• Reliability of retrospection of patients and
  parents
• Suicidal gesture vs. behavior
• COBY pt population not representative of general
  population
• Relationship between psychosocial and
  pharmacological therapy

16

• X-Ray showing metal pieces embedded in the left
  arm of a teenage girl- Radiological Society of
  North America

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Self-Embedding Pattern Among Abused Teens

• Safety of removing soft tissue foreign bodies
  percutaneously based on data on 505 patients over
  13 yrs of age
• Radiologists have identified self-inflicted
  injuries in 10 patients that involved embedding
  objects into arms, feet, and hands
• Objects included unfolded paper clips, glass,
  stone, wood, plastic items, and crayon

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Self-Embedding Pattern Among Abused Teens

• 90 of these pt demonstrated suicidal ideation
  and behavior
• 90 were female
• Had multiple psych comorbidities including
  BIPOLAR, borderline personality disorder,
  depression, PTSD, ADHD, and OCD
• All children had h/o physical/sexual abuse and
  were removed from homes

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Self-Embedding Pattern Among Abused Teens

• Perhaps this calls for a need for education about
  early detection to avoid complications
  (infection, nerve damage)
• Detection of such behaviors could potentially
  detect a future suicide attempt early

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References

• Birk, Susan. Radiologists report
  self-embedding pattern among abused teens.
  Elsevier Global Medical News. 2009.
• Faust, Douglas et al. Diagnosis and Management
  of Childhood Bipolar Disorder in the Primary Care
  Setting. Clinical Pediatrics. Sage
  Publications. 2006 801-808.
• Goldstein TR. et al. History of suicide
  attempts in pediatric bipolar disorder factors
  associated with increased risk. Bipolar Disord.
  2005 7 525-535.