Better Use of Treatment Knowledge Could Cut Youth Suicide Rate

Psychologist, researcher, and author Kay Redfield Jamison, Ph.D., is no stranger to suicidal thoughts, having struggled with the manic form of bipolar disorder since she was a teenager.

She first considered suicide at age 17, seeing it as the only solution to an unendurable level of mental pain, said Jamison at the Canadian Psychiatric Association (CPA) annual meeting in Montreal in November.

After a serious suicide attempt when she was 28, she began investigating bipolar disorder and suicide professionally as a faculty member in the department of psychiatry at the University of California at Los Angeles.

She made some startling discoveries. Twice as many young American men died from suicide during the Vietnam War as young men who died in combat.

Suicide is the third-leading cause of death among adolescents who are between 15 and 19 years old in the United States, according to Jamison, who gave the R.O. Jones, M.D., memorial lecture at the CPA meeting. Jones was the first CPA president.

“There is the societal illusion that suicide is rare. It is not rare, and certainly the mental illnesses that are tied to suicide are not rare. Unlike cancer and heart disease, they disproportionately kill the young,” said Jamison.

Bipolar and other major mood disorders, severe anxiety disorders, schizophrenia, and addictive disorders account for most suicides, according to Jamison. Personality disorders also are associated with a high suicide risk. Having a major psychiatric illness and comorbid drug or alcohol abuse increases the suicide rate significantly, she noted. In bipolar patients, substance abuse increases the suicide rate 60 percent, said Jamison.

Youngsters at Highest Risk

The onset of bipolar disorder, schizophrenia, and major depression in late adolescence and early adulthood signals a sharply increased suicide risk, said Jamison.

Researchers in Sweden found that hospitalized bipolar patients were 15 to 22 times more likely to commit suicide than were control subjects. But bipolar patients under age 30 were 70 to 80 times more likely to commit suicide than controls in the same age group, said Jamison. The authors of the study, reported in the September 2001 Archives of General Psychiatry, noted that the mortality rate from suicide was especially high for younger patients during the first years after diagnosis.

Several factors converge in the early stage of the illness. “A person knows little about the illness, is usually not in effective treatment, and if prescribed medication, is usually noncompliant,” said Jamison.

The noncompliance rate for lithium, for example, hovers around 50 percent, with a relapse rate slightly above that.

“It’s incredibly hard to convince an 18-year-old to stay on lithium when the side effects can cause acne, weight gain, a tremor, a lack of coordination in sports, and slowness in thought,” said Jamison.

She also explained why she was noncompliant for many years. “I had to deny that I could have another psychotic episode in order to get out of bed each morning. But, I also had euphoric manias that left cocaine in the dust in terms of enjoyment, intensification of the senses, high energy, and quick thinking. I am convinced that you have to treat the manic type of bipolar disorder as two separate disorders. Euphoric manias are extremely addictive biologically and psychologically. You have an incredible system in your brain that always wants to recapture that high,” said Jamison.

Sticking With Treatment

Jamison eventually stayed on lithium, which she credits with keeping her alive. Multiple studies have shown a ninefold reduction in the suicide rate when patients stay on lithium, she pointed out.

She found psychotherapy helped her live with her illness. Research has shown that combining lithium with cognitive-behavioral therapy increased compliance and reduced the relapse rate significantly, according to Jamison.

The suicide rate for adolescents aged 15 to 19 appears to have declined in the last few years, said Jamison. “One reason may be that physicians are recognizing depression earlier and prescribing antidepressants.”

However, the link between antidepressant use and suicide-risk reduction has not been studied in the United States, because drug companies exclude people who have attempted suicide or describe severe suicidal ideation, said Jamison.

She referred to a recent Swedish study showing that when general physicians were taught to recognize depression in all age groups and use antidepressants in effective doses the suicide rate decreased dramatically.

Where’s the Outrage?

In spite of treatments that can save lives, knowledge of the biological underpinnings of mental illness and suicide, and public health strategies to reduce the suicide rate, “the effort seems remarkably unhurried,” said Jamison. “Every 17 minutes, someone in America commits suicide. Where are the public concern and outrage?”

“Looking at suicide—the sheer numbers, the pain leading up to it, and the suffering left behind—is harrowing. For every moment of exuberance in science or success in government, there is a matching and terrible reality of the deaths themselves, the young deaths, the violent deaths, the unnecessary deaths,” said Jamison, reading from her 1999 book Night Falls Fast: Understanding Suicide.

“Like many of my colleagues who study suicide, I have seen the limitations of our science, been privileged to see how good some doctors are, and am appalled by the callousness and incompetence of others. Mostly, I have been impressed by how little value our society puts on saving the lives of those who are in such despair as to want to end them,” said Jamison. ▪