JOURNAL OF ADOLESCENT HEALTH 1992;13:409-414
CONFERENCE PROCEEDINGS
OLIVIER JEANNERET,
M.D.
During adolescence (by convention, lo-19 years of age), the global mortality rates are relatively low in most countries. Nevertheless, s&i&i mortuiity rates are usually second (after all accidents) or third (after accidents and homicides), depending on the country. Rates in males are regularly higher than those in females. Owing to the universal absence of a systematic recording of parusuicide cases, morbidity data are obviously much more difficult to get and to analyze properly. Data based on hospital admissions give only approximations. Nevertheless, in this age group, parasuicide is expected to be many times more frequent in females than in males. Epidemiologic studies on relapses as well as parasuicide follow-up are rare. Taking into account the number and heterogeneity of known risk factors, suicidal behavior predktion is based on probability statistics: valuable only for groups (“high-risk pmfi! es”!, never for individualls. This is particularly true in adolescence, when so many changes occur rapidly. Preventative measures are to be discussed according to their pertinence in each of the three classic levels of prevention.
In this paper, relevant epidemiologic data are presented in order to pose some pertinent questions about prevention. The iceberg paradigm (Figure 1) is useful for visualizing the problem: Above the visibility threshold (floating line) are the completed suicides, some of them disguised as accidents, as well as attempted suicides that end in hospital admission and can therefore be officially registered. Below this threshold, we find all other attempted suicides, suicidal threats, depressive equivalents and suicidal thoughts, rarely spontaneously expressed in medical settings but often recorded in systematic interviews. Whereas the inside of a real iceberg is frozen, the levels in the paradigm iceberg are obviously moving: starting from the thought to the equivalent, even to the attempt, as well as to the relapse.
KEY WORDS:
Suicide Parasuicide Mortality Prevention
Mortality
Among typical risk-taking behaviors in adolescence,
suicidal behaviors are distinguished outcome: death.
by the expected
From the Department of Social and Preventive Medicine, University of Geneva Medical School, Geneva, Switzerland. Address reprint requests to: Olivier leanneret, M.D., Department of Social and Preventive Medicine, University of Geneva Medical School, 1211 Geneva 4, Switzerland. This paper was presented at the 5th Congress of the International Assoication for Adolescent Health, ]uly 3-6, 1991, Montreux, Switzerland. Manuscript accepted January 31, 1992.
Suicide is the second or third leading cause of death (Figure 2) in the age group 15-24 years. Taking into account the fact that suicidal behaviors begin at the end of childhood (3$, it is important for epidemiologists to go further than the conventional 5 years of age grouping of data. In Figure 3 are suicide cases registered by age in Switzerland during a 4-year period. For both sexes, the increase with age is progressive, but more obvious in boys. This sex ratio in crude numbers is obviously also found in mortality rates, because the population denominators are about the same in boys and girls. This higher male death rate by suicide is notable, because of its contrast with suicide mpjrbidity.
D Society for Adolescent Medicine, 1992 Published by Elsevier %ence Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
409 1054-139x/92/$3.00
410
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
JEANNERET
Pseudo - accidents
/ Suicide fr6ussi)
S
pr&uicidates
Time trends are very important, as exemplified in Canada (Figure 4), and globally in many Western counties for the age group 15-19 years (Figure 5). In Canada for instance, the 1980 rate for girls 15-
19 years of age is almost the same as the 1960 rate for boys of the same age group. Interestingly, European countries where the suicide rate (all ages) is known to be very high, like Hungary and the former West Germany, are those countries where a decrease is noticed between 1970 and 1985 (Figure 5). Owing to the diversity among countries in suicidal death recording, their reported mortality rates-as the only reliable marker of the magnitude of this behavior-are more appropriate for observing these time trends within each country than for comparing one country with another. In one publication (6) the phenomenon of suicide clusters is mentioned as being prevalent in adolescents.
Morbidity (Parasuicide) Table 1 summarizes some of the main facts related to parasuicide in the 15-19 year age group by sex, according to three sources of data.
...*.............*.......*........
*....a
. . . .
act.+
adverse effects
suicide
I
homicide
80
. . . .
. . . .
. . . .
.
. .
. .
. .
. .
. . .
. .
. .
. . .
. .
. . .
. .
. .
. . .
.
. . .
. . . .
.
. . .
other violence
mates SSl females
males
France
.__
. . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
&Sl females
Mexico
.......................................... Figure 2. Percentage of the four main categories oj violent deaths in youth 25-24 years in France (1986, n = 3,934J upper left, in Mexico (1983, n = 11,313) above, and in Chile (1986, n = 1,178) lefi (from ref. 2).
.......................................................................................
...................
a=+
adverse effects
suicide m
males Chile
.............
bmicide KSI females
other violence
July 1992
EPIDEMIOLOGIC APPROACH TO SUICIDE PREVENTION
411
x n
10
11
12
13
A
14
15
16 17 16 Age (years)
19
20
21
22
23
24 B
Figure 3. A) Deaths by suicide (ICD-8: AZ47) and deaths by injuries in which the intention is not known WD-8: AZ49) before the age of25, in Swiss males, 1985-2988 (reproduced from ref. 11. 8) Deaths by suicide (KD-8: A247) and deaths by injuries in which the intention is not known (ICD-8: A149) before !!z age of25, in Swiss females, 1985-1988
(reproduced,+mn ref. I). (The meaning of the empty segment of each column in histograms of Figure 3 A) and B) KD A 149) is useful for the certifying physician to prevent a wrongattribution to suicide or to accident categories ojcases for which there is still a doubt regarding the real cause of a violent death. One case of six in males (Figure 3 A) and one of four in female (Figure 3 B) has to be classified that way.)
There is an obvious female predominance in annual incidence, prevalence, and hospital admission rates. As a result, the ratio of parasuicide/suicide is expected to be at least six times higher in girls than in boys. To the question of the time-trend relationships between morbidity and mortality, suicide epideFigure 4. Suicide mortality rate, by sex and age (per 200,QOO) in 2960, 1970, and 1980 in Canada (reproduced by permission from Reed et al., ref. 4). 34. 32. 30. 26. 26. 0
24.
8 d z
22.
miologist RFW Diekstra provides a clear answer: “Data from centers with well-defined catchment area collected over a number of years in several countries [ . . . ] indicate that hospital admission rates for attempted suicide for adolescents and young adults rose sharply during the same period (1965-19SOM) when their national suicide (mortality) rates were increasing” (5). From a prevention perspective, we obviously have to focus on relapses. In Table 2 are summarized the most important results of three studies or reviews of the literature (a-lo), that describe the magnitude of the phenomenon. In brief, suicide relapses are more frequent in adolescents than in adults, are concentrated closer to the first episode, and are obviously multifactorial, especially when lethal. Regarding the further risk of death, see the contribution of L. Kotila (11).
Risk Factors In order to show the number and the heterogeneity of risk factors, a flow chart based on a US study (12) is presenteid in Figure 6. Faced with such a variety of risk factors, the epidemiologist is obviously concerned with the probFigure 5. Variation fin o/o)of suicide mortality rates in 13 Western countries between 1970 and 1985 (reproduced by permission from Diekstra ref. 5).
20. ‘m 16
Austria Belgium Canada Denmark England & Wales Hungary Ireland My Japan t Netherlands Norway U.S.A. West-Germany
; 16. ca 14.
a
Age (years)
12. 10.
6. 6. 4.
55-59
Me
65-69
-100 .*. WHO DaIsbank **-
100
200 %
Change
300
400
412
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
JEANNERET
Table 1. Crude Data on Parasuicide in Adolescents
Table 2. Crude Data [ref. no.] on Suicide Relapses in Adolescents
Gender Age 15-19 years, [ref. no.] Annual incidence rate (per low I71 Proportion of parasuicide to ali hospital admissinns (%) Ratio parasuicidelsuicide
(81
Prevalence (%) of reported former parasuicide [ 71 Prevalence (%) of reported former suicidal thoughts [ 71 Prevalence (I) of “frequent” reported former suicidal thoughts [ 71
F
M -2
-5
Variations according to time interval [9]: first month: 1 of 5 first 6 months: 1 of 2 I rare after ’ year
-
2
7
3-4
25/l (all ages 6/l)
160/l (3011)
11011
3.3
2.3
1.5
Without indication on the time interval [ 81: adolescents: z 1 of 3 (all ages: 1 of 6 or 7)
M+F
22
38
-
3
9
-
Lethal relapses 181:maximum risk in boys (16-20 years) in the first three months increasing with the number of risk factors increasing with the lethality of the means used the first time Later lethality rate (without precision on the interval) [lo] cases controls (same age) Relative risk 4 1
“Information from F. Ladame, personal communication (1990).
/1/
aivorce rate
vihence
REDUCEDCOPllNG LOSS OF HOPE
1
Figure 6. Macro- and rnicrosocialfactors linked to suicidal behavior increase in adolescence, United States, /n = increase: \r = decrease (from ref. 23).
July 1992
EPIDEMIOLOGIC
Table 3. Prevalence of Natural History Data in
ParasuicideCases and Controls in French College Students (reproduced from ref. 13). Parasuicide a %
Controls b %
a i
Sleep disorders
59
20
3.0
Frequent
fatigue
49
10
4.9
Psychological problems and character disorders
46
10
4.6
Heavy smoking
45
10
4.5 4.1
Use of “nervous
pills”
41
10
Poor (perceived)
health
27
10
2.7
Use of “sleeping
pills”
25
8
3.1
School truancy
21
4
5.0
Heavy drinking
16
4
4.0
14
2
7.0
Psychosomatic
disorders
lem of measurement of the potential role of each. Closer to the clinician’s perspective are the criteria collected by history-taking in two groups of French adolescents, cases of parasuicide and controls (Table 3). This study found the prevalence of symptoms like school truancy to be five times higher in cases than in controls. Clinicians are well aware that “sleep disorders,” like all other prevalence data in this list are found in the natural history of many syndromes and diseases in adolescents, as well as in healthy adolescents. This serves as an additional reminder that, in general, all risk factors are not causes, but correlates of pathologies and that predictive factors are always based on a probability concept and not on an etiological one.
Prevention Any prudent epidemiologist is expected to raise questions rather than to give advice: actual questions about suicide are numerous and only a few of them are addressed in this paper: 1. In the field of primary prevention, are not all of ub ready to admit that the amount, the diversity, and the complexity of (risk) factors involved in suicidal behavior are such that the search for a specific preventive program for the individual adolescent is completely meaningless? And that therefore this level of prevention can only be nonspecific--that is preventive of poor adjustment to his/her family, occupational, and/or social environment? 2. Regarding the level of secondary prevention, a first
APPROACH
TO SUICIDE PREVENTION
413
question concerns the target for any preventative measure or program: is it the high-risk situation or the immediate presuicidal stage? Are we ready to agree that early detection is potentially appropriate for the progressive formation of a high-risk situation (14)? Another perplexing question is where to concentrate this early detection effort: in primary cases or in relapses? The high ratio of parasuicide to completed suicide in the adolescent and young adult age groups could support the position of giving preference to preventing relapses. This answer is becoming a highly ethical one: is it acceptable in any highly medicalized society to exclude “primary cases” from aggressive preventive efforts, arguing that in these age groups only a small proportion will die? 3. In terms of tertiary prevention, the future health and well-being of parasuicide cases is so often threatened or compromised-even in absence of psychosis (11,15) that careful follow-up measures are badly needed. Are our Western (mental) health systems well enough staffed and trained to meet such P challenge, when facing the previously mentioned increase in morbidity and relapse rates?
References 1. Jeanneret 0. Suicides et tentatives chez Ies adolescents: Aspects fipidemiologiques et preventifs Bull Int Ped Ass 1985;6:332-52. 2. World Health Organization. neva: WHO, 1989.
Health Statistics
Annual.
Ge-
3. Jeanneret 0, Krotenberg A. Conauites suicidaires chez I’enfant. In: Manciaux M, Lebovici S. leanneret 0. L’enfant et sa Sante;AspectskpiidCmiologiqu& Biologiques, Psychologiques et Sociaux. Paris: Doin, 1987:897-904. 4. Reed J Camus J, Last JM. Suicide in Canada: Birth-cohort Analysis. Can J Pub1 Hlth, 1985;76:43-47. 5. Diekstra RFW. Suicidal behavior in adolescents and young adults: The international picture. In: Tentatives de suicide a I’adolescence. Colloque du Centre International de I’Enfance. Paris 12-14 decembre 1988. Paris: Centre International de I’Enfance, 1989:11-37. 6. Gould MS, Wallenstein S, Kleinman MH, et al. Suicide clusters: An examination of age-specific effects. Am J Pub1 Health, 1990;80:211-212. 7. Davicison F, Philippe A. Suicide et tentatives de suicide aujourd’hui; etude Cpidemiologique. Paris: Doin, 1986. 8. Aladjem D. L’intoxication volontaire chez les adolescents et les jeunes adultes suisses: Aspects 6pidCmiologiques. These (Gen+ve) en prkparation. 9. Webfir D, Botta JM. L/adolescent paro!.e. In: VCdrinne J, et al., eds. cidaires. Tome II: Aspects cliniques Mas:jon, 1982 (Collection Med Log
suicidant: Du geste B la Suicide et conduites suiet institutionnels. Paris: Toxicol MPd, 122).
10. Goklacre M, Hawton K. Management of children and adolescents following suicide attempts. In: Hawton K, ed. Suicide and attempted suicide among chiidren and adolescents.
414
JEANNERET
London: Sage, 1986 (Developmental Clinical Psychology and Psychiatry, ~015). 11. Rotifa L. Prevention of suicide and parasuicide. J. Adolesc Health 1992;13:415-417. 12. Sudak HS, Ford AB, Rushforth NB. Adolescent suicide: an overview. Am J Psychotherap 1984;38:350-63. 13. Philippe A, Choquet M. Chomage et tentatives de suicide. In: Davidson F, Philippe A, eds. Suicide et tentatives de
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
suicide aujourd’hui; 1986:112.
etude
Cpidemiologique.
Paris: Doin,
lri. Ladame F, Jeanneret 0. Suicide in adolescence; some comments on epidemiology and prevention. J Adolesc 1982;5:355366. 15. Otto U. Suicidal acts by children and adolescents: A followup study. Acta Psychiatr Stand [Suppl] 1972;233.
CONFERENCE PROCEEDINGS
OLIVIER JEANNERET,
M.D.
During adolescence (by convention, lo-19 years of age), the global mortality rates are relatively low in most countries. Nevertheless, s&i&i mortuiity rates are usually second (after all accidents) or third (after accidents and homicides), depending on the country. Rates in males are regularly higher than those in females. Owing to the universal absence of a systematic recording of parusuicide cases, morbidity data are obviously much more difficult to get and to analyze properly. Data based on hospital admissions give only approximations. Nevertheless, in this age group, parasuicide is expected to be many times more frequent in females than in males. Epidemiologic studies on relapses as well as parasuicide follow-up are rare. Taking into account the number and heterogeneity of known risk factors, suicidal behavior predktion is based on probability statistics: valuable only for groups (“high-risk pmfi! es”!, never for individualls. This is particularly true in adolescence, when so many changes occur rapidly. Preventative measures are to be discussed according to their pertinence in each of the three classic levels of prevention.
In this paper, relevant epidemiologic data are presented in order to pose some pertinent questions about prevention. The iceberg paradigm (Figure 1) is useful for visualizing the problem: Above the visibility threshold (floating line) are the completed suicides, some of them disguised as accidents, as well as attempted suicides that end in hospital admission and can therefore be officially registered. Below this threshold, we find all other attempted suicides, suicidal threats, depressive equivalents and suicidal thoughts, rarely spontaneously expressed in medical settings but often recorded in systematic interviews. Whereas the inside of a real iceberg is frozen, the levels in the paradigm iceberg are obviously moving: starting from the thought to the equivalent, even to the attempt, as well as to the relapse.
KEY WORDS:
Suicide Parasuicide Mortality Prevention
Mortality
Among typical risk-taking behaviors in adolescence,
suicidal behaviors are distinguished outcome: death.
by the expected
From the Department of Social and Preventive Medicine, University of Geneva Medical School, Geneva, Switzerland. Address reprint requests to: Olivier leanneret, M.D., Department of Social and Preventive Medicine, University of Geneva Medical School, 1211 Geneva 4, Switzerland. This paper was presented at the 5th Congress of the International Assoication for Adolescent Health, ]uly 3-6, 1991, Montreux, Switzerland. Manuscript accepted January 31, 1992.
Suicide is the second or third leading cause of death (Figure 2) in the age group 15-24 years. Taking into account the fact that suicidal behaviors begin at the end of childhood (3$, it is important for epidemiologists to go further than the conventional 5 years of age grouping of data. In Figure 3 are suicide cases registered by age in Switzerland during a 4-year period. For both sexes, the increase with age is progressive, but more obvious in boys. This sex ratio in crude numbers is obviously also found in mortality rates, because the population denominators are about the same in boys and girls. This higher male death rate by suicide is notable, because of its contrast with suicide mpjrbidity.
D Society for Adolescent Medicine, 1992 Published by Elsevier %ence Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
409 1054-139x/92/$3.00
410
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
JEANNERET
Pseudo - accidents
/ Suicide fr6ussi)
S
pr&uicidates
Time trends are very important, as exemplified in Canada (Figure 4), and globally in many Western counties for the age group 15-19 years (Figure 5). In Canada for instance, the 1980 rate for girls 15-
19 years of age is almost the same as the 1960 rate for boys of the same age group. Interestingly, European countries where the suicide rate (all ages) is known to be very high, like Hungary and the former West Germany, are those countries where a decrease is noticed between 1970 and 1985 (Figure 5). Owing to the diversity among countries in suicidal death recording, their reported mortality rates-as the only reliable marker of the magnitude of this behavior-are more appropriate for observing these time trends within each country than for comparing one country with another. In one publication (6) the phenomenon of suicide clusters is mentioned as being prevalent in adolescents.
Morbidity (Parasuicide) Table 1 summarizes some of the main facts related to parasuicide in the 15-19 year age group by sex, according to three sources of data.
...*.............*.......*........
*....a
. . . .
act.+
adverse effects
suicide
I
homicide
80
. . . .
. . . .
. . . .
.
. .
. .
. .
. .
. . .
. .
. .
. . .
. .
. . .
. .
. .
. . .
.
. . .
. . . .
.
. . .
other violence
mates SSl females
males
France
.__
. . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
&Sl females
Mexico
.......................................... Figure 2. Percentage of the four main categories oj violent deaths in youth 25-24 years in France (1986, n = 3,934J upper left, in Mexico (1983, n = 11,313) above, and in Chile (1986, n = 1,178) lefi (from ref. 2).
.......................................................................................
...................
a=+
adverse effects
suicide m
males Chile
.............
bmicide KSI females
other violence
July 1992
EPIDEMIOLOGIC APPROACH TO SUICIDE PREVENTION
411
x n
10
11
12
13
A
14
15
16 17 16 Age (years)
19
20
21
22
23
24 B
Figure 3. A) Deaths by suicide (ICD-8: AZ47) and deaths by injuries in which the intention is not known WD-8: AZ49) before the age of25, in Swiss males, 1985-2988 (reproduced from ref. 11. 8) Deaths by suicide (KD-8: A247) and deaths by injuries in which the intention is not known (ICD-8: A149) before !!z age of25, in Swiss females, 1985-1988
(reproduced,+mn ref. I). (The meaning of the empty segment of each column in histograms of Figure 3 A) and B) KD A 149) is useful for the certifying physician to prevent a wrongattribution to suicide or to accident categories ojcases for which there is still a doubt regarding the real cause of a violent death. One case of six in males (Figure 3 A) and one of four in female (Figure 3 B) has to be classified that way.)
There is an obvious female predominance in annual incidence, prevalence, and hospital admission rates. As a result, the ratio of parasuicide/suicide is expected to be at least six times higher in girls than in boys. To the question of the time-trend relationships between morbidity and mortality, suicide epideFigure 4. Suicide mortality rate, by sex and age (per 200,QOO) in 2960, 1970, and 1980 in Canada (reproduced by permission from Reed et al., ref. 4). 34. 32. 30. 26. 26. 0
24.
8 d z
22.
miologist RFW Diekstra provides a clear answer: “Data from centers with well-defined catchment area collected over a number of years in several countries [ . . . ] indicate that hospital admission rates for attempted suicide for adolescents and young adults rose sharply during the same period (1965-19SOM) when their national suicide (mortality) rates were increasing” (5). From a prevention perspective, we obviously have to focus on relapses. In Table 2 are summarized the most important results of three studies or reviews of the literature (a-lo), that describe the magnitude of the phenomenon. In brief, suicide relapses are more frequent in adolescents than in adults, are concentrated closer to the first episode, and are obviously multifactorial, especially when lethal. Regarding the further risk of death, see the contribution of L. Kotila (11).
Risk Factors In order to show the number and the heterogeneity of risk factors, a flow chart based on a US study (12) is presenteid in Figure 6. Faced with such a variety of risk factors, the epidemiologist is obviously concerned with the probFigure 5. Variation fin o/o)of suicide mortality rates in 13 Western countries between 1970 and 1985 (reproduced by permission from Diekstra ref. 5).
20. ‘m 16
Austria Belgium Canada Denmark England & Wales Hungary Ireland My Japan t Netherlands Norway U.S.A. West-Germany
; 16. ca 14.
a
Age (years)
12. 10.
6. 6. 4.
55-59
Me
65-69
-100 .*. WHO DaIsbank **-
100
200 %
Change
300
400
412
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
JEANNERET
Table 1. Crude Data on Parasuicide in Adolescents
Table 2. Crude Data [ref. no.] on Suicide Relapses in Adolescents
Gender Age 15-19 years, [ref. no.] Annual incidence rate (per low I71 Proportion of parasuicide to ali hospital admissinns (%) Ratio parasuicidelsuicide
(81
Prevalence (%) of reported former parasuicide [ 71 Prevalence (%) of reported former suicidal thoughts [ 71 Prevalence (I) of “frequent” reported former suicidal thoughts [ 71
F
M -2
-5
Variations according to time interval [9]: first month: 1 of 5 first 6 months: 1 of 2 I rare after ’ year
-
2
7
3-4
25/l (all ages 6/l)
160/l (3011)
11011
3.3
2.3
1.5
Without indication on the time interval [ 81: adolescents: z 1 of 3 (all ages: 1 of 6 or 7)
M+F
22
38
-
3
9
-
Lethal relapses 181:maximum risk in boys (16-20 years) in the first three months increasing with the number of risk factors increasing with the lethality of the means used the first time Later lethality rate (without precision on the interval) [lo] cases controls (same age) Relative risk 4 1
“Information from F. Ladame, personal communication (1990).
/1/
aivorce rate
vihence
REDUCEDCOPllNG LOSS OF HOPE
1
Figure 6. Macro- and rnicrosocialfactors linked to suicidal behavior increase in adolescence, United States, /n = increase: \r = decrease (from ref. 23).
July 1992
EPIDEMIOLOGIC
Table 3. Prevalence of Natural History Data in
ParasuicideCases and Controls in French College Students (reproduced from ref. 13). Parasuicide a %
Controls b %
a i
Sleep disorders
59
20
3.0
Frequent
fatigue
49
10
4.9
Psychological problems and character disorders
46
10
4.6
Heavy smoking
45
10
4.5 4.1
Use of “nervous
pills”
41
10
Poor (perceived)
health
27
10
2.7
Use of “sleeping
pills”
25
8
3.1
School truancy
21
4
5.0
Heavy drinking
16
4
4.0
14
2
7.0
Psychosomatic
disorders
lem of measurement of the potential role of each. Closer to the clinician’s perspective are the criteria collected by history-taking in two groups of French adolescents, cases of parasuicide and controls (Table 3). This study found the prevalence of symptoms like school truancy to be five times higher in cases than in controls. Clinicians are well aware that “sleep disorders,” like all other prevalence data in this list are found in the natural history of many syndromes and diseases in adolescents, as well as in healthy adolescents. This serves as an additional reminder that, in general, all risk factors are not causes, but correlates of pathologies and that predictive factors are always based on a probability concept and not on an etiological one.
Prevention Any prudent epidemiologist is expected to raise questions rather than to give advice: actual questions about suicide are numerous and only a few of them are addressed in this paper: 1. In the field of primary prevention, are not all of ub ready to admit that the amount, the diversity, and the complexity of (risk) factors involved in suicidal behavior are such that the search for a specific preventive program for the individual adolescent is completely meaningless? And that therefore this level of prevention can only be nonspecific--that is preventive of poor adjustment to his/her family, occupational, and/or social environment? 2. Regarding the level of secondary prevention, a first
APPROACH
TO SUICIDE PREVENTION
413
question concerns the target for any preventative measure or program: is it the high-risk situation or the immediate presuicidal stage? Are we ready to agree that early detection is potentially appropriate for the progressive formation of a high-risk situation (14)? Another perplexing question is where to concentrate this early detection effort: in primary cases or in relapses? The high ratio of parasuicide to completed suicide in the adolescent and young adult age groups could support the position of giving preference to preventing relapses. This answer is becoming a highly ethical one: is it acceptable in any highly medicalized society to exclude “primary cases” from aggressive preventive efforts, arguing that in these age groups only a small proportion will die? 3. In terms of tertiary prevention, the future health and well-being of parasuicide cases is so often threatened or compromised-even in absence of psychosis (11,15) that careful follow-up measures are badly needed. Are our Western (mental) health systems well enough staffed and trained to meet such P challenge, when facing the previously mentioned increase in morbidity and relapse rates?
References 1. Jeanneret 0. Suicides et tentatives chez Ies adolescents: Aspects fipidemiologiques et preventifs Bull Int Ped Ass 1985;6:332-52. 2. World Health Organization. neva: WHO, 1989.
Health Statistics
Annual.
Ge-
3. Jeanneret 0, Krotenberg A. Conauites suicidaires chez I’enfant. In: Manciaux M, Lebovici S. leanneret 0. L’enfant et sa Sante;AspectskpiidCmiologiqu& Biologiques, Psychologiques et Sociaux. Paris: Doin, 1987:897-904. 4. Reed J Camus J, Last JM. Suicide in Canada: Birth-cohort Analysis. Can J Pub1 Hlth, 1985;76:43-47. 5. Diekstra RFW. Suicidal behavior in adolescents and young adults: The international picture. In: Tentatives de suicide a I’adolescence. Colloque du Centre International de I’Enfance. Paris 12-14 decembre 1988. Paris: Centre International de I’Enfance, 1989:11-37. 6. Gould MS, Wallenstein S, Kleinman MH, et al. Suicide clusters: An examination of age-specific effects. Am J Pub1 Health, 1990;80:211-212. 7. Davicison F, Philippe A. Suicide et tentatives de suicide aujourd’hui; etude Cpidemiologique. Paris: Doin, 1986. 8. Aladjem D. L’intoxication volontaire chez les adolescents et les jeunes adultes suisses: Aspects 6pidCmiologiques. These (Gen+ve) en prkparation. 9. Webfir D, Botta JM. L/adolescent paro!.e. In: VCdrinne J, et al., eds. cidaires. Tome II: Aspects cliniques Mas:jon, 1982 (Collection Med Log
suicidant: Du geste B la Suicide et conduites suiet institutionnels. Paris: Toxicol MPd, 122).
10. Goklacre M, Hawton K. Management of children and adolescents following suicide attempts. In: Hawton K, ed. Suicide and attempted suicide among chiidren and adolescents.
414
JEANNERET
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