Official journal of the Pacific Rim College of Psychiatrists
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Asia-Pacific Psychiatry ISSN 1758-5864
ORIGINAL ARTICLE
Association among depressive disorder, adjustment disorder, sleep disturbance, and suicidal ideation in Taiwanese adolescent Ming-Shun Chung1,2 MD, Hsien-Jane Chiu3 PhD, Wen-Jung Sun4 PhD, Chieh-Nan Lin1 MD, Chien-Cheng Kuo1 MD, Wei-Che Huang5 MD, Ying-Sheue Chen6 MD, Hui-Ping Cheng1 MA & Pesus Chou2 DrPH 1 Jianan Mental Hospital, Tainan City, Taiwan 2 National Yang-Ming University, Taipei City, Taiwan 3 Min-Sheng General Hospital, Taoyuan, Taiwan 4 Taipei City Hospital Zhongxing Branch, Taipei City, Taiwan 5 Sin Lau Hospital Madou Branch, Tainan City, Taiwan 6 Taipei Veterans General Hospital, Taipei City, Taiwan
Keywords adjustment, adolescent suicide, depression, risk factor, sleep Correspondence Pesus Chou DrPH, Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei 112, Taiwan. Tel: +886 2 2826 7050 Fax: +886 2 2820 1461 Email: [email protected] Received 20 March 2013 Accepted 29 September 2013 DOI:10.1111/appy.12112
Abstract Introduction: The aim of this study is to investigate the association among depressive disorder, adjustment disorder, sleep disturbance, and suicidal ideation in Taiwanese adolescent. Methods: We recruited 607 students (grades 5–9) to fill out the investigation of basic data and sleep disturbance. Psychiatrists then used the Mini International Neuropsychiatric Interview-Kid to interview these students to assess their suicidal ideation and psychiatric diagnosis. Multiple logistic regression with forward conditionals was used to find the risk factors for multivariate analysis. Results: Female, age, depressive disorder, adjustment disorder, and poor sleep all contributed to adolescent suicidal ideation in univariate analysis. However, poor sleep became non-significant under the control of depressive disorder and adjustment disorder. Discussion: We found that both depressive disorder and adjustment disorder play important roles in sleep and adolescent suicidal ideation. After controlling both depressive disorder and adjustment disorder, sleep disturbance was no longer a risk of adolescent suicidal ideation. We also confirm the indirect influence of sleep on suicidal ideation in adolescent.
Introduction Suicide is an important public health problem worldwide. Approximately one million people die by suicide every year (World Health Organization, 2013). Longitudinal studies indicate that the peak prevalence of suicide ideation occurs in mid-adolescence, and children who survive a suicide attempt continue to have the risk of completing suicide or poor psychological outcomes to adulthood (Kerr et al., 2008). In Taiwan, suicide is the fourth and third leading cause of death among 10- to 14-year-old children and 15- to 19-yearold young adults for 2009 and 2010, respectively (Taiwan Department of Health, 2013a). The rate of
Asia-Pacific Psychiatry 6 (2014) 319–325 © 2013 Wiley Publishing Asia Pty Ltd
completed suicides by 10- to 14-year-old children was 0.004%, and by 15- to 19-year-old young adults it was 0.037%. Moreover, the standardized mortality rate for suicide in 15- to 19-year-old Taiwanese young adults increased rapidly from 2.0 per 100,000 in 2000 to 3.7 per 100,000 in 2009 (Taiwan Department of Health, 2013a,b). Despite suicide prevention countermeasures conducted by the Department of Health, the standardized mortality rate for suicide in 15- to 19-year-olds remained at 0.03% in 2010 (Taiwan Department of Health, 2013b). Youth suicide elicits serious problems and effects on parents, friends, and the public (Brent et al., 1996). These factors underscore the importance of research on suicide prevention among adolescents.
319
Factors for adolescent suicidal ideation
Age, gender, family factors, personality trait, and psychiatric disorders have been reported as risk factors for adolescent suicide risk (Brent, 1995; Evans et al., 2005).The severity of depression is the most important predictive factor for adolescent suicide ideation (Esposito and Clum, 2002). But lower rate of psychiatric disorder, particularly depression, was found in Chinese (Law and Liu, 2008); depressive symptoms had less impact on adolescent in Hong Kong than in America (Stewart et al., 2006). Some studies also found that adjustment disorder was a risk factor for adolescent suicide (Rich et al., 1986; Runeson, 1989; Apter et al., 1993; Shaffer et al., 1996). A growing body of work, including electroencephalographic sleep studies, indicates a relationship between sleep problems and suicide ideation (Selvi et al., 2010; Fitzgerald et al., 2011; McKnight-Eily et al., 2011). After controlling for additional variables, such as depression and gender, nightmares have been found to be associated with suicidality (Bernert et al., 2005; Sjöström et al., 2007, 2009). Sleep patterns and architecture undergo substantial changes during the adolescent period. Dramatic changes occur in sleep– wake patterns, for example, decreases in sleep duration (Liu et al., 2000; Iglowstein et al., 2003), delays in the timing of sleep (Carskadon et al., 1993, 1998), and an increasingly large discrepancy between weekday and weekend sleep patterns (Wolfson and Carskadon, 1998; Pollak and Bright, 2003). The short sleep duration and nightmares correlate with adolescent suicidal behavior, and are likely to signal an increased risk of future suicidal action in adolescents (Liu, 2004; Liu and Buysse, 2006). As suicide risk begins to increase during adolescence, the relationship of sleep disturbance and suicidal ideation during adolescence is important to explore. For example, doubt exists as to whether sleep disturbance in itself or the depressive symptoms predict suicide (Selvi et al., 2010). In line with this uncertainty is the unanswered question as to the associations among psychiatric disorders, sleep disturbance, and adolescent suicidal ideation. We sought to address this issue in the current study.
M.-S. Chung et al.
provided signed informed consent participated in the study. The protocol was approved by the institutional review boards of the Jianan Mental Hospital. In our study, licensed psychiatrists conducted the Mini International Neuropsychiatric Interview-Kid (MINI-Kid) with participants to assess suicidal ideation and psychiatric diagnosis. These four psychiatrists were all certified by the Taiwanese Psychiatric Society to conduct the MINI-Kid. Measures The suicidal ideation and psychiatric diagnosis of participants were assessed with the Suicidality Module and Disease Diagnostic Module of the MINI-Kid. The MINI-Kid is a structured interview for psychiatric evaluation and outcome tracking in clinical psychopharmacology trials and epidemiological studies. The MINI-Kid has been well validated and has been used for suicide risk assessment in community-based adolescents (Wang et al., 2009; Chung et al., 2011). The MINI-Kid takes approximately 15 minutes to complete. The Suicidality Module includes the following items: In the past month did you (1) “wish you were dead?” (1 point), (2) “want to hurt yourself?” (2 points), (3) “think about killing yourself?” (6 points), (4) “think of a way to kill yourself?” (10 points), (5) “try to kill yourself?” (10 points); (6a) “Have you ever felt so bad that you wished you were dead?” (1 point); (6b) “Have you ever tried to hurt yourself?” (2 points); (6c) “Have you ever tried to kill yourself?” (4 points). The total number of points was calculated to classify the suicidal ideation. According to the rank of suicidal ideation in the MINI-Kid, “high risk,” “moderate risk,” and “low risk” were scored as above 10 (>10), between six and nine (6–9), and between one and five (1–5). To take every risk into consideration, we regarded 0 points as negative for current and past suicidal ideation, and 1 point or above as positive for analysis. The demographic data and sleep disturbance were self-reported. Sleep disturbance was assessed with the frequency of poor sleep in a week. The frequency of poor sleep were ranked “none or seldom,” “sometimes,” “frequently,” and “always.”
Methods Procedure Participants We recruited 607 students (grades 5–9) from five primary schools and one junior high school in Hunei, Kaohsiung City, Taiwan. Kaohsiung is the second biggest city in Taiwan. Only the students who
320
After providing written informed consent, participants filled out a self-reported questionnaire on basic demographic data and sleep disturbance. They were then interviewed by one of the four psychiatrists using the MINI-Kid to assess their suicidal ideation and
Asia-Pacific Psychiatry 6 (2014) 319–325 © 2013 Wiley Publishing Asia Pty Ltd
M.-S. Chung et al.
psychiatric diagnosis. The questionnaire was filled out in the classroom after a full explanation of precautions, and further interventions were arranged by the consultant at the school if participants screened positive. The institutional review board of Jianan Mental Hospital approved the study protocols. Statistical analysis We used descriptive statistics to show basic demographic data, sleep disturbance, and psychiatric diagnoses. The univariate test was performed by the chi-square test and Fisher’s exact test for the suicidal ideation, with a statistical significance of P < 0.05. Multiple logistic regression with forward conditionals was used to identify the risk factors for multivariate analysis. In model 1, sleep disturbance and basic demographic data were included. In model 2, a diagnosis of depressive disorder, sleep disturbance, and basic demographic data were included. In model 3, a diagnosis of adjustment disorder, sleep disturbance, and basic demographic data were included. In model 4, a diagnosis of adjustment disorder, depressive disorder, sleep disturbance, and basic demographic data were included.
Results Demographics of participants and their parents Students (n = 607; 305 male) were recruited, and their mean age was 13.09 ± 1.40 years. Slightly more than half (48.5% of fathers, 52.3% of mothers, and 50.4% overall) of the parents had completed nine years (through junior high school) or less of formal education. More than three quarters (82.5% of fathers and 74.1% of mothers) were steadily employed, almost all of the parents (84.5%) lived together, and an even higher percentage (94.8%) of parents were the primary caregivers of their children (Table 1). Suicidal ideation Of the participants, 17.7% had suicidal ideation, including 12.5% with low risk, 2.1% with moderate risk, and 3.1% with high risk (Table 2). Disease-related data and univariate analysis Demographic factors associated with suicidal ideation in univariate analysis were female gender and school grade (Table 1). However, diagnoses of depressive
Asia-Pacific Psychiatry 6 (2014) 319–325 © 2013 Wiley Publishing Asia Pty Ltd
Factors for adolescent suicidal ideation
Table 1. Demographic data and univariate analysis
Total Gender Male Female Grade Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Father’s educational level Junior high school or below Senior high school or above Mother’s educational level Junior high school or below Senior high school or above Father’s regular job No Yes Mother’s regular job No Yes Parent’s marriage Living together Divorce or separate Caregiver Parents Others
Suicidal ideation group
Total
n (prevalence)
n
108 (17.8%)
607
41 (13.4%) 67 (22.2%)
305 302
12 28 15 15 38
(10.5%) (14.9%) (12.1%) (20.0%) (35.5%)
114 188 124 75 107
47 (21.3%) 45 (19.1%)
221 235
55 (22.9%) 40 (18.3%)
240 219
23 (21.9%) 84 (17.0%)
105 494
31 (20.0%) 76 (17.1%)
155 444
87 (17.2%) 20 (21.5%)
506 93
99 (17.4%) 8 (25.8%)
568 31
P-value
bs_bs_banner
Asia-Pacific Psychiatry ISSN 1758-5864
ORIGINAL ARTICLE
Association among depressive disorder, adjustment disorder, sleep disturbance, and suicidal ideation in Taiwanese adolescent Ming-Shun Chung1,2 MD, Hsien-Jane Chiu3 PhD, Wen-Jung Sun4 PhD, Chieh-Nan Lin1 MD, Chien-Cheng Kuo1 MD, Wei-Che Huang5 MD, Ying-Sheue Chen6 MD, Hui-Ping Cheng1 MA & Pesus Chou2 DrPH 1 Jianan Mental Hospital, Tainan City, Taiwan 2 National Yang-Ming University, Taipei City, Taiwan 3 Min-Sheng General Hospital, Taoyuan, Taiwan 4 Taipei City Hospital Zhongxing Branch, Taipei City, Taiwan 5 Sin Lau Hospital Madou Branch, Tainan City, Taiwan 6 Taipei Veterans General Hospital, Taipei City, Taiwan
Keywords adjustment, adolescent suicide, depression, risk factor, sleep Correspondence Pesus Chou DrPH, Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei 112, Taiwan. Tel: +886 2 2826 7050 Fax: +886 2 2820 1461 Email: [email protected] Received 20 March 2013 Accepted 29 September 2013 DOI:10.1111/appy.12112
Abstract Introduction: The aim of this study is to investigate the association among depressive disorder, adjustment disorder, sleep disturbance, and suicidal ideation in Taiwanese adolescent. Methods: We recruited 607 students (grades 5–9) to fill out the investigation of basic data and sleep disturbance. Psychiatrists then used the Mini International Neuropsychiatric Interview-Kid to interview these students to assess their suicidal ideation and psychiatric diagnosis. Multiple logistic regression with forward conditionals was used to find the risk factors for multivariate analysis. Results: Female, age, depressive disorder, adjustment disorder, and poor sleep all contributed to adolescent suicidal ideation in univariate analysis. However, poor sleep became non-significant under the control of depressive disorder and adjustment disorder. Discussion: We found that both depressive disorder and adjustment disorder play important roles in sleep and adolescent suicidal ideation. After controlling both depressive disorder and adjustment disorder, sleep disturbance was no longer a risk of adolescent suicidal ideation. We also confirm the indirect influence of sleep on suicidal ideation in adolescent.
Introduction Suicide is an important public health problem worldwide. Approximately one million people die by suicide every year (World Health Organization, 2013). Longitudinal studies indicate that the peak prevalence of suicide ideation occurs in mid-adolescence, and children who survive a suicide attempt continue to have the risk of completing suicide or poor psychological outcomes to adulthood (Kerr et al., 2008). In Taiwan, suicide is the fourth and third leading cause of death among 10- to 14-year-old children and 15- to 19-yearold young adults for 2009 and 2010, respectively (Taiwan Department of Health, 2013a). The rate of
Asia-Pacific Psychiatry 6 (2014) 319–325 © 2013 Wiley Publishing Asia Pty Ltd
completed suicides by 10- to 14-year-old children was 0.004%, and by 15- to 19-year-old young adults it was 0.037%. Moreover, the standardized mortality rate for suicide in 15- to 19-year-old Taiwanese young adults increased rapidly from 2.0 per 100,000 in 2000 to 3.7 per 100,000 in 2009 (Taiwan Department of Health, 2013a,b). Despite suicide prevention countermeasures conducted by the Department of Health, the standardized mortality rate for suicide in 15- to 19-year-olds remained at 0.03% in 2010 (Taiwan Department of Health, 2013b). Youth suicide elicits serious problems and effects on parents, friends, and the public (Brent et al., 1996). These factors underscore the importance of research on suicide prevention among adolescents.
319
Factors for adolescent suicidal ideation
Age, gender, family factors, personality trait, and psychiatric disorders have been reported as risk factors for adolescent suicide risk (Brent, 1995; Evans et al., 2005).The severity of depression is the most important predictive factor for adolescent suicide ideation (Esposito and Clum, 2002). But lower rate of psychiatric disorder, particularly depression, was found in Chinese (Law and Liu, 2008); depressive symptoms had less impact on adolescent in Hong Kong than in America (Stewart et al., 2006). Some studies also found that adjustment disorder was a risk factor for adolescent suicide (Rich et al., 1986; Runeson, 1989; Apter et al., 1993; Shaffer et al., 1996). A growing body of work, including electroencephalographic sleep studies, indicates a relationship between sleep problems and suicide ideation (Selvi et al., 2010; Fitzgerald et al., 2011; McKnight-Eily et al., 2011). After controlling for additional variables, such as depression and gender, nightmares have been found to be associated with suicidality (Bernert et al., 2005; Sjöström et al., 2007, 2009). Sleep patterns and architecture undergo substantial changes during the adolescent period. Dramatic changes occur in sleep– wake patterns, for example, decreases in sleep duration (Liu et al., 2000; Iglowstein et al., 2003), delays in the timing of sleep (Carskadon et al., 1993, 1998), and an increasingly large discrepancy between weekday and weekend sleep patterns (Wolfson and Carskadon, 1998; Pollak and Bright, 2003). The short sleep duration and nightmares correlate with adolescent suicidal behavior, and are likely to signal an increased risk of future suicidal action in adolescents (Liu, 2004; Liu and Buysse, 2006). As suicide risk begins to increase during adolescence, the relationship of sleep disturbance and suicidal ideation during adolescence is important to explore. For example, doubt exists as to whether sleep disturbance in itself or the depressive symptoms predict suicide (Selvi et al., 2010). In line with this uncertainty is the unanswered question as to the associations among psychiatric disorders, sleep disturbance, and adolescent suicidal ideation. We sought to address this issue in the current study.
M.-S. Chung et al.
provided signed informed consent participated in the study. The protocol was approved by the institutional review boards of the Jianan Mental Hospital. In our study, licensed psychiatrists conducted the Mini International Neuropsychiatric Interview-Kid (MINI-Kid) with participants to assess suicidal ideation and psychiatric diagnosis. These four psychiatrists were all certified by the Taiwanese Psychiatric Society to conduct the MINI-Kid. Measures The suicidal ideation and psychiatric diagnosis of participants were assessed with the Suicidality Module and Disease Diagnostic Module of the MINI-Kid. The MINI-Kid is a structured interview for psychiatric evaluation and outcome tracking in clinical psychopharmacology trials and epidemiological studies. The MINI-Kid has been well validated and has been used for suicide risk assessment in community-based adolescents (Wang et al., 2009; Chung et al., 2011). The MINI-Kid takes approximately 15 minutes to complete. The Suicidality Module includes the following items: In the past month did you (1) “wish you were dead?” (1 point), (2) “want to hurt yourself?” (2 points), (3) “think about killing yourself?” (6 points), (4) “think of a way to kill yourself?” (10 points), (5) “try to kill yourself?” (10 points); (6a) “Have you ever felt so bad that you wished you were dead?” (1 point); (6b) “Have you ever tried to hurt yourself?” (2 points); (6c) “Have you ever tried to kill yourself?” (4 points). The total number of points was calculated to classify the suicidal ideation. According to the rank of suicidal ideation in the MINI-Kid, “high risk,” “moderate risk,” and “low risk” were scored as above 10 (>10), between six and nine (6–9), and between one and five (1–5). To take every risk into consideration, we regarded 0 points as negative for current and past suicidal ideation, and 1 point or above as positive for analysis. The demographic data and sleep disturbance were self-reported. Sleep disturbance was assessed with the frequency of poor sleep in a week. The frequency of poor sleep were ranked “none or seldom,” “sometimes,” “frequently,” and “always.”
Methods Procedure Participants We recruited 607 students (grades 5–9) from five primary schools and one junior high school in Hunei, Kaohsiung City, Taiwan. Kaohsiung is the second biggest city in Taiwan. Only the students who
320
After providing written informed consent, participants filled out a self-reported questionnaire on basic demographic data and sleep disturbance. They were then interviewed by one of the four psychiatrists using the MINI-Kid to assess their suicidal ideation and
Asia-Pacific Psychiatry 6 (2014) 319–325 © 2013 Wiley Publishing Asia Pty Ltd
M.-S. Chung et al.
psychiatric diagnosis. The questionnaire was filled out in the classroom after a full explanation of precautions, and further interventions were arranged by the consultant at the school if participants screened positive. The institutional review board of Jianan Mental Hospital approved the study protocols. Statistical analysis We used descriptive statistics to show basic demographic data, sleep disturbance, and psychiatric diagnoses. The univariate test was performed by the chi-square test and Fisher’s exact test for the suicidal ideation, with a statistical significance of P < 0.05. Multiple logistic regression with forward conditionals was used to identify the risk factors for multivariate analysis. In model 1, sleep disturbance and basic demographic data were included. In model 2, a diagnosis of depressive disorder, sleep disturbance, and basic demographic data were included. In model 3, a diagnosis of adjustment disorder, sleep disturbance, and basic demographic data were included. In model 4, a diagnosis of adjustment disorder, depressive disorder, sleep disturbance, and basic demographic data were included.
Results Demographics of participants and their parents Students (n = 607; 305 male) were recruited, and their mean age was 13.09 ± 1.40 years. Slightly more than half (48.5% of fathers, 52.3% of mothers, and 50.4% overall) of the parents had completed nine years (through junior high school) or less of formal education. More than three quarters (82.5% of fathers and 74.1% of mothers) were steadily employed, almost all of the parents (84.5%) lived together, and an even higher percentage (94.8%) of parents were the primary caregivers of their children (Table 1). Suicidal ideation Of the participants, 17.7% had suicidal ideation, including 12.5% with low risk, 2.1% with moderate risk, and 3.1% with high risk (Table 2). Disease-related data and univariate analysis Demographic factors associated with suicidal ideation in univariate analysis were female gender and school grade (Table 1). However, diagnoses of depressive
Asia-Pacific Psychiatry 6 (2014) 319–325 © 2013 Wiley Publishing Asia Pty Ltd
Factors for adolescent suicidal ideation
Table 1. Demographic data and univariate analysis
Total Gender Male Female Grade Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Father’s educational level Junior high school or below Senior high school or above Mother’s educational level Junior high school or below Senior high school or above Father’s regular job No Yes Mother’s regular job No Yes Parent’s marriage Living together Divorce or separate Caregiver Parents Others
Suicidal ideation group
Total
n (prevalence)
n
108 (17.8%)
607
41 (13.4%) 67 (22.2%)
305 302
12 28 15 15 38
(10.5%) (14.9%) (12.1%) (20.0%) (35.5%)
114 188 124 75 107
47 (21.3%) 45 (19.1%)
221 235
55 (22.9%) 40 (18.3%)
240 219
23 (21.9%) 84 (17.0%)
105 494
31 (20.0%) 76 (17.1%)
155 444
87 (17.2%) 20 (21.5%)
506 93
99 (17.4%) 8 (25.8%)
568 31
P-value
