Audenaert, Kurt

Portzky, Gwendolyn

Van Heeringen, Cornelis

English

Ghent University Academic Bibliography

www.elsevier.com/locate/jadJournal of Affective DisordResearch reportAdjustment disorder and the course of the suicidalprocess in adolescentsGwendolyn Portzky*, Kurt Audenaert, Kees van HeeringenUnit for Suicide Research, Department of Psychiatry, University Hospital Gent, De Pintelaan 185, 9000 Gent, BelgiumReceived 4 January 2005; received in revised form 5 April 2005; accepted 25 April 2005Available online 6 July 2005AbstractBackground: Adjustment disorders are often associated with suicidal behaviour but there is little information regarding thenature of the relationship and the effect of adjustment disorders on the suicidal process. The authors’ goal was to investigate theassociation of adjustment disorders (with depressed mood) and suicide in adolescents by means of a psychological autopsystudy.Method: Relatives and other informants of 19 suicide victims were interviewed by means of a semi-structured interviewschedule. Differences in duration of the suicidal process between suicide victims diagnosed with adjustment disorder andsuicide cases diagnosed with other psychiatric disorders were examined.Results: The suicidal process was significantly shorter in suicide victims diagnosed with adjustment disorder compared withsuicide cases diagnosed with other disorders. No indications of a history of emotional or behavioural problems during earlyadolescence were found in suicide cases diagnosed with adjustment disorder.Limitations: The study sample consists of a small sample size and retrospective interviews of relatives were used.Conclusions: The suicidal process in suicide victims diagnosed with adjustment disorder appears to be short and rapidlyevolving without any prior indications of emotional or behavioural problems. The importance of assessing the suicidal risk inpatients diagnosed with adjustment disorder is underlined.D 2005 Elsevier B.V. All rights reserved.Keywords: Adolescents; Suicidal process; Adjustment disorder with depressed mood1. IntroductionA review of the literature regarding adjustmentdisorders indicates that there are relatively few studiesof the disorder with additional difficulties in establish-0165-0327/$ - see front matter D 2005 Elsevier B.V. All rights reserved.doi:10.1016/j.jad.2005.04.009* Corresponding author. Tel.: +32 92404848; fax: +32 92404989.E-mail address: Gwendolyn.portzky@ugent.be (G. Portzky).ing its construct validity (Kovacs et al., 1994; New-corn and Strain, 1992). Nonetheless, the diagnosis ofadjustment disorder is frequently made with an esti-mated incidence of 5–21% in psychiatric consultationservices for adults (Jones et al., 1999). Although thereis less information regarding the estimated incidenceof adjustment disorder in adolescents, there are sev-eral reports indicating that adjustment disorder is moreers 87 (2005) 265–270G. Portzky et al. / Journal of Affective Disorders 87 (2005) 265–270266often found in young people (Despland et al., 1995;Snyfer et al., 1990).Adjustment disorders are typically associated withless severe symptoms, a lower level of impairmentand a reasonably good short-term prognosis whencompared to other psychiatric disorders (Greenberget al., 1995; Kovacs et al., 1994). However, there is ahigh association between adjustment disorders andsuicidal behaviour. Adjustment disorder with de-pressed mood is the most common diagnosis in sui-cide attempts in young people (Bhatia et al., 2000; HoKong Wai et al., 1999; Skopek and Perkins, 1998).With regard to fatal suicide, there is however moreevidence of the high prevalence of major depressionand substance abuse. Nonetheless, psychological au-topsy studies have shown a prevalence of adjustmentdisorder among suicide victims ranging between 5%and 36% (Cavanagh et al., 1999; Schaffer et al., 1996;Henriksson et al., 1993; Marttunen et al., 1991; Richet al., 1990).Adjustment disorder is thus a relatively commondiagnosis among suicide attempters and suicide vic-tims. However, little is known about the effect of thisdiagnosis on the suicidal process and thus on thepossibilities to prevent suicide, particularly amongyoung people. The concept of the suicidal process isused to describe the onset and development of suicid-ality as a process within the individual and in inter-action with surrounding people. The suicidal processstarts with suicidal ideation and implies a progressionof suicidality which can evolve through ideation,plans about taking one’s life and communication re-garding suicidal ideation, and growing through oftenrecurrent suicide attempts with increasing lethalityand suicide intent, and ends with fatal suicide (vanHeeringen, 2001). More knowledge regarding thesuicidal process and adjustment disorder could becrucial for the development of prevention strategiesand for clinical practice.The psychological autopsy study of Runeson et al.(1996) in 15–29 year olds is, to our knowledge, theonly study examining the suicidal process in youngpeople according to psychiatric disorder. The resultsshowed that there were no differences in duration ofthe suicidal process between adjustment disorder andmajor depression but differences could be found be-tween adjustment disorder and schizophrenia. Theduration of the suicidal process was however mea-sured by the time interval between the suicide and firstreported suicidal communication or observed attempt,which can not be considered as the starting-point ofthe process.This study aimed at further establishing the effectof adjustment disorder on the course of the suicidalprocess, measured from the starting-point, and exam-ining the possible differences with other psychiatricdiagnoses.2. MethodThe data was provided by a case-control psycho-logical autopsy study. For the purpose of the presentstudy, only data regarding suicide cases will be dis-cussed. Inclusion criteria regarding suicide cases in-cluded: relatives or other informants of adolescents(aged 15–19) with a definitive verdict of suicide inFlanders (Dutch-speaking part of Belgium) during1997–2001. A total of 32 relatives and other infor-mants regarding 19 adolescent suicide victims wererecruited from support-groups for surviving relatives.Written informed consent was obtained after com-plete description of the study to the informants.A semi-structured interview schedule, developedand previously piloted by Houston et al. (2001) wasused. The interview schedule was translated intoDutch and had been previously piloted. Informantswere asked about several aspects including circum-stances of the death (presuicidal behaviour, presuici-dal communication, method, intent), childhood,adolescence, family and interpersonal relationships,life events, educational and occupational history, fi-nancial and legal problems, medical history, psychi-atric history and previous suicidal behaviour.Psychiatric diagnosis was made using a semi-struc-tured interview schedule based on ICD-10 criteria.Allocation to diagnostic categories was made by twosenior psychiatrists separately. Inter-rater reliabilitywas measured by using the kappa statistic. In caseof diagnostic disagreement, a reanalysis was done byboth psychiatrists to reach a consensus.The duration and course of the suicidal processwere assessed using four different measures: (1) thestart of the suicidal process was assessed by the firstsigns of suicidal ideation. Due to the bhiddenQ char-acter of this suicidal component, the informationG. Portzky et al. / Journal of Affective Disorders 87 (2005) 265–270 267could only be derived from letters, journals and notesleft by the adolescents; (2) first communication re-garding suicidal ideation; (3) first suicide attempt; (4)last suicide attempt prior to the suicide.Beck’s Suicidal Intent Scale (Beck et al., 1974)was used to evaluate the severity of suicidal intent.One psychologist was assigned as interviewer as itis reported that having fewer interviewers result inhigher reliability in psychiatric diagnoses and smallermethodological error variance (Isometsa¨, 2001).This study was approved by the Ethical Committeeof the University Hospital Ghent.Kaplan Meier Survival analysis with significancetesting in accordance with Breslow (Generalized Wil-coxon) was used for the duration of the suicidalprocess. Other comparisons were examined by usingIndependent Samples t-test and chi-square tests orFisher’s exact tests.3. ResultsAll suicide cases were diagnosed with a ICD-10psychiatric disorder at the time of death. The mostcommon disorders were affective disorders (N =13;68.5%) including 12 subjects (63.2%) with a de-pressive episode and one subject with bipolar affec-tive disorder, current episode mixed. Adjustmentdisorder with depressed mood was diagnosed infour suicide victims (21.1%) as principal diagnosiswith only one subject diagnosed with co-morbidsubstance abuse.1Survival analysis regarding the suicidal processmeasured from the first signs of suicidal ideation tothe suicide resulted in a significant difference (Bre-slow=14.45; df =4; pb0.01) between suicide victimsdiagnosed with adjustment disorder (M time=3months) and victims diagnosed with other psychiatricdisorders (M time depression=30 months; M timesubstance abuse=60 months; M time schizo-affectivedisorder=24 months; M time eating disorder=48months). The temporal distribution of the suicidalprocess measured from the first signs of suicidal1 As it is mentioned by the DSM-IV diagnostic features, adjust-ment disorder may be diagnosed in the presence of another Axis I orII disorder if the latter does not account for the pattern of symptomsthat have occurred in response to the stressor.ideation to the suicide according the psychiatric dis-order is shown in the Kaplan–Meier curve (Fig. 1).Suicide cases diagnosed with adjustment disorderalso showed a much shorter time interval between thefirst communication and their suicide (M time=2months) compared to those with other diagnoses (Mtime=22 months) (Breslow=7.97; df =1; p b0.01).None of the four suicide victims diagnosed withadjustment disorder had engaged in previous suicidalbehaviour compared to 7 of the 15 suicide casesdiagnosed with other disorders. As a result, the sur-vival analysis regarding the suicidal process measur-ing the time from the suicide attempt to the suicide didnot include suicide cases diagnosed with adjustmentdisorder and was not significant.Further analysis revealed that there was a signifi-cant difference regarding emotional or behaviouralproblems in early adolescence (Fisher exacttest=0.033) with none of the suicide cases diagnosedwith adjustment disorder having any emotional orbehavioural problems compared to 10 of the 15other suicide cases.There were no differences between suicide casesdiagnosed with adjustment disorder and suicide caseswith other psychiatric disorders regarding the numberand type of life events experienced in the past year.The analysis of the SIS revealed that there were nodifferences (t= .659; df =17; p =0.519) betweensuicide cases with adjustment disorder (M SIS=21.5) and cases with other psychiatric disorders (MSIS=23.2) regarding the severity of the suicidal intentof the suicide.4. DiscussionThis study showed that one fifth of all suicide caseswere diagnosed with adjustment disorder with de-pressed mood. More importantly, the results indicatethe incidence of a very short suicidal process invictims diagnosed with adjustment disorder with anaverage duration of 3 months between the first signsof suicidal ideation and the suicide, a mean durationof 2 months between the first communication and thesuicide and without a history of previous suicideattempts. There were also no indications of previousemotional or behavioural problems during early ado-lescence in those diagnosed with adjustment disorder.Durat ion between 1th ideat ion and suic ide ( in months)8 06 04 02 00Proportion without completed suicide 1 , 21 , 0,8,6,4,20 , 0-,2Diagnosisa d j u s t m e n t  d i s o r d e re a t i n g  d i s o r d e rschizo-affective diss u b s t a n c e  a b u s ed e p r e s s i v e  d i s o r d e rFig. 1. Temporal distribution of the suicidal process (first signs of suicidal ideation to the suicide) according to psychiatric disorder.G.Portzkyetal./JournalofAffectiveDisorders87(2005)265–270268G. Portzky et al. / Journal of Affective Disorders 87 (2005) 265–270 269Although this sample is too small for extensivegeneralizations, the results suggest that the suicidalprocess in young suicide victims diagnosed with ad-justment disorder was triggered by the experience ofan adverse life event and resulted in a rapidly evolvingsuicidal process ending in a fatal suicide with a sui-cidal intent as strong as compared to those suicidevictims diagnosed with other psychiatric disorders andwith a more prolonged and slowly evolving suicidalprocess.The findings also confirm that suicide is common-ly preceded by a process of increasing suicidality,starting with thoughts about taking one’s life andevolving through communication and possible sui-cide attempts.The results of this study are partially similar to thestudy of Runeson et al. (1996) who also found adifference in duration of the suicidal process betweenadjustment disorder and schizophrenia. In contrast,our study identified a difference in duration of theprocess between adjustment disorder and depressivedisorder, which could not be found in the Runeson-study. Although it is reasonable to assume that thisdifference in results could be associated with thedifferent measure used as starting-point of the suicidalprocess, i.e. first suicidal ideation in the present studyand first reported communication or observed attemptin the Runeson-study, the results of this study alsoshowed a significant difference in the suicidal process,measured from first reported communication.To conclude, this study suggests that the suicidalprocess is to a large extent different in victims diag-nosed with adjustment disorder due to its rapidlyevolving course resulting in less time and possibilitiesto assess the suicidal risk and to intervene.Although adjustment disorders are often associatedwith less severe psychiatric symptoms and a compar-atively beneficial outcome, the diagnose of adjustmentdisorder should thus include a thorough assessmentof suicidal ideations in view of the prevention ofsuicide.Although the small sample size is an obviouslimitation of this study, it is important to considerthe small geographical area and population size ofthe selected area in this study. The annual numberof adolescent suicides in Flanders is approximately30, which means that almost one fifth of all adolescentsuicides in Flanders during 1997–2001 is covered inthis study. The limitation of this study also comesfrom the use of retrospective interviews of relativesalthough there is evidence indicating that the infor-mation obtained from psychological autopsy studies isboth reliable and valid (Brent, 1989; Kelly and Mann,1996). Personal journals, letters and notes were usedto assess first signs of suicidal ideation but there isalways the difficulty to ascertain with precision thefirst signs of suicidal ideation.Nevertheless, more comprehensive research isneeded to further examine the possible implicationsof adjustment disorders in the course of the suicidalprocess.AcknowledgementsThe study was supported by the Fund for ScientificResearch—Flanders (Belgium).ReferencesBeck, A., Schuyler, D., Herman, I., 1974. In: Beck, A., Resnik, H.,Lettieri, D. 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Adjustment disorder and the course of the suicidal process in adolescents

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Adjustment disorder and the course of the suicidal process in adolescents

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