Volume 25, Issue 3 - Special Issue: Education of health professionals about adolescent psychiatry / Editors: Leo Sher and Joav Merrick

The aim of this paper was to discuss the results of a review of literature related to suicide in military veteran populations. Suicide in veteran populations has been increasing in recent years, and continues to be a medical and social problem across the globe. For medical health professionals, knowledge of the risk factors for suicide, careful assessment, and appropriate interventions are key to suicide prevention. The main aim of this review is to better understand the risk factors present in veteran suicide and find ways by which to educate medical professionals in suicide prevention. Key suicide risk factors found in veteran populations include posttraumatic stress disorder, major depressive disorder, physical injuries, substance use disorders, traumatic brain injury, combat-related guilt, access to firearms, and insufficient social support. Some psychosocial difficulties are unique to veteran populations, and medical professionals should be culturally sensitive to these factors. Psychosocial changes upon discharge from active duty, as well as stigma against mental health disorders and treatment, should also be considered and assessed. Given that general practitioners may be the first line of defense for these veterans, they should be educated in risk factors for veteran suicide and proper assessment techniques. Any suicide risk in a veteran population should be taken very seriously, and responded to appropriately.

Background: At present, there are scarce clinical and basic lab data concerning the risk of acute serotonin toxicity from selective serotonin reuptake inhibitors (SSRIs) and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) co-administration. The health care community can strongly benefit from efforts to address the high risks associated with serotonin syndrome from this specific drug combination. Objective: The aim of this work is to review the risk of serotonin syndrome in adolescents and young adults prescribed with SSRIs and are concurrently using ecstasy. Data sources: An electronic search of the major behavioral science bibliographic databases (Pubmed, PsycINFO, Medline) was conducted to retrieve peer-reviewed articles, which detail the clinical characteristics, biological mechanisms and social implications of SSRIs, MDMA, and their potential synergism in causing serotonin syndrome in the pediatric and young adult population. Search terms included “serotonin syndrome”, “ecstasy”, “MDMA”, “pediatric”, and “SSRI”. Additional references were incorporated from the bibliographies of these retrieved articles. Results: MDMA, in combination with the widely-prescribed SSRI antidepressant class, can lead to rapid, synergistic rise of serotonin (5-HT) concentration in the central nervous system, leading to the acute medical emergency known as serotonin syndrome. This review addresses such complication through an exploration of the theoretical mechanisms and clinical manifestations of this life-threatening pharmacological interaction. Conclusion: The increasing incidences of recreational ecstasy use and SSRI pharmacotherapy among multiple psychiatric disorders in the adolescent population have made this an overlooked yet increasingly relevant danger, which poses a threat to public health. This can be curbed through further research, as well as greater health care provision and attention from a regulatory body owing.

Background: Child sexual abuse (CSA) is widespread and is associated with various psychopathologies, including Axis I and II disorders, maladaptive and impulsive behaviors, and suicidal behavior in adolescence and adults. The pathophysiology of this association is not well understood; however, it is clear that suicidal behavior in individuals with a history of CSA is a significant social and medical problem that warrants further investigation. Methods: An electronic search of the major behavioral science databases (limited to the most recent studies in the last 20 years) was conducted to retrieve studies detailing the social, epidemiological, and clinical characteristics of child sexual trauma and their relation to suicidal behavior in adolescents and adults. Results: Studies indicate that CSA is related to an increase in Axis I and II diagnoses, including depression, post-traumatic stress disorder, conduct disorders, eating disorders, alcohol and drug abuse, panic disorders, and borderline personality disorder. CSA not just related to an increase in impulsivity and risky behaviors, it has also been linked to an increase in suicidality as well. Conclusion: CSA makes both direct and indirect contributions to suicidal behavior. It is a complex process involving multiple variables, which include psychopathology, maladaptive personality features and the direct contribution of CSA itself. Psychopathologies, such as impulsivity and mood and personality disorders, may modulate the relationship between CSA and suicidal behavior. Some preventive measures for decreasing the prevalence of CSA and suicidality may include education as well as increased access to mental health services.

Suicide is both a public and mental health problem, and is a leading cause of deaths, especially among adolescents. Two factors that contribute to the decision of adolescents to commit suicide are having a primary mood disorder and/or substance use. In the Indian culture, the family unit has both a positive and negative impact on suicide. The family serves as a protective factor that provides a strong support for the individual, but alternately creates an inseparable individual when seeking mental health care, which often complicates the situation. Due to the stigma, Indians typically perceive having a mental illness as shameful. Religion is integral to the Indian culture so much so that individuals often use herbal remedies, seek help from religious leaders, and attend religious establishments prior to obtaining a mental health evaluation in those that are subsequently deemed as mentally ill. Despite the fact that suicides are underreported and misdiagnosed in India, it is known that the highest rates are among those <30 years old. The methods most commonly used to commit suicide in India include the ingestion of poison (often pesticides), hanging, burning, and drowning. When immigrating, Indians tend to switch the methods they use to commit suicide from ingestion of poison to hanging, which may reflect a lack of available poisonous substances or the influence of the host culture. Considering the high suicide rates in adolescents, the importance of providing psychoeducation, restricting access to lethal means, and promoting social integration in immigrants are various ways by which suicides in Indian adolescents can be avoided.

Major depressive disorder (MDD) is a frequent condition among children and, especially, among adolescents. However, its clinical presentation usually differs from that of adults. It is also associated with other diagnoses and with an increased morbidity and mortality. However, MDD in this population remains underrecognized and undertreated. Antidepressants (ATDs) are chosen when psychoeducational, psychosocial and/or psychotherapeutic approaches have failed. ATDs are generally used in severe cases, and are always combined with psychological treatments. The objective of this work is to discuss the role of ATD in child and adolescent MDD. We focus on the recommendations of the most cited and updated clinical guidelines and discuss some controversial aspects with regards efficacy and safety issues that have been raised based on the information obtained from clinical trials. Finally, we offer some practical recommendations for clinicians. All these findings also pose some doubt on the hypothesis of MDD as a homogeneous phenomenon during the human life cycle.

Adolescent depression is a highly prevalent disorder with significant morbidity and suicide mortality. It is simultaneously highly responsive to treatment. Adolescents wish to discuss depression with their providers, and providers routinely receive opportunities to do so. These characteristics of prevalence, morbidity, mortality, responsiveness, and accessibility make adolescent depression an excellent target of care. However, most health care trainees and professionals report low confidence in caring for adolescent depression. As a caregiver community, we fare poorly in routine matters of assessment and management of adolescent depression. All health care professionals are trained within a medical model. In this light, the conceptualization of adolescent depression and suicidality within the medical model may increase provider confidence and performance. Epidemiology and neurobiology are presented with emphasis in this review. Legal concerns also affect health care professionals. For example, providers may deviate from evidence-based medicine owing to anxieties that the identification and treatment of depression may induce suicide and consequent legal culpability. A review of the historical context and relevant outcome trials concerning the increased risk of suicidality in depressed adolescents treated with selective-serotonin reuptake inhibitors may increase provider comfort. Furthermore, increased didactic and experiential training improve provider performance. In this work, proven models were discussed, and the testable hypothesis that education incorporating the views of this article can produce the best care for depressed adolescents.

A wide range of comorbid psychiatric disorders overlap with attention-deficit hyperactivity disorder (ADHD) across the life span. There is a robust and complex link between ADHD and substance use disorders (SUD). The aim of this report was to review the neurobiological and other vulnerability factors explaining the comorbidity of ADHD and an addictive disorder, as well as the key aspects of the assessment and diagnosis of dually diagnosed ADHD patients. A comprehensive and systematic search of relevant databases (PubMed, Embase, and PsychINFO) was conducted to identify studies published in peer-reviewed journals until July 31, 2012, with the aim of exploring the association of ADHD and SUD with postgraduate training and residency education. Across the life span, ADHD is associated with significant impairment and comorbidity. Data from epidemiological, clinical and epidemiological studies show a very solid link between ADHD and SUD. Therefore, it is very important to carefully and systematically assess for any substance use in patients with suspected ADHD coming to initial assessment, and vice versa. While there are various valid and reliable rating and screening scales, diagnosis cannot solely rely on any of the instruments available for both SUD and ADHD in adult patients with dual pathology. The most important and effective tool in the assessment of dually diagnosed patients with ADHD and SUD is a full and comprehensive clinical and psychosocial assessment. Hence, it is essential to actively incorporate training opportunities on the assessment, diagnosis, and management of adult ADHD and dually diagnosed ADHD patients during postgraduate education residency or specialist training.

During adolescence, hormonal and neurodevelopmental changes geared to ensuring reproduction and achieving independence are very likely mediated by the growth of neural processes, remodeling of synaptic connections, increased myelination in prefrontal areas and maturation of connecting subcortical areas. These processes, greatly accelerated in adolescence, follow an asynchronous pattern in different brain areas. Neuroimaging research using functional and structural magnetic resonance imaging has produced most of the insights regarding brain structural and functional neuropathology in adolescent psychiatric disorders. In schizophrenia, first episodes during adolescence are linked to greater-than-normal losses in gray matter density and white matter integrity and show a divergence of maturational trajectories from normative neural development in a progression similar to that of adult-onset schizophrenia. Anxiety and mood disorders in adolescence have been linked to abnormally increased activity in the amygdala and ventral prefrontal cortical areas, although some data suggest that neural abnormalities in the amygdala and anxiety maybe particularly more frequent in adolescents than in adults. Alcohol misuse in adolescence results in reduced integrity in the white matter and reduced gray matter density that, given the high intensity of adolescent synaptic and myelin remodeling, may result in persistent and profound changes in circuits supporting memory and emotional and appetitive control. The interaction of persistent changes due to prenatal exposure with the contemporaneous expression of genetic factors and disturbing environmental exposure may be an important factor in the appearance of psychiatric disorders in adolescence. Further progress in understanding adolescent psychopathology will require postmortem research of molecular and cellular determinants in the adolescent brain.

The aim of this paper is to assess the possible consequences of adolescent physical, emotional and sexual dating violence through a review of the literature on the topic. An electronic search of major biomedical bibliographic databases (Pubmed, ISI, PsycINFO) was used to retrieve articles providing information on the prevalence rates, risk factors, associated consequences and possible preventive measures for adolescent dating violence across different populations. Currently, there have been few longitudinal studies conducted to identify potential risk factors for entering a violent dating relationship in adolescence. Risky behaviors such as early sexual intercourse may predispose someone for victimization. Dating violence itself is also a predictor of future dating violence. Adolescent dating violence was associated with an increase in other violence-related behaviors, substance use, depression, poorer educational outcomes, posttraumatic stress, unhealthy weight control and risky sexual behavior. The association between adolescent dating violence and an increase in suicidal behavior is a major public health concern. Future research should focus on longitudinal studies so that a causal relationship between dating violence and suicidality may be better understood.

Several lines of evidence suggest that there is an association between testosterone and suicidal behavior. A link between testosterone and the neurobiology of suicidal behavior may be related to: a) a direct effect of testosterone on suicidality via certain brain mechanisms; and/or b) a testosterone influence on aggression and, consequently, suicidality; and/or c) a testosterone effect on mood and, consequently, suicidality; and/or d) a testosterone effect on cognition and, consequently, suicidality. At least one study has demonstrated a relation between high levels of testosterone and suicide in young people. A significant number of studies suggest that high testosterone levels are associated with aggression in adolescents and adults. Multiple lines of evidence indicate that aggression is associated with suicidal behavior. The effect of high testosterone levels on suicidality in adolescents and young adults may be mediated by testosterone-related elevated aggression. It is also possible that, in young people, high testosterone levels are directly linked to suicidality via certain brain mechanisms. In older men, decreased testosterone levels are associated with depressive symptoms and reduced cognitive function, whereas higher blood levels of testosterone are associated with better mood and cognitive functioning. Depression and reduced cognition are associated with suicidal behavior and may mediate the effect of decreased testosterone levels on suicidality. Therefore, it is reasonable to propose that suicidal behavior in adolescents and young adults is associated with high testosterone levels, whereas suicidality in older men is associated with decreased testosterone secretion.

Background: Military Sexual Trauma (MST) is defined as sexual harassment and or sexual assault experienced by a military service member. It is much more widespread and common than reported. It is associated with pre-combat traumatic experiences and pathologic sequelae including mental and medical illness. Methods: An electronic search of the major behavioral science databases was conducted to retrieve studies detailing the social, epidemiological and clinical characteristics of MST and its relationship to psychiatric and medical illness. Results: Studies indicate that military sexual trauma is related to an increase in psychiatric pathology, including posttraumatic stress disorder (PTSD), substance abuse and dependence, depression, anxiety, eating disorders and suicidal behavior. MST is also related to an increase in medical illness, primarily pain-related symptoms involving multiple organ systems, including gastrointestinal, neurological, genitourinary and musculoskeletal. Conclusion: MST is associated with an increased prevalence of mental and physical illness. Although there are some gender differences in the reported rates of MST and there may be some variables, such as prior traumatic experiences, that may make an individual more vulnerable to the psychiatric and medical sequela of MST, it is clear that MST is a major healthcare issue that affects both sexes and warrants further attention and an increase in clinical resources devoted to it. Some preventive measures for decreasing the prevalence of MST may include increasing education and legal prosecution of perpetrators in the military, and increasing access to mental health services for individuals who have suffered from MST.

The original theory behind separating juvenile offenders from adult offenders was to provide care and direction for youngsters instead of isolation and punishment. This idea took hold in the 19th century and became mainstream by the early 20th century. In the 1950s and 1960s, public concern grew because of a perceived lack of effectiveness and lack of rights. The Supreme Court made a series of rulings solidifying juvenile rights including the right to receive notice of charges, the right to have an attorney and the right to have charges proven beyond a reasonable doubt. In the 1980s, the public view was that the juvenile court system was too lenient and that juvenile crimes were on the rise. In the 1990s, many states passed punitive laws, including mandatory sentencing and blanket transfers to adult courts for certain crimes. As a result, the pendulum is now swinging back toward the middle from rehabilitation toward punishment.

Posttraumatic stress disorder (PTSD) is concerning not only because of the severity and chronicity of its symptoms – including distressing nightmares, flashbacks, anxiety attacks and maladaptive patterns of avoidant and nearly paranoid behavior – but also because of the wide spectrum of clinical and social impairments it is tightly associated with. The most striking example of clinical morbidity associated with PTSD is the well-known increase in the risk of suicidal behavior. Given that PTSD and medical illnesses increase the likelihood of suicide separately and independently, it is reasonable to suggest that the risk of suicidal behavior differs between patients suffering from PTSD comorbid with medical illnesses and patients having either condition alone. The available data point toward a novel clinical notion, an altered risk of suicidal behavior in patients suffering from comorbid PTSD and medical illnesses. This area of overlap between medicine and psychiatry is still in its infancy, with many unanswered questions about the rate, patterns and psychobiological mechanisms of suicidal behavior in this patient population. The positive association between PTSD, medical illness and suicidal behavior that appears to exist in the adult population, most likely affects the pediatric population as well. Closer investigation into the significance of the association between chronic medical illnesses, PTSD and suicidality in children, adolescents and adults is necessary.

Post-traumatic stress disorder (PTSD) is significantly associated with an increased risk for suicidal behavior among adolescents. Suicide is one of the top three causes of adolescent deaths worldwide. Despite the strong relationship between PTSD and suicidal behavior, precise causal pathways linking PTSD to suicide in adolescents remains unclear. A slew of mediating factors and variables commonly present themselves with both suicide and PTSD, including co-morbid psychiatric disorders, exposure to different forms of trauma and stressful life events, core neurobiological changes, and mental, emotional, and physiological states such as hyperarousal, impulsivity, and aggression. Because youth is such a critical stage of development, it is very important that at-risk adolescents are identified and referred for treatment. With many treatment challenges in these populations, effective implementation and use of prevention methods are of increasing importance. The most proven prevention methods include physician education, means restriction, and gatekeeper training. Other strategies that have received empirical support are public education campaigns and implementing guidelines for the media, including those for television, print media, and the Internet.

Bullying is a highly prevalent behavior which carries a significant social, medical and financial cost for its victims and perpetrators, with powerful and long-lasting psychological and social impact. Bullying has been defined as a specific form of intentional, repeated aggression, that involves a disparity of power between the victim(s) and perpetrator(s). The aggression can take physical, verbal or gestural forms. The behavior of bullying crosses sociodemographic categories of age, gender, ethnicity, level of academic achievement and professional environment. It has been abundantly observed by teachers and parents in elementary schools, but has also shown its negative presence in corporate boardrooms. The direst outcome of bullying, for both victims and perpetrators, is an increased risk of psychiatric disorders including depression, post-traumatic stress disorder, anxiety disorders, substance abuse and suicidal behavior. Cruelty (and bullying, as one of its manifestations) breaks the basis of morality. Mental health professionals usually treat the victims of those actions unfortunately long after they have been exposed to the harm. The evidence does not support the idea that the majority of cruel actions are intrinsically “pathological”, in the sense of being motivated by “mental disorders”. Therefore, only moral rules and legal actions – but not psychiatric or psychological interventions – may dissuade humans from this form of cruelty.

The purpose of the current study was to examine the effects of training first year medical students using a Child Advocacy Studies Training (CAST) elective course. The 9-month course was taught by a multidisciplinary group of professionals and addressed prevention, identification, reporting, and responding to all forms of child and adolescent maltreatment. It was hypothesized that, relative to students in a comparison group, students who completed the elective course would report being significantly more prepared to identify signs of maltreatment, to report a case of suspected maltreatment, and to recommend or secure needed services for a maltreated child or adolescent, more likely to report suspected maltreatment, even if they did not know for sure it happened, and demonstrate improved knowledge in the areas of maltreatment identification and reporting. Results supported all five of the study’s hypotheses and indicate that the CAST program may be an effective method of better preparing future physicians to address child and adolescent maltreatment.

Cannabis use is common in youth and there is evidence that the co-occurrence of cannabis use (and other substance use) with mental illnesses predicts poorer outcomes, including suicide. The main purposes of this study were to: (i) identify rates of cannabis use and substance use disorder risk, and (ii) predictors for cannabis use among youth seeking help for mood and/or anxiety concerns in a sample population prescreened to exclude primary substance use disorders; and (iii) to determine if there was an association between cannabis use and functional impairment in this sample. We investigated substance use risk as well as hypothesized predictors of cannabis use and functional impairment including demographic characteristics, socioeconomic status, trait coping style, age of onset of several risk behaviors, current use of common addictive substances, level of functional impairment, and current psychiatric symptom severity. Results showed that approximately half of the participants were at moderate to high risk for a substance use disorder, and just over 4% appeared to have a primary substance use disorder. They also suggested an association between cannabis use and gender (male), age of first cannabis use, recent cigarette use, and functional impairment. Independently, functional impairment was predicted by inattentive coping style, depression severity, and total cannabis use score. These results confirm a high risk for addictive disorders and an association between cannabis use and functional impairment in this sample. These results support the need for substance use treatment programs to optimize care wherever youth with primary mood and/or anxiety concerns are seen.

Higher physician-per-population ratio may improve access to medical care, decrease waiting times, increase the opportunity for contact between the patient and physician, and has been associated with earlier stage of diagnosis and better prognosis in patients with some medical conditions. It appears that an increase in the physician density generally improves the quality of healthcare and should prevent suicides. However, several research reports suggest that of those people who committed suicide, many saw a physician shortly before their suicide completion. Besides, studies show that many physicians do not have adequate training in suicide evaluation techniques and treatment approaches to suicidal patients, especially young people. Therefore, we hypothesized that the physician density does not affect suicide rates among adolescents and young adults. Correlations were computed to examine relationships between suicide rates in 15–24-year-old and 25–34-year-old males and females and the physician density in European countries. Countries were also divided into two groups, according to the median split of the physician density. Suicide rates among 15–24-year-old and 25–34-year-old males and females in these two groups were compared using the t-test. We found no relationships between suicide rates and the physician density. The results of our study suggest that either physicians do not take an appropriate care of suicidal patients, or suicide is not preventable, or both. The results of this study should be treated with caution because many confounding variables are not taken into account.

A global public health problem, non-suicidal self-injury (NSSI) is highly prevalent in both males and females, and tends to first occur in adolescence. NSSI is correlated with a history of childhood trauma, and with a variety of developmental and psychiatric disorders. NSSI is associated with increased risk of morbidity and premature death from suicide, accidents, and natural causes. Current treatment approaches are inadequate for a substantial number of people. Converging evidence for opioid system dysregulation in individuals with NSSI make this a promising area of investigation for more effective treatments. The pharmacological profile of buprenorphine, a potent μ-opioid partial agonist and κ-opioid antagonist, suggests that it may be beneficial. In this paper, we describe the successful treatment of severe NSSI with buprenorphine in six individuals, followed by discussion and further recommendations.