Depression and suicidal behavior in adolescent inpatients with obsessive compulsive disorder

Abstract

Background: To investigate the prevalence and correlations of suicidal behavior in obsessive compulsive disorder (OCD) among adolescent psychiatric inpatients. Methods: A total of 348 adolescents, representing consecutive admissions to an adolescent inpatient unit, were assessed. Of these, 40 patients had OCD, 118 had schizophrenia, 59 had an affective disorder, 81 had a conduct disorder and 50 had an eating disorder. In addition, 87 normal community controls were assessed. All subjects were assessed for suicidal behavior by the Childhood Suicide Potential Scale (CSPS), for depression by the Beck Depression Inventory, for impulsiveness by the Impulse Control Scale, for anxiety by the State-Trait Anxiety Scale and for aggression by the Yudowsky Overt Aggression Scale. Results: All the psychiatrically ill subjects, including those with OCD, had high levels of depression, anxiety and impulsiveness, which were far higher than those of the controls. The rate of attempted suicide was, however, much lower in the OCD subjects. In addition, there was a significant inverse correlation between suicidal behavior levels on the CSPS and depression in the OCD subjects, while all other subjects showed the expected significant positive correlation between level of suicidal behavior and depression. Limitations: This study looked at a referred population and generalization to outpatient and community samples cannot be made. Distinguishing between the primary and the comorbid diagnosis is difficult and some findings are based on small sample size and therefore may be vulnerable to type I error. Conclusions: Although suicidal ideation and depressive symptoms are common in OCD adolescent inpatients, they seem to be protected against suicide attempts. The inverse relationship between suicidal behavior and depression may mean that suicidal behavior is, in some ways, qualitatively different from that seen in other psychiatrically ill adolescents.

Introduction

Obsessive compulsive disorder (OCD) is a well described disorder in childhood and adolescence occurring in ∼3% of 16-year-olds (Apter et al., 1996). Although effective methods of treatment are available, ∼30–40% of patients do not respond to therapy and have a relatively poor prognosis (Greist et al., 1995). The factors contributing to treatment failure include: comorbidity with personality disorders, tic disorders, conduct disorders and oppositional disorders, dysfunctional families and the presence of depression and suicidal behavior (Foa, 1979). The present study will focus on those adolescent inpatients with OCD in whom suicidal behavior was prominent and will look at the context in which the suicidal behavior took place, especially in relation to depression.

OCD is a common co-morbid condition with affective disorder. About 10% of unipolar depressives and 21% of bipolar sufferers show comorbid OCD (Chen and Dilsaver, 1995). Perugi et al. (1997) found that 15.7% of subjects with OCD had episodes of bipolar disorder. It appears that depression is also common among adolescents with OCD (Swedo et al., 1989, Valleni-Basile et al., 1994) and that depression, in combination with OCD, may confer an increased risk for suicidal behavior (Valleni-Basile et al., 1994, Chen and Dilsaver, 1995). Non-fatal suicidal behavior occurs in ∼15% of individuals suffering from OCD (Angst, 1993, Hollander et al., 1996), principally in those showing comorbidity with anti-social behavior or borderline personality disorder. It appears, therefore, that the potential risk factors for suicidal behavior in OCD may include comorbidity with major depressive disorder, comorbidity with bipolar affective disorder and comorbidity with conduct disorder and impulsiveness.

Although inpatients cannot be regarded as a representative population, adolescent psychiatric inpatients represent an important group of individuals for research into suicidal behavior, for a number of reasons. First, the prevalence of suicidal behavior in this group is high (Motto, 1984, Robbins and Alessi, 1985). Moreover, many studies have suggested that the majority (up to 90%) of young people who commit suicide and those who make serious suicide attempts have at least one diagnosable mental disorder at the time of their suicide attempt (Brent et al., 1993, Shaffer et al., 1996, Beautrais et al., 1998). Second, adolescent patients usually have a history of repeated suicide attempts (Barter et al., 1968). Third, a high percentage of adolescents who have a history of psychiatric hospitalization go on to commit suicide (Welner et al., 1979, Motto, 1984, Pfeffer et al., 1988).

Severe depression is ubiquitous in adolescent psychiatric inpatients, irrespective of diagnosis (Apter et al., 1988a) and there have been many studies of the correlates of suicidal behavior in adolescent psychiatric inpatients. Important correlates include depression, anxiety, aggression, anger, impulsiveness and anti-social behavior (Apter et al., 1988b, Apter et al., 1995, Stein et al., 1998). We were not able to find a specific report of the relationship of these variables to suicidal behavior in adolescent OCD. Thus, the study of depression and suicide in adolescents who have been hospitalized for OCD seems to be an important but rather neglected area for study.

The aims of the present report were thus: (1) to determine the prevalence of attempted suicide in adolescent inpatients with OCD, (2) to describe the psychiatric comorbidity of inpatient OCD attempters, and (3) to determine the association of suicidal behavior with negative affects in these subjects.

The specific hypotheses of this study were:

• Adolescent inpatients with a diagnosis of OCD will show high levels of depression

• Adolescent inpatients with a diagnosis of OCD will show high levels of suicidal behavior

• The correlations of suicidal behavior with other psychological dimensions will be similar to those shown by suicidal adolescents with other diagnoses.