JGIM

BRIEF REPORT

Suicidal Ideation among Urban Medical Outpatients Mark Zimmerman, MD, Jennifer D. Lish, PhD, David T. Lush, MD, Neff J. Farber, MD, Gary Plescia, MA, Mary Ann Kuzma, MD

The prevalence o f current su ic ida l ideat ion a m o n g urban pri- mary care outpat ients was a s s e s s e d , and su ic ida l and non- suicidal pat ients were compared wi th regard to their demo- graphic characterist ics and their att itudes toward mental heal th screening. Twenty (3.3%) pat ients reported having t h o u g h t s o f kil l ing themse lve s . The pat ients w h o had su ic ida l ideat ion were s igni f icant ly y o u n g e r and more f requent ly divorced. Al- most all (97 .6%) o f the pat ients indicated that their phys i - c ians should inquire about e m o t i o n a l hea l th i s s u e s at s o m e time, and the su ic idal pat ients were n o n s i g n i f i c a n t l y more l ikely to r e c o m m e n d inquiry about psychiatr ic s y m p t o m s at every visit (55 .0% vs 3 7 . 0 % , p < 0 . 1 1 ) . Only hal f o f the suicidal pat ients reported l i f e t ime h i s tor ies o f menta l hea l th treatment. The majority (70 .2%) o f the pat ients be l i eved that it would be easy to d i s c u s s menta l hea l th problems wi th their medical phys ic ians . A m o n g the pat ients w h o had prev ious ly received psychiatr ic treatment , the su ic ida l pat ients were nearly three t imes more l ike ly to ant ic ipate that it w o u l d be diff icult or very di f f icult to talk to their p h y s i c i a n s about psychiatric problems. In contras t , a m o n g the pat ients w h o had no h i s tory o f menta l hea l th treatment , there was n o as- soc iat ion b e t w e e n suic idal ideat ion and ant ic ipated d i scom- fort in tnlklng wi th their p h y s i c i a n s about e m o t i o n a l hea l th . KEY WORDS: depress ion; su ic ida l ideat ion; screen ing . J GEN INTERN MED 1 9 9 5 ; 1 0 : 5 7 3 - - 5 7 6 .

S uic ide is the e igh th l ead ing cause of d e a t h in the United S ta tes , a c c o u n t i n g for more t h a n 30 ,000

dea ths per year . l It is e s t i m a t e d t h a t su i c ide a t t e m p t s are approx ima te ly ten t imes more f r equen t t h a n com- pleted su i c ides are. 2

Most r e sea rch on su i c ide h a s focused on su i c ida l acts; there a re relat ively few s t u d i e s of su i c ida l t h o u g h t s in nonpsych ia t r i c samples . S t u d i e s of genera l popu la - t ion samples have found prevalence ra t e s of su i c ida l idea t ion r ang ing f rom 5% to 37% ,3-6 wi th the r a t e s vary-

Received from the Department of Psychiatry (MZ, JDL. GP), Division of General Medicine (DTL, NJF, MAK), Medical Col- lege of Pennsylvania, and the Department of Medicine (NJF). Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania.

Address correspondence and reprint requests to Dr. Zim- merman: Department of Psychiatry. Rhode Island Hospital, 593 Eddy Street, APC 9. Providence, RI 02903.

ing accord ing to t ime pe r iod covered (l ifet ime vs preced- ing mon th ) a n d the b r o a d n e s s of the de f in i t ion of su i - cidal idea t ion (e.g., occas iona l ly t h i n k life is no t w o r t h living vs p lan to c o m m i t suic ide) . We are no t aware of any pub l i shed s t u d y a s s e s s i n g c u r r e n t su i c ida l i dea t i on in p r imary care medica l o u t p a t i e n t s . F r o m the phys i - c ian 's perspect ive, i t would be more m e a n i n g f u l to have in format ion a b o u t the preva lence of c u r r e n t su i c ida l though t s in medica l p a t i e n t s p r e s e n t i n g for t r e a tmen t ,

because th i s is when a n i n t e rve n t i on would occur. In a d d i t i o n to a s s e s s i n g the p re sence of su ic ida l

ideation, we a s k e d p a t i e n t s how diff icult it wou ld be to d i scuss menta l hea l t h p r o b l e m s wi th t he i r phys i c i ans , and how often they w a n t e d the i r p h y s i c i a n s to a s k t h e m a b o u t psych ia t r i c s y m p t o m s . Previous r e sea rch indi- cated tha t the ma jo r i t y of medica l p a t i e n t s would w a n t t r ea tmen t from the i r family p h y s i c i a n s for m e n t a l hea l t h problems such as su ic ida l i ty . 7-9 However, the p a t i e n t s in these surveys r e p r e s e n t e d a r a n d o m s a m p l e of medica l ou tpa t i en t s , m a n y of w h o m did not have psych ia t r i c dis- orders. Consequent ly , m a n y of the p a t i e n t s in these sur - veys were r e spond ing hypothetical ly, ind ica t ing wha t level of involvement they would w a n t f rom the i r p h y s i c i a n s / f they had a p sych ia t r i c p rob lem. In the p r e s e n t s t u d y we compared the su ic ida l a n d n o n s u i c i d a l p a t i e n t s regard- ing the i r des i re a n d comfor t in d i s c u s s i n g m e n t a l hea l t h problems wi th the i r phys i c i ans .

METHODS

A consecut ive se r ies of 658 o u t p a t i e n t s a t t e n d i n g the faculty genera l i n t e rna l m e d i c i n e p rac t ice at the Med- ical College of Pennsy lvan ia were a s k e d to p a r t i c i p a t e in a research s t u d y involving the comple t i on of two ques- t ionnai res . Th i s first scale i n q u i r e d a b o u t p sych i a t r i c symptoms , a n d the s econd q u e s t i o n n a i r e a s s e s s e d the patients" a t t i t u d e s toward comple t i ng the f i rs t scale a n d thei r op in ions r e g a r d i n g i n q u i r y a b o u t emot iona l p rob- lems by the i r medica l phys i c i ans .

The p a t i e n t s were a p p r o a c h e d af te r they h a d reg- is tered and had been escor ted into a p h y s i c i a n ' s ex- a m i n i n g room. After a n u r s e r ecorded the p a t i e n t ' s ch ie f complain t , a r ecep t ion i s t i n t r o d u c e d a r e sea rch ass i s - tant , who exp la ined the p u r p o s e of the s t u d y to the pa-

573

574 Z i m m e r m a n et al., Su ic ida l Idea t ion in Urban Ou tpa t i en t s )GIM

tient. The pa t i en t s were ensu red anonymi ty , and they

were told tha t the q u e s t i o n n a i r e s would not be reviewed

by their physic ians . We app roached every pa t i en t except

hospi tal employees and medical s tuden t s . Ninety-one

percent (601/658) of the pa t i en t s agreed to par t ic ipa te

in the study. The mos t f r equen t reasons for nonpar -

t ic ipat ion were pa t i en t refusal (n = 16), lack of read ing

glasses (n = 17), and insuf f ic ien t t ime to comple te the

ques t ionna i res (n = 15). The n o n p a r t i c i p a n t s were sig-

nificantly older (47,4 + 14.9 vs 39.4 + 15.2 years, t =

3,8, p < 0.001) and less well educa ted (11.7 _+ 1.9 vs

12.6 _+ 2.1 years, t = - 3 . 0 . p < 0.011.

The SCREENER is a se l f -admin is te red q u e s t i o n n a i r e

that was des igned to sc reen for several different DSM-

IV disorders. ~o. ~ ~ There are two versions of the SCREENER--

a 44-i tem shor t vers ion and a 96- i tem long version. All

ques t ions are answered yes or no. In two s tud ies of more

than 1,300 pr imary care medica l ou tpa t i en t s , a lmos t all

of the SCREENER subsca les had h igh levels of in te rna l

cons i s t ency and t e s t - r e t e s t re l iabi l i ty (mean Cron-

bach 's a lpha = 0.78; m e a n t e s t - r e t e s t reliabil i ty coef-

ficient = 0.79). To examine the d i s c r i m i n a n t and con-

vergent validity of the d iagnosis -speci f ic subscales , we

examined the i t e m - s c a l e correlat ions between each i tem

and its own paren t scale compared wi th the o ther scales.

Almost all i tems correlated more h ighly wi th thei r pa ren t

scales t han wi th o ther scales. Cons t ruc t validity was

demons t ra t ed by f inding tha t the pa t i en t s who repor ted

his tor ies of menta l hea l th care scored h ighe r on all of

the SCREENER subscales . Similarly, the pa t i en t s whose

global ra t ings of cu r r en t men ta l hea l th were fair or poor

scored h igher on the SCREENER subsca les t han did the

pat ients who rated thei r menta l hea l th as good or ex-

cellent. Thus , the SCREENER is a reliable and valid in-

s t rument .

Both vers ions of the SCREENER include three ques-

t ions about t h o u g h t s of death , dea th wishes , and sui-

cidal ideation. Midway t h rough the s tudy we ch a n g e d

one of these q u e s t i o n s from "Do you f requent ly t h ink of

dying in passive ways like going to sleep and not wak ing

up?" to "Do you wish you were dead?" The o ther two

ques t ions r ema ined the s a m e t h r o u g h o u t the s tudy ("Do

you think you'd be bet ter off dead?'" "'Do you have thoughts

of killing yourself?").

On the Pat ient Acceptabi l i ty Scale (PAS), we asked

the pa t ien ts the i r op in ions abou t how easy it would be

to speak to the i r medical phys ic ians abou t emot ional ,

nerve, drug, or alcohol problems (very easy, easy, ne i the r

easy nor difficult, difficult, very difficult), and how often

their phys ic ians shou ld ask t h e m some q u e s t i o n s about

emotional or nerve p rob lems as par t of the i r eva lua t ions

(each t ime I see the phys ic ian , on yearly checkups , only

when a problem is suspec ted , not at all). Finally, the PAS

included ques t ions abou t the n u m b e r of phys ic ian vis i ts

in the preceding year, h i s tory of men ta l hea l th care, and

self-rated global eva lua t ions of cu r r en t physical and

emotional heal th.

RESULTS

The majori ty of the pa t i en t s were w o m e n (81.3%),

black (86.5%), and h igh school g radua te s (81.9%). The

mean age of the sample was 39.4 years ( s tandard devia-

tion = 12.9), and most of the pa t i en t s were e i ther cur-

rently mar r ied (32.5%) or never mar r i ed (49.6%).

Twenty [3.3%; 95% conf idence interval (CI) 1.9% to

4.7%1 pa t ien ts repor ted hav ing t h o u g h t s of kil l ing them-

selves, and 28 (4.7%; 95% CI 3.0% to 6.4%) t h o u g h t tha t

they would be be t te r off dead. Ten percen t (95 % CI 6.8 %

to 13.2%) of the subsample assessed for passive though t s

of dying responded yes (35/339), and 4.2% (95% CI 1.8%

to 6.6%) (11/262) of the pa t i en t s ind ica ted tha t they

wished they were dead. For the ent i re sample, 7.3% re-

sponded yes to one of the three ques t ions , 2.2% re-

sponded yes to two ques t ions , and 1.3% responded yes

to all three ques t ions . To be conservat ive in our analyses, we def ined the

suicidal ideat ion group as the pa t i en t s who repor ted

having though t s of kil l ing themselves . The pa t i en t s who

had suicidal ideat ion were s igni f icant ly younge r (32~7

+_ 12.7 vs 39.8 + 15.2 years, t = 2.04, p < 0.05) and

more likely to be divorced (20.0% vs 7.1%, ×2 = 4.59, p

< 0.04). There was no difference be tween the g roups in

gender, educa t iona l level, or race.

We did not assess the d u r a t i o n of the suic idal idea-

tion. However, the t e s t - r e t e s t reliabil i ty of the SCREENER

was s tudied with regard to 90 pa t i en t s who comple ted

the scale two t imes, a m e d i a n of four days apart . The

two pa t ien ts who repor ted t h o u g h t s of ki l l ing themse lves

did so on both a d m i n i s t r a t i o n s of the scale (the intervals

between the two a s s e s s m e n t s were two days for one pa-

t ient and five days for the other).

Almost all of the pa t i en t s ind ica ted tha t the i r med-

ical physic ians should i n q u i r e about emot iona l hea l th

problems (on each visit, 37.7 %; at yearly checkups, 25.2 %;

only when a problem is suspec ted , 34.5%: never, 2.6%).

The suicidal pa t i en t s were nons ign i f i can t ly more likely

to r ecommend inqu i ry abou t psychia t r ic s y m p t o m s at

every visit (55.0% vs 37.0%, X 2 = 2.66, p < 0.11).

Only half of the suic idal pa t i en t s repor ted l ifet ime

histories of menta l heal th t r ea tmen t , t h o u g h th is rate

was s ignif icant ly h igher t h a n the rate for the nonsu i -

c i d a l p a t i e n t s ( 5 5 . 0 % v s 2 0 . 5 % , X 2 = 1 3 . 6 1 , p < 0 . 0 0 1 ) .

Health care ut i l izat ion, as m e a s u r e d by the repor ted

number of vis i ts to a medical phys ic ian in the p reced ing

year, was not s ignif icant ly h igher for the suic idal pa-

t ients than it was for the nonsu ic ida l pa t i en t s (3.3 -+

2.7 vs 2.9 +_ 2.6, t = 0.70. NS). The majori ty of the pa t i en t s believed tha t it would

be easy to d i scuss menta l hea l th p rob lems wi th the i r

medical phys ic ians (70.3%), a l though the suic idal pa-

t ients more f requent ly repor ted tha t it would be difficult

(25.0% vs 10.2%, X2 = 4.45, p < 0.04). We examined

whether the assoc ia t ion be tween suic idal s t a tu s and an-

t icipated difficulty in d i s c u s s in g psychia t r ic p rob lems

JGIM Volume 1 O, October 1995 575

with the medical phys ic ian was related to pa t ien t h is tory of menta l heal th t rea tment . Among the pa t i en t s who had

previously received psychiatr ic t r ea tment , the suic idal pat ients were nearly three t imes more likely to an t ic ipa te

that it would be difficult or very difficult to talk to their

phys ic ians abou t psychiat r ic problems (36.4 % vs 12.9 %, ×2 = 4.33, p < 0.04). In contras t , a m o n g the pa t i en t s

who had no his tory of men ta l hea l th t rea tment , there was no associa t ion be tween suicidal ideat ion and ant ic- ipated discomfort in ta lk ing wi th their phys ic ians abou t emotional heal th (11.1% vs 9.8%).

DISCUSSION

Suicidal though t s are no t u n c o m m o n in u r b a n med- ical ou tpa t i en t s p re sen t ing to their p r imary care phy-

sicians. The prevalence of suic idal ideat ion is a func t ion

of the b roadness of its def ini t ion. When passive t hough t s of death were inc luded in the def ini t ion, more t h a n 10%

of the sample had suic idal ideat ion; w h e n suicidal idea- t ion was narrowly defined as hav ing t hough t s of ki l l ing oneself, the prevalence was 3.3%.

We expected medical pa t i en t s to have h igher rates of suicidality t h a n a r a n d o m sample of c o m m u n i t y res-

idents did, because the rates of psychia t r ic disorders, which are risk factors for suicide, are h igher in medical

pat ient samples. However, it is difficult to compare our results with those of s tud ies of general popu la t ion sam-

ples because the methods of a s s e s s m e n t differed. The most s ignif icant difference be tween the s tud ies is the time frame of the assessment . Most s tud ies i nqu i r ed

about a lifetime his tory of suic idal t hough t s a n d behav- iors. However, in a s tudy of near ly 4 ,000 c o m m u n i t y residents, Vandivort and Locke 4 assessed the f requency

of suicidal ideat ion d u r i n g the preceding m o n t h (very often, fairly often, occasionally, rarely, or never), a n d

found that 5.4% of the ind iv idua l s reported any suic idal ideation. In an epidemiologic s tudy in n o r t h e r n Florida, Schwab and colleagues 5 asked 1,645 indiv iduals how

often they though t of suicide, and 3.1% responded some-

times (2.6%), often (0.4%), or all the t ime (0.1%).

Recently, Cooper-Patrick et al. ~2 looked at the fre- quency of suic idal ideat ion d u r i n g the year prior to a psychiatric interview for 6,000 commun i ty residents who

had received care in the general medical sect ion in the six m o n t h s before the base l ine interview. The 6 ,000 in-

dividuals who had received medical care d u r i n g this six- mon th period represented nearly 60% of the ent i re gen-

eral popula t ion sample evaluated in the study, a n d the authors did no t indica te whe the r suic idal ideat ion was more f requent a m o n g the pa t i en t s who had received

medical care t h a n it was a m o n g those who had not. Also,

they did no t assess suic idal idea t ion at the t ime of the medical visit. Thus , the i r s tudy is more a quasi-epide- miologic survey of suic idal idea t ion t h a n it is a survey

of suicidal ideat ion a m o n g pa t i en t s p r e s e n t i n g for treat- ment . C o n s i s t e n t wi th o the r epidemiologic surveys,

Cooper-Patrick et al. found tha t 2.6% of the sample had experienced suicidal thoughts wi th in the preceding year.

A l imi ta t ion of the p resen t s tudy is the skewed de-

mographic composi t ion of the sample. General izabi l i ty

to other samples needs to be demons t ra ted . Because the sample size of suicide ideators was small, the power of our analyses compar ing suicide ideators a nd non idea -

tors was low and t h u s may have resul ted in type II error

(i.e., failure to detect t ruly s ign i f ican t differences). A fi- nal l imi ta t ion is tha t we did no t conduc t follow-up psy-

chiatric evaluat ions to de te rmine the patients" diag-

noses. How do f ind ings abou t suic idal ideat ion relate to

suicidal behavior? There is controversy as to whe ther there is a suicidal i ty d imens ion , s t r e tch ing from non-

serious suicidal thoughts to completed suicide, or whether

suicidal ideation, suic ide a t t empts , a n d completed su-

icide are dis t inct , though overlapping, constructs .~3- ~s The demographic correlates of suic idal ideat ion a n d

completed suicide differ. The demographic prototype of the suicide completer is the older man , whereas suicide a t tempters are more often y o u n g women.~6 S tud ies of

psychiatric pa t i en t s compar ing suic ide ideators a n d su- icide a t tempters have tended to find more s imi lar i t ies

than differences, a n d both groups are different from nonsuic ida l pat ients . ~3. ~6. 17

Our clinical experience suggests tha t the presence of suicidal ideat ion is the major proximate r isk factor

for suicidal behavior. Mental i l lness, par t icular ly depres-

sion and alcoholism, confers an ongoing r isk for suicidal behavior, thereby necess i t a t ing an ongoing a s s e s s m e n t of suicidal risk (i.e., suic idal ideation) d u r i n g the course

of t reatment . Certainly, some suicidal acts are impul- sive, and thus more difficult to predict a nd prevent. However, others are the c u l m i n a t i o n of prolonged con-

s iderat ion and distress. No prospective s tudy has ex- amined the likelihood of suic idal behavior by medical ou tpa t ien ts with suicidal ideat ion p r e sen t i ng to their

pr imary care physic ians . Our resul ts suggest tha t medical pa t i en t s w a n t to

talk to their medical phys ic ians abou t menta l heal th issues, and that suic idal pa t i en t s prefer more regular inqui ry about psychiatr ic symptoms. This is cons i s t en t with the l i terature showing tha t pa t i en t s are more sat-

isfied with their medical care if their phys ic ians inqu i re about psychosocial issues, a nd that pa t i en t s wish to discuss psychosocial concerns with their family physi- cians.7 9

There was an in te rac t ion be tween the perceived dif- ficulty in speak ing to medical phys ic ians abou t men ta l health problems a nd the presence of a h is tory of men ta l

health t r e a t m e n t - - t h e suic idal pa t i en t s who had his-

tories of menta l heal th care were three t imes more likely than were the nonsu i c ida l pa t i en t s a n d the suic idal pa- t ients who had no his tory of men ta l heal th t r e a tmen t to feel uncomfor table d i s cus s ing their psychiat r ic prob- lems with their p r imary care phys ic ians . The presence

576 Z i m m e r m a n et al., Suicidal Ideation in Urban Outpatients JG1M

of th is i n t e r ac t ion s h o u l d not , however , d i s t r a c t from the ma in f ind ing tha t a lmos t all the p a t i e n t s t h o u g h t tha t the i r p h y s i c i a n s s h o u l d a s s e s s t h e i r m e n t a l hea l th , and tha t only a m i n o r i t y of the p a t i e n t s bel ieved t h a t it would be difficult to d i s c u s s m e n t a l hea l t h p r o b l e m s with the i r phys i c i ans .

In conclus ion , su ic ida l i dea t i on a p p e a r s to have a s igni f icant prevalence a m o n g u r b a n p r i m a r y care pa-

t ients , only ha l f of these su i c ida l p r i m a r y care p a t i e n t s have ever h a d men ta l hea l t h t r e a t m e n t , a n d a lmos t all pa t i en t s (suic idal a n d nonsu i c ida l ) t h i n k t ha t i t is ap- p ropr ia te for the i r p r i m a r y care p r a c t i t i o n e r s to evalua te them for psych ia t r i c d i so rders .

REFERENCES

1, U.S. B u r e a u of the C e n s u s . S ta t i s t i ca l A b s t r a c t of the Uni ted S ta tes :

1993 (113th edi t ion] . W a s h i n g t o n , DC: U.S. B u r e a u of the C e n s u s

1993.

2. Hirschfeld RMA, Dav idson L. R i sk fac tors for suic ide . In: F r a n c e s

AJ, Hales RE {eds]. Review of Psych ia t ry , vol. 7. W a s h i n g t o n , DC:

Amer ican Psych ia t r i c Press , 1988.

3. R a m s a y R, Bagley C. The prevalence of su ic ida l behav io r s , a t t i t u d e s

a n d a s s oc i a t ed socia l exper i ences in a n u r b a n population. Su ic ide

Life Th rea t Behav. 1 9 8 5 ; 1 5 : 1 5 1 - 6 7 .

4. Vandivor t DS, Locke BZ. Su ic ide idea t ion : i ts r e la t ion to dep re s s ion ,

suicide a n d suicide a t tempt , Suic ide Life Threa t Behav, 1 9 7 9 : 9 : 2 0 5 -

18.

5, S c h w a b J J , Warhe i t G J , Holzer CE. Su ic ida l i dea t ion a n d b e h a v i o r

in a genera l popu la t i on . Dis Nerv Sys tem. 1 9 7 2 ; 3 3 : 7 4 5 - 8 ,

6. Paykel ES, Myers JK, L i n d e n t h a l J J , T a n n e r J . Su ic ida l feel ings in

t he g e n e r a l p o p u l a t i o n : a p r e v a l e n c e s t u d y . B r J P s y c h i a t r y .

1 9 7 4 : 1 2 4 : 4 6 0 - 9 . 7. Clark CH, S c h w e n k TL, Plackis CX. Pat ients" pe rspec t ive of behav -

ioral sc ience care by family p rac t i ce p h y s i c i a n s . J Med Educ .

1 9 8 3 ; 5 8 : 9 5 4 - 6 1 . 8, Frowick B, S h a n k JC, Doher ty WJ, Powell TA, Wha t do p a t i e n t s

really w a n t ? Redef in ing a behav io ra l sc ience c u r r i c u l u m for family

phys ic ians . J F a m Prac t . 1 9 8 6 : 2 3 : 1 4 1 - 6 .

9. S c h w e n k TL, Clark CH, J o n e s GR, S i m m o n s RC, C o l e m a n ML, De-

f in ing a behav io ra l sc ience c u r r i c u l u m for family p h y s i c i a n s : w h a t

do p a t i e n t s t h i n k ? J Faro Prac t . 1 9 8 2 : 1 5 : 3 3 9 - 4 5 .

I0. Z i m m e r m a n M, Fa rbe r NJ, H a r t u n g J , L u s h DT, K u z m a M. Screen-

ing for p sych ia t r i c d i s o r d e r s in medica l pa t i en t s : a feasibi l i ty a n d

pa t i en t acceptance s tudy . Med Care. 1 9 9 4 : 3 2 : 6 0 3 - 8 .

i I. Z i m m e r m a n M. Lish J D . F a r b c r NJ, et aL S c r e e n i n g for d e p r e s s i o n

in medical p a t i e n t s - - i s the focus too n a r r o w ? Gen Hosp Psych ia t ry .

1 9 9 4 : 1 6 : 3 8 8 - 9 6 . 12. Cooper -Pa t r ick L, C r u m RM, Ford DE, Ident i fy ing su ic ida l i dea t ion

in genera l medica l pa t i en t s . JAMA, 1 9 9 4 ; 2 7 2 : 1 7 5 7 - 6 2 .

13, Kosky R, S i l b u r n S, Z u b r i c k SR. Are c h i l d r e n a n d ado le scen t s w h o

have su ic ida l t h o u g h t s d i f ferent f rom those w h o a t t e m p t s u i c i d e ?

J Nerv Ment Dis. 1 9 9 0 : 1 7 8 - 3 8 - 4 3 , 14. Ga r l and AF, Zigler E. Adolescen t su i c ide p reven t ion . Am Psychol .

1 9 9 3 : 4 8 : 1 6 9 - 8 2 . 15. Pfeffer CR. L ipk ins R, P lu t ch ik R, Miz ruch i M, Normal ch i ld ren a t

r i sk for su ic ida l behav ior : a two yea r follow-up s tudy . J Am Acad

Child Psychiatry. 1 9 8 8 : 2 7 : 3 4 - 4 1 . 16. Murphy GE. Preven t ion of su ic ide . In: F r a n c e s AJ , Hales RE (eds).

Review of Psychia t ry . vol, 7. W a s h i n g t o n , DC: A m e r i c a n Psych ia t r i c

Press, 1988. 17. F r i e d m a n JM, Asn i s GM, Boeck M. DiFiore J , Prevalence of specif ic

suic idal behav io r s in a h i g h school sample . A m J Psych ia t ry .

1 9 8 7 : 1 4 4 : 1 2 0 3 - 6 .