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Risk factors for nonimmigrant, adolescent-completed suicide and suicidality in North America are similar (1) and have included mood disorders (2), family conflict (3), poor social adjustment (4), substance abuse (5), and behavioural problems (6). One might assume that immigrant adolescents are particularly susceptible to these risks, given the stress of their conflicting allegiances between cultural values of the host country and the country of origin (7) and their often traumatic experiences in the country they left behind (8). Although the 1997 overall suicide rates for Canadian and Quebec youth aged 15 to 24 years were 13.7 and 20.1, respectively, the Canadian immigrant suicide rate, however, has been as low as 6.8 in 1995–1997 among those aged 15 to 24 years (9), and the same trend toward a lower suicide rate for immigrants was observed among youth in the US (10). In an attempt to understand the discrepant suicide rates between host-country and immigrant adolescents and to determine protective factors for future generations of all adolescents, we launched this hypothesis-generating secondary analysis of data compiled during an investigation of a rapid-response approach to suicidal adolescents (11). Two hypothesis-generating questions emerged. First, do immigrant and nonimmigrant adolescents presenting to a Canadian metropolitan pediatric hospital ER for assessment of suicidality differ with respect to recognized diagnostic, demographic, and lifestyle risk factors? Second, are there intergroup differences with respect to the evolution of their disorders over a 6-month period? MethodPlease refer to the original study (11) for a full description of the recruitment process, informed consent, original group assignment, measures, and follow-up procedure. Subjects With respect to the subjects’ and parents’ cultural origins, we collected data for 233 (81%) of the 286 subjects originally recruited. The following 3 groups of adolescents were identified for this analysis: The North American group (n = 134, 57.5%) comprised subjects who, along with their parents, were born in Canada or the US. Although the group was not homogenous, we felt that the nonimmigrant adolescents from these 2 North American countries could comprise one group because they derived from the same geocultural region (12). The Mixed group, consistent with the observations of Lauth Bacas (13), comprised patients (n = 47, 20.2%) with one parent who was born in the US or Canada and the other who was not. Four of these subjects were first-generation immigrants, and 43 were not foreign-born. The Immigrant group (37% first generation and 63% second generation) comprised subjects (n = 52, 22.3%) with both parents born outside of Canada or the US, mainly in Southeast Asia, the West Indies, Europe, and the Middle East. First- and second-generation immigrants were combined into one “Immigrant” group, because this strategy corresponds to standard practice in transcultural investigations (14) and the combination permitted a large enough sample size for comparison with the other groups in this study. Recruitment During the original study period (December 1996 to October 1998), 344 suicidal adolescents aged 12 to 17 years (mean age 14 years), inclusively, came to the ER of a large North American metropolitan teaching hospital. After evaluation by the on-call pediatrician, an immediate psychiatric consultation was requested for assessment of their potential for suicide ideation, suicide threat, or attempt to commit suicide. Of those, 41 (12%) were hospitalized for medical or surgical reasons, and the rest (303, 88%) were approached for participation in a management study of suicidal adolescents (11). Of the latter, 17 (5%) refused to participate. After we obtained informed consent, 286 (83%) adolescents were administered a battery of demographic and diagnostic measures at the time of recruitment and at 6-month follow-up. We recorded patients’ and both biologic parents’ country of origin at baseline. All measures were administered to all patients. The interview protocol at recruitment included the 8 measures and questionnaires described below. Sociodemographic information included information concerning parents’ income, marital status, and place of birth. A substance use questionnaire comprised a list of substances commonly used by adolescents and a scale to record the frequency of use. The IFR (15), administered to patients, quantified the extent, severity, or magnitude of family problems. The Coddington Life Events Scale, a 40-item scale (16), measured the patient’s and family’s stressful and precipitating life events. The DISC (17) was administered to the adolescents, specifically, those sections dealing with DSM-III-R diagnoses that commonly occur among suicidal adolescents—conduct and major affective disorders. The CGAS (18), adapted from the Global Assessment Scale for Adults, measured the patient’s level of functioning. Representing the third part of the Kiddie-SADS (19) it is a 10-category description of adaptive behaviours (for example, level of functioning) scored along a 100-point scale. It is guided in its scoring by questions about the patient’s global functioning: the higher the score on the CGAS, the better the patient’s psychosocial functioning. The Spectrum of Suicidal Behavior Scale (20), administered during a semistructured interview, measured suicidal behaviour in a hierarchy along a 5-point ordinal scale that includes no suicidal behaviour, scored as 1; suicidal ideation, scored as 2; suicidal threats, scored as 3; mild suicide attempts, scored as 4; and serious suicide attempts, scored as 5. We used the Ab-DIB (21) to assess borderline personality disorder. This scale required approximately 10 minutes of administration time during a semistructured interview at the end of the DISC. Evaluation at the 6-month follow-up included the Depression and Conduct Disorder modules, the CGAS, the Spectrum of Suicidal Behavior Scale, the Ab-DIB, and a separate semistructured, 20-minute clinical interview to guide determination of patients’ functioning for the CGAS. In this study, the term suicidality includes points 2 through 5 on Pfeffer’s Spectrum of Suicide Behavior Scale (20): 1) no evidence of suicidal thoughts or actions, 2) suicidal ideation, 3) suicidal threat, 4) mild attempt, and 5) serious attempt. Analysis We calculated descriptive statistics (percentages, means, and SDs) for each of the 3 groups (North American, Mixed, and Immigrant) for demographics, parents’ marital status, immigrant profile, and alcohol and drug use. We analyzed continuous variables at recruitment and at 6-month follow-up, using 1-way ANOVA with group as the factor. ANOVAs were performed on the difference of scores (follow-up compared with baseline), because we were interested in the difference in group change. We analyzed categorical variables at recruitment and at 6 months, using the chi-square test, when applicable, and Fisher’s exact test. ResultsTable 1 provides a demographic profile of the 3 groups. Fisher’s exact test revealed that parents’ marital status and ethnicity differed among groups.
There were no statistically significant intergroup baseline differences with respect to diagnostic measures (for example, depression, conduct disorder, and borderline personality disorder), levels of functioning and of suicidality (noncompletions), use of alcohol, or baseline measures of family functioning and stressful life events (16). However, the North American population used drugs to a statistically significant greater extent at baseline than did either the Immigrant or the Mixed groups (c2 = 20.214; P < 0.05). There were also no intergroup differences regarding the extent of improvement on measures of diagnostic variables from baseline to 6-month follow-up. This same absence of outcome differences applied when we made comparisons between first- and second-generation immigrants, between the North American group and a group of subjects from both the Immigrant and the Mixed groups, and between the Immigrant group and subjects from the both the North American group and the Mixed group. DiscussionThis article reports on the results of a secondary data analysis obtained from a study of suicidal adolescents who presented to the ER of a Canadian metropolitan pediatric hospital. We designed the study to generate hypotheses as to why first- and second-generation immigrant adolescents have a lower suicide rate than do their nonimmigrant host-country peers, including later generations of immigrant adolescents. The only between-group difference observed in this study was the lower rate of reported drug consumption by the Immigrant group at the time of crisis. Since the literature links drug and alcohol use with suicide risk (5,22), it is possible that this correlation could partly account for the decreased suicide rate among Canadian adolescent immigrants. This study also suggests that there are no other statistically significant diagnostic or family functioning differences between suicidal immigrant and nonimmigrant adolescents at baseline and at 6-month follow-up. The relative absence of differences concerning family functioning might seem surprising in light of the stresses that immigrant families experience during their transition to host-country socialization. There are several possible explanations for this. First, the difference could be an artifact of the population sampled, since the limited number and heterogeneity of subjects in this analysis did not permit stratification along geographic lines, which might otherwise have permitted detection of differences. Second, perhaps these immigrant suicidal adolescents are drawn from those who acculturated more to host-country behaviours and idioms of distress than the general population of migrant youth and thus selectively appear similar in profile to their North American peers. This hypothesis is supported by the higher average income reported among our immigrant sample, compared with that reported among Canadian immigrant families (14,23,24). The fact that we selected wealthier immigrant families than those previously reported on might also explain the low level of stressful events experienced by our sample of relatively shielded immigrant youth. Thus the group similarities in this study may reflect the competent help-seeking patterns and service use of a more acculturated subgroup of the immigrant population. Third, but far less likely, it is possible that the cohort of immigrant and nonimmigrant adolescents reported on in this article were not characteristic of adolescents who ultimately complete a suicide. However, as noted earlier, it appears that youth suicide attempters may have similar profiles to suicide completers (1), so the subjects of this study may in fact be representative of youth who are at risk for a completed suicide. Fourth, it is possible that differences between broadly defined groups of immigrant and mainstream adolescents are not apparent with the traditional psychological measures employed in this study and require more subtle instruments or strategies for their detection. In that context, it is interesting to consider that drug use may stimulate impulsivity (25), thus increasing suicide risk among a subset of suicides (26), and can derive from (27) and contribute to family distress and dysfunction, interactions that are difficult to measure. LimitationsIn this hypothesis-generating analysis, the patients were clinic-referred and the groups were not homogeneous; there were fewer subjects in the Mixed and Immigrant groups, precluding definitive conclusions. Future studies can address these limitations in anticipation of second- and thirdgeneration immigrants who may progressively adopt the idioms of distress and behaviour (for example, drug use) of the host-country adolescents (28). Funding and SupportThis study was supported by the Hogg Family Foundation via the Montreal Children’s Hospital Foundation. The original study was supported by Grant 6605-4656-011 from the Canadian National Health Research and Development Program. References1. Gould MS, Greenberg T, Velting DM, Shaffer D. Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2003;42:386–405. 2. Kovacs M, Goldston D, Gatsonis C. Suicidal behaviors and childhood-onset depressive disorders: a longitudinal investigation. J Am Acad Child Adolesc Psychiatry 1993;32:8–20. 3. Spirito A, Valeri S, Boergers J, Donaldson D. Predictors of continued suicidal behavior in adolescents following a suicide attempt. J Clin Child Adolesc Psychol 2003;32:284–9. 4. Pfeffer CR, Klerman GL, Hurt SW, Kakuma T, Peskin JR, Siefker CA. Suicidal children grow up: rates and psychosocial risk factors for suicide attempts during follow-up. J Am Acad Child Adolesc Psychiatry 1993;32:106–13. 5. American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry 2001;40:24S–51S. 6. Sourander A, Helstelä L, Haavisto A, Bergroth L. Suicidal thoughts and attempts among adolescents: a longitudinal 8-year follow-up study. J Affect Disord 2001;63:59–66. 7. Jaycox LH, Stein BD, Kataoka SH, Wong M, Fink A, Escudero P, and others. Violence exposure, posttraumatic stress disorder, and depressive symptoms among recent immigrant schoolchildren. J Am Acad Child Adolesc Psychiatry 2002;41:1104–10. 8. D’Avanzo CE. Southeast Asians: Asian-Pacific Americans at risk for substance misuse. Subst Use Misuse 1997;32:829–48. 9. Malenfant EC. Suicide in Canada’s immigrant population. Health Rep 2004;15(2):9–17. 10. Sorenson SB, Shen H. Youth suicide trends in California: an examination of immigrant and ethnic group risk. Suicide Life Threat Behav 1996;26:143–54. 11. Greenfield B, Larson C, Hechtman L, Rousseau C, Platt R. A rapid-response outpatient model for reducing hospitalization rates among suicidal adolescents. Psychiatr Serv 2002;53:1574–9. 12. Bibeau G, Chan-Yip AM, Lock M, Rousseau C, Sterlin C, Fleury H. La santé mentale et ses visages: un Québec pluriethnique au quotidien. Boucherville (QC): Gaëtan Morin; 1992. 13. Lauth Bacas J. Cross-border marriages and the formation of transnational families: a case study of Greek-German couples in Athens. Oxford: University of Oxford. Transnational communities programme. Working paper series, WPTC-02-10; 2002. Available: www.transcomm.ox.ac.uk/working%20papers/WPTC-02-10%20Bacas.pdf. Accessed 2003 May 22. 14. Beiser M, Hou F, Hyman I, Tousignant M. Poverty, family process, and the mental health of immigrant children in Canada. Am J Public Health 2002;92:220–7. 15. Hudson WW. The clinical measurement package: a field manual. Homewood (IL): Dorsey Press; 1982. 16. Coddington RD. The significance of life events as etiologic factors in the diseases of children. II. A study of a normal population. J Psychosom Res 1972;16:205–13. 17. Costello AJ, Edelbrock C, Dulcan MK, Kalas R, Klaric SH. Development and testing of the NIMH diagnostic interview schedule for children in a clinical population: final report. Rockville (MD): National Institute of Mental Health. Center for Epidemiologic Studies; 1984. 18. Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, and others. A Children’s Global Assessment Scale (CGAS). Arch Gen Psychiatry 1983;40:1228–31. 19. Chambers WJ, Puig-Antich J, Hirsch M, Paez P, Ambrosini PJ, Tabrizi MA, and others. The assessment of affective disorders in children and adolescents by semistructured interview. Test-retest reliability of the schedule for affective disorders and schizophrenia for school-age children, present episode version. Arch Gen Psychiatry 1985;42:696–702. 20. Pfeffer CR. The suicidal child. New York (NY): Guilford Press; 1986. 21. Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL. The revised diagnostic interview for borderlines. J Personal Disord 1989:3:10–8. 22. Preuss UW, Schuckit MA, Smith TL, Danko GP, Bucholz KK, Hesselbrock MN, and others. Predictors and correlates of suicide attempts over 5 years in 1,237 alcohol-dependent men and women. Am J Psychiatry 2003;160:56–63. 23. Munroe-Blum H, Boyle MH, Offord DR, Kates N. Immigrant children: psychiatric disorder, school performance, and service utilization. Am J Orthopsychiatry 1989;59:510–9. 24. Rousseau C, Drapeau A, Platt R. Living conditions and emotional profiles of Cambodian, Central American, and Québécois youth. Can J Psychiatry 2000;45:905–11. 25. Morgan M. Recreational use of “ecstasy” (MDMA) is associated with elevated impulsivity. Neuropsychopharmacology 1998;19:252–64. 26. Turecki G. Dissecting the suicide phenotype: the role of impulsive-aggressive behaviours. J Psychiatry Neurosci 2005;30:398–408. 27. Maharaj RG, Rampersad J, Henry J, Khan KV, Koonj-Beharry B, Mohammed J, and others. Critical incidents contributing to the initiation of substance use and abuse among women attending drug rehabilitation centres in Trinidad and Tobago. West Indian Med J 2005;54:51–8. 28. Fuligni AJ. The academic achievement of adolescents from immigrant families: the roles of family background, attitudes, and behavior. Child Dev 1997;68:351–63. Author(s)Manuscript received August 2005, revised, and accepted December 2005. 1. Assistant Professor, Department of Psychiatry, Faculty of Medicine, McGill University, Montreal, Quebec; Director, Emergency Room Follow-up Team, Montreal Children’s Hospital, Montreal, Quebec. 2. Associate Professor, Department of Psychiatry, Faculty of Medicine, McGill University, Montreal Quebec; Director, Transcultural Child Psychiatry, Montreal Children’s Hospital, Montreal, Quebec. 3. Doctoral Student, Department of Psychology, University of Victoria, Victoria, British Columbia. 4. Doctoral Student, Department of Psychology, McGill University, Montreal, Quebec. 5. Associate Professor of Pediatrics, McGill University, Montreal, Quebec; Consultant Respiratory Physician, Division of Respiratory Medicine, Montreal Children’s Hospital, Montreal, Quebec. 6. Clinical Research Coordinator, Montreal Children’s Hospital, Montreal, Quebec. 7. Associate Dean, John Abbott College, St. Anne de Bellevue, Quebec; Staff, Transcultural Psychiatry, Jewish General Hospital, Montreal Quebec, and Staff, The Montreal Children’s Hospital, Montreal, Quebec. 8. Staff, Consultation Service, Montreal Children’s Hospital, Montreal, Quebec. 9. Student, Marital and Family Therapy Program, Argyle Institute of Human Relations, Montreal, Quebec. 10. Faculty, Concordia University; Faculty of Creative Arts Therapy, Art and Drama Therapist, Emergency Room Follow-Up Team, Montreal Children’s Hospital, Montreal, Quebec. Address for correspondence: Dr B Greenfield, 3450 Drummond # 1114, Montreal, QC H2G 1Y2 e-mail: brian.greenfield@muhc.mcgill.ca
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