Adolescent Health Care: A Practical Guide

Chapter 79

Suicide

Sara Sherer

Suicide in adolescents is especially tragic because of the many years of life lost. Adolescent suicide is often precipitated by a stressor that once relieved, greatly reduces the suicidal tendency. Despite the fact that suicide is rare before puberty, it is a significant contributor to adolescent mortality worldwide. More teenagers and young adults die of suicide than from cancer, heart disease, acquired immunodeficiency syndrome, birth defects, stroke, pneumonia and influenza, and chronic lung disease combined. Suicide is the third leading cause of death in adolescence after unintentional injuries and homicide.

Adolescent suicide rates have varied dramatically over the last 50 years. From 1950 to 1990, the suicide rate for adolescents 15- to 24-years-old increased threefold. This increase has been attributed to greater access to firearms and an increase in substance use and abuse. Since 1990, adolescent suicide rates have decreased. A substantial national campaign to reduce the availability of firearms has contributed to a significant reduction in suicide by firearm. In addition, the increase use of antidepressant medications (selective serotonin reuptake inhibitors) is also thought to contribute to the decrease in teen suicide rates.

Although accurate data on attempted suicides are not available, researchers estimate that there are a minimum of 8 to 25 attempted suicides to one completed suicide. Six times as many male youth die by suicide, but girls attempt suicide more often. Tracking youth at high risk for suicide is a complex task. The Center for Disease Control and Prevention (CDC) has collected data on nonlethal suicide behaviors since the early 1990 using the Youth Risk Behavior Surveillance (YRBS). Recent YRBS data does not show a parallel decline in suicide attempts to the decline observed for completed suicides. However, the 2005 YRBS data does show a significant linear decline since 1991 in those high schools students seriously considering suicide in the last 12 months and also those teens who had made a suicide plan in the last 12 months. More studies are necessary to fully understand the relationship between nonlethal suicide behaviors and death by suicide.

Suicidal behaviors may be conceptualized as the adolescent's ultimate, yet inadequate coping behavior. For the adolescent, a suicide attempt may represent an attempt to escape pain or to obtain relief. For the family, suicide imposes grief at the loss, rage at the act of suicide, and guilt for having failed to prevent an untimely death. For the health care professional, a suicide attempt presents a crisis that he or she may feel totally inadequate to handle if lacking prior training.

This chapter discusses adolescent suicide and suicide attempts, including epidemiology, risk profile, etiology, warning signs, evaluation, and treatment.

Epidemiology

  1. Suicide rates: Efforts to estimate attempted and completed suicides are confounded by the fact that many suicide attempts are recorded as accidents. In 2003, 11.9% of all deaths in the 15- to 24-year-old age-group were attributed to suicide (CDC, http://www.cdc.gov/ncipc/wisqars/). The CDC reported 4,316 suicides among 15- to 24-year-olds in the United States in 2004. Thirty-seven percent were 15- to 19-year-old adolescents and 63% were 20- to 24-year-old young adults. In that same year, 283 adolescents 10- to 14-years-old died by suicide. Suicide was also the third leading cause of death for adolescents 10- to 14-years-old (after unintentional injuries and malignant neoplasias).

Since 1950, suicide rates have increased 3 to 4 times for 15- to 24-year-old males. The suicide rate has also increased by approximately 10% for females in the same age-group. Since 1990, suicide rates declined by 28% in 15- to 19-year-old group (from 11.4 to 8.2 per 100,000) and by 17% in 20- to 24-year-olds (from 15.1 to 12.47 per 100,000). However, suicide rates are still higher than what they were in the 1950s.

  1. Suicide rates for adolescent males in the United States are shown in Table 79.1.
  2. Suicide rates for adolescent females in the United States are shown in Table 79.2.
  3. Trends in suicide rates from 1950 to 2004 in the 15 to 24 years age-group are shown in Figure 79.1.
  4. Suicide attempts: Table 79.3 and 79.4 review the results of the 2005 YRBS. The YRBS showed that it is not uncommon for adolescents to consider suicide. It reported that 28.5% of students felt so sad or hopeless almost every day for >2 consecutive weeks that they stopped doing their usual activities. Female and Hispanic teens were more likely to feel sad or hopeless. Overall, 16.9% of students had seriously considered attempting suicide during the 12 months before the

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survey, 13% had a specific suicide plan, and 8.4% had attempted suicide during the preceding 12 months. Youth not attending high school are at higher risk for suicide than those attending school and as such the YRBS probably underestimated the prevalence of nonlethal suicidal behaviors because it is a survey of high school students. Chapter 84 reviews suicide rates in college students.

  1. Ratios of suicide attempts to completed suicide range from 8:1 to 200:1 depending on the study. In 2004 there were 4,316 suicides, approximating anywhere from 32,000 to 800,000 suicide attempts per year. Preventing and accurately assessing for suicide attempts is essential because about one third of all adolescent suicides are committed by youth who were previously known to attempt suicide.
  2. Gender: Males outnumber females (6:1) in completed suicides, whereas females outnumber males (4:1) with respect to suicidal ideation and attempts. The gender difference in the rate of completed suicides is attributed to the suicide method. Males tend to use firearms, a method that is more fatal and prevents high rates of rescue. Females most often ingest poisons, which in the United States results in better rescue opportunities. In 2003, among all age-groups nationwide, white males accounted for 72.5% of all suicides and both white males and females accounted for >90% of all suicides.
  3. Race: As in previous years, the 2004 suicide rate among Native American male adolescents (30.90 per 100,000) was significantly higher than the overall suicide rate and the rates reported for non-Hispanic white males (18.95 per 100,000), African-American males (12.2 per 100,000), and Latino males (13.45 per 100,000). From 1980 to the early 1990s, suicidal behaviors among all adolescents increased. However, rates for African-American adolescents increased at a higher rate, having more than doubled during that time and therefore dramatically shrinking the gap between the races. Since the early 1990s, adolescent suicide rates have been falling, but the suicide rate for African-American youth between 10 and 19 years of age fell by only 26.5%, demonstrating a higher vulnerability in this group. Hispanic adolescents report more suicide attempts than any other ethnic group. In the 2005 YRBS, 11.3% of the Latino high school students reported a suicide attempt compared to 7.6% African-American and 7.3% white students. Latino females were 2.5 times more likely to report a suicide attempt than Latino males.
  4. Age: Suicide is uncommon in adolescents younger than 14 years. There is a dramatic rise in the rates of suicide thereafter. The largest increase in suicide rates since 1970 has been in 15- to 19-year-old males.
  5. Psychiatric comorbidity: Rich et al. (1986) summarized their study results by concluding that “psychiatric illness is a necessary (but insufficient) condition for suicide.” A review of the literature indicates that a history of a suicide attempt and a history or diagnosis of a mental or addictive disorder is associated with 90% of suicides. The most common psychiatric illnesses are mood disorders, alcohol and substance use disorders, conduct disorders, and anxiety disorders. Sixty percent of youth who complete suicide suffered from depression. Suffering from a depressive disorder and the expression of hopelessness is also associated with suicidal ideation and attempts. Other factors contributing to suicide attempts include impulsive, aggressive, and antisocial behaviors.
  6. Method used for completed suicides
  7. Firearms and explosives: Firearms are the most common method used in adolescent suicide. This is the case for both males and females. The use of firearms is more common in male suicides. However, firearm suicides have increased significantly in female adolescents. In 2004, firearms accounted for 49% of adolescent suicides. The CDC attributes almost all of the increase in the suicide rates since the 1980s to firearm-related suicides.

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  1. Suffocation: Among adolescents 10 to 14 years old, suffocation (especially hanging) has replaced firearms as the most common method used in suicides. In 2004, suffocation accounted for 35% of suicides in 15- to 24-years-olds.
  2. Poisoning: In 2004, poison was used in 8.4% of adolescent suicides.
  3. Other: A small percentage of suicides are accomplished through gas poisoning, cutting and piercing with a sharp instrument, or jumping from high places.
  4. Marital status: In the general population, suicide rates are lower for married individuals. In contrast, married adolescents between 15 and 19 years of age have a 1.5 to 1.7 times higher suicide rate compared to unmarried individuals.
  5. Season: Suicide rates increase in the spring and fall.
  6. Geography: Suicide rates are highest in the western United States and Alaska and lowest in the southern, north-central, northwestern, and midwestern states. The lowest rates for both African-American and

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white suicides are in the northeast and the deep south.

  1. Suicide at college: Suicide is the third leading cause of death on college campuses. Most studies indicate that suicide rates in college students are no higher than that in the general population for the same age-group. College students who commit suicide tend to be depressed, quiet, and socially isolated, whereas young adults in the noncollege population tend to abuse substances and demonstrate impulsive and risk-taking behaviors. Approximately 10% of college students contemplate suicide each year; 5% to 6% make a plan and approximately 1.5% attempt (see Chapter 84 for more information on suicide in college students).

TABLE 79.1
Adolescent Male Suicide Rates in the United States

Year

Suicide Rate in 15- to 19-Year-Olds (per 100,000)

Suicide Rate in 20- to 24-Year-Olds (per 100,000)

From US Department of Health and Human Services. Center for Disease Control and Prevention. National Center for Health Statistics. Health, United States, 2004 With Chartbook on trends in Health of Americans. Hyattsville, Maryland: 2004 and National Center for Injury Prevention and control: at http://www.cdc.gov/nchs/data/hus/hus04.pdf.

1950

3.5

9.3

1960

5.6

11.5

1970

8.8

19.3

1980

13.8

26.8

1990

18.1

25.7

2000

13.0

21.4

2001

12.9

20.5

2002

12.2

20.8

2003

11.62

20.25

2004

12.65

20.85

TABLE 79.2
Adolescent Female Suicide Rates in the United States

Year

Suicide Rate in 15- to 19-Year-Olds (per 100,000)

Suicide Rate in 20- to 24-Year-Olds (per 100,000)

From US Department of Health and Human Services. Center for Disease Control and Prevention. National Center for Health Statistics. Health, United States, 2004 With Chartbook on trends in Health of Americans. Hyattsville, Maryland: 2004 and National Center for Injury Prevention and control: at http://www.cdc.gov/nchs/data/hus/hus04.pdf.

1950

1.8

3.3

1960

1.6

2.9

1970

2.9

5.7

1980

3.0

5.5

1990

3.7

4.1

2000

2.7

3.2

2001

2.7

3.1

2002

2.4

3.5

2003

2.66

3.39

2004

3.52

3.59

 

FIGURE 79.1 Suicide rates for adolescents 15 to 24 years of age, 1950 to 2004. (Adapted from U.S. Department of Health and Human Services. Center for Disease Control and Prevention. National Center for Health Statistics. Health, United States, 2006 with chartbook on trends in health of Americans. Hyattsville: 2006.)

TABLE 79.3
Behaviors Related to Attempted Suicide Among High School Students During 12 Months Preceding Survey, 2005

Category

Seriously Considered Attempting Suicide (%)

Made a Suicide Plan (%)

Attempted Suicide (%)

Suicide Attempt Required Medical Attention (%)

From Centers for Disease Control and Prevention. Youth risk behaviors surveillance—United States, 2005, Surveillance Summaries, June 9, 2006. MMWR 2006;55 (No. SS-5).

Sex

       

 Female

21.8

16.2

10.85

2.9

 Male

12.0

9.9

6.0

1.8

Grade

       

 9

17.9

13.9

10.4

3.0

 10

17.3

14.1

9.1

2.3

 11

16.8

12.9

7.8

2.2

 12

14.8

10.5

5.4

1.6

Race or ethnicity

       

 White

16.9

12.5

7.3

2.1

 African-American

12.2

9.6

7.6

2.0

 Hispanic

17.9

14.5

11.3

3.2

Total

16.9

13.0

8.4

2.3

TABLE 79.4
Trends in Behaviors Related to Suicide Among High School Students During 12 Months Preceding Survey, 2005

Category

Seriously Considered Attempting Suicidea (%)

Made a Suicide Plana (%)

Attempted Suicideb (%)

Suicide Attempt Required Medical Attentionb (%)

aSignificant linear decrease in rates between 1991 and 2005. 
bNo significant change between 1991 and 2005. 
From Centers for Disease Control and Prevention. Youth risk behaviors surveillance—United States, 2003, Surveillance Summaries, May 21, 2004. MMWR 2004; 53 (No. SS-2):[45–47].

1991

29.0

18.6

7.3

1.7

1993

24.1

19.0

8.6

2.7

1995

24.1

17.7

8.7

2.8

1997

20.5

15.7

8.7

2.6

1999

19.3

14.5

8.3

2.6

2001

19.0

14.8

8.8

2.6

2003

16.9

16.5

8.5

2.9

2005

16.9

13.0

8.4

2.3

Risk Factors

To date, there are no assessment tools to help identify adolescents who will attempt suicide. Risk factors for suicide frequently occur in combination with each other. Certain risk factors should increase the health care provider's index of suspicion for a potentially suicidal adolescent. A risk assessment identifies both risk factors and protective factors and can help differentiate the risk factors that can be modified from ones that cannot. The following text outlines risk factors for suicide:

  1. A history of co-occurring mental disorder and substance abuse disorder: More than 90% of teen suicide victims have a mental disorder such as depression and/or a history of alcohol or drug abuse. Studies report that the rate of substance abuse disorders is 7.5 to 9 times higher in adolescents who complete suicide compared to their nonsuicidal peers. Psychological autopsies reveal that most teens who complete suicide suffered from depression and experienced higher levels of hopelessness, helplessness, or low self-esteem than their nonsuicidal peers. There appears to be a strong association between adolescent suicide behavior and substance abuse. Adolescents who abuse psychoactive substances experience greater psychological distress and appear to be at higher risk for suicidal behavior.
  2. Prior suicide attempts: A previous suicide attempt is one of the strongest predictors of both future attempts and death by suicide. Approximately one third of teenage suicide victims have made a previous suicide attempt. A male teen who has attempted suicide in the past is >30 times more likely to complete a suicide than a male who has never attempted before. A female teen with a history of a suicide attempt presents with 3 times the risk of suicide. This relationship is the strongest among adolescents suffering from mood disorders. It is important to assess the adolescent's intention to repeat, the agent used in a past attempt (jumping and shooting are of higher risk than ingestion or cutting), and the location and likelihood of rescue (the risk is higher among adolescents who have attempted suicide in a remote site or who have taken steps to eliminate or reduce the probability of discovery).
  3. History of suicide in the family: A history of suicide attempt(s) or completed suicides among first- or second-degree relatives substantially increases the likelihood of attempted and completed suicides in the adolescent. This relationship exists even when studies control for parental psychopathology.
  4. History of prior physical and sexual abuse: Adolescents who had been physically or sexually abused are significantly more likely to experience suicidal thoughts and behaviors than those adolescents who have not been exposed to this type of abuse. Some studies report up to a 5 times greater risk of suicide in adolescents with a prior history of physical abuse and a threefold increase of suicidal behaviors in teens with a history of sexual abuse. Runway and homeless youth, who often report escaping abuse and neglect, are especially vulnerable.
  5. Family history of mental and substance abuse disorders: The parents of suicidal adolescents consistently show higher rates of mood disorders, substance abuse, and aggressive and suicidal behaviors. Environmental

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and genetic mechanisms may contribute to this relationship.

  1. History of a broken family or family discord including low levels of communication with parents: Parent–child conflict and lack of family support increases the likelihood of suicidal behaviors. Other family influences include a history of violence, family disruption due to death, divorce, moving, and rapid sociocultural changes. This relationship is strongest among younger adolescents.
  2. Stressful life event or loss: Psychosocial problems and stressors are often cited by adolescents as reasons for attempting suicide. It is important to recognize that the degree of stress the adolescent experiences is subjective and reflects a personal level of vulnerability (such as experiencing a loss of a significant person or relationship, a conflict with parents or peers, problems at school, or the risk of incarceration). Suicidal behaviors resulting from stressful life events are more common in adolescents than in adults.
  3. Gay and bisexual adolescents: Gay and bisexual youth are confronted by challenges in domains such as identity development, family and community values that stigmatize homosexuality, and a climate of homophobic attitudes. Research shows that gay and bisexual adolescents experience higher rates of depression and gay males are 4 times more likely than their heterosexual peers to attempt suicide.
  4. Easy access to firearms: In 2004, almost half of 15- to 24-year-olds who completed suicide used a firearm. The most common location for teen suicides by firearms is in their homes. The risk is directly related to the accessibility and the number of guns in the home. The presence of firearms in the home is associated with a 31.3 to 107.9 times increase in adolescent suicide even in the absence of clear psychiatric illness. Some researchers claim that suicides by firearms tend to be more impulsive and spontaneous.
  5. Suicide contagion: Suicide clusters and imitating suicide has been reported throughout human history. They account for 1% to 5% of all teen suicides in the United States. Although rare, they are observed on high school and college campuses, among religious sects, in prisons, and among marine troops. They often follow highly publicized suicides of teenagers and popular young adults. They can be provoked by membership in the same educational or social groups and shared environmental stressors. It is not necessary for the decedents to know each other or to have direct contact.

Research in chronic illness in adolescents and young adults show a significant association between chronic illness, emotional distress, and suicidality that persists even after adjusting for depressive illness and alcohol use. The association is especially significant for adolescent females. The findings support the need to screen for suicidality in general medical settings, especially in adolescents presenting with a range of physical health problems and in those with chronic illness.

The Adolescent Suicide Attempt

Although each suicidal adolescent is different, many exhibit a behavioral pattern that can be broken down into the following four components:

  1. Long-standing history of difficulties: Suicide is a disease of deficiency, a deficiency of early social connections that a developing teen uses later as the basis for conflict resolution and problem-solving skills. Many adolescents who attempt suicide exhibit a long history of deficiency that creates an underlying vulnerability. These problems include parents or relatives who have attempted suicide, one or both natural parents absent from the home, unwanted stepparents, divorce in the family, history of family conflicts, parents with alcohol problems, history of foster placements, or marked residential mobility.
  2. Escalation phase: For many adolescents who have attempted suicide, the vulnerability created during childhood increases during adolescence. This period of escalating difficulties is characterized by frequent family conflicts as the family fails to deal adequately with the adolescent developmental process. The adolescent often begins to feel isolated from his or her family and other social structures. Significant physical or mental illness in the family and loss of the family unit may also exacerbate the adolescent's vulnerability.
  3. Progressive social isolation: Failure of available adaptive techniques for coping with old and new problems often leaves the suicidal adolescent feeling progressively more socially isolated. This is often associated with a significant breakdown of communication with parents. The adolescent seems to have lost or never developed the capability to appropriately express his or her feelings. Although these adolescents are often depressed, one must remember that child and adolescent depression may not mirror the typical adult behaviors of depressed affect. In fact, adolescent depression may manifest itself through oppositional or evasive behaviors such as reduced school attendance and performance, substance abuse, delinquency, runaway behavior, early onset of sexual activity, or sexual promiscuity.
  4. Final stage: The suicide attempt is often preceded by a precipitating event that caps this long process of increasing despair. Precipitating events often include a family conflict, loss of a girlfriend or boyfriend, school problems, pregnancy, or loss or death of a friend or relative.

Warning Signs

Several signs should alert family, friends, and health care providers to the potential for suicide. These prodromal signs include sadness, hopelessness, emptiness, lack of energy, insomnia, eating problems, loss of interest in social life and school, boredom, loneliness, irritability, truancy, substance abuse, or a change in social behavior. Other signs include atypical accident proneness, giving away prized possessions, and statements such as, “My family (or the world) would be better off without me.”

Assessment of the Suicidal Adolescent

Interview and History

All adolescents identified to be at risk of suicide need help. Most suicidal adolescents are not likely to initiate help-seeking behaviors. The adolescents who seek help should

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be interviewed alone as long as they can provide a clear history. The clinician should involve parents or guardians at some point during the assessment. Asking adolescents about suicide or using a screening tool will not cause them to attempt suicide. In fact, asking an adolescent about suicidal feelings can come as a great relief and can provide an opportunity for the adolescent to get help.

The interview with the adolescent should consist of open-ended nonjudgmental questions. For instance, “When you feel sad or depressed do you ever feel like there is no hope?” If the answer is yes, the clinician should follow-up with more direct, close-ended questions like, “Have you ever felt so sad or depressed that you thought about killing yourself?” If the response is yes, the clinician should follow-up with questions to assess suicide risk. Any adolescent with a well-thought-out plan that includes intent, plan for place and time, and access to lethal means should be considered to be at high risk. Even adolescents presenting with low or medium risk must be screened to assess past and present suicide-related factors. On the basis of the screening, the degree of protection and intervention necessary can then be determined.

The following issues need to be assessed:

  1. All suicidal adolescents
  2. Sex and age of adolescent
  3. History of mental disorders including history of substance abuse
  4. Description of current depressive symptoms
  5. History of accidents or prior self-destructive behavior
  6. History of suicide attempts, mental disorders, or substance abuse in family members
  7. History of family, school, or peer problems
  8. History of incest or abuse (physical, sexual, or emotional)
  9. Sexual orientation
  10. Recent experience of loss
  11. Prior use of coping strategies
  12. Available support systems including reaction by parents and others: Do the parents take the attempt seriously and are they supportive of seeking help? What family or peer support system will the adolescent be returning to at home?
  13. Adolescents who present with suicidal ideation
  14. Suicidal ideations (type and frequency)
  15. Plan and motivation
  16. Access to methods (especially firearms)
  17. History or evidence of prior suicide attempts
  18. History of depression
  19. History of substance use
  20. Life stressor (e.g., school difficulties, relationship issues, job loss) that precipitated the thoughts
  21. Access to firearms and other weapons
  22. Access to potentially harmful medications
  23. Adolescent who has attempted suicide
  24. Medical therapy: The first priority is to treat any life-threatening medical complication of the suicide attempt.
  25. Physical protection: The suicidal adolescent should be provided with immediate physical protection so that a reattempt does not occur. Depending on the degree of risk and the resources available, an adolescent should be hospitalized or sent home with family members who know how to ensure the youth's safety and are aware of the help resources that are available to the family.
  26. Psychological evaluation: As soon as the medical evaluation and treatment are completed, an initial evaluation should be performed. This evaluation should attempt to assess the following:
  • Method: Lethality and access to means
  • Timing: Sudden impulse versus a well planned attempt
  • Intent: Strength of intention to die
  • Desire to repeat
  • Circumstances surrounding the attempt: Possibility of rescue versus an attempt carried out in isolation
  • Life stressor (e.g., school difficulties, relationship issues, job loss) that precipitated the attempt
  • Access to firearms and other weapons
  • Access to potentially harmful medications

Mental Status

Evaluating the adolescent's mental status includes the following:

  1. Level of depression, level of hopelessness, helplessness, and self-esteem
  2. Feelings of expendability (e.g., the adolescent feels not important to the family and that to some extent the family would be “better off” without the adolescent)
  3. Openness to further interventions
  4. Level of panic and disorganization
  5. Attitude about death
  6. A suicide scale such as the Child-Adolescent Suicide Potential Index or voluntary school screening instruments such as the Columbia Suicide Screen can also be administered. These scales and screening instruments must be followed by a clinical interview conducted by a mental health professional. Furthermore, they cannot substitute for a thorough suicide assessment, which will help determine if further evaluation and treatment are needed. Following the clinical interview, the parents or guardians of the minor adolescent must be informed about treatment recommendations. In addition, appropriate referral information must be provided to the patient and family.

Disposition

The disposition of the suicidal adolescent often depends on the resources available to the patient, family, and health care provider. Although a consultation with a mental health provider is recommended for all suicide assessments, this service is not always available. The following is intended as guiding principles to help determine the most appropriate arrangement for the suicidal adolescent:

  1. Indications for inpatient hospitalization
  2. Medical complications
  3. Patient is psychotic
  4. Attempt was near-lethal, premeditated, or involved use of a lethal method with clear intent to die
  5. An uncommunicative adolescent who cannot establish a trusting relationship with the evaluator, someone who communicates ambivalence regarding the will to live, or someone who has a persistent intent to die
  6. History of a psychiatric disorder(s) or substance abuse (especially with current intoxication)

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  1. Current agitation, poor judgment, or refusal of help
  2. Lack of family support

High-risk adolescents (presenting with a strong wish to die and a persistent plan to hurt themselves) must remain in a safe and protected environment. Patient and parental consent is highly recommended. However, if the adolescent refuses voluntary admission, procedures for involuntary hospitalization should be initiated. Discharge should be considered once the suicide risk has declined and the youth and family are able to utilize appropriate resources. Following discharge, the adolescent and the family should receive intense outpatient mental health services to manage the psychological needs of the adolescent.

  1. Indications for outpatient management
  2. Outpatient management should only be considered if the adolescent has demonstrated a low suicide risk (no current wish to die and no current plan to hurt oneself; close outpatient follow-up) and if the adolescent has a supportive home environment where appropriate supervision can be established.
  3. Adolescent no longer feels actively suicidal and does not wish to die.
  4. No history of a serious suicide attempt (plan, method, and intent have low lethality).
  5. No evidence of long-standing psychiatric disorder, especially severe depression or substance abuse.
  6. Adolescent has a supportive family willing to help, and communication at home is appropriate. An adult at home is capable of securing the environment and accessing additional services as determined.
  7. Appropriate medical and psychosocial follow-up has been arranged.

Follow-up

Every suicidal adolescent should have conscientious follow-up care by a psychiatrist, psychologist, or other qualified mental health provider. The adolescent and family should be provided with these services when a decision is made to either not hospitalize the adolescent or discharge the adolescent from the hospital. The collaborative care between a medical physician and the mental health providers is an essential component to follow-up. Initially, weekly or more frequent mental health visits should be scheduled. During this period, the adolescent's problems can be explored, with careful attention given to the areas of school, social and family problems, and existing support mechanisms.

The outpatient management of an at-risk adolescent is characterized by close follow-up with an appropriate mental health provider. Often a no-suicide contract is established. A no-suicide contract is an agreement in which the adolescent promises not to harm or kill himself or herself. No-suicide contracts can be written or verbal. The no-suicide contract is a tool used to document the adolescent's and family's responsibilities, expectations, and desire for change. Although it is common practice to develop and sign a no-suicide contract in the outpatient setting, the health care provider should be aware that a signed contract does not eliminate suicide risk. This tool should be used as an adjunct to an ongoing comprehensive evaluation and treatment plan. These contracts do not provide legal protection and should be viewed as a tool to assess the degree to which the adolescent feels capable to keep oneself safe. If the attempt to develop a no-suicide contract reveals suicidal ideations, or the suicide potential is judged to be high, voluntary or involuntary hospitalization should be reconsidered. If the adolescent is at risk of suicide, the appropriate persons should be notified.

Suicidal ideation, gestures, or attempts must be taken seriously, even if one suspects that these behaviors are a “manipulative attempt” to get attention. The clinician should attend to these behaviors in a supportive and professional manner.

Recommendations for Primary Care Physicians

Adapted from a policy statement by the American Academy of Pediatrics (April, 2000).

  1. Know the risk factors associated with adolescent suicide. Be prepared to serve as a resource to adolescents, parents, and other members of the community.
  2. Routinely ask questions about depression and suicide.
  3. Ask specific questions about the availability of firearms. Advise parents of suicidal teens to remove firearms and other potential methods from the home.
  4. Recognize the medical and psychiatric needs of the suicidal adolescent, and work closely with health care professionals and family members to best manage the suicidal adolescent.
  5. Physicians should become familiar with local, state, and national resources concerned with youth suicide. Working relations should be established with colleagues specializing in adolescent suicide to manage the care and follow-up of adolescents at risk of suicide.

Suicide Prevention

In 1999, David Satcher, the Surgeon General, hosted a press conference where he unveiled a blueprint to prevent suicide in the United States. The document entitled The Surgeon General's Call to Action to Prevent Suicide outlined more than a dozen steps that individuals, communities, organizations, and policy makers can take to prevent suicide. The call for action resulted in a task force established by the Department of Health and Human Services (DHHS). In 2001, the DHHS published the National Strategy for Suicide Prevention (NSSP): Goals and Objectives for Action. The document identified multiple goals and objectives in the areas of awareness, intervention, and methodology of suicide prevention. The NSSP represents the first U.S. attempt at suicide prevention through a coordinated approach. Information about NSSP is available at the DHHS Web site www.mentalhealth.samhsa.gov/suicideprevention/strategy.asp.

Web Sites

http://www.suicidology.org Provides information on current research, prevention, and help for the suicidal person. A list of crisis centers and support groups is also included.

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http://www.afsp.org The American Foundation for Suicide Prevention provides research, education, and current statistics regarding suicide.

http://www.suicidehotlines.com Suicide Crisis Center provides a state-by-state listing of suicide-prevention resources.

http://www.aap.org/pubed/ZZZ7FR2VR7C.htm?&sub_cat=1 Information on suicide from the American Academy of Pediatrics and fact sheets for parents and caregivers on teen depression and preventing youth suicide.

http://www.safeyouth.org/scripts/index.asp National Youth Violence Prevention Resource Center includes hot topics on youth suicide.

http://www.aacap.org/publications/factsfam/suicide.htm The American Academy of Child and Adolescent Psychiatry Web site includes facts for families, including information on teen suicide, depression, and other related topics.

http://www.cdc.gov/nchs/hus.htm Center for Disease Control and Prevention (CDC), the National Center for Health Statistics.

http://www.spanusa.org Suicide Prevention Advocacy Network.

http://www.suicidology.org American Association of Suicidology or call-1-800-273-TALK.

http://www.teenscreen.org/index.htm Columbia University Teen Screen program.

References and Additional Readings

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 Psychiatry 2001;40(Suppl 7):24S.

American Academy of Pediatrics, Committee on Adolescents. Suicide and suicide attempts in adolescents. Pediatrics 2000;105:871.

Anderson RN, Smith BL. Deaths: leading causes for 2002. National vital statistics reports, Vol. 53 No. 17 Hyattsville, MD: National Center for health Statistics, 2005.

Bagley C, Tremblay P. Elevated rates of suicidal behavior in gay, lesbian, and bisexual youth. Crisis: J Crisis Interv Suicide 2000;21(3):111.

Beautrais AL. Gender issues in youth suicidal behaviour. Emerg Med (Fremantle) 2002;14(1):35.

Beautrais AL. Risk factors for suicide and attempted suicide among young people. Aust N Z J Psychiatry 2000;34(3):420.

Berman AL, Jobes DA. Adolescent suicide: assessment and intervention. Washington, DC: American Psychological Association, 1991.

Brent DA, Baugher M, Bridge J, et al. Age-and sex-related risk factors for adolescent suicide. J Am Acad Child Adolesc Psychiatry 1999;38:1497.

Brent DA. Assessment and treatment of the youthful suicidal patient. Ann N Y Acad Sci 2001;932:106.

Canetto SS. Meanings of gender and suicidal behavior during adolescence. Suicide Life Threat Behav 1997;27(4):339.

Cantor CH, Baume PJ. Access to methods of suicide: what impact? Aust N Z J Psychiatry 1998;32(1):8.

Cavaiola AA, Lavender A. Suicidal behavior in chemically dependent adolescents. Adolescence 1999;34:735.

Cavanagh JT, Carson AJ, Sharpe M, et al. Psychological autopsy studies of suicide: a systematic review. Psychol Med 2003;33(3):395.

Craney JL, Geller B. A prepubertal and early adolescent bipolar disorder-I phenotype: review of phenomenology and longitudinal course. Bipolar Disord 2003;5(4):243.

Centers for Disease Control and Prevention. Methods of suicide among persons aged 10–19 years, United States, 1992–2001. MMWR 2004;53:471.

Centers for Disease Control and Prevention. Surveillance SummariesMMWR 2004;53(SS-2).

Center for Disease Control and Prevention. WISQARS. National Center for Health Statistics (NCHS) National Vital Statistics System, 2005.

Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2005. MMWR CDC Surveill Summ 2006;55(SS05):1.

Douglas J, Brewer M. American psychiatric association practice guideline for assessing and treating patients with suicidal behaviors. Psychiatr Ann 2004;34(5):373.

Druss B, Pincus H. Suicidal ideation and suicide attempts in general medical illnesses. Arch Intern Med 2000;160:1522.

Esposito-Smythers C, Spirito A. Adolescent substance use and suicidal behavior: a review with implications for treatment research. Alcohol Clin Exp Res 2004;28(Suppl 5):77S.

Evans E, Hawton K, Rodham K. Factors associated with suicidal phenomena in adolescents: a systematic review of population-based studies. Clin Psychol Rev 2004;24(8):957.

Evans E, Hawton K, Rodham K. Suicidal phenomena and abuse in adolescents: a review of epidemiological studies. Child Abuse Negl 2005;29(1):45.

Fergusson DM, Horwood LJ, Beautrais AL. Is sexual orientation related to mental health problems and suicidality in young people? Arch Gen Psychiatry 1999;56:876.

Frankenfield D, Keyl PM, Gielen A, et al. Adolescent patients—healthy or hurting? Missed opportunities to screen for suicide risk in the primary care setting. Arch Pediatr Adolesc Med 2000;154:162.

Galloucis M, Francek H. The Juvenile Suicide Assessment: an instrument for the assessment and management of suicide risk with incarcerated juveniles. Int J Emerg Ment Health2002;4(3):181.

Gary FA, Yarandi HN, Scruggs FC. Suicide among African Americans: reflections and a call to action. Issues Ment Health Nurs 2003;24(3):353.

Gould MS Suicide Contagion. Research article—American Foundation for Suicide Prevention. http://www.afsp.org/research/articles/gould.html.

Gould MS, Greenberg T, Velting DM, et al. Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2003;42(4):386.

Gould MS, Marrocco FA, Kleinman M, et al. Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA 2005;293(13):1635.

Haliburn J. Reasons for adolescent suicide attempts. J Am Acad Child Adolesc Psychiatry 2000;39:13.

Handwerk ML, Larzelere RE, Friman PC, et al. The relationship between lethality of attempted suicide and prior suicide communications in a sample of residential youth. J Adolesc 1998;21:407.

Hart TA, Heimberg RG. Presenting problems among treatment seeking gay, lesbian, and bisexual youth. J Clin Psychol 2001;57(5):615.

Hawton K, James A. Suicide and deliberate self harm in young people. BMJ 2005;330(7496):891.

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James A, Lai FH, Dahl C. Attention deficit hyperactivity disorder and suicide: a review of possible associations. Acta Psychiatr Scand 2004;110(6):408.

Kennedy SP, Baraff LB, Suddath R, et al. Emergency department management of suicidal adolescents. Ann Emerg Med 2004;43(4):452.

Koplin B. Agathen J Suicidality in children and adolescents: a review. Curr Opin Pediatr 2002;14(6):713.

Kulkin HS, Chauvin EA, Percle GA. Suicide among gay and lesbian adolescents and young adults: a review of the literature. J Homosex 2000;40(1):1.

Lebson M. Suicide among homosexual youth. J Homosex 2002;42(4):107.

Links PS, Gould B, Ratnayake R. Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry 2003;48(5):301.

Londino DL, Mabe PA, Josephson AM. Child and adolescent psychiatric emergencies: family psychodynamic issues. Child Adolesc Psychiatr Clin N Am 2003;12(4):629.

Malone KM, Oquendo MA, Haas GL, et al. Protective factors against suicidal acts in major depression: reasons for living. Am J Psychiatry 2000;157:1084.

McBride HE, Siegel LS. Learning disabilities and adolescent suicide. J Learn Disabil 1997;30:652.

McKeown RE, Garrison CZ, Cuffe SP. Incidence and predictors of suicidal behaviors in a longitudinal sample of young adolescents. J Am Acad Child Adolesc Psychiatry 1998;37:612.

McQuillan CT, Rodriguez J. Adolescent suicide: a review of the literature. Bol Asoc Med P R 2000;92(1–3):30.

Miller AL. Dialectical behavior therapy: a new treatment approach for suicidal adolescents. Am J Psychother 1999;53(3):413.

Miller AL, Glinski J. Youth suicidal behavior: assessment and intervention. J Clin Psychol 2000;56(9):1131.

Mino A, Bousquet A, Broers B. Substance abuse and drug-related death, suicidal ideation, and suicide: a review. Crisis 1999;20:28.

Moscicki EK. Identification of suicide risk factors using epidemiologic studies. Psychiatr Clin North Am 1997;20(3):499.

Moskos MA, Achilles J, Gray D. Adolescent suicide myths in the United States. Crisis: J Crisis Interv Suicide 2004;25(4):176.

National Center for Health Statistics. Health, United States, 2004 With Chartbook on Trends in Health of Americans. Hyattsville, MD: 2004. Accessed at http://www.cdc.gov/nchs/data/hus/hus04.pdf

Pelkonen M, Marttunen M. Child and adolescent suicide: epidemiology, risk factors, and approaches to prevention. Paediatr Drugs 2003;5(4):243.

Pfeffer C, Normandin L, Kakuma T. Suicidal children grow up: suicidal behavior and psychiatric disorders among relatives. J Am Acad Child Adolesc Psychiatry 1994;33:8.

Pfeffer CR. Childhood suicidal behavior. A developmental perspective. Psychiatr Clin North Am 1997;20(3):551.

Pfeffer CR. Diagnosis of childhood and adolescent suicidal behavior: unmet needs for suicide prevention. Biol Psychiatry 2001;49(12):1055.

Pfeffer CR, Jiang H, Kakuma T. Child-Adolescent Suicidal Potential Index (CASPI): a screen for risk for early onset suicidal behavior. Psychol Assess 2000;12(3):304.

Poland S, Lieberman R. Questions and answers: suicide interventions in the schools. NASP Communique 2004;31:7.

Pumariega AJ, Rothe E. Cultural considerations in child and adolescent psychiatric emergencies and crises. Child Adolesc Psychiatr Clin N Am 2003;12(4):723.

Remafedi G. Sexual orientation and youth suicide. JAMA 1999;282:1291.

Rich CL, Young D, Fowler RC. San Diego suicide study. I. Young vs. old subjects. Arch Gen Psychiatry 1986;43:577.

Rosenberg ML, Mercy JA, Potter LB. Firearms and suicide [Editorial]. N Engl J Med 1999;341:1609.

Rosewater KM, Burr BH. Epidemiology, risk factors, intervention, and prevention of adolescent suicide. Curr Opin Pediatr 1998;10(4):338.

Rowan AB. Adolescent substance abuse and suicide. Depress Anxiety 2001;14(3):186.

Safer DJ. Self-reported suicide attempts by adolescents. Ann Clin Psychiatry 1997;9(4):263.

Safer DJ. Adolescent/adult differences in suicidal behavior and outcome. Ann Clin Psychiatry 1997;9(1):61.

Sanchez LE, Le LT. Suicide in mood disorders. Depress Anxiety 2001;14(3):177.

Shaffer D, Pfeffer CR. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry2001;40(7):24S.

Shaffer D, Scott M, Wilcox H, et al. The Columbia suicide screen: validity and reliability of a screen for youth suicide and depression. J Am Acad Child Adolesc Psychiatry2004;43:71.

Shenassa ED, Rogers ML, Spalding KL, et al. Safer storage of firearms at home and risk of suicide: a study of protective factors in a nationally representative sample. J Epidemiol Community Health 2004;58(10):841.

Spirito A, Overholser J. The suicidal child: assessment and management of adolescents after a suicide attempt. Child Adolesc Psychiatr Clin N Am 2003;12(4):649.

Suicide Prevention Resource Center. Promoting mental health and preventing suicide in college and university settings. Newton, MA: Education Development Center, Inc, 2004.

Suris JC, Parera N, Puig C. Chronic illness and emotional distress in adolescence. J Adolesc Health Care 1996;19(2):153.

U.S. Department of Health and Human Services. National strategy for suicide prevention; Goals and objectives for action. Rockville, MD: U.S. Department of Health and Human Services, 2001.

U.S. Preventive Services Task Force Screening for suicide risk: recommendation and rationale. Ann Intern Med 2004;140:820.

U.S. Public Health Service. The surgeon general's call to action to prevent suicide. Washington, DC: U.S. Public Health Service, 1999.

Van Heeringen C. Suicide in adolescents. Int Clin Psychopharmacol 2001;16(Suppl 2):S1.

Welch SS. A review of the literature on the epidemiology of parasuicide in the general population. Psychiatr Serv 2001;52(3):368.

Wilcox HC, Conner KR, Caine ED. Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug Alcohol Depend2004;76(Suppl):S11.

Willis LA, Coombs DW, Drentea P. et al Uncovering the mystery: factors of African American suicide. Suicide Life Threat Behav 2003;33(4):412.