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.
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.
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.
white suicides are in the northeast and the deep south.
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.)
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:
and genetic mechanisms may contribute to this relationship.
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:
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
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:
Evaluating the adolescent's mental status includes the following:
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:
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.
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).
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.
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.
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.
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