In the adolescent and young adult population, suicide continues to be a growing and difficult challenge in the United States and globally. Worldwide, suicide is the second leading cause of death in adolescents and young adults age 15 to 29 years.1 In the United States, it has become the second leading cause of death (behind unintentional injury) for young people age 10 to 24 years.2 For younger adolescents, the number of suicide incidents for those age 10 to 14 years is 517, compared to 6,252 among adolescents and young adults age 15 to 24 years.2 It is notable that suicide accounts for approximately 60% of deaths compared to unintentional injury in the younger category, and approximately 47% of deaths compared to unintentional injury in the older group.2
Gender does seem to play a role in the incidence and expression of suicidality. According to the Centers for Disease Control and Prevention, adolescent boys and young adult men (age 15–24 years) have a suicide completion rate that is approximately 4 times higher than age-matched girls and young adult women. However, adolescent girls report a significantly higher rate of suicidal ideation than boys (22% in girls, 11.9% in boys), as well as suicide plans (17% in girls, 10% in boys), and suicide attempts (9% in girls, 5% in boy).3 Additionally, girls are twice as likely as boys to present to emergency departments with self-inflicted injury, a well-established risk factor for future suicide.4 Also, suicide completion rates in adolescent girls have grown over time.2
Being a part of an ethnic or other minority population may also play a role. In particular, Native Americans have the highest rate of suicide for people age 10 to 24 years.5 Although historically having a lower suicide rate, it is notable that the rate has been steadily increasing among African American adolescents.6 Studies of adolescents in Europe and North America have found that immigrant and first-generation youth have higher suicide rates than their native peers.7,8 People who identify as part of the LGBTQI (lesbian, gay, bisexual, transgender, queer/questioning, intersex) community are also highly impacted, with meta-analyses revealing double the number of suicide attempts compared to control populations.9
Risk Factors Versus Protective Factors Versus Warning Signs
It is well established that certain psychiatric disorders increase the likelihood of suicidality in adults. For example, patients with depression are 20 to 30 times more likely to commit suicide than the general population.10,11 One analysis showed that more than one-half of adolescents who committed suicide did not have a diagnosed mental health or substance use disorder12 and, therefore, likely had not engaged in treatment. Therefore, it is imperative for all health clinicians (not just mental health professionals) to be mindful of risk factors and warning signs for suicidal behaviors in adolescents.
Much attention has been directed toward identifying factors that put adolescents at risk, serve a protective function, or warn of higher acute risk of suicide completion. Protective factors are important to consider both to assess where a person is as well as to improve factors that may decrease the likelihood of suicide attempts or completion. Protective factors include lack of access to deadly weapons, access to mental health services, positive connections with school and peers, family stability, religious involvement, and the ability to solve problems and overcome adversity.13–15
Risk factors for suicidality increase the likelihood of suicide completion over a lifetime. Although risk factors are often assessed in mental health care settings, they do little in terms of predicting an increased likelihood of suicide completion in the near future. Warning signs, on the other hand, serve as more acute signs that someone may be at more risk of suicide completion. Imminent risk factors for suicide completion include factors such as nonsuicidal self-injury (NSSI), previous suicide attempts, psychopathology, peer victimization, a history of sexual or physical trauma, social isolation, poor problem-solving and coping skills, low self-esteem, dysfunction in the family, repeated exposure to violence, and ease of means to deadly weapons.16,17 In particular, NSSI confers the highest elevation in risk, even higher than previous suicide attempt, as published in the Treatment of Resistant Depression in Adolescent study.17
Warning signs were developed in a Consensus Statement by the American Association of Suicidology and can be easily remembered by the mnemonic, “IS PATH WARM,” as follows: Increased Substance use; no sense of Purpose in life; Anxiety, agitation or sleep disturbance; feeling Trapped; Hopelessness; Withdrawal from family, friends, society; uncontrolled Anger or rage, revenge-seeking; Reckless or risky activities, seemingly without thinking; dramatic Mood changes.
Assessment of warning signs may give physicians a chance to both assess and treat vulnerability factors in people that put them at higher risk of imminent self-harm or suicide. As stated above, most adolescents who complete suicide do not have a diagnosed mental health condition; therefore, the role of the pediatrician becomes particularly important in recognizing the warning signs of suicide in their patient population. Upon recognizing these signs, pediatricians should be comfortable asking direct questions about suicidal thoughts and plans and should also be equipped to refer their patients to mental health professionals as needed to ensure proper treatment and follow-up care.18
The Role of Technology
There has been a lot of attention focused on the use of social media and its effect on suicide in adolescents. One study found that cyberbullying can increase suicidal ideation by 15% and suicide by 9%.19 Unfortunately, the Internet is filled with information that instructs people about different ways to commit suicide. There is even a phenomenon called “cybersuicide,” in which a person livestreams his or her suicide act for online viewership. Still, the Internet provides a semblance of connectivity for adolescents who are able to find support networks and kinship online. There are even smartphone apps that are available to help users access support systems and preventive measures.20 Thus, it must be emphasized that the monitoring an adolescent's use of technology is an important reality of parenting in this technological age.
Prevention of Suicide
Suicide prevention programs have gained prevalence as communities have sought ways of decreasing suicide in children and adolescents. Widespread programs such as public service announcements, gate-keeper training programs (increasing awareness of suicidality in school staff), and targeted psychoeducation programs have been implemented. Evidence of their effectiveness in reducing suicidal behaviors has been mixed. One study found that there was benefit to school- and community-based programs in decreasing adolescent suicidality.21 However, a review article found that adolescents who have risk factors may be less likely to seek help after such initiatives.22 And, another study suggested that physician-education and decreased access to firearms proved to be the most effective means of reducing adolescent suicide.23
Unfortunately, there is no gold standard for assessing suicidality in adolescents. Still, a variety of screening tools have been developed to screen for suicidal ideation and can be applied in multiple clinical settings from emergency departments to general practitioner offices and range from 4- to 20-item assessments.
The Depressive Symptom Inventory - Suicidality Subscale is a 4-item self-report questionnaire designed to identify the frequency and intensity of suicidal ideation and impulses over the most recent 2-week period. It was developed as part of a larger depressive symptom index called the Hopelessness Depression Symptom Questionnaire.24 Scores on each item range from 0 to 3 and, for the inventory, from 0 to 12, with higher scores reflecting greater severity of suicidal ideation. Some preliminary data have supported the scale's internal consistency and validity.
The General Health Questionnaire-12 is a 12-item self-report questionnaire designed to identify those patients awaiting general practitioner consultations who may require further evaluation due to generalized emotional distress. Scores range from 0 to 12, with higher scores representing more distress. The scale has accrued reasonable reliability and validity data.
The Center for Epidemiologic Studies Depression Scale is a 20-item questionnaire developed for use in epidemiological surveys to identify persons with depressive symptoms.25 Its scores range from 0 to 60, with higher scores reflecting more depressive symptoms. The scale has been widely used in epidemiological surveys, with demonstrated reliability and validity.
Other screening tools that can potentially be used in adolescents include the Columbia Suicide Severity Rating Scale and the Nurses Global Assessment of Suicide Risk.
Treatment of Adolescent Suicide
Adolescent suicide is often the result of multiple, complicated factors that can be difficult to pinpoint until after an attempt is made and even once a survivor is in treatment. Furthermore, there is evidence that suicidality during adolescence is not of the same nature as a mental illness in adults, but instead more closely linked to neurological, hormonal, and social changes associated with puberty.26 Typically, there is no single intervention that can be credited with reducing suicidality in adolescents; therefore, a patient-centered, multimodal-approach is usually necessary for success.
Patients who have suicidal intention and plan, or who have recently attempted a suicidal act will more likely than not require inpatient psychiatric hospitalization. Patients who appear to have lower risk factors for suicide but present with frequent somatic complaints or who joke often about suicide may require frequent follow-up with mental health providers as their risk for suicide might be higher than expected.
Pharmacology efforts have been targeted toward the treatment of comorbid conditions. As depressive symptoms are most commonly associated with suicidality in adolescents, antidepressants are often used as first-line medications. Paradoxically, antidepressants have been given a black-box label from the US Food and Drug Administration for increasing the risk of suicide ideation in adolescents and young adults.27 Therefore, the clinician must weigh the risk-benefit ratio of treating a major depressive disorder (MDD) with the risk of increased suicidality in the pediatric patient. A 2016 meta-analysis of antidepressant use for youth with MDD found fluoxetine to be the best option.28 Lithium is known to reduce suicidality in adults with bipolar disorder; however, one analysis found insufficient data to make similar claims in children and adolescents.29
Therapeutic interventions aimed at adolescents with risk factors for suicide with the largest effect sizes were dialectical-behaviorial therapy (DBT), cognitive-behavioral therapy, and mentalization-based therapy.30 DBT, in particular, was found to reduce depression, self-harm, and suicidal ideation in adolescents.31 Further studies about the use of electroconvulsive therapy and ketamine infusions in adolescents will be needed to establish their role in this population.
Suicidality is a growing crisis in adolescents around the world. More studies of the factors contributing to and the nature of suicidal behavior in this patient population are needed to ensure appropriate preventive and treatment strategies. Although it is a collective societal effort to better humanity for the future, pediatricians, psychiatrists, and mental health providers play a distinct role in protecting children from psychogenic distress and destruction.
- World Health Organization. Suicide. Key facts. https://www.who.int/en/news-room/fact-sheets/detail/suicide. Accessed May 9, 2017.
- Centers for Disease Control and Prevention. Leading causes of death reports, 1981–2017. https://webappa.cdc.gov/sasweb/ncipc/leadcause.html. Accessed May 14, 2019.
- Centers for Disease Control and Prevention. High school YRBS. http://nccd.cdc.gov/youthonline/. Accessed May 9, 2019.
- Mercado M, Holland K, Leemis R, Stone D, Wang J. Trends in emergency department visits for nonfatal self-inflicted injuries among youth aged 10 to 24 years in the United States, 2001–2015. JAMA. 2017;318(19):1931–1933. doi:. doi:10.1001/jama.2017.13317 [CrossRef]
- Centers for Disease Control and Prevention. Fatal injury reports, National, Regional, and State, 1981–2017. https://webappa.cdc.gov/sasweb/ncipc/mortrate.html. Accessed May 9, 2019.
- Bridge J, Horowitz L, Fontanella C, et al. Age-related racial disparity in suicide rates among US youths from 2001 through 2015. JAMA Pediatr. 2018;172(7):697–699. doi:. doi:10.1001/jamapediatrics.2018.0399 [CrossRef]
- McMahon E, Corcoran P, Helen Keeley et al. Mental health difficulties and suicidal behaviours among young migrants: multicentre study of European adolescents. BJPsych Open. 2017;3(6):291–299. doi:. doi:10.1192/bjpo.bp.117.005322 [CrossRef]
- Peña J, Wyman P, Brown C, et al. Immigration generation status and its association with suicide attempts, substance use, and depressive symptoms among Latino adolescents in the USA. Prev Sci. 2008;9(4):299–310. doi:. doi:10.1007/s11121-008-0105-x [CrossRef]
- King M, Semlyen J, Tai S, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. 2008;8:70. doi:. doi:10.1186/1471-244X-8-70 [CrossRef]
- Osby U, Brandt L, Correia N, Ekbom A, Sparén P. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry. 2001;58:844–850. doi:10.1001/archpsyc.58.9.844 [CrossRef]
- Harris E, Barraclough B. Suicide as an outcome for mental disorders: a meta-analysis. Br J Psychiatry. 1997;170:205–228. doi:10.1192/bjp.170.3.205 [CrossRef]
- Trigylidas T, Reynolds E, Teshome G, Dykstra H, Lichenstein R. Paediatric suicide in the USA: analysis of the National Child Death Case Reporting System. Inj Prev. 2016;22(4):268–273. doi:. doi:10.1136/injuryprev-2015-041796 [CrossRef]
- Taliaferro L, Muehlenkamp J. Risk and protective factors that distinguish adolescents who attempt suicide from those who only consider suicide in the past year. Suicide Life Threat Behav. 2014;44(1):6–22. doi:. doi:10.1111/sltb.12046 [CrossRef]
- Wang M, Lightsey O, Tran K, Bonaparte T. Examining suicide protective factors among black college students. Death Stud. 2013;37(3):228–247. doi:. doi:10.1080/07481187.2011.623215 [CrossRef]
- Choi K, Wang S, Yeon B, et al. Risk and protective factors predicting multiple suicide attempts. Psychiatry Res. 2013;210(3):957–961. doi:. doi:10.1016/j.psychres.2013.09.026 [CrossRef]
- Miller DN, Eckert TL. Youth suicidal behavior: an introduction and overview. School Psychol Rev. 2009;38(2):153–167.
- Asarnow JR, Porta G, Spirito A, et al. Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: findings from the TORDIA Trial. J Am Acad Child Adolesc Psychiatry. 2011;50(8):772–781. doi:. doi:10.1016/j.jaac.2011.04.003 [CrossRef]
- Dilillo D, Mauri S, Mantegazza C, et al. Suicide in pediatrics: epidemiology, risk factors, warning signs and the role of the pediatrician in detecting them. Ital J Pediatr. 2015;41:49. doi:. doi:10.1186/s13052-015-0153-3 [CrossRef]
- Nikolaou D. Does cyberbullying impact youth suicidal behaviors?J Health Econ. 2017;56:30–46. doi:. doi:10.1016/j.jhealeco.2017.09.009 [CrossRef]
- Larsen M, Nicholas J, Christensen H. A systematic assessment of smartphone tools for suicide prevention. PLoS One. 2016;11(4):e015228. doi:. doi:10.1371/journal.pone.0152285 [CrossRef]
- Calear A, Christensen H, Freeman A, et al. A systematic review of psychosocial suicide prevention interventions for youth. Eur Child Adolesc Psychiatry. 2016;25(5):467–482. doi:. doi:10.1007/s00787-015-0783-4 [CrossRef]
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- US Food and Drug Administration. Suicidality in children and adolescents being treated with antidepressant medications. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/suicidality-children-and-adolescents-being-treated-antidepressant-medications. Accessed May 14, 2019.
- Cipriani A, Zhou X, Del Giovane C, et al. Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. Lancet. 2016;388(10047):881–890. doi:. doi:10.1016/S0140-6736(16)30385-3 [CrossRef]
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