Suicide is a major public health problem in the United States, and suicide and attempted suicide are important causes of morbidity and mortality in adolescents.
It is important for clinicians to recognize risk factors for suicide and to screen ALL adolescents for suicidal thoughts and feelings.
Epidemiology
- Suicide is the third leading cause of death in youth between the ages of 10 and 24. It results in approximately 4600 lives lost each year.
- In addition a nationwide survey of youth in grades 9-12 found that
● 16% of students reported seriously considering suicide
● 13% reported creating a plan, and
● 8% reported an attempt in the past year
- The top three methods of suicide in youth include firearm (45%), suffocation (40%), and poisoning (8%).
- Adolescent females are more likely to attempt suicide.
- Adolescent males are more likely to complete suicide, actually they are 4 times more likely to complete suicide than females.
- White and Native American populations have significantly higher rates of suicide than African American, Latino or Asian populations.
- Gay youth may be 2 to 3 times more likely to attempt suicide as compared to their peers. This is more prevalent in homosexual/bisexual males, who in some studies have been found to be 7 time more likely to have suicide attempts.
Risk factors:
Personal
- Mood Disorder
- Alcohol and/or substance abuse
- Conduct disorder
- Personality disorders
- Impulsive behavior
- Violent behavior
- Chronic physical illness
- Being isolated
- Real or imagined loss (relationships, school or financial losses)
- Gay, lesbian, bisexual, transgender or questioning youth, especially males
- Previous suicide attempt
Family
- Physical or sexual abuse of children in the family
- Family history of mental health issues or substance abuse
- Family history of suicidal behavior
- Familial conflict and stress (death, divorce)
Environmental
- Access to lethal methods (especially firearms)
- Local suicide epidemics
- Barriers to access mental health treatment
Protective Factors:
Personal
- Problem solving skills
- Religious beliefs
- Academic achievement
Familial
- Family support and connectedness
Environmental
- Support from medical and mental health providers
- No access to lethal methods
- Community and school support/connectedness
Prevention and Intervention strategies
The USPSTF has recommended that primary care physicians should screen adolescents 12-18 for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy , and follow up. There is NO evidence to suggest asking about suicide increases suicide risk.
Several screening tests have also been used successfully in adolescents in primary care settings:
● Patient Health Questionnaire for Adolescents (PHQ-A)
● Beck Depression Inventory for Primary Care (BDI-PC)
Common symptoms include frequent crying, isolation, weight loss or gain, fatigue, insomnia. Some symptoms are more common in adolescents, such as:
- Irritability, behavior problems, violence issues, vague systemic complaints like headache, abdominal pain, syncope
Always ask about school, grades, drug abuse, sexual promiscuity and truancy. These may be clues to possible suicidal behavior
If a patient has suicidal thoughts, further assessment must include:
- frequency of thoughts
- presence and specificity of a plan
- lethality/availability of means to follow through with the plan
- protective factors, such as social support; and whether there are any other factors, such as substance use or a previous suicide attempt.
If it is determined that a patient is at risk of self-harm, urgent referral to a mental health professional or emergency department is warranted.
Adolescents must be made aware that this is one of the rare occasions in which strict confidentiality may not be kept. This will have to be assessed on an individual case basis assessment of risk.
Interventions for patients at lower risk of self-harm include:
- Involving parents or caregivers to provide close observation of the patient, and removing any weapons or means to self-harm.
- The frequency of follow-up visits may be increased, and patients may benefit from education on how to seek assistance after hours (e.g., emergency departments, crisis hotlines http://www.suicidepreventionlifeline.org/ 1-800-273-8255).
- Parents and family members should be educated about behaviors that would warrant immediate follow-up, such as increased suicidal ideation, impulsivity, irritability, restlessness, pressured speech, or psychomotor agitation.
Treatment
A recent Cochrane review determined it was not possible based on the amount of evidence to determine the optimal treatment strategy (pharmacotherapy or psychotherapy or a combination) for adolescent depression.
However, the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry recommend that psychotherapy always be a component of treatment for childhood and adolescent depression.
They recommend:
- Psychotherapy as an acceptable treatment option for patients with milder depression
- A combination of medication and psychotherapy in those with moderate to severe depression.
Among pharmacotherapies, the SSRI fluoxetine has been found to be efficacious in studies with adolescents. However, because of the risk of suicidality, SSRIs should be considered only if clinical monitoring is possible, and family members should be counseled on warning signs (mentioned above) to watch out for.
Treatment of depression in children and adolescents should continue for six months after remission.
When to Refer to a Child Psychiatrist or Mental Health Specialist
- Moderate or severe depression, with significant impairment in functioning or suicidal ideation, plan, or intent.
- Coexisting substance abuse
- Coexisting psychosis
- Patients who fail to respond to initial interventions within 6 to 8 weeks
- Other complicating factors, conditions or concerns
Resources
Erika's Lighthouse is an educational organization dedicated to raising awareness of adolescent depression and mental health for young people. Their website has links to various resources in the Chicago Area, including a Parent Handbook on Childhood and Adolescent Depression. Click on the icon above to link to the site.
References
- Clark MS, Jansen KL, Cloy JA. Treatment of Childhood and Adolescent Depression Am Fam Physician. 2012 Sep 1;86(5):442-448.
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Cox GR, Callahan P, Churchill R, Hunot V, Merry SN, Parker AG, Hetrick SE. Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database of Systematic Reviews 2012, Issue 11.
- Johnson JG, Harris ES, Spitzer RL, Williams JBW. The patient health questionnaire for adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients. Journal of Adolescent Health, Volume 30, Issue 3, March 2002, Pages 196-204,
- Prager LM. Depression and Suicide in Children and Adolescents. Pediatrics in Review 2009; 30; 199.
- U.S. Preventive Services Task Force Screening and Treatment for Major Depressive Disorder in Children and Adolescents: Recommendation Statement. Am Fam Physician. 2010 Jul 15;82(2):178-179.