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(See also See also Suicidal Behavior.)
Suicidal behavior includes completed suicide, attempted suicide, and suicide gestures; suicidal ideation is thoughts and plans about suicide. Psychiatric referral is usually required.
Youth suicide rates have declined in recent years after more than a decade of steady increase, only to have started climbing again. The exact reasons for these fluctuations are unclear. Many experts believe that the changing rates with which antidepressants are prescribed may be a factor. Some experts hypothesize that antidepressants have paradoxical effects, making children and adolescents more vocal about suicidal feelings but less likely to commit suicide. Nonetheless, suicide is the 2nd or 3rd leading cause of death in 15- to 19-yr-olds and remains a considerable public health concern.
Etiology
Risk factors vary by age. Predisposing factors include
More immediate precipitating factors can include
Other contributing factors may include a lack of structure and boundaries, leading to an overwhelming feeling of lack of direction, and intense parental pressure to succeed accompanied by the feeling of falling short of expectations. A frequent motive for a suicide attempt is an effort to manipulate or punish others with the fantasy “You will be sorry after I am dead.”
A rise in suicides is seen after a well-publicized suicide (eg, of a rock star) and among groups (eg, a high school, a college dormitory) in which a suicide occurred, indicating the power of suggestion. Early intervention to support youths in such circumstances may be helpful.
Treatment
Every suicide attempt is a serious matter that requires thoughtful and appropriate intervention. Once the immediate threat to life is removed, a decision regarding the need for hospitalization must be made. The decision involves balancing the degree of risk with the family's capacity to provide support. Hospitalization (even in an open medical or pediatric ward with special-duty nursing) is the surest form of short-term protection and is usually indicated if depression, psychosis, or both are suspected.
Lethality of suicidal intent can be assessed based on the following:
Drugs may be indicated for any underlying disorder (eg, depression, bipolar or conduct disorder, psychosis) but cannot prevent suicide. Antidepressant use may increase risk of suicide in some adolescents. Use of drugs should be carefully monitored, and only sublethal amounts should be supplied.
Psychiatric referral is usually needed to provide appropriate drug treatment and psychotherapy; treatment is most successful if the primary care practitioner continues to be involved.
Rebuilding morale and restoring emotional equilibrium within the family are essential. A negative or unsupportive parental response is a serious concern and may suggest a need for a more intensive intervention such as out-of-home placement. A positive outcome is most likely if the family shows love and concern.
Prevention
Suicidal incidents are often preceded by behavioral changes (eg, despondent mood, low self-esteem, sleep and appetite disturbances, inability to concentrate, truancy from school, somatic complaints, and suicidal preoccupation), which often bring the child or adolescent to the physician's office. Statements such as “I wish I had never been born” or “I would like to go to sleep and never wake up” should be taken seriously as possible indications of suicidal intent. A suicidal threat or attempt represents an important communication about the intensity of experienced despair.
Early recognition of the risk factors mentioned above may help prevent a suicide attempt. In response to these early cues, to threatened or attempted suicide, or to severe risk-taking behavior, vigorous intervention is appropriate. Adolescents should be directly questioned about their unhappy or self-destructive feelings; such direct questioning may diminish suicide risk. A physician should not provide unfounded reassurance, which can undermine the physician's credibility and further lower the adolescent's self-esteem.
The effectiveness of suicide prevention programs is being evaluated. The most effective programs are those that strive to ensure that the child has a supportive nurturing environment, ready access to mental health services, and a social setting that is characterized by respect for individual, racial, and cultural differences.
Self-Injurious Behavior
Self-injurious behaviors that are sometimes confused with suicidal intentions include superficial scratching and cutting, burning the skin with cigarettes or curling irons, and crude ballpoint pen tattoos.
In some communities, self-injurious behaviors suddenly sweep through a high school in fad-like fashion and then gradually diminish over time.
In many adolescents, these behaviors do not indicate suicidality but instead are an effort to establish autonomy, identify with a peer group, or provocatively gain parental attention. However, even when these behaviors are not an expression of suicidality, they are serious and warrant intervention. Such behaviors are often associated with illicit substance abuse and suggest that an adolescent is in great distress.
All self-injurious behaviors should be evaluated by a clinician experienced in working with troubled adolescents to assess whether suicidality is an issue and to identify the underlying distress leading to the self-injurious behaviors.
Last full review/revision April 2009 by Hugh F. Johnston, MD
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