Suicidal behavior includes completed suicide, attempted suicide (with at least some intent to die), and suicide gestures; suicidal ideation is thoughts and plans about suicide. Psychiatric referral is usually required.
(See also Suicidal Behavior in adults.)
Between 1999 and 2019, suicide rates among American Indian/Alaskan Native, White, Black, Asian/Pacific Islander, and Hispanic youths (males and females ages 15 to 24) were reported at 23, 6.1, 4.3, 5.1, and 4.4 per 100,000 individuals. During the latter part of this time period, rates for Black and Asian Pacific Islander youths increased by 30% and 16%, respectively (1). In a report detailing increasing trends in suicide mortality in the United States (NCHS Brief No 398, February 2021), females (ages 10 to 14) showed an increase in deaths by suicide from 0.5% in 1999 to 3.1% in 2019; in males (ages 10 to 14) rates increased from 1.9% to 3.1%.
A number of factors may be contributing to the increase in attempts, including the increase in adolescent depression, especially in girls (2); increased parental opioid prescriptions (3); increased suicide rates among adults leading to increased awareness of suicide by youths (4) ; increasingly conflicted relationships with parents; and academic stressors (5, 6). The COVID-19 pandemic is a recent factor contributing to increased trends in suicide. Compared to the same time periods in 2019, emergency department visits for suspected suicide attempts were 22% higher during the summer of 2020 and 39% higher during the winter of 2021 in adolescents 12 to 17 years of age for both sexes. Higher rates were reported in girls (26% higher during the summer and 51% during the winter) (7).
Many experts believe that the changing rates with which antidepressants are prescribed may be a factor (see Depressive Disorders in Children and Adolescents: Suicide risk and antidepressants). Some experts hypothesize that antidepressants have paradoxical effects, making children and adolescents more vocal about suicidal feelings but less likely to commit suicide. Nonetheless, although rare in prepubertal children, suicide is the 2nd leading cause of death in 10- to 24-year-olds and the 9th cause of death among children 5 to 11 years old (8). This remains a considerable public health concern, especially in minority groups, as the rate of suicide nearly doubled in Black elementary school children between 1993 and 2012 (9).
General references
1. Rachmand R, Gordon JA, Pearson JL: Trends in suicide rates by race and ethnicity in the United States. JAMA Netw Open 2021:4(5):e2111563. doi: 10.1001/jamanetworkopen.2021.11563
2. Mojtabai R, Olfson M, Han B: National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics 138(6):e20161878, 2016. doi: 10.1542/peds.2016-1878
3. Brent DA, Hur K, Gibbons RD: Association between parental medical claims for opioid prescriptions and risk of suicide attempt by their children. JAMA Psychiatry 76(9):941-947, 2019. doi: 10.1001/jamapsychiatry.2019.0940
4. Wang J, Sumner SA, Simon TR, et al: Trends in the incidence and lethality of suicidal acts in the United States, 2006 to 2015. JAMA Psychiatry 77(7):684-693, 2020. doi: 10.1001/jamapsychiatry.2020.0596
5. Shain B, Committee on Adolescence: Suicide and suicide attempts in adolescents. Pediatrics 138(1):e20161420, 2016. doi: https://doi.org/10.1542/peds.2016-1420
6. Bilsen J: Suicide and youth: Risk factors. Front Psychiatry 9:540, 2018. doi: https://doi.org/10.3389/fpsyt.2018.00540
7. Yard E, Radhakrishnan L, Ballesteros MF, et al: Emergency department visits for suspected suicide attempts among persons aged 12–15 years before and during the COVID-19 pandemic—United States, January 2019–May 2021. MMWR Morbid Mortal Wkly Rep 70; 888-894, 2021. doi: 10.15585/mmwr.mm7024e1
8. Centers for Disease Control and Prevention: WISQARSTM: Web-based Injury Statistics Query and Reporting Systems. 2020. Accessed March 12, 2021.
9. Bridge JA, Asti L, Horowitz LM, et al: Suicide trends among elementary school-aged children in the United States from 1993 to 2012. JAMA Pediatr169(7):673-677, 2015. doi: 10.1001/jamapediatrics.2015.0465
Etiology
In children and adolescents, risk of suicidal behavior is influenced by the presence of other psychiatric disorders and other disorders that affect the brain, family history, psychosocial factors, and environmental factors (see table Risk Factors for Suicidal Behavior in Children and Adolescents).
1), based on the medical claims data of private insurers collected by MarketScan on over 150 million people between 2003 to 2014. However, this increased suicidal risk may have been due to the increased risk conferred by infections (2
Other contributing factors may include
A lack of structure and boundaries, leading to an overwhelming feeling of lack of direction
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.”
Protective factors associated with decreased suicidal events include
Effective clinical care for mental, physical, and substance use disorders
Easy access to clinical interventions
Family and community support (connectedness)
Skills in conflict resolution
Cultural and religious beliefs that discourage suicide
Etiology references
1. Gibbons R, Hur K, Lavigne J, et al: Medications and suicide: High dimensional empirical Bayes screening (iDeas). Harvard Data Sci Rev 1.2 2019 (revised 2020). doi: 10.1162/99608f92.6fdaa9de
2. Lund-Sorensen H, Benros ME, Madsen T, et al: A nationwide cohort study of the association between hospitalization with infection and risk of death by suicide. JAMA Psychiatry 73:912-919, 2016. doi: 10.1001/jamapsychiatry.2016.1594
3. Gibbons RD, Hur K, Lavigne HE, et alJAMA Psychiatry79(11):1118-1123, 2022. doi: 10.1001/jamapsychiatry.2022.2990
Treatment
Crisis intervention, possibly including hospitalization
Psychotherapy
Possibly medications to treat underlying disorders, usually combined with psychotherapy
Psychiatric referral
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:
Degree of forethought evidenced (eg, by writing a suicide note)
Steps taken to prevent discovery
Method used (eg, firearms are more lethal than pills)
Degree of self-injury sustained
Circumstances or immediate precipitating factors surrounding the attempt
Mental state at the time of the episode (acute agitation is especially concerning)
Recent discharge from inpatient care
Recent discontinuation of psychoactive medications
Medications may be indicated for any underlying disorder (eg, depression, bipolar disorder, conduct disorder, psychosis) but cannot prevent suicide. Antidepressant use may increase risk of suicide in some adolescents (see Depressive Disorders in Children and Adolescents: Suicide risk and antidepressants). Use of medications should be carefully monitored, and only sublethal amounts should be supplied.
Psychiatric referral is usually needed to provide appropriate drug treatment and psychotherapy. Cognitive-behavioral therapy for suicide prevention and dialectical behavioral therapy may be preferred. 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.
Treatment reference
1. Hesdorffer DC, Ishihara L, Webb DJ, et al: Occurrence and recurrence of attempted suicide among people with epilepsy. JAMA Psychiatry 73(1):80-86. 2016. doi: 10.1001/jamapsychiatry.2015.2516
Response to suicide
Family members of children and adolescents who committed suicide have complicated reactions to the suicide, including grief, guilt, and depression. Counseling can help them understand the psychiatric context of the suicide and reflect on and acknowledge the child’s difficulties before the suicide.
After a suicide, the risk of suicide may increase in other people in the community, especially friends and classmates of the person who committed suicide. Resources (eg, guides for coping with a suicide loss) are available to help schools and communities after a suicide. School and community officials can arrange for mental health care practitioners to be available to provide information and consultation.
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.
Physicians should screen for suicide in the medical setting. Research published in 2017 indicated that 53% of pediatric patients presenting to the emergency department for medical reasons not related to suicide screened positive for suicidality (1). There is also evidence that most adults and children who eventually die by suicide had received medical care in the year prior to death (2, 3). Starting in July 2019, the Joint Commission has been requiring hospitals to screen for suicide as part of standard medical care (4, 5). However, in adults, almost 40% of suicide attempts and over 30% of suicide deaths have been reported to occur within 30 days of a negative patient health questionnaire (PHQ) screen (6). The development of better screening tools is ongoing. The "open source suicidality scale" (7) that also includes questions on suicide debate and whether life is worth living is reported to have high predictive ability across demographic groups in ages 13 and above (7).
Physicians should inquire about firearms, the leading cause of death for youth in the United States (60% homicides, 35% suicides, 4% unintentional) (8). Physician counseling combined with provision of a cable gun lock has been reported to increase safe storage of firearms (9).
In addition to screening for suicide, physicians should help patients do the following, which may help reduce the risk of suicide:
Get effective care for mental, physical, and substance use disorders
Access mental health services
Get support from the family and community
Learn ways to peacefully resolve conflict
Limit media access to suicide-related content (10)
Suicide-prevention programs can also help. The most effective programs are those that strive to ensure that the child has the following (11):
A supportive nurturing environment
Ready and equitable access and delivery of mental health services for all youths
A social setting that is characterized by respect for individual, racial, and cultural differences
In 2022 a new 3-digit code (988), referred to as the 988 Suicide and Crisis Lifeline, was activated in the United States. A call, text, or chat from 988 will route callers to the National Suicide Prevention Lifeline (whose previous Lifeline phone number, 1-800-273-8255, will continue to remain available). Trained counselors, in English and Spanish, available 24/7, will provide support and connect callers to resources if necessary. The service is confidential and free of charge. The SPRC Suicide Prevention Resource Center lists some of the programs. Additional information about the Suicide and Crisis lifeline is available online (988Lifeline.org).
Prevention references
1. Ballard ED, Cwik M, Van Eck K, et al: Identification of at-risk youth by suicide screening in a pediatric emergency department. Prev Sci 18(2);174-182, 2017. doi: 10.1007/s11121-016-0717-5
2. Ahmedani BI, Simon GE, Stewart C, et al: Health care contacts in the year before suicide death. J Gen Intern Med 29(6):870-877, 2014.
3. Oein-Odegaard C, Reneflot A, Haugue LI: Use of primary healthcare services prior to suicide in Norway: A descriptive comparison of immigrants and the majority population. BMC Health Serv Res19(1):508, 2019.
4. The Joint Commission: Detecting and treating suicide ideation in all settings. Sentinel Alert Event, 56:1-7, 2016.
5. Brahmbhatt K, Kurtz BP, Afzal KI, et al: Suicide risk screening in pediatric hospitals: Clinical pathways to address a global health crisis. Psychosomatics 60(1):1-9, 2019. doi: 10.1016/j.psym.2018.09.003
6. Simon GE, Coleman KJ, Rossom RC, et al: Risk of suicide attempt and suicide death following completion of the PHQ depression module in community practice. J Clin Psychiatry77; 221-227, 2016. doi: 10.4088/JCP.15m09776
7. Harris KM, Wang L, Mu GM, et al: Measuring the suicidal mind: The "open source"Suicidality Scale, for adolescents and adults. PLoS ONE 18(2): e0282009. https://doi.org/10.1371/journal. pone.0282009
8. Cunningham RM, Walten MA, Carter PM: The major causes of death in children and adolescents in the United States. N Engl J Med Dec 379(25):2468-2475, 2018. doi: 10.1056/NEJMsr1804754
9. Barkin SL, Finch SA, Ip EH, et al: Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics 122(1)e15-25, 2008. doi: 10.1542/peds.2007-2611
10. Bridge JA, Greenhouse JB, Ruch D, et al: Association between the release of Netflix's 13 Reasons Why and suicide rates in the US: An interrupted time series analysis. J Am Acad Child Adolesc Psychiatry 59(2):236-243. doi:https://doi.org/10.1016/j.jaac.2019.04.020
11. Brent DA: Master clinician review: Saving Holden Caulfield: Suicide prevention in children and adolescents. J Am Acad Child Adolesc Psychiatry58(1):25-35, 2019. https://doi.org/10.1016/j.jaac.2018.05.030
Key Points
Suicide is rare in prepubertal children but is the 2nd or 3rd leading cause of death in 15- to 19-year-olds.
Consider drug treatment for any underlying disorder (eg, mood disorders, psychosis); however, antidepressants may increase risk of suicide in some adolescents, so carefully monitor use of medications, and supply only sublethal amounts.
Look for early warning changes in behavior (eg, skipping school, sleeping or eating too much or too little, making statements suggesting suicidal intent, engaging in very risky behavior).
More Information
The following English-language screening tools for suicide in the medical setting may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Ask Suicide-Screening Questions (ASQ) Toolkit: This five-question screening tool is designed to be used by doctors to screen children and adolescents for suicide risk for immediate, appropriate treatment.
Columbia Suicide Severity Rating Scale (C-SSRS): Comprehensive information on a unique suicide risk assessment tool that is endorsed by the World Health Organization, the Food and Drug Administration, and the Centers for Disease Control and Prevention, among other prestigious agencies.
Patient Health Questionnaire (PHQ-9) Tool: Along with this tool, there is in-depth information on when and why to use it as well as the pearls and pitfalls associated with its use.
