Suicidal behavior includes completed suicide, attempted suicide (with at least some intent to die), and suicide gestures; suicidal ideation encompasses thoughts of and plans to attempt suicide. Psychiatric referral is 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 and substance use disorder (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). During the peak of the COVID-19 pandemic, emergency department visits for suspected suicide attempts were between 22% to 39% higher in adolescents 12 to 17 years of age for both sexes, with higher rates reported in females (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 die by suicide. Nonetheless, although rare in prepubertal children, suicide is the second leading cause of death in 10- to 24-year-olds and the ninth 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). Race and sex continue to impact the rate of suicide. Child suicides increased for Black (95%), White (158%), male (95%), and female (300%) children during 2010 to 2019 (10).
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 Pediatr.169(7):673-677, 2015. doi: 10.1001/jamapediatrics.2015.0465
10. Price JH, Khubchandani J. Childhood Suicide Trends in the United States, 2010-2019. J Community Health. 2022;47(2):232-236. doi:10.1007/s10900-021-01040-w
Etiology of Suicidal Behavior
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).
Risk Factors for Suicidal Behavior in Children and Adolescents
Type | Examples |
|---|---|
Psychiatric disorders and general medical disorders that affect the brain | Mood disorders* (eg, schizophrenia, depressive disorders) Substance use, particularly alcohol and THC† and/or substance use in adolescents Aggressive, impulsive tendencies (conduct disorder) Previous suicide attempts Posttraumatic stress disorder (PTSD) Anxiety disorders |
Family history | Family history of suicidal behavior Completed suicide in adults Parental opioid use‡ Mother with a mood disorder Father with a history of trouble with law enforcement Poor communication with parents |
Psychosocial factors | Recent disciplinary action§ (most commonly, school suspension) Interpersonal loss (loss of a girlfriend or boyfriend, especially in boys; separation from parents) Difficulties in school Social isolation (particularly not working or going to college) Victim of bullying Media reports of suicide (copycat suicide) Identification as LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning) |
Environmental factors | Easy access to lethal methods (eg, guns) Barriers to and/or stigma associated with accessing mental health services |
Medications | MontelukastMontelukasta GabapentinGabapentinb Selective serotonin reuptake inhibitorsc, d PrednisonePrednisoned Benzodiazepinesd (alprazolam, diazepam)(alprazolam, diazepam) |
* Mood disorders are present in more than one-half of suicidal adolescents. | |
† Gobbi G, Atkin T, Zytynski, et al. Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: A systematic review and meta-analysis. JAMA Psychiatry. 76(4):426-434, 2019. doi: 10.1001/jamapsychiatry.2018.4500 | |
‡ Turecki G, Brent DA, Gunnell D, et al. Suicide and suicide risk. Nat Rev Dis Primers. 5(1):74, 2019. doi: 10.1038/s41572-019-0121-0 | |
§ Almost half of completed suicides occur after recent disciplinary action. aBenard B, Bastein V, Vinet B, et al. Neurosychiatric adverse drug reactions in children initiated on montelukast in real-life practice. . Neurosychiatric adverse drug reactions in children initiated on montelukast in real-life practice.Eur Respir J. 50(2):1700148. doi: 10.1183/13993003.00148-2017 bMolero Y, Larsson H, D'Onofrio B, et al. Associations between gabapentinoids and suicidal behaviour, unintentional overdoses, injuries, road traffic incidents, and violent crime: Population based cohort study in Sweden. BMJ Clin Res. 365:12147, 2019. doi: 10.1136/bmj.l2147 cGibbons RD, Brown CH, Hur K, et al. Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry. 164(9);1356-1363, 2007. doi: 10.1176/appi.ajp.2007.07030454 dGibbons 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: 10.1162/99608f92.6fdaa9d | |
Other medications have also been reported to increase suicide risk, leading to boxed warnings by the Food and Drug Administration. However, in some cases, such as with use of antiseizure medications, the exact cause of increased risk in any given case is difficult to determine because the disease being treated (ie, epilepsy) is itself associated with a 5-fold increased risk of suicide in the absence of antiepileptic medications (1). Likewise, azithromycin was associated with increased suicidal risk (). Likewise, azithromycin was associated with increased suicidal risk (2), based on the medical claims data of private insurers collected by MarketScan on over 150 million people between 2003 to 2014. However, subsequent studies found that increased suicidal risk may have been due to the increased risk conferred by infections (3). Liraglutide and varenicline (used to treat, respectively, obesity and smoking cessation) were also found to be associated with increased risk of suicide; in both cases, the increased risk may have been conferred by the underlying conditions the medications were prescribed to address. Randomized trials will be necessary to ascertain actual risk from these medications.). Liraglutide and varenicline (used to treat, respectively, obesity and smoking cessation) were also found to be associated with increased risk of suicide; in both cases, the increased risk may have been conferred by the underlying conditions the medications were prescribed to address. Randomized trials will be necessary to ascertain actual risk from these medications.
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 the following:
Effective clinical care for mental, general medical, 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
Medications: 44 medications, many of which are psychotropic (including antidepressants, antipsychotics, mood stabilizers, lithium, alpha agonists, antiseizure medications) as well as folic acid (Medications: 44 medications, many of which are psychotropic (including antidepressants, antipsychotics, mood stabilizers, lithium, alpha agonists, antiseizure medications) as well as folic acid (2).
Folic acid's protective effective was replicated in additional data from 2021 to 2022 (Folic acid's protective effective was replicated in additional data from 2021 to 2022 (4). Randomized trials are difficult to complete given that L-methyl folate is a supplement that is easily obtained without a prescription. However, given the existing knowledge (5), L-methyl folate supplementation, which can cross the blood-brain barrier, could be considered as an adjunct in the treatment of depression and other conditions with suicidality risk.
Etiology references
1. Hesdorffer DC, Ishihara L, Webb DJ, Mynepalli L, Galwey NW, Hauser WA. Occurrence and Recurrence of Attempted Suicide Among People With Epilepsy. JAMA Psychiatry. 2016;73(1):80-86. doi:10.1001/jamapsychiatry.2015.2516
2. 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
3. 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
4. Gibbons RD, Hur K, Lavigne HE, et al. Association between folic acid prescription fills and suicide attempts and intentional self-harm among privately insured US adults. . Association between folic acid prescription fills and suicide attempts and intentional self-harm among privately insured US adults.JAMA Psychiatry.79(11):1118-1123, 2022. doi: 10.1001/jamapsychiatry.2022.2990
5. Liwinski T, Lang UE. Folate and Its Significance in Depressive Disorders and Suicidality: A Comprehensive Narrative Review. Nutrients. 2023;15(17):3859. Published 2023 Sep 4. doi:10.3390/nu15173859
Treatment of Suicidal Behavior
Crisis intervention, possibly including hospitalization
Psychiatric referral
Psychotherapy
Possibly medications to treat underlying disorders, usually combined with psychotherapy
Every suicide attempt is a serious matter that requires thoughtful and appropriate crisis intervention (1). 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 and a safe environment. 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
The United States Preventive Services Task Force has found insufficient evidence for universal screening of suicidal behaviors; however, it does recommend screening for major depressive disorder in adolescents aged 12 to 18 years (2). The association between depressive and other mood disorders and suicide is well-established. Thus, medications may be indicated for any underlying disorder (eg, depression, bipolar disorder, conduct disorder, psychosis) but cannot prevent suicide (see Depressive Disorders in Children and Adolescents: Suicide risk and antidepressants). Use of medications should be carefully monitored, and only sublethal amounts should be prescribed and 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 (3). 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 references
1. Hua LL, Lee J, Rahmandar MH, Sigel EJ; COMMITTEE ON ADOLESCENCE; COUNCIL ON INJURY, VIOLENCE, AND POISON PREVENTION. Suicide and Suicide Risk in Adolescents. Pediatrics. 2024;153(1):e2023064800. doi:10.1542/peds.2023-064800
2. US Preventive Services Task Force, Mangione CM, Barry MJ, et al. Screening for Depression and Suicide Risk in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;328(15):1534-1542. doi:10.1001/jama.2022.16946
3. Asarnow JR, Mehlum L. Practitioner Review: Treatment for suicidal and self-harming adolescents - advances in suicide prevention care [published correction appears in J Child Psychol Psychiatry. 2019 Dec;60(12):1357. doi: 10.1111/jcpp.13166.]. J Child Psychol Psychiatry. 2019;60(10):1046-1054. doi:10.1111/jcpp.13130
Response to suicide
Family members of children and adolescents who complete 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 completed 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 of Suicidal Behavior
Suicides 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), which includes questions on suicide debate and whether life is worth living, is reported to have high predictive ability across demographic groups in those aged 13 and older (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, general medical, and substance use disorders
Access mental health care 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 to 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.
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 Res.19(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 Psychiatry.77; 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 Psychiatry.58(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 second or third 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 prescribe only sublethal amounts to be dispensed.
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.
Drugs Mentioned In This Article
