By Karyn Horowitz, M.D.
Despite the efforts of the mental health and public health fields, suicide remains the 3rd most common cause of death for adolescents 15-19 years of age (behind accidents and homicide).
Youth suicide accounts for approximately 4,500 lives lost each year (10-24 years of age). Although suicide rates declined between 1990 and 2003, they went up significantly for three groups between 2003 and 2004 - females 10-14 years and 15-19 years, and males 15-19 years (www.cdc.gov). While we do not know if this will be an upward trend or a one year anomaly, as professionals and parents concerned about the health and safety of children and adolescents, we must take note of this increase.
November 2009 Vol. 25, No. 11
This article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.
Although facts such as these can leave us feeling hopeless, there are myths that may lead us to act inappropriately or not take action at all. By dispelling myths with currently known research findings, we can improve our ability to identify children at risk and more effectively intervene to prevent suicide.
Myth: Suicide always occurs without any warning signs.
Fact: There are disorders and behaviors that can be diagnosed and/or observed that can assist with identifying youth at risk for suicide. Depression is the single most significant psychiatric risk factor for adolescent suicidal behavior. Some predictors of suicidal events in treated, depressed samples of adolescents include a past suicide attempt and high baseline levels of suicidal ideation, agitation, and anger. Other significant risk factors for suicide in adolescents include other mood disorders, anxiety disorders, substance use, and disruptive behaviors (such as conduct disorder and significant impulsivity). A recent study revealed that family conflict is also a significant contributor to suicidality in a depressed population (Brent et al., 2009). Further, a recent stressful life event in combination with a psychiatric condition is an increased risk for suicide attempts (Gould et al., 1996).
Myth: If you ask a child or adolescent about suicidal thoughts, you might put an idea into their heads, so you should not ask.
Fact: A recent multi-site study looked at predictors of suicidal adverse events in a population of depressed adolescents and found that relying on "spontaneous report of suicidal adverse events will underestimate the rate of events compared to systematic assessment" (Brent et al., 2009). In the study, they detected more suicidal adverse events, nonsuicidal self-injury events as well as more suicide attempts when the monitoring was conducted in a systematic manner. These findings suggest that not asking a child about suicidal ideation is significantly more dangerous than asking.
Myth: If an adolescent has made a suicide attempt in the past, they are not likely to try again in a more lethal manner. They are just trying to get attention.
Fact: While suicidal ideation alone would tend to over predict the likelihood of a suicide attempt, a previous attempt is a very strong indicator of high risk. A previous suicide attempt is the number one and two predictors, for boys and girls respectively, of a completed suicide. Some believe that adolescents who make a second attempt might just be dramatic, when in fact they are truly at risk of taking their lives.
Myth: Media coverage about suicide attempts or completed suicides does not impact suicidal behavior in youth.
Fact: Suicide contagion is real. There is an increase in suicide by readers/ viewers when the number of stories
about individual suicides increases, a particular death is reported at length or in many stories, the story of a suicide is placed on the front page or at the beginning of a broadcast, or the headlines about a suicide death is dramatic. It is important to not dramatize the impact of suicide through descriptions and pictures as this can encourage other adolescents to seek attention in the same way.
Of more recent concern is the use of the internet as a tool for attention and communication about suicide among
teens. There is no research yet to understand the impact of cyberspace on youth suicide.
The National Institute of Mental Health has a website devoted to assisting the media with appropriate reporting
of suicide (www.nimh.nih.gov/).
Myth: Taking medication for depression may make a child suicidal.
Fact: Although there is significant controversy about this issue, many researchers have found the opposite to be true. The introduction of the SSRI's (selective serotonin reuptake inhibitors) in the 1980's was believed to contribute to the steady decrease in suicides between 1990 and 2003. Following the institution of the "black box warnings" for SSRI's, between 2003 and 2005, the prescription rate of SSRI's for adolescents dropped 22% in the United States.
During this same period suicide rates increased in the Netherlands by 49% and in the United States by 14%. Several researchers have advocated the theory that the reduction in use of SSRI's led to the increased rates in
Myth: Once people decide to die by suicide, there is nothing you can do to stop them.
Fact: While suicide prevention is still far from perfect, there have been a few agreed upon effective interventions.
Those interventions that have been shown to be beneficial include physician education, means restriction,
and gatekeeper education (Mann et al., 2005). Education of primary care physicians about the diagnosis and
treatment of depression in children and adolescents is an important component to decreasing youth suicide.
By ensuring that youth do not have access to the most commonly used lethal methods of suicide we can decrease the number of completed suicides (firearms, pesticides, etc.). Although gatekeepers refer to such groups as the military, it is possible that schools can perform such a function. The Columbia Suicide Screen (www.teenscreen.org) has been utilized to identify suicidal and emotionally troubled students that would not otherwise be identified by school professionals.
Myth: Only a professional would be able to identify a child at risk for suicide.
Fact: Parents, caregivers, and involved school personnel may be the first to notice changes in a child at risk for suicide. Some warning signs include those that indicate a severe depression and others that are particular risk factors for suicide. Some signs to watch for include: change in eating and sleeping habits, withdrawal from friends/family, violent actions, running away, substance use, neglect of personal appearance, personality
change, boredom, decline in academic functioning, frequent physical complaints, lack of enjoyment in activities, and intolerance to praise.
Also, as per the American Academy of Child and Adolescent Psychiatry Facts for Families (www.aacap.org), a teenager who is planning to commit suicide may also: complain of being a bad person or feeling rotten inside, give verbal hints with statements such as: I won't be a problem for you much longer, Nothing matters, It's no use, and I won't see you again, become suddenly cheerful after a period of depression, and develop signs of psychosis (hallucinations or bizarre thoughts).
Although the rates of adolescent suicide are disheartening, by learning about the facts and making informed decisions, professionals and parents involved in the lives of adolescents can begin to make a difference.
Karyn Horowitz, M.D., is Clinical Assistant Professor of Psychiatry and Human Behavior at Warren Alpert Medical School of Brown University and is the Director of Psychotherapy Training for the Child & Adolescent Psychiatry Fellowship and Triple Board Residency. She is also the Director of Outpatient Services at Emma Pendleton Bradley Hospital.
Brent DA, Emslie GJ, Clarke GN, et al.: Predictors of spontaneous and systematically assessed suicidal adverse events in the treatment of SSRIresistant depression in adolescents (TORDIA) study. Am J Psychiatry 2009; 166(4):418-426.
Gould MS, Fisher P, Parides M, et al.: Psychological risk factors of child and adolescent completed suicide. Arch Gen Psychiatry 1996; 53:1155-1162.
Mann JJ, Apter A, Bertolote J, et al.: Suicide prevention strategies a systematic review. JAMA 2005; 294(16):2064-2074.