AMERICAN ACADEMY OF PEDIATRICS: Suicide and Suicide Attempts in Adolescents

(excerpts from http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/4/871)

Suicide is the third leading cause of death for adolescents 15 to 19 years old.

The number of adolescent deaths from suicide in the United States has increased dramatically during the past few decades. In 1997, there were 4186 suicides among people 15 to 24 years old, 1802 suicides among those 15 to 19 years old, and 2384 among those 20 to 24 years old.1 In 1997, 13% of all deaths in the 15- through 24-year-old age group were attributable to suicide.1 The true number of deaths from suicide actually may be higher, because some of these deaths are recorded as "accidental."3

From 1950 to 1990, the suicide rate for adolescents in the 15- to 19-year-old group increased by 300%.4 Adolescent males 15 to 19 years old had a rate 6 times greater than the rate for females.1 The ratio of attempted suicides to completed suicides among adolescents is estimated to be 50:1 to 100:1, and the incidence of unsuccessful suicide attempts is higher among females than among males.5 Suicide affects young people from all races and socioeconomic groups, although some groups seem to have higher rates than others. Native American males have the highest suicide rate, African American women the lowest. A statewide survey of students in grades 7 through 12 found that 28.1% of bisexual and homosexual males and 20.5% of bisexual and homosexual females had reported attempting suicide.6 The National Youth Risk Behavior Survey of students in grades 9 through 12 indicated that nearly one fourth (24.1%) of students had seriously considered attempting suicide during the 12 months preceding the survey, 17.7% had made a specific plan, and 8.7% had made an attempt.7

Firearms, used in >67% of suicides, are the leading cause of death for males and females who commit suicide.8 More than 90% of suicide attempts involving a firearm are fatal because there is little chance for rescue. Firearms in the home, regardless of whether they are kept unloaded or stored locked up, are associated with a higher risk for adolescent suicide.9,10 Parents must be warned about the lethality of firearms in the home and be advised strongly to remove them from the premises.11 Ingestion of pills is the most common method among adolescents who attempt suicide.

Youth, who seem to be at much greater risk from media exposure than adults, may imitate suicidal behavior seen on television.12 Media coverage of a teenage suicide may lead to cluster suicides, additional deaths from suicides in youths within a 1- to 2-week period afterward.12-14

ADOLESCENTS AT INCREASED RISK

Although no specific tests are capable of identifying suicidal persons, specific risk factors exist.

Adolescents at higher risk commonly have a history of depression, a previous suicide attempt, a family history of psychiatric disorders (especially depression and suicidal behavior), family disruption, and certain chronic or debilitating physical disorders or psychiatric illness.15 Alcohol use and alcoholism indicate high risk for suicide.16 Alcohol use has been associated with 50% of suicides.17 Living out of the home (in a correctional facility or group home) and a history of physical or sexual abuse are additional factors more commonly found in adolescents who exhibit suicidal behavior.18 Psychosocial problems and stresses, such as conflicts with parents, breakup of a relationship, school difficulties or failure, legal difficulties, social isolation, and physical ailments (including hypochondriacal preoccupation), commonly are reported or observed in young people who attempt suicide. These precipitating factors often are cited by youths as reasons for attempting suicide. Gay and bisexual adolescents have been reported to exhibit high rates of depression and have been reported to have rates of suicidal ideation and attempts 3 times higher than other adolescents. Studies of twins show that monozygotic twins show significantly higher concordance for suicide than dizygotic twins.16 Long-term high levels of community violence may contribute to emotional and conduct problems and add to the risk of suicide for exposed youth.19 Adolescent and parent questionnaires that cover those risk factors listed above, may be useful in the office setting to assist in obtaining a complete history.20

Serious depression in adolescents may manifest in several ways. For some adolescents, symptoms may be similar to those in adults, with signs, such as depressed mood almost every day, crying spells or inability to cry, discouragement, irritability, a sense of emptiness and meaninglessness, negative expectations of self and the environment, low self-esteem, isolation, a feeling of helplessness, markedly diminished interest or pleasure in most activities, significant weight loss or weight gain, insomnia or hypersomnia, fatigue or loss of energy, feelings of worthlessness, and diminished ability to think or concentrate.21 However, it is more common for an adolescent with serious depression to exhibit psychosomatic symptoms or behavioral problems. Such a teenager may seek care for recurrent or persistent complaints, such as abdominal pain, chest pain, headache, lethargy, weight loss, dizziness and syncope, or other nonspecific symptoms.22 Behavioral problems that may be manifestations of masked depression include truancy, deterioration in academic performance, running away from home, defiance of authorities, self-destructive behavior, vandalism, alcohol and other drug abuse, sexual acting out, and delinquency.23 Episodic despondency leading to self-destructive acts can occur in any adolescent, including high achievers. These adolescents may believe that they have failed or disappointed their parents and family and perceive suicide as their only option. Other adolescents may believe that suicide is a better option than life as they experience it.

TABLE 1 Examples of Adolescents at Low, Moderate, and High Risk for Suicide

Low risk:

Took 5 ibuprofen tablets after argument with girlfriend

Impulsive; told mother 15 minutes after taking pills

No serious problems at home or school

Occasionally feels "down" but has no history of depression or serious emotional problems

Has a number of good friends

Wants help resolving problems and is no longer considering suicide after interview

Moderate risk:

Suicidal ideation precipitated by recurrent fighting with parents and failing grades in school

Wants to "get back" at parents

Cut both wrists while at home alone; called friend 30 minutes later

Parents separated, changed school this semester, history of attention-deficit hyperactivity disorder

Symptoms of depression for the last 2 months, difficulty controlling temper

Binge drinking on the weekends

Answers all the questions during the interview, agrees to see a therapist if parents get counseling, will contact the interviewer if suicidal thoughts return

High risk:

Thrown out of house by parents for smoking marijuana at school, girlfriend broke up with him last night, best friend killed in auto crash last month

Wants to be dead; sees no purpose in living

Took father's gun; is going to shoot himself where "no one can find me"

Gets drunk every weekend and uses marijuana daily

Hates parents and school; has run away from home twice and has not gone to school for 6 weeks

Hospitalized in the past because he "lost it"

Does not want to answer many of the questions during the interview and hates "shrinks"