Definition
Suicidality refers to thoughts or actions related to suicide, including suicidal ideation (ranging from passive thoughts of
death to active, specific thoughts of suicide with plans and intent), suicide attempts, and completed suicide.
Epidemiology
The estimated prevalence of any sort of suicidal ideation in adolescence is approximately 15-25%.
Estimates of annual suicide attempt rate in adolescents are from 1-3%.
Suicide death rates in youth and young adults declined steadily during the surveillance period from 1990 – 2003. However,
a recent report released by the CDC showed that suicide death rates in this group increased 8% from 2003 to 2004. The most
significant increases were seen in males aged 15-19 and females aged 10-14 and 15-19.
[Lubel: 2007]
A recent study showed an association between this increase in suicide rates and the decrease in antidepressant prescriptions
that came in the wake of the FDA’s black box warning.
[Gibbons: 2007] Further data and studies are needed to determine if this increase represents a true statistical trend, however.
The most common methods of youth suicide in the U.S. are: firearms, suffocation, and poisoning. [
Youth Suicide] The aforementioned CDC report on suicide death rates showed a significant increase in suicide deaths by suffocation and
poisoning in females.
Risk factors for suicide include: mood disorders, substance use, disruptive behavior disorders, previous suicide attempts,
personal losses, exposure to suicide and access to lethal means.
Despite the high prevalence of suicidality in the adolescent population, the majority of primary care physicians do not routinely
screen for suicidality during health care encounters.
[Frankenfield: 2000]
Assessment
Goals of assessment are to determine risk of death or attempts as well as to determine underlying diagnoses and risk factors.
Asking directly about suicidality is likely to produce honest answers from adolescents. It is unlikely to increase risk for
suicide. The AACAP practice parameter suggests the following questions
[Jacobsen: 1994]:
- “Have you ever felt so upset you wished you were not alive or wanted to die?”
- Have you ever hurt yourself or tried to hurt yourself?”
- “Haveyou ever tried to kill yourself?”
- “Have you ever thought about or tried to commit suicide?”
- "Have you ever done something you knew was so dangerous that you could get hurt or killed by doing it?”
[AACAP: 2001]
Assessment must involve not only the patient but also a reliable third party such as a parent or guardian.
It is important to assess risk factors, especially risk factors that can be modified.
As depression is a top risk factor, its identification and treatment is a major goal of assessment.
Other mood disorders must be considered in assessment, as they also increase risk. These include mania, hypomania, and mixed
states.
Access to lethal means is a major modifiable risk factor. Evaluators should ask about presence of firearms in the home. Note: Some states have placed legal restrictions upon medical practitioners inquiring about gun ownership. Physicians should be aware of laws pertaining to such questions in their community. It is also important to ask about how
medications are secured in the home.
Substance abuse is another modifiable risk factor, and assessment should always include questions about this behavior.
Treatment
Inpatient psychiatric hospitalization is the standard of care for the acutely suicidal patient.
If a child or adolescent being evaluated for suicidality expresses a persistent wish to die, or is in an altered mental state,
he or she should be referred for inpatient hospitalization. Altered mental states include but are not limited to severe depression,
mania/hypomania, severe anxiety, psychosis, or intoxication.
It may be possible to manage adolescents with suicidal ideation or behavior in an outpatient setting but this decision entails
careful assessment and decision-making:
- The child or adolescent must not have a persistent wish to die or plans to harm him- or herself.
- Follow up for thorough psychiatric evaluation must be assured.
- Proper adult supervision must be in place.
- The evaluator should initiate discussion of removing lethal means (guns, medications, e.g.), and expressly recommend their
removal.
- It may also be valuable to provide education about other risk factors such as substance abuse.
Medications are often used to treat an underlying psychiatric disorder, if present. For full details on medication treatment
of depression, please see the treatment section of the main page. With particular respect to suicidality:
- Lithium has been shown to decrease risk of suicide in adults with bipolar disorder, and may be considered in the therapy of
children and adolescents with bipolar disorder and suicidality, though its use entails careful monitoring of blood levels
due to its low therapeutic index.
- Tricyclic Antidepressants (TCAs) should not be used as first-line medication for depression in suicidal children and adolescents
due to their lethality in overdose and lack of established efficacy in this age group.
[AACAP: 2001]
Prevention
General suicide awareness programs for youth have not been shown to be effective in reducing suicide rates. In fact, they
may be detrimental, especially for children or adolescents already contemplating suicide.
Screening for depression, mental illnesses, and suicidality in school settings and/or clinical setting may be the most effective
way to decrease suicide rates. This effort should involve education of school staff and health care providers.
Suicide contagion may occur in the aftermath of a suicide within a particular school or community. Health care providers
may play a role in this circumstance by increasing screening for mental health problems, and directing individuals who screen
positive for mental illness or suicide to appropriate treatment.
Resources
Helpful Articles
AACAP.
Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of
Child and Adolescent Psychiatry.
J Am Acad Child Adolesc Psychiatry.
2001;40(7 Suppl):24S-51S.
PubMed abstract / Full Text
Bridge JA, Goldstein TR, Brent DA.
Adolescent suicide and suicidal behavior.
J Child Psychol Psychiatry.
2006;47(3-4):372-94.
PubMed abstract / Full Text
Lubel KM, Kegler SR, Crosby AE, Karch D.
Suicide trends among youths and young adults aged 10-24 years--United States, 1990-2004.
MMWR Morb Mortal Wkly Rep.
2007;56(35):905-8.
PubMed abstract / Full Text
Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, Erkens JA, Herings RM, Mann JJ.
Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents.
Am J Psychiatry.
2007;164(9):1356-63.
PubMed abstract / Full Text
Authors
| Content Last Updated: |
4/2012 |
Page Bibliography
AACAP.
Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of
Child and Adolescent Psychiatry.
J Am Acad Child Adolesc Psychiatry.
2001;40(7 Suppl):24S-51S.
PubMed abstract / Full Text
Frankenfield DL, Keyl PM, Gielen A, Wissow LS, Werthamer L, Baker SP.
Adolescent patients--healthy or hurting? Missed opportunities to screen for suicide risk in the primary care setting.
Arch Pediatr Adolesc Med.
2000;154(2):162-8.
PubMed abstract / Full Text
Despite the substantial proportion of primary care providers who encountered suicidal adolescent patients, most providers
still do not routinely screen their patients for suicidality or associated risk factors.
Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, Erkens JA, Herings RM, Mann JJ.
Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents.
Am J Psychiatry.
2007;164(9):1356-63.
PubMed abstract / Full Text
Jacobsen T, Huss M, Ziegenhain U.
Prepubertal suicide attempts.
J Am Acad Child Adolesc Psychiatry.
1994;33(6):908-9.
PubMed abstract
Lubel KM, Kegler SR, Crosby AE, Karch D.
Suicide trends among youths and young adults aged 10-24 years--United States, 1990-2004.
MMWR Morb Mortal Wkly Rep.
2007;56(35):905-8.
PubMed abstract / Full Text
