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.


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 during the surveillance period from 1991 – 2009.
The most common methods of youth suicide in the U.S. are: firearms, suffocation, and poisoning. [Youth Suicide] Despite an overall decrease in suicide rates, over the period from 1992-2006, there has been an as yet unexplained increase in youth and young adult (age 10-24) suicide deaths by suffocation. [Bridge: 2010]
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]


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?”
  • “Have you 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.


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]


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.


Author: Thomas G. Conover, MD - 2/2009
Content Last Updated: 9/2013

Page Bibliography

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, Greenhouse JB, Sheftall AH, Fabio A, Campo JV, Kelleher KJ.
Changes in suicide rates by hanging and/or suffocation and firearms among young persons aged 10-24 years in the United States: 1992-2006.
J Adolesc Health. 2010;46(5):503-5. 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.

Jacobsen T, Huss M, Ziegenhain U.
Prepubertal suicide attempts.
J Am Acad Child Adolesc Psychiatry. 1994;33(6):908-9. PubMed abstract