Adolescent Suicidal Behavior: Risk Factor Identification, Screening, Prevention

Introduction

Suicide is the third leading cause of death, following unintentional injuries and homicide, among adolescents in the United States.[1] There have been approximately 2000 adolescent suicides per year during the past decade, accounting for some 10% of all deaths in adolescents. Further, in an alarming trend, adolescent suicide rates have doubled in the United States over the past 50 years.[2] This increase may be attributed at least in part to increased rates of depression, alcohol and substance abuse, family disintegration, and access to deadly weapons during this time.

With the exception of suicidal ideation, most types of suicidal behavior are rare before the onset of adolescence. After the onset of adolescence, there is a very clear increasing risk for both suicidal attempts and completions. Recent survey data[3] have shown that nearly 15% of all US high school students have seriously considered attempting suicide; more than 11% have made a plan for suicide; and almost 7% have attempted suicide in the past year. Although girls are more likely to engage in suicidal ideations, planning, and attempts, boys are more likely to complete a suicide due to boys using more violent and dangerous means. White male adolescents have the highest rate of suicide.[4] With such high rates of contemplated, attempted, and successful suicide among adolescents, it is particularly important to understand the risk factors for suicide, as well as ways to screen for it and effectively prevent it.
Risk Factors for Suicide

Suicide risk is greatly increased with the presence of both depression and an anxiety or disruptive disorder.[5] Concerns over an association between selective serotonin reuptake inhibitor (SSRI) therapy and suicide risk in adolescents led to the US Food and Administration (FDA) issuing a warning in 2004.[6] Since then, however, observational studies[7,8] have found that a broader extent of SSRI prescriptions in the population are associated with lower suicide rates in children. These findings may reflect on antidepressant efficacy, adherence, the quality of mental healthcare, and the lower toxicity of these medications in the event of an overdose or suicide attempt. Several organizations have issued specific prescribing recommendations for SSRIs.[9-11] The American College of Neuropsychopharmacology (ACNP), the American Academy of Child and Adolescent Psychiatry (AACAP), and the Society for Adolescent Medicine (SAM) all recommend the use of fluoxetine in the treatment of depression in adolescents. Their findings suggested that use of SSRIs, such as fluoxetine, may have a slightly higher risk of increasing suicidal ideation but do not increase the risk for completed suicides.

Suicidal behavior risk factors have been classified into 2 separate categories: predisposing factors and precipitating factors.[12] Predisposing factors are those that directly increase an adolescent's risk for suicide. They include the following.
Previous Suicide Attempt

Adolescents who have had a previous suicide attempt are much more likely to try again, with an even more marked increase in those with multiple previous attempts. Between one quarter and one third of adolescents who attempt suicide will go on to try again, with the greatest risk for recurrence falling between 6 months and 1 year after their first attempt.[13]
History of a Prior or Ongoing Psychiatric Disorder

A prior or ongoing psychiatric disorder is a major risk factor for suicide, with studies showing that adolescents who commit suicide have a higher rate of depression, substance abuse disorders, eating disorders, anxiety disorders, and antisocial disorders.[14-16]
History of Sexual or Physical Abuse

Studies have shown that adolescents who are victims of sexual or physical abuse are up to 3 times more likely to commit suicide and up to 8 times more likely to have repeated suicide attempts.[17]
History or Exposure to Violent Behavior

Adolescents who have been exposed to high levels of violence are twice as likely to attempt suicide as those who have not.[18]
Family History of Suicidal Behavior or Mood Disorders

A family history of suicidal behavior plays both a genetic and environmental role in increasing the risk for an adolescent's likelihood to attempt or commit suicide.[19]
Biological Factors, Including Male Sex and Gay or Lesbian Sexual Orientation

Boys are about 5-6 times more likely to complete suicide than girls.[4] Gay and lesbian teens are much more likely to have suicidal ideations and attempt suicide than heterosexual teens.[20,21] There is some evidence to suggest that those adolescents with smaller concentrations of serotonin and all of its metabolites and receptors and neurons are at a greater risk of attempting and committing suicide.[22]

In addition to these 6 direct risk factors, 4 main precipitating, or potentiating, factors play a role in adolescent suicide. Although they are not sufficient in and of themselves to increase suicide risk, they can synergistically increase the likelihood of some form of suicidal behavior when they are present. They include:

* Substance abuse[23];

* Access to firearms or other means[24];

* Social stress, such as interpersonal conflicts with friends, family, or law enforcement[25];

* Emotional factors, such as feelings of despair or hopelessness.[2]

Community-Based Prevention of Suicide

Several strategies are commonly employed in community-based adolescent suicide prevention. The first and probably best known of these strategies is the crisis prevention hotline. However, outcome among hotline use is mixed. Although some work has shown some beneficial effect, particularly with effective training, other studies suggested that teenagers in particular not only do not use hotlines but have negative attitudes toward them.[26-28]

The most frequently used accessories to suicide are firearms and alcohol. Creating a barrier against their use has proved to have some utility in preventing suicide. For example, in one study of households with firearms,[29] the rate of suicide in children and adolescents was most affected by a decrease in firearm ownership. Specifically, the rate of suicide among children up to 19 years old decreased by 8.3% for every 10% decline in the percentage of households with firearms and children (95% confidence interval, 6.1%-10.5%). A study of alcohol use found an association between higher rates of suicide in 18- to 20-year-olds in states with a minimum legal drinking age of 18 years than in ones where the drinking age was 21 years.[30]

In terms of education and counseling, it appears that the manner in which one is delivered is important. Blanket educational seminars to all high school students have not been shown to be effective in suicide prevention.[31] In fact, they may be counterproductive in some instances, with some suggestion existing that suicidal adolescents can be disturbed by these classes and actually have worse outcomes. In contrast, targeted, one-on-one counseling in high schools, detention centers, and other institutional facilities has been shown to be an excellent method of suicidal behavior identification and prevention.[32] This type of approach involves specific questioning by mental health providers. During such a conversation, the clinician should maintain a demeanor that instills confidence in the adolescent by asking questions in a direct, nonthreatening, nonjudgmental way. The questions should be very specific, and seek to elicit the frequency of suicidal ideation and any possible plans for suicide that may have been developed. The healthcare provider should never act surprised or exhibit disapproval, but instead should maintain a calm, measured tone of voice.

Screening for Suicide

The US Preventive Services Task Force has determined that there is insufficient evidence to recommend either for or against suicide risk screening in the general adult population.[33] They have no specific recommendations for the adolescent population. However, the key to suicide prevention is early identification of adolescents at risk.

The most effective way to screen adolescents for suicidal behavior continues to be through a clinical assessment with very careful questioning.[4] In an effort to help clinicians get to those adolescents, the American Association of Suicidology highlighted 10 behavior patterns that clinicians should closely monitor.[34,35] These behavior patterns should serve as alarm bells for doing a further, more thorough behavioral health history-taking process, particularly involving the presence and degree of suicide intent. The 10 patterns to look for are:

1. Talking or in any other way communicating about a willingness to die or kill oneself;

2. Increased substance abuse;

3. Expressing a sense of purposelessness;

4. Showing signs of anxiety, including agitation and changes in sleep patterns;

5. Expressing feelings of being trapped in various personal situations;

6. Expressing feelings of hopelessness;

7. Withdrawing from social activities with friends and family;

8. Showing unusual signs of anger;

9. Engaging in reckless behavior; and

10. Exhibiting signs of mood changes.

Of note, many self-administered questionnaires try to mimic the accuracy of an experienced behavioral health provider in assessing suicide risk, but there is no evidence showing that they can substitute for a proper behavioral health visit.

Summary

Suicide ranks as the third most common cause of death among adolescents. Suicidal ideation with a specific plan to act is associated with a significant risk for attempted suicide. There are identifiable risk factors for attempted suicide, but there is no evidence that screening for suicide risk reduces suicide attempts or mortality. Nonetheless, clinicians should remain alert to the possibility of suicide in patients with the noted risk factors. Identification of children and adolescents with these risk factors and the provision of linkages to evidence-based services are clinically warranted.

Source : http://cme.medscape.com/viewarticle/702018