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MauriMarttunen

Risk of Suicide in Adolescence

Essentials

  • Suicidal thoughts and attempted and completed suicides are rare in childhood but the incidence increases during adolescence.
  • An earlier attempted suicide and self-destructive behaviour, even if it would not be associated with a wish to die (like cutting) are important risk factor for a reattempted or committed suicide.
  • Structured assessment methods are useful aids when assessing self-destructive behaviour in an adolescent.
  • A safety plan should be developed for a clearly self-destructive adolescent.

Epidemiology

  • The annual prevalence of suicidal thoughts among adolescents is approximately 10-15%, and that of attempted suicides at least 4-5%.
  • Suicidal thoughts and attempts are more common among girls, but about 70-80% of all suicides are committed by boys.
  • About half of adolescents who have attempted suicide will later make an another attempt.

Risk factors for adolescent suicide

  • One in three has previously attempted suicide.
  • About 60% of adolescents who commit suicide had talked to someone about their suicidal thoughts, often, however, only to their peers.
  • Psychiatric disorders precede suicide in about 90% of the cases, mood disorder in at least half of the cases.
  • At least one quarter have suffered from serious substance abuse.
  • Common precipitants to suicide and suicide attempts are failure, disappointment, a break-up of a relationship or an argument with someone close. Conflicts in family relations, domestic violence and arguments with the parents are also common.

Symptoms

  • Suicidal behaviour in adolescence is often associated with current psychosocial problems, such as arguments, bereavement and disappointment.
  • Mood disorders, serious substance abuse and, particularly among males, antisocial behaviour is common.

Recognition and assessment Suicide Prevention Programs for Children and Youth

  • Self-destructive behaviour in adolescence is strongly associated with depression and substance abuse.
  • When depression is suspected in an adolescent, suicidal thoughts and suicide attempts should always be broached.
  • Assess current living circumstances and family situation always if an adolescent expresses suicidal thoughts or intents.
  • Evaluate the type and severity of associated psychiatric disorder and/or substance abuse.
  • Ask whether the patient has attempted suicide or harmed him-/herself in some other way in the past.
  • Assess whether the patient really wants to die, has he/she made suicidal plans or arrangements.
  • The use of structured assessment forms, such as the C-SSRS (Columbia Suicide Severity Rating Scale http://cssrs.columbia.edu/), improves the assessment of the risk for immediate self-destructive behaviour.

Treatment

  • Always agree on follow-up appointments and encourage the patient to carry on with the treatment.
  • Facilitate easy access to treatment.
  • Meet the young person's parents as well and assess whether the family is able to sufficiently support the patient.
  • Develop a safety plan for the young person together with him/her and the parents.
  • If necessary, contact the child protection services in order to arrange support for the family.
  • If self-destructiveness is associated with depression, its treatment should be instigated without delay.
  • Of the selective serotonin reuptake inhibitors (SSRIs), fluoxetine is the first choice in the psychopharmacological treatment of a self-destructive adolescent with major depression Depression in Adolescents.
  • Always refer an adolescent who has attempted suicide for psychiatric consultation, the quicker the better.
  • Psychiatric hospitalization should be considered Factors Associated with Suicide after Parasuicide in Young People if the suicidal adolescent suffers from
    • psychotic disorder
    • major depression
    • bipolar disorder
    • severe aggressive behaviour
    • severe substance abuse or dependence
    • if care in the community after a previous suicidal episode has failed.
  • Hospitalization is also justified after a serious suicide attempt (high lethality or high suicidal intent), if the adolescent's suicidal thoughts do not subside, and if the adolescent's family cannot offer sufficient support.

    References

    • Castellví P, Lucas-Romero E, Miranda-Mendizábal A et al. Longitudinal association between self-injurious thoughts and behaviors and suicidal behavior in adolescents and young adults: A systematic review with meta-analysis. J Affect Disord 2017;215():37-48. [PubMed]
    • Consoli A, Peyre H, Speranza M et al. Suicidal behaviors in depressed adolescents: role of perceived relationships in the family. Child Adolesc Psychiatry Ment Health 2013;7(1):8. [PubMed]
    • Brent DA, McMakin DL, Kennard BD et al. Protecting adolescents from self-harm: a critical review of intervention studies. J Am Acad Child Adolesc Psychiatry 2013;52(12):1260-71. [PubMed]
    • Hawton K, Saunders KE, O'Connor RC. Self-harm and suicide in adolescents. Lancet 2012;379(9834):2373-82. [PubMed]
    • Pelkonen M, Karlsson L, Marttunen M. Adolescent suicide: epidemiology, psychological theories, risk factors, and prevention. Current Pediatric Reviews 2011;7:52-67.
    • Burns CD, Cortell R, Wagner BM. Treatment compliance in adolescents after attempted suicide: a 2-year follow-up study. J Am Acad Child Adolesc Psychiatry 2008 Aug;47(8):948-57. [PubMed]