Adolescent Suicide as a Public Health Threat. David S. Bloch.
Journal of Child and Adolescent Psychiatric Nursing, Jan 1999 v12 i1 p26(1)
Full Text: COPYRIGHT 1999 Nursecom, Inc.
TOPIC. Adolescent suicide patterns.
PURPOSE. To raise awareness of the seriousness of adolescent suicidal behavior by reviewing international research on adolescent suicide and evaluating the prospects for identification and intervention.
SOURCES. Published literature.
CONCLUSIONS. Adolescent suicide research is complicated and often contradictory, but it does provide some insight into prevalence, risk factors, screening tools, and interventions. For completers, the problem may be intractable. But a few broad-based identification and prevention efforts show promise, and psychotherapy is a proven success. Even if suicide rates remain high, treatment of attempters should prevent further self-harm and reduce the completion rate, and thus should be funded.
Key words: Adolescence, adolescent suicide, attempted suicide, psychology
Adolescent suicide is not common (Group for the Advancement of Psychiatry [Group], 1996). In the general population, only children are less likely to kill themselves (American Academy of Child and Adolescent Psychiatry [AACAP], 1994).
But suicide is consistently the second- or third-leading cause of death from the ages of 13 to 19, and the third-leading cause of death among 15- to 24-year-olds (Lewinsohn, Rhode, & Seeley, 1996; U.S. Preventive Services [USPS] Task Force, 1989). Between 1980 and 1992, 67,369 children, adolescents, and young adults (ages 10-24 years) committed suicide. The 10- to 24-year-old age group represented 16.4% of all suicides in 1992 (Centers for Disease Control and Prevention [CDC], 1995).
Further, the social cost of adolescent suicide is disproportionately great. Completed suicide results in immeasurable grief for families and friends (Eggert, Thompson, Herting, & Nicholas, 1995), and adolescent suicide results in a measurable cost: the death of an adolescent represents a significant number of years of potential life lost (YPLL) (USPS, 1989). YPLL (essentially, years of potentially productive life less age at death) is the best way to calculate the societal loss each suicide represents. By this measure, adolescent suicide dominates many diseases of later life. Overall, adolescent suicide was the fifth-leading cause of years of potential life lost in 1990 (CDC, 1995).
Adolescent suicide is the driving force
behind increases in the overall suicide rate (CDC, 1995), and
rates are rising fast. The rate of adolescent suicide in America
has tripled since 1950 (CDC; Rotherman-Boris, Walker, & Ferns,
1996). Between 1968 and 1985, suicide rates nearly tripled among
American 10- to 14-year-olds and doubled among 15- to 19-year-olds
(Takanishi, 1993). Figure 1 shows the remarkable rise in suicide
rates since 1950.
Figure 1. Suicides per 100,000 People ages 15 to 24 1950 1960 1970 1980 1990 Male 6.5 8.2 13.5 20.2 22.0 Female 2.6 2.2 4.2 4.3 3.9 Total 4.5 5.2 8.8 12.3 13.2
Source: Centers for Disease Control, 1992.
Potential Explanations for the Rise in Suicide Rates
The reasons for the spiraling increase in American suicide rates are unknown. Some theorize it is a result of greater adolescent population density, which is associated with a disproportionate increase in suicide rates (USPS, 1989). Alternatively, the younger generation of adolescents may simply attempt more often, or lethality of attempt may have increased (Lewinsohn et al., 1996; CDC, 1995). Most researchers agree that population or cohort effects cannot fully explain the suicide epidemic of the past 30 years, but they cannot agree on the other causes.
Some researchers argue that rise in rates is an artifact: the 1960s ushered in a new era of psychological awareness, highlighting a suicide rate that had previously been underreported (Garland & Zigler, 1993), while others hold that reporting rates cannot explain the magnitude of the increase (Kleck, 1988).
Alternatively, changing social mores, especially with respect to drugs, marriage, and sexuality, may lead to increased adolescent suicide. The social movements of the 1960s led to a new tolerance for consciousness- and mood-altering drugs, the use of which is highly correlated with suicide in adolescents (Rotherman-Boris et al., 1996). That decade also marked the beginning of the sexual revolution, whose cavalier attitudes toward sex may not be psychologically healthy--especially in teenagers (Group, 1996; Mack, 1986). In the older generation the sexual revolution coincided with a massive jump in divorce rates. Disruption of family structures increases suicide risk in teens (King, Hovey, Brand, Wilson, & Ghaziuddin, 1997). And newer social phenomena, such as the heavy-metal subculture, may reinforce or even glorify suicidal behavior (Stack, Gundlach, & Reeves, 1994).
In sum, suicide is a leading cause of death among adolescents and young adults. Because the affected population is young, the number of years of potential life lost is disproportionately great. In addition, adolescent suicide has skyrocketed in the past 30 to 40 years. Researchers have not reached a consensus on the causes of this increase, but modern suicide research has identified many population dynamics of adolescent suicide.
Populations at Risk for Adolescent Suicide
Ideators. Most research holds that suicidal ideation, suicide attempts, and completed suicides are related but separate phenomena (Fergusson & Lynskey, 1995). An estimated 200,000 to 300,000 adolescents (about 1%-2% of the total adolescent population) think about suicide (Schepp & Biocca, 1991). But because suicidal ideation is relatively common in the adolescent population, it is not a particularly useful indicator of genuine suicidal intent (Lewinsohn et al., 1996). In France, only 20% of ideators go on to attempt suicide (Ladame, 1991).
Suicidal thoughts, however, are an unambiguous indicator of adolescent psychopathology. In the Oregon Adolescent Depression Project, only 0.6% of subjects without a prior diagnosed mental disorder reported suicidal ideation (Lewinsohn et al., 1996). Such thoughts are an important clinical indicator that should be carefully monitored by mental health professionals, and although the correlation is not perfect, teens usually express suicidal thoughts before making an attempt (Lewinsohn et al., 1996). Roughly 88% of attempters report prior suicidal thoughts, leaving only 12% who attempt "spontaneously" (Lewinsohn et al., 1996).
Attempters. Suicide attempters are at much higher risk than adolescents who only think about suicide. Teens who attempt have higher rates of psychopathology; adjustment disorders, and family problems than do adolescents who simply express suicidal ideation (Fergusson & Lynskey, 1995). In an Oklahoma study, attempters were more than twice as likely to report depression, reported significantly more suicidal ideation, used alcohol, and ran away from home more often than nonattempters (Rotherman-Boris et al., 1996).
Attempters, attention-starved and depressed, may be more interested in self-harm than in death (Hoberman & Garfinkel, 1988). Many will act when parents are at home or when and where someone is likely to find them (Leehey, 1986). Suicide attempters most commonly use over-the-counter medications (Myers, Otto, Harris, Diaco, & Moreno, 1992): In the United States, 83% of attempters overdose, and about 50% of those overdoses are mildly or moderately lethal (Garland & Zigler, 1993). Overall, 75% of attempts, or "parasuicides," are classified as "low medical risk" (Lewinsohn et al., 1996).
Nevertheless, the attempt phenomenon is extremely serf-destructive and should concern mental health practitioners and public health officials. Moreover, previous attempts correlate strongly with later completed suicide (Garland & Zigler, 1993). Estimates vary widely (from 0.1% to 14%) of how many attempters eventually will complete; researchers agree, however, that fully 40% of parasuicides attempt more than once (Lewinsohn et al., 1996). The American Academy of Child and Adolescent Psychiatry (1994) suggests that professionals immediately refer teens who express suicidal ideas to specialists in adolescent mental health.
Completers. Despite the close links between attempt and completion, most researchers still contend they are distinct phenomena with relatively little psychological overlap (Bloch, 1995). Estimates of the suicide attempt rate range from 50 to 200 times that of completion rate (Garland & Zigler, 1993; USPS, 1989).
In adolescents, the act of suicide usually is impulsive (Garland & Zigler, 1993). Postmortem psychological profiles of completers depict them as impulse-ridden people who act out of feelings of inner worthlessness or hopelessness (Feldman & Wilson, 1997). The motivations of completers, however, are difficult to examine with confidence. As a group, they can be studied only retrospectively. (Suicide survivors -- people who survive jumps from bridges or gunshots -- can be studied, but their numbers are quite small.) Studying suicide attempters or those displaying suicidal ideation probably does not provide significant insight into the psychology of those who complete. A researcher can gain only limited insight from the information the completer leaves behind or from the hindsight-tainted recollections of peers and family (Bloch, 1995).
A past history of attempts remains the single best predictor of future attempts and completed suicide (Lewinsohn et al., 1996). But many completed suicides occur during an adolescent's first episode of depression or other mental disorder, before he or she reaches treatment (Brent & Perper, 1995). Further, an adolescent may suicide as a form of self-punishment or in response to parental strife, which means the immediate precipitant may be difficult to anticipate (Bloch, 1995).
Race and Gender Disparities
Race and suicide. White males account for a substantial majority (perhaps as much as 71%) of all suicides (Leehey, 1986; McCall & Land, 1994). Black adolescents are far less likely to kill themselves than are their white counterparts (CDC, 1995). But Earls and Jemison (1986) and Feldman and Wilson (1997) observe that self-destructive and antisocial behavior among young American black males commonly leads to violent death in circumstances sometimes not readily distinguishable from suicide. In addition, a sizable number of potentially suicidal minority youths are removed from the population prematurely by homicide and incarceration (Garland & Zigler, 1993; Hammond & Yung, 1993). The notion that suicide and homicide are inversely related is supported by research on suicide in war zones (Somasundaram & Rajadurai, 1995).
Studies of differences in depression rates among different ethnic populations are inconclusive: Some report higher depression rates among blacks (Fleming & Offord, 1990), some report lower rates (Dornbusch, Mont-Reynaud, Ritter, & Chen, 1991) and some report no significant difference between black and white adolescent populations (Petersen & Compas, 1993). In the Feldman & Wilson (1997) sample of minority youth, fewer than half the suicidal teens were depressed, and a sizable number of the depressed teens were not suicidal. Depression is among the best predictors of adolescent suicide (Garland & Zigler, 1993). However, it is impossible to determine whether the lower black suicide rate is a result of lower depression rates (Harvey & Rauch, 1997).
The racial gap may be closing. The black male suicide rate skyrocketed between 1980 and 1992: for 15-to 19-year-olds overall, suicide rates increased 28.3%, but jumped 165.3% for black males of that age group (CDC, 1995). The black male suicide rate increased 300% during that period, compared with a white increase of 120% (Harvey & Rauch, 1997).
Gender and suicide. Adolescent females are three times more likely than males to attempt suicide, while males are four times as likely to complete the act (Garland & Zigler, 1993). Thus, while females attempt far more often, as many as 15 of 100,000 boys will commit suicide, compared with 3.3 of 100,000 girls (Lewinsohn et al., 1996).
Researchers differ on the reasons for this disparity. Some contend it is attributable to method choice: Boys are far more likely to attempt with firearms, while girls typically overdose (Petersen & Compas, 1993). Boys prefer guns and hanging, followed by carbon-monoxide poisoning, falls, and suffocation; girls are most likely to overdose, followed by carbon-monoxide poisoning, guns, and falls (Hoberman & Garfinkel, 1988). Also, males are disproportionately involved in substance abuse, which is a significant correlate of suicidality (Rotherman-Boris et al., 1996).
Others note that depressive disorders occur more frequently in girls than in boys during adolescence and throughout life (Petersen & Compas, 1993). A Finnish study suggests that adolescent female completers suffer from more severe mental disorders (commonly bipolar disorder or major depression) than do their male counterparts (Marttunen et al., 1995). Different rates of psychopathology may result from the fact that statistically, a girl is more likely than a boy to experience parental divorce in early adolescence (Petersen & Compas, 1993).
The male-female imbalance has been noted throughout the world, perhaps indicating a biological difference in suicide propensity (Etzersdorfer, Pribauer, & Sonneck, 1996). Certainly, boys and girls exhibit significantly different cognitive styles during adolescence (Group, 1996). But research on various American Indian populations, most of which have extremely high youth suicide rates, and in the People's Republic of China suggests that cultural factors also may influence suicide propensity (Group, 1996; Pritchard, 1996). Mainland (Communist) Chinese women commit suicide at much higher rates than do mainland Chinese men, across all age groups, in sharp contrast to a pattern well documented throughout the West and noted (at least anecdotally) worldwide (Pearson, 1995; Pritchard). Ethnicity cannot explain this result: The Western suicide pattern, predominantly urban and male, is replicated in ethnically Chinese Hong Kong, as well as in Singapore and Japan, though Japan's female suicide rate is higher than that of most other industrialized countries (Group, 1996; Pritchard). It is reasonable to conclude, then, that cultural factors may play an important role in explaining the link between gender and suicide rates.
Case Finding, Screening, and Prevention
Identification of potential suicides. It is important to understand the correlates of adolescent suicide to determine whether there are any suicide early warning signs. Research reveals several factors linked to suicide: mental disorders, family problems, a family history of parental or sibling suicide, substance abuse, mood disorders, and antisocial behavior (AACAP, 1994). But case finding will continue to be difficult without more rigorous definitions and better validation of suicide-detection instruments (Garrison, Lewinsohn, Martseller, Langhinrichsen, & Lann, 1991).
Depression and other mental disorders. A current major depressive disorder is one of the two major risk factors for adolescent suicide (Lewinsohn et al., 1996). Adolescent depression, however, is associated more strongly with suicide attempts than with completion (AACAP, 1994). Completed suicide is more strongly associated with hopelessness (Stack et al., 1994).
According to post mortem retrospective studies, more than 90% of completers have identifiable mental disorders (Brent & Perper, 1995). In an Oregon sample (Lewinsohn et al., 1996), 40.7% of adolescents with pure depression exhibited suicidal ideation, compared with 5.4% of those with anxiety disorders, 4.3% with disruptive behavior disorders, and 7.7% with substance abuse disorder. Kotila (1992) reported that psychosis correlated with attempts in 27% of cases seen in a roughly 500-patient sample from Helsinki emergency rooms. The sample studied by Feldman and Wilson (1997) using the Epigenic Assessment Rating System found correlations with aggression, while Ohberg et al. (1996) AU: need ref show a correlation with trait anxiety.
Based on such results, researchers consider suicidal ideation, plans, and attempts to be hallmarks of a major depressive disorder (Petersen & Compas, 1993). Two thirds of attempters are in the throes of a DSM-III major depressive episode (Ladame, 1992). Even in the presence of other mental disorders (e.g., mania), the severity of depressive symptoms is independently predictive of suicidality (Lewinsohn et al., 1996).
As a result, some suicide interventions focus on alleviating general depression rather than suicidal intent (Rotherman-Boris et al., 1996). Lewinsohn et al. (1996) report success in the 1,709-strong Oregon Adolescent Depression Project. Their course, Adolescent Coping With Depression, seeks to reduce adolescent depression by emphasizing mood control (Lewinsohn et al., 1996). The course uses the Schedule for Affective Disorders and Schizophrenia for School-Age Children (Orvaschel, Puig-Antich, Chambers, Tabrizi, & Johnson, 1982) to rank intent and the Lethality of Suicide Attempts Rating Scale (first proposed by Smith, Conroy & Ehler, 1984) to quantify a method's dangerousness. Similarly, researchers in Oklahoma have developed a Life Attitudes Schedule, which includes assessments of self-destructive, health-promoting, and injury-avoiding behaviors (Lewinsohn et al., 1995).
An accurate assessment of the clinical importance of suicidal attempts would be of significant value. "Lumping self-harm with suicide distorts research and clinical knowledge, thereby increasing the risk of missing truly suicidal persons' (Leehey, 1986, p. 19). However, approaches that emphasize depression rather than suicidality will miss those suicidal adolescents who do not present with depression. Moreover, the long-term efficacy of depression-based interventions on adolescent suicide has yet to be demonstrated. Indeed, Feldman and Wilson (1997) and others question whether depression is an adequate proxy for suicidality at all. Depression may be diagnosed by clinicians using the DSM-IV (American Psychiatric Association, 1994), but relying on DSM-IV diagnosis to detect at-risk individuals is untenable, since adolescents are not seen by mental health clinicians as a matter of course.
Some diagnostic questionnaires oriented toward the layperson are fairly sensitive (USPS, 1989). They probably will never be more than moderately successful at predicting suicidal behavior, though, because the underlying conduct and motivations are so complex (Larzelere, Smith, Batenhorst, & Kelly, 1996; Shaffer, 1996). For example, the Suicide Probability Scale, which
measures ideation, hopelessness, social alienation/isolation, and self-esteem, significantly predicts deliberate self-harm and suicide attempts, but it misses more than half the cases evaluated, apparently because these variables are common in troubled but nonsuicidal youths (Larzelere et al.).
Substance abuse. In addition to depression, suicide risk increases when the adolescent is a substance abuser (Rotherman-Boris et al., 1996). Half or more adolescent suicides occur under the influence of alcohol or drugs (Rotherman-Boris et al.; Shaffer et al., 1988; USPS, 1989). But studies have not demonstrated that substance-abuse-related interventions reduce suicide rates (USPS). It is not clear whether substance abuse causes suicide or just co-varies with it. For that reason, caregivers should attempt to determine the pattern of teen drug and alcohol use, but should not resort to more invasive techniques (e.g., blood tests) unless the person involved has been identified as a suicide risk (USPS).
Past history. Family problems or conflicts can lead to significant depression and possible suicidality, especially (though not exclusively) in broken homes (King et al., 1997). In addition to intrafamily strife, parental illness is associated strongly with adolescent suicide. Mental health professionals should keep the possibility of suicide in mind whenever an adolescent patient reports significant family problems.
Past suicide attempts are a major risk factor for later completion (King et al., 1997). Though Rotherman-Boris and colleagues (1996) note that the truly significant variable is previous attempts using methods other than pills, any adolescent who has attempted suicide, even using pills, should be considered at high risk (Lewinsohn et al., 1996).
Personal history by itself (as opposed to prior attempts) is a poor predictor of suicide because it is nonspecific: The same events that may trigger suicide in some are quite commonly experienced in the nonsuicidal population (Ladame, 1992). It is not clear whether other risk factors such as delinquency, conduct problems, stress, low self-esteem, recent suicide attempts by friends or family members, low educational attainment, poor school performance, negative affect, and being born to a teen mother are causal, contributing, or incidental relationships (Lewinsohn et al., 1996; Rotherman-Boris et al., 1996).
Screening for potential suicides. AACAP (1994) and CDC (1992) emphasize the ways laypeople can identify potential suicides. The CDC lists eight suicide prevention strategies: school gatekeeper training, community gatekeeper training, general suicide education, screening programs, peer support programs, crisis centers and hotlines, restriction of access to lethal means, and intervention after a suicide. A great deal of research has focused on school-based screening programs. The logic behind this approach is persuasive: Adolescents spend more of their waking hours at school than at home or in any other place.
Though a large number of false positives is likely, using lists like those found in Tables 1 and 2 can provide early warning in the hands of an alert parent or teacher. Some detection technologies must be made available to parents or teachers, as a suicidal adolescent is unlikely to approach a mental health professional on his or her own (USPS, 1989). The U.S. Preventive Services Task Force also suggests the use of uniform Suicidal Ideation Questionnaires and checklists of known risk factors. Both tests require teachers or parents to check whether their charges exhibit any of a number of behaviors. Adolescents with specified risk factors should be referred to psychiatrists or other mental health specialists (USPS) (Table 1).
Table 1. Indicators for Referral to Mental Health Professionals
* Changed eating habits
* Social withdrawal
* Unusual violent or rebellious activity, including running away
* Substance abuse
* Atypical neglect of personal appearance
* Dramatic changes in personality or affect
* Boredom, difficulty in concentration, poor and declining school performance
* Complaints of illness (e.g., headaches, fatigue, stomachaches)
* Anomie or hopelessness
* Inability to tolerate praise
Source: American Academy of Child and Adolescent Psychiatry, 1994.
Table 2. Signs of a Decision to Commit Suicide
* Preoccupation with suicide/death
* Verbal hints or statements suggesting despair or imminent departure
* Complaints of being "rotten inside"
* Distributing or discarding favorite possessions, cleaning room, or "putting affairs in order"
* Sudden cheerfulness following depression
Source: American Academy of Child and Adolescent Psychiatry, 1994.
Most school-based screening programs assume that teachers or administrators will detect potential suicides. Some research, however, focuses on students. Peer confidantes can play an important role in identifying suicidal teens (Kalafat & Elias, 1992). High school peers are much more likely than are adults to know of adolescent suicide attempts, and teens who are personally familiar with a person who committed suicide are much more likely to report attempters or ideators (Kalafat & Elias). But the adolescent "code of silence" is hard to break. Among teens who personally knew a completed suicide, only 25% told an adult when they later learned of a peer with suicidal ideation or intent (Kalafat & Elias). Nevertheless, interventions aimed at impressing adolescents with the seriousness of suicide might work (Kalafat & Elias).
In a Finnish study (Isometsa et al., 1995), 41% of suicides had contacted a healthcare professional within 4 weeks before committing suicide. Research in America suggests that roughly 25% of all attempts come within 1 month of the attempter seeking treatment (Rotherman-Boris et al., 1996). If primary healthcare providers were more knowledgeable, perhaps some of these suicides could be detected and prevented (Group, 1996). But it is not clear that educating pediatricians, general practitioners, school nurses and counselors, nurse practitioners, and physician assistants will lead to increased ability to detect suicidal behavior, as intent is communicated only in roughly one fifth of all cases (Isometsa et al.). Also, while suicidal adolescents are more likely to use mental health services, completers have fewer treatment experiences than attempters (Pfeifer, Peskin, & Siefker, 1992). Without question, mental health professionals should as a matter of course screen for suicidality at intake (Rotherman-Boris et al.). Table 2 lists signs to look for intention to commit suicide.
Preventing adolescent suicides. Identifying traits common to at-risk individuals is the first step toward treatment and prevention of adolescent suicide. The second step is to develop some tool that effectively screens at-risk populations for suicidality--a daunting prospect. The final step, from a public health perspective, is preventive intervention with individuals, identified subpopulations, or the population at large. The literature contains little guidance on effective early interventions or preventive treatment approaches for high-risk populations (Rudd et al., 1996). Table 3 lists the major approaches to adolescent suicide prevention.
Table 3. Approaches to Primary Prevention of Adolescent Suicides
* Identification of risk factors
* Restricted access to suicide tools
* Detection and treatment of psychiatric disorders associated with suicide
* Immediate psychological assessment of adolescents expressing suicidal intent
* Increased suicide awareness and prevention training for primary healthcare providers
* Peer-group interventions and increased suicide-related education
* Increased family and adult suicide education
* Increased access to public support services
* Increased public awareness
Source: The Group for the Advancement of Psychiatry, 1996.
Psychotherapy. If adolescent suicide is generated by some form of mental stress or disorder, the logical intervention is psychological or psychiatric in nature. All available studies confirm (to greater or lesser degrees) that depression and associated disorders can be alleviated through mental health treatment (Petersen & Compas, 1993). Ladame (1992) and Kotila (1992) also suggest that improving adolescent coping devices is important, because an adolescent's adaptive resources will determine whether he or she responds to adverse pressures by suicide or parasuicide.
Drug and alcohol abuse are highly correlated with adolescent suicide and parasuicide. To the extent that this relationship is causal (a controversial proposition), therapies for drug addiction may have a salutary effect on the suicidal tendencies of drug-using adolescents (Shaffer et al., 1988). But research on the topic is inconclusive, and the many suicidal teens who do not use intoxicants before suicide will not be helped by addiction interventions (USPS, 1989).
Short-term outpatient interventions show limited promise. Rudd et al. (1996) evaluated a 2-week outpatient treatment program that sought to enhance adaptive coping and improve deficient problem-solving skills. Their research did not demonstrate the efficacy of their program --both the control (inpatient/no program) and experimental populations improved markedly--but the researchers continue to believe that time-limited outpatient interventions may work (Rudd et al.). Similarly, an English study team passed out doctor-referral "tokens" to a group of hospitalized attempters on discharge, but the intervention's positive results were statistically insignificant (Cotgrove, Zirinsky, Black, & Weston, 1995).
Long-term psychotherapeutic treatment has had more tangible success. A multiyear follow-up study of suicidal preteens demonstrates a positive effect of intensive psychotherapeutic treatment (Pfeifer et al., 1992). But this effect may be explained by selection bias (motivations for suiddal preteens may be different from those of suicidal teens) or the fact that the study population is not yet through the high-risk period (Pfeifer et al.). Another 7-year follow-up of former adolescent psychiatric inpatients suggests that psychiatric treatment (including psychotherapy) longer than 3 months has a significant positive effect on suicide rates (Ladame, 1992).
Psychotherapeutic treatment of at-risk adolescents --particularly the clinically depressed, drug abusers, and known attempters--is the best avenue to reducing the rate of adolescent suicide (Garland & Zigler, 1993). Attempters in particular should be treated by skilled mental health professionals, as an attempt is the best-known predictor of eventual suicide (Lewinsohn et al., 1996). Primary care health professionals should screen for depression in adolescents using ready-made tests and should consult a mental health professional whenever they detect depression (USPS, 1989).
But such therapy-intensive recommendations raise the question of treatment compliance. In one New York study, 59% of suicidal adolescents complied with their psychotherapeutic treatment regimen 3 months after hospitalization (Spirito et al., 1992). The problem of compliance is enhanced when researchers look at broader-based interventions. The Group for the Advancement of Psychiatry (1996) suggests that therapeutic interventions with families may be more effective than treatment of the adolescent alone. King and associates (1997), however, indicate that rates of compliance differ depending on the type of follow-up treatment rendered: Compliance is highest in medication-based interventions (66.7%), lower in individual therapy (50.8%), and lowest in group or family therapy (33.3%). Legal obstacles to involuntary commitment of adolescents also are a significant barrier to effective treatment in some cases (Group, 1996).
Pharmacotherapy. Pharmacotherapy of adolescents with mental disorders, an increasingly common intervention, has serious drawbacks. Early pharmaceutical interventions may lead families to discount the psychological elements of a suicide attempt, contributing to a lack of compliance with post-hospitalization treatment regimens (King et al., 1997). In addition, most early controlled studies do not indicate that pharmacotherapy is efficacious in treating adolescent depression (Brent & Perper, 1995). Tricyclic antidepressants (TCAs), the focus of most early research, potentially are lethal, and their use is associated with reattempt (Brent & Perper). (This increase in attempt risk does not imply causality, however; it is quite possible that adolescents being treated with TCAs are at higher suicide risk to begin with.) Serotonin reuptake inhibitors are less dangerous and more promising. Suicidally depressed patients have lower levels of the neurotransmitter serotonin in their cerebral spinal fluid than do nonsuicidal patients with diagnosed depression (Ladame, 1992). Research is continuing, but the only case-control study to date shows a substantial placebo effect (Walkup, 1996).
Finally, "there is great danger that the message conveyed to the suggestible adolescent recipient of medication from the adult prescriber is that one looks to pills for solutions to developmental problems" (Bloch, 1995, pp. 378-379). Although adolescent suicide may not be a developmental problem per se, the same basic objection remains--that prescribing medication may lead teens to seek or expect pharmacological solutions to other life problems. In sum, medicating teens may do more harm than good, especially if the diagnosis is only suspicion of suicidal intent.
Nonmedical interventions. Because medical interventions reach only a minority of potentially suicidal teens, many researchers have investigated the use of nonmedical support services as suicide-prevention tools. Simply focusing societal attention on the problem may yield some benefit. Between 1980 and 1987, states that sponsored antisuicide legislation, commissions, task forces, advisory groups, manuals, brochures, or public action of nearly any other sort all experienced a smaller increase in the adolescent suicide rate (Lester, 1992).
The most common but least successful nonmedical interventions are so-called crisis hot-lines and school-based suicide awareness/prevention programs (Miller, Coombs, & Leeper, 1984). In such programs, adolescent teens are given the opportunity to speak anonymously to peers or volunteer counselors. The overwhelming consensus is that these interventions do not work (Garland & Zigler, 1993). The research by Miller and colleagues suggests that suicide hotlines have a statistically significant effect on suicides only among white women. In support of such services, though, there is evidence that they serve a population not reached by other mental health interventions (Garland & Zigler).
Similarly, curriculum-based educational interventions have grown tremendously over the past 10 years (by 200% between 1984 and 1989), but they have not been particularly successful (Garland & Zigler, 1993). Educational interventions that use a model of suicide based on stress rather than mental disorder, underemphasizing or denying altogether the link to depression and mental illness, are only minimally effective in transmitting knowledge and do not change participant attitudes (Garland & Zigler).
This is not to say that school-based efforts are destined to fail. At least one school-based nursing intervention has reported good results using a different conception of suicide. Eggert and colleagues (1995) created an intervention that divided troubled teens (identified before the study) into three groups: a suicide assessment evaluation group, an assessment plus a one-semester Personal Growth Class group, and an assessment group plus a two-semester class group. Assessment alone seems to reduce suicide risk behaviors, depression, hopelessness, stress, and anger, and to increase self-esteem and network social support; the groups attending classes also exhibited increased personal control (Eggert et al.). The Eggert team's nursing-based research shows that school programs can change attitudes and problem-solving strategies; Kalafat and Elias (1994) also report success in increasing knowledge. Whether any of this translates into fewer suicides is, at this point, unknown (Eggert et al.).
Although the Eggert group's results are promising, many researchers are pessimistic about the viability of school-based interventions. Vieland et al. (1991) conclude that although suicide education programs are intuitively appealing, they are ineffectual in preventing teen suicide and may even promote it. In a survey of state-mandated school-based interventions, Lester (1992) found that the more students are enrolled in educational programs, the greater the increase in suicide rates--more evidence that school-based education programs can be iatrogenic. Even more optimistic researchers note there are substantial obstacles facing any school-based intervention (Group, 1996). A school-based suicide prevention program cannot be effective, for instance, unless program designers understand the knowledge base of all participants--school personnel, parents, and teens (Schepp & Biocca, 1991).
Restricting access to tools and information. A third line of attack is the restriction of information and tools that may lead to or facilitate adolescent suicide (CDC, 1992; Group, 1996). Sensationalistic accounts of teen suicides apparently lead to copycat attempts (Garland & Zigler, 1993; Group). This may give rise to the "cluster effect," in which the suicide of one adolescent spurs suicidal activities in others (Group). According to the cluster-effect hypothesis, which is not universally embraced, children learn suicidal behaviors from suicidal peers and family members, as well as from the media (Rotherman-Boris et al., 1996). Such learning is facilitated by public information resources, such as the Internet, which may contain suicide "recipes" or advice. But restricting the free flow of information is difficult. The First Amendment represents a high hurdle, even where the protection of children is the object of the regulation. The media should be warned that news stories can directly affect adolescent suicide rates. Awareness can lead to voluntary restraint.
Although legal barriers make regulating suicide information difficult in the population at large, mental health providers can control the flow of knowledge in inpatient settings. The cluster pattern has been documented among young psychiatric inpatients (Runeson, Beskow, & Waern, 1996). In controlled settings (such as psychiatric hospitals), it is advisable to restrict information about completed suicides and to monitor survivors closely.
The U.S. Preventive Services Task Force (1989) recommends restricting access to common suicide tools. Guns are the primary suicide weapon for adolescents and thus are logical targets of a public health intervention (Brent & Perper, 1995). In 1992, 64.9% of suicides in children, adolescents, and young adults were accomplished using firearms; in the 15-to-19 age group, 81% of the increase in suicides is attributable to suicide by gun (CDC, 1995).
It is not obvious, however, that gun control is a solution to adolescent suicide. Regulating tools will not remove the suicidal impulse, and it is impossible to control an adolescent's access to rope or tall buildings (Ohberg, Lonnqvist, Sarna, & Vuori, 1996). Removing one avenue of suicide simply may drive an impulsive adolescent to another. It is true that suicide rates are relatively lower in U.S. geographic regions typified by stricter firearm-ownership laws (Brent & Perper, 1995). That said, the gun-control movement (which started in the 1970s and gained force in the 1980s and 1990s) has not reduced epidemic-level suicide rates, and it is not clear whether suicide-by-gun rates have been reduced disproportionately in these geographic regions. In Finland, rates of violent adolescent suicide have risen in tandem with those in the United States since the 1960s, despite extremely restrictive gun laws throughout the entire period. Ohberg et al. conclude that it is "hard to explain the significantly increased rate of suicide by firearms solely by availability" (p. 149). On the other hand, the suicidal impulse in adolescents appears to be transitory (if recurrent). An adolescent who lacks an immediate route to suicide may not re-attempt. Moreover, suicides by gun are quick, painless, and require a minimum of skill. Thus, the theoretical argument for limiting teen access to guns remains, even though there is little empirical support (Group, 1996). As with information restrictions, significant firearm regulations may impinge on constitutional liberties and predictably encounter political resistance.
A third "social" intervention, also proposed by the U.S. Preventive Services Task Force (1989), would restrict adolescent access to mind-altering chemicals. There is little to be said in favor of adolescent drug or alcohol use, but such use is already illegal. It is difficult to formulate additional recommendations that will result in decreased adolescent access to drugs.
This article has discussed, in broad outline, current research on the prevalence of adolescent suicide, the primary risk factors associated with suicide and parasuicide, the tools available for identification and screening, and the possibility of effective intervention with at-risk youth. Though the corpus of adolescent suicide research is complicated and sometimes contradictory, we can draw a few conclusions from the literature.
For completers, the problem of adolescent suicide probably is somewhat intractable. As Leehey (1986) notes, "It is unlikely that studying suicide attempters or persons with suicidal ideation gives a reasonable approximation of studying suicide completers" (p. 18). Nevertheless, there is a correlation between completion and prior attempt (Runeson et al., 1996). School-based prevention efforts have largely failed (Vieland et al., 1991), but a few projects, like that of Eggert et al. (1995), bear watching and, if their early results hold, emulating. Psychotherapeutic treatment of depressed adolescents is also a proven success (Shaffer, 1996). Identification of potential suicides through school or doctor or nurse-based screening questionnaires is feasible, if not infallible.
Even if suicide rates remain high, treatment of attempters and at-risk adolescents (ideators) holds out the possibility of averting serious instances of deliberate self-harm, while also potentially reducing the likelihood of a later completed suicide. Considering the severity of the problem, earmarking resources for such treatment clearly is worth the cost.
Acknowledgments. The author would like to thank Carol Essick, RN, and W. Scott Schroth, MD, for comments on earlier drafts.
American Academy of Child and Adolescent Psychiatry. (1994). Facts for teachers: Teen suicide. Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Bloch, H.S. (1995). Adolescent development, psychopathology, and treatment. Madison, CT: International Universities Press.
Brent, D.A., & Perper, J.A. (1995). Research in adolescent suicide: Implications for training, service delivery, and public policy. Suicide and Life-Threatening Behavior, 25, 222-230.
Centers for Disease Control. (1992). Youth suicide prevention programs: A resource guide. Atlanta, GA: Author.
Centers for Disease Control and Prevention. (1995). Suicide among children, adolescents, and young adults--United States, 1980-1992. Journal of School Health, 65, 272-273.
Cotgrove, A.J., Zirinsky, L., Black, D., & Weston, D. (1995). Secondary prevention of attempted suicide in adolescence. Journal of Adolescence, 18, 569-577.
Dornbusch, S.M., Mont-Reynaud, R., Ritter, EL. & Chen, Z. (1991). Stressful events and their correlates among adolescents of diverse backgrounds. In M.E. Colten & S. Gore (Eds.), Adolescent stress: Causes and consequences (pp. 111-130). New York: Aldine de Gruyter.
Earls, E, & Jemison, A. (1986). Suicidal behavior in American blacks. In G.L. Klerman (Ed.), Suicide and depression among adolescents and young adults (pp. 131-146). Washington, DC: American Psychiatric Press.
Eggert, L.L., Thompson, E.A., Herting, J.R., & Nicholas, L.J. (1995). Reducing suicide potential among high-risk youth: Tests of a school-based prevention program. Suicide and Life-Threatening Behavior, 25, 276-296.
Etzersdorfer, E., Pribauer, E, & Sonneck, G. (1996). Sex differential for suicide among Austrian age cohorts. Acta Psychiatrica Scandinavica, 93, 240-245.
Feldman, M., & Wilson, A. (1997). Adolescent suicidality in urban minorities and its relationship to conduct disorders, depression, and separation anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 75-84.
Fergusson, D.M., & Lynskey, M.T. (1995). Suicide attempts and suicidal ideation in a birth cohort of 16-year-old New Zealanders. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1308-1317.
Fleming, J.E., & Offord, D.R. (1990). Epidemiology of childhood depressive disorders: A critical review. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 571-580.
Garland, A.E, & Zigler, E. (1993). Adolescent suicide prevention: current research and social policy implications. American Psychologist, 48, 169-182.
Garrison, C.Z., Lewinsohn, EM., Martseller, E, Langhinrichsen, J., & Lann, I. (1991). The measurement of suicidal behavior in adolescents. Suicide and Life-Threatening Behavior, 21, 217-230.
Group for the Advancement of Psychiatry. (1996). Adolescent suicide. Washington, DC: American Psychiatric Press.
Hammond, W.R., & Yung, B. (1993). Psychology's role in the public health response to assaultive violence in young African-American men. American Psychologist, 48, 142-155.
Harvey, A.R., & Rauch, J.B. (1997). A comprehensive Afrocentric rites of passage program for black male adolescents. Health and Social Work, 22, 30-42.
Hoberman, H.M., & Garfinkel, B.D. (1988). Completed suicide in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 689-695.
Isometsa, E.T., Heikkinen, M.E., Marttunen, M.J., Henriksson, M.M., Aro, H., & Lonnqvist, J. (1995). The last appointment before suicide: Is suicide intent communicated? American Journal of Psychiatry, 152, 919-922.
Kalafat, J., & Elias, M. (1992). Adolescents' experience with and response to suicidal peers. Suicide and Life-Threatening Behavior, 22, 315-321.
Kalafat, J., & Elias, M. (1994). An evaluation of a school-based suicide awareness intervention. Suicide and Life-Threatening Behavior, 24, 224-233.
King, C.A., Hovey, J.D., Brand, E., Wilson, R., & Ghaziuddin, N. (1997). Suicidal adolescents after hospitalization: Parent and family impacts on treatment follow-through. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 85-93.
Kleck, G. (1988). Miscounting suicides. Suicide and Life-Threatening Behavior, 18, 219-236.
Kotila, L. (1992). The outcome of attempted suicide in adolescence. Journal of Adolescent Health, 13, 415-417.
Ladame, E (1992). Suicide prevention in adolescence: An overview of current trends. Journal of Adolescent Health, 13, 406-408.
Larzelere, R.E., Smith, G.L., Batenhorst, L.M., & Kelly, D.B. (1996). Predictive validity of the suicide probability scale among adolescents in group home treatment. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 166-172.
Leehey, K. (1986, November). Suicide in adolescence. Psychiatric Times, 18-19.
Lester, D. (1992). State initiatives in addressing youth suicide: Evidence for their effectiveness. Social Psychiatry and Psychiatric Epidemiology, 27, 75-77.
Lewinsohn, EM., Rhode, E, & Seeley, J.R. (1996). Adolescent suicidal ideation and attempts: Prevalence, risk factors, and clinical implications. Clinical Psychology: Science and Practice, 3, 25-46.
Lewinsohn, EM., Langhinrichsen-Rohling, J., Langford, R., Rohde, E, Seeley, J.R., & Chapman, J. (1995). The life attitudes schedule: A scale to assess adolescent life-enhancing and life-threatening behaviors. Suicide and Life-Threatening Behavior, 25, 458-474.
Mack, J.E. (1986). Adolescent suicide: An architectural model. In G.L. Klerman (Ed.), Suicide and depression among adolescents and young adults (pp. 53-76). Washington, DC: American Psychiatric Press.
Marttunen, M.J., Henriksson, M.M., Aro, H.M., Heikkinen, M., Isometsa, E., & Lonnqvist, J. (1995). Suicide among female adolescents: Characteristics and comparison with males in the age group 13 to 22 years. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1297-1307.
McCall, E, & Land, K. (1994). Trends in white male adolescent, youngadult, and elderly suicide: Are there common underlying structural factors? Social Science Research, 23, 57-81.
Miller, H.L., Coombs, D.W., & Leeper, J.D. (1984). An analysis of the effects of suicide prevention facilities on suicide rates in the United States. American Journal of Public Health, 74, 340-343.
Myers, W.C., Otto, T.A., Harris, E., Diaco, D., & Moreno, A. (1992). Acetaminophen overdose as a suicidal gesture: A survey of adolescents' knowledge of its potential for toxicity. Journal of the American Academy of Child and Adolescent Psychiatry, 4, 686-690.
Ohberg, A., Lonnqvist, J., Sama, S., & Vuori, E. (1996). Violent methods associated with high suicide mortality among the young. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 144-153.
Orvaschel, H., Puig-Antich, J., Chambers, W.J., Tabrizi, M.A., & Johnson, R. (1982). Retrospective assessment of prepubertal major depression with the Kiddie-SADS-E. Journal of the American Academy of Child and Adolescent Psychiatry, 21, 392-397.
Pearson, V. (1995). Goods on which one loses: Women and mental health in China. Social Science and Medicine, 41, 1159-1173.
Petersen, A.C., & Compas, B.E. (1993). Depression in adolescence. American Psychologist, 48, 155-168.
Pfeifer, C.R., Peskin, J.R., & Siefker, C.A. (1992). Suicidal children grow up: Psychiatric treatment during follow-up period. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 679-685.
Pritchard, C. (1996). Suicide in the People's Republic of China categorized by age and gender: Evidence of the influence of culture on suicide. Acta Psychiatrica Scandinavica, 93, 362-367.
Rotherman-Boris, M.J., Walker, J.U., & Ferns, M. (1996). Suicidal behavior among middle-class adolescents who seek crisis services. Journal of Clinical Psychology, 52, 137-143.
Rudd, D.M., Rajab, M.H., Orman, D.T., Stulman, D.A., Joiner, T., & Dixon, W. (1996). Effectiveness of an outpatient intervention targeting suicidal young adults: Preliminary results. Journal of Consulting and Clinical Psychology, 64, 179-190.
Runeson, B.S., Beskow, J., & Waern, M. (1996). The suicidal process in suirides among young people. Acta Psychiatrica Scandinavica, 93, 35-42.
Schepp, K.G., & Biocca, L. (1991). Adolescent suicide: Views of adolescents, parents and school personnel. Archives of Psychiatric Nursing, 5, 57-63.
Shaffer, D. (1996). Discussion of "predictive validity of the suicide probability scale among adolescents in group home treatment." Journal of the American Academy of Child and Adolescent Psychiatry, 35, 172-174.
Shaffer, D., Garland, A., Gould, M., Fisher, P., & Trautman, P. (1988). Preventing teenage suicide: A critical review. Journal of the American Academy of Child & Adolescent Psychiatry, 27, 675-685.
Smith, K., Conroy, R., & Ehler, B. (1984). Lethality of suicide attempt rating scale. Suicide and Life-Threatening Behavior, 14, 215-242.
Somasundaram, D.J., & Rajadurai, S. (1995). War and suicide in northern Sri Lanka. Acta Psychiatrica Scandinavica, 91, 1-4.
Spirito, A., Plummer, B., Gispert, M., & Levy, M. (1992). Adolescent suicide attempts: Outcomes at follow-up. American Journal of Orthopsychiatry, 62, 464-468.
Stack, S., Gundlach, J., & Reeves, J.L. (1994). The heavy metal subculture and suicide. Suicide and Life-Threatening Behavior, 24, 15-23.
Takanishi, R. (1993). The opportunities of adolescence research, interventions, and policy. American Psychologist, 48, 85-88.
U.S. Preventive Services Task Force. (1989). Guide to clinical preventive services. Baltimore: Williams & Wilkins.
Vieland, V., Whittle, B., Garland, A., Hicks, R., & Shaffer, D. (1991). The impact of curriculum-based suicide prevention programs for teenagers: An 18-month follow-up. Journal of the Academy of Child and Adolescent Psychiatry, 30, 811-815.
Walkup, J. (1996, January-February). Fluoxetine and major depression. AACAP News, p.16.
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David S. Bloch, MPH, JD, is an attorney at law with Lynch, Gilardi, & Grummer, San Francisco, CA.