The phenomenon of deliberate self-harm, often with a wish to die.
Suicide is the third leading cause of death among adolescents, occurring at a rate of 10.8 per 100,000 among 15-19 year olds in 1992. Suicide is much less common among 10-14 year olds, at 1.7 per 100,000, although the rate of suicide has increased dramatically since 1950 among all age groups. Suicide attempts are much more common, occurring in 2% of adolescent girls and 1% of adolescent boys per year. Significant suicidal ideation (with a plan to commit suicide or intent to die) is more common, occurring in 5-10% of child and adolescent youth.
The suicide completion rate is about four times higher in males than females, while the rate of attempt is two to three times higher in females than males. Completed suicide may be greater among males because of their tendency to utilize methods of more potential lethality. The rate of suicide also varies according to victims' race. Highest are Native Americans and whites. The suicide rate among African American males increased dramatically in the 1980s, and now approaches 80% of the white male suicide rate.
In the United States, the most common method for completed suicide is firearms, followed by hanging, carbon monoxide, and jumping. A gun in the house, particularly a loaded gun, appears to increase the risk for completed suicide, even in those youth without other obvious risk factors for suicide. Among suicide attempters, the two most common methods are overdose and wristcutting.
The most common precipitants for suicidal behavior among children and adolescents involve interpersonal conflict or loss, most frequently with parents or romantic attachment figures. Family discord, physical or sexual abuse, and an upcoming legal or disciplinary crisis are also commonly associated with completed and attempted suicide. Adolescents who complete suicide show relatively high suicidal intent (wish to die), although many are intoxicated at the time of death. The most serious suicide attempters leave suicide notes, show evidence of planning, and use an irreversible method. Most adolescent suicide attempts, though, are of relatively low intent and lethality, and only a minority actually want to die. Usually, suicide attempters want to escape psychological pain or unbearable circumstances, gain attention, influence others, or communicate strong feelings, such as anger or love.
Risk factors
The vast majority of both suicide attempters and completers have evidence of at least one major psychiatric disorder. These disorders are most often affective disorders, causing changes in moods or emotions. Major depressive disorder is the single biggest risk factor for attempted or completed suicide, with the risk heightened even further by comorbid anxiety, substance abuse, or conduct disorder.Bipolar affective disorder also conveys increased risk for completed and attempted suicide. There is an average of seven years between the onset of disorder and completed suicide in adolescence, so repeated suicide threats or attempts are common. Youths who attempt suicide feel hopeless, are impulsive, and have poor problem-solving and social skills. Children with other illnesses may also face an increased risk of suicidal behavior. For example, children with epilepsy have a higher suicide rate, which may be related to the side effects of the drug phenobarbital.
Family history and environment are also risk factors for suicide. The relatives of both suicide attempters and completers have high prevalences of affective disorder, substance abuse, assaultive behavior, suicide, and suicide attempts. The tendency for suicidal behavior appears to be passed on independently of the transmission of psychiatric disorders, and may be more closely related to the tendency for impulsive aggression. The family environments of suicide attempters and completers have been described as discordant, with greater exposure to family violence, including physical and sexual abuse. Both have also been exposed to suicidal behavior. Studies of friends and siblings of suicide victims show they tend not to imitate the act, suggesting that increased risk is related more to distant exposure. For example, media publicity about fictional or true suicides have been shown consistently to increase the risk for suicide and suicidal behavior.
Repeated suicide attempts are common, but rates vary. Follow-up studies ranging from one to 12 years found a re-attempt rate among adolescents of between 6% and 15% per year, with the greatest risk within the
first three months after the initial attempt. Factors associated with a higher reattempt rate included chronic and severe psychopathology (depression and substance abuse), hostility and aggression, non-compliance with treatment, poor level of social adaptation, family discord, abuse, or neglect, and parental psychopathology. The risk for completed suicide ranges from 0.7% per year among males and 0.1% per year among females seen in an emergency room for an overdose. Among psychiatric inpatients after a 10-15 year follow-up, the risks are higher, 10% for males and 2.9% for females.
Suicidal ideation, or thinking about suicide, is even more common than suicidal behavior. Suicidal ideation spans a continuum from non-specific thoughts, for example, "life is not worth living," to specific ideation. Community surveys indicate that between 12 and 25% of primary and high school children have some form of suicidal ideation, whereas 5-10% have suicidal ideation with a plan or intent to make a suicide attempt. Not surprisingly, specific ideation is more closely associated with risk for attempted suicide, and frequently occurs with other risk factors.
Developmental issues
Suicidal behavior is rare in prepubertal children, probably because of their relative inability to plan and execute a suicide attempt. Psychiatric risk factors, such as depression and substance abuse, become more frequent in adolescence, contributing to the increase in the frequency of suicidal behavior in older children. The emergence of conflicts with parents and with boy/girlfriends and legal or disciplinary problems are frequently associated with suicidal behavior. Some view the transition from primary to middle school as particularly stressful, especially for girls. Finally, parental monitoring and supervision decrease with increasing age, so that adolescents may be more likely to experience emotional difficulties without parents' knowledge.
Care of suicidal patients
The first step in the care of a suicidal patient is to determine the degree of suicidal risk and the appropriate level of care. It is critical to obtain a no-suicide contract with the patient and family, in which the patient promises to refrain from self-destructive behavior and to notify the professional or caregiver if he or she does feel suicidal again. Treatment of the suicidal youngster should proceed on four levels: (1) removal of firearms and dangerous medications from the home; (2) treatment of the underlying psychiatric disorders; (3) remediation of social and problem-solving skills; and (4) family education about psychiatric problems and suicidal risk.
Books
Cytryn, Leon, and Donald H. McKnew. Growing Up Sad: Childhood Depression and Its Treatment. New York: Norton, 1996.
Periodicals
Brent, D. A. "Risk Factors for Adolescent Suicide and Suicidal Behavior: Mental and Substance Abuse Disorders, Family Environmental Factors, and Life Stress." Suicide Life-Threat Behavior 25, 1995, pp. 52-63.
Brent, D. A., J. A. Perper, C. E. Goldstein, D. J. Kolko, M. J. Allan, C.J. Allman, and J. P. Zelenak. "Risk Factors for Adolescent Suicide: A Comparison of Adolescent Suicide Victims with Suicidal Inpatients." Archives of General Psychiatry 45, 1988, pp. 581-88.
Lewinsohn, P. M, P. Rohde, and J. R. Seeley. "Adolescent Suicidal Ideation and Attempts: Prevalence, Risk Factors, and Clinical Implications." Clinical Psychology: Science and Practice 3, 1996, pp. 25-46.
Shaffer, D., M. S. Gould, P. Fisher, P. Trautman, D. Moreau, M. Kleinman, and M. Flory. "Psychiatric Diagnosis in Child and Adolescent Suicide." Archives of General Psychiatry 53, 1996, pp. 339-48.
—David A. Brent, M.D.
Western Psychiatric Institute & Clinic
