Suicide is the third leading cause of death among teenagers, and there are as many as 25 attempts for every completed suicide. According to the Centers for Disease Control and Prevention, the number of teenagers who have thought about hurting themselves in the past year in the United States is estimated to be as high as 20 percent, with approximately 5 percent having shown injurious behaviors, such as cutting themselves or overdosing on drugs.
The most vulnerable age for adolescent suicidal behavior is the mid- to late-teens: The suicide rate for U.S. 15- to 19-year-olds is about 8.9 per 100,000. The biggest risk factor for suicide is depression. Roughly 70 percent of teens who attempt or complete suicide are depressed. Untreated depression, in particular, is highly associated with suicide and suicidal behavior. A family history of depression or suicide can also be a potent risk factor.
Another major risk factor for teens is a sense of social isolation, according to Stuart Goldman, MD, a specialist in depressive disorders at Children’s Hospital Boston. In addition, psychiatric conditions, such as psychosis, place teens at increased risk because their behavior becomes unpredictable. Similarly, substance abuse may increase risk due to uninhibited behavior.
Other predictive factors for suicidal behavior include exposure to violence or abuse, access to guns, post-traumatic stress and panic disorders, chronic illness, failure to meet expectations, emotional arguments and recent losses. Furthermore, if a suicide occurs within a teen’s circle of acquaintances, it can reverberate across the child’s network—a phenomenon known as "contagion"—increasing the chances that others will attempt suicide.
Warning signs tend to be non-specific and similar to those for depression. Predictive signs are poor at differentiating between "attempters" and "completers." However, according to Dr. Goldman, physicians should pay close attention to teenagers’ emotional states and note if they exhibit symptoms such as withdrawal, social isolation or stress. One particularly important sign is if teenagers have done anything to hurt themselves before, since the risk of hurting himself again is significantly higher.
William Beardslee, MD, chair of Children’s Department of Psychiatry and a specialist in childhood depression, says that with parental permission children and teens should have annual mental health screenings at the time of their physical checkup with their primary care physician.
There are several mental health screening tools available for pediatricians that are endorsed by the American Academy of Pediatrics. If, during the screening, there is any indication of suicidal tendencies, the physician should directly ask the teenager about it. Dr. Beardslee suggests clinicians ask some of the following questions:
- Do you sometimes feel that life is not worth living?
- Have you felt that your life is meaningless?
- Have you ever done something to hurt yourself?
- Have you considered ending your life?
- Are you considering it now?
- Have you made any specific plans to do so, and if so, what are the means?
- Have you made any attempts to kill yourself and what were they?
If pediatricians detect depressive tendencies in a teenage patient, they can also refer the patient for a thorough psychiatric evaluation. If a pediatrician is not comfortable asking suicide screening questions, she can have the teenager seen by a mental health professional.
The statewide Massachusetts Child Psychiatry Access Program is available as a resource for local pediatricians to contact when they have positive screenings. A psychiatrist from the program will call physicians back within 30 minutes to provide a consultation. It’s important that if a patient has made any serious attempt at suicide, he should be immediately sent to the emergency room to be thoroughly evaluated and potentially hospitalized.
According to Children’s experts, if a physician believes her patient is at risk, she should advise the patient’s parents to monitor their child’s emotional state, reduce risk factors in the home and become familiar with resources for suicide prevention. One such resource is the Youth Centered Suicide Prevention Program, which is in some Massachusetts schools. Developed and led by Glenn Saxe, MD, of Children’s Department of Psychiatry, the program consists of a network of teenagers who can identify children at school who may be at risk.
Children’s Emergency Psychiatry Department: childrenshospital.org/emergencypsychiatry
Emergency phone consultations: 617-355-6363 or page the on-call Emergency Department physician