Suicide and Suicidal behavior

Key Points

Prevalence

Third leading cause of death in 15-24 year olds (Centers for Disease Control and Prevention 2004) .
Suicidal ideation: 19.3% of high school students seriously considered attempting suicide in the last year (King, CA ) .
Suicide attempts: 8.7% of high school-aged adolescents have attempted suicide in last year (American Academy of Pediatrics 2000) .
Suicide completion: 0.7% of boy attempters complete; 0.1% of girl attempters complete.
Native American males have the highest suicide rate, African American women the lowest (American Academy of Pediatrics 2000) .
Homosexual and bisexual youth have higher rates of attempted suicide - 28.1% for boys and 20.5% for girls (American Academy of Pediatrics 2000) .
Rates increase after puberty^[note] as ability to plan increases and the prevalence of mood disorders increases.
Girls attempt suicide more frequently but five times more boys (aged 15-19) die from suicide due to more lethal methods used (NIMH 2003) although these rates are becoming more similar.
More specific ideas in the plan is associated with higher risk for completion.

Methods:

Self-poisoning is most common method among adolescent suicide attempters (American Academy of Pediatrics 2000) . Use of firearms is most common method among completers, followed by hanging, jumping, carbon monoxide, and self-poisoning.
Most attempts are impulsive and do not necessarily involve a plan - only 1/3 of adolescents who attempt intend to die. Completions usually involve a plan that may be told to no one or only one peer.

Risk Factors for Suicide Attempt: (See also: Substance Abuse DTW, Sadness dtw, Anxiety DTW)

Individual factors

Past suicide attempt is the most significant predictor of future suicidal ideation and behavior.
Interpersonal conflict or loss.
Disciplinary crises and/or school failure.
Recent sexual assault, pregnancy concern, STD.
Exposure to suicide by peer or in media.
Homosexual or lesbian sexual orientation.

Psychiatric factors

Depression, bipolar disorder, conduct disorder, and/or substance abuse (Brent, DA 1993b) .
Depression for more than 2 years co-morbid with substance abuse.
Poor social skills, poor problem solving, hopelessness.

Family factors

History of impulsive violence.
Family disruption: divorce, parental absence, abuse (20% of attempters were sexually abused), less support, more conflict, more hostility.
Access to lethal methods (esp. firearms, medications)

Risk for suicide completion (Brent DA 1995) , (Brent DA 1997)

More likely to complete if:

Firearms are available
Male
No precipitants
High intent
Active method
Major depression combined with substance use, or
Disruptive behavior, bipolar disorder or psychotic disorder.

According to the Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version (Wolraich, M. (Ed.) 1996) , the following are the definitions for Suicidal variations and problems:

V40.2 Thoughts of Death Variation

Anxiety about death in early childhood. Focus on death in middle childhood or adolescence.

V40.2 Thoughts of Death Problem

The child has thoughts of or a preoccupation with his or her own death. If the child has thoughts of suicide, consider 319.89 Suicidal Ideation and Attempts.

According to the Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version (Wolraich, M. (Ed.) 1996) , the following may be used to identify suicidal thoughts or behavior:

319.89 Unspecified mental disorder

This code represents an unspecified mental disorder. It is to be used when no other condition is identified. This code may be used when the child has thoughts about causing intentional self-harm or performs acts that cause intentional self-harm or death.

Differential Diagnosis/Comorbidities

Depression
Anxiety
Psychotic disorder
Substance abuse
Poor social skills
Antisocial behavior
Learning disorders
Sexual or Physical Abuse

Management

Prevention

Listen to the child non-judgmentally in confidence^[note]
Routinely ask trigger questions about suicide^[note] as well as if the child seems upset or depressed. (Brent, DA 1993a) , (American Academy of Pediatrics 2000)
Assess level of risk of suicide^[note] if any routine trigger questions are positive (See also: Risk factors for adolescent suicide pt, Tools: Suicidality Screening Questions)
Areas to assess: (For a complete listing see also: Trigger Questions for Assessing Suicidality)

Ideation^[note] or thoughts of death^[note]
Onset, frequency, recency^[note] of ideations
Presence of a plan
Lethality of method^[note] (American Academy of Pediatrics 2000)
Availability of firearms^[note]
Social support: Deterrents and triggers^[note]
Mental status
Mental health history and past attempts^[note]
Substance use/abuse^[note]

Ask about the most common reasons: crisis in relationships, pregnancy, an impending loss, homosexual experiences^[note] (Garafalo et al, 1999). (See My teenager wants to know "Am I gay?" pt, Am I gay? tt)
In Emergency Department settings consider using a standard screen^[note] for all teens that are presenting following an actual attempt, suspected attempt or for psychiatric reasons (Horowitz, LM 2000) (Tools: Risk of Suicide Questionnaire)

Treatment when risk of suicide is present

Always inform parents of suicidal ideation or intent. (See Limits of confidentiality pt)
Assess firearm and medication availability^[note] and assure removal (Brent, DA 1993c)
Make a safety contract with the child^[note]
Assess for depressive symptomatology (Tools: Columbia Depression Inventory) and suggest treatment when appropriate.
Review stressors and risk factors with the patient and develop a coping plan. (See: Risk factors for adolescent suicide pt)
Discuss some facts about suicide with the child (See Myths about suicide tt)
Make a referral for mental health treatment with a psychiatrist, psychologist or social worker experienced in working with adolescents.^[note] (Brent DA 1997)

Referral for outpatient mental health treatment is strongly indicated when patient is psychotic, has a mood or anxiety disorder, needs drug or alcohol detoxification, has medical problems complicating treatment, or needs psychotropic meds.
Treatments involving family interventions, interpersonal therapy and cognitive behavioral therapy appear to be the most effective, although few studies have been conducted.
No studies have evaluated the efficacy of specific psychopharmacological treatments for suicidal adolescents. However, recent research has found that some SSRI's (e.g. Prozac) may actually increase suicidal ideation and behavior in some children. (See: Child Psychopharmacology DTW)
Inpatient mental health treatment is required^[note] when a patient cannot make a safety contract, has active ideations and a plan, has a means to act on the plan and has high intent (See What happens when my child is admitted to the hospital for suicidal thoughts or behavior? pt).

Resources for Parents

American Psychiatric Association. (1996). Adolescent Suicide. American Psychiatric Association Press.

Marcus, E. (1996). Why Suicide?: Answers to 200 of the Most Frequently Asked Questions about Suicide, Attempted Suicide. Harper: San Francisco.

Shamoo, T and Patros, P. (1996). Helping Your Child Cope with Depression and Suicidal Thoughts. Jossey-Bass.

Blauner, S.B. (2002). How I Stayed Alive When My Brain Was Trying to Kill Me: One Person's Guide to Suicide Prevention. William Morrow.

Tools

Risk of Suicide Questionnaire

Risk of Suicide Questionnaire (RSQ). Horowitz LM, Wang PS, Koocher GP et al (2001). Detecting suicide risk in a pediatric emergency department: Development of a brief screening tool. Pediatrics 107(5):1133-1137.

A 4-item screening questionnaire designed for emergency department triage with adolescents. In this study, 98% of adolescents meeting criteria for suicidality were identified with the RSQ. The four questions about current suicidal behavior, past suicidal ideation, past self-destructive behavior and current stressors.

Risk of Suicide Questionnaire
1. Are you here because you tried to hurt yourself?	Yes	No	No Response	If yes, how _____________________________
2. In the past week, have you been having thoughts about killing yourself?	Yes	No	No Response	If yes, how _____________________________
3. Have you ever treid to hurt yourself in the past (other than this time)?	Yes	No	No Response	If yes, how _____________________________
4. Has something very stressful happened to you in the past few weeks (a situation very hard to handle)?	Yes	No	No Response	If yes, how _____________________________

Copyright ©2000 by Children's Hospital, Boston, MA. For permission contact: Lisa M. Horowitz, PhD, MPH, Children's Hospital, Program for Patient Safety and Quality,300 Longwood Avenue, Boston, MA 02115. Phone: 617-355-6536.

Suicidality Screening Questions

Adapted from the Columbia Depression Inventory.

In the last four weeks...

Have you often thought about death or about people who had died or about being dead yourself?
Have you thought seriously about killing yourself?
Have you tried to kill yourself in the last four weeks?
Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

Trigger Questions for Assessing Suicidality

Ideation or thoughts of death

Do you think about dying? Or wish you were dead?
Have you ever felt that life is not worth living?
Did you ever wish you could go to sleep and just not wake up?
Do you think about people who have died?
Do you think about how it would be if you were dead?
Have you ever thought seriously about killing yourself?

Onset, frequency, recency of ideations

How often do you think about dying (or suicide)?
When was the first time you had those thoughts?
When was the most recent time?
How often do you think about it?

Presence of a plan

Do you have a plan?
How would you kill yourself?
Who would you tell?
Are (guns/pills/other methods) (at home/easy to get)?

Note to clinician: Firearms are the most common method for suicide among completers, followed by hanging, jumping, carbon monoxide, and self-poisoning. The combination of a plan, lethal method and ready access to a method equal high suicidal risk.

Availability of firearms

Where could you get access to a gun?
Are there guns in your home?
Are there guns in a friend or family members home?

Social support: Deterrents and triggers

How supportive are family and friends?
Is there someone you trust that you can talk to when you feel like hurting yourself?
Can that person keep you safe?
What things would make you feel more/less hopeful about the future?
What things would make you more/less likely to want to kill yourself?
What things would make you more/less likely to try to kill yourself?
What things make you want to go on living?
Do you know someone who ended his or her own life?
Do you know someone who tried to kill himself or herself?
What was going on with you or in your life that made you think about killing yourself?
Has anything changed since you tried to end your life/thought seriously about ending your life)?

Mental status

Appearance (e.g., well groomed, disheveled, appropriate dress, apparent age, build)
Manner (e.g., interpersonal style, speech, psychomotor presentation)
Orientation/Alertness (e.g., knows day of week, year, place, time)
Thought Process (e.g., loose associations, tangential thinking, racing thoughts, simple recall)
Mood (e.g. depressed, sad, angry, euthymic, euphoric, worried, anxious)
Affect (e.g. labile, appropriate, flat, constricted, blunted)

Mental health history and past attempts

If yes to thoughts of death or suicide in the past ask:

How close have you come to acting on those thoughts, doing something to end your life?
What would you do?
When did you think you would do it?
Where did you think you would do it?
Have you ever started to do something to end your life but changed your mind?
Have you ever started to do something to end your life but someone stopped you or interrupted you?
What happened?
Was there ever a time when you tried to end your life?
At the time you did that how much did you want to die?
At the time you did that, how certain were you that you would die?
Afterward, did you feel glad or sorry that you were alive?
Around the times you (tried to end your life/thought seriously about ending your life), were you drinking or using drugs?

Substance use/abuse

Do you drink or use drugs?
How often?
What kinds?
Around the times you (tried to end your life/thought seriously about ending your life), were you drinking or using drugs?

Adapted in part from the Columbia Depression Inventory.

Comments

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Rates increase after puberty: Suicidal ideation and behavior is less common in pre-pubertal and preschool children. Preschool suicide ideation and behavior is usually due to abuse.

Suicidal ideation and behavior is less common in pre-pubertal and preschool children. Preschool suicide ideation and behavior is usually due to abuse.

Listen to the child non-judgmentally in confidence: Limits of confidentiality should be explicitly set out. For example, "Everything we talk about stays here unless I hear you are going to hurt yourself or someone else or someone is hurting you".

Limits of confidentiality should be explicitly set out. For example, "Everything we talk about stays here unless I hear you are going to hurt yourself or someone else or someone is hurting you".

trigger questions about suicide: Move from general to more specific questions. (1) Have you ever thought that life was not worth living?; (2) Have you ever wished you were dead?; (3) Have you ever felt so unhappy or depressed that you thought about killing yourself or wished you were dead? (4) Have you ever tried to hurt yourself?; (5) Do you know anyone who has attempted suicide?; (6) Have you ever attempted suicide?; (7) Do you intend to hurt yourself now?; (8) Do you have a plan?; (9) How would you do it (means)? (10) Do you intend to do it?; (11) When?; (12) Would you tell anyone before? Who?.

Move from general to more specific questions. (1) Have you ever thought that life was not worth living?; (2) Have you ever wished you were dead?; (3) Have you ever felt so unhappy or depressed that you thought about killing yourself or wished you were dead? (4) Have you ever tried to hurt yourself?; (5) Do you know anyone who has attempted suicide?; (6) Have you ever attempted suicide?; (7) Do you intend to hurt yourself now?; (8) Do you have a plan?; (9) How would you do it (means)? (10) Do you intend to do it?; (11) When?; (12) Would you tell anyone before? Who?.

Assess level of risk of suicide: LOW RISK requires a mental health referral and "safety contract"; MODERATE and HIGH RISK require immediate in office consultation with mental health provider, "safety contract" and possibly hospitalization. Following are examples of risk status: LOW- ideation, no plan, no firearm availability, no history of mental illness, adequate family support; MODERATE-ideation, plan, moderately lethal method (overdose on pills in presence of others), no firearm availability, mental illness present, some family discord; HIGH-ideation, plan, high lethality method, firearm availability, mental illness present, high family discord, academic problems, poor peer supports.

LOW RISK requires a mental health referral and "safety contract"; MODERATE and HIGH RISK require immediate in office consultation with mental health provider, "safety contract" and possibly hospitalization. Following are examples of risk status: LOW- ideation, no plan, no firearm availability, no history of mental illness, adequate family support; MODERATE-ideation, plan, moderately lethal method (overdose on pills in presence of others), no firearm availability, mental illness present, some family discord; HIGH-ideation, plan, high lethality method, firearm availability, mental illness present, high family discord, academic problems, poor peer supports.

Ideation: Current suicidal ideation is defined as follows: Thinking about killing self within the last three months Includes transient thoughts of killing self that occurred within the last three months Does not include thoughts about suicide as an abstract concept

Current suicidal ideation is defined as follows: Thinking about killing self within the last three months Includes transient thoughts of killing self that occurred within the last three months Does not include thoughts about suicide as an abstract concept

thoughts of death: Do you think about dying? Or wish you ere dead? Have you ever felt that life is not worth living? Did you ever wish you could go to sleep and just not wake up? Do you think about people who have died? Do you think about how it would be if you were dead? (Have you ever/On the questionnaire, you mentioned that there was a time when you) thought seriously about killing yourself.

Do you think about dying? Or wish you ere dead? Have you ever felt that life is not worth living? Did you ever wish you could go to sleep and just not wake up? Do you think about people who have died? Do you think about how it would be if you were dead? (Have you ever/On the questionnaire, you mentioned that there was a time when you) thought seriously about killing yourself.

Onset, frequency, recency: How often? Since when? When was the first time you had those thoughts? When was the most recent time? How often did you think about it?

How often? Since when? When was the first time you had those thoughts? When was the most recent time? How often did you think about it?

Lethality of method: Use of firearms is most common method among suicide completers, followed by hanging, jumping, carbon monoxide, and self-poisoning.

Use of firearms is most common method among suicide completers, followed by hanging, jumping, carbon monoxide, and self-poisoning.

Availability of firearms: Where could you get access to a gun? Are there guns in your home? A friend or family members home?

Where could you get access to a gun? Are there guns in your home? A friend or family members home?

Deterrents and triggers: DETERRENTS: How supportive are family and friends? Is there someone you trust that you can talk to when you feel like hurting yourself? Can that person keep you safe? What things would make you feel more/less hopeful about the future? What things would make you more/less likely to want to kill yourself? What things would make you more/less likely to try to kill yourself? What things make you want to go on living? TRIGGERS: Do you know someone who ended his or her own life? Do you know someone who tried to kill himself or herself? What was going on with you or in your life that made you think about killing yourself? Has anything changed since you tried to end your life/thought seriously about ending your life?

DETERRENTS: How supportive are family and friends? Is there someone you trust that you can talk to when you feel like hurting yourself? Can that person keep you safe? What things would make you feel more/less hopeful about the future? What things would make you more/less likely to want to kill yourself? What things would make you more/less likely to try to kill yourself? What things make you want to go on living? TRIGGERS: Do you know someone who ended his or her own life? Do you know someone who tried to kill himself or herself? What was going on with you or in your life that made you think about killing yourself? Has anything changed since you tried to end your life/thought seriously about ending your life?

past attempts: Past suicide attempts are defined as: Any self-injurious behavior accompanied by evidence (either explicit or implicit) that the person intended to die regardless of lethality of method. Includes aborted or interrupted attempts and any potentially self-injurious behavior accompanied by evidence (either explicit or implicit) that the person intended to die but stopped or was interrupted before physical damage occurred.

Past suicide attempts are defined as: Any self-injurious behavior accompanied by evidence (either explicit or implicit) that the person intended to die regardless of lethality of method. Includes aborted or interrupted attempts and any potentially self-injurious behavior accompanied by evidence (either explicit or implicit) that the person intended to die but stopped or was interrupted before physical damage occurred.

Substance use/abuse: Do you drink or use drugs? How often? What kinds? Around the times you (tried to end your life/thought seriously about ending your life), were you drinking or using druges?

Do you drink or use drugs? How often? What kinds? Around the times you (tried to end your life/thought seriously about ending your life), were you drinking or using druges?

homosexual experiences: Homosexual teens were 3.4 times as likely to report a suicide attempt as heterosexual teens.

Homosexual teens were 3.4 times as likely to report a suicide attempt as heterosexual teens.

Emergency Department settings consider using a standard screen: Often triage staff who do not have a background in mental health feel more comfortable - and are more effective -- with a standard screening measure than trying to intuit suicide risk.

Often triage staff who do not have a background in mental health feel more comfortable - and are more effective -- with a standard screening measure than trying to intuit suicide risk.

Assess firearm and medication availability: Even if firearms or lethal medications are locked up, children often know where the keys or bullets are. Suicide among adolescents with no apparent psychiatric condition may be more likely when firearms are available in the home.

Even if firearms or lethal medications are locked up, children often know where the keys or bullets are. Suicide among adolescents with no apparent psychiatric condition may be more likely when firearms are available in the home.

Make a safety contract with the child: Patient agrees not to hurt himself. If he feels as though he might, he agrees to tell caregiver or physician immediately. These contracts have not been proven effective, however.

Patient agrees not to hurt himself. If he feels as though he might, he agrees to tell caregiver or physician immediately. These contracts have not been proven effective, however.

Make a referral for mental health treatment with a psychiatrist, psychologist or social worker experienced in working with adolescents.: Have patient sign consent allowing communication between mental health provider and primary care physician and follow up with mental health provider regarding patient compliance and progress. Treatment plan should include addressing mental health disorders, remediation of social and problem solving deficits, family psychoeducation and conflict resolution

Have patient sign consent allowing communication between mental health provider and primary care physician and follow up with mental health provider regarding patient compliance and progress. Treatment plan should include addressing mental health disorders, remediation of social and problem solving deficits, family psychoeducation and conflict resolution

Inpatient mental health treatment is required: Mediating factors that may sway a decision for inpatient admission include prior attempts, noncompliance with mental health visits, substance abuse, severe parental psychiatric illness, or a family who is unable or unwilling to monitor patient. Voluntary admission is always preferable over non-voluntary admission so efforts to maintain patient rapport and investment are important. Help the adolescent understand that inpatient admission is required to keep them safe from harm not as a punishment.

Mediating factors that may sway a decision for inpatient admission include prior attempts, noncompliance with mental health visits, substance abuse, severe parental psychiatric illness, or a family who is unable or unwilling to monitor patient. Voluntary admission is always preferable over non-voluntary admission so efforts to maintain patient rapport and investment are important. Help the adolescent understand that inpatient admission is required to keep them safe from harm not as a punishment.