Suicide is now the second leading cause of death in adolescents, in the United States, surpassing homicide and second only behind unintentional injuries (motor vehicle accidents, accidental overdose). This switch occurred because of both a reduction in deaths from homicide and a modest increase in deaths from suicide. Deaths from suicide had been decreasing from 1990 to 2000; this seems partly related to better treatment options for depression in teens, including better access to mental health services and antidepressant medications. The rate has been fluctuating in the last 15 years, partly because of increase in certain risk factors, and there is concern about the negative influence of the FDA Black Box warning on antidepressant medications on the prescribing practices of these medications in the primary care setting. Teen girls are more likely to make suicide attempts and teen boys are more likely to have completed suicides.
Because of the prevalence of suicidal thoughts in adolescents, it is important for all medical and mental health providers to be comfortable asking questions related to suicide risk. With these new findings, the American Academy of Pediatrics revised their 2007 guidelines on “Suicide and Suicide Attempts in Adolescents” recently to urge pediatricians to screen patients for suicidal thoughts. The report identifies risk factors linked to teen suicide attempts, including:
- Family history of completed suicide and suicide attempts
- Personal history of suicide attempt and/or non-suicidal self injury
- History of physical, sexual or emotional abuse or neglect
- Mood disorders and psychotic disorders
- Drug and alcohol use
- Sexual orientation
- Firearms in the home
- Strained parent-child relationship or living outside of the home
- Poor school attendance and/or performance
- Bullying, including cyber-bullying – highest risk in teens who are both bullies and victims of bullying
- Internet exposure/social media – particularly concerning if using more than 5 hours/day
Screening for suicidal thoughts is important, and studies show that asking about suicide risk does not increase the risk of suicide attempts or “put the idea in the patient’s head” as some providers are concerned. It is helpful to talk with a teen patient privately to increase their comfort in disclosing sensitive information, but it is also important to review mandated reporting with the teen.
Within the context of a more general empathic inquiry into how the adolescent is doing overall, and especially if there are indications of concerns about depression or anxiety symptoms or problems being experienced at home, in school or with friends, an appropriate screening question such as: “So, have you ever thought about hurting or killing yourself or wished you were dead or never born?” will be experienced as caring and appropriate.
If the answer to either question is yes, it is important to obtain more details as regards when and why these tendencies may arise (or may have arisen) for the teen and to make an assessment as to whether there is any current potential of intent and lethality so as to determine the appropriate management. Prospective interventions to address these concerns, and a discussion of implementing a safety plan to minimize risks and obtain relief of distress should be initiated. A referral to a behavioral health provider or to the SmartCare program for further intervention may be highly appropriate. If there is a concern about acute risk without active supports in place, a provider should err on the side of caution and seek out emergency mental health services.
It is our hope that this article brings each of you closer to the goal of being comfortable in discussing a challenging topic with your patients.