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Suicidality

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Description

Suicidality refers to thoughts or actions related to suicide, including suicidal ideation (ranging from passive thoughts of death to active and/or specific thoughts of suicide with plans and intent), suicide attempts, and completed suicide.
According to the Youth Risk Behavior Surveillance System (CDC), about 17% of students had seriously thought about suicide in the previous 12 months, 8.6% of students had made at least 1 attempt, and about 3% of students had made an attempt that required medical treatment. In 2015, suicide was the second leading cause of death in children 9-18 years of age. [Centers: 2015] Females are twice as likely to attempt suicide, but males are 3 times more likely to complete suicide. [Shain: 2016] Sexual minority youth (lesbian, gay, bisexual, transgender, or questioning) have more than twice the rate of suicidal ideation. [Levine: 2013]
Firearms, poisoning, and suffocation are the most common methods of youth suicide in the United States; the rate of suicide by suffocation is increasing. [Sullivan: 2015]

Risk Factors

It is important to assess risk factors, especially risk factors that can be modified. Risk factors for suicide include:
  • Mood disorders
  • Substance use
  • Disruptive behavior disorders
  • Sleep problems
  • Impulsivity
  • Family history of suicide attempts or completions
  • Previous suicide attempts
  • Personal losses
  • Exposure to suicide
  • Access to lethal means.
The American Academy of Pediatrics (AAP) also highlights the following as significant risk factors: [Shain: 2016]
  • Being a victim or perpetrator of bullying
  • Pathologic internet use and related online issues
  • Lack of treatment with antidepressant medication when indicated

Screening and Assessment

Clinicians should be comfortable screening patients for suicide, mood disorders, and substance abuse and dependence. Since depression is a top risk factor, its identification and treatment is a major goal of assessment. Depression screening instruments shown to be valid in adolescents can be found in the Screening section of Depression.
Substance use and abuse is another modifiable risk factor, and assessment should always include questions about this behavior. Follow-up on any of the screening questions that the patient endorses. See Substance Use Disorders, Ongoing Assessment.
Other psychiatric disorders, such as mania, hypomania, and mixed mood states must also be considered in assessment as they increase risk. Assessing for depression and other psychiatric disorders may provide a natural transition into asking more probing questions about suicidal thoughts and behaviors.
Asking directly about suicidality is likely to produce honest answers from adolescents. It is unlikely to increase risk for suicide. [Gould: 2005] Although older than 5 years, the American Academy of Child and Adolescent Psychiatry practice parameter suggests the still relevant questions: [AACAP: 2001]
  • Have you ever felt so upset you wished you were not alive or wanted to die?
  • Have you ever hurt yourself or tried to hurt yourself?
  • Have you ever tried to kill yourself?
  • Have you ever thought about or tried to commit suicide?
  • Have you ever done something you knew was so dangerous that you could get hurt or killed by doing it?
Affirmative answers to any of the above warrants additional questioning, including:
  • Previous attempts or thoughts
    • How many times have you tried to hurt or kill yourself?
    • How did you attempt?
    • Did you tell anyone? Who?
    • How did [your parents] find out about what happened?
    • What happened? Did you have to go to a doctor, hospital, or Emergency Department?
    • Have you had any other plans or ways you’ve thought about to end your life?
    • What made you stop or want to live?
  • Current thoughts
    • Do you have thoughts of harming or killing yourself now?
    • How would you do it?
    • How do you feel about being alive now?
    • What do you have to live for right now?
Assessment must involve not only the patient but also a reliable third party such as a parent or guardian. It is important to give the patient an opportunity to be interviewed alone. Confidentiality must be considered when talking to an adolescent about suicidal thoughts; however, when there is concern for acute or imminent safety risk, it is necessary to notify appropriate supports to maintain safety. Adolescents should be made aware of this obligation. Providers should be aware of confidentiality laws in their state of practice.
Access to lethal means is a major modifiable risk factor. Evaluators should ask about presence of firearms in the home. Note: Some states have placed legal restrictions upon medical practitioners inquiring about gun ownership. Physicians should be aware of laws pertaining to such questions in their community. It is also important to ask about how medications are secured in the home.

Treatment

Inpatient psychiatric hospitalization is the standard of care for the acutely suicidal patient. If a child or adolescent being evaluated for suicidality expresses a persistent wish to die or is in an altered mental state, refer for inpatient hospitalization. Altered mental states include, but are not limited, to severe depression, mania/hypomania, severe anxiety, psychosis, or substance intoxication.
It may be possible to manage adolescents with suicidal ideation or behavior in an outpatient setting, but this decision entails careful assessment and decision making:
  • The child or adolescent must not have a persistent wish to die or plans for self-harm.
  • Follow-up for thorough psychiatric evaluation must be assured.
  • Proper adult supervision must be in place.
  • The evaluator should initiate a discussion about removing lethal means (guns, medications) and expressly recommend their removal from the home.
  • It may also be valuable to provide education about other risk factors, such as substance abuse.
  • Provide community resources and hotlines and encourage the patient to use them. The American Foundation for Suicide Prevention has useful resources including monitored chat, crisis text lines, and a prevention lifeline that can be accessed through the website.
Medications are often used to treat an underlying psychiatric disorder if present. For details about medication treatment of depression, see the Management section of Depression. With particular respect to suicidality:
  • Lithium has been shown to decrease risk of suicide in adults with bipolar disorder, and it may be considered in the therapy of children and adolescents with bipolar disorder and suicidality, though its use entails careful monitoring of blood levels due to its low therapeutic index.
  • Tricyclic antidepressants (TCAs) should not be used as first-line medication for depression in suicidal children and adolescents due to their lethality in overdose and lack of established efficacy in this age group. [AACAP: 2001]
  • All medications with approval for use in treatment of depression in children, adolescents, and young adults up to age 25 have an FDA Black Box warning for risk of increasing suicidal thoughts and behaviors. This risk should be disclosed to patients and families, and risks of suicide associated with ongoing untreated or undertreated depression should be weighed with risk of treatment. [Hetrick: 2012] For additional information and discussion, please see Antidepressant Medications and Suicide section of Suicide and Suicide Attempts in Adolescents (AAP).

Prevention

General suicide awareness and prevention programs for youth have not been shown to be effective in reducing suicide rates. [Das: 2016] Screening for depression, mental illnesses, and suicidality in school settings and/or clinical setting may be the most effective way to decrease suicide rates. Media coverage of an adolescent’s suicide may lead to cluster suicides with the magnitude of additional deaths proportional to the amount, duration, and prominence of the media coverage. Suicide contagion may also occur in the aftermath of a suicide within a particular school or community. Health care providers may play a role in this circumstance by increasing screening for mental health problems and directing individuals who screen positive for mental illness or suicide to appropriate treatment.

Resources

Services for Patients & Families in Rhode Island (RI)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Shain B.
Suicide and Suicide Attempts in Adolescents.
Pediatrics. 2016;138(1). PubMed abstract / Full Text

AACAP.
Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of Child and Adolescent Psychiatry.
J Am Acad Child Adolesc Psychiatry. 2001;40(7 Suppl):24S-51S. PubMed abstract

Gould MS, Marrocco FA, Kleinman M, Thomas JG, Mostkoff K, Cote J, Davies M.
Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial.
JAMA. 2005;293(13):1635-43. PubMed abstract

Authors & Reviewers

Initial publication: January 2009; last update/revision: December 2018
Current Authors and Reviewers:
Author: Thomas G. Conover, MD
Authoring history
2017: update: Mary Steinmann, MD, FAAP, FAPAR
2009: first version: Thomas G. Conover, MDA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

AACAP.
Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of Child and Adolescent Psychiatry.
J Am Acad Child Adolesc Psychiatry. 2001;40(7 Suppl):24S-51S. PubMed abstract

Centers for Disease Control & Prevention.
10 Leading Causes of Death, United States.
(2015) https://webappa.cdc.gov/sasweb/ncipc/leadcause.html. Accessed on April 2017.
For the custom age ranges of 9-18 years old, suicide is the second leading cause of death.

Das JK, Salam RA, Lassi ZS, Khan MN, Mahmood W, Patel V, Bhutta ZA.
Interventions for Adolescent Mental Health: An Overview of Systematic Reviews.
J Adolesc Health. 2016;59(4S):S49-S60. PubMed abstract / Full Text

Gould MS, Marrocco FA, Kleinman M, Thomas JG, Mostkoff K, Cote J, Davies M.
Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial.
JAMA. 2005;293(13):1635-43. PubMed abstract

Hetrick SE, McKenzie JE, Cox GR, Simmons MB, Merry SN.
Newer generation antidepressants for depressive disorders in children and adolescents.
Cochrane Database Syst Rev. 2012;11:CD004851. PubMed abstract

Levine D.
Office-based care for lesbian, gay, bisexual, transgender, and questioning youth.
Pediatrics. 2013;132(1):198-203. PubMed abstract / Full Text
Guidance from the AAP for primary care providers caring for lesbian, gay, bisexual, transgender and questioning youth, including information on dispelling myths, providing support to sexual minority youth and their families, mental and sexual health, and testing for sexually transmitted illnesses.

Shain B.
Suicide and Suicide Attempts in Adolescents.
Pediatrics. 2016;138(1). PubMed abstract / Full Text

Shain B.
Teen suicide: a closer look at three key factors.
American Academy of Pediatrics; (2016) http://www.aappublications.org/news/2016/06/27/suicide062716. Accessed on 12/2018.

Sullivan EM, Annest JL, Simon TR, Luo F, Dahlberg LL.
Suicide trends among persons aged 10-24 years--United States, 1994-2012.
MMWR Morb Mortal Wkly Rep. 2015;64(8):201-5. PubMed abstract / Full Text