Among US children and young adults aged 10 to 24, suicide is now the second most common cause of death, ahead of many others such as heart disease, cancer, and stroke. In fact, suicide mortality rates in this group surpass the combined number of deaths due to these and several other causes, including AIDS, birth defects, and influenza.1 A sizable body of recent research highlights a wide range of factors linked to increased risk, as well as those factors that appear to be protective against suicide, among teens, Much research has also been focused on the efficacy of various prevention programs.
“A history of suicide attempt is perhaps the strongest risk factor for suicide in teens–it’s one of the reasons, from a prevention perspective, that so much effort is put into averting a first suicide attempt in at-risk youth,” according to Jeff Bridge, PhD, director of the Center for Suicide Prevention and Research at Nationwide Children’s Hospital in Columbus, Ohio. Being male also appears to greatly increase the odds of suicide, as rates have been consistently higher among males than females. “Males drastically dominate completed suicides while females are much more likely to attempt suicides than males,” explained William Feigelman, PhD, an emeritus professor of sociology at Nassau Community College in Garden City, New York. While females are 3 times more likely to attempt suicides, males are roughly 3.5 times more likely to complete suicide.2 “The biggest reason for this difference in outcomes reflects the differences in lethal means chosen to take one’s life–males are more likely to use firearms, while females more often choose pills,” he told Psychiatry Advisor.
Over 90% of individuals who complete suicide have psychiatric disorders–especially depression, or substance use disorders (SUDs), or both.3 Additional risk factors include trauma exposure, social isolation, low self-esteem, sleep deprivation, impulsivity, access to lethal means, parental psychopathology, and exposure to the suicidal behavior of others (see previous Psychiatry Advisor article on adolescent vulnerability to suicide clusters). “However, immediate stressful life events–or tipping points–often precede a suicide, such as a recent loss, rejection, humiliation, or disciplinary crisis,” Catherine Strunk, MSN, RN, who developed and directs the Surviving the Teens® program at Cincinnati Children’s Hospital Medical Center told Psychiatry Advisor.
“One main risk factor for teen suicide that has attracted considerable public attention recently is bullying or victimization,” noted Marie-Claude Geoffroy, PhD, a researcher and assistant psychiatry professor at McGill University in Montréal, Canada. In epidemiological research that she co-authored, adolescents who were often victimized by peers had an elevated risk of developing serious suicide ideation and attempts, and this increase was similar between boys and girls.4 “It is important to note that associations between bullying and suicidality were distinct from previous mental health problems and family adversity that are linked with victimization and thus could confound association,” she told Psychiatry Advisor. Though such findings do not prove causality, bullying is of significant concern because of how common it is: an estimated 15-20% of adolescents report that they have experienced chronic and severe bullying, she said.
Just as many of the risk factors for suicide pertain to interpersonal relationships, so too do the primary factors that have been shown to be protective against suicide: a sense of close connection to, and frequent interaction with, family members and friends, being willing to talk to others–including mental health professionals–and feeling supported by them, and having positive skills pertaining to coping, problem-solving, and conflict resolution. That willingness or ability to get professional help appears to be a key factor in distinguishing completed suicides from attempted ones, according to findings by Fiegelman. In research based on data from a study that has followed more than 20 000 individuals since 1995, beginning when they were high school students, Fiegelman and colleagues discovered 22 cases of death by suicide, 21 of which were male. Compared to participants who were still living, greater number of these individuals had experienced the loss of a family member to suicide, expulsion from school, delinquent behavior, or involvement with the criminal justice system.5
The data further suggest that these individuals were not likely to seek or engage in mental health counseling. “In these 21 particular cases of males taking their lives, despite their records of difficulties with schools, juvenile authorities, and probably with their families, these youngsters successfully managed to evade the outreachings of counselors,” said Fiegelman. On the other hand, the results show that those who had attempted but not completed suicide were more likely to use therapy.
It is also worth noting that only a single individual out of the 21 male completers had a prior attempt at any previous wave point in the study, suggesting that professionals should not over-rely on previous attempts as a top risk factor. “If the suicide rate is to be stemmed it will require the development of new and innovative approaches to reach those at higher risk for completing suicide who presently avert conventional approaches designed to engage them,” he emphasized. These, along with efforts to distinguish between attempters and completers, should be top research priorities.
In terms of youth suicide prevention efforts, several programs have shown promise in reducing the rate of completed suicides and attempts, including Signs of Suicide, the Good Behavior Game, and the Garrett Lee Smith Program.6,7 According to Dr Bridge, key elements of effective prevention programs include increasing awareness among students and staff regarding depression and other suicide risk factors, learning how to recognize and respond appropriately to warning signs of suicide, reducing stigma, and encouraging help-seeking for oneself as well as peers who might be at risk.
Strunk’s Surviving the Teens® program appears to meet these criteria. The 5-day program is typically delivered in health class to students in grades 8 through 12, and it incorporates real-life success stories of teens who have successfully dealt with depression. “I think the growing push in recent years to move suicide prevention efforts ‘upstream’ so that risk factors can be identified and targeted for intervention earlier–before suicidal behavior occurs–has incredible potential to reduce adolescent suicide rates,” Dr Bridge told Psychiatry Advisor.
Future research efforts in the realm of youth suicide should include further investigation into school-based suicide prevention efforts, explanatory factors, reasons for the increased risk among bullied adolescents, and more. “We also need to study the influence of cyberbullying on suicidal risk–cyberbullying is concerning as it can be perpetrated 24-7, has the potential to go viral, and is often anonymous, which leaves less opportunity for the victim to escape,” Dr Geoffrey said.
For mental health clinicians, though evaluation of risk and protective factors is important in assessing suicide risk, the Interpersonal-Psychological Theory of Suicide by Thomas Joiner “informs clinicians to also be aware of their clients’ levels of belongingness, burdensomeness, and capability of hurting themselves,” Strunk added. Dr Geoffrey suggests that when clinicians conduct routine mental health evaluations, they should ask questions about the bullying and its nature, frequency, and age at onset, as adolescents may be more open to sharing such information with healthcare providers than parents.
If intervention is required, it should involve multidisciplinary actions involving the school, parents, and health professionals. “Psychiatrists can liaise directly with the school to ensure that adequate interventions are implemented,” she advises. “All adolescents, victimized or not, who think often or seriously about suicide should see a mental health professional such as a psychiatrist or a psychologist,” she said.
1. The Jason Foundation. Facts & stats. Retrieved 9/2/16 from http://jasonfoundation.com/youth-suicide/facts-stats
2. American Foundation for Suicide Prevention. Suicide statistics. Retrieved 9/2/16 from https://afsp.org/about-suicide/suicide-statistics
3. American Psychological Association. Teen suicide is preventable. Retrieved 9/2/16 from http://www.apa.org/research/action/suicide.aspx
4. Geoffroy MC, Boivin M, Arseneault L, et al. Associations between peer victimization and suicidal ideation and suicide attempt during adolescence: results from a prospective population-based birth cohort. J Am Acad Child Adolesc Psychiatry. 2016; 55(2):99-105.
5. Feigelman W, Joiner T, Rosen Z, Silva C. Investigating Correlates of Suicide Among Male Youth: Questioning the Close Affinity Between Suicide Attempts and Deaths. Suicide Life Threat Behav. 2016; 46(2):191-205.
6. Katz C, Bolton SL, Katz LY, et al. A systematic review of school-based suicide prevention programs. Depress Anxiety. 2013; 30(10):1030-45.
7. Walrath C, Garraza LG, Reid H, Goldston DB, McKeon R. Impact of the Garrett Lee Smith youth suicide prevention program on suicide mortality. Am J Public Health. 2015; 105(5):986-93.