A Rising Tide of Youth Suicide

An increasing youth suicide rate may point toward an emerging public health crisis, necessitating national efforts to develop effective interventions, experts recently warned. Some efforts are already under way. Researchers are reporting significant findings from new studies on suicidal adolescents, particularly those who make multiple attempts.

In a recently published trend analysis, Bridge and colleagues¹ found that after a decade-long decline in the suicide rate among youths aged 10 to 19 years in the United States, there was an 18% increase in suicide rates in 2004. This upward trend persisted in 2005 (Figure).

The analysis showed 326 more deaths than would have been expected in 2004 and 292 more deaths than expected in 2005 when compared with the number of deaths predicted by the regression model.

Concerned about an emerging crisis, Bridge and associates recommend studies on possible factors that have contributed to the increase in youth suicides.

These include the influence of Internet social networking sites, the effects of combat in Iraq and Afghanistan on soldiers returning home, untreated depression in the wake of recent boxed warnings on antidepressants, and access to firearms. Those studies, they added, should involve comprehensive assessment of individual-level exposure and outcome data, because “aggregate data alone cannot establish causal links.”

In another measure, the CDC’s national Youth Risk Behavior Surveillance Survey of 2007 (www.cdc.gov/ mmwr) showed that 6.9% of US high school students (grades 9 through 12) had attempted suicide at least once during the 12 months before the survey and 14.5% had seriously considered suicide. Overall, the prevalence of attempted suicides was highest among females, black and Hispanic students, and 9th and 10th graders.

Predicting reattempts
Burns and coworkers² studied treatment compliance in adolescents after attempted suicide. They found that up to 50% of adolescents who attemptsuicide may reattempt it. Up to 11% of those who attempt suicide eventually die by suicide.² David Shaffer, MD, Irving Philips Professor of Child Psychiatry and professor of psychiatry and pediatrics at Columbia University Medical Center, explained that differences occur in reattempt statistics-depending on whether the source is a survey or clinical sample. Dr Shaffer is a strong proponent of suicide prevention efforts through screening.

According to Shaffer, about 10% of attempters identified in large anonymous surveys of high school students report having made more than 1 previous attempt. The rate in clinical samples is higher: approximately one-third of attempters seen in a clinic repeated their attempt within 3 years. Our research on youth identified as being at risk for suicide (after screening in the general population), Shaffer added, shows that teens who make multiple attempts are more likely to be girls and to have an associated psychiatric disorder than teens who make a single attempt.

Studies of inpatients show that a reattempt at suicide is most likely within a year after discharge. The peak incidence occurs between 3 and 6 months after the original attempt, said Shaffer.

Predictors of future attempts, Burns told Psychiatric Times, include greater intent to die; lethality of first attempt; general psychopathology, particularly depressive symptoms; the intensity, number, and range of life stressors experienced by the adolescent following the initial suicide attempt; negative perceptions of the family function (eg, high levels of family conflict); and feelings of hopelessness and helplessness. Prior attempts also serve as a major predictor, Shaffer reported.

Miranda and colleagues³ recently published a study of 228 teens who reported a lifetime suicide attempt or suicidal ideation during a 2-stage high school screening done in the mid- 1990s in the New York metropolitan area. These teens were contacted 4 to 6 years later as young adults and asked whether they had made any further suicide attempts.

According to Shaffer, results suggest that psychiatrists should be asking teenagers who present to the emergency department not only whether they have ever attempted suicide but also how many times they have made such attempts.

“Knowing whether teens had ever made more than 1 suicide attempt when we first interviewed them gave us more information about how likely they were to make another suicide attempt during the ensuing 4 to 6 years than even knowing whether they had a history of a psychiatric disorder,” he said.

Currently, Shaffer and his team are investigating whether teens’ comments about the circumstances surrounding their attempts (eg, how impulsive the attempts were) indicate something about their risk for a future suicide attempt.

“We are also developing an interview designed to assess the events, thoughts, and feelings that lead teenagers to think about suicide. We know very little about what exactly teenagers think about when they consider suicide, how often they think about it, or how long a typical episode of suicidal ideation lasts. We hope that such an instrument can eventually serve as a guideline for other researchers and clinicians on how best to interview teenagers who have thought about or tried to commit suicide,” Shaffer said.

Treatment compliance
Burns and colleagues² recently looked at treatment use and subsequent treatment compliance in a sample of hospitalized adolescents who made a recent suicide attempt. Participants included 85 adolescents hospitalized at 4 different psychiatric hospitals and at least 1 of their primary caregivers- usually a parent.

At the time of the indexed suicide attempt, the adolescents ranged in age from 13.3 to 18.7 years. Sixty-four (75%) attempted suicide by drug overdose (eg, over-the-counter medications); 8 (9.4%) used a combination of overdose and self-cutting or alcohol poisoning; and 13 (15.3%) used other methods, such as shooting, stabbing, or jumping from a high place.

The teens were assessed as soon as possible after their suicide attempt and every 6 months for 2 years thereafter to determine treatment use and compliance, attitudes toward treatment, and suicide attempts and ideation.

Sixteen adolescents (18.8%) had made at least 1 repeat suicide attempt during the follow-up period, and 7 (8%) had made multiple attempts, Burns said.

No statistically significant results were found for predictions of reattempts based on treatment noncompliance, according to Burns.

“Measures of treatment compliance in our study did not significantly predict suicide reattempts across time points,” he said. The same held true for suicidal ideation, with one exception. Compliance with therapy at 18 months predicted lower suicidal ideation at 24 months.

Individual psychotherapy, the researchers found, was the most common form of treatment. (Pharmacotherapy was only slightly less common throughout the 2 years.) There was also a relatively high prevalence of meeting with school psychologists and guidance counselors both before and after suicide attempts.

Types of psychopathology predicted noncompliance with some treatment approaches.

At baseline, 52 (61.2%) of the adolescents had 1 or more affective/anxiety diagnoses; 36 (42.4%) had 1 or more disruptive behavior diagnoses; 28 (32.9%) had both affective/anxiety and disruptive behavior diagnoses; and 32 (37.7%) had no diagnosis within either category.

Those adolescents with affective and/or anxiety disorders were less compliant with psychopharmacological interventions at 6 months, said Burns. Those with disruptive behavior diagnoses were less compliant with individual psychotherapy. Adolescents with a substance dependence disorder other than alcohol or marijuana dependence were also quicker to drop out of individual therapy.

Parents’attitudes toward treatment can make a difference, according to Burns. Parental ratings of individual psychotherapy as helpful were a significant predictor of decreased dropout from individual therapy during the study.

If parents believe particular treatments are helpful, Burns said, they are more likely to facilitate them by getting the teens to treatment and paying for the treatments.

The study by Burns and colleagues was part of a larger prospective project that examined the risk factors associated with suicidal behavior in adolescents.

“Our research team is continuing to analyze and write up a great deal of data from this larger project,” said Barry Wagner, who is professor of psychology at the Catholic University of America.

Two as yet unpublished studies look at whether suicidal youths are “scapegoated” in families and also at negative family communication and parent-child relationships as risk factors for suicidal behaviors.

The scapegoating study indicates not only that suicidal adolescents perceive more negative parental treatment than their siblings but also that parents report having treated the suicidal child more negatively as well.

“Importantly, the suicidal adolescents’ perceptions of negative differential treatment by fathers-but not by mothers-were associated with greater suicidal ideation at baseline and were predictive of heightened suicidal ideation across an 18-month period following the index suicide attempt,” Wagner said.

Wagner and his team observed mother-adolescent and father-adolescent interactions when discussing a topic identified by family members as highly conflictual.

“The results showed that parents of suicide attempters interacted with their adolescents in much the same way as the parents of psychiatric controls,” Wagner said. But, “the suicidal adolescents displayed significantly more emotional invalidation toward their mothers than did the control adolescents. A similar finding for fathers closely approached significance.”

Treatment approaches
Shaffer was asked which treatment approaches are effective in preventing reattempts.

“There are various approaches (eg, Beck’s cognitive therapy, Linehan’s dialectical behavior therapy, mindfulness- based cognitive therapy) that have all been found to be effective with adults in preventing suicide attempts,” he said. “Elements of these treatments have been or are being adapted for adolescents. However, there is relatively little research on their efficacy and effectiveness with adolescents."

As to whether SSRI antidepressants prevent or provoke suicide, Shaffer said that careful examination of both epidemiological and autopsy studies shows that very few adolescents commit suicide while complying with SSRI treatment. In general, most morbidity associated with SSRI exposure takes the form of expressions of suicidality, such as reporting ideation or attempts to others.

Regardless of treatment approach, Shaffer cautioned, no youth should be discharged from care before identifying and removing, where possible, potential dangers such as firearms and without establishing a “plan for safety.” That plan-what a teen might do if he or she again feels an urge to commit suicide-should include a list of emergency contact numbers for a clinician, a responsible adult, and others.

“Other aspects of treatment should deal with decreasing the teen’s wish to commit suicide by addressing the reasons for engaging in the behavior (eg, avoidance, escape from their distress),” Shaffer said. “For example, there is evidence . . . that people make suicide attempts when they see no other optons available to deal with their problems. Strengthening teenagers’ skills for and increasing their ability to come up with alternative solutions to problems may go a long way toward preventing another attempt.”

References:

1.Bridge JA,Greenhouse JB,Weldon AH,et al. Suicide trends among youths aged 10 to 19 years in the United States,1996-2005.JAMA. 2008;300:1025-1026.
2. Burns CD, Cortell R,Wagner BM.Treatment compliance in adolescents after attempted suicide: a 2-year follow-up study. J Am Acad Child Adolesc Psychiatry. 2008;47:948-957.
3. Miranda R, Scott M, Hicks R, et al. Suicide attempt characteristics,diagnoses,and future attempts:comparing multiple attempters to single attempters and ideators. J Am Acad Child Adolesc Psychiatry. 2008; 47:32-40.