Abstract
Suicide among youth is a major public health concern globally. According to the WHO, suicide is the second leading cause of death in the world for 10–29-year-olds. It is important to recognize that young people are more likely to die by suicide than by any other single medical illness, underscoring the need for increased emphasis on medical education regarding suicide and the potential lifesaving impact of identification and effective care for youths with elevated suicide risk. Because suicidal ideation and behavior tend to have their first onsets during adolescence, this developmental period may offer an important window of opportunity to prevent the development of suicidal thoughts and behaviors, which lead to elevated risk of premature death, mental health and functioning problems, and psychological pain and distress.
A Introduction: Youth Suicide, a Global Public Health Crisis
Suicide among youth is a major public health concern globally. According to the WHO, suicide is the second leading cause of death in the world for 10–29-year-olds. It is important to recognize that young people are more likely to die by suicide than by any other single medical illness, underscoring the need for increased emphasis on medical education regarding suicide and the potential lifesaving impact of identification and effective care for youths with elevated suicide risk. Because suicidal ideation and behavior tend to have their first onsets during adolescence, this developmental period may offer an important window of opportunity to prevent the development of suicidal thoughts and behaviors, which lead to elevated risk of premature death, mental health and functioning problems, and psychological pain and distress.
Among the 40 countries with national suicide prevention plans, many address youth suicide utilizing a public health approach that includes universal education about mental health, suicide risk factors, and warning signs, and how to change culture and stigma particularly surrounding help seeking. Additionally, targeted efforts are underway to augment peer support training, engage high risk populations, and better prepare health professionals and systems to appropriately identify and care for youth at risk for suicide.
B Principles
Youth suicide is a global public health crisis warranting major investments and actions commensurate with its morbidity and mortality toll.
Youth suicide takes more lives in the USA than all other medical causes of death together.
Suicide risk factors in youth include family, school, and peer interactions in addition to the universal risk factors for all ages such as unaddressed mental health conditions, lethal means availability, and genetics.
The clinical identification and management of emerging mental health conditions in youth is a critical aspect of youth suicide prevention.
Health professionals can play an important role in dispelling myths surrounding medications as well as utilizing or advocating for all effective treatment modalities.
Social media plays a significant role in the mental health and suicide risk for some youth. Incorporating social media utilization and its particular impact on an individual into clinical assessment and treatment planning is recommended.
Youth are more susceptible to suicide contagion than adults, therefore mitigating suicide exposure among youth is a key prevention strategy.
Suicide screening and assessment for youth are recommended with recently validated tools.
It is imperative for pediatricians, parents, school personnel, and peers to all play a role to prevent youth suicide.
C Scope of the Problem and Trends
Suicide is rare in children under 13 years old, however during the adolescent years rates increase and the gender differential gap begins and widens into adulthood.
While rates are lower in youth than in middle and older age groups in most high-income countries (in the USA, American Indians are one exception), any loss of life early to a preventable cause like suicide is tragic and warrants effort and attention.
Figure 13.2 Teenage suicide (15–19 years) by country per WHO Mortality Database
Trends are shown for each country, e.g., blue and green markers above the red bar indicate a decrease in teen suicide rates over nearly two decades.1
Spotlight on Youth Suicide in the USA
As is the case globally, suicide is the second leading cause of death for youth aged 15–24 in the USA. Only unintentional injuries, including car accidents and drug overdoses, take more young American lives every year.
Approximately one in six teenagers in the USA seriously considers suicide over a 12-month period.3
In the USA an estimated 100–200 youth attempt suicide for every youth death by suicide. The suffering and trauma that suicidal behavior encompasses, for the young person, their parents, siblings, peers, and for schools and others is enormous. In the USA the K-12 educational system has become increasingly involved in suicide prevention of youth via school suicide prevention policies, mandatory suicide prevention training of teachers and staff, and procedures for handling suicidal students and re-entry to school after inpatient or intensive mental health treatment for suicide attempts.
Girls are more likely to attempt suicide than boys, but as with the adult population, boys are more likely to die by suicide than girls. A 2019 study of the 40-year youth suicide trends in the USA found that youth suicide rates increased from 1975 to 1992, decreased from 1992–2007, and have been increasing from 2007 to 2016.4 In fact a CDC report on US youth suicide trends published in 2020 found the suicide rate among adolescents and young adults aged 10–24 in the USA increased an astounding 57.4% from 6.8 per 100,000 in 2007 to 10.7 in 2018.5 Additionally the gender gap is narrowing especially for youth aged 10–14 years old. Among youth suicide decedents, the more lethal method of suffocation/hanging has been rising particularly for girls over this past decade.
Girls between the ages of 15 and 19 years old attempt suicide at twice the rate of boys, yet boys’ suicide rate which was three times the rate of girls, has more recently been found to be two times higher, indicating a narrowing of the gender gap in American youth suicide rates, with both genders’ rates on the rise.4
Figure 13.3 Suicide is a leading cause of adolescent and young adult death in the USA
For youth aged 15–24 in the USA, suicide takes more lives than the other leading health-related causes of death in youth combined.2
D Suicide Risk Factors Specific to Youth
Many suicide risk factors – notably depression and other mental health deterioration including substance abuse – are as true for adolescents as they are for adults. There are however more young suicide decedents for whom the deterioration in mental health may have been undetected due to their early life stage and less time and history to have noted the signs of a mental health condition. Changes in mental health tend to be more challenging to recognize during the adolescent years related to actual variability in clinical presentations during youth as well as difficulty many parents have differentiating between “normal teen angst” and clinically significant symptoms.
Behaviors in the Home Matter
Research from the Family Acceptance Project led by Dr. Caitlin Ryan found specific behaviors in the home contribute to serious health outcomes for LGBTQ youth. Supportive versus rejecting behaviors in the home were associated with significantly different health-, mental health-, and suicide-related outcomes. Rejecting behaviors such as parents or other family members telling the child they are ashamed of them, blaming the child when peers mistreat them because of their LGBTQ identity or gender expression, not using the name or pronoun that matches the child’s gender identity, or causing them to leave home because they are LGBTQ were associated with serious health outcomes including depression, suicidal thoughts and attempts, substance use, and HIV/AIDS. The more of these behaviors that parents and family members do, the greater the risk to the LGBTQ child’s health, whereas supporting behaviors such as telling the child you love them and expressing affection when the child talks about being LGBTQ, supporting their gender expression, requiring other family members to treat the child with respect, and speaking with faith leaders and others to help them become supportive of LGBTQ people, are all associated with reductions in the child’s likelihood of experiencing suicidal thoughts, attempts, and substance use problems. Please visit https://familyproject.sfsu.edu/ to learn more and request posters for your clinic that provide this critically important information for parents.9
There are also particular risk factors that are more critical in youth suicide risk than for adults: these include child–parent conflict and negative family dynamics, parental substance use or mental illness, peer conflict, LGBTQ rejection by parents and others, bullying and cyberbullying, heavy use of online and social media utilization, ADHD and impulsivity, all of which contribute to teen suicide risk in a more powerful way than in adults.
Factors such as depression, anxiety, substance use, ADHD, learning disabilities, non-suicidal self-injury, trauma, early childhood adversity, perfectionism, and genetic loading combine with external life circumstances to push the young person toward a sense of hopelessness and feeling overwhelmed, trapped, or like a burden. And as is the case with adult suicide risk, access to lethal means plays a major part in increasing risk. An important risk factor is the presence of firearms and other lethal means in the home. Studies show that access to firearms increases suicide risk 2–5 times for youth in firearm-owning homes.6, 7 In a 2019 study of state-level firearm ownership and suicide rates, results indicated that for each 10 percentage-point increase in state-wide household firearm ownership, the state’s youth suicide rate increased by 26.9%.8
External psychosocial stressors that increase suicide risk can include:
family violence
physical abuse
sexual abuse
rejection related to sexual orientation or gender identity
experiences with loss or humiliation
Adolescence Presents a Window of Opportunity To Prevent Serious Outcomes in the Short and Longer Term
Because suicidal ideation and behavior often have their first onset during adolescence, this developmental period offers an important window of opportunity to engage the youth in treatment and support which can avert a path to elevated risk of premature death, mental health, and functioning problems. Youths with suicidal ideation, attempts, and other forms of deliberate self-harm (NSSI such as cutting or burning oneself without suicidal intent) are at risk for both death by suicide and death by other unnatural causes such as alcohol and drug overdose, and accidents.10
Nonsuicidal Self-Injury
Nonsuicidal self-injurious behaviors are common among youth with a lifetime prevalence of 18% worldwide and include cutting, scratching, burning, and head banging. NSSI is by definition not intended to end one’s life, but there are different ways of understanding NSSI. Because it has some different associated features from suicidal behavior such as positive affect and being used as a way to cope and even avoid suicide, it can be viewed as quite separate from suicidal thoughts and behaviors. However, NSSI can also be viewed as a precursor to suicidal behavior in some individuals since the presence or history of NSSI does demonstrate a higher likelihood of later developing suicidal behavior and risk of suicide. NSSI is most likely to lead to future suicidal behavior when there is a family history of suicide attempts or death, aggression, and higher levels of severity and chronicity of depression. Treatment should consider the broader clinical picture but can also target NSSI. Treatments that have been studied include DBT, CBT, mentalization therapy, and parent/family therapy. Elements across therapeutic modalities that are most effective for reducing NSSI behaviors include:
Incorporating coping skills or safety planning
Addressing negative affect
Emotion regulation
Distress tolerance
Interpersonal skills building
Increasing social connection and support
E Treatment of Child and Adolescent Mental Health Conditions
One in four Americans will have a mental health condition in their lifetime and 50% of these conditions have their onset by age 14; 75% by age 24. Therefore, the need to identify and treat mental health deterioration and illness in children and adolescents is compelling, and yet less than half of young people with depression and other psychiatric disorders receive treatment.
As discussed in Chapter 9 special consideration that occurred in the early 2000s was the UK’s MHRA and USA’s FDA decision to place warnings on all antidepressants for youth and young adult patients. In the USA the black box warning was issued for antidepressant use in patients under 24 years old for “increased risk of suicidal thinking, feeling and behavior.” After this occurred, there was a documented decrease in diagnosing and treating depression in primary care during the years following the black box warning in 2004. In a large cohort study that included 1.1 million adolescents, 1.4 million young adults, and 5 million older adults, data related to mental health over a 10-year period from 2000 to 2010 was collected.11 The study revealed significant reductions in antidepressant use within two years of the FDA advisory release: relative reductions of 31.0%, 24.3%, and 14.5% among adolescents, young adults, and older adults respectively. Even though the warning was for youth and young adults under the age of 24, the effect seemed to spill over into the identification and treatment of depression across all ages. Moreover, the use of non-pharmacologic treatments for depression and anxiety such as CBT did not increase to replace the decreases in treatment with medications.12 This was thought to be associated with fear and confusion regarding use of antidepressants among clinical providers, as well as among parents and the general population, leading to reluctance among healthcare practitioners to appropriately treat depression with antidepressant medication.
The FDA’s decision to place the black box warning on antidepressant labeling for use in young people under 24 years old was based on higher rates (4%) of suicidal ideation than placebo (2%), however, the methodology did not allow for examination of potential positive effects on suicide risk, nor incorporation of pre-study levels of suicidal ideation or behaviors.13 Notably there were no suicide deaths and extremely few attempts in the data set on which the FDA based its decision. (See Chapter 9 for more information on the USA’s FDA and UK’s MHRA antidepressant warnings.)
According to the American Academy of Pediatrics, the benefits of antidepressants outweigh the potential risks to most young patients. Many studies support this opinion.14, 15 For example, one research team conducted a reanalysis of all the trials related to two medications, fluoxetine and venlafaxine.16 The researchers did not find any evidence of increased suicidal ideation or behavior. It did find a significant significantly positive impact on depression for all age groups, but especially for youth. A total of 46.6% of young patients treated with fluoxetine witnessed a decrease in their depression compared with 16.5% of young patients treated with the placebo.17
Use of Antidepressants in Youth
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