DSM-IV-TR Diagnostic Criteria

Suicidal ideation consists of thoughts of wishing to be dead or wishing to kill or inflict life-threatening harm on oneself. Suicide attempt refers to deliberate self-destructive action intended to kill oneself. Because the attempter’s intention is often ambivalent, an assessment of severity of intent is a crucial part of clinical evaluation. Lethality, in contrast, refers to the actual likelihood that the attempt will cause death. The term “parasuicide” has been used to denote attempts at self-injury that are of low lethality and involve little or no wish to actually die, while deliberate self-cutting refers to non-lethal, usually repetitive self-cutting apparently motivated by feelings of tension, depersonalization, or emptiness, rather than a wish to die.

Although mood disorders, psychosis, and substance abuse are potent risk factors for completed suicide, suicide attempts and ideation in children and adolescents can occur in a wide variety of disorders and psychopathological conditions.

Suicidal ideation—thoughts of wishing to be dead, or to kill or inflict life-threatening harm on oneself

Suicide attempt—deliberate self-destructive action intended to kill one self

Lethality—likelihood that an attempt will cause death

Parasuicide—low lethality attempts at self-injury that involve little or no wish to die

Epidemiology

Completed Suicide

Completed suicide is rare in prepubertal children, with an annual rate in the US on the order of 0.6 per 100,000 for children age 5–14 in 2003. Completed suicide in adolescents, however, is the third leading causes of mortality in the U.S. in this otherwise generally healthy age group, and in 2003 accounted for the death of 7.3 teens, age 15–19, per 100,000. The most recent international data show a similar pattern of relatively low rates for youngsters age 5–14 (ranging from 0–2.4 per 100,000), with higher rates for youth age 15–24 (ranging from 2.4 to 33.1 per 100,000) (see Table 40–1). Although young male suicides substantially outnumber female suicides throughout much of the world, the pattern is reversed in rural parts of the developing world, such as India and China, perhaps due to ready access to lethal insecticides used in agriculture. Although variations in reporting practices make direct comparisons difficult, there are apparent wide international variations, with high rates of youth suicide associated with rapid political and economic changes, widespread gun availability, breakdown of traditional culture among indigenous peoples, and changes in the status of women. Reported youth suicide rates are low in many predominantly Muslim and Catholic countries.

Dramatic secular trends are also apparent internationally in the epidemiological data. According to the World Health Organization, youth suicide rates rose dramatically between the 1950s and mid-1980s in the US, much of Europe, Mexico, the Western Pacific; speculations as to the cause of this trend include rising divorce rates, increased adolescent substance use, demographic competition, erosion of religious/cultural taboos against suicide, and mass media coverage of celebrity and other suicides. The decade from 1990 to 2000 showed a decline in youth suicide rates in many, but not all countries (with Eastern Europe and Ireland being dramatic exceptions). The reasons for this decline are unclear, although greater awareness of adolescent depression and widespread availability of effective antidepressants have been speculated to play a role. In this connection, it is of note that after a decade of decline in the US, the death rate from suicide for youngsters aged 19 and under jumped 18.2% from 2003 to 2004, a period coinciding with a sharp downturn in use of antidepressants in children and adolescents due to widely publicized safety concerns.

Suicidal Ideation and Attempts

In contrast to completed suicide, suicidal ideation and attempts are far more common. The 2005 biennial national Youth Risk Behavior Survey found that, during the preceding 12 months, 16.9% of high school students had seriously contemplated attempted suicide; 13% had made a plan to attempt suicide; 8.4% had actually attempted suicide one or more times; and 2.3% had made a suicide attempt involving an injury, poisoning, or overdose that had to be treated by a doctor or nurse. Rates of suicidal ideation and attempts among younger children, age 7–12 years, are substantially lower (on the order of 4% and 1.5%, respectively).

Suicidal ideation or behavior is a common cause for pediatric emergency room (ER) visits. During the period 1997–2002, the annual rate of ER visits in the US for deliberate self-harm was 225 per 100,000 7–24-year-olds. About 20% of such ER visits result in hospitalization. The annual hospitalization rate of youth with self-inflicted injuries is 44.9 per 100,000 5–20-year-olds. Among these hospitalized patients, the rate of cutting is 13.2%, hanging or suffocation 1.3%; and ingestion of acetaminophen 26.9%, antidepressants 14%, opiates 3.3%, salicylates 10.2%,

Gender

Suicidal behavior varies markedly by gender. Attempted suicide is much more common in girls aged 15–19 years than in same-aged boys. Girls in this age group attempt suicide almost twice as often as boys, while boys complete suicide about four times more often than girls. Thus, for adolescent boys, the ratio of completed to attempted suicides is about 1:517, where as it is 1:4000 for girls.

Etiology

Completed Suicide

Major Psychiatric Disorder

The psychological autopsy is a procedure for reconstructing a decedent’s life to understand the psychological antecedents and circumstances of the death; this process includes a review of available records and systematic interviews of knowledgeable informants regarding the decedent’s lifestyle and expressed thoughts, feelings and behaviors, especially those that might provide evidence of psychopathology. Such studies find that about 90% of adolescent suicide completers have at least one diagnosable major psychiatric disorder, especially depressive, substance abuse, and conduct disorders. In about half of adolescent suicides, one or more psychiatric disorder has been present for at least three years at the time of suicide.

From a screening and prediction perspective, although these diagnostic risk factors are sensitive (i.e., which are found in most cases of adolescent suicide), they are very nonspecific, since they are found in a very large number of adolescents who do not commit suicide. The small minority of adolescent suicides without a discernable major psychiatric diagnosis still show elevated rates, compared to community controls, of family psychiatric disorder, past suicidal ideation or behavior, legal or disciplinary problems in the prior year, and firearms in the home.

Psychopathological and Psychosocial Risk Factors

Additional psychosocial risk factors for completed suicide include: Isolative or impulsive character traits; recent life stressors, such as interpersonal loss or legal or disciplinary problems (especially in youngsters with substance abuse or disruptive disorders); and family history of suicide, depression, or substance abuse. Despite variations across ethnic and racial groups, completed suicide rates do not appear to be influenced by socioeconomic status per se. Troubled parent–child relationships and nonintact family of origin appear to be associated with youth suicide, although once parental or youth psychopathology is controlled for the magnitude of this association is unclear.

Media and Suicide “Contagion”

Clusters of apparently imitative suicide attempts and completions occur in adolescents and are estimated to account for 1–13% of youth suicides in the United States. Sensationalized media coverage of local, celebrity, or fictional suicides may provoke imitative suicidal behavior.

Suicidal Ideation and Attempts

Psychopathology