Basics
Description
- Suicidal behavior is a voluntary self-harming act with the intent of ending one 's own life.
- Attempted suicide occurs when the act does not result in death (also, failed or near-suicide).
- Suicidal ideation is any thought, with or without a specific plan, to end one 's life.
- Suicidality can include suicidal ideation, preparatory acts, and/or attempts.
Epidemiology
- Suicide is the 3rd leading cause of death for adolescents and emerging young adults (10 " 26 years), whereas it is the 10th overall cause of death for Americans.
- Adolescent mortality from suicide tripled between the 1950s and the 1990s and has remained overall stable since, after declining in 1990s then rising over the past decade.
- Females attempt suicide at a rate 2 " 4 times that of males and are most likely to attempt suicide through ingestion.
- Males 15 " 24 years old are 5 times as likely to die by suicide as females and are most likely to use more lethal methods.
- Completed suicide rates are highest in non-Hispanic white (13.9/100,000) and Native American (10.6/100,000) adolescents. Suicide rates for black males 10 " 19 years old doubled between the years 1980 and 1995.
- Gay, lesbian, bisexual, transgender, and questioning youth report significantly higher rates of suicide thoughts and attempts than their heterosexual peers.
- More than half of all deaths by suicide in the United States involve a firearm.
Incidence
- Annually in the United States, ’ Ό2,000 adolescents die from suicide and over a million suicide attempts come to medical attention; there were as many as 11 times the number of attempts as completed suicides.
- Overall, suicide accounted for 10.9 deaths per 100,000 persons aged 15 " 24 years in 2011.
- In 2013, 17% of youth surveyed in grades 9 " 12 reported seriously considering suicide at some point in the preceding year: >8% reported attempting suicide in the previous year.
Risk Factors
- Previous suicide attempt(s)
- Social isolation
- Substance/alcohol abuse
- Family history of suicide
- Family history of severe mental illness or substance abuse
- Past or present sexual or physical abuse
- Family conflict or disruption
- Presence of firearms in the home
General Prevention
- Universal screening of all adolescents for suicidality should occur in primary and acute care settings.
- Brief, validated screening tools are available for medical settings.
- There is ample evidence that direct inquiry, paper-and-pencil questionnaires, and computer-assisted screening enhance identification.
- Warning signs, aside from obvious emotional distress, can include the following:
- Chronic physical symptoms, with or without discrete physiologic etiology (e.g., chronic headache, abdominal pain)
- Change in level of functioning in school, work, or home
- Changes in mood or affect
- If suicidal ideation is reported, components of risk assessment include the following:
- Frequency and timing of suicidal thoughts
- Active planning
- Access to lethal means such as firearms
- History of past suicide attempt(s)
- History of mental health problems, including substance abuse, and treatment
- Acute or anticipated psychosocial stressor
- Family history of suicide
- Family violence
- Exploration of coping strategies and social support systems
- Referral or consultation with a psychiatrist or mental health professional is indicated with any question or risk for suicide attempt.
Pathophysiology
- Decreased central serotonergic activity may result in aggressive or impulsive behaviors, which may be aimed at oneself.
- An underlying psychiatric or personality disorder acutely worsened by a stressful life event may trigger a suicidal act.
- Feelings of isolation and lack of external support can result in hopelessness and limit opportunities for care.
- Suicide may be an impulsive act to express frustration or rage.
Etiology
Suicidal behavior in adolescents results from the interaction of long-standing individual and family factors, social environment, and acute stressors:
- Diagnostic criteria for psychiatric disorders such as major depressive episode and borderline personality disorder include suicidality (DSM-5).
- Intense emotional state, in particular shame or humiliation, can be "trigger events " for a suicidal act.
- Personality and social factors, such as antisocial behavior, aggressive or impulsive proclivities, and social isolation, can also contribute.
Diagnosis
History
- The provider should establish a quiet environment with clear discussion of confidentiality and limitations before inquiring about suicidal ideation or attempt.
- If positive, a comprehensive history should always be obtained or reviewed by a trained mental health worker. Components include the following:
- Sensitively ascertain any planning, including method and timing.
- Ask factors that could increase lethality of attempt (e.g., number of pills ingested).
- Circumstances of attempt (e.g., remote site, public display)
- History of prior attempts
- Current psychological status (e.g., feelings and/or level of depression, hopelessness, impulsivity, self-esteem)
- Family consistency and dynamics
- Pharmaceuticals available at home; what is missing
- History of interpersonal conflict or loss
- Family history of suicide
- History of substance use
- History of psychological disorder
- History of abuse, neglect, or incest
- Social supports and coping strategies
- Feelings of regret or continued desire for self-harm
Physical Exam
- Regardless of ingestion history, closely observe vital signs, skin, mucous membranes, and pupils for evidence of toxidrome.
- Examine skin for signs of physical abuse or self-mutilation, including extremities and torso.
- A complete neurologic examination is essential for the evaluation of intracranial processes, acute mental status changes, and ingestions.
Diagnostic Tests & Interpretation
Different laboratories offer different spectra and sensitivities in their toxicology screens.
Lab
- Serum and urine toxicology screens
- Urine pregnancy test: Pregnancy status could be a precipitating factor and, if positive, could affect treatment options.
- Acetaminophen level, as it is highly hepatotoxic and is used frequently by teenagers
- EKG is indicated for ingestions, including antidepressants and benzodiazepines.
Imaging
Abdominal plain film: if history of iron or vitamin ingestion or severe trauma
Treatment
Medication
- For recent ingestions, GI decontamination with activated charcoal may be appropriate, as is the administration of pertinent antidotes (e.g., naloxone for opioids, N-acetylcysteine for acetaminophen).
- Although psychotherapy is an essential component to the care of the suicidal ideation, pharmacotherapy with antidepressants can also play a role.
- SSRIs (fluoxetine, sertraline, and citalopram) have been shown to be effective in treating depressive disorders in adolescents. Use of SSRIs in patients with the potential for suicidal behavior requires close monitoring. In general, SSRIs may cause a short-term increase from 1 to 2% in the risk of suicidality in depressed teens.
- Tricyclic antidepressants (TCAs) have high lethality potential. TCAs are not indicated in treating depression in children and adolescents.
Additional Treatment
General Measures
- Parents and professionals should avoid minimizing attempts as "not serious " or as "just seeking attention. "
- Psychiatric disposition should be determined by, or in conjunction with, a mental health professional. Considerations for admission:
- Historical factors indicating high risk for repeated attempt
- Ongoing suicidal ideation and/or planning
- Family instability and lack of support
- Altered mental status
- Lack of alternative interventions (e.g., intensive psychiatric follow-up, day treatment program)
- Medication initiation that has risk for increasing suicidal thoughts (e.g., SSRIs)
- When discharge to a caregiver is being considered, the following minimal criteria should be in place at the time of discharge:
- The patient reliably expresses regret and denies ongoing suicidal thoughts.
- The patient is medically stable.
- The patient 's adult caregiver reports understanding of the seriousness of the attempt and importance of follow-up.
- The patient and parents agree to contact a health professional or go to the emergency department if suicidal intent recurs. The patient and family should have 24-hour access to mental health or physical health professionals.
- The patient must not have impaired mental status (e.g., psychoses, delirium).
- Lethal methods of self-harm are not immediately available to the patient.
- Follow-up for underlying mental health disorders have been arranged, including a transfer of key information and clear communication of follow-up locations and times with a behavioral health provider accessible to the patient.
- Acute precipitants and crises have been addressed.
- Caregivers and patients are in agreement with the discharge plan.
- Barriers to obtaining follow-up treatment, in particular insurance and social stigma, have been addressed and will not preclude the next step toward ongoing treatment.
Additional Therapies
In addition to medication, important psychiatric interventions include acute, short-term, inpatient psychiatric hospitalization, partial hospitalization (with intensive treatment and support), and outpatient therapy.
Inpatient Considerations
Initial Stabilization
- Airway, breathing, circulation (ABCs)
- One-to-one monitoring is typically indicated until formal mental health evaluation is obtained.
- Decontamination of GI tract and circulation is rarely indicated.
- When available, a poison control center or toxicologist will be helpful with evaluation and treatment of most drug ingestions.
Ongoing Care
Follow-up Recommendations
Long-term psychotherapy (individual and family therapy) is often needed for adolescents who attempt suicide. Improvement may be slow and punctuated by setbacks.
Prognosis
- 20 " 50% of those attempting suicide will try again.
- Multiple reports show that a majority of adolescents and young adults who attempt suicide disengage with treatment after a few visits due to a multitude of systemic and societal factors.
Complications
- Long-term organ damage or physical disability, depending on the method used
- Long-lasting emotional sequelae in survivors, resulting from frustration, anger, and guilt
- Repeat suicide attempt or completion
Additional Reading
- Centers for Disease Control and Prevention. Suicide and self-inflicted injury. http://www.cdc.gov/nchs/fastats/suicide.htm. Accessed June 22, 2014.
- Cooper WO, Callahan ST, Shintani A, et al. Antidepressants and suicide attempts in children. Pediatrics. 2014;133(2):204 " 210. [View Abstract]
- National Institute of Mental Health. Statistics. http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml#intro. Accessed February 29, 2011.
- Shain BN, American Academy of Pediatrics Committee on Adolescence and the American Academy of Child and Adolescent Psychiatry. Suicide and suicide attempts in adolescents. Pediatrics. 2007;120(3):669 " 676. [View Abstract]
- Williams SB, O 'Connor EA, Eder M, et al. Screening for child and adolescent depression in primary care settings: a systemic evidence review for the US Preventive Services Task Force. Pediatrics. 2009;123(4):e716 " e735. [View Abstract]
Codes
ICD09
- V62.84 Suicidal ideation
- 300.9 Unspecified nonpsychotic mental disorder
ICD10
- R45.851 Suicidal ideations
- T14.91 Suicide attempt
- Z91.5 Personal history of self-harm
SNOMED
- 44301001 Suicide (disorder)
- 82313006 suicide attempt (event)
- 267073005 Suicidal (finding)
- 6471006 Suicidal thoughts (finding)
- 225444004 At risk for suicide
FAQ
- Q: Should I ever keep suicide attempts or plans confidential?
- A: No. The limits of confidentiality should be clearly outlined to patients and families at the first visit or early in the patient 's adolescence. These limits include anything that will directly place the patient 's life in danger such as suicidal intent, ongoing or recent abuse, or homicidal intentions.
- Q: If I directly question my patients about suicide, won 't that put the idea in their head?
- A: No. In the majority of cases, patients will be relieved by having a professional who wants to talk about suicide. There is only risk in asking if nothing is done with the answer. Appropriate referral to mental health services or counseling will save patients ' lives.
- Q: Is a patient who is engaging in self-injurious behavior but denies suicidal ideation actually suicidal?
- A: Any adolescent who is practicing self-mutilation to cope with emotional distress is at risk of developing additional unhealthy coping behaviors. Furthermore, they are likely suffering from a mood disorder that places them at risk for developing suicidality. There is no evidence to support management of self-injurious behavior as if the patient has a secret agenda.