• 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 is the likelihood of an individual completing suicide.
  • This chapter will focus on recognizing suicidal ideation and preventing suicide attempt.


  • In 2014, suicide was the 2nd leading cause of death for adolescents and emerging young adults (10 to 24 years) and the 10th overall cause of death in the United States.
  • Adolescent mortality from suicide tripled between the 1950s and the 1980s, falling steadily until 1999, then increasing since 1999
  • From 1999 to 2014, the age-adjusted suicide rate in the United States has increased 24%, with an increased rate of rise since 2008.
  • Females attempt suicide at a rate 2 to 4 times that of males and are most likely to attempt suicide through ingestion.
  • Males 15 to 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 (9.5/100,000) adolescents.
  • Gay, lesbian, bisexual, transgender, and questioning youth experience 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.


  • Annually in the United States, ~2,000 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 11.9 deaths per 100,000 persons aged 15 to 24 years in 2014.
  • In 2015, 18% of youth surveyed in grades 9 to 12 reported seriously considering suicide at some point in the preceding year, whereas >8% reported attempting suicide in the previous year.

Risk Factors

  • Previous suicide attempt(s)
  • Mental health disorder
  • Social isolation
  • Substance/alcohol use disorder
  • 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

  • Primary prevention of suicide involves addressing its root causes, including social isolation, childhood trauma, substance use, and depression.
  • Predicting which patients will attempt suicide is an emerging science.
  • It is possible to identify who may be at risk and to provide resources to address underlying factors.
  • Several methods of providing brief, validated screening tools to identify risk factors for suicide are available for primary care and many other medical settings.
  • It is recommended to directly ask about suicidal ideation routinely when providing health care to adolescents.
  • Talking about or writing about death or suicide, threatening to kill oneself, or looking for ways to kill oneself can all be evidence of suicidal ideation.
  • 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)
    • Apathy or disengagement with school, work, or home
    • Changes in mood or affect
  • If suicidal ideation is suspected, a risk assessment that includes the following components should occur:
    • Frequency and chronicity of suicidal thoughts
    • Evidence of active, detailed 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
  • Referral or consultation with a psychiatrist or mental health professional is indicated with any question or risk for suicide attempt.
  • Developing clear referral processes and regular communication with mental health providers is the standard of care for pediatric practitioners.


  • 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.
  • Suicidal and self-harming behavior may be associated with the onset of other chronic mental health diseases that can occur during adolescence or young adulthood, including schizophrenia.


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.

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