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.
• Suicidal ideation is any thought, with or without a specific plan, to end one’s life.
• Passive suicidal ideation refers to thoughts about one’s own death without consideration of any specific action (e.g., a wish to no longer be alive). Active suicidal ideation refers to thoughts about ending one’s life with consideration of a specific action, possibly with some intent.
• Nonsuicidal self-injury (NSSI) refers to an intentional, self-inflicted wound without the intent to die. NSSI is a top risk factor for suicidal thoughts and attempts.
• This chapter will focus on recognizing suicidal ideation and preventing suicide attempt.
• Note that risk and protective factors may differ for youth with marginalized identities (i.e., youth of color; lesbian, gay, bisexual, transgender, and queer [LGBTQ] youth) given social determinants of health may affect symptom presentation, etiology, and access to care.
• Prevention and response strategies should be culturally affirming.

EPIDEMIOLOGY

• In 2020, suicide was the 2nd leading cause of death for adolescents and emerging young adults (aged 14 to 44 years) and the 10th overall cause of death in the United States.
• Women and girls attempt suicide at a rate of 2 to 4 times that of men and boys and are most likely to attempt suicide through ingestion of harmful substances. Men and boys 15 to 24 years old are 5 times as likely to die by suicide as women and girls and are most likely to use more lethal methods.
• LGBTQ youth experience significantly higher rates of suicide thoughts and attempts than their heterosexual and cisgender (i.e., nontransgender) peers. Stigma is a prominent risk factor for these groups, and family acceptance/social support/LGBTQ community membership is protective.
• More than half of all deaths by suicide in the United States involve a firearm.
• 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.

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 suicidal thoughts and behaviors.
• Intense emotional states, 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.
• Decreased aversion to death
• An underlying psychiatric 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.

RISK FACTORS

• Previous suicide attempt(s)
• NSSI
• Mental health disorder
• Social isolation
• Substance/alcohol use disorder
• Family history of suicide
• Family history of severe mental illness or substance abuse
• History of abuse
• Presence of firearms in the home
• Social marginalization, experiences of discrimination, identity-related rejection from family

GENERAL PREVENTION

• Prevention of suicide attempts for at-risk individuals involves safety planning, reducing access to suicide means, and calling mobile crisis or 911 in the event of a crisis.
• Secondary prevention (i.e., working with a patient or family after a suicide attempt) may include addressing emotional concerns after the suicide attempt, addressing grief/guilt within the family, building support through family, spiritual community, or school.
• 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. Clinicians should ask about suicidal ideation routinely when providing health care to adolescents (e.g., “Many people your age have thoughts about being better off dead or of hurting themselves. Have you been having these thoughts at all recently?”).
• 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
  • Extreme changes in mood or affect
• If suicidal ideation is suspected, a risk assessment that includes the following components should occur:
  • Frequency, recency, and chronicity of suicidal thoughts
  • Evidence of planning, including exploring/discussing suicide method options in online communities
  • 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 other 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.

PATHOPHYSIOLOGY

• Pathophysiology of suicide is an ongoing area of research, and it is difficult to assess physiologic correlates of suicide in individual patients.
• Decreased central serotonergic activity may result in aggressive or impulsive behaviors, which may be aimed at oneself.
• History of traumatic brain injury
• Neurologic correlates of low motivation and emotional challenges