Suicide has jumped form the third to the second leading cause of death for teens, and the AAP says pediatricians are uniquely positioned to spot risk factors that could lead to suicidal ideation or behaviors.
Suicide is now the second leading cause of death for adolescents, and the American Academy of Pediatrics (AAP) has released new guidance urging pediatricians to identify at-risk teenagers and screen all their patients for suicidal thoughts.
Benjamin Shain, MD, PhD, of NorthShore University HealthSystem, in Deerfield, Illinois, a member of the AAP’s Committee on Adolescence and author of the new guidelines, says that although there is no method that is 100% effective in preventing adolescent suicide, knowing the risk factors is one of the best ways to identify and manage potentially suicidal teenagers.
Shain says pediatricians should pay special attention to how patients are functioning as a red flag to suicidal behaviors. Have their grades dropped? Are they participating in their regular activities? Have there been emotional changes? Are they getting into trouble?
“Psychiatrically impaired adolescents often appear, at least superficially, fairly normal,” Shain says, noting it sometimes can be more difficult to recognize suicidal behaviors in teenagers than in adults. “Adolescents also tend to be less forthcoming about distressing events and feelings,” he points out.
Shain says he hopes pediatricians will become more aware of behavioral and emotional issues and how they are put into perspective in teenaged patients. He also wants pediatricians to understand when referrals are appropriate because the problem is only getting worse.
When the AAP’s last clinical report on suicide was released in 2007, suicide was the third leading cause of death in teenagers. Now, it is the second leading cause of death in adolescents aged 15 to 19 years. Suicide rates rose 300% between 1950 and 1990, when suicide actually began to decline, dropping 28% from 1990 to 2013. In 2013, there were nearly 1800 recorded suicides, according to the AAP, although the actual number may be higher because some deaths were recorded as accidental.
Adolescent boys are at higher risk of succeeding in suicide than girls, with suicide rates 3 times higher in boys compared with girls, although girls are more likely to attempt suicide at double the rate of boys. Boys typically choose more lethal methods of suicide, according to the AAP.
Race, ethnicity, sexuality, and socioeconomic status also come into play, with American Indians and Alaska Native males having the highest rates of suicide, compared with black females having the lowest. Lesbian, gay, bisexual, transgender, and questioning adolescents have twice the rate of suicidal ideation than their peers, says the AAP.
The clinical report cites the 2013 Youth Risk Behavior Survey in providing a snapshot of high school students in the United States, noting that 39.1% of girls and 20.8% of boys reported feeling sad or helpless almost every day for at least 2 weeks; 16.9% of girls and 10.3% of boys had planned a suicide attempt; 10.6% of girls and 5.4% of boys had attempted suicide; and 3.6% of girls and 1.8% of boys had made a suicide attempt requiring medical attention.
Healthcare providers are often taught to question not only whether a patient has the desire, but also the plans and the means to commit suicide. The top method of suicide for teenagers-suffocation (43%)-requires little effort to access, compared with other causes including firearms (42%) and poisoning (6%).
Media also has a magnifying effect on suicide, with studies identifying clusters of suicides after media coverage of an adolescent suicide, as well as increased risk of suicide with the exposure to the suicide of a peer. Prominence of the media coverage matters, too, with front-page coverage of an adolescent suicide being tied to increased clustering of other adolescent suicides, the AAP reports.
There is no catchall test to identify adolescents who are at risk for suicide, says the AAP, and pediatricians should keep in mind that even those who don’t have any of the identified risk factors may still contemplate suicide.
Some risk factors for suicide include a family history of suicide or suicide attempts, adoption, male gender, parental mental health problems, sexual orientation, a history of physical or sexual abuse, and previous suicide attempts. Certain mental health problems also make adolescents more prone to suicide-depression, bipolar disorder, substance abuse, psychosis, posttraumatic stress disorder, sleep problems, panic disorders, and aggression or anger issues-and the AAP says 90% of adolescents who succeed in suicide met the criteria for a psychiatric disorder before their death.
Social factors may also play a role, says the AAP. Adolescents who are bullied, homeless, dealing with romantic problems or a difficult relationship with a parent, or who are socially isolated also have a higher risk of suicide or suicidal ideation.
The Internet is also a factor in suicide risk. The AAP says that suicidal ideation, suicide attempts, and depression are strongly associated with more than 5 hours of video games and Internet use daily. Exposure to pro-suicide websites and news about suicide also increases risk, with social networks being particularly concerning because posts of such networks may include details that would not be available in a traditional news report.
As healthcare providers who typically have well-established relationships with patients by their adolescent years, pediatricians are in a unique position to stay on top of changes that could signal an adolescent is in danger of developing suicidal risk factors.
Pediatricians should be comfortable screening all adolescent patients for depression, mood disorders, substance abuse, and suicide, says the clinical report. Screening tools like the Patient Health Questionnaire (PHQ)-9 and PHQ-2 are useful, as are referrals to mental health professionals. The AAP says pediatricians should not shy away from asking direct questions about suicidal ideation or self-injury, suicide plans, and specific risk factors. However, the AAP recommends that pediatricians take care in how questions are asked because abrupt or intrusive questions may damage rapport. Also, adolescents should be interviewed separately from parents so that they don’t withhold information that they wouldn’t want the parents to hear.
When a teenager is deemed to be suicidal, the AAP recommends management based on the acuity of the risk. Management can include additional counseling, hospitalization, and medication.
The AAP offers the following guidance for pediatricians:
• Ask questions about risk factors, such as mental health disorders, previous suicidal thoughts or attempts, substance abuse, and more. Use depression screening tools regularly at health maintenance visits.
• Be aware of the risks and benefits of antidepressants in managing patients at risk for suicide.
• Be involved even after the referral. Treat the medical and psychological needs of the patient and work with families and other healthcare professionals on the follow-up.
• Be knowledgeable about local resources including local hospitals with psychiatric units, crisis hotlines, and intervention centers. Create a list with names and contact information to give to patients and families as needed.
• Consider additional training on diagnosing and managing adolescent mental health issues, particularly in underserved areas where referrals may not be feasible.
• Ask about firearms and prescription medications in the home and recommend removal of these items to parents of at-risk adolescents.