Suicide is the second leading cause of death among all youth in the United States between 10 and 24 years old.¹ Suicide rates have increased almost steadily from 1999 through 2014 for both males and females of all ages between 10–74 years old. The percent increase in suicide rates for females was greatest for those aged 10–14 years.² A review of youth suicides in 2014 revealed the greatest number and percentage of death was among youth age 15 to 24 years old, with 5079 youths in this age group having died from suicide as compared with 425 children age 10–14 years.¹

Males continue to have higher rates of suicide, with 18.2% of male youth between 15 and 24 years old committing suicide in 2014 compared with 4.6% of females in the same age group.² The most common means of suicide among youth 10 to 14 years old in 2010 were suffocation (56.1% males/77% females), firearms (37.8% males/13.8% females), and poisoning (2.8% males/5.7% females).³ The most common means of suicide among youth 15 to 24 years old were firearms (48.9% males/ 24.4% females), suffocation (37.4% males/49.9% females), and poisoning (6.2% males/16.8% females).³ More recent data from 2014 shows that overall, percentages of suicides in the United States involving suffocation (including hanging and strangulation) increased from 1999–2014, while suicides by firearm and poisoning decreased.²

Nonfatal suicide attempts are more prevalent than suicides, with ranges between 5% and 8% of youths annually.⁴ It is estimated that there is one completed suicide per 100 to 200 suicide attempts among youth between 15 and 24 years old, which is a greater ratio than for adults.⁵ Results from the 2015 national Youth Risk Behavior Surveillance (YRBS) indicated that 17.7% of high school students nationwide had seriously considered attempting suicide in the past year, 14.6% had made a plan about how they would attempt suicide and 8.6% had attempted suicide one or more times during the 12 months before the survey.⁶ Suicidal ideation and attempts were higher among females than males and greater in Hispanic females than black or white females.⁶

With numbers and prevalence this high it is important that pediatricians are not only aware of the issue of suicide, but feel competent in helping address this problem. This includes screening for suicidality in youth (many youth may not open up about suicidal ideation unless directly asked), conducting an adequate suicide assessment, and knowing how to acutely manage patients who are suicidal or have had a suicide attempt.^7-9

PATHOPHYSIOLOGY

Understanding Suicidality: Biological, Psychological, and Social Etiological Factors

An increase in both suicide and suicide attempts is seen with adolescence.^3,7,10 This increase is likely attributed to biological, psychological, and social factors that influence each other. Adolescent brains are still developing, including the frontal lobes and neural circuits involved in emotional and cognitive regulation.¹¹ Therefore cognition and executive functioning are not fully matured and may be manifested by a narrow view of options when faced with challenges, impaired decision making, increased impulsivity, and increased emotional dysregulation.^10-13 Suicidality has been associated with novelty-seeking and risk-taking behaviors in adolescents, which may be influenced by age-related differences in the reward system (nucleus accumbens) and executive functioning (prefrontal cortex), and imbalance in dopamine–serotonin activity (dopamine input to prefrontal cortex greater than serotonin input).^11,14

There are far less neurobiological studies of adolescent suicide than there are of adult suicide.¹⁵ Few but significant postmortem adolescent brain studies compared with controls provide preliminary evidence suggesting that adolescents who commit suicide have lower than normal phosphoinositide-phospholipase C, protein kinase A activity, transcription factor CREB protein, BDNF protein, and gene expression in the prefrontal cortex. They also have lower than normal full-length tyrosine kinase B receptors, gene expression, and protein kinase C activity in the prefrontal cortex and hippocampus.¹⁵

The most common biological system related to suicidality is the serotonergic system, as evidenced by postmortem findings, serotonin receptor abnormalities on platelets, metabolite levels, and candidate gene association studies relating to the serotonergic system.¹⁴ Findings include postmortem brains of adolescents who have committed suicide having higher than normal 5HT_2A receptor binding and gene expression in the prefrontal cortex and hippocampus, and negative correlation between plasma serotonin levels and the severity of suicidal behavior.¹⁴ Additional biological difference has been seen in the hypothalamic-pituitary-adrenal axis, adrenergic system, and growth hormone secretion.¹⁴ Accumulating evidence is also showing the impact of adverse childhood experiences on some of the biological systems noted above, including epigenetic effects and impact on stress response systems.^16-18

One of the most relevant biological factors to play a role in adolescent suicidality is the increase in psychiatric disorders associated with increased suicide, including mood disorders, anxiety disorders (especially females), substance use disorders, disruptive behavior disorders (especially males), and psychotic disorders.^19-22 However, adoption studies suggest that there is a genetic susceptibility to suicide that is partially independent of the presence of a psychiatric disorder.¹⁴ Additional biological factors may include hormonal changes, physical changes, and sleep disturbance.^7,11,23

Psychologically, adolescents are more vulnerable as they begin to develop their sense of self (e.g. personal and sexual identity). They may move from a more predictable and validating supportive system (i.e. family) to one that is less so (i.e. peers) while they strive to be more independent. This developmental process may preclude them from utilizing their adult supports and promote internalization and maladaptive coping (e.g. substance use, self-injurious behaviors). This also accompanies an increased exposure to potential social stressors, including bullying, alienation, negative romantic and sexual experiences, and increased academic pressure and other responsibilities (e.g. finding a job). High-risk behaviors (e.g. sexual activity and substance use) associated with adolescence may result in negative consequences such as dropping out of school, getting pregnant, being sexually assaulted, or contracting a sexually transmitted disease.^10,24 It is not uncommon that a suicide attempt or suicide is preceded by a stressful life event.⁷ Additionally, youth are more impressionable than adults and have been shown to be more influenced by media, and susceptible to cluster suicides.⁹

How all of these biological, psychological, and social factors influence one other (e.g. in which direction and to what degree) is not entirely clear. Another issue to consider is why the suicide rate for adolescents 15 to 19 years old increased by 300% (particularly males) from 1950 to 1990, decreased by about 35% from 1990 to 2003, and more recently has begun to rise.^3,9,25 Changes in treatment (e.g. introduction of antidepressants and impact of the black box warning), access to means (e.g. guns, hanging, overdose), family and community structure (e.g. dispersal of families and reduced sense of community), and culture (e.g. internet and media content) are just some of the factors to consider when trying to understand this issue.^7,21 What we do know is that adolescents are biologically and psychologically more vulnerable as they move into a period of increased social stressors that they may not be prepared to handle in a healthy manner.

Clinical presentation may vary in regard to setting, source, and level of concern. Suicidal youth may present in the emergency, outpatient, and inpatient settings. According to the 2015 YRBS, 2.8% of ninth to twelfth grade students nationwide made a suicide attempt that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse in the 12 month period prior to the survey.⁶ Pediatric emergency department (ED) visits for mental health concerns are increasing at a faster rate than ED visits related to other medical illnesses.²⁶ The total proportion of pediatric patients admitted to a general medical inpatient setting from the ED for mental health problems is also increasing.⁸

The source of information may vary and include the patient, caregivers, schools, or other clinical providers. For example, a patient admitted after a motor vehicle accident, who becomes quadriplegic, states, “I’d rather die than be like this.” Or a 10-year-old who is sick may make suicidal statements, such as “If this pain doesn’t go away, I’ll kill myself.” Some patients may be brought into the ED for a school-mandated evaluation because they were overheard making statements in class regarding self-harm. Concerns may arise based on other factors, such as prior history (e.g. prior suicide attempts or recent discharge from an inpatient psychiatric facility) or while conducting a physical exam (e.g. cutting marks on forearms).

These presentations may also vary in severity from low concern (e.g. an isolated suicidal statement in reaction to a transient stressor) to high (e.g. patient brought to the ED after a severe suicide attempt). However, there are times when the level of severity is less clear (e.g. caregivers are not concerned, but school is very concerned about patient’s suicidal statements or patient brought into the ED after taking 14 stimulant tablets, claiming that it was just to get high and not to hurt self). Regardless of setting, source, and level of concern, a suicide assessment is indicated.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommends obtaining psychological consultation to assess immediate risk of all patients admitted for medical treatment following a suicide attempt.²⁷ If a patient has not had a suicide attempt but there is still concern regarding suicidality, a mental health consultation should also be obtained. However, there are often circumstances where a mental health consultant is not readily available, therefore pediatricians should be prepared to conduct suicide assessments.

RISK ASSESSMENT

Knowing and routinely asking about risk factors for youth suicide will help guide more thorough but efficient assessments (e.g. know what to look for and ask directly about) and promote better screening and determination of level of risk. Some of the most serious risk factors for youth suicide are prior suicide attempts, access to firearms/means, family/friends who completed suicide (particularly if recent), and certain psychiatric disorders as noted above.^7,9,21 Approximately a third of those who have died by suicide have had a prior suicide attempt.⁷ It is estimated that over 80% to 90% of youth who have committed suicide met criteria for a psychiatric disorder, with up to 70% of youth having multiple comorbid disorders.^7,9,19,21 Please refer to Table 136-1 for a more comprehensive list of risk factors.