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Teen suicide: a multifaceted problem.

"Why are teenagers killing themselves?"

This question accompanies nearly every headline about adolescent suicide. A litany of possible reasons follows, including drugs, mental illness, physical or sexual abuse, social and academic pressures, homosexuality, and media influence.

Despite efforts to make sense of the tragedy of teen suicide, it does not fit easily into a standard cause-and-effect equation. Suicidal behaviors--completed suicides as well as suicidal thoughts and plans--in adolescents and teens are usually the result of multiple social, economic, familial, and individual risk factors. The interaction of the various elements rather than a single definitive condition determines actual risk.

For example, childhood trauma and adverse experiences are documented risk factors for adolescent suicide, but not all adolescents who have been traumatized or subjected to adverse experiences try to kill themselves. Similarly, mental illness, substance abuse, family history of suicide, homosexuality, and access to firearms have all been linked to an increased risk of suicide in teens. Yet, these risk factors are not necessarily predictive.

In fact, one landmark study showed that the effect of suicide risk factors in teens can be offset by certain protective factors (Pediatrics 2001;107:485-93).

The study, based on interviews with more than 13,000 students in grades 7 through 12 from 134 U.S. schools, identified several risk factors associated with suicide, including previous suicide attempts, use of illicit drugs or alcohol, academic problems, and a history of being a perpetrator or victim of violence. At the same time, however, the study showed that the risk of suicide was diminished by 70%-85% among youth who reported feeling a sense of connectedness to parents, family, or other caregiving adults.

Acquiring insight into the range of factors that predict and protect against suicidal behavior in adolescents and teens and developing meaningful preventive interventions is critical from a public health perspective. Suicide is the third-leading cause of death (after accidents and homicide) for 15- to 24-year-olds, according to the Centers for Disease Control and Prevention (CDC). And although completed suicide is still a relatively rare event in this population (occurring in 7-8 of every 100,000 teenagers aged 15-19 years, according to data from the National Institute of Mental Health), the prevalence of suicidal behavior and ideation increases the magnitude of the problem substantially.

In the CDC's most recent Youth Risk Behavior Survey, nearly 17% of the students surveyed reported seriously considering attempting suicide during the 12 months before the interview. Additionally, 13% made specific suicide plans, 8.4% had made one or more previous suicide attempts, and 2.2% made medically serious suicide attempts that required medical attention (MMWR 2006 June 9;55[SS05]:1-108).

Because of the complexity of youth suicide, there is no single "right" solution to the problem, according to Madelyn S. Gould, Ph.D., professor of psychiatry and public health/epidemiology at Columbia University's College of Physicians and Surgeons in New York. "Rather, a comprehensive, integrated effort involving multiple domains is needed."

A key element in such efforts is screening adolescents for mental illness and other suicide risk factors. Studies have shown that school-based screening programs can be especially effective.

In one study, the Columbia Suicide Screen--a risk measure developed by researchers at Columbia University--was administered to about 1,700 high school students. In more than half of the confirmed cases of suicide-related behavior identified, school counselors had been unaware of the individual students' risk factors (J. Am. Acad. Child Adolesc. Psychiatry 2004;43:71-9).

Screening is only the first step. Unless the appropriate infrastructure and services are in place in either the school or the community to deal with those youth who screen positive for being at risk for suicide, the screening process is futile.

In contrast, combining screening with preventive interventions is an effective strategy. For example, in a study designed to evaluate the efficacy of a prevention program called Signs of Suicide (SOS), more than 2,000 high school students were randomly assigned to control or intervention conditions. The intervention group underwent screening for depression and other suicide risk factors, and was taught to recognize the signs of suicide and depression in themselves and what to do if they observed those signs. In a follow-up evaluation, the intervention group showed a 40% reduction in self-reported suicide-related behavior and attempts, compared with the controls (Am. J. Public Health 2004;94:446-51).

The program "actually reduced suicidal behavior," according to lead author Robert Aseltine, Ph.D., of the University of Connecticut Health Center in Farmington.

Other interventions are being designed and implemented as part of the U.S. Department of Health and Human Services' National Strategy for Suicide Prevention, which was released in 2001 as a response to former U.S. Surgeon General David Satcher's 1999 'A Call to Action to Prevent Suicide."

By Diana Mahoney, New England bureau. Share your thoughts and suggestions at

RELATED ARTICLE: A Population-Based Success Story

The burden of teen suicide weighs especially heavily on Native Americans.

According to the Indian Health Service, an agency of the U.S. Department of Health and Human Services, the suicide rate among Native American adolescents and teens is about three times higher than the national average.

The mechanisms behind this rate are not fully understood. But some risk factors for suicidal behavior in this population include depression, family history of drug abuse, alcohol abuse, arrest history, and racial discrimination, says a study by the Buder Center for American Indian Studies and the Comorbidities Center at Washington University in St. Louis (Suicide Life Threat. Behav. 2004;34:160-71).

The lack of and obstacles to services, especially among Native Americans living on reservations, further exacerbates the problem. But the development and implementation of culturally sensitive, population-based interventions can offset the suicide risk disparity.

In an evaluation of 15 years of a public health--oriented suicidal-behavior prevention program, Philip A. May, Ph.D., of the Center on Alcoholism, Substance Abuse, and Addiction at the University of New Mexico in Albuquerque, and his colleagues found that the program significantly reduced chronic suicidal behavior among teens living on a reservation of the Western Athabaskan Tribal Nation (Am. J. Public Health 2005;95:1238-44).

The program, called the Adolescent Suicide Prevention Project, was designed to target tribal members aged 15-19 years. It included screening and clinical interventions through extensive outreach in health clinics, schools, and social welfare programs, as well as in some unconventional settings, including community functions; access to social services; school-based prevention programs; and community education on general topics.

Using age-specific analyses over time to assess outcomes, the investigators demonstrated that the intervention over 15 years resulted in a 73% reduction in the total number of self-destructive acts among tribal adolescents. This success can be largely attributed to the program's public health approach, according to the investigators. To be effective, they wrote, "a suicide prevention program must include an emphasis on root conditions and an array of social, psychological, and developmental issues."

Another important consideration is that the model was developed specifically to address the unique cultural norms of the Western Athabaskan Tribal Nation. Toward this end, the program designers solicited active involvement from key constituencies, including tribal leadership, health care providers, parents, elders, and youth.
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Author:Mahoney, Diana
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Dec 1, 2006
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