Scott Poland, EdD

Medscape Psychiatry & Mental Health.  2009; ©2009 Medscape

Posted 03/11/2009

A Suicide Cluster

A small Midwestern town in the fall of 2007 had 3 adolescent suicides in 2 months. That high a number in that short a period of time constitutes a suicide cluster. In response to the cluster, the community turned to guidelines developed by the Centers for Disease Control and Prevention (CDC).^[1] The guidelines emphasize that no single entity or agency alone can stop a youth suicide cluster and that teenagers are more susceptible to contagion than are any other age group. A suicide-response task force that included school leaders, clergy, mental-health representatives, law enforcement, and physicians was formed and a meeting held. At the meeting, a prominent pediatrician in the community broke down crying, explaining that all 3 teenage victims had seen her about physical ailments shortly before they died by suicide. This is not unusual; a common conclusion in the literature is that adult suicide victims often see their physicians before their deaths. This reality raises some critical questions about the role of physicians in suicide prevention:

Incidence of Suicide

Suicide is the second or third leading cause of death for teens in the United States, depending on the state or county in which they reside.^[2] Suicide rates vary by state and are expressed as number of deaths per 100,000 in a particular age group per year. Western states have the highest incidence of suicide. In the most recently available statistics, Alaska had the highest suicide rate (29.8 per 100,000) and Hawaii the lowest (5.7 per 100,000) for the age group of 15- to 24-year-olds.

The incidence of suicide has remained relatively constant for the high school population over the years. A review of figures from the Youth Risk Behavior Surveillance Survey (YRBSS)^[3] completed by the CDC in 2007 showed that 28.5% of the 15,000 students surveyed nationwide reported feeling sad or hopeless, 11.3% had made a suicide plan, and 6.9% had made a suicide attempt within the last year (parents and other adults often have no idea that a child has made an attempt). The YRBSS survey for middle school students did not include questions about suicidal thought, but the latest available information for the middle school population indicates that the suicide rate has increased by approximately 100% in the last decade, especially death by hanging.^[4]

Who Is Most at Risk for Suicide?

Although the YRBSS results indicate that large numbers of youth are at risk, it is extremely difficult to identify specific individuals. Cultural, gender, and developmental factors are all important in determining risk. A recent assessment^[5] of family and developmental background identified the following factors as markers of increased suicide risk:

Key gender- and culture-related statistics in youth have also been identified^[4]:

Sexual orientation appears to be a contributing factor in youth suicide, with homosexual and transgendered youth experiencing between 17% and 42% more suicide attempts than their heterosexual peers. It is important to recognize that sexual orientation is not the cause of the increased suicide attempts but that external factors present in the lives of these youth are very significant stressors. These youth often experience harassment and abuse and lack support in their families and schools. The majority of secondary schools do not have active programs to support them.

Warning Signs of Suicide

International research has shown that teaching the warning signs of depression to physicians and reducing access to guns are the most effective strategies for reducing suicide.^[4] In accordance with this, an increasing number of medical schools are providing extensive suicide prevention information to their students. Teaching the warning signs of suicide is referred to as "gatekeeper training." Gatekeeper training ensures that suicidal behavior will be taken seriously so that appropriate interventions can occur.^[6] It also emphasizes working as part of a team and never keeping knowledge of suicidal behavior a secret.

Autopsy studies have found that 90% of youth who died by suicide had at least one diagnosable mental disorder.^[6] The most common were mood disorders, conduct disorder, substance abuse, and anxiety. Gatekeepers should be aware of the risks associated with these disorders and taught to identify them. It is also important for gatekeepers to be aware of precipitating events that might cause a young person to act on already thought-out suicide plans. The most common precipitating events, in order of their power, are severe argument with parents, break-up of romances, legal and discipline problems, humiliation, and loss. Warning signs for physicians include:

Protective Factors Against Suicide

Factors that protect against youth suicide risk include:

These protective factors are categorized as internal or external. Internal factors include the ability to cope with stress, frustration tolerance, religious beliefs, and absence of psychosis. External factors include social support, positive therapeutic relationships, and responsibility to others and pets.

Screening for Depression

Depression screening is a universal intervention provided to large numbers of secondary school students. Developed at Harvard and Columbia Universities, Signs of Suicide (SOS)^[7] and TeenScreen^[8] are the most widely recognized programs. Both programs have very promising research data that found a correlation between an increase in adult help-seeking behavior and a decrease in suicide attempts. The increase in adult help-seeking behavior is especially significant because suicidal students almost always tell their friends of their plans, but too often they delay in getting adult and professional help. Both programs are based on the premise that students will answer questions about suicide honestly when they are asked about it. Indeed, that has been this author's experience in more than 30 years of working with suicidal young people. A limitation of the depression screening programs is that a student might not be suicidal on the date surveyed but might become suicidal later. However, the programs teach students where to go for assistance should they or a friend become suicidal at a later date.

What if You Suspect That a Youth Is Suicidal?

Joiner^[9] suggests that suicide is not often adolescents' first option. Rather, they work up to suicide through a series of provocative experiences, such as accidents, injuries, self-injury, eating disorders, and exposure to pain and suffering. Many of these behaviors may come to the attention of physicians, and physicians must be aware not only of strategies for treating that behavior but also the potential for it to escalate. The issue of suicide should be faced head-on. Although questioning a young person about suicidal thoughts can cause anxiety in any professional, it is important to recognize that direct inquiry about suicidal ideation does not plant the idea in a patient's head. It is crucial to reach a comfort level with the topic through training, reading the literature, and consultation with colleagues. A calm and caring approach is recommended, with previously determined plans of action ready should a patient be imminently suicidal. These include knowledge of local and state resources and guidelines for involuntary hospitalization. These 3 key questions will help determine what additional steps should be taken for treatment and supervision:

It is important to be nonjudgmental and avoid statements such as "It can't be that bad" or "You would never do that." An approach that helps the young person see alternatives and makes him or her aware of resources in the community (ie, the national suicide crisis hotline, 1-800-SUICIDE, which connects the caller to the nearest local crisis hotline) is preferred. Patients may be asked to sign a no-harm agreement, but be aware that there are no research data to prove the effectiveness of such contracts or that they reduce the liability for a professional. Therefore, it is recommended that the contract be viewed as only a part of the intervention; it is not intended as a substitute for supervision and treatment. The parents of a suicidal youth must be notified unless information is obtained that indicates that the youth is being abused by parents. In such cases, the appropriate authorities for protective services must be notified. The primary goal of parental notification is to determine how everyone can work together to obtain the treatment and supervision needed. If the youth has mentioned a specific suicide method, then steps need to be taken to remove access to it. Guns remain the number-one method of youth suicide. Unfortunately, adults are sometimes reluctant to remove or secure guns in their home even when they have been notified that their child is suicidal. One Houston teenager commented in her goodbye to her parents, "Why did you make this so easy and leave the gun so accessible?" It is very important to document parental notification; it is recommended that parents sign a form indicating that they have been notified of the suicide-related emergency of their child and provided with referral information.

Conclusions

Suicide prevention is a very challenging task for physicians. The assessment of risk level is based on clinical judgment after reviewing the risk and protective factors and conducting a direct inquiry of suicidal thoughts and actions. Physicians are in a unique role to promote mental-health treatment for adolescents in their community and to serve on youth suicide-prevention task forces that bring community leaders together to work on prevention. Suicidal thoughts in adolescents are often very situational, and the intervention of a physician can make all the difference. It is vitally important to become more comfortable with direct inquiry when something just does not seem right. A young man who survived jumping off of the Golden Gate Bridge said that he had decided he would not jump as long as any one person recognized his agitation. He walked around on the bridge for 45 minutes and no one recognized his despair or said a word to him, so he jumped. He was very lucky and survived to make the point to all of us to be more alert so that we can make a difference. In the case of the small Midwestern town, once the physicians became more comfortable with the subject of suicide and learned what to look for and which questions to ask, they were in a better position to identify and help any at-risk patients and prevent further suicides.

US Department of Health and Human Services. National Strategy for Suicide Prevention: Goals and Objectives for Action. 2001. Available at: http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3517/ Accessed February 12, 2009. National Suicide Statistics. Available at: http://suicidology.org/web/guest/stats-and-tools/statistics Accessed February 12, 2009. National Center for Chronic Disease Prevention and Health Promotion. YRBSS: Youth Risk Behavior Surveillance System. Available at: http://www.cdc.gov/HealthyYouth/yrbs/index.htm Accessed February 12, 2009. Lieberman R, Poland S, Cassel R. Best practices in suicide intervention. In: Thomas A, Grimes J, eds. Best Practices in School Psychology V. Washington, DC: National Association of School Psychologists; 2008:1457-1472. Hardt J, Johnson JG, Courtney EA, Sareen J. Childhood activities associated with suicidal behavior. Psychiatric Times. 2006;23:1-2. Poland S. Suicide Intervention in the Schools. New York: Guilford Press; 1989. Screening for Mental Health. Signs of suicide. Available at: http://www.mentalhealthscreening.org/schools/index.aspx Accessed February 12, 2009. National Center for Mental Health Checkups at Columbia University. TeenScreen. Available at: http://www.teenscreen.org/ Accessed February 12, 2009. Joiner T. Why People Die by Suicide. Cambridge, Mass: Harvard Press; 2006;14-24.

Scott Poland, EdD, Associate Professor, Coordinator, Suicide and Violence Prevention Office, Nova Southeastern University, Fort Lauderdale, Florida

Disclosure: Scott Poland, EdD, has disclosed no relevant financial relationships.