SUICIDE ASSESSMENT AND PREVENTION
| SUICIDE BEHAVIOR IN ADOLESCENTS —David A. Brent, MD, Academic Chief, Child and Adolescent
Psychiatry, Endowed Chair in Suicide Studies, and Professor of Psychiatry, Pediatrics, and Epidemiology,
University of Pittsburgh School of Medicine, and Director, Services for Teens at Risk, Pittsburgh,
PA
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| Rule of five: 5 domains to assess in suicidal adolescent are characteristics of suicidality, psychopathology,
psychologic characteristics, family and environmental factors, and availability of lethal agents
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 | Characteristics of suicidality: suicide intent (ie, suicide attempt or current suicidal ideation); lethality of
attempt; precipitant; motivation; environmental response
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| Suicidal intent: measure of “wish to die” based on observable behavior; people who tell others about
intent to commit suicide have higher intent than those who do not tell
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| Lethality: do not confuse lethality with intensity of wish to die; adolescents may not appreciate lethality
of certain gestures; eg, adolescent may not know certain medications not lethal; however, attempting
to hang or shoot oneself indicates high intent; nonsuicidal self-harm, eg, cutting, may or
may not indicate suicidality; other factors to assess in determining severity of intent are preparatory
behavior and prevention of discovery
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| Precipitant: most common precipitants are family discord (especially in younger children) and disruption
of romantic attachment (in adolescents); abuse, although not common in adolescents, significant
precipitant; legal or disciplinary problem frequent precipitant for boys
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| Motivation: important for clinician to understand motivation so he or she can help adolescent find another
method of accomplishing goal; for one third of adolescents, goal is to die or to escape psychologic
pain; for other two thirds, goal is interpersonal communication (eg, influence someone else, get
attention, express hostility, make someone feel guilty)
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| Psychopathology: mood disorder most common contributor to suicidality; high risk in bipolar disorder,
particularly mixed state; other contributors include substance abuse, conduct disorder, and combination
thereof
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| Psychologic characteristics: hopelessness; impulsivity and aggression; deficits in social skills; homosexuality
and bisexuality
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| Family and environmental factors: “suicide runs in families”; family history of suicide predisposes adolescent
to suicide, above and beyond transmission of psychiatric disorders; study showed this due to
transmission of impulsive aggression through families; family discord and abuse and neglect significant
contributors to suicidality; protective factors—good connection between adolescent and parents;
parents’ having high behavioral and academic expectations; good parental supervision; having nondeviant
peer group; religious affiliation had weaker protective effect
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| Availability of lethal agents in home: given that many suicide attempts impulsive, presence of lethal
agent in home differentiates fatal from nonfatal outcome; studies address presence of guns, carbon
monoxide, acetaminophen, and tricyclic antidepressants, and all find increased risk for suicide when
lethal agents present
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| Treatment of depression: study found that treatment of depression does not change suicide risk; ie, reductions
in suicide risk can be achieved without changing depression and depression can be reduced
without having effect on suicide risk; however, the most suicidal individuals excluded from studies, so
hard to know exact relationship between depression and suicidality; speaker concludes that suicidal behavior
seems to arise from interaction of depression and other risk factors (such as impulsive aggression),
and treatment of depression alone probably insufficient to relieve suicide risk
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| Establish safety plan: adolescent promises family and clinician not to engage in suicidal behavior or that
he or she will contact clinician or other responsible adult if suicidal thoughts recur (clinician must have
24-hr availability or back-up); review precipitants, develop truce, and provide brief training in emotional
regulation; secure lethal agents in home
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| Emotional thermometer: tell adolescent that 10 is out of control and zero is really calm, then ask “what is
a 2 for you? a 4? a 6?” and so on; “what is the point of no return?” help adolescent to identify what he
or she will feel like before point of no return and what can be done to avoid getting there
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| Securing lethal weapons: find out motivation for gun ownership; find out who owns gun (one study
found clinicians interacted mostly with mothers, who promised to rid home of guns, but guns owned
by fathers, who refused to get rid of them); negotiate most secure situation possible; parental regulation
of medications
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| Increase likelihood of adherence: target hopelessness; provide education to patient and family; inquire
about previous treatment experiences; have clear treatment goals; remind patient and family of appointments;
establish liaison to help patient make transition from one level of care to another
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| Hopelessness: address hopelessness about treatment first; establish concrete, realistic, and achievable
goals; ask patient his or her reasons for living; advise patient and family that course of treatment will
not be smooth, and encourage them not to lose hope at rough places; consider developing “hope kit,”
something written down or object patient “can take out and look at if they feel particularly hopeless,
that will help to bring them back up”
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| Education: educate patient and family about depression as chronic and recurrent illness; depression nobody’s
“fault”; negotiate communications between parents and adolescent (ie, how much do parents
need to know to be comfortable and how much is adolescent willing to tell?); teach patient and parents
how to monitor for treatment response, side effects, and long-term course
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| Hospitalization: necessary if adolescent cannot or will not agree to safety plan or where many factors, eg,
substance dependence, mania, psychosis, make it unlikely that he or she can adhere to treatment plan;
also consider hospitalization when symptoms so unstable that adolescent’s behavior at home not predictable
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| Treatment of Adolescent Suicide Attempters (TASA) study: adolescents who presented to emergency
department treated with development of safety plan, intensive case management, and chain analysis of
suicide attempt, with focus on cognitions that led to attempt; initial study found 2-fold reduction in repeat
suicide attempts
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| Chain analysis: identifies precipitant, motivation, affect at time of suicide attempt, emotional dysregulation,
and environmental response; provides very detailed exploration of suicide attempt; analyzes internal
and external factors that contributed to suicide attempt and suggests “antidotes”; eg, if
adolescent has interpersonal difficulties, provide training in social skills
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| “Manipulation is just another word for out of control”; “if they really were under control, they wouldn’t
need to involve you and their family and the school and their friends and everybody else in their
drama”
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| Prevention of relapse and recurrence: sleep regularity, avoidance of tobacco, alcohol, and drugs, increase
in pleasurable activities, exercise, and teaching patient how to recognize early signs of relapse; last
session in TASA protocol is relapse-prevention session (involves role playing in imaginary situation
that led to suicide attempt)
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| Duration of treatment: treat acute phase for 12 to 16 wk; continue treatment for same period with less
frequent visits; then follow up every other month for at least 1 yr
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| CAN THERAPY PREVENT SUICIDE? —Charles L. Rich, MD, Professor and Chair of Psychiatry, University
of South Alabama College of Medicine, Mobile
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| Introduction: do not confuse suicidality with suicide; very difficult to determine whether treatment of depression
prevents deaths by suicide
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| Steps to determine whether treatment prevents suicide: identify population at risk; develop intervention;
apply intervention; demonstrate efficacy of intervention; address safety
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| Identify population at risk: 60% to 70% of suicides had diagnosis of full-blown depressive syndrome or
adjustment disorder (“whatever that is”); but only 3.5% of people with depressive syndrome at risk for
suicide; suicide predictors sensitive but not specific; therefore, individuals in depressed population at
risk for suicide cannot be identified, so entire depressed population must be considered at risk
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| Develop intervention: in clinical trials, ≈70% of people treated for depression show response, complicating
problem of identifying population at risk
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| Apply intervention: estimated that only ≈50% of people with depression get treatment; 75% of those
treated with antidepressants; however, some people at risk do not utilize intervention; in toxicology
study, only one third of suicides for whom antidepressants had been prescribed had medication in blood
at time of death
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| Determine efficacy of intervention: difficult to develop and test null hypothesis because clinical trials
usually have small numbers of cases and most are short term (8-12 wk); also, people who are suicidal
usually not eligible for clinical trials; long-term data cannot be extrapolated from short-term trials; open-
treatment trials difficult to interpret
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| Prescription data: several studies looked at relationship between sales or prescription of antidepressants
and suicide rates and found inverse relationship; ie, as antidepressant sales and prescriptions went up,
suicide rates went down; aggregated data from all studies suggest preventive effect, particularly in older
people
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| Caveats: experimental data will probably never be able to demonstrate efficacy of intervention because
trials cannot generate enough power; nonexperimental data look positive but not controlled
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| Safety: no evidence to date that antidepressants cause suicide; nonexperimental evidence (cited above)
suggests use of antidepressants help prevent suicide; each practitioner must decide for himself or herself
whether antidepressants safe
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| Conclusions: “because suicide is rare and unpredictable, a prevented suicide is a nonevent; [if clinician
thinks] you have prevented somebody in your practice from committing suicide you’re kidding yourself;
you have no idea who was going to do it, when, where, whatever”; however, that does not justify
failing to treat depression
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Educational Objectives
| The goal of this program is to educate the listener about assessing suicidal behavior and preventing suicide.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Assess suicidal behavior in adolescents.
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| 2. Discuss the significance of family history in adolescent suicide attempts.
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| 3. Formulate a treatment plan for suicidal adolescents.
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| 4. Explain why it is important to differentiate between suicide and suicidality when trying to determine
whether treatment of depression prevents suicide.
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| 5. Describe the experimental and nonexperimental evidence that treating depression does or does not prevent
suicide.
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Suggested Reading
Beck RW, Morris JB, Beck AT: Cross-validation of the Suicidal Intent Scale. Psychol Rep 34:445, 1974;
Brent DA et al: A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and
supportive therapy. Arch Gen Psychiatry 54:877, 1997; Brent DA et al: Age- and sex-related risk factors for
adolescent suicide. J Am Acad Child Adolesc Psychiatry 38:1497, 1999; Brent DA et al: Risk factors for adolescent
suicide. A comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry
45:581, 1988; Brent DA, Mann JJ: Family genetic studies, suicide, and suicidal behavior. Am J Med Genet
C Semin Med Genet 133:13, 2005; Brent DA: Correlates of the medical lethality of suicide attempts in children
and adolescents. J Am Acad Child Adolesc Psychiatry 26:87, 1987; Bridge JA, Brent DA: Adolescents
with depression. JAMA 292:2578, 2004; Carter GL et al: Postcards from the Edge project: randomised controlled
trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning.
BMJ 331:805, 2005; Dhossche DM, Rich CL et al: Patterns of psychoactive substance detection from routine
toxicology of suicides in Mobile, Alabama, between 1990 and 1998. J Affect Disord 64:167, 2001;
Dhossche DM, Rich CL, Isacsson G: Psychoactive substances in suicides. Comparison of toxicologic findings
in two samples. Am J Forensic Med Pathol 22:239, 2001; Donaldson D, Spirito A, Esposito-
Smythers C: Treatment for adolescents following a suicide attempt: results of a pilot trial. J Am Acad Child
Adolesc Psychiatry 44:113, 2005; Forman EM et al: History of multiple suicide attempts as a behavioral
marker of severe psychopathology. Am J Psychiatry 161:437, 2004; Harrington R et al: Randomized trial of
a home-based family intervention for children who have deliberately poisoned themselves. J Am Acad Child
Adolesc Psychiatry 37:512, 1998; Huey SJ Jr et al: Multisystemic therapy effects on attempted suicide by
youths presenting psychiatric emergencies. J Am Acad Child Adolesc Psychiatry 43:183, 2004; Isacsson G,
Rich CL: Antidepressant drug use and suicide prevention. Int Rev Psychiatry 17:153, 2005; Isacsson G,
Rich CL: Getting closer to suicide prevention. Br J Psychiatry 182:457, 2003; Katz LY et al: Feasibility of
dialectical behavior therapy for suicidal adolescent inpatients. J Am Acad Child Adolesc Psychiatry 43:276,
2004; Kellermann AL et al: Suicide in the home in relation to gun ownership. N Engl J Med 327:467, 1992;
Kessing LV et al: Suicide risk in patients treated with lithium. Arch Gen Psychiatry 62:860, 2005; Mann JJ
et al: Suicide prevention strategies: a systematic review. JAMA 294:2064, 2005; Mann JJ, Brent DA et al:
Family history of suicidal behavior and mood disorders in probands with mood disorders. Am J Psychiatry
162:1672, 2005; March J et al: Treatment for Adolescents With Depression Study (TADS) Team. Fluoxetine,
cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents
With Depression Study (TADS) randomized controlled trial. JAMA 292:807, 2004; Paykel ES:
Depression: major problem for public health. Epidemiol Psychiatr Soc 15:4, 2006; Rathus JH, Miller AL:
Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav 32:146, 2002; Rich
CL, Isaccson G: Treatment of anxiety in suicidal patients. J Clin Psychiatry 64):1518, 2003; Rotheram-
Borus MJ et al: Six-year intervention outcomes for adolescent children of parents with the human immunodeficiency
virus. Arch Pediatr Adolesc Med 158:742, 2004; Simon GE et al: Suicide risk during antidepressant
treatment. Am J Psychiatry 163:41, 2006; Wintemute GJ et al: Mortality among recent purchasers of
handguns. N Engl J Med 341:1583, 1999.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any
significant financial relationship with the manufacturer or provider of any commercial product or service
discussed. For this issue, the faculty reported nothing to disclose.
Dr. Brent was recorded at Mood Disorders in Children and Adolescents, held November 15, 2005, in
Wilmington, DE, and sponsored by Nemours Alfred I. duPont Hospital for Children. Dr. Rich was recorded
at Treatment Resistant Disorders, held March 31 to April 2, 2006, in San Francisco, CA, and sponsored
by the American Academy of Clinical Psychiatrists. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
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