Primary Care Recognition and
Management of Suicidal Behavior in
Juveniles
Jeffrey I. Hunt, MD
Alpert Medical School of Brown University
The Scope of the Problem
3rd leading cause of death among 10-14 and
15-19 year olds. (Anderson, 2002)
 1 out of 5 teenagers in the US seriously
considers suicide. (Grunbaum et al., 2002)
 1600 US teenagers die by suicide each year.

Rates of Suicidal Behaviors
Youth risk behavior study (YRBS)
conducted by CDC indicated:
 19% of HS students contemplate suicide
 15% made specific plans
 8.8% attempted suicide
 2.6% made medically significant attempts
 Overall, decrease in youth suicides in past
decade. (JAACAP April, 2003)

The Challenge for Primary Care

Many suicidal young people seek medical care in the
month preceding their suicidal behavior, fewer than half of
doctors reported that they routinely screen for suicide risk
(Pfaff, 1999; Frankenfield, 2000)

Need for training


72% of 600 family physicians and pediatricians
in NC had prescribed an SSRI but only 8% had
adequate training and only 16% said they were
comfortable treating depression (Voelker, 1999)
Educational approaches for primary care MDs have led to
reductions in suicide rate in adult studies (Rutz, 1992)
Clinical Characteristics of Teens
Who Commit Suicide

Most Common Diagnoses
 Mood Disorder
 Antisocial Disorder
 Substance Abuse
 Anxiety Disorder
60%
50%
35%
27%
Gould et al., 1996
Clinical Features of Suicide
Attempt vs. Completed Suicide

Completers more likely than attempters:
 have bipolar disorder
 have firearm in the home
 have high suicidal intent
 have dual diagnosis of mood and nonmood disorder
Brent et al, 1993; Gould et al., 1996
Onset of Any Psychiatric Symptoms
Before a Suicide
Time before death
 > 12 months
 3-12 months
 < 3months

63%
13%
4%
Shaffer et al., 1996
Most suicides preceded by a
stressful event
disciplinary crisis
 relationship problem
 humiliation
 contagion

Gould et al., 1996
Onset of Ideation Before a
Teen’s Suicide Attempt
(N=29)
< 30 minutes
 39-119 minutes
 > 2 hours

69%
24%
7%
Negron et al., 1997
SuicideFacts
Age
 Uncommon in childhood, early
adolescents.
 Increases markedly in late teens to 20’s.
 Gender
 Suicide attempts more common among
females
 Completed suicides 5X more among
males.

Suicide Facts


Ethnicity
 More common among Caucasians than AfricanAmericans.
 Highest among native Americans and lowest
among Asians/ Pacific- Islanders.
Motivation and Intent
 Expression of extreme distress
 2/3 attempt suicide for reasons other than to
die.
 Result of an impulsive act, desire to influence
Suicide Facts
Highest in western states and Alaska
 Firearms most common method
 rural: firearms
 urban: jumping from a height
 suburban: asphyxiation by CO
 Ingestions in 15-24 year olds: 16% of
female suicides, 2% of male suicides

Risk Factors

Psycho-pathology
 90% of youth suicides have at least one
major psychiatric disorder. (Beautrais, 2001)
 Depression, substance abuse and
aggressive or disruptive behaviors very
common.
 49% – 64% of all adolescent suicide
victims have depressive disorders.
 10% - 15% of all patients with bipolar
disorder commit suicide.
Risk Factors
Immediate Risk elevated by severe anxiety
or agitation
 Prior suicide attempt is a strong predictor of
completed suicide.
 Serotonin function abnormalities.
 Reduced serotonin metabolites in the
brain and CSF of suicide victims.

Risk Factors

Family factors
 Parental psycho-pathology particularly
depression and substance abuse.
 Family history of suicide.
 Parental conflicts / divorce.
 Parent – child relationship
Risk Factors

Socio-environmental factors.
 Life stressors (interpersonal losses).
 Physical / Sexual abuse.
 School / Work problems.
 Lack of meaningful peer relationships.
 Access to firearms.
 Chronic / Multiple physical illness.
Protective Factors
Family cohesion
 Religiosity
 Ability to form therapeutic alliance

Secular Trends


Suicide rate declining
Possible reasons:
 Increase in prescriptions of antidepressants
 firearm legislation
 Firm conclusions not possible
Suicide Risk Assessment


One of the most complex,
difficult and challenging
clinical tasks in psychiatry
Forecasting the weather as
metaphor for suicide risk
assessment (Simon, 1992)


suicide risk is time
driven assessments
 short term
assessments more
accurate
Like a weather forecast suicide
risk assessments need to be
updated frequently
Suicide Risk Assessment
Needs to be systematic
 Checklists helpful but not sufficient
 “Contracting for safety” does not eliminate
need for risk assessment
 Documentation of clinical decision making
is important

Assessment of Suicidal Behavior

Assessment of the Attempt
 type of method
 potential lethality
 degree of planning involved
 degree of chance of intervention
 previous suicide attempts
 pervasive suicidal ideation
 availability of firearms or lethal
Assessment of Underlying
Conditions
Psychiatric diagnoses
 Social/environmental factors
 Cognitive distortions
 Coping style
 History of family psychopathology
 Family discord or other life event stresses

Acute Management
Identify all risk factors
 Identify resources that potentially reduce
risk
 If risk outweighs available resources
consider increased level of care

Factors Indicating
Hospitalization



Gender: All males over
age 12
Mental State: Depression,
psychosis, hopelessness,
social withdrawal,
persisting SI, Intoxication
Nature of Attempt:
Potentially lethal attempt


Past History: previous
suicide attempts and/or
history of volatile and
unpredictable behavior
Home Background:
absence of caring or
responsible setting
Shaffer et al., 2000
Minimum Steps to Take Before
Discharge from Office or ED




Always talk to the parent or caregiver to
corroborate the adolescent’s history and to
establish treatment alliance and plan to maintain
safety
Secure any firearms and medication
Concrete and precise follow-up appointment with
emergency telephone numbers
No-suicide contract (helpful but not sufficient)
Shaffer, et al., 2000
Treatment: Inpatient & Partial
Hospitalization
No evidence that exposure to other suicidal
psychiatric inpatients increases the risk of
suicidal behavior
 Stabilize mood
 Address environmental stresses
 Address clearly dysfunctional family
patterns or parental psychiatric illness

Treatment Approaches
Problem oriented
 Cognitive Behavior Therapy
 Dialectical Behavior Therapy
 Medication
 Family Therapy
 Group Therapy

Suicide Prevention
Crisis Services
 Educational approaches
 Case Finding
 Professional education

Community-Based Suicide
Prevention
Crisis hot lines
 little research fails to show impact
 Method restriction
 gun-security laws little impact
 raised minimum drinking age significant
impact
 Indirect case finding through education
 fails to increase help-seeking behavior

Community-Based Suicide
Prevention

Direct case finding
cost-effective and highly sensitive
 screening in a non-threatening way at risk
youth in high schools, detention centers, etc.
 www.teenscreen.org


Media Counseling


CDC and AFSP guidelines regarding risk of
prominent coverage of youth suicide
Training

educating primary care providers regarding
identification and treatment of mood disorders
Legal Issues in Suicide
Assessment versus prediction
 No standard of exists for the prediction of
suicide
 standard exists requiring adequate
assessment of suicide
 Courts analyze suicide cases to determine
whether suicide was foreseeable
 Contemporaneous documentation of suicide
risk assessment is vital

Team approach




Know the mental health clinicians with whom you
are working
Establish regular means of communicating about
your mutual patients
Identify with the patient and parents who is to be
first point of contact
Document discussions with collaborators
Summary
Suicidal behavior in adolescents is very
common
 Primary care clinicians often have contact
with suicidal adolescents prior to them
making attempts
 Systematic and timely risk assessments can
reduce morbidity and mortality
