Primary care recognition and management of suicidal behavior in juveniles
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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. 3 rd leading cause of death among 10-14 and 15-19 year olds. (Anderson, 2002)

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Primary Care Recognition and Management of Suicidal Behavior in Juveniles

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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 60%

    • Antisocial Disorder 50%

    • Substance Abuse 35%

    • Anxiety Disorder 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 non-mood disorder

Brent et al, 1993; Gould et al., 1996

Onset of Any Psychiatric Symptoms Before a Suicide

  • Time before death

  • > 12 months 63%

  • 3-12 months 13%

  • < 3months 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 69%

  • 39-119 minutes 24%

  • > 2 hours 7%

Negron et al., 1997


  • 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.

    • Firearm and strangulation in males vs. OD in females.

Suicide Facts

  • Ethnicity

    • More common among Caucasians than African-Americans.

    • 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 others, gain attention and escape a noxious situation.

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 medications

    • motivating feelings

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

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

Factors Indicating Hospitalization

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

Crisis Services

Educational approaches

Case Finding

Professional education

Suicide Prevention

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 and activates SI in previously suicidal adolescents

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.


  • 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


  • 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

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