Youth Suicide: A Population Crying for Help? A System Overloaded? Who Can Help?

Abstract

Suicide is the second leading cause of death in young adults (15–24 years old). There continues to be limited access to mental health services for many patients who are in mental health crisis because of shortage of trained psychiatrist and mental health providers. Patients identified with high risk factors should get a full comprehensive psychiatric evaluation. Management should focus on preventative strategies, early identification as well as treatment with appropriate psychopharmacology and psychotherapy.

Introduction

Suicide has been one of the leading causes of death in youth. It was identified as the second leading cause of death in young adults (15–24 years old) from 2011–2015.¹ According to the National Vital Statistics Reports, suicide was the second leading cause of death in younger age group of 10–24 years of age accounting for 16.8% of deaths. It was also the fourth leading cause of death for ages 25–44 accounting for 11.2% of deaths.² It is interesting to note, that even though suicide was among the top 10 leading causes of death in 45–64 age group it had dropped to the eighth leading cause of death.² In looking at the data it is clear that youth is clearly an extremely vulnerable population for suicide. What is even more alarming is there continues to be a concern for a national shortage of child and adolescent psychiatrists. This shortage led the American Academy of Child and Adolescent Psychiatry to start a work force initiative in 2002 to address this. The American Medical Association estimated 8,000 child and adolescent psychiatrists in the United States in 2013.³ The U.S. Bureau of Health Professions estimated a need for approximately 12,600 by 2020 to meet the mental health needs of the country.⁴

According to American Foundation for Suicide Prevention suicide is the tenth leading cause of death in Missouri ranking it eighteenth compared to the other states. In breaking down the suicide by age groups it is the second leading cause of death of 15–24 years, third leading cause of death of 25–34 years, fourth leading cause of death of 35–54 years, eighth leading cause of death of 55–74 years, and seventeenth leading cause of death in individuals above the age of 65. According to this report “on average one person dies by suicide every eight hours in the state.” A brief report in April 2015 by Missouri Suicide Prevention Project, the suicide rates in Missouri have remained stable but, have been higher than the national average. Seventy-five percent in 2013 were white males between the ages of 18–24 with 49% using firearms.⁵

Many mental health problems in adults have origins in adolescence who lack access to services during this time.⁶ Three national surveys showed that of the children between the ages of 6–17 who were screened for mental health services only one-fifth actually received the services.^{7, 8} It is also interesting to note that one-third of individuals 16 years or older presented to emergency departments in the preceding year of completing the suicide.⁹

Risk Factors

The assessment of suicide risk factors should include a comprehensive psychiatric evaluation of the youth including collateral information from parents, other family members, teachers, caregivers and friends. Psychopathology,¹⁰ substance misuse,¹¹ and a history of suicide attempt¹² are considered strongest predictors of future suicidal behaviors in youth. Major depressive disorder carries the greatest risk for suicide attempts and a higher severity of depressive symptoms is associated with a greater likelihood of attempting suicide.^10,11 In numerous studies, a history of previous suicide attempt has been associated with increased future suicide attempts.^13–15 A family history of suicide attempt seems to convey a greater risk of suicide attempts in youth as shown by monozygotic twin studies.¹⁶

A history of interpersonal violence or maltreatment (e.g. being a victim of bullying or physical/sexual abuse) increases the risk for completed suicide. According to a study, adolescents with a history of cyberbullying were 11.5 times more likely to report suicidal ideation compared to adolescents without any bullying experiences.¹⁷ A recently published study found that increased weekend screen time was associated with higher child-reported suicidality while increased parental supervision and positive school involvement were found to be associated with a decrease in child reported suicidality.¹⁸ Conflicts and dysfunction in families are also associated with an increase in the risk of suicidal behaviors in youth.¹⁸ Other risk factors include a history of adoption,¹⁹ male gender, and a history of physical or sexual abuse.²⁰

Adolescence is also the time when many youth may experiment with substances which may be mood-altering. In a systematic review and meta-analysis published in February 2019 that involved 23,317 adolescents and 11 studies, use of cannabis in adolescence did have an increased risk having depression and suicidal concerns even later in life.²¹ Rates of cannabis use in individuals aged 18–29 years have almost doubled between 2001–2002 to 2012–2013 from 10.5%–21.2%.²² In August 2019, the U.S. Surgeon General also put out a Health Advisory on “Marijuana Use and Developing Brain” stressing importance of need for protecting youth and pregnant women.²³ Educating teenagers about the risks of cannabis and providing resources for youth to teach them skills to resist peer pressure and getting them access to other prevention programs should be a key component in program implementation. These findings should be considered in developing public health policy and prevention programs.

Treatment and Management

For management of suicide in youth, prevention is the key. In public health there are three major categories of prevention: primary, secondary, and tertiary prevention.

In primary prevention the main target is the general population of youth before developing suicidal thoughts, gestures, or actions. This can include a wide range of interventions, one of which is legislative policies restricting access to firearms. ²⁴ Adolescent suicide by firearm kills more than 1,000 10–19 years old children and adolescents annually in the U.S.²⁵ This article is not necessarily against the second amendment constitutional right to “keep in bear arms.” Citizens of Missouri have the right to protect themselves and many Missouri families enjoy hunting. However, it is a crucial for caregivers of youth to know that the mere presence of firearms in a household increases the suicide risk to all children at home.²⁶ Caregivers must appreciate their responsibility in preventing gun access to children,²⁷ since suicide in youth is generally more impulsive and with lower intent level compared to adults.²⁸ Another crucial intervention is educating youth against substance use and resisting peer pressure. Studies have shown adolescent cannabis consumption was associated with increased risk of developing depression and suicidal behavior even in the absence of a premorbid condition.²⁹

Other primary preventative interventions include construction barriers to where suicide could be committed by jumping, detoxification of domestic gas, restriction of pesticides, use of lower toxicity antidepressants, restricting sales of lethal hypnotics.³⁰ In general, children and adolescents need to be educated about the seriousness of suicide, making suicidal statements, the seriousness of bullying and cyber bullying.

In secondary prevention, the main goal is early identification of children and adolescents at risk for suicide and then referring them for assessment and treatment.²⁴ Please refer to list of resources for the state of Missouri at the end of this article. Thus, training individuals who could have contact with high risk children and adolescents is imperative.³¹ For example, school teachers, school counselors, parents, foster parents, staff in residential facilities, staff in the juvenile system, pediatricians, ER providers, etc., are trained to recognize at-risk youth. They are encouraged to ask them directly about suicidal thoughts and intentions ³² and then refer them to mental health providers.

In tertiary prevention, the goal is to prevent suicidal actions. This typically occurs after youth have been identified as a high-risk individual and have been referred to mental health. Numerous randomized clinical trials showed that cognitive behavioral therapy (CBT) and other psychotherapies are effective in reducing suicidal ideations and attempts.³³ CBT is a form of talk therapy that works on changing cognitive distortions which are negative perceptions of reality. Dialectical behavioral therapy (DBT) is a subtype of CBT. It is an evidence-based therapy that has also been proven to reduce suicide attempts in adolescents.^34,35 DBT adds emphasis on emotional regulation, grounding techniques and interpersonal relationships.

The combination of psychopharmacology (medication management) with psychotherapy shows improvement of depression and suicidality scales which was found to be similar to those observed in non-suicidal children.³⁶ Another tertiary preventative strategy is developing a safety plan with the patient. It is a written list of coping strategies and support resources that the patient can use when endorsing suicidal thoughts.³⁷

Resources in Missouri.

Crisis Text Line

Text HELLO to 741741 and speak anonymously to a crisis counselor. FREE, 24/7 support

National Suicide Prevention Lifeline

800-273-8255

TLC (Talk, Listen Care) Warmline

4-10 pm 7/365

Local: 573-651-3642

Toll Free: 877-626-0638

Mental Health Association of the Heartland Compassionate Ear Warmline

Local: 913-281-2251

Toll-free: 866-927-6327

English: 4–10 pm 365

Spanish: 5–8 pm M-F

Depressive, Manic-Depressive Association of St. Louis Friendship Line

Toll-free: 866-525-1442

Local: 314-652-6105

Central Missouri Crisis Hotline

Toll-free: 800-833-3915

National Alliance on Mental Illness Missouri Warmline

Local: 573-624-7727

Toll Free: 800-374-2138

Hours: 9 am–9 pm M–F