Chapter 75 Suicide
PATHOPHYSIOLOGY
Suicide is the third leading cause of death among youth in the United States. Risk of suicide is the most frequent reason for inpatient psychiatric hospitalizations of adolescents. Suicidal behaviors represent a continuum ranging from the completed act to suicide attempts and self-inflicted injury. Suicidal ideations are recurrent thoughts of death and of killing oneself. Suicidal ideations do not necessarily include a plan or intention to kill oneself but may be a precursor to suicidal behavior. A carefully formulated suicide plan is an indicator that the youth has serious intentions of carrying out his or her plan.
Contributing factors to youth suicide are complex and fall within the following areas: psychiatric illnesses, family problems, major life changes, and demographics. Mood disorders, especially untreated depression and substance abuse, place the youth in considerable jeopardy. Family history of emotional problems, multiple family moves, problematic parent-child relationships, sexual abuse, emotional neglect, parental divorce, and family violence are risk factors for suicide. Significant recent life changes such as loss of a parent, end of a romantic relationship, and a recent move are also associated with suicidal behaviors. Demographic risk factors include being a member of a single-parent family or in a noncustodial living arrangement, being male, and being in one’s late teens. Ready access to firearms in the home is positively associated with suicide attempts.
Suicide clusters have been identified among adolescents who imitate their peers in committing suicide. Three or more suicides or attempts occurring within 3 months within a specific geographic area constitute a suicide cluster. During adolescence the sense that death is final may not be entirely grasped. The youth may fantasize about being at his or her own funeral and observing other’s reactions to his or her death. Suicide methods used by adolescents include poisoning, hanging, jumping from a high place, jumping out of a car, inhaling carbon monoxide fumes, drowning, and overdosing from medications. Use of a firearm is the most common method used to commit suicide in the United States, by adults as well as youth. Females use less violent methods of suicide than males. Males are 4 times more likely to die from suicide attempts than females.
INCIDENCE
1. Depression with functional impairment occurs in 2% to 10% of children and adolescents who complete suicide.
2. Mood disorders account for most suicide attempts.
3. Suicide is the third leading cause of death in 15- to 19-year-olds and the fourth leading cause in 10- to 14-year-olds.
4. American Indians and Alaska Natives have the highest suicide rate in the 15- to 24-year age-group.
5. For every suicide among high school students, there are approximately 350 unsuccessful suicide attempts.
6. Suicide rates in the United States are highest in the spring and lowest in the winter.
7. Adolescent suicide risk increases sevenfold with maternal suicide attempts and fivefold with marital discord.
8. Use of firearms is the method most often employed in completed suicides among those 10 to 14 years old, followed by hanging and drug overdose.
9. Use of firearms, hanging, and drug overdose are the methods used most often by 15- to 24-year-olds who complete suicide.
CLINICAL MANIFESTATIONS
1. Prolonged unhappiness, sadness, tearfulness, and moodiness
2. Social withdrawal from friends, family, and usual social activities
3. Acting out and aggressive behaviors, fighting with peers and/or siblings
4. Sense of hopelessness and despair
5. Delinquent behaviors: stealing, lying, property destruction (e.g., graffiti)
6. Sleep disorders and disturbances such as nightmares, excessive sleeping, and insomnia
7. Eating disorders; changes in weight and appetite
8. Changes in school performance
9. Somatic complaints such as abdominal pain and headaches
10. Feelings of shame and guilt
11. Low self-esteem as evidenced by self-deprecating remarks, sense of worthlessness, and behavior
MEDICAL MANAGEMENT
The suicide risk must be assessed by a professional. Assessment must include inquiry into suicidal ideation, plan, intention, and available means to carry out a suicide plan. If the child or youth reports suicidal ideations with a plan, and has the means and the intention to carry out the plan, the individual should be continually supervised or monitored until he or she is evaluated by a mental health professional. Children and youths who attempt suicide should receive emergency treatment.
If the suicide risk is acute, hospitalization is necessary for stabilization, intensive monitoring, and comprehensive diagnostic evaluation. Follow-up in outpatient treatment is imperative and may include individual and family psychotherapy as well as medication. Depression underlies most suicidality and is best treated with a combination of psychotherapy (i.e., cognitive behavioral or psychodynamic approaches) and medications. When mood disorder symptoms interfere with the child’s functioning, antidepressants are typicially indicated.
Youths taking antidepressants are at risk during the early stage of medication treatment for behavioral activiation, or a switch to mania and suicidal thoughts. For this reason the U.S. Food and Drug Administration recently issued warnings on the use of antidepressants in children. During the first 4 weeks of antidepressant treatment, children and adolescents should be followed once a week by a mental health provider such as a psychiatric nurse practitioner or psychiatrist, then every other week for the next 4 weeks and finally, when dosage and symptoms are stabilized, every 4 months. If the youth has a problem with drug and/or alcohol abuse, chemical dependency treatment should be rendered concurrently with the psychiatric interventions.
NURSING ASSESSMENT
1. Do not be afraid to ask child or youth about suicidal thoughts and whether he or she has a plan and/or intentions to carry out plan. Does he or she have history of past suicides attempts, access to drugs or medications, or weapons?
2. Assess for alcohol and drug use (when under influence of alcohol and other drugs that cause disinhibition, child or youth may act impulsively on suicidal thoughts).
3. Assess for significant changes in behavior (refer to Clinical Manifestations section in this chapter).
NURSING INTERVENTIONS
1. Recognize warning signs of mood disorders and suicidal behaviors.
2. Identify children and youths at risk for suicide and refer for comprehensive interdisciplinary treatment services (e.g., crisis intervention team).
3. Refer child or youth to psychotherapist, school psychologist, or counselor for ongoing treatment.
4. Encourage sharing of feelings and family’s active listening to child’s or youth’s concerns.
5. Promote use of positive coping strategies; focus on emphasizing child’s or youth’s strengths.
6. Provide support for problem solving and positive use of alternative strategies.
7. Restrict access to firearms and lethal weapons.
Discharge Planning and Home Care
1. Provide information to parents about association between ready access to guns in home and increased risk of adolescent suicide. Encourage parents to limit access to firearms or remove them from home.
2. Advocate positive parent-child relationships and positive communications; refer to family-centered therapy services, parenting skills programs, psychotherapy, and psychoeducational programs.
3. Facilitate referrals for children and youths to peer support programs.
4. Coordinate prevention efforts with educational and community-based colleagues focused on self-awareness for mood disorders and suicide, and methods to enhance self-esteem.
Dopheide JA. Recognizing and treating depression in children and adolescents. Am J Health Syst Pharm. 2006;1:63(3):233.
Kochanck KD, et al. Deaths: Final data for 2002. Natl Vital Stats Rep. 2004;53(5):1.
Murphy K. What can you do to prevent teen suicide? Nursing. 2005;35(12):43.
National Institute of Mental Health. Suicide facts and statistics, 2006. (website): www.nimh.nih.gov/suicideprevention/suifact.cfm. Accessed March 10
