Teaching medical professionals and trainees about adolescent suicide prevention: five key problems

Predicting and preventing suicide represent very difficult challenges for clinicians. The awareness of adolescent suicide as a major social and medical problem has increased over the past years. However, many health care professionals who have frequent contact with adolescents are not sufficiently trained in suicide evaluation techniques and approaches to adolescents with suicidal behavior. Suicide prevention efforts among adolescents are restricted by the fact that there are five key problems related to the evaluation and management of suicidality in adolescents: 1. Many clinicians underestimate the importance of the problem of adolescent suicidal behavior and underestimate its prevalence. 2. There is a misconception that direct questioning of adolescents about suicidality is sufficient to evaluate suicide risk. 3. Another misconception is that adolescents with non-psychiatric illnesses do not need to be evaluated for suicidality. 4. Many clinicians do not know about or underestimate the role of contagion in adolescent suicidal behavior. 5. There is a mistaken belief that adolescent males are at lower suicide risk than adolescent females. Educating medical professionals and trainees about the warning signs and symptoms of adolescent suicide and providing them with tools to recognize, evaluate, and manage suicidal patients represent a promising approach to adolescent suicide prevention.     

Alcohol and adolescent suicide

Adolescent suicide is a major public health problem. In this review, the authors discuss different aspects of the relation between alcohol abuse and suicidal behavior in adolescents, including epidemiology, role of family history, comorbidity, gender differences, neurobiology, treatment, and prevention. In the general population, about 2,000 adolescents in the United States die by suicide each year. Suicide continually ranks as the second or third leading cause of death of persons between the ages of 15 and 34 years old. The suicide rate in young people has more than doubled during the period from 1956 to 1993. This increasing suicide rate has been blamed on the increase of adolescent alcohol abuse. Availability of alcohol and guns at home may contribute to suicide risk in adolescents. Comorbid psychopathology, which is common among adolescent alcohol abusers, substantially increases risk for suicide completions and attempts. Depressed adolescents may use alcohol to self-medicate depressive symptoms. Alcohol abuse and suicidal behavior in adolescents and in adults has been found to have biochemical, genetic, and psychological correlates. Ideally, treatment of adolescents who receive a diagnosis of an alcohol use disorder and co-occurring suicidality should follow an integrated protocol that addresses both conditions. Future studies of psychological and neurobiological mechanisms of suicidality in adolescents with alcohol and/or substance abuse are merited.     

Preventing suicide in adolescents with alcohol use disorders

Adolescent suicide is an escalating crisis that needs to be addressed by clinicians and researchers. Alcohol use has consistently been implicated in adolescent suicide and it is generally assumed that alcohol use leads to an increased risk in suicidality, suicide attempts and completed suicides. It can lead to adolescent suicidality through alcohol myopia, disinhibition, and impaired judgment. Multiple genetically related intermediate phenotypes might contribute to the risk of alcohol misuse and suicidal behavior in adolescents. Genetic variations that enhance the risk for mood and anxiety symptoms or susceptibility to stress might increase risk through different mechanisms. Comorbid disorders such as depression are frequently exhibited in adolescents who misuse alcohol, therefore any adolescent who appears to be at risk for alcoholism or depression should always be screened for all other psychiatric disorders and for suicidality; some signs suicidal adolescents may exhibit include withdrawal, personality change, and a loss of interest in pleasurable activities. While assessment is important, prevention is crucial in any attempt to decrease the incidence of adolescent suicide. The US Center for Disease Control and Prevention (CDC) has established a set of seven guidelines that can be implemented from kindergarten through high school in order to establish alcohol prevention efforts in schools. Through beginning prevention efforts at a young age, it is hopeful that both alcohol misuse and adolescent suicide can be reduced.     

广州市青少年危害健康行为调查

目的了解广州市青少年危害健康行为发生情况，为制定青少年健康政策和采取干预措施提供科学依据。方法采用分层整群抽样方法分别抽取广州市8所小学和8所中学约8100名学生进行无记名问卷调查。结果危害青少年健康的危险行为主要为意外伤害、自杀、吸烟、饮酒、不良膳食行为、缺乏体育锻炼、接触毒品和无保护性行为。危险行为的发生率与年龄有密切关系。且男生和女生之间差异有统计学意义（P〈0．05）。结论应重视青少年危险行为，并及早干预其危险行为以促进育少年身心健康。     

Suicidality, depression, and alcohol use among adolescents: a review of empirical findings

Suicide is a serious health problem as it is currently the third leading cause of death for teenagers between the ages of 15 and 24 years. Depression, which is also a serious problem for adolescents, is the most significant biological and psychological risk factor for teen suicide. Alcohol use remains extremely widespread among today's teenagers and is related to both suicidality and depression. Suicidality refers to the occurrence of suicidal thoughts or suicidal behavior. The consensus in empirical research is that mental disorders and substance abuse are the most important risk factors in both attempted and completed adolescent suicide. Therefore, it is incumbent upon researchers to identify the factors that can lead to their prevention among today's youth. This review compiles the existing literature on suicidality, depression, and alcohol use among adolescents spanning over the past 15 years. Both Problem Behavior Theory and Stress-coping Theory can explain the relationships among suicidality, depression and alcohol use. The prevention of suicidality is critical, especially during the early school years, when it is associated with depression and alcohol use. Suicidality, depression and alcohol use are three phenomenon that noticeably increase in adolescence marking this time period as an ideal opportunity for prevention efforts to commence. Future empirical work is needed that will further assess the impact of adolescent depression and alcohol use on suicidality. In sum, this review of empirical research highlights critical results and limitations, as well as indicates a need for continued efforts in preventing suicidality, depression, and alcohol use among adolescents.     

Psychotherapy in the treatment of alcohol and substance abusing adolescents with suicidal behavior

Adolescence is a unique time period in an individual's life, one in which suicide and substance abuse become substantial health risks. Currently, suicide accounts for approximately 14% of all deaths among 15-24 year olds in the U.S.A. Drug, alcohol abuse and dependence are the most prevalent causes of adolescent morbidity and mortality in the USA. Numerous studies have demonstrated the link between adolescent alcohol, substance abuse and suicide. When compared to community controls, the rate of a substance abuse disorder was 8.5 times higher in a sample of adolescent suicide completers and the rate of alcohol abuse was 7.5 times higher. Genetic and biological variables may also be responsible for either alcohol and substance abuse or suicide or both alcohol and substance abuse and suicide. There is little empirical research evaluating the effectiveness of alcohol and substance abuse treatments for adolescents. Therapies such as multisystemic therapy, functional family therapy, motivational interviewing, community reinforcement, the 12-step approach and contingency management reinforcement seem to be effective treatments. Despite the strong association between adolescent alcohol and substance use and suicidal behaviors, few studies have investigated the combined treatment of these two issues. Cognitive behavioral therapy, particularly dialectical behavior therapy, seems to be a promising psychotherapy treatment for suicidality in alcohol and substance abusing adolescents. Further research is needed to determine the efficacy of various treatments of alcohol and substance abusing adolescents with suicidal behavior.     

Childhood abuse and adolescent suicidality: a direct link and an indirect link through alcohol and substance misuse

Childhood abuse is responsible for a variety of outcomes that are characterized by maladjustment and maladaption. Two of the most significant results are suicide and alcohol and substance misuse. This paper explores the direct link between childhood abuse and adolescent suicide, the direct link between childhood abuse and adolescent alcohol and substance misuse, the indirect link between childhood abuse and adolescent suicide through alcohol and substance misuse, and finally implications of these links for practitioners working with adolescents who are experiencing or who have experienced childhood abuse. Both suicide and alcohol and substance misuse are prevalent in the adolescent population; however those adolescents who were victims of childhood abuse show an even greater prevalence of both suicidality and substance and alcohol misuse. Additionally adolescents who exhibit alcohol or substance misuse show greater rater of suicidality than those without alcohol and substance misuse. It appears that abuse is a risk factor for eventual suicidality. Practitioners working with children or adolescents who have experienced abuse need to work towards secondary prevention by identifying, predicting and treating those at risk for substance abuse and/or suicide; and those working with adolescents who are already abusing substances and/or are suicidal should work with the adolescent to identify and examine life events such as abuse that may have triggered the chain towards substance misuse and/or suicidal ideation.     

Genetic Contribution to Suicidal Behaviors and Associated Risk Factors among Adolescents in the U.S.

This paper examines genetic contribution to suicidal behaviors and other risk factors associated with suicidal behavior among adolescents in the U.S. Using adolescent twin data in the National Longitudinal Study of Adolescent Health (N=1448), we compared concordance in suicidal ideation and attempt among monozygotic (MZ) and dizygotic (DZ) twins. Heritability of risk factors for suicidal behaviors also was examined using Pearson correlation and mixed-model analyses. A trend of higher concordance in suicidal ideation and attempt was found among MZ than DZ twins but the difference was not statistically significant by the stringent test of bootstrapping analysis. Evidence of heritability was found for several suicide risk factors. The percentage of variance explained by heritability was larger among female twins for depression, aggression, and quantity of cigarettes smoked in comparison to heritability estimates for male twins. However, estimated heritability was larger among male than female twins for alcohol use and binge drinking. Heritability influence was negligible among both sexes for other drug use. Risk factors for suicidal behaviors among adolescents may be heritable. Gender differences found in the heritability of some suicide risk factors suggest these genetic contributions are gender specific. Future research examining potential interactions between expression of genetic influence and particular environmental contexts may enhance prevention and intervention efforts.     

Ethnicity and the relationship between adolescent alcohol use and suicidal behavior

Adolescent suicide is the 3rd leading cause of death in the United States and alcohol consumption is estimated to cause adolescent males to be up to 17 times more likely to attempt suicide, and females three times more likely to attempt suicide. Suicide and suicide attempt rates vary across different ethnicities. Also, associated psychopathology, stressors and substance use differ across ethnic groups in adolescents. In an exhaustive review of the literature, we found that depressed Asian-American youth were four times more likely to display suicidal behavior when compared to other Asian youths with other diagnoses; and depressed African-American females were more likely to report suicidal ideation than male adolescents. We also found that Asian-Americans who experience high parental conflict are 30 times more likely to engage in suicidal behavior when compared to Asian-American youths with low parental conflict. African-American adolescents are 6.4 times more likely to attempt suicide as a result of parental conflict. With respect to alcohol use and dependence, Caucasian adolescents were twice as likely as the African American victims to have used alcohol before committing suicide. Alcohol use among adolescents was associated with increased suicidal behavior. Cultural differences in alcohol consumption may account for disparities, however future research is needed to further examine cultural trends in suicidal behavior and alcoholism.     

The role of the hypothalamic-pituitary-adrenal axis dysfunction in the pathophysiology of alcohol misuse and suicidal behavior in adolescents

Alterations in the mechanisms that regulate hypothalamic-pituitary-adrenal (HPA) axis activity predate the development of alcohol use disorders. Human and animal studies indicate that chronic alcohol consumption induces a persistent impairment in the ability of the HPA axis to respond to stress. Therefore, HPA axis abnormalities may contribute to the development of alcohol use disorders and may be a result of alcohol misuse. HPA axis interacts with serotonergic mechanisms. Hippocampal function is modulated by serotonergic projections mostly from dorsal raphe nucleus in the midbrain. Glucocorticoids modulate the activity of this raphe-hippocampal system in various ways. These effects are mediated via central corticosteroid receptors, which include glucocorticoid and mineralocorticoid receptors located in the hippocampus and in other cortical structures. An association between suicidal behavior and hyperactivity of the HPA axis has been suggested. An abnormal interaction between the HPA mechanisms and serotonergic systems may substantially contribute to suicidal behavior in adolescents, because abnormalities in HPA and serotonin functions may be inherited and may manifest at young age. Vulnerability to alcohol use disorders and suicide is likely to be due to multiple interacting genetic loci of small to modest effects. The identification and treatment of adolescents at risk for suicide is one of the most critical issues in adolescent psychiatry. The identification of alcohol and drug misuse is critical to the proper assessment of suicide risk in adolescents. HPA dysregulation may contribute to both alcohol abuse and suicidal behavior in adolescents. Studies of HPA function in alcohol abusing adolescents may lead to the development of new diagnostic tests for predisposition to suicidal behavior. Furthermore, study of biological markers may help us towards an understanding of the neurophysiological substrates of severe dysphoric mood states, alcohol and substance abuse, and suicidal behavior in adolescents.     

Adolescent suicide attempters: do physicians recognize them?

The single most important risk factor for adolescent suicide is a previous attempt. It is unclear if physicians can identify adolescents who have attempted suicide. Our objectives were to determine the prevalence of previous attempts in an adolescent clinic population, if physicians identify attempters, and if attempters demonstrate persistent distress. Of 332 patients aged 12-19 years attending a medical clinic, 48 (14.5%) reported a previous attempt. The physician's visit note documented that only 8 (16.7%) of the 48 attempters were asked about suicidal behavior. Attempters were more likely than nonattempters (p less than 0.05) to be female; to come to clinic without a guardian; to give a chief complaint pertaining to sexually transmitted disease, obstetrics-gynecology, or mental health; and to report previous mental health care. Attempters had poorer mean scores (p less than 0.05) on validated subscales for family relationships, social competence, depression, unpopularity, somatic complaints, thought disorders, delinquency, aggression, and identity. We conclude that suicide attempts are common among adolescent clinic patients, that physicians may not recognize attempters, and that attempters remain distressed and in need of care. Physicians who see adolescents for routine medical problems must consider the potential for self-destructive behavior, regardless of the presenting complaint.     

Adolescent Alcohol Use,Suicidal Ideation,and Suicide Attempts

PurposeTo examine the association between self-reported alcohol use and suicide attempts among adolescents who did and did not report suicidal ideation during the past year.MethodsScreening data from 31,953 students attending schools in the United States that implemented the Signs of Suicide (SOS) program in 2001–2002 were used in this analysis. Two types of alcohol use were investigated: heavy episodic drinking, and drinking while down. Self-reported suicide attempts were regressed on suicidal ideation and both measures of alcohol use, controlling for participants’ levels of depressive symptoms, and demographic characteristics.ResultsLogistic regression analyses indicated that both drinking while down and heavy episodic drinking were significantly associated with self-reported suicide attempts. Analyses examining the conditional association of alcohol use and suicidal ideation with self-reported suicide attempts revealed that drinking while down was associated with significantly greater risk of suicide attempt among those not reporting suicidal ideation in the past year. Heavy episodic drinking was associated with increased risk of suicide attempt equally among those who did and did not report suicidal ideation.ConclusionsThis study identified the use of alcohol while sad or depressed as a marker for suicidal behavior in adolescents who did not report ideating prior to an attempt, and hence, may not be detected by current strategies for assessing suicide risk. Findings from this study should provide further impetus for alcohol screening among clinicians beyond that motivated by concerns about alcohol and substance use.     

Co-Occurrence of Substance Use and Loneliness as a Risk Factor for Adolescent Hopelessness

ABSTRACT: This research among a sample of 1,915 Mississippi adolescents investigated whether lonely adolescents who use illicit substances were at increased risk of hopelessness. Relative risk of scoring within the severe hopelessness range was 6.9 for non-substance users who were lonely and 4.2 for substance users who were not lonely. Yet, relative risk for severe hopelessness in substance-using lonely adolescents was 25.2. Lonely, substance-using adolescents were 25 times more likely to be severely hopeless than the reference group composed of non-substance using, not-lonely adolescents. Lonely adolescents who get drunk also were 15.9 times more likely to be severely hopeless than the reference group. Because hopelessness often is an indicator of suicidal behavior, these results may have important implications for school health adolescent suicide prevention efforts.     

High School Health Teachers'' Perceived Self-Efficacy in Identifying Students at Risk for Suicide

A national random sample of 228 high school health teachers completed a 45-item survey to examine their perceived self-efficacy regarding adolescent suicide. Most respondents were female, White, and held master's degrees. Most believed it was their role to recognize students at risk for suicide, believed that if they did recognize students at risk it would reduce the chances that the student would commit suicide, and believed that one of the most important things they could do would be to prevent a suicidal student from committing suicide. However, only 9% believed they could recognize a student at risk for suicide. High efficacy expectations scores were associated with working at a school that offered an inservice program on adolescent suicide, included teaching about suicide prevention in the curriculum, and had a crisis intervention team. This study suggests that teacher health education programs should spend more time on developing the skills necessary to identify students at risk. In addition, a comprehensive school suicide prevention program is strongly encouraged for all high schools.     

Substance use and mental health problems as predictors of HIV sexual risk behaviors among adolescents in foster care

This study examined the relationship between substance use, mental health problems, and HIV sexual risk behaviors among a sample of foster care adolescents. Data were collected through structured baseline interviews with 320 adolescents (ages 15 to 18 years) who resided in foster care placements and participated in a larger evaluation study of an HIV prevention program. Final logistic regression models indicated that delinquent behavior and marijuana use were the most significant predictors of engaging in any one HIV risk behavior. Adolescents who reported delinquent behaviors, alcohol use, and marijuana use and who were female were more likely than their counterparts to engage in vaginal sex without using a condom. Future research is needed to further identify risk and protective factors for substance use, mental health problems, and HIV sexual risk behaviors among adolescents in foster care. HIV prevention efforts for these vulnerable adolescents should target those with substance use and delinquent behaviors.     

抑郁障碍青少年自杀行为预测因素研究进展

近年来,青少年自杀行为的发生率逐年升高,成为威胁青少年身心健康乃至生命的严重公共卫生问题。抑郁障碍青少年是自杀行为发生的高危人群。研究从影响抑郁障碍青少年自杀行为的个人心理因素、家庭因素以及学校和社会因素3个方面进行综述,为青少年自杀行为的有效预防提供科学依据。     

河南省城市初中学生自杀及相关因素研究

目的了解河南省城市初中学生自杀行为流行情况及影响因素,为采取干预措施提供依据。方法采用分层整群抽样方法,抽取河南省4个省辖市12所初中的5158名学生,应用中国疾病预防控制中心制定的＂中国青少年健康相关行为调查问卷＂进行调查,并对影响因素进行分析。结果初中生在调查前1a产生过自杀意念、企图自杀和自杀未遂报告率分别为23.5%,7.7%和2.5%;非条件Logis-tic回归分析结果表明,抑郁、看色情书籍和音像、学习压力、离家出走意念、每天运动时间、课外补习时间、与祖辈一起生活、孤独感、节食减肥、饮酒次数10项因素与自杀意念密切相关。结论应高度重视学生自杀行为的预防控制。针对影响因素积极采取有效措施,减少青少年自杀行为的发生。     

Mental health care providers' suggestions for suicide prevention among people with substance use disorders in South Africa: a qualitative study

Background

People with substance use disorders (PWSUDs) are a clearly delineated group at high risk for suicidal behaviour. Expert consensus is that suicide prevention strategies should be culturally sensitive and specific to particular populations and socio-cultural and economic contexts. The aim of this study was to explore mental health care providers' context- and population-specific suggestions for suicide prevention when providing services for PWSUDs in the Western Cape, South Africa.

Methods

Qualitative data were collected via in-depth, semi-structured interviews with 18 mental health care providers providing services to PWSUDs in the public and private health care sectors of the Western Cape, South Africa. Data were analysed inductively using thematic analysis.

Results

Participants highlighted the importance of providing effective mental health care, transforming the mental health care system, community interventions, and early intervention, in order to prevent suicide amongst PWSUDs. Many of their suggestions reflected basic principles of effective mental health care provision. However, participants also suggested further training in suicide prevention for mental health care providers, optimising the use of existing health care resources, expanding service provision for suicidal PWSUDs, improving policies and regulations for the treatment of substance use disorders, provision of integrated health care, and focusing on early intervention to prevent suicide.

Conclusions

Training mental health care providers in suicide prevention must be augmented by addressing systemic problems in the provision of mental health care and contextual problems that make suicide prevention challenging. Many of the suggestions offered by these participants depart from individualist, biomedical approaches to suicide prevention to include a more contextual view of suicide prevention. A re-thinking of traditional bio-medical approaches to suicide prevention may be warranted in order to reduce suicide among PWSUDs.

     

溧水县高中学生健康危险行为现状调查

目的:了解南京市溧水县高中学生健康危险行为现状,为制定相关伤害的预防控制措施提供依据。方法:根据《江苏省青少年健康相关行为调查问卷》内容,对6所高中2 482名学生进行问卷调查。结果:调查中有17.1%的学生想过自杀,32.0%的学生发生过严重受伤,28.2%的学生尝试过吸烟,58.4%的学生尝试过饮酒,学生中使用过网络的达92.5%,2.9%的学生有过性行为。结论:南京市溧水县高中学生健康危险行为发生状况不容忽视,迫切需要开展各种行为干预措施。