1. Jeffrey I. Hunt, MD Alpert Medical School of Brown University
Primary Care Recognition and Management of Suicidal Behavior in Juveniles
Jeffrey I. Hunt, MD
Alpert Medical School of Brown University

2. The Scope of the Problem
3rd leading cause of death among and 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.

3. 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)

4. 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)

5. Clinical Characteristics of Teens Who Commit Suicide
Most Common Diagnoses
Mood Disorder %
Antisocial Disorder %
Substance Abuse %
Anxiety Disorder %
Gould et al., 1996

6. 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

7. Onset of Any Psychiatric Symptoms Before a Suicide
Time before death
> 12 months %
3-12 months %
< 3months %
Shaffer et al., 1996

8. Most suicides preceded by a stressful event
disciplinary crisis
relationship problem
humiliation
contagion
Gould et al., 1996

9. Onset of Ideation Before a Teen’s Suicide Attempt (N=29)
< 30 minutes %
minutes %
> 2 hours %
Negron et al., 1997

10. 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.
Firearm and strangulation in males vs. OD in females.

11. 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.

12. 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 year olds: 16% of female suicides, 2% of male suicides

13. 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.

14. 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.

15. Risk Factors Family factors
Parental psycho-pathology particularly depression and substance abuse.
Family history of suicide.
Parental conflicts / divorce.
Parent – child relationship

16. 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.

17. Protective Factors Family cohesion Religiosity
Ability to form therapeutic alliance

18. Secular Trends Suicide rate declining Possible reasons:
Increase in prescriptions of antidepressants
firearm legislation
Firm conclusions not possible

19. 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

20. 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

21. 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

22. Assessment of Underlying Conditions
Psychiatric diagnoses
Social/environmental factors
Cognitive distortions
Coping style
History of family psychopathology
Family discord or other life event stresses

23. Acute Management Identify all risk factors
Identify resources that potentially reduce risk
If risk outweighs available resources consider increased level of care

24. 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

25. 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

26. 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

27. Treatment Approaches Problem oriented Cognitive Behavior Therapy
Dialectical Behavior Therapy
Medication
Family Therapy
Group Therapy

28. Suicide Prevention Crisis Services Educational approaches Case Finding
Professional education

29. 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

30. 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

31. 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

32. 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

33. 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