Suicide is a serious problem among youths and is the third leading cause of death for those aged 10-24. Risk factors include depression and other mental illnesses. While suicide attempts are more common among girls, boys are more likely to die by suicide. Effective prevention and treatment includes evaluating suicidal thoughts and intentions, providing support, and treating any underlying conditions through psychotherapy, medication, or both. Cognitive behavioral therapy and dialectical behavioral therapy can help reduce suicidal ideation and behaviors.

1. “I can’t take the pressure any longer. I love my family and I hope they will
Suicide in Youths

2. WHO Health
 Health is a state of complete physical,mental and social well-being an
dnot merely absence of disease
 Health is the ability to adapt and self manage
Mental health is a state of well being in which the individual realizes his
/her own abilitis,can cope with the normal stresses of life,can work
productively and able to make contributions to his family/community

3. Definitions
Suicide
• Death caused by self-directed injurious behavior with any intent to die as a result of the
behavior
Suicide attempt
• A non-fatal self-directed potentially injurious behavior (may or may not result in injury)
with any intent to die as result of the behavior
Suicidal ideation
• Thoughts of suicide that can range in severity from a vague wish to be dead to active
suicidal ideation with a specific plan and intent

4. How serious is the problem ?
 Myth – Suicide in youth is not a problem
 Truth - Suicide in young people is a serious
and prevalent problem:
» 3rd leading cause of death for young people
ages 10-24 and accounts for 20% of all
deaths annually
» Top methods used - firearms, suffocation,
poisoning

5. But every 6 hours, one succeeds.
The WHO reports about 1 million suicides a year, which would be a
rate of about 14 per 100,000.
In India the rate is 16 per 100,000 and in USA it is 12.2 per 100,000.
Every 90 minutes a teenager tries to commit suicide in India.
Many of these attempts are half-hearted cries for attention, help and
love.

6. Suicidal Behavior: A Serious Problem
 Boys are more likely than girls to die from suicide
 Of the reported suicides in the 10-24 age group, 81% were males
 Girls attempt suicide more than boys, a particular problem for girls
from Latina backgrounds

7. “Suicidal behavior is the end result of a complex
interaction of psychiatric, social and familial.
There are more suicidal attempts and gestures than
actual completed suicides.
One study indicates that there are 23 suicidal
gestures and attempts for every completed suicide.”
Carol Watkins, MD Baltimore Maryland

8. Risk Factors

9. • Depression is the strongest risk factor for suicide
among the adolescent psychiatric disorders.
• It also increases the risk of a suicide attempt by a
factor of 12 in boys and 15 in girls.
• Comorbid disorders, including anxiety, substance
use and disruptive behavior disorders, all increase
suicidality risk.
Risk factor for teen suicide

10. Any mention of dying, disappearing, jumping, shooting oneself, or other types
of self harm
Talking About Dying
Sad, withdrawn, irritable, anxious, tired, indecisive, or apathetic
Change in Personality
Difficulty concentrating on school, work, or routine tasks
Change in Behavior
Insomnia, often with early waking or oversleeping, nightmares
Change in Sleep
Patterns
Loss of appetite and weight, overeating
Change in Eating
Habits
Acting erratically, harming self or others
Fear of losing control

11. Assessing Suicide Risk
Ask about both ideation and attempts
Ideation
• Have you wished you were dead or you could go to
sleep
• Have you actually had any thoughts of killing yourself?
Attempts
• Have you made a suicide attempt? Tried to kill
yourself?
• Done anything to harm yourself?
• Anything dangerous where you could have died?
Adapted from the Columbia suicide severity rating scale, Posner et al 2009

12. Barriers to Treatment of At-Risk Teens
 Many at-risk teens do not get needed treatment, including an estimated
2/3 of those with depression
 Reasons:
» Neither teens nor the adults who are close to them recognize symptoms as a
treatable illness
» Fear of what treatment might involve
» Belief that nothing can help
» Perception that seeking help is a sign of weakness or failure
» Feeling too embarrassed to seek help
» Belief that adults aren’t receptive to teens’ mental health problems
 But – depression and other mental disorders CAN be– effectively
treated.

14. Prevention of Suicide in Youths
 Evaluating the patient’s state
 Recognition of depression in adolescents
 Recognition of suicidality in adolescents
 What are the patient’s expectations of suicide?
 Evaluating the patient’s intent
 Is there a history of self-destructive behavior?
 Assessing the patient’s coping ability

15. Interim Interventions
LISTEN
• Encourage the child to talk to you or to some other trusted person.
• Listen to the child’s feelings.
• Don’t give advice or feel obligated to find simple solutions.
BE HONEST
• If the child’s words or actions scare you, tell him or her.
• If you’re worried or don’t know what to do, say so.
• Don’t be a cheerful phony.
SHARE FEELINGS
• At times everyone feels sad, hurt, or hopeless.
• You know what that’s like; share your feelings.
• Let the child know he or she is not alone.

16. Facts about Treatment
 Some depressed teens show improvement in 4-6 weeks with structured
psychotherapy alone.
 Most others experience significant reduction of depressive symptoms
with antidepressant medication
 Supplementary interventions – exercise, yoga, breathing– exercise,
changes in diet – improve mood, relieve anxiety and reduce stress that
contributes to depression
 Medication is usually essential in treating severe depression, and other
serious mental disorders (bipolar disorder, schizophrenia, etc.)

17. Intervention Programs
 Psychotherapy is an important component in the management of
suicidal ideation and behaviors
 There are two documented effective psychotherapies for treating those
who attempt suicide:
» Cognitive behavior therapy (CBT)
» Dialectical behavioral therapy (DBT) for youth diagnosed with
borderline personality disorder and recurrent suicidal ideation

18. CBT for Adolescent Depression – Does it affect
Suicidality?
 Do we need to specifically treat suicidality or is treatment of depression
enough?
 Large studies conducted in the last decade have shown that CBT for
depression in adolescents does result in reducing suicidality.
TADS
TORDIA

19. TADS – Slight protective effect
• Reductions in SI were greater for youth randomized to
combination therapy than fluoxetine therapy, CBT only, or
placebo, though SI was lower than baseline in all conditions.
At 12 weeks
• Suicidal events were more common in patients treated with
fluoxetine alone (14.7%), compared to 8.4% for combination and
6.3% for CBT alone
At 36 weeks
(March et al, 2004; 2007)

20. TORDIA
58.5% of participants reported clinically significant SI and 23.7% reported
a prior suicide attempt.
SI decreased from baseline to posttreatment for participants across all
conditions.
5% of participants attempted suicide and 20% experienced a self-harm
related event (SI, suicide attempt, self-injurious behavior) during
treatment, with no differences across conditions.
(Brent et al, 2008)

21. SAFETY Program
 A novel 12-week ecological cognitive-behavioral treatment
 The treatment emphasizes enhancing protective supports within social
system.
 Sessions include :
» First component youths work with the youth-therapist, while parents work with
the parent-therapist
» Second family-component where all come together to practice skills identified as
critical in the pathway for preventing repeat sas.
Henggeler S, Schoenwald SK, Rowland MD, Cunningham PB. Serious Emotional Disturbance in Children and
Adolescents: Multisystemic Therapy. New York: Guilford Press; 2002.

22. SAFETY Pyramid: Conceptual Model and youth and parent intervention modules and foci.

23. Pharmacological Treatment
Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and
insomnia is recommended.
Treatment with antidepressants of children and adolescents should only be given under
supervision of a specialist.
Long-term treatment with lithium has been shown to be effective in preventing both suicide and
attempted suicide in patients with unipolar and bipolar depression.
Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia.
Other atypical antipsychotics are promising but more evidence is required.
The European Psychiatric Association (EPA) guidance on suicide treatment and prevention. Neuropsychopharmacol Hung. 2012 Jun;14(2):113-36.

24. What do we know today of the risk of suicidality in
adolescents treated with SSRIs ???
 No evidence supporting an increased suicide rate among
adolescents treated with SSRIs.
 Only an increase in the rate of suicidal ideation and behavior.
 Studies have suggested that the late 20th century reversal of rising
adolescent suicide rate is attributable to the increased use of SSRIs
in treating depressed adolescents.
 With psychotherapy as a key factor, TADS found that CBT
alleviated the increased suicidality risk.
Int J Adolesc Med Health 2013; 25(3): 221–229
Treatment for Adolescents with Depression Study (TADS)