Virginia Commission on Youth

Suicide and suicide attempts by children and adolescents constitute a major public health problem in the

United States

. Suicide is the third leading cause of death, behind accidents and homicide, among adolescents (Fritz, 2001). Moreover, the middle teenage years are the period in the life cycle where the incidence of suicide attempts is the greatest (Fritz).

Over the last thirty years, there has been a sharp proliferation at the national level in the rates for both completed suicide and suicide attempts among adolescents and young adults. According to Garland and Zigler and cited by the Virginia Commission on Youth (2001), the adolescent suicide rate increased 200 percent, compared with a 17 percent increase in the general population over the last three decades. According to the National Center for Health Statistics (Virginia Commission on Youth), an average of one young person every two hours took his or her own life. Furthermore, the actual number of deaths caused by suicide is likely to be higher due to the fact that some of the deaths may have been classified as accidental. Chart 1 shows the suicide rates for persons in the

U.S.

ages 15 to 24.

Source: American Association of Suicidology, 2000, as cited by the Virginia Commission on Youth, 2001.

There has been increasing attention paid to the issue of suicide and suicide prevention and, in 1999, the U.S. Surgeon General issued a "Call to Action" emphasizing the need for greater awareness on this national problem (Vetter, 2002). Shortly thereafter, the National Strategy for Suicide Prevention was published by the U.S. Department of Health and Human Services, addressing issues such as collaboration with agencies and stakeholders (Vetter). Table 1 sets forth Virginia ’s suicide statistics.

In Virginia , suicide is:

° the third leading cause of death for ages 10-24,

° the second leading cause of death for ages 25-34, and

° the fourth leading cause of death for ages 35-54.

° In almost all age groups, Virginia ’s suicide rates are slightly higher than the national average.

° One teenager a week, two adults each day, and one older adult every 3 days are lost to suicide.

° There are an estimated 25 suicide attempts for every death by suicide.

° In 2000, the total cost for hospitalizations due to suicide attempts in Virginia was over $25 million.

The Virginia Department of Health conducted a study on Suicide in the Commonwealth of Virginia and the findings are discussed in the following paragraphs. The study revealed that the suicide rate for young Virginians, aged 10 to 19, had increased an alarming 32 percent since 1975. In 1998, seven Virginia children, aged 5-14, were reported to have died from suicide. Another 50 children, aged 15-19 ended their lives. Furthermore, approximately one Virginia teenager every week takes his or her own life. Chart 2 shows Virginia deaths for children and adolescents from 1950 to 1998.

Several different factors contribute to a child or adolescent attempting or completing suicide. The American Academy of Pediatrics, as cited by the Virginia Commission on Youth (2001), identifies a number of factors which may explain the dramatic increase in youth suicide in recent years:

· It’s easier to get the tools for suicide. (Boys often use firearms to kill themselves; girls usually use pills.)

Source: Virginia Center for Health Statistics, 2000, as cited by the Virginia Commission on Youth, 2001.

Table 2 presents statistics addressing risk factors for youth suicide, as reported by the American Academy of Pediatrics, as cited by the Virginia Commission on Youth (2001).

° Suicide is much more common in adolescent and young adult males than females.

° The ratio for male to female suicides is 3:1 in the rare prepubescent suicides to approximately 5.5:1 in 15- to 24-year-olds.

° Mood disorders, poor parent communication, and a previous suicide attempt are risk factors for suicide in both boys and girls.

° Previous suicide attempts are more predictive in male.

° Substance and/or alcohol abuse significantly increases the risk of suicide in teenagers aged 16 and older.

° Family pathology and a history of family suicidal behavior may also increase risk and should be investigated.

Research reveals that youth suicide is neither random nor inevitable. The Virginia Commission on Youth (2001) discussed in its summary of findings that¾in order to address youth suicide and the problem¾one must also be made aware of the dynamics surrounding this issue. In its report, Suicide Fatalities among Children and Adolescents in Virginia from 1994-95, the Virginia State Child Fatality Review Team found that more than 40 percent of the children who took their lives had told someone about their intent to die (Virginia Commission on Youth). Unfortunately, for various reasons, the opportunity to intercede was lost. Other and potentially more important implications discussed in this report were that the warning signs for youth suicide were not recognized. Other factors are that the extent of the problem was not understood, the means for conducting the act were not removed, or the family thought they could handle the problems themselves. Other contributing factors were that families may not have known where or how to get help, or that help was not available.

The factors that predispose children and adolescents to complete suicide are numerous.

The Academy of Child & Adolescent Psychiatry’s Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behavior (2000) discusses the importance of understanding the various risk factors for potential suicidal behavior. The following elements are discussed in this practice parameter:

Awareness and acknowledgment of the various risk factors that can trigger both suicide and suicide attempts are crucial in assessing and potentially preventing suicide. Such factors include preexisting psychiatric disorders, which are considered to be both biological and social-psychological facilitating factors. More than 90 percent of adolescents who commit suicide suffered from an associated psychiatric disorder at the time of their deaths. More than half had suffered from a psychiatric disorder for at least two years preceding the event.

Disruptive disorders increase the risk of suicidal thoughts in children 12 years old and younger. Moreover, substance use or separation anxiety may incite adolescents to attempt suicide. Mood and anxiety disorders increase the risk of suicidal ideation in children and adolescents. Panic attacks are a risk factor for both ideation and attempts in females, while aggressiveness increases the risk of suicidal ideation or attempt in males.

As stated in a Joint Statement by the American Academy of Child & Adolescent Psychiatry & American Psychiatric Association (2001), some of the psychiatric illnesses in adolescents which include suicidal thoughts or behaviors include depression, ADHD, and bipolar disorder. Depression has been identified as the top risk factor in youth suicide with estimates of five percent of children and adolescents in the general population being depressed at any point in time. Children at a higher risk for depression are those under stress, those experiencing loss, and those with attention, learning, conduct or anxiety disorders. Also, studies conducted disclose that teenagers with bipolar disorder may have an ongoing combination of moods which may make the child at risk.

Stress events often precede adolescents' suicides; however, it is difficult to discern whether the stress is a result of the mental disorder or of events with which the child or adolescent having a mental disorder may not be able to cope ( American Academy of Child & Adolescent Psychiatry, 2000). Furthermore, an adolescent with a mental disorder may be faced with a greater number of stressful events and may perceive the events that occur as more stressful than an adolescent who does not have a diagnosed mental disorder ( American Academy of Child & Adolescent Psychiatry).

Even the most capably trained clinician can find it difficult to differentiate between those youth who have thoughts of engaging in suicide and those youth intending to commit the act of suicide. Many adolescents who have made a medically serious attempt will never do so again, while others who have made what seemed like only a mild attempt may eventually commit suicide ( Academy of Child and Clinical Psychiatry, 2001). However, research has provided some broad indicators about risk factors and means for assessing the risk.

SJR 148, introduced in the 2000 General Assembly, directed the Commission on Youth, with the assistance of the Departments of Health, Education, and Mental Health, Mental Retardation, and Substance Abuse Services, to develop a comprehensive youth suicide prevention plan. With the support of the departments identified above and significant input from survivors, service providers, and other stakeholders, the Commission undertook development of the plan.

The goals of the Virginia Youth Suicide Prevention Plan, as presented by the Virginia Commission on Youth (2001) were:

· To reduce the impact of suicide and suicidal behavior on individuals, families, and communities; and

· To improve access to and availability of appropriate prevention services for vulnerable individuals and groups.

The Virginia Commission on Youth conducted an extensive review of the research and in the Suicide Prevention Plan, discussed the evidence for effectiveness of various youth suicide prevention strategies in place around the country. General recommendations were made, based on research compiled by the Centers for Disease Control and Prevention (1992):

· Ensure that new and existing suicide prevention programs are linked as closely as possible with professional mental health resources in the community.

· Incorporate promising but underused strategies into current programs where possible.

· Incorporate evaluation efforts into all new and existing suicide prevention programs.

Universal prevention strategies were recommended as part of Virginia 's Youth Suicide Prevention Plan. The Commission on Youth model for Virginia ’s Youth Suicide Prevention Plan was adapted from the model developed by the Institute of Medicine and the National Institutes of Health. The prevention scheme included three levels of prevention strategies: universal, selective, and indicated. This three-tier approach targeted prevention at varying degrees and to different audiences.

Universal prevention is the provision of needed interventions to keep communities healthy. These programs provide general awareness information and education. The mission of selective prevention is to prevent the onset of suicidal behavior in targeted risk groups. These strategies include screening and assessment, training of “gatekeepers,” and community-based mental health treatment. Finally, indicated prevention strategies target individual youth known to be at high risk for suicide in order to provide skill building and supportive services and treatment.

Upon the recommendation of the Virginia Commission on Youth, the 2001 General Assembly enacted legislation which designated the Virginia Department of Health as the lead agency for directing youth suicide prevention activities across the Commonwealth. The Department of Health was charged with coordinating the activities of agencies pertaining to youth suicide prevention to address various preventive and support issues. Currently, the Department of Heath and the Virginia Department of Mental Health Mental Retardation and Substance Abuse Services actively participate in the Virginia Suicide Prevention Council, a public-private partnership designed to concentrate on suicide prevention in the Commonwealth. These activities assist with education and the implementation of prevention practices found to be crucial in reducing youth suicide.

As interventions for preventing suicide are developed and implemented, several key factors must be considered. It is critical that youth with psychiatric disorders or otherwise at increased suicidal risk receive adequate assessment, treatment, and follow-up care (U.S. Department of Health and Human Services, 2001).

The following finding emerged from information reported by the U.S. Department of Health and Human Services (2001): clinical studies have shown the efficacy of training emergency department staff to treat suicide attempts with gravity and to emphasize family members the dangers of ignoring suicide attempts. Furthermore, the benefits of follow-up treatment to reduce the recurrence of attempted suicide should be emphasized. Such training has been linked to greater completion of treatment on the part of persons having sought care in emergency departments.

According to the American Academy of Child and Adolescent Psychologists (2001), clinicians should be prepared to admit suicide attempters who express a persistent wish to die or are exhibiting symptoms of severe mental disorders. Discharging the youth should only occur once the following three issues have been addressed. These include: making certain adequate supervision is available; ensuring that the level of suicidality has stabilized; and gaining assurance that the youth’s environment will be rid of all potentially lethal items such as guns or medications. Following up with appropriate psychotherapy is vital in order to appropriately treat the mental disorders associated with suicidal behavior. Additionally, psychotherapy must be tailored to appropriately meet the needs of the youth and to effectively treat any diagnosed mental disorders.

U.S. Department of Health and Human Services (2001) has outlined pharmacological interventions thought to be effective in reducing suicide. However, it must be emphasized that any medications prescribed to the suicidal child or adolescent must be carefully monitored by a third party and any change of behavior or side effects immediately reported. New interventions are being developed and tested for the treatment of disorders associated with suicidal behaviors. Because few studies of treatments for mental disorders have included suicidal individuals, treatments need to be assessed for their potential to reduce suicide and suicidal behaviors. Furthermore, the youth must be thoroughly assessed for any mental disorders and psychopharmacological interventions must be tailored to address any diagnosed disorders.

To date, there are only two psychopharmacological treatments that have been associated with reduced suicide¾lithium and clozapine (Baldessarini et al., as cited by the U.S. Department of Health and Human Services). Research into lithium, which is shown to have a significant impact on the reduction in the suicide rate, is extensive.

According to the American Academy of Child & Adolescent Psychiatry (2001), selective serotonin reuptake inhibitors (SSRIs) may be successful in reducing suicidal ideation and suicide attempts in non-depressed adults certain personality disorders. Research has shown them to be safe in children and adolescents due to their low lethality and effectiveness in treating depression in non-suicidal children and adolescents. However, it is necessary to closely monitor children and adolescents on SSRIs to insure that no new suicidal ideations are noted.

As noted by the American Academy of Child & Adolescent Psychiatry (2001), tricyclic antidepressants should not be prescribed for the suicidal youth as a first line of treatment because the potential for toxic effect outweighs the therapeutic effects. Studies have not found these drugs to be effective in reducing suicide in children or adolescents. Furthermore, other medications that may increase disinhibition or impulsivity, such as the benzodiazapines and Phenobarbitol, should be prescribed with caution.

American Academy of Child & Adolescent Psychiatry. (2000). Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. 40:7.

American Academy of Child & Adolescent Psychiatry and American Psychiatric Association. (2001). Joint Statement from the American Academy of Child & Adolescent Psychiatry and the American Psychiatric Association for the Senate Children and Families Subcommittee of the Health, Education, Labor and Pensions Committee Hearing on Teen Suicide given September 7, 2001.

Centers for Disease Control and Prevention. (1992). Youth Suicide Prevention Programs: A Resource Guide. Atlanta: Centers for Disease Control.

Fritz, G. K. (2001). Prevention of Child and Adolescent Suicide. The Brown University Child and Adolescent Behavior Letter.

Joint Commission on Behavioral Health Care. (2002). Developing a Plan and Strategy for Suicide Prevention in the Commonwealth Draft Report to the Joint Commission on Behavioral Health Care (SJR 108). [Online]. Available: http://dls.state.va.us/groups/jcbhc/110602/suicprev.pdf. [November 2002].

U.S. Department of Health and Human Services. (2001). National Strategy for Suicide Prevention: Goals and Objectives for Action. [Online]. Available: www.mentalhealth.org/suicideprevention. [November 2002].

U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Rockville, MD.

U.S. Public Health Service. (1999). The Surgeon General's Call to Action to Prevent Suicide. Washington, D.C. Rockville, MD.

Vetter, J. B. (2002). Suicide Prevention in Virginia: Problem, Planning and Activity — An Overview, Presentation to the Joint Commission on Behavioral Health Care, Nov. 6, 2002. Suicide and Youth Violence Prevention Program, Virginia Department of Health.

Virginia Department of Health Center for Injury and Violence Prevention
James B. Vetter, Ed.M., Suicide and Youth Violence Prevention Consultant
P.O. Box 2448, 1500 E. Main St., Room 105 - Richmond, VA 23218-2448
(804) 786-2611 - fax: (804) 786-0917
http://www.preventsuicideva.org.

National Hopeline Network - 1-800-SUICIDE 784-2433 (Prevent Suicide Virginia)

The Link's National Resource Center for Suicide Prevention - Atlanta, GA
http://www.thelink.org

Organization of Attempters and Survivors of Suicide in Interfaith Service (OASSIS) - Washington, DC - http://www.oassis.org

13 Virginia agencies listed by the National Hopeline Network as offering telephone crisis hotline services. These agencies and additional information can be found at http://www.preventsuicideva.org.