In light of recent suicides and the ever-present need to address prevention of suicide, this week’s column addresses risk factors, especially in youth. 

Clinical depression is a devastating, potentially lethal illness characterized by emotional and physical pain that affects millions of people in the United States. Based on large population studies, the incidence of depression ranges between 10% to 15%, affecting 30 to 45 million individuals in the United States. Women are affected twice as often as men. The reported death rate (suicide) due to depression is variable, but 15% of patients hospitalized for depression ultimately take their lives. In the Surgeon General’s Report of 1999, suicide was designated as the 8^th cause of death in the United States with 30,000 suicides occurring annually.  Suicide can occur throughout the lifespan, but there are two major populations at risk: adolescents and the elderly.

Adolescence is an extremely vulnerable period of life and there are the risk issues of self-esteem, relationship difficulties, growing responsibilities, hormonal changes and substance abuse among other stresses. In the adolescent population, symptoms of depression include sadness, loss of interest, self-criticism, and feeling unloved, hopeless, irritable, aggressive and indecisive. In addition, anxiety, general aches and pains, stomach aches and headaches occur more often than in adults.

Important indicator signals of suicide in adolescence include withdrawal from usual activities, isolation, commenting about death and dying, threatening to harm one’s self or trying to obtain methods to take one’s life.

Suicidal adolescents constitute a psychiatric emergency and prompt, effective treatment is necessary. In addition to therapy and counseling, antidepressant medications can be life saving. While there is a current controversy about the possible connection between modern SSRI antidepressant medications and adolescent suicide, the data show that the suicide rate in adolescence during the last decade since these drugs have become available has dropped by one-third: from 15 to 10 per 100,000 children and adolescents.

While the Food and Drug Administration has required the antidepressant manufacturers to include a warning of worsening depression and increased potential for suicide, there is much confusion. The potential for suicide not only includes a suicide attempt, but also any type of cutting, self-mutilating behavior or suicidal thinking. In adolescent girls, especially, cutting oneself is often a manifestation of emotional problems, and teenagers often express death wishes over broken relationships or overwhelming stress.

In a review of 4,000 children and adolescents in clinical trials in the United States, 109 were labeled suicidal, but only 66 harmed themselves, 47 went to the hospital, and none died.

The key to good clinical practice is to consider the child’s or adolescent’s individual needs, discuss medication side effects with the patient and family, and have close regular return visits until the patient is clearly stabilized. Communication by family members to their teens, and concern and support are of paramount importance in treating this major health problem.

Paul M. Packman, M.D.
Clinical Associate Professor of Psychiatry
Washington University School of Medicine

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