Improving Injury Prevention Capacity in the Child Death Review Process: Best Practices: Suicide

List of Potential Interventions

Overview

Each year, one in five teenagers in the United States seriously considers suicide; 5% to 8% of adolescents attempt suicide, representing approximately 1 million teenagers, of whom nearly 700,000 receive medical attention for their attempt (Grunbaum et al., 2002); and approximately 1,600 teenagers die by suicide (Anderson, 2002).

The Youth Risk Behavior Survey (YRBS) indicated that during the past year, 19% of high school students "seriously considered attempting suicide," nearly 15% made a specific plan to attempt suicide, 8.8% reported any suicide attempt, and 2.6% made a medically serious suicide attempt that required medical attention.

Risk factors for suicidal ideation, suicidal behavior and completed suicide among youth are well described: over 90% of youth suicide completers have least one major psychiatric disorder, most commonly a depressive disorder; and in many studies, the impact of other identified risk factors is clearly mediated by their effect on depression. A history of a prior suicide attempt is one of the strongest predictors of completed suicide, conferring a particularly high risk for males.

Other risk factors include:

substance abuse (more strongly associated with suicide attempts than with ideation);
posttraumatic stress disorder;
hopelessness;
poor interpersonal problem-solving;
difficulties in school;
homosexual or bisexual orientation;
family history of suicidal behavior;
parental psychopathology; and
life stressors, such as interpersonal losses, parent-child conflict, and legal or disciplinary problem.

While controversial, suicide clusters do seem to exist with evidence of "suicide contagion." These temporo-spatial clusters typically involve only teens and young adults.

Family cohesion has been reported as a protective factor, as has religiosity — often identified as underlying the lower suicide rates among African Americans.

The number of proven effective interventions for youth suicide is extremely limited. While many interventions have been implemented, few have been evaluated, mostly with non-rigorous designs. The evaluation of suicide prevention programs is very difficult because it is a relatively rare event, and because most suicide attempts are not reported. Thus, statistically significant reductions in suicide rates are difficult to show and require very large samples. For example, to demonstrate a reduction in the suicide rate among young males by 20% would require an intervention group of nearly 3 million and a control group of similar size.

Prevention strategies reviewed for this project include:

Primary Prevention — strategies to reduce the prevalence of risk factors for suicidality in a population of young people
Secondary Prevention — strategies to reduce risk of attempted or completed suicide among youth with depression, hopelessness or suicidal ideation.
Tertiary Prevention — strategies to reduce the recurrence risk among youth with identified suicide attempts or to decrease the lethality of such attempts.

Note that our review focuses on interventions that have been tested with suicide, suicide attempts or suicidality as identified outcomes or those targeting risk factors with the explicit goal of reducing youth suicide. However, many evidence based practices may impact known risk factors for suicide and, thereby, reduce the risk of youth suicide without ever being studied for this purpose. Such interventions might include prevention,detection and treatment of youth depression or the prevention, detection and treatment of youth substance abuse — topics currently beyond the scope of this review.

References

Grunbaum JA, Kann L, Kinchen SA, Williams B, Ross JG, Lowry R, Kolbe L. Youth risk behavior surveillance--United States, 2001. J Sch Health, 2002 Oct;72(8): 313-28.

Anderson RN (2002), Deaths: leading causes for 2000. National Vital Statistics Reports 50(16). Hyattsville, MD: National Center for HealthStatistics.

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