Suicide is the second-leading cause of death for adolescents ages 15-19 years old. Three areas highlighted in an updated AAP clinical report recently have been identified as significant for adolescents at risk: being a victim or perpetrator of bullying; pathologic internet use and related online issues; and lack of treatment with antidepressant medication when indicated.
The report Suicide and Suicide Attempts in Adolescents, http://pediatrics.aappublications.org/content/early/2016/06/24/peds.2016-1420, from the AAP Committee on Adolescence will be published in the July issue of Pediatrics and includes a more complete discussion of adolescent suicide.
Bullying
Bullying has three elements: aggressive or deliberately harmful behavior 1) between peers that is 2) repeated and over time and 3) involves an imbalance of power, for example, related to physical strength or popularity, making it difficult for the victim to defend himself or herself.
Females are at risk regardless of frequency, whereas males are at higher risk only with frequent bullying. Suicidal ideation and behavior are greater in those bullied, controlling for age, gender, race/ethnicity and depressive symptomology. Suicidal ideation and behavior are increased in victims as well as bullies and are highest in those who have been both victims and bullies.
Internet use
There are at least four internet-related factors that may increase suicide risk in susceptible youths:
Pathological internet use is strongly associated with higher levels of depression and suicidality, according to an AAP clinical report on suicide in adolescents.
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Pathological internet use. Self-reported daily use of video games and internet exceeding five hours is strongly associated with higher levels of depression and suicidality (ideation and attempts) in adolescents.
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Searches for suicide-related topics. Suicide-related searches are associated with completed suicides among young adults. Pro-suicide websites and online suicide pacts facilitate suicidal behavior, with adolescents and young adults at particular risk.
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Learning of another’s suicide online. Such information is available through online news sites (44%), social networking sites (25%), online discussion forums (15%) and video websites (15%). Social networking sites, in particular, may reveal information on others’ suicidality that would not otherwise be available. Fortunately, exposure to information from social networking sites does not appear related to changes in suicidal ideation, likely because increased exposure is mitigated by greater social support. Participation in online forums, however, is associated with increases in suicidal ideation. Discussions in these forums may be anonymous and not particularly supportive, at times even encouraging suicide attempts by susceptible individuals.
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Cyberbullying. Similar increases in suicide attempts are found comparing face-to-face bullying with cyberbullying, both for victims and bullies.
Antidepressant medications and suicide
In October 2004, the Food and Drug Administration (FDA), amidst heavy media coverage, directed pharmaceutical companies to label all antidepressant medications distributed in the United States with a black-box warning of an increased risk of suicidality in children and adolescents treated with these agents. Their use was not prohibited, but the FDA called on clinicians to balance increased risk of suicidality with clinical need and to monitor closely “for clinical worsening, suicidality or unusual changes in behavior.” The need for close monitoring during the first few months of treatment and after dose changes was particularly stressed.
The results of subsequent studies suggest that, for appropriate youths, the risk of not prescribing antidepressant medication is significantly higher than the risk of prescribing: The 2% increased risk of suicidality cited by the FDA may be an overestimate; there is a negative correlation between antidepressant prescribing and completed adolescent suicide; very few adolescent suicide victims were found to have recent exposure to antidepressant medications; and the increase in adolescent suicides following the warning appears to correlate to a documented reduction of antidepressant prescribing.
Nonetheless, the FDA has not removed or changed the black-box warning despite the new information.
When prescribing antidepressant medications, the warning should be discussed with parents or guardians and appropriately documented. Furthermore, depression is a significant suicide risk factor and careful monitoring of emotional and behavioral status is important, particularly when initiating or changing treatment.
Guidance for pediatricians
1. Ask adolescents about mood disorders, use of drugs and alcohol, suicidal thoughts, bullying, sexual orientation and other risk factors associated with suicide via routine history-taking. Consider using a depression screening instrument at 11- to 21-year-old health maintenance visits and as needed.
2. Educate yourself and your patients about the benefits and risks of antidepressants.
3. Recognize the medical and psychiatric needs of the suicidal teen, and work closely with families and other health care professionals in the management and follow-up of those who are at risk or have attempted suicide. Develop working relationships with colleagues in the community. Ensure good communication, continuity and follow-up through the medical home.
4. Become familiar with local, state and national resources related to suicide prevention in youths.
5. Consider additional training in diagnosing and managing adolescent mood disorders, especially if practicing in an area underserved by mental health professionals.
6. During routine evaluations, ask whether firearms are kept in the home and discuss with parents the increased risk of adolescent suicide with the presence of firearms. For teens at risk of suicide, advise parents to remove guns and ammunition from the house, and secure supplies of prescription and over-the-counter medications.
Dr. Shain, lead author of the clinical report, is the former liaison from the American Academy of Child and Adolescent Psychiatry to the AAP Committee on Adolescence.
