Youth Suicide Awareness and Prevention for Clinicians

For clinicians working with young people recognizing and properly assessing suicidal risk may be the most important, yet most overlooked, competency for practitioners in the mental health community. Suicide is the third largest cause of death, falling short of only accidents and homicide for adolescents. As clinicians it is essential we understand the common risk factors, warning signs, and be able to effectively intervene. I have compiled key information utilized in the training clinicians on the front lines of managing psychiatric crisis.

Understanding trends and tendencies can be helpful in awareness and prevention. The CDC has identified the following trends:

• Gender – A higher percentage of female students reported suicidal ideation and suicide attempts but male students were more likely to complete suicide

• Race – Hispanic students were more likely then black or white students to report all 5 suicide risk behaviors: 1. Feeling sad or hopeless 2. Seriously considering suicide 3 Having a plan for suicide 4. Attempting suicide 5. Making a suicide attempt that required medical attention

• Age – Suicidality was more prevalent among 9th, 10th, and 11th graders then 12th graders.

Per NIMH the prevalence of suicidal thoughts among adults is highest among people ages 18-25

Suicide Definitions and Theories

• Suicidal ideation – thinking about suicide

• Suicidal Intent – ideation is present as well as plan to act on the ideation

• Suicidal plan – ideation is present, a intent to act on ideation, and a specific way to act on the ideation has been identified

• Means – access to what would be necessary to carry out suicide plan, significant for determining how imminent the risk

• Suicide attempt – when an individual has actually attempt to commit suicide; A successful attempt results in completed suicide

• Self-injury – inflicting nonlethal harm to oneself, typically superficial to moderate damage is caused

• Precipitating event – the triggering event or circumstance that subjective leads to increased symptoms, suicidality.

Dr Thomas Joiner, one the leading experts of suicidal behavior, has theorized three preconditions that contribute to suicide.

1. Fearlessness or “acquired capability”: People who commit suicide have conditioned themselves not to fear death. This is described as an acquired ability to enact lethal injury.

2. Perceived burdensomeness: A belief they are a burden to others

3. Thwarted belongingness: A profound sense of isolation

Dr Joiner theorized that all 3 factors must be present before an individual will commit suicide. All three factors are significant risk factors to pay attention to and respond.

Biology and suicide

• The link between biology and suicide has been well established and many believe that genetic links exists

• Many believe that if you have lost a family member to suicide you are at a higher risk for suicide

• Young people who have diagnosed mental illness are at a must greater risk of attempted/completing suicide

• Research has been making progress in understanding the neurobiology of suicide. Studies have been beginning to identify biomarkers for suicidal behavior which will hopefully have a positive impact on treatment strategies in the future.

Assessment and Warning Signs

Warning signs are indicators that a person may be thinking about killing themselves. The good news is that there are warning signs most of the time. Increasing awareness of warning signs and predictive factors is essential for mental health clinicians

Recognizing warning signs

As many as 4 out of 5 teens that attempt suicide have given clear warnings such as

• Verbalizing suicidal threats

• Poems, essays, drawings, notes

• Dramatic change in personality or appearance

• Irrational, bizarre behavior

• Overwhelming sense of guilt, shame, or reflection

• Changes to eating and/or sleeping patterns

• Severe decline of school performance

• Giving away belongings/prized possessions

The CDC has identified the following potential risk factors

• History of previous suicide attempts(most significant risk factor)

• Family history of suicide

• Easy access to lethal means

• History of mental illness

• Substance use

• Stressful life event or loss

• Exposure to suicidal behavior of others

• Incarceration

Typically adolescents who commit suicide have a combination of several risk factors

Additional risk factors include:

• Family history of abuse/neglect

• Barriers to accessing mental health treatment

• Physical illness

• Recent bereavement

• Anniversary phenomenon(of past losses or major life events)

• Early loss experiences

• School failure

• Perfectionists who have high expectations or themselves

Common traits among adolescents who are contemplating suicide

• An inability to tolerate emotional, interpersonal, and behavioral stressors

• Cognitive rigidity = they do not see other options, only see one way out

• A reduced flexibility in thinking

• Dichotomous thinking = black and white, all or nothing

• Poor abstract and interpersonal problem solving skills

• Reduced or extremely impaired coping skills

Common symptoms of adolescents at risk for suicide

• A prolonged negative mood

• A marked change in sleeping or eating habits

• An inability to cope with problems and daily stressors

• Substance use – as many as 50% who attempt suicide have used substances in the past.

• Frequent emotional outbursts

• Excessive complaining of physical ailments

• Defiance or authority, truancy, and/or vandalism

• Preoccupation with weight and appearance

• Withdrawal/Isolation from friends and family

• Unusual neglect of personal appearance

Plans, preparation, and risk

• All suicidality should be taken seriously but Individuals who have displayed ideation, intent to commit suicide, and a plan to do so present a significantly higher risk then individuals who express a death wish, not wanting to be alive, or who have even made a suicidal gesture.

• Some individuals may express ambivalence about their feelings. They may express having feeling of both wanting to live and wanting to die.

• Communication is a key: Adolescents who attempt suicide often felt they were unable to cope with their problems, that others deny their need for help, and others do not attend to their for help even if recognized

• Adolescents may verbalize thoughts of suicide or communicate through their behavior.

• An adolescent that is feeling suicidal is often in the midst of crisis – will be experiencing strong and conflicting emotions, will be unable to cope effectively, and may be confused or illogical – Crisis upsets the balance between thoughts/feelings and behavior

• A crisis provides an unusual opportunity for intervention. While the crisis is happening is time to act, time to access assessment/treatment

How to assess for suicide ideation and risk as a clinician

Any time a clinician suspects there is a risk of suicide, they should ask the client directly about whether or not they are experiencing suicidal ideation. A t a minimum, ask the client directly about the presence, frequency, and nature of any suicidal thoughts.

1. Remain calm and non-judgemental while assessing

2. Phrase questions in a way the patient can understand and avoid jargon

3. Try to use open ended questions that allow the patient to explain their situation versus answering yes or no

Key questions/areas to cover

• Ask directly about suicidal thoughts

• Determine the frequency/circumstances

• Determine if there is actual intent and/or plan

• Explore history of attempts or suicidality

• Determine availability of means and lethality

• Assess for drug or alcohol use

• Assess current circumstances

• Differentiate between self-injury and suicidality

Is Path Warm tool

I – Ideation

S – Substance use

P – Purposeless/no reason to live

A – Anxiety, agitation, insomnia

T – Trapped/feeling no way out

H – Hopelessness

W – Withdrawal

A – Anger

R – Recklessness/risk taking behavior

M – Mood changes

Knowing when your patient should be evaluated for a higher level of care can be the difference between life and death. Your role as a clinician may not always be to make the determination that hospitalization is needed but recognizing and understanding the warning signs and risk factors can help you guide your clients successfully. Some level of assessment of risk factors for suicide should be a regular part of treatment for all patients but understanding the complexity of this issue for young people takes patience and experience.