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(p. 533) Research Agenda for Youth Suicide Prevention 

(p. 533) Research Agenda for Youth Suicide Prevention
Chapter:
(p. 533) Research Agenda for Youth Suicide Prevention
Author(s):

Ann P. Haas

, Herbert Hendin

, Jill Harkavy-Friedman

, and Maggie Mortali

DOI:
10.1093/med-psych/9780199928163.003.0025
Page of

date: 19 September 2018

(p. 534) What We Know

Youth Suicide

  • Between 1955 and 1980, the suicide rate among young people in the United States roughly tripled from about 4 suicides per 100,000 population ages 15 to 24 to over 12 suicides per 100,000. Most of this was due to a startling increase in the suicide rate among young males. Through the 1980s and early 1990s, the youth suicide rate increased much more slowly, reaching a peak rate of over 13 per 100,000 in 1994, and then generally declined to a low of 9.6 in 2003. Since 2004, the youth suicide rate has again been trending upward, rising to 12.3 in 2015, the last year for which national data are available. In 2015, the suicide rate among youth approximated what it was in 1980.

  • In 2015, almost 5,500 young people ages 15 to 24 died by suicide.

  • Suicide is the currently the third leading cause of death among youth ages 15 to 24.

  • Among young people ages 15 to 24, the suicide rate for males is almost four times the rate for females. In recent years, the gender difference in suicide rates has been generally decreasing.

  • Youth suicide rates vary widely among different racial and ethnic groups. In 2015, the highest rate was among American Indian and Alaskan Native youth (21 per 100,000), followed by white youth (13 per 100,000), Asian American/Pacific Islander youth (10 per 100,000), and black youth (8 per 100,000). With the exception of Hispanics, youth in all racial and ethnic groups have recently experienced rising suicide rates.

  • Like gender differences, racial-ethnic differences have been decreasing somewhat in recent years.

  • Although college enrollment is not systematically identified postmortem, studies point to a significantly lower suicide rate in college students compared to youth of the same ages who are not in school.

  • In 2015 school-based surveys, 9% of American high school students reported making a suicide attempt within the previous 12 months, with female students more likely than males to report an attempt. Eighteen percent of high school students reported having seriously considered suicide during the previous 12 months.

  • Although mortality statistics do not identify sexual orientation or gender identity, studies consistently point to elevated rates of reported suicide attempts among sexual and gender minority (SGM) youth relative to the general youth population. Specific stressors related to SGM status, including rejection, discrimination, and victimization, appear to contribute to higher rates of mental health problems, suicidal ideation, and suicide attempts in SGM youth.

  • Among youth (and adults), a prior suicide attempt significantly increases the risk of subsequent attempts and suicide death.

  • A large majority of youth (70%–90%) who die by suicide had at least one psychiatric illness at the time of death. The most common diagnoses among youth are depression, substance abuse, and conduct disorders.

  • Other factors associated with youth suicide include physical abuse, sexual abuse, serious conflict with parents, interpersonal loss, not being in school or not working, exposure to the juvenile justice system, knowing someone who has attempted suicide or died by suicide, and access to firearms.

  • Suicide and suicide attempts are increased in families in which a parent has died by suicide or attempted suicide.

  • Factors that appear to protect against suicidal behavior in youth include family connectedness and support, school connectedness, school safety, reduced access to lethal means, and social-behavioral (p. 535) skills. Among SGM youth, acceptance by family and peers appears to protect against suicidal ideation and behavior.

Youth Suicide Prevention Programs

  • Programs that screen high school and college students to identify those at risk for suicide and refer them for treatment can identify some high-risk individuals who were not previously recognized or treated.

  • Programs that train teachers and school personnel, counselors, and community gatekeepers about suicide intervention can increase knowledge about suicide and suicide prevention, increase self-confidence and willingness to intervene, and increase referrals to treatment.

  • Under adequate conditions of implementation, programs that educate students about suicide can increase students’ knowledge of mental health conditions and suicide, encourage more adaptive attitudes about these problems, encourage help-seeking behaviors, and increase referrals of at-risk students to treatment.

  • Skills training programs that enhance problem-solving, coping, and cognitive skills, which have been found to be impaired in suicidal youth, may reduce suicide risk factors associated with depression, hopelessness, and substance abuse among at-risk individuals.

  • Comprehensive programs that aim to create a supportive school environment by fostering a climate of open communication can serve as a protective factor against suicide risk and increase help-seeking among at-risk students.

Treating Suicidal Ideation and Behavior and Underlying Disorders in Youth

  • Under adequate conditions of implementation, intensive school-based programs focusing on improving problem solving and social behavior can reduce rates of depression, suicidal ideation, and suicide attempts in students at risk of dropping out of school.

  • Programs that engage young suicide attempters and their families while they are in the emergency department can increase adherence to outpatient treatment and decrease immediate and subsequent hospital admissions.

  • Psychotherapies that include a focus on managing suicidal ideation can improve social functioning and reduce suicidal ideation and self-harm behaviors among suicidal youth. When families are available and willing to participate in treatment, family therapy that includes a focus on understanding and managing the adolescent’s suicidal behavior has demonstrated effectiveness for reducing suicidal ideation and behavior.

  • Cognitive-behavioral therapy (CBT), Dialectical Behavioral Therapy (DBT), and Interpersonal Therapy (IPT) have demonstrated the ability to relieve depression and improve social functioning in adolescents. CBT and DBT have shown some success, at least in the short term, in reducing suicidal ideation and behaviors in suicidal youth.

  • There is evidence that treatment with fluoxetine (Prozac) can reduce depression, alcohol dependence, and suicidal ideation in youth.

  • Combination treatment involving fluoxetine and psychotherapy appears to result in the most positive outcomes for depressed, suicidal youth.

  • There is some evidence that posthospitalization programs for suicidal youth can reduce subsequent suicidal ideation and mood impairment among female participants.

What We Don’t Know

Despite considerable research and program development focusing on youth suicide, there is much we do not yet know about the factors that cause or significantly influence suicidal behavior among youth, and how this behavior (p. 536) can be prevented or treated. Listed below are the key knowledge needs our review has identified, which constitute a future research agenda for youth suicide.

Youth Suicide

  • Although psychopathology has been well documented to be the most potent factor underlying suicide among all age groups, relatively little is known about the specific clinical pathways to youth suicide. In particular, more needs to be known about the contribution of bipolar disorder, panic attacks, and posttraumatic stress disorder to suicide deaths among youth. The impact of demographics, including race, ethnicity, sexual orientation, and gender identity, on diagnostic profiles and clinical pathways to suicide likewise needs greater scrutiny. Longitudinal studies of young people with suicidal ideation and behavior are especially needed. In addition, because most people with psychopathology do not engage in suicidal behavior, and suicidal behavior crosses many different psychopathologies, more research is needed on the interactions among specific forms of psychopathology, suicide risk factors other than mental disorders, and factors that protect against suicide.

  • Much more needs to be known about the role of neurobiological abnormalities that contribute to youth suicidal behavior, especially the role of genetic processes such as gene expression. Family studies of adults and adolescents who have attempted suicide or died by suicide can provide important information about the interaction between genes and the environment, and it is essential that youth be included in such research.

  • The extent to which parental/familial psychopathology influences suicide ideation, attempts, and completions among youth, over and above genetic influences, needs to be examined. Specifically, what is the effect of exposure to parental suicide attempts and completion on the suicide risk among youth? Does childhood physical and sexual abuse confer suicide risk independent of other effects of family psychopathology?

  • Because sexual orientation and gender identity are not systematically identified at the time of death, mortality rates cannot be determined for SGM people. Psychological autopsy studies have produced equivocal conclusions about whether SGM youth make up a higher percentage of youth suicides than their prevalence in the population. Although recent analyses of psychological autopsy findings suggest a higher rate of completed suicide in SGM youth, these studies are not an adequate substitute for systematic, routine identification of sexual orientation and gender identity in suicide decedents.

  • Although suicide clusters have been identified among youth, the characteristics of those most vulnerable to “contagion” and the mechanisms through which contagion occurs have not been precisely identified.

  • More needs to be understood about the role of personal and social skills in protecting youth from suicidal behavior. Do strong problem-solving skills, decision-making abilities, and support from family and schools actually protect young people from developing suicidal impulses, or is the absence of such skills a manifestation of psychopathology that is more directly related to suicidal thoughts or behavior? What is the role of culture, identity, and religious beliefs in reducing suicide risk?

  • Both theoretically and in practical programmatic terms, it is essential to have better understanding of which combinations of risk and protective factors have the greatest predictive value for youth suicide. Current research points to the identification and treatment of psychopathology among adolescents as a priority suicide prevention strategy, but better understanding is needed of the (p. 537) wide range of interpersonal, cultural, and environmental factors that may exacerbate or mitigate the impact of psychopathology among particular groups of high-risk youth. In addition, some treatments have been found to reduce suicidal ideation and behavior without significantly affecting psychopathology. Research to date has focused almost exclusively on looking at relationships between single risk or protective factors and adolescent suicidal behavior. Comprehensive analyses that simultaneously consider a number of individual variables are essential.

  • Greater understanding of the suicidal state, including onset, cognitions, access to self-care, and protective factors, is needed to assist youth in managing a suicide crisis.

Youth Suicide Prevention Programs

  • Most suicide education programs have not identified the active ingredients responsible for the outcomes they produce.

  • Most suicide education programs target outcomes whose relationship to youth suicide has not been precisely identified. Many, for example, have reported increased knowledge of mental health conditions and suicide among students, although the impact of this outcome on suicidal behavior is not known. Greater attention needs to be given to identifying long-term behavioral outcomes among students who have received such education, particularly those with particular risk factors.

  • Although increasing the number of referrals to treatment is a key goal of screening programs, there is no clear evidence of a direct linkage between increased referrals and decreased suicidal behavior among youth.

  • Screening programs have generally not identified effective mechanisms for encouraging larger numbers of youth identified as being at risk for suicide to enter treatment.

  • Few data are currently available about the cost-effectiveness of school-based screening programs.

  • Although popular in recent years, the effects of postvention programs, both positive and adverse, on youth exposed to a suicide death have not been clearly documented.

  • Despite limited evidence that educational programs directed to parents, particularly fathers, can decrease youth access to firearms, the impact of means restriction programs on decreasing suicide attempts and suicide deaths among youth has not been documented.

Treatment of Suicidality and Underlying Disorders Among Youth

  • The active ingredients of comprehensive high school–based programs for treating at-risk students, including those who are depressed and suicidal, have not been clearly identified.

  • It has not been demonstrated that students at risk of dropping out of school are representative of suicidal youth generally, and therefore that programs that address this population have wide applicability.

  • The replication of such programs, which require considerable personnel and financial resources, has not been established.

  • The impact of emergency department programs for young suicide attempters and their families on decreasing suicide deaths has not been established.

  • Although studies have demonstrated the success of behavioral and educational treatments in improving the social skills and reducing the aggressive behavior of autistic children and adolescents, their effect on reducing suicidal behavior has not yet been determined.

  • Assessment of suicide risk in emergency departments is still challenging, and although new screening approaches are currently being tested, the best method for implementing risk assessment has yet to be determined. (p. 538)

  • Engagement in treatment in the emergency department can facilitate treatment and reduce suicidal ideation and behavior in the short term, yet the impact on engagement and effectiveness in longer-term treatment is unclear.

  • Although some promising outcomes have been reported, long-term effects of psychotherapy with suicidal youth are not yet known.

  • Although fluoxetine (Prozac) and other selective serotonin reuptake inhibitors (SSRIs) have been shown to reduce depression, alcohol dependence, and suicidal ideation in youth, the long-term effects of these drugs on adolescents are not known.

  • Much more needs to be known about the combinations of psychotherapeutic and pharmacological treatment that produce the most positive short- and long-term outcomes for depressed, suicidal youth.

  • Long-term effects of posthospitalization programs for suicidal youth have not been documented.

Methodological Challenges

Our review has made clear the extent to which scientific evaluation of youth suicide prevention programs has lagged far behind their development and implementation. As a result, efforts may show promise, but very few have been shown with reasonable certainty to be effective in preventing suicidal ideation, suicide attempts, or suicide deaths among youth.

Prospective randomized controlled trials (RCTs) are needed to determine the effectiveness, safety, and active ingredients of universal and targeted suicide prevention programs, including school-based education, screening, and skills development programs, and school and community interventions for at-risk populations, including limiting access to lethal means such as firearms and implementing gatekeeper training programs.

Some suicide prevention programs, in particular universal education programs, have targeted outcome variables whose relationship to youth suicide has not been precisely identified. Clearer hypotheses about variables believed to contribute to suicidal behavior need to be formulated, justified, and addressed in the prevention strategy. Following the intervention, changes in the variable must be specifically measured to determine if in fact it functions as a mediator of suicide-related outcomes. Without such a procedure, findings from many studies are difficult to integrate, leaving the field with an absence of information as to what actually worked, and what directions and models are worthy of further investigation.

Since universal and selective suicide prevention programs focus heavily on encouraging help seeking and on identifying vulnerable youth and referring them to treatment, their impact on reducing youth suicide depends ultimately on the effectiveness of the treatments that are available to such young people. Thus, the single highest priority must be given to determining the relative efficacy and effectiveness of all currently employed treatments and indicated interventions for suicidal youth.

Sampling Strategies

Relatively few suicide prevention programs have systematically studied adequate numbers of representative at-risk youth to allow meaningful conclusions to be reached about program effectiveness, and only rarely have appropriate comparison groups been simultaneously studied. Further, most outcome studies have had access to program participants for a short period of time, which precludes identification of any long-term effects of the program, including adverse effects.

Evaluation

In regard to school-based programs in particular, effective evaluation requires follow-up of students who have participated in curricular or screening activities in order to determine long-term outcomes. To date, sufficient resources for such research programs have not been available. Further, evaluations of youth suicide prevention programs have been largely (p. 539) internal, and objective third-party evaluation of outcomes remains rare. Few youth suicide prevention programs have had the necessary personnel or financial resources to conduct independent program evaluations. If the field is to move forward, however, mechanisms need to be established that mandate and support comprehensive, well-designed outcome studies as a regular part of prevention programming.

Treatment Research

As has been noted, RCTs of treatments used for suicidal youth are seriously lacking, and there are improvements in the approach to suicide prevention that have yet to be systematically tested. Comparative RCTs of clinical treatment are clearly needed to determine the impact of brief interventions with young suicide attempters presenting to emergency departments, psychotherapeutic strategies for suicidal youth, pharmacological treatments for young suicide ideators and attempters, as well as hospitalization, partial hospitalization, and posthospitalization support programs for youth. Psychotherapies that have been found to be effective for suicidal youth have many components, and further study is needed to determine which components are the essential ingredients for effective treatment. Also, while most treatment studies have focused on a particular therapy such as CBT, DBT, or IPT, clinicians who treat suicidal adolescents or adults frequently use aspects of each of these therapies, in addition to psychodynamic techniques and medication when indicated. Although many clinicians believe an “integrative approach” is the best treatment strategy, to date its effectiveness in reducing suicidal ideation and behavior has not been definitively demonstrated, at least in part because of the challenges of clearly specifying and measuring the components of therapies that combine multiple techniques. As part of future research efforts, an integrative treatment for suicidally depressed adolescents should be developed, implemented, and tested for effectiveness, using a treatment like CBT as a control.

In addition to the general evaluation concerns noted above, treatment trials involving high-risk youth need to be especially attentive to building in appropriate safeguards. Although control or comparison groups are essential, the inclusion of such groups necessitates ethical consideration of appropriate “control” treatments. Few studies involving treatments for suicidality among youth have adequately defined or measured the therapeutic effects of treatment as usual.

Many treatment trials involving adolescents deemed to be at risk for suicide eliminate those who have recently made a suicide attempt. Although recent attempters are at increased risk for suicide, they can and need to be included unless they are actively suicidal. Further, youth who engage in suicidal behavior vary considerably with respect to specific forms of psychopathology, substance abuse, and other psychosocial problems, and treatment trials must address this variability (Hawton & Sinclair, 2003). Particular protections must be developed to allow inclusion in such trials of suicidal youth with serious alcohol and drug problems, which confer considerable risk for subsequent attempts and suicide death. Adverse effects of treatment, including medications, also need to be more closely evaluated.

A major problem for suicide research in general, and for research with adolescents in particular, is keeping patients at serious risk for suicide involved in outpatient treatment, and hence in treatment evaluation studies. Innovative approaches need to be developed to engage and sustain troubled youth in treatment, in order both to prevent subsequent suicidal behavior and to allow short- and long-term treatment outcomes to be observed.

The ultimate criteria for effectiveness in suicide prevention remain reduction in suicide attempts and suicide deaths, events for which the population base rate is low. The primary limitation of virtually all studies of the effectiveness of treatments for suicidal patients has been their relatively small size and thus their limited power to detect significant differences between or among alternative strategies (Hawton & Sinclair, 2003). Enrolling adequate (p. 540) numbers of appropriate participants into treatment trials can best be achieved through a number of centrally coordinated treatment research centers that can pursue common studies of treatment effectiveness. The formation of such centers was a primary recommendation of a 2002 Institute of Medicine report on suicide (Goldsmith, Pellmar, Kleinman, & Bunney, 2002), but limited progress has been made toward this goal. The Internet has facilitated virtual collaborations for researchers, and more attention needs to be given to these and other strategies for securing a large enough patient population to reliably determine the impact of specific treatments on suicide-related outcomes, specifically suicidal ideation and behavior.

Conclusion

Much has been learned about why suicide occurs in young people and how it can be prevented, but more needs to be done. Based on our review, we offer the following summary conclusions to guide future research and prevention efforts:

  1. 1. Suicidal ideation, suicide attempts, and completed suicide are distinct behaviors, and findings about one behavior do not necessarily explicate the others. Thinking about suicide and attempting suicide are indicators of distress and/or limited personal resources, but only infrequently are they markers for completed suicide. Even with recent increases, death by suicide in youth is rare. While relying on expanding understanding of ideation and attempts, research must also seek to learn more about young people who have died by suicide.

  2. 2. Suicide is a complex phenomenon with multiple biological, psychological, social, and environmental contributors. How these converge to produce a state of suicide crisis is not well understood. Greater focus on understanding how the suicidal state develops and resolves in youth is critical.

  3. 3. To be effective, suicide prevention will need to occur simultaneously on both the individual and community levels, with continued attention to developing, implementing, and evaluating empirically based universal, targeted, and indicated interventions.

  4. 4. Limiting access to lethal means is an essential consideration in any effort to prevent suicide.

  5. 5. Longitudinal studies of large samples are needed to follow up suicidal and at-risk youth through their young adult, middle adult, and later life years. It is clear that risk factors experienced early in life, including psychopathology, can have long-term impact, and sustained attention to the problems evidenced by vulnerable youth population is needed across the lifespan.