Editorial: Adolescent Suicide and Suicidal Behavior: A Time to Assess and a Time to Treat
Brent, David A., Apter, Alan, The Israel Journal of Psychiatry and Related Sciences
In the past two decades, there has been tremendous progress in understanding the phenomenology, risk factors and prognosis of adolescent suicide and suicidal behavior. When we both began working in this area, experts would list 10 "myths" of adolescent suicide, beginning with "adolescents who commit suicide are mentally ill." Now, on the basis of psychological autopsy studies conducted in the United States, Israel, Canada, New Zealand and Finland, we know that most youths who commit suicide have one, and often more than one major psychiatric illness (1).
While some youths commit suicide relatively early in the course of their illness (2), most adolescent suicide victims commit suicide after chronic difficulties. Among the psychiatric difficulties associated with completed suicide are mood disorders, substance abuse and conduct disorder; the combination of all three is very typical of older male adolescent suicide victims (3, 4).
Past suicide attempt is a particularly potent risk factor for completed suicide, and belies another "myth" of adolescent suicidal behavior - that people who talk about suicide don't complete it. The exact opposite is actually true. People who talk about suicide and engage in suicidal behavior are at the highest risk for completed suicide. In addition to psychiatric risk factors, a history of abuse, "drifting," that is being disconnected from family, work and school, family history of psychiatric disorder and of suicidal behavior, and availability of firearms and other potentially lethal agents appear to increase the risk for completed suicide (5). The latter finding may be culturally specific, since availability of firearms has been shown to be related to suicide in the United States but not New Zealand, whereas availability of acetominophen has been related to risk for suicide and suicidal behavior in the United Kingdom (6-8).
As noted above, at one time, suicide attempters and completers were considered two completely different populations. Now, with further study, we have learned that attempters and completers are quite similar, although more females attempt and more males complete suicide. The risk factors are similar for this spectrum of suicidal behavior; because suicide attempters are alive, we have learned about their psychological profile as well. Hopelessness, impulsive aggression (a tendency to react to frustration or provocation with hostility or aggression), impulsivity and neuroticism are some of the psychological traits that predispose to suicidal behavior (9, 10). Impulsive aggression appears to account in part for the familial transmission of suicidal behavior above and beyond the transmission of psychiatric disorder per se (11, 12). Impulsive aggression may be an additional target for treatment besides treatment of psychiatric conditions such as depression.
Moreover, a series of community studies have conclusively demonstrated that gay/bisexual sexual orientation is a risk factor for suicidal behavior, although it is unclear if this is because of higher rates of mood and substance abuse disorders in gay and bisexual youths or if there are other factors, such as victimization and family rejection, that also contribute to increased suicidal risk in this population (13).
Risk factors for repetition of suicidal behavior and ultimate completion include greater initial lethality and intent, presence of mood disorder comorbid with non-affective conditions such as substance abuse, more severe and chronic depression, greater aggression and hostility, and availability of a lethal agent (14).
When we first became interested and concerned with the clinical problem of adolescent suicide, the suicide rates were rapidly increasing. Now, for the first time in three decades, the rates have declined (15). The increase has been attributable to secular trends in substance abuse, depression, increased publicity about suicide, increased unemployment and increased availability of lethal agents. …