Tuesday, May 12, 2009

Risk factors in Adolescent Suicide

Suicidal Behavior in Adolescents: Risk Factor Identification, Screening, and Prevention

Jaspal S. Ahluwalia, MD, MPH

Suicide is the third leading cause of death, following unintentional injuries and homicide, among adolescents in the United States.[1] There have been approximately 2000 adolescent suicides per year during the past decade, accounting for some 10% of all deaths in adolescents. Further, in an alarming trend, adolescent suicide rates have doubled in the United States over the past 50 years.[2] This increase may be attributed at least in part to increased rates of depression, alcohol and substance abuse, family disintegration, and access to deadly weapons during this time.

With the exception of suicidal ideation, most types of suicidal behavior are rare before the onset of adolescence. After the onset of adolescence, there is a very clear increasing risk for both suicidal attempts and completions. Recent survey data[3] have shown that nearly 15% of all US high school students have seriously considered attempting suicide; more than 11% have made a plan for suicide; and almost 7% have attempted suicide in the past year. Although girls are more likely to engage in suicidal ideations, planning, and attempts, boys are more likely to complete a suicide due to boys using more violent and dangerous means. White male adolescents have the highest rate of suicide.[4] With such high rates of contemplated, attempted, and successful suicide among adolescents, it is particularly important to understand the risk factors for suicide, as well as ways to screen for it and effectively prevent it.

Risk Factors for Suicide

Suicide risk is greatly increased with the presence of both depression and an anxiety or disruptive disorder.[5] Concerns over an association between selective serotonin reuptake inhibitor (SSRI) therapy and suicide risk in adolescents led to the US Food and Administration (FDA) issuing a warning in 2004.[6] Since then, however, observational studies[7,8] have found that a broader extent of SSRI prescriptions in the population are associated with lower suicide rates in children. These findings may reflect on antidepressant efficacy, adherence, the quality of mental healthcare, and the lower toxicity of these medications in the event of an overdose or suicide attempt. Several organizations have issued specific prescribing recommendations for SSRIs.[9-11] The American College of Neuropsychopharmacology (ACNP), the American Academy of Child and Adolescent Psychiatry (AACAP), and the Society for Adolescent Medicine (SAM) all recommend the use of fluoxetine in the treatment of depression in adolescents. Their findings suggested that use of SSRIs, such as fluoxetine, may have a slightly higher risk of increasing suicidal ideation but do not increase the risk for completed suicides.

Suicidal behavior risk factors have been classified into 2 separate categories: predisposing factors and precipitating factors.[12] Predisposing factors are those that directly increase an adolescent's risk for suicide. They include the following.

1.Previous Suicide Attempt
Adolescents who have had a previous suicide attempt are much more likely to try again, with an even more marked increase in those with multiple previous attempts. Between one quarter and one third of adolescents who attempt suicide will go on to try again, with the greatest risk for recurrence falling between 6 months and 1 year after their first attempt.[13]

2.History of a Prior or Ongoing Psychiatric Disorder
A prior or ongoing psychiatric disorder is a major risk factor for suicide, with studies showing that adolescents who commit suicide have a higher rate of depression, substance abuse disorders, eating disorders, anxiety disorders, and antisocial disorders.[14-16]

3.History of Sexual or Physical Abuse
Studies have shown that adolescents who are victims of sexual or physical abuse are up to 3 times more likely to commit suicide and up to 8 times more likely to have repeated suicide attempts.[17]

4.History or Exposure to Violent Behavior
Adolescents who have been exposed to high levels of violence are twice as likely to attempt suicide as those who have not.[18]

5.Family History of Suicidal Behavior or Mood Disorders
A family history of suicidal behavior plays both a genetic and environmental role in increasing the risk for an adolescent's likelihood to attempt or commit suicide.[19]

6.Biological Factors, Including Male Sex and Gay or Lesbian Sexual Orientation
Boys are about 5-6 times more likely to complete suicide than girls.[4] Gay and lesbian teens are much more likely to have suicidal ideations and attempt suicide than heterosexual teens.[20,21] There is some evidence to suggest that those adolescents with smaller concentrations of serotonin and all of its metabolites and receptors and neurons are at a greater risk of attempting and committing suicide.[22]

In addition to these 6 direct risk factors, 4 main precipitating, or potentiating, factors play a role in adolescent suicide. Although they are not sufficient in and of themselves to increase suicide risk, they can synergistically increase the likelihood of some form of suicidal behavior when they are present. They include:

Substance abuse[23];

Access to firearms or other means[24];

Social stress, such as interpersonal conflicts with friends, family, or law enforcement[25];

Emotional factors, such as feelings of despair or hopelessness.[2]

for rest of article see: http://cme.medscape.com/viewarticle/702018

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