Youth Suicide

The research contributing to our understanding of who is at risk for suicide and how to prevent and treat suicide will be critically evaluated. A comprehensive understanding of this information is critical to clinicians who deal with the mental health problems of children and adolescents. Each year, one in five teenagers in the United States seri-

ously considers suicide (Grunbaum et al., 2002); 5% to 8% of adolescents attempt suicide, representing approx- imately 1 million teenagers, of whom nearly 700,000 receive medical attention for their attempt (Grunbaum et al., 2002); and approximately 1,600 teenagers die by suicide (Anderson, 2002). Only by recognizing who is at risk for suicide, and knowing how to prevent suicidal behavior and provide treatment for suicidal individuals, will mental health practitioners and those designing edu- cational and public health prevention programs have suf- ficient armamentaria to combat this major public health and clinical problem in youths. The current review is based on a comprehensive, but not exhaustive, review of the research on youth suicide conducted in the past decade. Preference was given to population-based epidemiolog- ical and longitudinal investigations and controlled pre- vention/intervention studies.

OVERALL RATES AND SECULAR PATTERNS

Suicide was the third leading cause of death among 10- to 14-year-olds and 15- to 19-year-olds in the United

Accepted December 3, 2002. Dr. Gould is a Professor at Columbia University in the Division of Child and

Adolescent Psychiatry (College of Physicians & Surgeons) and Department of Epidemiology (School of Public Health) and a Research Scientist at the New York State Psychiatric Institute (NYSPI). Mr. Greenberg is with the Division of Child and Adolescent Psychiatry, Columbia University, NYSPI. Dr. Velting is an Assistant Professor at Columbia University in the Division of Child and Adolescent Psychiatry (College of Physicians & Surgeons), and Dr. Shaffer is Irving Philips Professor of Child Psychiatry and Pediatrics at the College of Physicians & Surgeons at Columbia University.

The expert assistance of Margaret Lamm in the preparation of this manu- script is gratefully acknowledged.

Reprint requests to Dr. Gould, Division of Child and Adolescent Psychiatry, NYSPI, 1051 Riverside Drive, Unit 72, New York, NY 10032; e-mail: [email protected].

0890-8567/03/4204–0386�2003 by the American Academy of Child and Adolescent Psychiatry.

DOI: 10.1097/01.CHI.0000046821.95464.CF

Youth Suicide Risk and Preventive Interventions: A Review of the Past 10 Years

MADELYN S. GOULD, PH.D., M.P.H., TED GREENBERG, M.P.H., DREW M. VELTING, PH.D., AND DAVID SHAFFER, M.D.

ABSTRACT

Objective: To review critically the past 10 years of research on youth suicide. Method: Research literature on youth suicide

was reviewed following a systematic search of PsycINFO and Medline. The search for school-based suicide prevention pro-

grams was expanded using two education databases: ERIC and Education Full Text. Finally, manual reviews of articles’ ref-

erence lists identified additional studies. The review focuses on epidemiology, risk factors, prevention strategies, and treatment

protocols. Results: There has been a dramatic decrease in the youth suicide rate during the past decade. Although a num-

ber of factors have been posited for the decline, one of the more plausible ones appears to be the increase in antidepres-

sants being prescribed for adolescents during this period. Youth psychiatric disorder, a family history of suicide and

psychopathology, stressful life events, and access to firearms are key risk factors for youth suicide. Exciting new findings have

emerged on the biology of suicide in adults, but, while encouraging, these are yet to be replicated in youths. Promising pre-

vention strategies, including school-based skills training for students, screening for at-risk youths, education of primary care

physicians, media education, and lethal-means restriction, need continuing evaluation studies. Dialectical behavior ther-

apy, cognitive-behavioral therapy, and treatment with antidepressants have been identified as promising treatments but

have not yet been tested in a randomized clinical trial of youth suicide. Conclusions: While tremendous strides have been

made in our understanding of who is at risk for suicide, it is incumbent upon future research efforts to focus on the devel-

opment and evaluation of empirically based suicide prevention and treatment protocols. J. Am. Acad. Child Adolesc.

Psychiatry, 2003, 42(4):386–405. Key Words: suicide, epidemiology, risk factors, prevention, treatment, adolescence.

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States in 2000 (Anderson, 2002). While the rates of com- pleted suicide are low (1.5 per 100,000 among 10- to 14- year-olds and 8.2 per 100,000 among 15- to 19-year-olds), when nonlethal suicidal behavior and ideation are taken into account, the magnitude of the problem becomes obvi- ous. The surge of general population studies of suicide attempts and ideation has yielded reliable estimates of their rates (e.g., Andrews and Lewinsohn, 1992; Fergusson and Lynskey, 1995; Fergusson et al., 2000; Garrison et al., 1993; Gould et al., 1998; Grunbaum et al., 2002; Lewinsohn et al., 1996; Roberts and Chen, 1995; Sourander et al., 2001; Swanson et al., 1992; Wichstrom, 2000; Windle et al., 1992). Of these studies, the largest and the most representative is the Youth Risk Behavior Survey (YRBS) (Grunbaum et al., 2002), conducted by the Centers for Disease Control and Prevention (CDC). The YRBS indicated that during the past year, 19% of high school students “seriously considered attempting suicide,” nearly 15% made a specific plan to attempt suicide, 8.8% reported any suicide attempt, and 2.6% made a medically serious suicide attempt that required medical attention. These results are consistent with those cited in the epi- demiological literature.

Age

Suicide is uncommon in childhood and early adoles- cence. Within the 10- to 14-year-old group, most sui- cides occur between ages 12 and 14. Suicide incidence increases markedly in the late teens and continues to rise until the early twenties, reaching a level that is maintained throughout adulthood until the sixth decade, when the rates increase markedly among men (Anderson, 2002).

In 2000, the suicide mortality rate for 10- to 14-year- olds in the United States was 1.5 per 100,000. Although 10- to 14-year-olds represented 7.2% of the U.S. popu- lation, the 300 children who committed suicide repre- sented only 1.0% of all suicides. The suicide mortality rate for 15- to 19-year-olds was 8.2 per 100,000, five times the rate of the younger age group.

The rarity of completed suicide before puberty is a universal phenomenon (World Health Organization, 2002). Shaffer et al. (1996) suggested that the most likely reason underlying the age of onset of suicide is that depres- sion and exposure to drugs and alcohol, two significant risk factors for suicide in adults (e.g., Barraclough et al., 1974; Robins et al., 1959) and adolescents (e.g., Brent et al., 1993a; Shaffer et al., 1996), are rare in very young children and become prevalent only in later adolescence.

Like completed suicides, suicide attempts are relatively rare among prepubertal children and increase in frequency through adolescence (Andrus et al., 1991; Velez and Cohen, 1988). However, unlike completed suicides, attempts peak between 16 and 18 years of age, after which there is a marked decline in frequency (Kessler et al., 1999), particularly for young women (Lewinsohn et al., 2001).

Gender

Paradoxically, although suicidal ideation and attempts are more common among females (Garrison et al., 1993; Gould et al., 1998; Grunbaum et al., 2002; Lewinsohn et al., 1996) in the United States, completed suicide is more common among males. Five times more 15- to 19- year-old boys than girls commit suicide (Anderson, 2002). The same pattern of sex differences does not exist in all countries (World Health Organization, 2002). While completed suicide is more common in 15- to 24-year old males than females in North America, Western Europe, Australia, and New Zealand, sex rates are equal in some countries in Asia (e.g., Singapore), and in China, the majority of suicides are committed by females.

The YRBS (Grunbaum et al., 2002) indicated that girls were significantly more likely to have seriously con- sidered attempting suicide (23.6%), made a specific plan (17.7%), and attempted suicide (11.2%) than were boys (14.2%, 11.8%, 6.2%, respectively); however, no signif- icant difference by gender in the prevalence of medically serious attempts (3.1% females, 2.1% males) was found.

Both psychopathological factors and sex-related method preferences are considered to contribute to the pattern of sex differences (Shaffer and Hicks, 1994). Completed sui- cide is often associated with aggressive behavior and sub- stance abuse (see discussion below), and both are more common in males. Methods favored by women, such as overdoses, which account for 30% of all female suicides yet only 6.7% of all male suicides (CDC, 2002), tend to be less lethal in the United States. However, in societies where treatment resources are not readily available or when the chosen ingestant is untreatable, overdoses are more likely to be lethal. Whereas in the United States, only 11% of completed suicides in 1999 resulted from an ingestion, in some South Asian and South Pacific coun- tries, the majority of suicides are due to ingestions of her- bicides, such as paraquat, for which no effective treatment is available (Haynes, 1987; Shaffer and Hicks, 1994).

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Ethnicity

Youth suicide is more common among whites than African Americans in the United States (Anderson, 2002), although the rates are highest among Native Americans and generally the lowest among Asian/Pacific Islanders (Anderson, 2002; Shiang et al., 1997; Wallace et al., 1996). Latinos are not overrepresented among completed sui- cides in the United States (Demetriades et al., 1998; Gould et al., 1996; Smith et al., 1985). The historically higher suicide rate among Native Americans is not fully under- stood, but proposed risk factors include low social inte- gration, access to firearms, and alcohol or drug use (Borowsky et al., 1999; Middlebrook et al., 2001). The historically lower suicide rate among African Americans has been attributed to greater religiosity and differences in “outwardly” rather “inwardly” directed aggression (Gibbs, 1997; Shaffer et al., 1994). However, the differ- ence in suicide rates between whites and African Americans has decreased during the past 15 years because of a marked increase in the suicide rate among African-American males between 1986 and 1994.

The YRBS (Grunbaum et al., 2002) found that African- American students were significantly less likely (13.3%) than white or Latino students (19.7% and 19.4%, respec- tively) to have considered suicide or to have made a spe- cific plan (African-Americans: 10.3%; whites: 15.3%; Latinos: 14.1%). Latino students (12.1%) were signifi- cantly more likely than either African-American or white students to have made a suicide attempt (8.8% and 7.9%, respectively); however, there was no preponderance of medically serious attempts among Latinos (3.4%) com- pared with whites (2.3%) or African Americans (3.4%). Although some studies have found higher rates of sui- cidal ideation and attempts among Latino youths (Roberts et al., 1997; Roberts and Chen, 1995), Grunbaum et al. (1998) and Walter et al. (1995) did not find a higher prevalence of either among Latinos. These equivocal find- ings highlight the need for further research in this area.

Secular Trends

Secular changes in the incidence of a disease are impor- tant because they may give an indication of causal and/or preventive factors. Following a nearly threefold increase in the adolescent male suicide rate between 1964 and 1988, the consistent increase in the white male suicide rate ceased and in the mid 1990s started to decline. Rates in African-American males, while still lower than among whites, showed no sign of a plateau or decrease until 1995.

At that time the decline gathered pace and included both white and African-American males and females. The rate among white males, nearly 20/100,000 in 1988, had fallen to approximately 14/100,000 by the year 2000 (Fig. 1).

The reasons for the decline are by no means clear. One of the more plausible reasons for the earlier increase had been the effects of greater exposure of the youth popu- lation to drugs and alcohol. Alcohol use had been noted to be a significant risk factor for suicide since the first psychological autopsy study (Robins et al., 1959), and at least in some studies (Shaffer et al., 1996) it has been a significantly more important risk factor for males, the group that had showed the dramatic increase. However, repeat benchmark studies that use similar measures and sampling methods such as the YRBS (CDC, 1995, 1996, 1998, 2000; Grunbaum et al., 2002) give no indication of a decline in alcohol or cocaine use during this time. Another reason posited for the earlier increase was an increased availability of firearms (Brent et al., 1991). Legislation restricting access to firearms was passed in 1994 (Ludwig and Cook, 2000), at the time that the decrease became more marked and the rate of handling firearms among high school students declined (CDC, 1995, 1996, 1998, 2000; Grunbaum et al., 2002). However, the proportion of suicides by firearms, a plausible proxy for method availability (Cutright and Fernquist, 2000), did not change between 1988 and 1999. There has been a decline ranging from 20% to 30% in the youth suicide rates in England, Finland, Germany, and Sweden, where firearms account for very few suicides (Krug et al., 1998), and a systematic examination of the proportion of sui- cides committed with firearms over a long period of time has shown that the proportion is only weakly related to overall changes in the rate (Cutright and Fernquist, 2000).

Another plausible cause of the reduction has been the extraordinary increase in antidepressants being prescribed for adolescents during this period. Olfson et al. (2002b) showed that between 1987 and 1996 the annual rate of antidepressant use increased from approximately 0.3% to 1.0% of those aged 6 to 19 years in the United States. Selective serotonin reuptake inhibitors (SSRIs) affect not only depression (see “Psychopharmacological Interventions” below), but also aggressive outbursts, and have been shown in adults to reduce suicidal thinking. It is unlikely that the increase in the prescription of antidepressants is an indication of a more general increase in access or use of mental health services. During the period from 1987 to 1997, the number of adolescents who received psycho-

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therapy actually declined (Olfson et al., 2002a). The delay in the onset of the decline in African-American suicides is compatible with a treatment effect because of African Americans’ greater difficulty in accessing treatment resources (Goodwin et al., 2001). Another indication that antide- pressant treatment may be a factor in the recent decline is the finding in Sweden that the proportion of suicide victims who received antidepressant treatment is lower than the rest of the depressed population (Isacsson, 2000). Firm conclusions, however, are not possible given the ecological nature of the supporting data. Randomized clinical trials will be necessary before the decline in rates can be confidently attributed to treatment with antide- pressants.

RISK FACTORS

Personal Characteristics

Psychopathology. More than 90% of youth suicides have had at least one major psychiatric disorder, although younger adolescent suicide victims have lower rates of psychopathology, averaging around 60% (Beautrais, 2001; Brent et al., 1999; Groholt et al., 1998; Shaffer et al., 1996). Depressive disorders are consistently the most

prevalent disorders among adolescent suicide victims, ranging from 49% to 64% (Brent et al., 1993a; Marttunen et al., 1991; Shaffer et al., 1996). The increased risk of suicide (odds ratios) for those with an affective disorder ranges from 11 to 27 (Brent et al., 1988, 1993a; Groholt et al., 1998; Shaffer et al., 1996; Shafii et al., 1988). Female victims are more likely than males to have had an affec- tive disorder (Brent et al., 1999; Shaffer et al., 1996). Substance abuse is another significant risk factor, espe- cially among older adolescent male suicide victims (Marttunen et al., 1991; Shaffer et al., 1996). A high prevalence of comorbidity between affective and sub- stance abuse disorder has consistently been found (Brent et al., 1993a; Shaffer et al., 1996). Disruptive dis- orders are also common in male teenage suicide victims (Brent et al., 1993a; Shaffer et al., 1996). Approximately one third of male suicides have had a conduct disorder, often comorbid with a mood, anxiety, or substance abuse disorder. Discrepant results have been reported for bipo- lar disorder: Brent et al. (1988, 1993a) reported relatively high rates, whereas others reported no or few bipolar cases (Apter et al., 1993a; Marttunen et al., 1991; Rich et al., 1990; Runeson, 1989; Shaffer et al., 1994). Despite the generally high risk of suicide among people with schizo-

Fig. 1 Teen suicide rates, 1964–2000: United States, ages 15–19 years. Sources: Anderson, 2002; CDC, 2002; National Center for Health Statistics, 1999. *Crude rates; prior to 1979, African-American data not broken out.

phrenia, schizophrenia accounts for very few of all youth suicides (Brent et al., 1993a; Shaffer et al., 1996).

The psychiatric problems and gender-specific diag- nostic profiles of youth suicide attempters are quite sim- ilar to the profiles of those who complete suicide (e.g., Andrews and Lewinsohn, 1992; Beautrais et al., 1996, 1998; Gould et al., 1998). However, despite the overlap between suicidal attempts and ideation (Andrews and Lewinsohn, 1992; Reinherz et al., 1995) and the signif- icant prediction of future attempts from ideation (Lewin- sohn et al., 1994; McKeown et al., 1998; Reinherz et al., 1995), the diagnostic profiles of attempters and ideators are somewhat distinct (Gould et al., 1998). Substance abuse/dependence is more strongly associated with sui- cide attempts than with ideation (Garrison et al., 1993; Gould et al., 1998; Kandel, 1988). Recent studies have found an association between posttraumatic stress disor- der and suicidal behavior among adolescents (Giaconia et al., 1995; Mazza, 2000; Wunderlich et al., 1998), but in the largest and most representative of the studies (Wunderlich et al., 1998), the association was not main- tained after adjusting for comorbid psychiatric problems. Panic attacks have also been reported to be associated with an increased risk of suicidal behavior in adolescents, even after adjusting for comorbid psychiatric disorders and demographic factors (Gould et al., 1996; Pilowsky et al., 1999). The negative finding by Andrews and Lewinsohn (1992) may be due to a gender specificity of the association: panic attacks may increase suicide risk for girls only (Gould et al., 1996). Inconsistent findings have been reported in the adult literature (Johnson et al., 1990; Warshaw et al., 2000; Weissman et al., 1989)

Prior Suicide Attempts. A history of a prior suicide attempt is one of the strongest predictors of completed suicide, conferring a particularly high risk for boys (30- fold increase) and a less elevated risk for girls (3-fold increase) (Shaffer et al., 1996). Between one quarter to one third of youth suicide victims have made a prior sui- cide attempt (see Groholt et al., 1997). Similarly strong associations between a history of suicidal behavior and future attempts have been reported in general popula- tion surveys and longitudinal studies (Lewinsohn et al.,1994; McKeown et al., 1998; Reinherz et al., 1995; Wichstrom, 2000) and clinical samples (Hulten et al., 2001; Pfeffer et al., 1991), with risk for an attempt increasing between 3 and 17 times for those with prior suicidal behavior.

Cognitive and Personality Factors. Hopelessness has been linked with suicidality (Howard-Pitney et al., 1992;

Marcenko et al., 1999; Overholser et al., 1995; Ruben- stein et al., 1989; Russell and Joyner, 2001; Shaffer et al., 1996); however, it has not consistently proven to be an independent predictor, once depression is taken into account (Cole, 1988; Howard-Pitney et al., 1992; Lewinsohn et al., 1994; Reifman and Windle, 1995; Rotheram-Borus and Trautman, 1988). Poor interpersonal problem-solv- ing ability has also been reported to differentiate suicidal from nonsuicidal youths (Asarnow et al., 1987; Rotheram- Borus et al., 1990), even after adjusting for depression (Rotheram-Borus et al., 1990). Social problem-solving has been found to partially mediate the influence of life stress on suicide, although life stress was a stronger pre- dictor than social problem-solving (Chang, 2002). Aggressive- impulsive behavior has also been linked with an increased risk of suicidal behavior (Apter et al., 1993b; McKeown et al., 1998; Sourander et al., 2001). In a Finnish school study (Sourander et al., 2001), aggressive 8-year-olds were more than twice as likely to think about or attempt sui- cide at age 16.

Sexual Orientation. Recent cross-sectional and longi- tudinal epidemiological studies found a significant two- to sixfold increased risk of nonlethal suicidal behavior for homosexual and bisexual youths (Blake et al., 2001; Faulkner and Cranston, 1998; Garofalo et al., 1998; Remafedi et al., 1998; Russell and Joyner, 2001; see McDaniel et al., 2001, for a recent review). In a study of a nationally represen- tative sample of nearly 12,000 adolescents, those who reported same-sex sexual orientation also exhibited sig- nificantly higher rates of other suicide risk factors (Russell and Joyner, 2001). After adjusting for these risks, the effects of same-sex sexual orientation on suicidal behav- ior remained, but were substantially mediated by depres- sion, alcohol abuse, family history of attempts, and victimization. Notably, most youths who reported same- sex sexual orientation reported no suicidality at all: 84.6% of males and 71.7% of females.

Biological Factors. Over the past 25 years, a substantial body of knowledge has accrued, indicating abnormali- ties of serotonin function in suicidal and in impulsive, aggressive individuals, regardless of psychiatric diagno- sis. Earlier studies focused on simple indices of seroto- nin activity, such as the reduced concentration of serotonin metabolites in the brain and cerebrospinal fluid (CSF) in suicide victims or among suicide attempters compared with age- and gender-matched controls (see Oquendo and Mann, 2000). More recently, neuroanatomical stud- ies have shown a reduction in the overall density of sero-

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tonin 1A receptors and serotonin transporter receptors (which regulate serotonin uptake) in the prefrontal cor- tex. Most recently, Arango and her colleagues (2001) found significant reductions in the number and binding capacity of serotonin 1A receptors in the dorsal raphe nucleus, from which serotonin innervation of the pre- frontal cortex arises (Arango et al., 2001).

To explain the often-replicated finding that serotonin dysregulation is associated with suicidality regardless of diagnosis, Mann et al. (1999) suggested that the dysreg- ulation is a biological trait that predisposes to suicide— a stress-diathesis model. Thus a mentally ill person with the diathesis is more likely to respond to a stressful expe- rience in an impulsive fashion that may include a deci- sion to commit suicide.

Despite the great volume of work, unanswered ques- tions remain. The behavioral correlates of low-serotonin states are assumed to include irritability, impulsivity, and emotional volatility, but most studies address diagnosis rather than specific symptoms and the correlation has yet to be explored in the general population. An absence of representative studies has meant that neither the relative risk of serotonin dysfunction nor the fraction of suicides attributable to serotonin underfunctioning is yet known. Finally, the examination of the association of serotonin metabolism with suicide has largely been limited to stud- ies of adults.

The documented suicide risk associated with family history (see “Family History of Suicidal Behavior” below) has led to an active investigation of candidate genes, attempting to identify what suicidogenic factor might be inherited. Given the substantial body of data that point to reduced serotonin neurotransmission in suicide (see above), the target of most recent association studies has been polymorphisms in three genes that play important roles in the regulation of serotonin. One gene is trypto- phan hydroxylase (TPH), the rate-limiting enzyme for the biosynthesis of serotonin. Early studies (Mann and Stoff, 1997; Nielsen et al., 1994, 1998) reported a rela- tionship between attempted suicide and a polymorphism on intron 7 of the TPH gene. Since then, a large num- ber of studies with inconsistent findings have been car- ried out on suicidal patients with various diagnoses with and without suicidality. The Utah Youth Suicide Study has been the main study to have examined adolescents (Bennet et al., 2000), and it has failed to find an associ- ation. There are several possible reasons for the inconsis- tent findings, including the probable heterogeneity and

complexity of the suicide phenotype; that the genetic effect is small and requires examination of large samples; or because a single genetic variant is less important than patterns of variance (Marshall et al., 1999). Support for this is offered by haplotype analyses (haplotypes are clus- ters of genes that are usually found together) that have shown a distinctive profile among both suicide completers (Turecki et al., 2001) and attempters (Rotondo et al., 1999) in samples in which single-gene polymorphisms did not differ significantly from those of controls.

The other two candidate genes that have been studied are the serotonin transporter (SERT ) gene and the sero- tonin A receptor gene. Polymorphisms in these genes have been reported in completed and attempted suicide (Arango et al., 2001; Courtet et al., 2001; Du et al., 2001; Neumeister et al., 2002).

While biological findings currently have little impact on clinical practice, Nordstrom and colleagues’ (1994) finding that suicide attempters with low levels of CSF 5- hydroxyindoleacetic acid have a significantly higher like- lihood of making further suicide attempts and/or committing suicide, coupled with the promising research on candi- date genes, may eventually take suicide prediction and prevention to new, more precise levels and/or may lead to specific interventions that will reduce the impact of the predisposing trait.

Family Characteristics

Family History of Suicidal Behavior. A family history of suicidal behavior greatly increases the risk of com- pleted suicide (Agerbo et al., 2002; Brent et al., 1988, 1994a, 1996; Gould et al., 1996; Shaffer, 1974; Shafii et al., 1985) and attempted suicide (Bridge et al., 1997; Glowinski et al., 2001; Johnson et al., 1998). Because suicide and psychiatric illness almost always co-occur, account has to be taken of whether apparent familiality reflects suicide specifically or instead an association with parental psychiatric illness (Brent et al., 1996). Most recently, the Danish Registry study (Agerbo et al., 2002) found youth suicide to be nearly five times more likely in the offspring of mothers who have completed suicide and twice as common in the offspring of fathers, adjust- ing for parental psychiatric history.

The Missouri Adolescent Twin Study (Heath et al., 2002) addressed the question of inheritance versus envi- ronment among teenage suicide attempters. One hun- dred thirty twin pairs had been affected by a suicide attempt within the total representative sample of 3,416

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female adolescent twins. After controlling for other psy- chiatric risk factors, the twin/cotwin odds ratio was 5.6 (95% confidence interval [CI] 1.75–17.8) for monozy- gotes and 4.0 (95% CI 1.1–14.7) for dizygotes, suggest- ing a degree of inheritance for suicidality (Glowinski et al., 2001). The heritability of youth suicide gains fur- ther support from a meta-analysis by McGuffin et al. (2001), who reexamined a large body of published twin data (all ages). They concluded that first-degree relatives of suicides have more than twice the risk of the general population, with the relative risk increasing among iden- tical cotwins of suicides to about 11. The estimated her- itability for completed suicide was 43% (95% CIs 25–60).

Parental Psychopathology. High rates of parental psy- chopathology, particularly depression and substance abuse, have been found to be associated with completed suicide (Brent et al., 1988, 1994a; Gould et al., 1996) and with suicidal ideation and attempts in adolescence (e.g., Fergusson and Lynskey, 1995; Joffe et al., 1988; Kashani et al., 1989). Brent and his colleagues (1994a) reported that a family history of depression and substance abuse significantly increased the risk of completed suicide, even after controlling for the victim’s psychopathology. They concluded that familial psychopathology adds to suicide risk by mechanisms other than merely increasing the lia- bility for similar psychopathology in an adolescent. In contrast, Gould and her colleagues (1996) found that the impact of parental psychopathology no longer contributed to the youth’s suicide risk after the study controlled for the youth’s psychopathology. To date, it is unclear pre- cisely how familial psychopathology increases the risk for completed suicide.

Parental Divorce. Suicide victims are more likely to come from nonintact families of origin (Beautrais, 2001; Brent et al., 1993a, 1994a; Gould et al., 1996; Groholt et al., 1998; Sauvola et al., 2001). However, the association between separation/divorce and suicide decreases when accounting for parental psychopathology (Brent et al., 1994a; Gould et al., 1996). Similarly, although many population-based studies have found significant univari- ate associations (e.g., Andrews and Lewinsohn, 1992; Fergusson and Lynskey, 1995), these associations are no longer evident or are markedly attenuated once psychosocial risk factors are taken into account (e.g., Beautrais et al., 1996; Fergusson et al., 2000; Groholt et al., 2000).

Parent–Child Relationships. Impaired parent–child rela- tionships are associated with increased risk of suicide and suicide attempts among youths (Beautrais et al., 1996;

Brent et al., 1994a, 1999; Fergusson and Lynskey, 1995; Fergusson et al., 2000; Gould et al., 1996; Lewinsohn et al., 1993, 1994; McKeown et al., 1998; Tousignant et al., 1993). However, because an underlying psychiat- ric problem in the youth may precipitate impaired par- ent–child relationships, it is necessary to disentangle these factors. While Gould et al. (1996) found that suicide vic- tims still had significantly less frequent and less satisfy- ing communication with their mothers and fathers than community controls, even after adjusting for their psy- chiatric disorders, others have found that the associations between nonlethal suicidal behavior and poor attachment and family cohesion are not independent of the youth’s psychological problems (Fergusson et al., 2000; McKeown et al., 1998). Similarly, parent–child conflict has been found to be no longer associated with completed suicide (Brent et al., 1994a) or attempts (Lewinsohn et al., 1993) once the youth’s psychopathology is taken into account.

Adverse Life Circumstances

Stressful Life Events. Life stressors, such as interpersonal losses (e.g., breaking up with a girlfriend or boyfriend) and legal or disciplinary problems, are associated with completed suicide (Beautrais, 2001; Brent et al., 1993c; Gould et al., 1996; Marttunen et al., 1993; Rich et al., 1988; Runeson, 1990) and suicide attempts (Beautrais et al., 1997; Fergusson et al., 2000; Lewinsohn et al., 1996), even after adjusting for psychopathology (Brent et al., 1993c; Gould et al., 1996) and antecedent social, family, and personality factors (Beautrais et al., 1997). The prevalence of specific stressors among suicide vic- tims varies by age: parent–child conflict is a more com- mon precipitant for younger adolescent victims, whereas romantic difficulties are more common in older adoles- cents (Brent et al., 1999; Groholt et al., 1998). Stressors also vary by psychiatric disorder: interpersonal losses are more common among suicide victims with substance abuse disorders (Brent et al., 1993c; Gould et al., 1996; Marttunen et al., 1994; Rich et al., 1988), and legal or disciplinary crises are more common in victims with dis- ruptive disorders (Brent et al., 1993c; Gould et al., 1996) or substance abuse disorders (Brent et al., 1993c). Bullying, whether as victim or perpetrator, has also recently been demonstrated to increase the risk for suicidal ideation (Kaltiala-Heino et al., 1999).

Physical Abuse. The association between physical abuse and suicide reported in case-control psychological autopsy studies (Brent et al., 1994a, 1999) has been replicated in

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prospective longitudinal community studies (Brown et al., 1999; Johnson et al., 2002; Silverman et al., 1996), the most methodologically rigorous design to examine this issue. Childhood physical abuse has been found to be associated with an increased risk of suicide attempts in late adolescence or early adulthood, even after adjusting for demographic characteristics, psychiatric symptoms during childhood and early adolescence, and parental psychiatric disorders (Johnson et al., 2002). Interpersonal difficulties during middle adolescence, such as frequent arguments with adults and peers and having no close friends, were found to mediate the association between child abuse and later suicide attempts (Johnson et al., 2002). Johnson and his colleagues (2002) suggested that children who are physically abused may have difficulty developing the social skills necessary for healthy rela- tionships, which leads to social isolation and/or antago- nistic interactions with others, which in turn puts them at increased risk for suicidal behavior.

Sexual Abuse. Longitudinal community studies are also the most methodologically rigorous design to examine the association between child sexual abuse (CSA) and subsequent suicidality due to the serious problems of ret- rospective recall in this area. Two such studies have found self-reported CSA to be significantly associated with an increased risk of suicidal behavior in adolescence (Fergusson et al., 1996; Silverman et al., 1996). Because CSA may be associated with reported risk factors for sui- cide (e.g., parental substance abuse), it is necessary to control for such factors. Fergusson et al. (1996) found that the association between CSA and suicidality was greatly reduced but was not eliminated, after controlling for a wide range of potentially confounding factors. This suggests that the increased risk of suicide from CSA may be partly, but not entirely, accounted for by other factors.

Socioenvironmental and Contextual Factors

Socioeconomic Status. Studies of suicide victims gener- ally have found no or small effects of socioeconomic dis- advantage (Agerbo et al., 2002; Brent et al., 1988). Specifically, Agerbo et al. (2002) noted that the effect of socioeconomic disadvantage decreased after adjustment for family history of mental illness or suicide. Gould et al. (1996) also found no effect of socioeconomic status for white or Latino victims, but African-American victims had a significantly higher socioeconomic status than their general population counterparts. Youth suicide attempters, compared with community controls, have consistently

been found to have higher rates of sociodemographic dis- advantage, even after controlling for other social and psy- chiatric risk factors (Beautrais et al., 1996; Fergusson et al., 2000; Wunderlich et al., 1998).

School and Work Problems. Difficulties in school, nei- ther working nor being in school, and not going to col- lege pose significant risks for completed suicide (Gould et al., 1996). Beautrais et al. (1996) reported that serious suicide attempters were also more likely to drop out of high school or not attend college, and Wunderlich and colleagues (1998) reported that German school dropouts were 37 times more likely to attempt suicide, even after adjusting for diagnostic and social risk factors.

Contagion/Imitation. Evidence continues to amass from studies of suicide clusters and the impact of the media, supporting the existence of suicide contagion. Several studies have reported significant clustering of suicides, defined by temporal-spatial factors, among teenagers and young adults (Brent et al., 1989; Gould et al., 1990a,b, 1994), with only minimal effects beyond 24 years of age (Gould et al., 1990a,b). Similar age-specific patterns have been reported for clusters of attempted suicides (Gould et al., 1994). Since 1990, the effect of the media on sui- cide rates has been documented in many other countries besides the United States, including Australia (e.g., Hassan, 1995), Austria (e.g., Etzersdorfer et al., 1992), Germany (e.g., Jonas, 1992), Hungary (e.g., Fekete and Macsai, 1990), and Japan (Ishii, 1991; Stack, 1996), adding to the extensive work prior to 1990 in the United States on newspaper articles, television news reports, and fictional dramatizations. Overall, the magnitude of the suicide increase is proportional to the amount, duration, and prominence of media coverage, and the impact of sui- cide stories on subsequent completed suicides appears to be greatest for teenagers (see Gould, 2001; Schmidtke and Schaller, 2000; Stack, 2000).

Stack’s (2000) review of 293 findings from 42 studies indicates that methodological differences among studies are strong predictors of differences in their findings. For exam- ple, although a highly publicized recent study (Mercy et al., 2001) found that exposure to media accounts of suicidal behavior and exposure to suicidal behavior in friends or acquaintances were associated with a lower risk of youth suicide attempts, the interpretability of the findings is lim- ited because (1) the media exposure factor was a conglom- erate of different types of media stories; (2) attempters may have had less exposure to media generally (e.g., read fewer books, fewer newspapers, etc.); (3) attempters had signifi-

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cantly more proximal stressors, possibly overshadowing their recollection of media exposure; (4) the timing of exposure was a 30-day interval, in contrast to most other studies, which examined a shorter interval following the exposure; and (5) nearly half of the sample was between 25 and 34 years of age, a group not particularly sensitive to imitation. Another study finding—no effect of parental suicide—was also inconsistent with the prevailing research literature. A summary of interactive factors that may moderate the impact of media stories, including characteristics of the stories, individual reader/viewer attributes, and social context of the stories, is presented by Gould (2001).

PROTECTIVE FACTORS

Family Cohesion

Family cohesion has been reported as a protective fac- tor for suicidal behavior among adolescents in a longitu- dinal study of middle school students (McKeown et al., 1998) and cross-sectional community studies of high school (Rubenstein et al., 1989, 1998) and college stu- dents (Zhang and Jin, 1996). Students who described fam- ily life in terms of a high degree of mutual involvement, shared interests, and emotional support were 3.5 to 5.5 times less likely to be suicidal than were adolescents from less cohesive families who had the same levels of depres- sion or life stress (Rubenstein et al., 1989, 1998).

Religiosity

Since Durkheim’s (1966) formulation of a social inte- gration model, the protective role of religiosity on sui- cide has been a focus of scientific investigation (e.g., Hovey, 1999; Lester, 1992; Neeleman, 1998; Neeleman and Lewis, 1999; Sorri et al., 1996; Stack, 1998; Stack and Lester, 1991). As noted previously, greater religios- ity has been posited as underlying the historically lower suicide rate among African Americans. However, only recently has the protective value of religiosity against sui- cidal behavior (Hilton et al., 2002; Siegrist, 1996; Zhang and Jin, 1996) and depression (Miller et al., 1997b) been documented in adolescents and young adults. Regrettably, these studies have not controlled for potential confounders, such as substance abuse, which may be less prevalent among religious youths.

PREVENTION STRATEGIES

Youth suicide prevention strategies have primarily been implemented within three domains—school, commu-

nity, and health-care systems—and generally have one of two general goals: case finding with accompanying refer- ral and treatment or risk factor reduction (CDC, 1994; Gould and Kramer, 2001).

School-Based Suicide Prevention Programs

Suicide Awareness Curriculum. These programs seek to increase awareness of suicidal behavior in order to facil- itate self-disclosure and prepare teenagers to identify at- risk peers and take responsible action (Kalafat and Elias, 1994). The underlying rationale of these programs is that teenagers are more likely to turn to peers than adults for support in dealing with suicidal thoughts (Hazell and King, 1996; Kalafat and Elias, 1994; Ross, 1985).

Several studies evaluated school-based suicide awareness programs in the past decade (Ciffone, 1993; Kalafat and Elias, 1994; Kalafat and Gagliano, 1996; Shaffer et al., 1991; Silbert and Berry, 1991; Vieland et al., 1991). While improvements in knowledge (Kalafat and Elias, 1994; Silbert and Berry, 1991), attitudes (Ciffone, 1993; Kalafat and Elias, 1994; Kalafat and Gagliano, 1996), and help- seeking behavior (Ciffone, 1993) have been found, other studies reported either no benefits (Shaffer et al., 1990, 1991; Vieland et al., 1991) or detrimental effects of sui- cide prevention education programs (Overholser et al., 1989; Shaffer et al., 1991). Detrimental effects included a decrease in desirable attitudes (Shaffer et al., 1991); a reduc- tion in the likelihood of recommending mental health eval- uations to a suicidal friend (Kalafat and Elias, 1994); more hopelessness and maladaptive coping responses among boys after exposure to the curriculum (Overholser et al., 1989); and negative reactions among students with a his- tory of suicidal behavior, including their not recommending the programs to other students and feeling that talking about suicide in the classroom “makes some kids more likely to try to kill themselves” (Shaffer et al., 1990). Other limitations of this strategy are that baseline knowledge and attitudes of students are generally sound (Kalafat and Elias, 1994; Shaffer et al., 1991), changes in attitudes and knowl- edge are not necessarily highly correlated with behavioral change (Kirby, 1985; McCormick et al., 1985), and the format and content of some programs might inadvertently stimulate imitation (Gould, 2001).

To date there is insufficient evidence to either support or not support curriculum-based suicide awareness pro- grams in schools (Guo and Harstall, 2002). Accordingly, emphasis has shifted toward alternative school-based strategies that will be presented below.

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Skills Training. In contrast to suicide awareness cur- riculum in schools, skills training programs emphasize the development of problem-solving, coping, and cog- nitive skills, as suicidal youths have deficits in these areas (e.g., Asarnow et al., 1987; Cole, 1989; Rotheram-Borus et al., 1990). It is hoped that an “immunization” effect can be produced against suicidal feelings and behaviors. The reduction of suicide risk factors (e.g., depression, hopelessness, and drug abuse) is also a targeted outcome.

Several evaluation studies have shown promising results, with some evidence for reductions in completed and attempted suicides (Zenere and Lazarus, 1997) and improvements in attitudes, emotions, and distress cop- ing skills (Klingman and Hochdorf, 1993; Orbach and Bar-Joseph, 1993). The most systematic evaluations have been conducted by a team of researchers (Eggert et al., 1995; Randell et al., 2001; Thompson et al., 2000, 2001) who have focused on skills training and social support programs for students at high risk for school failure or dropout. Enhancements of protective factors and reduc- tions in risk factors following the “active” interventions were consistently found, while the control “intervention as usual” did not yield an increase of protective factors. However, “intervention as usual” sometimes produced significant reductions in suicide risk behaviors (Eggert et al., 1995; Randell et al., 2001). Thus it is not clear which aspects of the skills training program were respon- sible for risk reduction, a limitation of other studies also (Zenere and Lazarus, 1997). While these studies yield encouraging data, additional research is sorely needed to refine the evaluation of this type of intervention.

Screening. A prevention strategy that has received increased attention is case-finding through direct screen- ing of individuals. Self-report and individual interviews are used to identify youngsters at risk for suicidal behav- ior (Joiner et al., 2002; Reynolds, 1991; Shaffer and Craft, 1999; Thompson and Eggert, 1999). School-wide screen- ings, involving multistage assessments, have focused on depression, substance abuse problems, recent and fre- quent suicidal ideation, and past suicide attempts. The few studies that have examined the efficacy of school- based screening (Reynolds, 1991; Shaffer and Craft, 1999; Thompson and Eggert, 1999) found that the sensitivity of the screens ranged from 83% to 100%, while the speci- ficities ranged from 51% to 76%. Thus, while there were few false-negatives, there were many false-positives. Although the number of false-positives could be mini- mized by using a more stringent cutoff criterion, the seri-

ousness of missing a suicidal individual precludes this scheme. Thus a tolerance for false-positives is essential for such endeavors (Thompson and Eggert, 1999), neces- sitating second-stage assessments to determine who is not actually at risk for suicide. Second-stage assessments usu- ally employ systematic clinical evaluations, using inter- views such as the Suicidal Behaviors Interview (Reynolds, 1990) or the Diagnostic Interview Schedule for Children (DISC), now available in a spoken, self-completion (Voice- DISC) version (Shaffer and Craft, 1999).

Although a screening strategy appears to be quite promising, a number of dilemmas still need to be addressed. First, because suicide risk “waxes and wanes” over time, multiple screenings may be necessary in order to mini- mize “false-negatives” (Berman and Jobes, 1995). Second, school-wide student screening programs have been rated by high school principals as significantly less acceptable than curriculum-based and staff in-service programs, although most respondents in this study have had either no or minimal exposure to screening programs (Miller et al., 1999). Finally, the ultimate success of this strategy is dependent on the effectiveness of the referral. Considerable effort must be made to assist the families and adolescents in obtaining help if it is needed.

Gatekeeper Training. Programs to train school person- nel as gatekeepers are based on the premise that suicidal youths are underidentified and that we can increase iden- tification by providing adults with knowledge about sui- cide. Only 9% of a national random sample of U.S. high school teachers believed they could recognize a student at risk for suicide, and while the overwhelming majority of counselors knew the risk factors for suicide, only one in three believed they could identify a student at risk (King et al., 1999).

The purpose of gatekeeper training is to develop the knowledge, attitudes, and skills to identify students at risk, determine the levels of risk, and make referrals when necessary (Garland and Zigler, 1993; Kalafat and Elias, 1995). Research examining the effectiveness of gatekeeper training is limited, but the findings are encouraging, with significant improvements in school personnel’s knowl- edge, attitudes, intervention skills, preparation for cop- ing with a crisis, referral practices (Garland and Zigler, 1993; King and Smith, 2000; Mackesy-Amiti et al., 1996; Shaffer et al., 1988; Tierney, 1994), and general satisfac- tion with the training (Nelson, 1987). As previously noted, in-service training programs are significantly more accept- able by principals than school-wide screening programs

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(Miller et al., 1999). This is consistent with the finding that 46% of school districts in Washington have gate- keeper training programs, while no districts use group screening of students (Hayden and Lauer, 2000).

Peer Helpers. The rationale underlying these programs is similar to that of suicide awareness programs: Suicidal youths are more likely to confide in a peer than an adult (e.g., Kalafat and Elias, 1994). The role that peers play varies considerably by program, with some limited to lis- tening and reporting any possible warning signs and oth- ers involving counseling responsibilities. Many programs address serious mental health problems, such as drug abuse, eating disorders, and depression, with 24% of pro- grams in Washington State involving some suicide pre- vention role (Lewis and Lewis, 1996). Empirical evaluations of these programs are quite limited (Lewis and Lewis, 1996) and often confined to student satisfaction mea- sures (Morey et al., 1993). Potential negative side effects are rarely examined. To date, there is not a sufficient body of evidence documenting the efficacy or safety of peer helping programs, despite their widespread use (Lewis and Lewis, 1996).

Postvention/Crisis Intervention. The rationale for school- based postvention/crisis intervention is that a timely response to a suicide is likely to reduce subsequent morbidity and mortality in fellow students, including suicidality, the onset or exacerbation of psychiatric disorders (e.g., posttraumatic stress disorder, major depressive disorder), and other symp- toms related to pathological bereavement (Brent et al., 1993b,e, 1994b). The major goals of postvention programs are to assist survivors in the grief process, identify and refer those individuals who may be at risk following the suicide, provide accurate information about suicide while attempt- ing to minimize suicide contagion, and implement a struc- ture for ongoing prevention efforts (Hazell, 1993; Underwood and Dunne-Maxim, 1997).

The existing research on school-based postvention pro- grams is sparse. Hazell and Lewin (1993) examined the efficacy of 90-minute group counseling sessions offered to groups of 20 to 30 students on the seventh day following a suicide. No differences in outcome were found between counseled subjects and matched controls. It was unclear whether this finding was due to inclusion criteria for postven- tion counseling (close friends of deceased student), the intervention itself, or the duration of the distress, or whether short-term effects dissipated by the assessment at 8 months after the death. An encouraging, though small and method- ologically limited, study by Poijula et al. (2001) found that

no new suicides took place during a 4-year follow-up period in schools where an adequate intervention took place, whereas the number of suicides significantly increased after suicides with no adequate subsequent crisis intervention. It is imperative for crisis interventions to be well planned and evaluated; otherwise, not only may they not help sur- vivors, but they may potentially exacerbate problems through the induction of imitation.

Community-Based Prevention Programs

Crisis Centers and Hotlines. The rationale for crisis hot- lines (Mishara and Daigle, 2001; Shaffer et al., 1988; Shneidman and Farberow, 1957) is that suicidal behav- ior is often associated with a crisis (Brent et al., 1993c; Gould et al., 1996; Marttunen et al., 1993; Rich et al., 1988, Runeson, 1990) and telephone crisis services can provide the opportunity for immediate support at these critical times by offering services that are convenient, accessible, and available outside of usual office hours.

Evidence of their efficacy on adult suicide is equivo- cal (Lester, 1997), and few studies have examined the uti- lization or efficacy of hotlines among teenagers (Boehm and Campbell, 1995; King, 1977; Slem and Cotler, 1973). Overall, between 1% and 6% of adolescents in the com- munity use hotlines (Offer et al., 1991; Slem and Cotler, 1973; Vieland et al., 1991) and only 4% of calls concern suicide (Boehm and Campbell, 1995). However, between 14% and 18% of suicidal youths have used hotlines (Beautrais et al., 1998; Shaffer et al., 1990). There is a dearth of information about the efficacy of telephone cri- sis services for teenagers and whether they adequately address suicide risk.

Restrictions of Firearms. The underlying rationale for means restrictions is that suicidal individuals are often impulsive, they may be ambivalent about killing them- selves, and the risk period for suicide is transient (Hawton et al., 2001; Miller and Hemenway, 1999). Restricting access to lethal methods during this period may prevent suicides, although it is not clear that method restriction has substantially contributed to the recent secular change in youth suicide.

Because the most common method of committing sui- cide in the United States is by firearms (CDC, 2002), this review will focus on restricting their access. The pres- ence of firearms in the home is a significant risk factor for suicide in youths (Brent et al., 1988, 1991, 1993d, 1999) and adults (Kellermann et al., 1992). Several stud- ies have found that restrictions on guns reduced the over-

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all suicide rate, as well as firearm-related suicides (e.g., Boor and Bair, 1990; Carrington and Moyer, 1994; Lester and Murrell, 1980, 1986; Loftin et al., 1991; Medoff and Magaddino, 1983), while others have found no overall effect (Rich et al., 1990) or equivocal results (Cantor and Slater, 1995; Cummings et al., 1997; Sloan et al., 1990). The equivocal findings largely reflected age-specific effects (Cantor and Slater, 1995; Sloan et al., 1990), in that restrictive gun laws had a greater impact on adolescents and young adults. Unfortunately, recent legislative ini- tiatives such as the 1994 Brady Bill, which imposes a delay in purchasing a handgun, did not find promising results: A comparison of states that did and did not pass Brady Bill statutes showed no impact on the proportion of sui- cides attributable to firearms except in elderly males (Ludwig and Cook, 2000).

Less controversial means-restriction measures in the United States involve education to parents of high-risk youths. Kruesi and colleagues (1999) demonstrated that injury prevention education in emergency rooms led par- ents to take new action to limit access to lethal means, such as locking up their firearms. Unfortunately, Brent et al. (2000) found that parents of depressed adolescents were frequently noncompliant with recommendations to remove firearms from the home.

A common concern is that method substitution will occur following a means-restriction program. Some evi- dence of method substitution exists (Lester and Leenaars, 1993; Lester and Murrell, 1982; Rich et al., 1990); how- ever, method substitution does not appear to be an inevitable reaction to firearms restriction (Cantor and Slater, 1995; Carrington and Moyer, 1994; Lester and Murrell, 1986; Loftin et al., 1991). Moreover, even if some individuals do substitute other methods, the chances of survival may be greater if the new methods are less lethal (Cantor and Baume, 1998).

Media Education. Given the substantial evidence for suicide contagion, a recommended suicide prevention strat- egy involves educating media professionals about conta- gion, in order to yield stories that minimize harm. Moreover, the media’s positive role in educating the public about risks for suicide and shaping attitudes about suicide should be encouraged.

A set of recommendations on reporting of suicide were recently developed by an international workgroup headed by the American Foundation for Suicide Prevention and the Annenberg School of Communication and Public Policy (American Foundation for Suicide Prevention,

2001). Guidelines for media reporting now exist in sev- eral countries. Recommendations generally include descrip- tions of factors that should be avoided because they are more likely to induce contagion (e.g., front page cover- age) and suggestions on how to increase the usefulness of the report (e.g., describing treatment resources).

Following the implementation of media guidelines in Austria, suicide rates declined 7% in the first year, nearly 20% in the 4-year follow-up period, and subway suicides (a particular focus of the media guidelines) decreased by 75% (Etzersdorfer et al., 1992; Etzersdorfer and Sonneck, 1998; Sonneck et al., 1994). In Switzerland, Michel et al. (2000) found that following the implementation of guide- lines, the number of articles increased but they were sig- nificantly shorter and less likely to be on the front page; headlines, pictures, and text were less sensational; there were relatively fewer articles with pictures; and their over- all “Imitation Risk Scores” were lower. Given the suc- cessful strategy of engaging the media in Austria and Switzerland, efforts to systematically disseminate and evaluate media recommendations in the United States are recommended.

Health Care-Based Prevention Programs

Educational/Training Programs for Primary Care Physicians and Pediatricians. The need for training primary care physi- cians and pediatricians in the United States is highlighted by the finding that while 72% of 600 family physicians and pediatricians in North Carolina had prescribed a SSRI for a child or adolescent patient, only 8% said they had received adequate training in the treatment of childhood depression and only 16% reported that they felt com- fortable treating children for depression (Voelker, 1999). Furthermore, although many suicidal young people (15–34 years) seek general medical care in the month preceding their suicidal behavior (Pfaff et al., 1999), fewer than half of physicians surveyed reported that they routinely screen their patients for suicide risk (Frankenfield et al., 2000).

Pfaff et al. (2001) demonstrated that after a 1-day train- ing workshop for 23 primary care physicians in Australia, inquiry about suicidal ideation increased by 32.5% and identification of suicidal patients increased by 130%, although no significant change in patient management resulted and referrals of suicidal youths to mental health specialists remained low. The effectiveness of educational programs for health care professionals has also been demon- strated by the Gotland study (Rutz et al., 1992). After the implementation of an intensive postgraduate training pro-

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gram aimed at improving general practitioners’ diagnosis and treatment of depression on the island of Gotland, Sweden, the adult suicide rate significantly declined. The decline was almost totally due to decreases in female sui- cides with major depression (the number of male suicides was unchanged). Three years after the project ended, the suicide rate returned almost to baseline rates (Rihmer et al., 1995), suggesting that ongoing repetition of the educa- tional program is warranted. A similar educational pro- gram for pediatricians could be an effective youth suicide prevention strategy; however, other adjunctive approaches to reach at-risk males should be considered.

TREATMENT

Recent reviews (e.g., Hawton et al., 1998, 2002; Rudd, 2000) note that few studies have systematically evaluated interventions aimed at reducing suicidal ideation and behavior in children and adolescents, i.e., randomized controlled trials that obtain reliable and valid measures of outcome variables during pretreatment, posttreatment, and follow-up periods. Most treatment efficacy studies of adolescent psychiatric populations exclude suicidal indi- viduals, possibly because the potential risks of treating high-risk youths outweigh benefits. The National Institute of Mental Health recently published guidelines that high- light a number of ethical, legal, and safety considerations associated with such studies (Pearson et al., 2001).

Treatment Service Utilization

Many adolescents contact a mental health professional before their suicidal behavior. Among suicide completers, rates of contact vary from 7% to 15% within the previ- ous month, 20% to 25% within the previous year, and 25% to 35% over the lifetime (Brent et al., 1993a; Groholt et al., 1997; Marttunen et al., 1992; Shaffer et al., 1996). Contact rates were higher, between 59% and 78%, in a New Zealand sample of attempters admitted for 24-hour hospital stay (Beautrais et al., 1998).

Emergency/Crisis-Service Interventions and Triage

Procedures for the acute care of suicidal adolescents have been described elsewhere (American Academy of Child and Adolescent Psychiatry, 2001). These recom- mendations are largely based on common sense approaches and expert clinical consensus. Such guidelines emphasize that certain preconditions must be satisfied before chil- dren and adolescents are discharged from the emergency service, e.g., the need to “sanitize” the home—make

firearms and/or lethal medications inaccessible to the child (Kruesi et al., 1999).

Similarly, a written or verbal “no-suicide” contract is commonly negotiated at the start of treatment in the hope that it will improve treatment compliance and reduce the likelihood of further suicidal behavior (Brent, 1997; Rotheram, 1987). However, no empirical studies have eval- uated the effectiveness of no-suicide contracts (Reid, 1998).

Rotheram-Borus et al. (1999) found that the imple- mentation of a brief set of specialized emergency room procedures increased eventual treatment adherence among Latina adolescent suicide attempters. The procedures aug- mented typical emergency room care by (1) using a stan- dardized protocol for training emergency room staff, (2) presenting a 20-minute videotape to patients and their families that models realistic expectations for aftercare treatment, and (3) providing a bilingual crisis therapist to promote compliance with outpatient therapy. Suicidal adolescents receiving the specialized emergency room procedure attended 3.8 more outpatient follow-up ses- sions than those receiving standard aftercare. The research was not able to identify which of these components were responsible for the increase in compliance.

Inpatient Care and Partial Hospitalization

While inpatient and partial hospitalization offer inten- sive multidisciplinary treatments and skilled observation and support, there is no empirical evidence that either of these interventions is effective in reducing rates of sui- cidal ideation, nonlethal attempts, or completed suicide among adolescents.

Outpatient Follow-up Treatment

Generally low rates of compliance with outpatient treatment among adolescent suicide attempters (e.g., Piacentini et al., 1995) make such investigations difficult to implement. Dropout rates as high as 59% have been reported (Spirito et al., 1992). King et al. (1997) found that compliance rates were highest for medication fol- low-up (66.7%), relative to rates for individual therapy (50.8%) and family therapy/parent psychoeducation (33.3%). Results of that study also indicate that non- compliance is associated with parental psychopathology and family dysfunction.

Psychotherapy

Hawton et al. (1998, 2002) reviewed all randomized controlled trials targeting suicide attempters. Of 23 stud-

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ies, only two explicitly obtained an adolescent sample (Cotgrove et al., 1995; Harrington et al., 1998). Unsuccessful treatments included problem-solving (e.g., Rudd et al., 1996), enhanced access to clinical service (e.g., Cotgrove et al., 1995; van der Sande et al., 1997), and home-based family therapy (Harrington et al., 1998). The only psy- chotherapy that has been shown to reduce repeat attempts in a randomized clinical trial is dialectical behavior ther- apy (DBT), a 12-month cognitive-behavioral intervention designed for adults with borderline personality disorder (Linehan et al., 1991). This study found that adults assigned to DBT engaged in fewer and less severe parasuicidal behav- iors post-treatment than patients assigned to treatment- as-usual, but this may partly be attributable to higher baseline attempt rates characteristic of patients with bor- derline personality disorder. Downward extensions of DBT such as DBT-A (Miller et al., 1997a) may be of value; how- ever, they have not yet been systematically evaluated in this age group or in males, who are most at risk for suicide (Anderson, 2002). No studies of cognitive-behavioral ther- apy with adolescent suicide attempters have been pub- lished, although it has been used successfully in adolescent patients with depression (Brent et al., 1997; Harrington and Clark, 1998).

Psychopharmacological Interventions

To our knowledge, there have been no psychophar- macological studies that have specifically targeted suicidal adolescents. However, it is likely that in spite of the absence of documented support, the use of SSRIs is common among teenagers who have been referred for suicidal ideation or after they have made an attempt. Rates of pre- scription of antidepressants among teenagers are extremely high (Olfson et al., 2002b) and almost certainly include adolescents who have attempted suicide. Indeed, this prac- tice may be a factor leading to the dramatic and encour- aging decline in youth suicide rates over the past decade (Isacsson, 2000). There are few a priori reasons not to treat suicidal adolescents with SSRIs, providing their progress and response to the medication is closely monitored.

SSRI antidepressants have been shown to reduce sui- cidal ideation in both depressed (Letizia et al., 1996) and nondepressed adults with cluster B personality disorders (Verkes et al., 1998) and in individuals who have made a limited number of previous suicide attempts. SSRIs have been shown to be more effective than placebo in treating depressed teenagers (Emslie and Mayes, 2001; Emslie et al., 1997; Keller et al., 2001), they are consid-

erably less dangerous in overdose than are tricyclic anti- depressants (Ryan and Varma, 1998), and there is evi- dence that they reduce the frequency of impulsive and aggressive behaviors (Coccaro and Kavoussi, 1997), which are a common occurrence in suicidal teenagers.

In rare instances, ruminative suicidal ideation com- bined with akathisia can occur during the course of antipsy- chotic (Hamilton and Opler, 1992) or SSRI treatment (King et al., 1991; Teicher et al., 1990). This complica- tion has been reported to respond to propranolol (Adler et al., 1985; Chandler, 1990). When SSRI treatment is started, parents should be routinely advised to inform the psychiatrist if akathisia develops; the suicidal teenager should likewise be advised to inform parents or physi- cians if there is an upsurge in suicidal ideation.

In adults with bipolar or other major affective disor- ders, long-term lithium treatment significantly reduces the recurrence of suicide attempts (Tondo et al., 1997) and sudden withdrawal from lithium increases the risk of suicide independent of any effect on other symptoms of mania (Tondo and Baldessarini, 2000). Similarly, cloza- pine is effective in reducing suicidality in adults with schizo- phrenia even when there is no apparent effect or impact on other symptoms of schizophrenia (see Meltzer, 2001). The antisuicidal effects of lithium and clozapine have not been assessed in children or adolescents. If lithium is being used to treat an adolescent, it would be wise to observe the same degree of caution as has been used in adults with respect to sudden withdrawal of the medication.

CONCLUSIONS

The past decade has witnessed a surge in research on youth suicide risk. The current review has underscored youth psychiatric disorder, a family history of suicide and psychopathology, stressful life events, and access to firearms as key risk factors for youth suicide. Exciting new find- ings have emerged on the biology of suicide in adults, but, while encouraging, these are yet to be replicated in youths. Factors that had been previously thought to be risks for youth suicide, such as divorce and impaired par- ent–child relationships, have been found to be largely explained by underlying psychiatric problems in the youth and/or parents, whereas other risk factors, such as same- sex sexual orientation and sexual abuse, while mediated by other psychosocial risks, have recently been found to make an independent contribution to youth suicide.

Despite the burgeoning research literature on risk fac- tors, there remains a paucity of information on protec-

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tive factors. Family cohesiveness and religiosity may be somewhat protective, but much more work needs to be done before we can have confidence that they mitigate the impact of accumulating risk factors. Future research needs to increasingly identify factors that protect against suicidal behavior so that they may be enhanced.

Several promising empirically based prevention strate- gies have been identified, including school-based skills training for students, screening for at-risk youths, edu- cation of primary care physicians, media education, and lethal-means restriction; however, these strategies need continuing evaluation studies before their efficacy can be established.

Because the decline in youth suicide seems likely to be a product of more widely administered and more effec- tive treatment, the burden on professionals to identify depressed and suicidal teenagers and bring them to treat- ment is greater than ever before. Well-designed studies on candidate medications and psychotherapies must be conducted as a matter of urgency.

Given the complexity of the mechanism of youth sui- cide, it seems likely that no one prevention/intervention strategy, by itself, is enough to combat this critical prob- lem. Rather, a comprehensive, integrated effort, involv- ing multiple domains—the individual, family, school, community, media, and health care system—is needed.

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