Adolescent Discussion

Adolescent Suicide Summer 2020

Scope of the Problem

• With more than 6,200 suicides among people aged 15 to 24, suicide

ranked as the second-leading cause of death for people in that age

group in 2017.

• In 2017, there were 47 percent more suicides among people aged 15 to 19 than in the year 2000.

• While girls are more likely to report attempting suicide, boys are more likely to complete suicide.

– This difference is explained partly by the differing lethality of methods they choose.

Scope of the Problem

Source: https://jamanetwork.com/journals/jama/article-abstract/2735809

Scope of the Problem

Source: https://jamanetwork.com/journals/jama/article-abstract/2735809

Suicide in Native American Adolescents

• The suicide rate for all ages was 19.5 per 100,000, much higher than the overall U.S. rate of 13.8 and the highest of all racial/ethnic groups. (CDC)

• The suicide rate among American Indian/Alaska Native adolescents and young adults ages 15-34 is 19.5 per 100,00, which is 1.5 times higher than the national average for that age group.

• Lifetime rates of having attempted suicide reported by adolescents ranged from 21.8% in girls to 11.8% in boys and from 17.6% of both sexes raised on reservations to 14.3% of both sexes raised in urban areas.

Suicide in Native American Adolescents

• Lifetime rates of suicidal ideation were significantly higher among youth raised on reservations (32.6%) compared to youth raised in urban areas (21%).

• Research shows that having a strong ethnic cultural identity has a protective effect on suicide characteristics.

Suicide in LGBTQ Adolescents

• Lesbian, gay, and bisexual kids are 3x more likely than straight kids to attempt suicide at some point in their lives.

• Medically serious attempts at suicide are 4x more likely among LGBTQ youth than other young people.

• 41% of trans adults said they had attempted suicide, in one study. The same study found that 61% of trans people who were victims of physical assault had attempted suicide.

Suicide in LGBTQ Adolescents

• Lesbian, gay, and bisexual young people who come from families that reject or do not accept them are over 8x more likely to attempt

• Each time an LGBTQ person is a victim of physical or verbal harassment or abuse, they become 2.5x more likely to hurt themselves.

• State same-sex policies have recently been linked to a decrease in suicide attempts among sexual minority adolescents (Raifman, Moscoe, Austin, & McConnell, 2017)

Common Misconceptions of Suicide

Misconception: Suicide only affects individuals with a mental health condition.

Fact: Many individuals with mental illness are not affected by suicidal thoughts and not all people who attempt or die by suicide have mental illness.

• Studies have shown that approximately 54% of individuals who have died by suicide did not have a diagnosable mental health disorder.

• Relationship problems and other life stressors such as criminal/legal matters, persecution, eviction/loss of home, death of a loved one, a devastating or debilitating illness, trauma, sexual abuse, rejection, and recent or impending crises are also associated with suicidal thoughts and attempts.

Common Misconceptions of Suicide

Misconception: Once an individual is suicidal, he or she will always remain suicidal.

Fact: Active suicidal ideation is often short-term and situation-specific. And for those with mental illness, the proper treatment can help to reduce symptoms.

• The act of suicide is often an attempt to control deep, painful emotions and thoughts an individual is experiencing. Once these thoughts dissipate, so will the suicidal ideation.

• While suicidal thoughts can return, they are not permanent. An individual with suicidal thoughts and attempts can live a long, successful life.

Common Misconceptions of Suicide

Misconception: Talking about suicide will lead to and encourage suicide.

Fact: There is a widespread stigma associated with suicide and as a result, many people are afraid to speak about it.

• Talking about suicide not only reduces the stigma, but also allows individuals to seek help, rethink their opinions and share their story with others. We all need to talk more about suicide.

Misconception: After a suicide crisis has passed, the adolescent is no longer at risk for suicide.

Fact: We always need to be assessing for suicide in our adolescent clients.

Risk Factors: Interpersonal, Family, and Psychosocial Characteristics • Disruptive and Violent Families

– Depressed male teenages with depressed male fathers are 7 times more likely to attempt suicide

– Family interactions characterized by anger, emotional

ambivalence, and rejection; decreased parent-child

involvement; inconsistency and instability

• Violent families - history of physical or sexual abuse in the family;

history of suicide in the family

– 75% children who were 11 years of age when a family member

committed suicide attempted suicide themselves when they

became adolescents

Risk Factors: Interpersonal, Family, and Psychosocial Characteristics

• Cluster Suicides - A suicide cluster may be defined as a group of suicides or suicide attempts, or both, that occur closer together in time and space than would normally be expected in a given community.

• – Research indicates that clusters of completed suicide occur

predominantly among adolescents and young adults, and that such clusters account for approximately 1%-5% of all suicides in this age group.

Source: https://www.cdc.gov/mmwr/preview/mmwrhtml/00001755.htm

Risk Factors: Interpersonal, Family, and Psychosocial Characteristics • Suicide clusters are thought by many to occur through a process of

"contagion," but this hypothesis has not yet been formally tested. – Anecdotal evidence suggests that, in any given suicide cluster, suicides

occurring later in the cluster often appear to have been influenced by suicides occurring earlier in the cluster.

– Cluster hypotheses 1) the act somehow becomes normalized for others 2) adolescents may begin to see suicide as a viable response to their feelings

Source: https://www.cdc.gov/mmwr/preview/mmwrhtml/00001755.htm

Risk Factors: Interpersonal, Family, and Psychosocial Characteristics

• Substance Use, misuse, and abuse

• Under- and overachievement

• Lack of connectedness

• Inadequate communication skills

– May have difficulty expressing distress to others

– May not feel it is safe to share their feelings

– Can lead to isolation and withdrawal

• Loss and separation

Risk Factors: Intrapersonal and Psychological Characteristics

• Self-Image - low self-esteem, poor self-concept worthlessness - can lead to hopelessness and depression

• Depression

• Impulsivity

• Hopelessness and despair

• Loneliness - isolation, and lack of connectedness; may feel rejected or unnoticed

• Faulty thinking and irrational beliefs – A rigid and unrealistic style of thinking

– A negative outlook

Risk Factors: Intrapersonal and Psychological Characteristics

Beck’s Cognitive Triad - automatic, spontaneous and seemingly uncontrollable negative thoughts about:

● The self ● The world ● The future

Examples of this negative thinking include:

● The self – "I'm worthless and ugly" or "I wish I was different"

● The world – "The world is a scary place" or "Everything is awful"

● The future – "Things will never change" or "Things can only get worse!"

Faulty Thinking of Suicide

Cognitive constriction The inability to see options for solving problems; thinking “this will never end.”

Dichotomous thinking Only able to see two solutions to the problem: 1) continue to exist in living hell or 2) find relief through death.

Cognitive rigidity A rigid style of perceiving and reacting. See the problem as catastrophic “I have no place to live and no one to help me and there’s nothing I can do about it.”

Cognitive distortion Overestimating the magnitude and insolubility of problems. Difficulties are generalized to the rest of life. Often assume they are the cause. “I didn’t get an A on the test, so I must be stupid and everything in my life is a mess.”

Risk Factors: Verbal Messages

• Some adolescents may give verbal hints, such as: – “I don’t see how I can go on; I wish I were dead.” – “You’ll be sorry you treated me this way.” – “Pretty soon my troubles will be over.”

• Suicidal adolescents may also talk about death and may also joke about killing themselves.

• Verbal warnings should be taken seriously – if this is ignored, it may be interpreted as confirmation that the adolescent is expendable and unloved.

Risk Factors: Behavioral Changes

• Mood swings or fluctuations

• A change from positive interactions with others to withdrawal and negativity

• Deterioration is academic performance

• Apathy or a lack of activity

• Changes in sleep or eating patterns

• Giving away prized possessions

Protective Factors

The risk factors that lead to suicide (especially mental and substance abuse disorders) and the protective factors that safeguard against it, form a conceptual framework for suicide prevention Sense of worth/confidence

• Stable environment

• Family cohesion (mutual involvement, shared interests, and emotional support)

• Responsibilities for others/pets

• School/community connectedness and belongingness; academic achievement

Protective Factors

• Social engagement in hobbies and extracurricular activities

• Cultural and spiritual/religious beliefs that discourage suicide, support reasons to live, and encourage help-seeking

• Important learned skills: problem-solving skills, effective communication (conflict resolution), impulse control, and stress management

• Access to and participation in effective mental health care; help- seeking behavior

• Restricted access to lethal means

Assessing Suicidal Ideation

Suicide Ideation: Thoughts of wanting to die or ending one’s life.

• Presence or absence of ideation has little predictive value by itself. • Ideation plus planning and preparation is more predictive

Assessment:

• How many times have you had these thoughts?

• When you have these thoughts how long do they last?

• Can you stop thinking about killing yourself if you want to?

• Are there things you can do to stop the thoughts or wanting to die?

• What sort of reasons do you have for wanting to die?

Assessing for Suicide Lethality

• The severity of risk for the adolescent depends on the specificity and lethality the method of choice.

• Major red flags:

– Ideation with a plan, including a time, place, and method

– A lethal method (such as a gun)

– Accessibility of a means to commit suicide (such as a loaded gun in the house)

– A history of previous suicide attempts

– A history of suicide in the family

– Lack of interpersonal support

– Recent loss of relationship or goal

– Reported feelings of hopelessness

Interviews for Suicide Lethality • Pay special attention to these factors:

– Symptoms of clinical depression and hopelessness

– Recent loss of an important relationship or life goal

– Serious family problems, such as divorce or abuse

– Personal history of physical disability, drug abuse, or psychiatric treatment

– Interpersonal impoverishment, or the absence of friends, family, and others who can provide emotional support

Assessing Suicide in Adolescents

• The interviewer should attempt to assess:

– The history of the presenting problem (e.g., loneliness, depression)

– The family constellation and relationships

– A developmental, medical, and academic history

– The status of interpersonal relationships

– Verbal and behavioral warning cues

– Any current stressors that may trigger a suicide attempt

Assessing Suicide in Adolescents: Current Suicidal Behavior

• Does the adolescent patient have a plan?

• How detailed is the plan?

• Do they have the means to carry it out?

• Have they used this method before?

• Have they acquired the means to carry out the plan?

• Have they begun preparations?

• What does the adolescent expect would be consequence of

behavior?

Assessing Suicide in Adolescents: Past Suicidal Behavior

• Have you ever made preparations to kill yourself?

• Have you made a suicide attempt?

• What did you do?

• Have you ever started to kill yourself but stopped or been stopped?

Assessments/Questionnaires

• Suicide Behaviors Questionnaire – Revised

– http://www.integration.samhsa.gov/images/res/SBQ.pdf

• University of Texas Health Care Center’s Evaluation of Suicide Risk for Clinicians

– http://www.cqaimh.org/pdf/tool_suicide_risklevl.pdf

• Columbia Suicide Severity Rating Scale

–http://www.integration.samhsa.gov/clinical-practice/Columbia_Su icide_Severity_Rating_Scale.pdf

• Patient Health Questionnaire (PHQ-9)

• – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/

Safety Planning • Safety Planning

• Decrease risk factors and warning signs

• Increase protective factors

• Focus on suicidality until resolved

• Plan for immediate, short-term, and continuing treatment