A Practical Guide to Working with Suicidal Youth: A New Zealand Perspective

The Norwegian initiative which provided follow-up care after suicide attempts via a chain-of-care network also is reported to reduce suicide rates. Involvement of the family in aftercare following a suicide attempt is critical since they may constitute the main support system.

The family may also serve as after care monitors for treatment adherence and detection of any signs of suicidality Suicide prevention requires strategies that encompass work at the individual, systems and community level. Policy directed at means restriction and public awareness campaigns can be used in combination with strategies directed at the individual, including identification, proper diagnosis and effective treatments. Given the complexity of identifying and managing suicide risk, a combination of interventions at a several levels will be required in order to implement an efficacious, comprehensive prevention program.

Giner has received compensation for development of educational presentations from Servier, Bristol-Myers Squibb, Janssen, and GlaxoSmithKline; has received compensation for travel, accommodations, and meeting expenses from Servier, Bristol-Myers Squibb, Janssen, and GlaxoSmithKline; and has received compensation for development of a presentation from GlaxoSmithKline; M.

Her family owns stock in Bristol-Myers Squibb. National Center for Biotechnology Information , U. Author manuscript; available in PMC Dec 1. Author information Copyright and License information Disclaimer. The publisher's final edited version of this article is available at Curr Psychiatry Rep. See other articles in PMC that cite the published article. Abstract Every year, suicide is among the top 20 leading causes of death globally for all ages.

Suicide, Risk factors, Diagnostic risk factors, Depressive disorders, Bipolar disorders, Anxiety disorders, Alcohol and other substance abuse, Schizophrenia, Aggression, impulsivity, and hostility, Hopelessness, Heredity, Childhood trauma, Past attempts, Prevention, Means restriction, Media coverage, Identification methods, Diagnosis, Treatment, Psychotherapy, Pharmacotherapy, Electroconvulsive therapy, Mood disorders, Psychiatry.

Bipolar disorders Suicidal ideation is highly prevalent in patients with bipolar disorders, and it is estimated that as many as half of those who have bipolar disorder attempt suicide at least once. Anxiety disorders Anxiety disorders are associated with lifetime suicidal ideation and suicide attempts, especially in adolescents and in young adults Alcohol and other substance abuse All substance disorders increase the risk of suicidal behaviors, alcohol being the most significant risk factor among the substances.

Personality disorders Personality disorders have been shown to be related to suicidal and self-injurious behavior, both among the general and the psychiatric population Other Risk Factors Aggression, impulsivity, and hostility Levels of impulsivity, hostility and aggression are higher in suicide attempters compared to non-attempters among people who suffer from major depression Hopelessness Hopelessness was found to be associated with future suicide attempts both in the short and long term 19 , 36 , 37 , Heredity Suicidal behavior is highly familial 39 , 3 , 40 and a family history of suicidal behavior is associated with suicide attempts and suicide all through the life cycle and across psychiatric diagnoses Childhood Trauma Childhood trauma is also a risk factor for suicide attempt.

Past attempts and ideation A suicide attempt in the past is a major risk factor for suicide 3 , 16 as well as future suicide attempt, especially among people suffering from affective disorders 46 , 47 , 48 , 49 , 50 , 51 , Means Restriction Suicide attempts using highly lethal means, such as firearms in US men, or pesticides in rural China, India, and Sri Lanka, result in high rates of death Responsible Media Coverage Responsible media coverage is key to suicide prevention by providing the public information on mental disorders and their treatment, and ways of identifying persons at risk.

Identification Methods Before suicidal behavior can be prevented, those at risk need to be identified. General public education Public education campaigns are aimed mostly at improving suicide risk recognition and help-seeking behavior and reducing the stigma of mental illness Gatekeeper training Gatekeepers are figures with the potential to influence the suicidal person on a temporary or ongoing basis e. Screening Screening aims to identify at-risk individuals and direct them to treatment Treatment Suicide is complex involving psychological, social, biological, cultural and environmental elements.

Psychotherapy Several evidence based psychotherapies have been shown to be of utility in the treatment of those at risk for suicidal behavior. Pharmacotherapy Given the importance of psychiatric illness as a contributor to suicide risk, providing suitable, robust pharmacotherapy for psychiatric disorders is critical to suicide prevention. Antidepressants Depression is the psychiatric condition most often associated with suicidal behavior. Mood stabilizers Lithium is reported to reduce both attempted and completed suicides in major mood disorders, such as unipolar depression and bipolar patients with long-term lithium treatment , Antipsychotics Clozapine has been shown to have an anti-suicidal effect in schizophrenia compared to both placebo and other second generation antipsychotics and is the only FDA approved drug for treatment of suicidal behavior.

Electroconvulsive therapy There is extensive evidence that ECT is an effective treatment for acute suicidality among severely depressed patients Follow-up after suicide attempt Recurrent suicidal behavior places a great burden on patients and their families, as well as on the health care system as a whole.

References Papers of particular interest, published recently, have been highlighted as: European psychiatric association Guidance on Suicide treatment and Prevention. Assessment and treatment of suicide risk in bipolar disorders.

Soloff PH, Fabio A. Prospective predictors of suicide attempts in borderline personality disorder. Major psychiatric disorders in suicide and suicide attempters. Wasserman D, Wasserman C, editors. Oxford Textbook of Suicidology and Suicide Prevention: Oxford University Press; Suicide risk in mood disorders. Classification trees distinguish suicide attempters in major psychiatric disorders: Contact with mental health and primary care providers before suicide: Contacts to the health care system prior to suicide: Global and regional burden of disease and risk factors: Systematic analysis of population health data.

The utilization of antidepressants-a key issue in the prevention of suicide: Use of antidepressants among people committing suicide in Sweden. Prospective studies of suicidal behavior in major depressive and bipolar disorders: Major Psychiatric disorders in suicide and suicide attempts. This systematic review of disorders that serve as risk factors for both suicide and suicide attempts provides a comprehensive summary of the literature to date.

Anxiety disorders and suicidal behaviours in adolescence and young adulthood: Panic Disorder, Comorbidity, and Suicide Attempts. Anxiety in major depression: American Journal of Psychiatry. Post-traumatic stress disorder and suicidal behavior: Suicides of alcohol misusers and non-misusers in a nationwide population. Mortality in schizophrenia — A measurable clinical endpoint. The lifetime risk of suicide in schizophrenia: Suicide Life Threat Behav. Hor K, Taylor M. Stanely B, Jones J. Risk for suicidal behavior in personality disorders.

Assessing suicide risk in cluster C personality disorders. Axis one disorders and personality disorders as risk factors for suicide.

Eur Arch Psychiatry Clin Neurosci. Changes in self-destructiveness of borderline patients in psychotherapy. J Nerv Ment Dis. Major depression and the risk of attempted suicide. Suicidal behavior in bipolar mood disorder: Can temperament identify affectively ill patients who engage in lethal or near-lethal suicidal behavior?

In this article

Psychopathological predictors of suicide in patients with major depression during a 5-year follow-up. Keller F, Wolfersdorf M. Hopelessness and the tendency to commit suicide in the course of depressive disorders. The prediction of parasuicide repetition in a high-risk group. Br J Clin Psychol. Family genetic studies, suicide, and suicidal behavior.

Roy A, Janal M. Family history of suicide, female sex, and childhood trauma: The genetics of suicidal behavior. Hawton K, van Heeringen K, editors. The international handbook of suicide and attempted suicide. Suicide and Family Loading for Affective Disorders. Peripubertal suicide attempts in offspring of suicide attempters with siblings concordant for suicidal behavior.

Familial pathways to early-onset suicidal behavior: Risk factors of attempted suicide in bipolar disorder. Suicide and Life-Threatening Behavior. Suicide risk in bipolar disorder during treatment with lithium and divalproex. Journal of the American Medical Association. Harris EC, Barraclough B.

Suicide as an outcome for mental disorders.

British Journal of Psychiatry. Suicide and attempted suicide in bipolar disorder: Journal of Clinical Psychiatry. Pharmacological prevention of suicide in bipolar patients a realizable target. Journal of Affective Disorder. Current Opinion in Psychiatry. Rihmer Z, Kiss K. Bipolar disorders and suicidal behaviour.

A Prospective study of fluoxetine treatment and suicidal behavior in affectively ill subjects. Adequacy of antidepressant treatment after discharge and the occurrence of suicidal acts in major depression: Suicidal ideation and attempts in bipolar I and bipolar II disorders. Coryell W, Young EA. Clinical predictors of suicide in primary major depressive disorder.

Juvenile suicide in confinement in the United States: Recurrence of suicidal ideation across depressive episodes. Clinical predictors of suicidal acts after major depression in bipolar disorder: Suicide attempts and ideation in patients with bipolar I disorder.

A multifaceted, community-based action programme against depression and suicidality. World J Biol Psychiatry. Effective strategies for suicide prevention in New Zealand: The new Zealand journal of medicine. Gun availability and use of guns for suicide, homicide, and murder in Canada. The association between changes in household firearm ownership and rates of suicide in the United States, — Firearm legislation reform in the European Union: Impact on firearm availability, firearm suicide and homicide rates in Austria.

Unanticipated benefits of automotive emission control: Reduction in fatalities by motor vehicle exhaust gas. Kelly S, Bunting J. Trends in suicide in England and Wales, — Eur J Public Health. Association between the accessibility to lethal methods and method-specific suicide rates: An ecological study in Taiwan. The epidemiology and prevention of suicide by hanging: Controlling access to suicide means. Why do people choose charcoal burning as a method of suicide? An interview based study of survivors in Taiwan. Imitative suicide on the Viennese subway. Best practice elements of multilevel suicide prevention strategies: This concise meta-review summarizes the data relevant to designing a comprehensive suicide prevention model, addressing the various levels of intervention that are essential to an effective campaign.

Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: Public attitudes towards treatment of depression: The impact of beyondblue: Akroyd S, Wyllie J. New Zealand Ministry of Health; The role of policy in public health and suicide prevention in particular is highlighted in this review of the evidence. The alliance against depression: Effectiveness of interventions to prevent suicide and suicidal behavior: Scottish Government Social Research; A suicide prevention program in a region with a very high suicide rate.

Mehlum L, Schwebs R. Suicide prevention in the military: Randomized trial of a gatekeeper program for suicide prevention: J Consult Clin Psychol. The Columbia Suicide Screen: Validity and reliability of a screen for youth suicide and depression. Screening for depression in adults: Screening for suicide risk in adults: The psychological and behavioural treatment of suicidal behaviour: Cognitive therapy for the prevention of suicide attempts: Cognitive treatment of suicidal adults; pp.

DBT for suicidal individuals; pp. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry. World Journal of Biological Psychiatry. Acute and continuation treatment of major depressive disorder.

The relationship between antidepressant medication use and rate of suicide. Relationship between antidepressant medication treatment and suicide in adolescents. Association between antidepressant prescribing and suicide in Australia, — Pharmacological and other biological treatments of suicidal individuals. Association between suicide attempts and selective serotonin reuptake inhibitors: Decreased risk of suicides and attempts during long-term lithium treatment: Lithium treatment reduces suicide risk in recurrent major depressive disorder.

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Mental health disorder is strongly associated with suicide but is not the only risk factor. Assessing wellbeing at every opportunity, providing culturally appropriate care and identifying risk early are key factors in suicide prevention. Both background risk factors, which are mainly static, and changeable risk factors can increase the overall risk of suicide.

Mood disorders and substance misuse including alcohol are strongly linked with suicide among young people. Young people who die by suicide often had a history of being irritable, impulsive, volatile and prone to angry outbursts 4. The risk of suicide is sensitive to changeable factors, which can increase vulnerability. For example, a male with a history of sexual abuse has background risk factors for suicide which may be increased by the onset of alcohol or drug binges, a relationship breakdown or other life crisis.

Accumulative risk of suicidal behaviour Suicidal behaviour in young people is unlikely to be solely due to a stressful life event or psychiatric disorder, but rather, a response to an unhappy or adverse life course, which has been characterised by the accumulation of risk factors during childhood and adolescence. Beliefs and attitudes towards mental health disorders and suicide may vary depending on the cultural background of the individual and the community in which they live. Differing attitudes, religious and spiritual beliefs may influence the way in which distress is manifested and also the way friends and family respond to this distress.

However, whakamomori has a broader meaning which includes feelings, thoughts, emotions and actions that may escalate and result in an attempt at suicide. Factors that may protect against suicide, arising from a cultural perspective, include: Primary care is the first point of contact for most young people with any health problem, therefore primary care clinicians are ideally placed to identify and help young people in distress.

It is important to ask the right questions, consider the presence of any suicidal behaviour and continually assess suicide risk. Although a recognisable mental health problem e.

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Be aware of all of the risk factors for suicide in young people including the potential for increased risk due to issues surrounding ethnicity. Early detection of distress should allow effective interventions within a primary care setting, with the aim of preventing a suicide attempt. This framework can be used to identify issues that need to be addressed to restore wellbeing.

Communicating with young people Consultations with young people can be difficult. History taking may be challenging especially when the young person has feelings such as embarrassment, fear, shame and shyness. The aim is to establish effective, non-judgemental communication, to be empathic and to gain trust.

Ask open questions to encourage conversation.

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Issues of confidentiality Reassure the patient that the consultation will remain confidential. However be aware that confidentiality has limits. If a high risk of suicide is suspected then there is an obligation for the GP to inform others, such as parents or a mental health team, even if the young person has not given their consent.

Young people are faced with challenges on many levels — physical, emotional, behavioural, educational and social. Determining what is normal and what may constitute a mental health problem can be difficult. The following criteria may be useful to help distinguish normal behaviours from behaviours that may be indicative of a mental health disorder: Other presentations of adolescent depression may include behavioural disturbances, problems at school and social withdrawal.

If suicidal ideation has been identified in a young patient, design and write an action plan with them. This could be in two parts:. Immediate same day referral to secondary mental health services should be made for any young person who has: Referral to secondary services may be required if a mental health problem is suspected but an accurate diagnosis has not been made. Referral should also be considered for young people who fail to respond to treatment in a primary care setting, or who may require medication. Early intervention has been identified as a key priority to help improve health outcomes.

For youth with mental health problems early intervention may potentially prevent these problems from continuing into adulthood. In any young person presenting with mental health problems, an assessment of suicide risk should always form part of the initial consultation and risk should be continually monitored. These tools are intended as a guide for questioning. Other factors, such as the specific presenting problem and clinical judgement, may alter the flow of questions within a consultation. A strengths-based approach to management Most young people with mild to moderate mental health problems can be managed in primary care with advice, active support and monitoring.

Referral to other services may be required for severe problems and for some conditions, e. Referral may also be required to access specialised therapies, e. The overall aim of management is to promote a positive attitude and encourage development of the skills required to help overcome issues affecting the person. Using a strengths-based approach helps to identify and develop these strengths and positive attributes. A strengths-based approach helps to build confidence, motivation and self esteem.

Encourage the young person to adopt coping strategies and to take an active role in their management, as this may be empowering and a significant influence in promoting recovery. Listening to and appreciating the unique perspective of a young person may help them feel valued and appreciated. This may not necessarily be a parent, particularly if the parental relationship is the cause of any distress.

In some cases the trusted adult may be an outreach worker, practice nurse or GP. Ensure the patient knows how to access urgent help if required. Offer self management advice including guidance on exercise, sleep hygiene, stress management and misuse of alcohol and other substances. Ensure there is a plan for follow-up and ongoing monitoring of suicidality. Consider referral to support services such as counselling, group therapy and other outreach services.

Check if follow-up is in place for young people, who have been discharged from secondary care following admission for self-harm or mental health problems. Medication in young people with mental health problems Some young people with moderate to severe mental health problems, particularly depression, may require medication.

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However, it is recommended that GPs only prescribe antidepressants for young people in consultation with a psychiatrist or paediatrician. Fluoxetine may be used for major depression in young people, but requires careful monitoring to detect any worsening of symptoms, suicidality or changes in behaviour.

The Lowdown is a free website aimed at young people, with downloadable self-management resources and youth counsellors available to provide online and text-based support services. The Ministry of Health, as part of the New Zealand National Depression Initiative , has launched a website including information, case studies, video stories and an online self-management programme, fronted by John Kirwan.