The primary care physician's role in suicide prevention

There is no doubt that suicide is a major public health problem for American youth. In 2004, suicide was the third leading cause of death among youth 15 to 24 years old, and 4,316 young people committed suicide in that year. In 2005, the percentage of high school students who seriously considered suicide was 8.4 percent. Suicide is a complex psychiatric and public health problem. Additionally, making sense of the literature regarding risk factors for suicide in youth can be equally as complex.

There are many barriers to mental health care for children, and the primary care clinician's office can be an ideal setting for a brief screening related to depression and suicidal risk factors. Risk factors for suicide can be modifiable or nonmodifiable. Also, acute stressors are distinct from risk factors but can play an important role in youth suicidal behavior. Categorization of suicidal risk is the quintessential element pediatricians can begin to assess in youth, followed by psychiatric referral or request for consultation, when appropriate. In a circumstance when a child is actively suicidal or has attempted suicide, urgent psychiatric assessment, and usually psychiatric hospitalization, is the standard of care.

The three most important risk factors for suicidal behavior and completed suicide in youth are the presence of a mood disorder, history of a suicide attempt and the presence of firearms in the home. Psychiatric disorders, including mood disorders such as depression, are very common among adolescent suicide victims. Mood disorders, particularly depression, have been shown to be the strongest modifiable risk factor for suicide in youth and adults. Alternatively, firearms account for the majority of completed youth suicides in Wisconsin. For all ages, firearms are the most common method used to commit suicide, and the presence of firearms in the home is an independent risk factor for suicide. Means restriction, or limiting access to firearms, is an important suicide prevention strategy used in some communities. Additionally, and not surprisingly, history of a prior suicide attempt is one of the strongest predictors of completed suicide, conferring a particularly high risk for boys. The presence of substance abuse is also a significant risk factor for suicide.

Other nonmodifiable risk factors are associated with suicide such as age, gender, a family history of psychopathology and completed suicide, and a history of abuse. As stated above, adolescents confer a higher risk for completed suicide and suicidal behavior based on age alone. Teenage males are more likely to complete suicide, while teenage girls are more likely to attempt. Childhood physical and sexual abuse have been found to be significantly associated with an increased risk of suicidal behavior in adolescence.

While the presence of mood disorders and previous suicidal behavior may be somewhat obvious risk factors for future suicidal behavior and completion, certain other risk factors may not be as obvious. Sexual orientation, contagion and bullying are important suicidal risk factors that can be overlooked. Regarding sexual orientation, cross-sectional and longitudinal epidemiological studies found a significant increased risk of nonlethal suicidal behavior for homosexual and bisexual youths. Additionally, 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. The impact of suicide stories on subsequent completed suicides appears to be greatest for teenagers and is proportional to the amount and prominence of media coverage. Common acute precipitants for youth suicide and suicide attempts are family and relationship problems.

The association between bullying behavior and depression, suicidal ideation and suicide attempts also has been studied recently. Studies of psychosocial health among victims and offenders of bullying have found that depression and suicidal ideation are common outcomes of being bullied in both boys and girls. Interestingly, these associations were found to be stronger for indirect (covert, relational) than direct (overt, physical) bullying.

Pediatricians and family practice physicians play a vital role in beginning the assessment of suicidal risk factors and referring children to appropriate resources or requesting consultation. These physicians have a unique relationship with their patients and families, and the primary care office is a setting where mental health issues may be more easily normalized by families if they are put into the context of a general screening. While there are multiple tools and standardized instruments that can be used for mental health screening as well as suicidal risk factors, none are designed particularly well for busy pediatricians. Rather than using a standardized screening instrument, simply asking about the presence of the above risk factors, most importantly the presence of depressed mood and suicidal thinking, and then referring to appropriate resources or requesting consultation is better than not asking at all or becoming overwhelmed with screening instruments. Suicide is a complex public health problem with no one-size-fits-all solution. However, we can do our best to identify those children who are at high risk, with the goal of addressing the relevant risk factors in a therapeutic way.

References

Gould MS, et al, "Youth suicide risk and preventive interventions: A review of the past ten years," Journal of the American Academy of Child and Adolescent Psychiatry, 2003, 42:3(386-405).

Klomek AB, et al, "Bullying, depression and suicidality in adolescents," Journal of the American Academy of Child and Adolescent Psychiatry, 2007, 46:1(40-49).

Schiffler T, et al, "The burden of suicide and homicide of Wisconsin's children and youth," Wisconsin Medical Journal, 2005, 104:1(62-67).

www.cdc.gov

Shane Moisio, MD, is pediatric psychiatrist at Children's Hospital of Wisconsin, an assistant professor of Child and Adolescent Psychiatry at the Medical College of Wisconsin and a member of Children's Specialty Group.

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