Adolescent suicide as a public health threat

Journal of Child and Adolescent Psychiatric Nursing, Jan-Mar 1999 by Bloch, David S

TOPIC Adolescent suicide patterns.

PURPOSE. To raise awareness of the seriousness of adolescent suicidal behavior by reviewing international research on adolescent suicide and evaluating the prospects for identification and intervention.

SOURCES. Published literature.

CONCLUSIONS. Adolescent suicide research is complicated and often contradictory, but it does provide some insight into prevalence, risk factors, screening tools, and interventions. For completers, the problem may be intractable. But a few broad-based identification and prevention efforts show promise, and psychotherapy is a proven success. Even if suicide rates remain high, treatment of attempters should prevent further self-harm and reduce the completion rate, and thus should be funded.

Key words: Adolescence, adolescent suicide, attempted suicide, psychology

Adolescent suicide is not common (Group for the Advancement of Psychiatry [Group], 1996). In the general population, only children are less likely to kill themselves (American Academy of Child and Adolescent Psychiatry [AACAP],1994).

But suicide is consistently the second- or third-leading cause of death from the ages of 13 to 19, and the thirdleading cause of death among 15- to 24-year-olds (Lewinsohn, Rhode, & Seeley, 1996; U.S. Preventive Services [USPS] Task Force, 1989). Between 1980 and 1992, 67,369 children, adolescents, and young adults (ages 10-24 years) committed suicide. The 10- to 24year-old age group represented 16.4% of all suicides in 1992 (Centers for Disease Control and Prevention [CDC], 1995).

Further, the social cost of adolescent suicide is disproportionately great. Completed suicide results in immeasurable grief for families and friends (Eggert, Thompson, Herting, & Nicholas, 1995), and adolescent suicide results in a measurable cost: the death of an adolescent represents a significant number of years of potential life lost (YPLL) (USPS, 1989). YPLL (essentially, years of potentially productive life less age at death) is the best way to calculate the societal loss each suicide represents. By this measure, adolescent suicide dominates many diseases of later life. Overall, adolescent suicide was the fifth-leading cause of years of potential life lost in 1990 (CDC,1995).

Adolescent suicide is the driving force behind increases in the overall suicide rate (CDC, 1995), and rates are rising fast. The rate of adolescent suicide in America has tripled since 1950 (CDC; Rotherman-Boris, Walker, & Ferns, 1996). Between 1968 and 1985, suicide rates nearly tripled among American 10- to 14-year-olds and doubled among 1- to 19-year-olds (Takanishi,1993). Figure 1 shows the remarkable rise in suicide rates since 1950.

The reasons for the spiraling increase in American suicide rates are unknown. Some theorize it is a result of greater adolescent population density, which is associated with a disproportionate increase in suicide rates (USPS, 1989). Alternatively, the younger generation of adolescents may simply attempt more often, or lethality of attempt may have increased (Lewinsohn et al., 1996; CDC, 1995). Most researchers agree that population or cohort effects cannot fully explain the suicide epidemic of the past 30 years, but they cannot agree on the other causes.

Some researchers argue that rise in rates is an artifact: the 1960s ushered in a new era of psychological awareness, highlighting a suicide rate that had previously been underreported (Garland & Zigler, 1993), while others hold that reporting rates cannot explain the magnitude of the increase (Kleck,1988).

Alternatively, changing social mores, especially with respect to drugs, marriage, and sexuality, may lead to increased adolescent suicide. The social movements of the 1960s led to a new tolerance for consciousness- and mood-altering drugs, the use of which is highly correlated with suicide in adolescents (Rotherman-Boris et al., 1996). That decade also marked the beginning of the sexual revolution, whose cavalier attitudes toward sex may not be psychologically healthy-especially in teenagers (Group, 1996; Mack, 1986). In the older generation the sexual revolution coincided with a massive jump in divorce rates. Disruption of family structures increases suicide risk in teens (King, Hovey, Brand, Wilson, & Ghaziuddin, 1997). And newer social phenomena, such as the heavy-metal subculture, may reinforce or even glorify suicidal behavior (Stack, Gundlach, & Reeves, 1994).

In sum, suicide is a leading cause of death among adolescents and young adults. Because the affected population is young, the number of years of potential life lost is disproportionately great. In addition, adolescent suicide has skyrocketed in the past 30 to 40 years. Researchers have not reached a consensus on the causes of this increase, but modern suicide research has identified many population dynamics of adolescent suicide.

Populations at Risk for Adolescent Suicide

Ideators. Most research holds that suicidal ideation, suicide attempts, and completed suicides are related but separate phenomena (Fergusson & Lynskey, 1995). An estimated 200,000 to 300,000 adolescents (about 1%-2% of the total adolescent population) think about suicide (Schepp & Biocca, 1991). But because suicidal ideation is relatively common in the adolescent population, it is not a particularly useful indicator of genuine suicidal intent (Lewinsohn et al., 1996). In France, only 20% of ideators go on to attempt suicide (Ladame, 1991).