Can We Reduce Youth Suicides by Understanding and Identifying Risk factors?

Coryell,WilliamWilliam Coryell, MD
George Winokur Professor of Psychiatry at the University of Iowa Carver College of Medicine

Today we begin a five part series on youth suicide prevention. Guest perspectives come from National Network of Depression Centers and the Active Minds, Inc., as well as personal stories from both a peer and family member.

In the United States, someone dies from suicide every 13.7 minutes. As a physician, I understand that the vast majority of people who die by suicide have a mental disorder at the time of their deaths, and that both attempted and completed suicide take a great emotional toll on family members. As a research scientist, I recognize that studying the characteristics of individuals who attempt and complete suicide will help us better understand who is most at risk. This knowledge can empower clinicians, family members and peers to seek emergency care for those in need.

I currently serve as co-chair of the National Network of Depression Centers Suicide Prevention Task Force, which is working to strengthen existing efforts in suicide prevention, with particular emphasis on measures that assess suicidality. While we do not yet have a sure-fire “suicide test,” a growing body of research is helping us identify those at higher risk. Raising awareness of these known risk factors can help people recognize signs of suicidal behavior in their loved ones; and that could help save lives and reduce suicide in young people.

Risk factors are not the same as warning signs. They are characteristics that make it more likely a person will consider, attempt, or die by suicide. Warning signs are behaviors that indicate suicide is an imminent risk. Understanding risk factors can help people identify warning signs so that they can help their friend or loved one obtain emergency care.

Risk factors

Major depression greatly increases the risk for suicide in young people. More than 90 percent of people who die of suicide have depression or another diagnosable mental disorder. However, not everyone with depression is at risk for suicide. The key to identifying those most at risk is to look for accompanying risk factors, as the presence of several risk factors at the same time greatly increases a person’s risk for suicide.

Additional risk factors include:

Substance abuse. A report by the Substance Abuse and Mental Health Services Administration found that substance abuse was a major risk factor for suicide, and one study found that alcohol and drug abuse disorders were associated with a six-fold increase in the risk of suicide attempts.

Impulsive or violent behavior. Research has established an association between impulsive and aggressive behavior and suicide risk, particularly in young adults. Some studies suggest that people who have difficulty controlling their anger may be more likely to act impulsively and turn the violence on themselves. Other studies suggest that people who have a higher level of impulsive behavior may be more at risk for mental disorders such as substance abuse, and that, in turn, increases their risk for suicide.

Past suicide attempt. Although it seems obvious that someone who attempted suicide in the past is at risk for trying it again, it is one of the most-established risk factors. It does not matter how long ago a person attempted suicide; if someone attempted it once, he or she is more likely to attempt it again, no matter how many years have elapsed.

Life events. Some people who have one or more risk factors may become suicidal when confronted with stressful life events, such as losing someone close, having a relationship conflict, bullying, or being exposed to another person’s suicide.

Pay attention to risk factors

It is especially important that peers and family members be attuned to risk factors other than threats of suicide, such as persistent signs of depression or expressions of hopelessness. That’s because while talking about suicide and making plans for suicide are clear warning signs, some people deny or minimize their suicidal intentions for fear of hospitalization or a desire to accomplish suicide without interference. One study found that 78 percent of people who attempted suicide had denied suicide plans when last questioned, in most cases shortly before the act.

Suicide prevention research

Through continued research we hope to gain a clearer understanding of why some people are prone to suicide and others are not. Through continued outreach and education efforts, we can raise awareness of suicide as a health risk so that we may decrease the number of these preventable deaths.

Your Turn

  • How can parents, teachers and people who work with youth be made aware of the risk factors involved in youth suicide?
  • What measures do your local schools, government, or other institutions have to help people understand youth suicide and how to prevent it?
  • What role should youth and young adults have in suicide prevention? Should their middle and high schools, and colleges and universities be teaching them how to identify suicide risk factors and warning signs?

Should Congress pass the Garrett Lee Smith Reauthorization Act of 2011 to continue funding for youth and young adult suicide prevention programs?

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Read more about the Garrett Lee Smith Reauthorization Act of 2011.

17 comments
trudy277
trudy277

This may sound arbitrary and invasive of privacy, but here's what I wish had happened in my life before I entered kindergarten. A school nurse interviews a parent and the pre-kindergarten child before registration. While the child plays with toys to the side of the nurse interviewer and their parent, the parent is asked questions on family health history, including substance abuse, chronic illnesses that can affect the child, how the child behaves with adults, children, habits... 


While the parent and child trade places - magazines/newspapers provided for the parent - the nurse engages the child in a sandbox game with movable objects that tell a story. (In-service training of the nurse in this would be given a month before the interview takes place.) For example, the question, "What has been your proudest moment so far?" The child would tell the story with the movable objects. Nurse would watch & listen for expression, non-expression,...


The interview would also give the nurse the opportunity to see the physical movements, coordination, communication, or lack thereof between the parent & child. Abusive, abrupt, flat behavior on the part of the parent or child would be noted, as well as bruises, contusions, other injuries on either. In that case, as a mandated reporter, the nurse would relay findings not just to a file but to a school psychologist designated for home visitation & follow-up.


Why so early? The seeds of suicide are sown early in the double whammy of genetic history and family/environmental abuse. A nurse trained to watch for certain signs in parent and child can offer help and support early rather than too late. Then it becomes the choice of the parent to act on behalf of their child or to hide from guilt. But at least the community tries to do something...

onelastresort
onelastresort

How can parents, teachers and people who work with youth be made aware of the risk factors involved in youth suicide?

I think that it should be mandatory for teachers and people who work with youth to be exposed to what the symptoms and signs are either in a seminar or at college. Parents should be aware of their child's actions and moods without being overbearing. Bullying of any kind should be taken seriously since it is one of the leading causes of teen suicide (in my opinion).

What measures do your local schools, government, or other institutions have to help people understand youth suicide and how to prevent it?

I do not think that schools near me and the government does a good job of enforcing the anti-bullying laws. I think that youth suicide should be taken seriously because it is a big issue. I think that there should be more available resources for preventing it as well as having people aware of the signs.

What role should youth and young adults have in suicide prevention? Should their middle and high schools, and colleges and universities be teaching them how to identify suicide risk factors and warning signs?

Youth and young adults should speak to peers about suicide prevention because it think that young people are more receptive to people their own age or slightly older. I think that it should be known especially in high schools and college since from about age 13 is where the symptoms first show up. But knowledge is the best way to prevent suicide.

StephenBonin
StephenBonin

KimGAllen, I agree with you that "studying anxiety and how to work with anxious patients and using trauma-informed care is mandatory." Let's look at that word "Study." In my post I wrote about Jerry White, for whom it comes natural to demonstrate superb care for the youth in his computer lab. For others, a curriculum would be effective. As with any skill, we have an impetus to learn. Secondly, we have in the curriculum bringing divergent populations together, development of the skilled "Youth Suicide Prevention Specialists." Everyone who owns a skill has Triumphs and Obstacles. Finally, skill owners have ways to maintain. Just as there are Lamaze classes the parents take to prepare for the birth of the baby, I can envision with the help of your comment a mandatory Course for parents of pre0-teens. Thank you. Stephen

StephenBonin
StephenBonin

Veronica, Thank you for posting. After writing my first response--for I still need to address questions 2 and 3--and reading yours, I gained a simple insight that I need to look closely at people. I read some of the article link highlighted in our essay #1 on this topic, which focusses on the prevalence of substance abuse as risk factors. At age 53, I have lived long enough to notice signs of substance abuse.

StephenBonin
StephenBonin

1. How can parents, teachers, and people who work with youth be made aware of the risk factors involved in youth suicide? They must be genuinely attuned to the young people. A friend, Pastor John Nader, of a Methodist Church here in Corsicana (about an hour below the Dallas-Fort Worth Metroplex, told me that when he started an assignment as youth pastor IN the metroplex--Arlington, specifically--he heard of an attempted suicide by an upper class teen. ( I was immediately shocked! That was yesterday. Today I realize that any person of any socioeconomic category can have the risk factors.

The risk factors that this teen faced: He had gone on a Mission experience with the youth group. Traditionally, youth leaders of Protestant Mission Teams expect the youth to be changed for the better afterward.

This teen, however, was drowning in severe guilt that he was materially loaded, and the people he had served in the past week were not.

Happy ending: The parents and church youth leaders instituted a new aspect of the Mission experience. For the week following their return home, they would meet to process. They would talk about their feelings and thoughts. They still do.

**************************************************

A second example: My friend Jerry White, 52, is director of the wonderful computer lab at Navarro College. This lab is in a building called Computer Science Building. Citizens of the county who are not taking college classes are welcome to use this lab. Not with my own computer, I use this space and the public library lab downtown.

So back to Jerry White. He is a hero. As I have observed him over the past six years, I have arrived at an assessment of him as "hero." Students--and ME RECENTLY--can become excessively intense when sitting in front of these screens. The special day I am thinking about occurred when I was definitely divulging some more personal information to you all. Jerry had been enacting his strength of floating around the room, being cheerful, breaking up people's intensity.

I was aware of him doing his heroic feat--away from me. Then, all of a sudden, he was in  my left eye periphery. I continued to hunker down face front and center until he spoke gently, caringly. He told me two days ago that he could see I was sinking. My tears streamed down my cheeks, and I, at his suggestion, took a break in the beautiful outdoors.

Per his strength 40 to 40-plus hours here, I see and hear him lightly tap students and say, "Come with me; I need to talk with you." They go to his office and close the door. From Jerry's life journey including distinctly dark times that he won't deny, he gets close with his student workers and the people who do their work in here. He asks " How are you?" and really means it.

veejay123
veejay123

As a person who has attempted many times to commit suicide )albeit after my 37th birthday).. I will say this my first suicidal thoughts that were severe and resulting in a plan was when I lost one of my favorite famous singing artist. (Phyllis Hyman - I got news over the networks she had committed suicide. for a long while I couldn't understand why she had done it and I was very sad for her and cried a lot. After my life became unbearable I began to see it as a way out as did Phyllis and an young boy attending school with my children ( no more than the 10th grade). Thus became my intentions to commit suicide when things got unbearable. To bring to light the risk factors to the close loved ones of suicidal persons whether diagnosis has been done or not would more likely save many lives from completed suicide as well the onset of failed attempts. I am sure the fore knowledge of the risk fathers of suicidal tendencies to the persons at risk as well as those in close association with those who are suicidal or at risk would indeed help those suffering.  Those who are in their youth who are suicidal - at risk persons - are I think more likely to attempt to hide and masquerade all things associated with their suicidal thoughts prior to the actual attempt. Because many times parents associate their teens as coming of age and growing pains often times the visual risk factors are left unnoticed and without intervention. Many teachers are not placing the importance of wellness of mind at the top of their daily task with their students... for one it is not an academic mandatory requirement. In addition religious and community youth programs are more geared to teach teamwork and other skill and so they lack in most cases to identify a suicidal teen whether the program is for the less advantaged or troubled teen or not. It is my hope that some break through with the recognition of those teens and adults who look to suicide as a means of comfort are given the watchful eyes of as well as the informed care from loved ones and others associated with those who are at risk of suicide. Veronica C. Jones

StephenBonin
StephenBonin

Dear Colleagues, I am glad to be finally entering the discussion. The last two weeks have brought positive, bright changes, which necessitated prioritizing other commitments. I will post responses to this first article of our new five-week unit very soon. Also, meet my friend Veronica Jones, us being in the same DBSA support group together. She is word processing her answers right now. Stephen

MarkPollackMD
MarkPollackMD

The conversation here is excellent. I wanted to add that anxiety is a potent risk factor for suicide. This association was first reported 25 years ago but has been debated since that time. ADAA’s journal, Depression and Anxiety, had a special issue on the topic of suicide last October than seems to put this debate to rest. In addition to the many studies published, examining the role of anxiety disorders across over 40 studies (totaling more than 300,000 adults) the analysis by Amrit Kanham and his colleagues conclusively showed that individuals with an anxiety disorder (panic, generalized anxiety, PTSD but not OCD) were 2.5 to 3.5 more likely to have suicidal ideation, attempts and completions.  Research strongly supports inclusion of diagnosis and treatment of anxiety to reduce associated symptoms. This should be part of suicide prevention programs. As president of the Anxiety and Depression Association of America, the organization has been engaged in multiple public education programs including one on college campuses to increase awareness about anxiety disorders and their treatment. More than 50,000 brochures across several hundred campuses have been distributed over the past 7 years. Other work aims to increase awareness and education about the anxiety and depression and how to find treatment. But to reach large audiences who may not even be aware that they will need this information one day, we need to work together. Only then can we begin to move more quickly to end the stigma that keeps so many from seeking help.

JohnGredenMD
JohnGredenMD

Dave, I did not know about the Japanese initiative.  Thank you for sharing. 

kimgallen
kimgallen

I will agree with Dr Greden that peer-to-peer programs in schools are remarkably accepted. I have worked with more than one university assisting them in how to recognize signs of substance use disorders and chemical dependency. Those programs have been very useful and highly valued. I agree that the teams involved should include administrators, school counselors, student, parents and community leaders. Students need to know very clear action plans and how to communicate in an effective fashion. 

davebaron
davebaron

The issue of teen suicide is a disturbing topic with global implications. The Japanese government has taken an active role in attempting to change the culture around SI, directly confronting the notion of this being a  "beautiful death", as portrayed in the popular literature and on the web. The Italian government created the AmicoCharley Foundation to address this problem by engaging teachers and youth sports coaches to help identify teenagers in emotional distress and at risk for suicide. A key factor in early identification of at-risk youth is educating non psychiatrists of the behavioral changes which may help predict suicidal behavior. It is important to not look for the classic signs of depression seen in adults, but rather focusing on increased impulsivity, irritability, and mood lability. We need to destigmatize help seeking, and create a very user-friendly referral network for crisis counciling.

Dave Baron, Prof. of Psychiatry, Univ. of Southern Calif, Keck School of Medicine

JohnGredenMD
JohnGredenMD

The University of Michigan Depression Center has been conducting "School Outreach" Programs in Schools regionally and nationally for 5 - 6 years, and they are remarkably accepted, well-received, and valued. Our experiences indicate it is important when establishing the partnership to include School Administrators, Counselors, Teachers, Students, Parents and Community members.  Integrating a number of foci produces great impact. Themes that we emphasize incluede awareness of depression, stress, sleep, and drug abuse signs; where to turn for help and support; peer-to-peer strategies are remarkably powerful in High School populations; periodic "re-innoculation with repeat sessions; training the trainers so that the programs are sustainable; and even assignments for students. Suicide prevention strategies are integrated into this overall depression and stress-reduction approach, rather than being the "sole" focus. Legislators make great partners in overall efforts.  

Momentum, resources, and dissemination are needed. We will need collective voices to triumph in passage of the Garrett Lee Smith act. Let your voices be heard.    

StacyK
StacyK

Hello Everyone! Dr. Coryell's article "Can We Reduce Youth Suicides by Understanding and Identifying Risk factors?" touches on a vitally important topic. The topic of youth suicide actually hits close to home for me. I have a daughter who has attempted suicide twice. Recently she told me that while she was in high school she actually made other attempts as well. Honestly, her dad and I did not see the typical warning signs like an expression of hopelessness or talk about suicide to name a few. Instead, it seems that we were taken by surprise when I found her on the morning of May 27, 2010 near death after an overdose. She was 21 years old at the time. She had taken over 90 of her psychotropic meds. the night before and had to be put into an induced coma. Miraculously she survived. Based on my experience, as a parent of a loved one who has attempted suicide, I believe that we have a lot of work to do to avoid this from happening to any other family, and I believe whole heartedly that we can prevent this from happening by educating ourselves and others and by pushing past our fears of stigma and talking about it just like we are doing here on Care For Your Mind. My husband and I didn't have the resources to know what we were dealing with. We were so busy trying to learn how to cope with her bipolar disorder diagnosis that suicide wasn't even a thought. I'm definitely putting any fears I may have in regard to talking openly in a public forum to the side. The mental wellness of our loved ones and families is just too important not too.

Below you will find my response to the three questions posed here on the blog. I hope you will join me in the conversation!

How can parents, teachers and people who work with youth be made aware of the risk factors involved in youth suicide?

I think that we need to bring mental health awareness programs into our schools just like we bring programs like "Dare" into our schools. Mental illness awareness is just as important as a drug abuse prevention program. In fact, oftentimes the two are related. I am aware of an organization where I live that is working on this. I hope to see that it grows and becomes a permanent fixture in our schools. I also think that we should start educating our children and parents in elementary school. There have been times when I thought about how much it would have helped if I would have known more about mental health and wellness including suicide prevention. It seems that for anyone to really understand what mental illness is or what damage suicide can do it has to happen to them personally. I'm wondering how we can grow empathy for others living with mental illness, and I think one way is to reach out to children and their families and teach them! I think that it's through empathy that we will be able to create real change. Without empathy how can we expect the general public to truly understand? I think this is one of the keys to increasing mental illness awareness and suicide prevention. What do you think?

What measures do your local schools, government, or other institutions have to help people understand youth suicide and how to prevent it?

Where I live the Karla Smith Foundation has created a program called "Think About It" which is a program dedicated to opening the lines of communication pertaining to mental illness awareness and suicide prevention among school staff, parents and students. There is also a program called "Youth Move" that I learned about from my involvement in volunteerism. I have not seen public announcements about "Youth Move." It seems that the information, as credible and worthy as it is, is not getting out to our youth or their parents. Have you had a similar experience? Maybe it's just me, but I'm not seeing programs such as "Think About It" and "Youth Move" being picked up by the local news media and discussed. There seems to be a disconnect in dissemination of information. I oftentimes find myself wondering how we can bridge the gap between the parents, youth and young adults who are knowledgable about mental illness awareness programs and suicide prevention programs with the general public who seems to remain largely unaware of these particular issues and the programs that exist to help when a loved one becomes ill. I didn't know where to turn when my daughter became mentally ill and then repeatedly attempted suicide. How can this be? Why should I feel so alone and isolated when in reality I'm not alone. There are others going through a similar experience.

What role should youth and young adults have in suicide prevention? Should their middle and high schools, and colleges and universities be teaching them how to identify suicide risk factors and warning signs?

I think that youth and young adults have such a powerful influence on one another. Maybe if we could harness that power somehow, perhaps through education, we could invite them to help us create a suicide prevention movement. If they feel that they have a voice maybe there would be an increase in accountability for the well being of their peers. This is just a thought. I think that most definitely our middle and high schools, and colleges and universities should be teaching our youth and young adults how to identify risk factors and warning signs. How can we hold them accountable for their mental health and well being if we don't provide them with the tools that they need to be successful?

careforyourmind
careforyourmind moderator

Congress does indeed often appear to work in mysterious ways. It baffles us at CFYM as well, as to why Congress has not passed the Garrett Lee Smith Reauthorization Act. One goal of the CFYM blog is to activate the readership. Contacting your national Representative and asking them to support this bill is an excellent goal of this five-week series. So how about it readers, do you agree? How many people are willing to take the next step and contact Congress asking them to pass this important legislation?

In the Burbs
In the Burbs

Did some research after reading Dr. Coryell's post, I'm confused and hoping someone can help me better understand the ways of  Congress.  The Garrett Lee Smith Reauthorization Act appears to be the primary funding vehicle for youth suicide prevention efforts, efforts that everyone agrees we need more of.  I haven't read many controversial points about the Act.  So why hasn't it been reauthorized?  Why are programs that the Act covers in jeopardy?  And shouldn't the blog be asking audience members to ask their members of Congress why haven't they reauthorized the Garrett Lee Smith Act or passed a better alternative?

kimgallen
kimgallen

@MarkPollackMD  Hello Dr Pollack. I have found this to be true in my work in residential treatment centers for chemical dependency. People come in with the intention of getting sober and often do, only to face intense levels of anxiety and multiple triggers. Overall, getting "worn down" equals failure to thrive. Being sober does not equal relief. The individual simultaneoulsy has lack of impulse control and is also depressed. Over and over I have seen young patients deemed noncompliant, whereas I feel they suffer from high levels of anxiety and depression. We have lost many people to suicide, so I will agree that studying anxiety and how to work with anxious patients and using trauma-informed care is mandatory.  

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