How to lower suicide risk in depressed children and adolescents
To determine if hospitalization is necessary, assess patients’ risk factors, attitude toward treatment
Table 3
Protecting against antidepressant-induced suicidality
| Before initiating antidepressant treatment |
|---|
| Review the patient’s psychiatric history |
| Assess for past suicidal behavior |
| Assess for a family history of mental illness or mood disorders and suicide attempts |
| Screen for unrecognized bipolar spectrum disorders |
| Educate patients and their families to watch for signs of worsening depression or suicidality, and to report such symptoms immediately |
| During antidepressant treatment |
| Pay attention to abrupt changes in symptoms, particularly symptoms that were not part of the patient’s initial presentation |
| Watch for deterioration of symptoms |
| Monitor for emergence of ‘activating’ symptoms (ie, irritability, impulsivity, anxiety, insomnia, agitation, hostility, akathisia, hypomania, or mania) |
| Evaluate the patient’s suicide risk factors, including having a specific plan and/or access to lethal means |
| Consider hospitalization if the patient is at high risk for suicide |
| Source: Reference 17 |
Lowering suicide risk
Up to 60% of adolescents who commit suicide had a depressive disorder. Risk factors for child and adolescent suicide attempts include:
- self-harm behaviors
- psychiatric disorders
- family disturbances
- substance abuse
- physical/sexual abuse.17
How to best manage suicidal youths depends on an adequate assessment of the severity of the patient’s current problems and conflicts and the degree of suicidal intent. Assessment of coping resources, access to support systems, and the attitude of the patient and family toward intervention and follow-up also is important.
Children and adolescents at high risk for suicide—those with a plan or recent suicide attempt with high probability of lethality, stated current intent to kill themselves, or recent suicidal ideation or behavior—may need inpatient psychiatric admission. Although no studies have shown that admitting high-risk suicidal patients prevents suicide, hospitalization often is the safest course of action. Develop ing a comprehensive outpatient treatment plan before discharge is essential. Patients with fewer risk factors, especially those who want help and have social support, hope for the future, and a desire to resolve conflicts, may require only a brief crisis-oriented intervention.
The following recommendations for managing suicidality in children and adolescents are based on clinical experience and have not been empirically validated.
Develop a safety plan to direct the patient’s behavior under various situations. For example, the patient would agree in writing that “If I feel depressed, I will do X, Y, and Z to address it,” or “If I find myself having suicidal thoughts, I will contact ABC.” Having a safety plan lowers the risk of a suicide attempt more than having a suicide contract, which does not give the patient any tools.35
Create a ‘hope box.’ This is a box in which the patient collects mementos and other objects that remind him or her of hope and reasons to live. The patient should be able to access it at all times, so he or she can tap into it during crisis periods to avert suicidal acts.35
Counteract alienation. A sense of social isolation and burdensomeness may be “tipping factors” for suicidal acts when adolescents feel depressed.35 Clinicians should try to help connect patients to meaningful social activities, even in small doses.
Manage overarousal. Overarousal in depressed children and adolescents is manifested as agitation. Insomnia is a clinically modifiable risk factor. Insomnia initially responds well to behavioral interventions such as sleep hygiene, sleep restriction, and stimulus control techniques.35
Related Resources
- National Suicide Prevention Lifeline. 800-273-TALK (8255). www.suicidepreventionlifeline.org.
- Suicide Prevention Resource Center. www.sprc.org.
Drug Brand Names
- Citalopram • Celexa
- Fluoxetine • Prozac
- Sertraline • Zoloft
- Venlafaxine • Effexor
Disclosures
Drs. Shailesh Jain and Islam report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Rakesh Jain is a consultant to or has received research/grant support from Eli Lilly and Company, Merck, Pfizer Inc., Shionogi Pharmaceuticals, and Shire.
