Canadian Journal of School Psychology

http://cjs.sagepub.com/ Adolescent Depression and Suicide: A Review and Analysis of the Current Literature
Louis A. Pagliaro Canadian Journal of School Psychology 1996 11: 191 DOI: 10.1177/082957359601100223 The online version of this article can be found at: http://cjs.sagepub.com/content/11/2/191

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Adolescent Depression and Suicide: A Review and Analysis of the Current Literature
Louis A. Pagliaro University of Alberta
Adolescent suicide is a major worldwide problem. Reported rates for suicide ideation, attempts, and completion are particularly high in developed countries. For Canada, the suicide rate for adolescents consistently has been among the highest of those rates reported. Despite significant gouvernment attempts at intervention and public atigst when confronted with specific tragic examples of adolescent suicide, the rate does not appear to be significantly decreasing. This article reviews the nature and extent of suicide among Canadian adolescents. It also provides a brief overview of current assessment and treatment perspectives. With this information, school teachers, counsellors, and psychologists may be better informed regarding the significant problem of adolescent suicide in Canada and hence better prepared to recognize adolescents at high risk of suicide and to appropriately intervene.

There are said to be occasions when a wise man [or woman] chooses suicide-but generally speaking it is not in an excess of reasonableness that people kill themselves. Most men and women die defeated. (Voltaire, 1694-1778)

Adolescence is a phase of rapid physical and psychological change associated with the transition from childhood to adulthood. Although fraught with many developmental hazards (e.g., delinquency, substance abuse, teenage pregnancy), adolescence is a period of relatively little serious physical disease {i.e., common childhood diseases have been survived and diseases of adulthood, such as heart disease and other diseases generally associated with lifestyle choices, are not yet commonly encountered). Among this relatively healthy group, one of the major sources of mortality is suicide, which is generally ranked, after accidents, as the second leading cause of death (Bagley et al.,1990; Ellis & Range, 1992; Holinger,

1990; Samy, 1993)..

Rates of suicide reported for North American adolescents are presented in Table 1. These data provide evidence that over the past ten years, adolescent suicide rates have been consistently higher in: (a) Canada in comparison with the USA; (b) males in comparison with females; and (c) caucasians in comparison with other races. In Canada, adolescent suicide rates are highest in the Yukon and the Northwest Territories (Bagley et al.,1990; Pronovost, Cote, & Ross, 1990). Data for suicide rates among Native adolescents in Canada tend to be incomplete and conflicting. However, available data suggest that suicide rates for off-reserve Native adolescents are similar to those for non-Native adolescents, whereas onreserve suicide rates are often found to be significantly higher (Aldridge & St. John, ~ 1991; Cooper, Corrado, Karlberg, & Adams, 1992). In comparison with completed suicides, it is generally estimated that 50 to 100 times as many adolescents attempt suicide (i.e., one adolescent attempts suicide approximately every 60 seconds in North America). Adolescent girls attempt

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Table 1
1 Reported Suicide Rates Over the Past Decade: Canada and the USA~

1 Table abbreviations: m: males; f females. 2Rates are per 100,000 individuals. 3only the first author and year of publication are listed in this table.
&dquo;References&dquo; section

Please see the

for complete reference citations.

more

suicide three

or

four times

frequently

than do adolescent

boys. However,

they generally use less lethal means (e.g., drug overdose versus firearm) and, consequently, have a significantly higher rate of survival (Bagley et al., 1990; Pronovost, Cote, & Ross, 1990; Rich, Kirkpatrick-Smith, Bonner, & Jans, 1992). These suicide attempts are generally viewed as desperate cries for attention or help and require immediate and appropriate intervention (Thibault, 1992).
Based
on

the reported rates of adolescent suicide in Canada and the estimates

a

of suicide attempts, it is expected that school teachers, counsellors, and psychologists in Canada encounter

significant

number of students at risk for suicide

or

suicide attempt. In order to effectively intervene with these students, it is important to be aware of and be able to recognize the major risk factors associated with suicide ideation and attempts among adolescents. Although schools were not

designed to be mental health agencies, it is critical that school teachers, counsellors,

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193

and psychologists are able to properly identify and deal with adolescents who are at particular risk. In the USA, school counsellors and psychologists are increasingly being held legally accountable in relation to claims of negligence for not having acted to prevent suicides among school students. For this reason, in addition to learning more about the issues regarding adolescent suicide, it has been recommended that school psychologists purchase malpractice insurance (de Groot,

1994).
A comprehensive search of the computerized Medline, CINAHL, and PsyLit databases (1990-1995) was conducted to identify those factors reported in the literature as being associated with adolescent suicides and suicide attempts. Nineteen major risk factors were identified in the published literature. These risk factors are presented in alphabetical order in Table 2. Perhaps unexpectedly, several factors (e.g., cancer, low socioeconomic status, pregnancy, sexually transmitted diseases), which are commonly encountered among adolescents, were not found to be significantly. related to risk for suicide (Bernard & Krupat, 1994; Perrone, 1993). Depression was found to be the most frequently reported factor associated with adolescent suicide. An examination of this factor and interpretation of its relationship to the other risk factors revealed that it was not only significantly correlated with suicide ideation and attempts, but also with most of the other identified risk factors. This finding supports the notion that depression should probably be considered as a general factor. Although, retrospectively, depression has a high correlation with suicide ideation and attempts (i.e., most adolescents who attempt suicide are depressed), prospective correlations are much lower (i.e., most depressed adolescents do not attempt suicide) (Kienhorst, de Wilde, Diekstra, & Wolters, 1991). Thus the predictive power of depression in determining specific adolescents who may be at significant risk for suicide is limited. However, researchers are increasingly noting the importance of interactions among risk factors in predicting suicide risk among adolescents (Berman & Schwartz, 1990; Choquet, Kovess, & Poutignat, 1993; Deykin & Buka, 1994; Kienhorst et al., 1991; Kosky, Silburn, & Zubrick, 1990; McKenna, Edwards, & Williamson, 1993; Young, Fogg, Scheftner, & Fawcett, 1994). In this regard, depression usually plays a major role.

Assessmen t
any adolescent can attempt suicide, knowledge of the reported risk factors can increase the ability of the school teacher, counsellor, or psychologist to appropriately identify those students at particular risk. Once identified, a program of effective intervention can be developed and implemented. Appropriate clinical intervention is always predicated on careful and comprehensive assessment. Whereas, specific psychometric instruments (e.g., Multi-Attitude Suicide Tendency Scale) have been developed and used to assess suicidal tendencies among adolescents (Lamb & Pusker, 1991), most such measures (e.g., Beck Depression Inventory, Child Depression Inventory) have focused on depression as the major underlying construct (Morgan, 1994; Wozencraft & Ellegrir~- 1991). The literature (Garrison, Lewinsohn, Marsteller, Langhinrichsen, & Lann, 1991) and the authors clinical experience indicate that a good clinical interview provides the best available method for assessment. In this regard, school teachers, counsellors, and psychologists might begin by: (a) identifying adolescents at risk (i.e., those who possess several of the risk factors noted in Table 2); (b) looking for clues (e.g., giving away of prized possessions); (c) conducting a complete evaluation for

Although

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194

additional suicide risk factors; and (d)

asking specifically about suicide (e.g., idea-

tion, previous attempts, specific suicide plan).

Intervention
after a potentially suicidal adolescent is identified, school teachers, counsellors, and psychologists should assess the severity of the risk and, based on

Generally,

this assessment, determine the appropriate intervention. For example, if the risk appears severe and involves significant lack of family support, notify the appropriate social service agency and ask them to intervene. If the social service agency will not intervene, the school administrator should be promptly notified and the adolescent taken to the nearest hospital emergency department where a psychiatric assessment should be requested. In all cases, the parent or legal guardian should be promptly informed of the actions taken. In addition, plans should be implemented to follow-up and evaluate the efficacy of the services provided to the adolescent. Long-term intervention should be directed toward the identified suicide risk factors. For example, if clinical depression or a substance abuse disorder is noted, appropriate referral should be made for proper assessment and treatment. Likewise, if risk factors such as gender identity crisis or low self esteem
have been

identified, they should

be treated

by appropriate counselling

or

psychotherapy.
It is important to note that specific individual assessment and related therapy, opposed to generalized group assessment and intervention, is recommended. Although several of the evaluative studies reported in the literature have been criticized for methodological inadequacies, the current consensus is that generalized group intervention (such as suicide prevention programs and &dquo;postvention&dquo; programs provided to schools following student suicides) have generally not yielded significant lasting results (Ciffone, 1993; Hazell & Lewin, 1993; McNamee
as

& Offord, 1990; Vieland et al, 1994). However, some general programs that deal with underlying issues, such as depression, may be of benefit. In addition, although lack of expression of suicidal intent does not eliminate the risk of suicide (Earle, Forquer, Volo, & McDonnell, 1994), many suicidal adolescents talk to peers about their problems prior to attempting suicide. Therefore, programs that are designed to encourage adolescents to report at-risk peers to a school teacher, counsellor, or psychologist have the potential to assist in reducing adolescent suicide and should be more widely implemented (Kalafat & Elias, 1992). A basic comparison of the various types of program approaches can be found in Thibault

(1992).

Summary
This article has reviewed the nature and extent of suicide among Canadian adolescents including the rates of incidence and major associated risk factors. It also provided a brief overview of current assessment and treatment perspectives. Every adolescent suicide is a unique tragedy and, unfortunately, many cannot be prevented. However, with increased knowledge regarding the nature and extent of this problem, the Canadian school teacher, counsellor, and psychologist will be better able to detect and appropriately intervene with adolescents at risk for suicide. In this regard, school teachers, counsellors, and psychologists are reminded that: (a) the suicide rate for adolescents in Canada has been consistently among the highest of those rates reported worldwide and does not appear to be significantly decreasing; (b) rates are highest among males when compared with

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195

females, caucasians when compared with other races, and Canadians when compared with Americans; (c) individual clinical interview is probably the better assessment procedure when compared with formalized testing; and (d) individual
intervention is generally much more effective than group intervention. With this information in mind, school teachers, counsellors, and psychologists may be better prepared for dealing with the significant problem of adolescent suicide in Canada.

Table 2 Major Risk Factors Associated with Adolescent Suicide Ideation and Attempts

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196

L.A.

Pagticrra

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197

10nly the first author and year of publication are listed in this table. Please &dquo;References&dquo; section for complete reference citations.
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see

the

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