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Teen Suicide
Do suicide-prevention programs work?
S
uicide is the second-leading cause of death among 13-
pinpoint why the rate has climbed, and they know little about
746 CQ Researcher
Teen Suicide
BY BARBARA MANTEL
THE ISSUES
aitlin Coleman first ex-
Last year, 17 percent of high
school students in the national
Youth Risk Behavior Survey,
coordinated by the Centers for
C perienced depression
when she was 15, but
her doctor discontinued her
Disease Control and Prevention
(CDC), said they seriously had
considered attempting suicide
antidepression medication be- during the prior 12 months;
cause it seemed to make the almost 14 percent said they had
drug she was taking for epilep- made a plan; 8 percent re-
sy less effective. Coleman says ported having attempted sui-
she was OK in high school cide one or more times over
and during her first year of that period; and just under 3
college, but her depression percent said they had made
worsenedin the beginning of an attempt that led to treat-
Livethroughthis.org/DeseRae L. Stage
her sophomore year, when ment by a doctor or nurse. 1
she was 19. Completed suicide among
I couldnt get up in the adolescents is rare. The sui-
morning. I became increas- cide death rate for those age
ingly isolated from my fam- 13 through 19 was 6.74 per
ily, she says. If I could put 100,000, for a total of 2,014
my clothes on, that was a teens, in 2011, the last year of
good day. available government data. 2
Coleman stopped taking That compares with 16.36 per
her epilepsy pills. She 100,000 for those 20 and older.
thought she would have a Nevertheless, it was the second-
seizure in the middle of the Suffering from depression, Caitlin Coleman attempted leading cause of death among
street, get hit by a car and suicide during her sophomore year of college. Now 31 adolescents in the United States
and working in New York City as a food server,
then no one could be mad bartender and sometime singer and pianist, she has that year, after unintended in-
at me for dying by suicide found stability. But, she says, Its a journey. Definitely jury and before homicide. 3
because it would look like an the first year or two were really, really hard. Yet mental health profes-
accident, she says. sionals know little about what
Around Christmas that year, Cole- pression. Suicide is one of the lead- causes someone who is thinking about
man took an overdose of the accu- ing causes of death among Americans suicide to attempt it. And the ability to
mulated pills and ended up in inten- age 13-19. Yet screening tools to iden- predict who is at immediate risk in
sive care. After several weeks, she tify teens at high risk of attempting the next day, week or month is frus-
transferred to the hospitals psychiatric suicide are not very effective, and tratingly limited. The government and
ward, where doctors put her back on those showing promise need more suicide-prevention organizations list sui-
an antidepressant; later, she entered a evaluation, say many suicide experts. cide risk factors, such as depression,
day program, where she participated Suicide-prevention programs in schools anxiety, past suicide attempts and a fam-
in individual, group and art therapy. may raise awareness, but the evidence ily history of suicidal behavior, as well
Now, at age 31, Coleman lives in that they increase mental health refer- as more immediate warning signs, such
New York City, working as a food serv- rals and reduce suicide rates is mixed. as hopelessness and anger. (See box, p.
er and bartender, and is a sometime medications often are effective at treat- 754.) But most people in these cate-
singer and pianist. But her return to ing the mental health disorders that fre- gories never try to take their life. more-
stability didnt happen overnight. Its a quently underlie suicidal behavior, yet over, such lists of risk factors typically
journey. Definitely the first year or two research on whether antidepressants help dont differentiate by age.
were really, really hard, she recalls. suicidal youths is scarce. And to date, we are just realizing that those risks
Like Coleman, the overwhelming only small studies have examined the and warnings signs are for suicidal
majority of suicidal teens have a men- efficacy of psychotherapy, including cog- ideation. But most people who think
tal health disorder, most often de- nitive behavior therapy, for suicidal teens. Continued on p. 749
748 CQ Researcher
Continued from p. 747
about suicide do not attempt it, says Youth Suicide Rate Reached 13-Year High in 2011
David Klonsky, a psychology professor Teen suicide reached 6.74 deaths per 100,000 teenagers in 2011,
at the University of British Columbia. according to the latest data. The rate had dipped to 5.26 in 2007.
Some scientists are studying the ado-
lescent brain for clues to the biology (No. of suicides Suicides per 100,000 People
per 100,000)
of suicide in hopes of better identify- 8 Ages 13-19, 1999-2011
ing and treating suicidal youths.
Knowledge about the causes of sui- 7
cide lags far behind our knowledge of
6
many other life-threatening illnesses
and conditions. In part, this is because 5
the stigma surrounding suicide has lim- 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
ited societys investment in suicide re- Sources: Fatal Injury Reports, National and Regional, 1999-2011, Web-based
search, according to the New York-based Injury Statistics Query and Reporting System (WISQARS), Centers for Disease
American foundation for Suicide Pre- Control and Prevention, http://tinyurl.com/8xl3mrt
vention, which provides up to $5 million
a year in research grants, making it the have the highest rate of death by sui- step in prevention, yet there seem to be
nations largest nonprofit supporter of sui- cide, followed by white teenagers, Asian many missed opportunities. Nearly 90 per-
cide research. 4 The National Institute of and Pacific Islanders and then blacks, ac- cent of suicidal youths saw their primary
mental Health (NImH) funds $40 million cording to government data. 8 care physician in the year before they
a year in suicide research, a fraction of Its difficult to pinpoint why suicide died. 12 forty percent of those who die
its annual budget of $1.5 billion. 5 death rates have risen recently among by suicide visited an emergency depart-
I think one of the indicators that teenagers. Kelly Posner, a professor of ment within the previous year, most for
we dont understand suicide well medical psychology at Columbia Uni- non-psychiatric complaints. 13
enough is that rates of suicide have versity, says possibilities include a growth So some suicide experts recommend
not meaningfully decreased and in in social media and cyberbullying; a casting a wide net and screening all
some demographics or areas have in- drop in antidepressant use after the teens to find those who might be sui-
creased over the last many years, even U.S. food and Drug Administration cidal. But others disagree, worrying
though suicide prevention has gotten (fDA) in 2004 required antidepressant that existing tools, such as the Suicide
a lot more attention, says Klonsky. labels to carry a warning of possible Ideation Questionnaire, the Beck Scale
The suicide death rate for young peo- suicide risk for children and adolescents; for Suicidal Ideation, and the Columbia-
ple between 13 and 19 fell, somewhat and the weak economy. 9 Suicide Severity Rating Scale (C-SSRS),
erratically, between 1999 and 2007, from In fact, a recent Duke University are not accurate enough when used
6.39 to 5.26 per 100,000. It then steadi- study of national data found that a for universal screening.
ly increased until 2011, when it slightly states job losses were associated with we should be asking these ques-
surpassed the 1999 rate. That pattern an increase in girls suicidal thoughts tions the way we monitor for blood
holds for both boys and girls, although and plans and with an increase in the pressure, says Posner, who co-created
the suicide death rate for boys each year thoughts, plans and suicide attempts the C-SSRS, designed to measure the
is three or four times greater than for of non-Hispanic black adolescents. 10 severity of suicidal thinking and be-
girls. 6 Even though girls are much more Economic hardship appears to deepen havior. The brief screening version in-
likely to attempt suicide, boys more the psychological problems of some cludes questions about death wishes,
often use the most lethal method: guns. vulnerable youth, the authors said. 11 suicidal thoughts, suicide plans and in-
According to case reports, 85 per- Against this backdrop, here are some tent to carry them out. It also asks
cent of those who attempt suicide with of the questions about teen suicide about past suicide attempts and current
a firearm die, compared with 69 per- that advocacy groups, researchers, clin- behavior, such as collecting pills, buy-
cent who try suffocation, 2 percent icians and survivors of suicide at- ing a gun and writing a suicide note.
who overdose and 1 percent who cut tempts are asking: But most doctors dont screen teenage
themselves. 7 patients for suicide risk. And when they
Some racial and ethnic groups have Should all teens be screened for do screen, some use formal screening
higher suicide rates than others. Ameri- suicide risk? tools and others dont, says Daniel Rei-
can Indian and Alaskan Native teenagers Identifying suicidal teens is the first denberg, executive director of minnesota-
750 CQ Researcher
A february report to Congress by a many teachers are not comfortable Hills, mass.,-based company behind
private consultant found that counties talking with kids about their emotional SOS. Using video and discussion, the
that implemented government-funded needs, and a gatekeeper training pro- hour-long program teaches students
youth suicide-prevention programs pre- gram is not going to change that, says how to identify in themselves or their
sented significantly lower youth suicide madelyn Gould, a professor of epidemi- friends the symptoms of depression
rates the year following the training im- ology in psychiatry at Columbia Univer- and whether someone is suicidal, and
plementation compared with similar sity. A lot of people have been realiz- encourages them to seek help from
counties that did not conduct training. 23 ing that the gatekeepers who are trained adults. Confidential screening is sup-
But a 2013 review of 16 studies need to be more targeted and selective. posed to follow. Each student gets a
many of them randomized controlled If youre going to do training, you response card that says, Based on the
trials, the gold standard for research first have to deal with the mental health video and/or our discussion, I feel I
showed that while individual school- community within schools, and then need to or I do not need to talk to
based suicide-prevention programs can
raise awareness and change attitudes,
only a few reduce suicide attempts
and none have been shown to reduce
death rates. 24
752 CQ Researcher
Esposito-Smythers is leading one study,
of cognitive behavioral therapy for sui- Teen Suicide-Attempt Rate Rises
cide prevention. The therapy consists of A larger share of U.S. high school students said they attempted suicide
individual therapy sessions for the teenag-
in 2013 (8 percent) than in 1991 (7.3 percent). However, the
er, individual sessions for the parents
and family sessions.
proportion of students who said they had seriously considered
The therapy targets common beliefs attempting suicide dropped from 29 percent in 1991 to 17 percent
and behaviors of suicidal teens and their in 2013, while the share of students who made plans to attempt
parents. Teens and parents work on skills suicide dropped 5 percentage points.
such as solving problems and regulat-
ing emotions, and families together learn Suicide-Related Behaviors, U.S. High School Students
how to communicate better and create 29% (by percentage, 1991-2013)
contracts for desired behavior.
Problems could include skipping
school and beliefs could include a teen 1991
who thinks she is unloved or a parent 17% 18.6%
2013
who thinks he has failed his child. we 13.6%
know parents blame themselves, and we
think these thoughts are often not very 7.3% 8%
true, says Esposito-Smythers. The ther-
apist will help the parent examine that 1.7% 2.7%
belief. . . . whats the evidence, what do Seriously
you do well as a parent? maybe you are considered Planned to
attempt Attempted
actually a really good parent and your attempting suicide Required
suicide suicide
kid is just struggling with depression. medical
treatment
A second NImH-funded trial is study-
ing whats known as dialectical behav- Source: Trends in the Prevalence of Suicide-Related Behavior, National Youth Risk
ior therapy, a modified form of cogni- Behavior Survey: 1991-2013, Centers for Disease Control and Prevention,
tive behavioral therapy that emphasizes http://tinyurl.com/pt2wxqo
validation. The therapist and the patient
work on accepting uncomfortable these negative ingrained thought pat- proposals, says clinical psychologist Jane
thoughts, feelings and behaviors rather terns . . . we think the stress is real, Pearson, chair of the Suicide Research
than struggling with them, according says Diamond. most of the kids we Consortium at NImH. maybe we need
to the virginia-based National Alliance see with depression or suicide live in to get investigators from other areas in-
on mental Illness, a grassroots mental families with a lot of trauma, and that volved, such as genetics and bioinfor-
health organization. Once that happens, could be abuse, alcoholism, divorce matics. we need to build the field.
the process of change no longer ap- or parents who are harsh and reject-
pears impossible. 34 ing or intrusive and controlling.
The third NImH-funded randomized
trial is examining attachment-based fam-
ily therapy, which is rooted in the be-
Attachment-based family therapy tries
to recalibrate family relationships, tak-
ing families that are out of kilter and
BACKGROUND
lief that strong family relationships can helping them to have an appropriate
provide a buffer against adolescent de- balance of warmth and structure so No Longer a Crime
pression or suicide and that ruptured that troubled teens can trust and con-
family relationships can be repaired. fide in their parents, says Diamond. n most of colonial America, suicide
Diamond, who is leading that trial,
says attachment-based family therapy dif-
These trials are a good start, men-
tal health researchers say, but they
I was considered a sin and a crime.
Property could be forfeited and Chris-
fers from cognitive behavioral therapy would like to see more research into tian burial denied. But as decades passed,
in a crucial way. Its more about chang- the basic understanding of suicide, its juries became increasingly reluctant to
ing the environment and less about causes and effective treatments. rule a suicide a crime and instead al-
changing the way kids think, he says. when there are good proposals, lowed evidence of melancholy to
we dont think that the kids have they get funded. we need more good form the basis for a plea of insanity.
754 CQ Researcher
Chronology
1987 called the National Suicide Preven-
1890s-1960s
Field of suicidology is estab-
families affected by suicide and sci- tion Lifeline. . . . federal govern-
entists form the American foundation ment publishes The National Strat-
lished; first crisis center opens. for Suicide Prevention. egy for Suicide Prevention,
designed to transform attitudes,
1897 1989 policies and services.
Groundbreaking study by french Adina wrobleski, whose daughter
sociologist Emile Durkheim exam- died by suicide, forms Suicide 2002
ines the different suicide rates Awareness voices of Education, to SAmHSA creates Suicide Prevention
among groups, such as men ver- prevent suicide and reduce stigma Resource Center, a registry of evi-
sus women and Catholics versus through public awareness and edu- dence-based practices and programs.
Protestants. cation. . . . first federal government
report on youth suicide, prepared 2003
1957 by the Task force on Youth Suicide, Clozapine for schizophrenia becomes
American psychologists Edwin cites a need for more research on the first fDA-approved drug for use
Shneidman and Norman farberow, youth suicide and more evaluations with suicidal patients.
in landmark Clues to Suicide, say of prevention programs.
no suicide is a rational act. 2004
1993 The Garrett Lee Smith memorial Act
1958 Shneidman publishes influential is adopted to provide grants for
The countrys first suicide-prevention Psychache: A Clinical Approach to youth suicide-prevention programs.
center opens in Los Angeles. Self-Destructive Behavior, concluding . . . fDA requires black-box warning
that suicide is the result of intoler- labels on antidepressants saying that
1962 able psychological pain. children and adolescents taking the
Actress marilyn monroes apparent drugs are at increased risk of suicidal
suicide prompts a surge in calls to 1997 thinking and behavior.
the Los Angeles crisis center. Congress passes resolutions recogniz-
ing suicide as a national problem 2005
1967 and prevention as a national priority. American psychologist Thomas
The National Institute of mental Joiner, in Why People Die by Suicide,
Health creates the Center for Studies 1998 says suicide results from thwarted
of Suicide Prevention with Shneid- Grassroots organizations and the feelings of belonging and percep-
man at its helm. Centers for Disease Control and tions of being a burden, combined
Prevention organize a national with the acquired capability to in-
1968 suicide summit in Reno, Nev. flict lethal self-injury.
Shneidman founds the American
Association of Suicidology. 2007
fDA extends the warnings on anti-
depressants to include young adults;
2000s-Present
Congress creates a grant program
prescriptions for antidepressants de-
cline over the next several years.
1970s-1990s
Families touched by suicide
for youth suicide-prevention pro-
grams. . . . Food and Drug 2012
form grassroots organizations; Administration (FDA) requires The National Strategy for Suicide
Congress passes resolutions controversial warnings on Prevention is revised to include an
calling suicide prevention a antidepressants about their emphasis on community involvement.
national priority. suicide risk.
2014
1976 2001 wyoming becomes the 13th state
American Association of Suicidology Substance Abuse and mental Health to pass the Jason flatt Act, which
establishes its crisis center certifica- Services Administration (SAmHSA) typically requires middle and high
tion program. establishes a national network of school educators to receive suicide
certified crisis call centers, now awareness and prevention training.
Continued from p. 754 after finding hundreds of suicide notes As an experiment, staff and volun-
at the Los Angeles County coroners teers stayed after working hours to see
Prevention Movement office. In 1957, Shneidman and fellow whether the need for service persisted
psychologist Norman farberow pub- throughout the night. Thus began the
y the mid-20th century, an esti-
B mated 16,000 Americans took their
lives each year. 40 Yet medical litera-
lished Clues to Suicide. Shneidman
and farberow concluded, based on a
study of the suicide notes, that no sui-
first suicide prevention crisis line, ac-
cording to a history of the center. In the
early 1960s, the coroners office began
ture and books on suicide were rare. cide was a rational act. 41 to ask the center staff to help investigate
That changed in the 1950s with the One year later, the two psychologists deaths with uncertain cause, and, in 1962,
emergence of the suicide-prevention opened the first U.S. suicide-prevention Litman led the investigation into the
movement and the field of suicidolo- center, in Los Angeles, with funding death of actress marilyn monroe at age
gy the formal, multidisciplinary study from the U.S. Public Health Service. Psy- 36. monroes death from an overdose of
of the nature, causes and prevention chiatrist Robert Litman was its director. barbiturates, ruled a probable suicide,
of suicide. The staff of three soon was overwhelmed prompted a surge in calls to the center.
In 1949, clinical psychologist Edwin with requests for services, and Litman Throughout the 1960s, other crisis-
Shneidman began to research suicide hired and trained eight volunteers. intervention centers were established, and
756 CQ Researcher
Suicide clusters are actually quite rare, says Gould, account-
ing for no more than 10 percent of all completed suicides among
teenagers, for example. But we think it [suicide clusters] can be
recent study of the impact of youth suicidal behavior on peers suicide clusters in teenagers in the USA, 1988-96: a retrospective, population-
based, case-control study, The Lancet Psychiatry, June 2014, http://tinyurl.
that the impact of suicide attempts may be even greater. Do com/os59o8x.
we know exactly why? No, she says. But she speculates that 3 Kelly mcBride, Can journalists prevent suicide clusters, Poynter Institute,
it could be because schools often are not aware of a students updated may 9, 2014, http://tinyurl.com/q85h6dv.
4 The Recommendations for Reporting on Suicide, undated, http://reporting
suicide attempt while friends are, and so the school has no
onsuicide.org.
chance to provide support and counseling. 5 Jennifer michael Hecht, Stay: A History of Suicide and the Philosophies
I think making it safe for kids to let adults in a school set- Against It, 2013, p. 171; margot Sanger-Katz, The Science Behind Suicide
ting know when they have attempted suicide or when they Contagion, The New York Times, Aug. 13, 2014, http://tinyurl.com/ogtewwn.
in 1967 the National Institute of mental ganization, these individuals and their ucate professionals and the public, and
Health created the Center for Studies of grassroots organizations set out to place provide resources for family and friends
Suicide Prevention, with Shneidman at suicide on the national agenda. 43 They and for people at risk. Two years later,
its helm. After observing the limited were especially concerned with rising Adina wrobleski, whose daughter died
amount of available data, Shneidman suicide rates among adolescents. The by suicide, founded Suicide Awareness
founded the American Association of suicide death rate for 15- to 19-year- voices of Education, or SAvE, to pro-
Suicidology in 1968 to study suicide. The olds, for instance, rose from 8.62 per vide public awareness and education.
association developed a certification pro- 100,000 in 1981 to 11.14 in 1990. * Other grassroots groups were formed
gram for suicide crisis centers and cer- In 1987, a group of families touched over the next decade.
tified its first center in 1976. 42 by suicide joined with scientists to In 1989, a government Task force
These early efforts were expanded form the American foundation for Sui- on Youth Suicide published a report
upon in the 1980s with the support and cide Prevention to fund research, ed- that found:
passion of individuals who had been Knowledge about youth suicide
bereaved by suicide loss, according to * Rates before and after 1999 should be com- was limited;
a report from the U.S. Surgeon Gener- pared cautiously because of changes in method- Acquiring this knowledge required
al. with limited funding and formal or- ology. in-depth research;
758 CQ Researcher
Internet Can Provide Support, Information
In some ways it did save my life.
hen University of British Columbia student Ameera Ladak, dal thoughts, but hearing about suicides through online forums
760 CQ Researcher
At Issue:
Should doctors universally screen teen patients for suicide risk?
yes
WRITTEN FOR CQ RESEARCHER, SEPTEMBER 2014 WRITTEN FOR CQ RESEARCHER, SEPTEMBER 2014
s
yes no s
uicide is one of societys greatest public health crises, uicide is the third-leading cause of death in young adults
and the magnitude of its global disease burden is under- and the second-leading cause in younger teenagers. The
recognized yet it is preventable. Every 13 minutes, need to reduce the incidence of suicidal behaviors is,
someone in this country dies by suicide, and it is the second- thus, greater than it has ever been in youths as well as
leading cause of death among 10- to 24-year-olds. Nearly 10 per- adults. So, I unequivocally support strategies that reduce suicide
cent of high school students report having attempted suicide in risk. But screening alone is not one of them.
the past year, and this is likely a gross underestimate. Depression affects one in six people in their lifetime. It is
In order to make an impact on these sobering statistics, we one of the greatest causes of medical morbidity and long-term
need to change the way we think and talk about suicide, and disability. Depression, as well, is found as an active condition
the best place to start is at the doctors office. why? fifty percent in the vast predominance of adults who take their lives. for
of people who die by suicide see their primary-care provider youths, the data are not as clear but depression is common.
within the month before they die, making doctor visits an Screening for medical conditions has become an essential
ideal opportunity for prevention. many adolescent attempters part of good medical care. Think of diabetes, hypertension,
come to the emergency room for non-psychiatric reasons, so colon cancer and many other conditions. Depression needs to
if we do not screen we will not find teens who need help. be detected in primary care and once found effectively treated;
we should be asking about suicide like we monitor for blood we dont just screen for high blood pressure, we treat it when
pressure but assessment of depression and suicide is typi- it appears.
cally not part of medical examinations. Evidence has shown The same is true for depression: we first must find it and
that screening is highly effective in identifying at-risk adoles- then treat it. If we dont have proven methods of delivering
cents, and that screening in primary care contributes to more effective care, and supplying the resources needed, we
accurate diagnosis and better treatment of adolescent depression, should not (yet) screen. (In the may 2014 issue of JAMA
and actually reduces rates of suicide. Psychiatry, I described the circumstances and interagency
why isnt screening the universal norm? Partly due to fear partnership that permitted the launch of a New York State
that screening can have an iatrogenic effect (i.e., asking about initiative to fully integrate behavioral health care into ambula-
suicide might put the idea in someones head), which has been tory primary-care resident training sites, including the essen-
specifically studied and clearly debunked as a myth. tial elements, implementation challenges and what must be
Additionally, some are concerned about the burden of such done for sustainability.)
general screening. However, from a cost-benefit standpoint, it Effective depression detection and treatment for adults in
should be an easy decision. Standardized screening takes a primary care has been achieved in more than 60 replication
few seconds, is freely available and actually decreases eco- studies. The work is beginning for youths: while promising,
nomic and systemic burdens by reducing unnecessary inter- it is not quite ready for prime time. we should not try to
ventions (such as ER overuse), all while helping to save lives. install depression screening in youths until we know that
meanwhile, the price of losing a loved one to suicide is in- depression can be effectively treated in a medical, primary-
comprehensibly high. care environment.
while no one approach will be the magic solution to the we should not screen for suicide (as opposed to depression)
crisis of suicide, screening is an essential tool in the prevention risk in youths because of how remarkably infrequently it will
repertoire. many expert organizations already advocate for be found. moreover, as already stated, if suicide risk were
primary-care screening, including the National Action Alliance found, we would then need to detect its primary driver(s),
for Suicide Prevention, American Academy of Child and Ado- including depression, and be able to care for that illness in
lescent Psychiatry, American Academy of Pediatrics, and Ameri- primary-care settings. we are not there yet. Some great teams
can medical Association. If we do not screen, we will not find are working on making depression care for youths happen in
the teens suffering in silence.
no general medical settings the sooner the better.
La.
Miss.
Ala. Ga. named after a 16-year-old who died by
Texas
Require annual suicide in 1997, usually requires two
Alaska training hours of training of school personnel
Require to recognize and respond to suicidal
Fla. non-annual
training youths. Some states require annual train-
Hawaii Encourage but ing, others every two, three or five years.
do not require Under Californias version of the law the
Source: State Laws: Suicide Prevention Training for School training
Have no training training is voluntary and up to each
Personnel, American Foundation for Suicide Prevention,
June 2014, http://tinyurl.com/q4k3pfd
law school district.
Although the foundation has online
Continued from p. 760 many at-risk youths are not fol- training seminars and DvDs, the law
in committee in both houses of Con- lowing through to obtain services, often never mandates that the foundations
gress since last year. because they fail to bring in parental materials be used. President Clark flatt,
Congress has never reauthorized the permission forms; Jasons father, says teacher training, no
act since President George w. Bush 19- to 24-year-olds not in college matter who provides it, doesnt need
signed it into law 10 years ago. Instead, are being neglected; to cost the state a penny. His group
lawmakers appropriate funds each year, more targeted prevention programs provides free training materials to states
never increasing the amount. funding are needed for youths involved in the that have passed the act, as do other
was $50 million at the start and its juvenile-justice and foster care systems mental health organizations.
$50 million now, says madigan. and those seen in emergency rooms; and flatt is working to pass the Jason flatt
According to a report to Congress Suicide awareness training should Act in Texas and North Carolina and
released in february, between Octo- be targeted to adults who demonstrate says he has been contacted by interest-
ber 2005 and September 2012 the youth a capacity for effectively relating to ed people from Georgia and montana.
suicide-prevention programs run by youths. 57 In the past, the law has met with
states and tribes have trained 490,000 Suicide-prevention organizations are initial skepticism from teachers. The
community members, teachers, fire also lobbying for the Sprint Act, short first time we presented it to the teachers
fighters, college students, professors, for Suicide Prevention Research Inno- union or association in all 13 states,
parents and others in suicide preven- vation Act, introduced in both the Sen- they said, we dont support it. what
tion; screened tens of thousands of ate and the House in february and now it boiled down to is that we used the
youths for suicide risk and steered in committee. It would double the amount word mandate, says flatt. But after ex-
many to services; and promoted col- of money the National Institute of men- plaining that many state child-abuse laws
laboration among public and private tal Health devotes to suicide research already hold teachers responsible for
agencies. 56 from $40 million to $80 million a year. reporting emotional and physical abuse,
Yet more work needs to be done, Even so, madigan calls it a drop in even when self-inflicted, and that train-
according to the report. Among other the bucket and says much more gov- ing does not try to turn teachers into
things, the report found that: ernment research funding is needed be- suicide counselors, flatt says, the foun-
762 CQ Researcher
dation convinced teacher groups to and that setting professional standards with the other groups when showing
support the law. is best left to licensing boards. them pictures of faces.
Other state laws call for training school Democratic Gov. Edmund G. (Jerry) In particular, Pan found that when
personnel in suicide prevention. In total, Brown Jr. will decide the bills fate. In adolescents who have attempted sui-
five states require annual training; 16 2011, Brown vetoed a similar bill that cide are processing negative emotion,
mandate less frequent training; 17, like would have required licensed health care the area of the brain needed to pay
California, encourage training; and 12 professionals to take a continuing edu- attention to process emotion is re-
have no training law. (See map, p. 762.) cation course on caring for lesbian, gay, quiring more activity, and then its
Some states have recently embraced bisexual and transgendered people. communicating less with another area
a more comprehensive approach to sui- I believe that respective licensing of the brain that tells you what the
cide prevention, says Nicole Gibson, se- boards are better suited than the Leg- emotion means to you, she says.
nior manager of state advocacy at the islature or the Governor to decide these Pan also found that the area of the
American foundation for Suicide Pre- matters, Brown wrote at the time. 58 brain important for understanding social
vention. Pennsylvania this year adopt- cues is smaller in adolescents who have
ed legislation requiring not only train- attempted suicide. So they may not be
ing of school personnel but also Neurobiology of Suicide good at reading social and emotional cues
development of formal school suicide- in other people and then understanding
prevention policies and student educa- hile researchers have identified what those emotions mean in their own
tion; Oklahoma adopted legislation en-
couraging such training and policies.
w factors that lead to a lifetime risk
of suicide, clinicians remain ill-
life, she says. So far, this research has
not yet translated into clinical practice.
Gibson says she cant think of any equipped to discern which children are Pan has also studied the spinal fluid
state legislation that requires or en- going to attempt to kill themselves, says of 21 depressed and suicidal teens and
courages screening students for sui- Lisa Pan, a psychiatry professor at the young adults resistant to standard
cide risk. Parents and guardians are University of Pittsburgh. we really cant medication. In research not yet pub-
concerned about their child being la- explain right now why of two adoles- lished, she has found that two-thirds
beled and making sure that they are cents with similar stressors and similar have some kind of metabolic disorder
asked for permission, she says. mental health conditions, one will at- compared with healthy control sub-
Training legislation aimed at other tempt suicide and one wont, she says. jects. She did publish a case study of
professionals is also running into ob- Clinicians also are not very good one such young man, who is now on
jections from trade associations. In 2012, at predicting who is at immediate risk, a supplement to replace the protein he
washington state passed the matt Adler she says, and even when at-risk teens is missing and is no longer suicidal or
Suicide Assessment, Treatment, and man- are identified, some dont respond to on antidepression medication.
agement Act, the first law in the coun- standard treatments. my metabolic research is in its in-
try to require that certain licensed health So researchers have been trying to fancy, says Pan.
care professionals obtain continuing ed- understand the neurobiology of teen
ucation in the assessment, treatment and suicide to identify markers that might
management of suicide risk. It went into
effect this January. But a similar bill in
California faces opposition.
better predict suicide risk and lead to
improved drug and psychotherapy treat-
ments. Some have found anomalies in
OUTLOOK
That legislation would require psy- the brains of teens who have died by
chologists, marriage and family coun- suicide. Telling Stories
selors and social workers to take a Pan has been pursuing two other
one-time, six-hour continuing educa- tracks. In the first, she uses functional or decades, most advocates for sui-
tion course. And it would require 15
hours of course work in suicide pre-
magnetic resonance imaging, or fmRIs,
to scan the brains of three groups: teens
f cide awareness, prevention programs
and research have been clinicians, sci-
vention for students in these fields. It with depression who attempted suicide; entists or family members of someone
passed both houses of the California teens with depression who never at- who died by suicide. But in the past few
legislature this year and is backed by tempted suicide, and healthy control years, an increasing number of survivors
mental health organizations. But the subjects. She found differences in brain of suicide attempts are speaking up, break-
associations representing psychologists, structure, blood flow and communica- ing a long-held taboo against sharing
counselors and social workers object tion between areas of the brain in the their stories for fear that doing so might
that such training might be redundant brains of suicide attempters compared be harmful to them and others.
Prioritized Research Agenda for Suicide more comprehensive approach in psy- of Public Health, 2001, http://tinyurl.com/kxk
Prevention: An Action Plan to Save Lives chotherapy. were seeing interventions muth; firearm Access is a Risk factor for Sui-
is to reduce the incidence of all suicides that are more comprehensive, that in- cide, Harvard School of Public Health, un-
by 20 percent in five years and 40 per- clude individual sessions, parent ses- dated, http://tinyurl.com/q6toapz.
8 fatal Injury Reports, National and Regional,
cent in the next 10. 59 sions and family sessions, she says.
One of the priorities for future re- But even as suicide attempt survivors 1999-2011, wISQARS, Centers for Disease Con-
trol and Prevention, http://tinyurl.com/8xl3mrt.
search will be understanding short-term help inform research, research priorities 9 for background, see Thomas J. Billitteri, Pre-
risk for suicide. How will we know are adjusted and larger studies are fund- venting Bullying, CQ Researcher, Dec. 10, 2010,
when [a suicidal] person is sitting in ed, suicidal teens must have access to pp. 1013-1036, updated may 31, 2012; and
front of us? Honestly, just asking them, quality mental health care if suicide death Thomas J. Billitteri, Cyberbullying, CQ Re-
Have you ever thought about it or have rates are to decline, prevention special- searcher, may 2, 2008, pp. 385-408.
you made an attempt? is not going to ists say. we are woefully in trouble and 10 Anna Gassman-Pines, et al., Effects of
tell you the answer to that, says Harkavy- understaffed in this country when it comes Statewide Job Losses on Adolescent Suicide-
friedman at the American foundation to psychiatrists, especially child and ado- Related Behaviors, American Journal of Pub-
for Suicide Prevention. lescent psychiatrists, says Reidenberg of lic Health, Aug. 14, 2014, http://tinyurl.com/
To support that research agenda, NImH SAvE. There is not enough time in the k9r6bbm.
11 Alison Jones-Duke, mass Layoffs may Trig-
asked researchers to submit applications day that these few providers can pro-
ger Teen Suicide, futurity.org. Aug. 15, 2014,
to develop and test screening ap- vide all of the things that are needed by
http://tinyurl.com/lhgnone.
proaches that emergency departments all of the people who need them. 12 michael L. Lefevre, Screening for Suicide
764 CQ Researcher
U.S. Preventive Services Task force Recom-
mendation Statement, op. cit., p. 721.
15 Caterino, et al., op. cit., p. 812.
16 Ibid., p. 813.
FOR MORE INFORMATION
17 Ibid.
American Association of Suicidology, 5221 wisconsin Ave., N.w., washington,
DC 20015; 202-237-2280; www.suicidology.org. Promotes research and training.
18 Suicide Risk in Adolescents, Adults, and
Older Adults in Primary Care: USPSTf Rec- American Foundation for Suicide Prevention, 120 wall St., 29th floor, New
York, NY 10005; 212-363-3500; www.afsp.org. funds research.
ommendation Statement, U.S. Preventative Ser-
vices Task force, may 2014, www.uspreven Jason Foundation, 18 volunteer Dr., Hendersonville, TN 37075; 615-264-2323;
tiveservicestaskforce.org/uspstf13/suicide/sui jasonfoundation.com. Provides suicide prevention material for students and teachers.
cidefinalrs.htm. Live Through This, livethroughthis.org. Profiles survivors of suicide attempts.
19 Screening for Suicide Risk in Adolescents,
National Action Alliance for Suicide Prevention, 1025 Thomas Jefferson St., N.w.,
Adults, and Older Adults in Primary Care: Suite 700, washington, DC 20007; 202-572-3784; actionallianceforsuicideprevention.
U.S. Preventive Services Task force Recom- org. Public-private partnership advancing strategies for suicide prevention.
mendation Statement, op. cit., p. 720. National Suicide Prevention Lifeline, 50 Broadway, 19th floor, New York, NY
20 morton m. Silverman and Alan L. Berman,
10004; 212-614-6309; www.suicidepreventionlifeline.org. Network of 165 crisis centers.
Suicide Risk Assessment and Risk formulation
Suicide Awareness Voices of Education (SAVE), 8120 Penn Ave. S., Suite 470,
Part I: A focus on Suicide Ideation in Assess-
Bloomington, mN 55431; 952-946-7998; www.save.org. Educates the public about
ing Suicide Risk, Suicide and Life-Threatening
depressive brain illnesses.
Behavior, August 2014, pp. 420-431, http://tiny
url.com/ppbuk2p. Suicide Prevention Resource Center, 43 foundry Ave., waltham, mA 02453;
21 Stephen D. whitney, et al., Principals per- 877-438-7772; www.sprc.org. maintains database of prevention practices.
ceptions of benefits and barriers to school-
based suicide prevention programs, Children of Child and Adolescent Psychiatry, October 2009, 46 2012 National Strategy for Suicide Preven-
and Youth Services Review, June 2011, pp. 874- pp. 987-996, http://tinyurl.com/pjpxnsz. tion: Goals and Objectives for Action, op. cit.,
33 Berk, et al., op. cit., p. 4.
875, http://tinyurl.com/mnlyzz3. p. 96.
22 Ibid. 34 Dialectical Behavior Therapy, National Al- 47 Ibid., p. 97.
23 Report to Congress: Garrett Lee Smith liance on mental Illness, february 2013, http:/ 48 National Strategy for Suicide Prevention:
Youth Suicide Prevention Program, SAmHSA, /tinyurl.com/p7xd3us. Goals and Objectives for Action, U.S. De-
35 Howard I. Kushner, Self-Destruction in the
february 2014, p. 33. partment of Health and Human Services, 2001,
24 Cara Katz, et al., A Systematic Review of Promised Land: A Psychocultural Biology of pp. 15-16, http://tinyurl.com/ll79jxt.
School-Based Suicide Prevention Programs, American Suicide (1989), p. 28. 49 Spencer-Thomas and Jahn, op. cit., p. 82.
36 Ibid., p. 30. 50 maurizio Pompili and mark J. Goldblatt,
Depression and Anxiety, may 3, 2013, http://
37 Ibid., pp. 39-41.
tinyurl.com/kr9whu3. Psychopharmacological Treatment to Reduce
25 Ibid., pp. 1033-1034. 38 Ibid., p. 53.
Suicide Risk, Psychiatric Times, April 2, 2012,
26 Ibid., pp. 1032-1033. 39 Ibid., pp. 55-56, 58.
http://tinyurl.com/om52sg9.
27 Ibid., p. 1035. 40 Edwin S. Shneidman and Norman L. farberow, 51 Ibid.
28 matthew K. Nock, et al., Prevalence, Cor- Clues to Suicide (1957), p. vii. 52 Ibid.
41 Ibid., pp. 3, 40. 53 Christine Y. Lu, et al., Changes in anti-
relates, and Treatment of Lifetime Suicidal Be-
42 History of the American Association of
havior Among Adolescents: Results from the depressant use by young people and suici-
National Comorbidity Survey Replication Suicidology, American Association of Suici- dal behavior after fDA warnings and media
Adolescent Supplement, JAMA Psychiatry, dology, undated, http://tinyurl.com/msb4jmx. coverage: a quasi-experimental study, BmJ,
43 2012 National Strategy for Suicide Pre-
march 2013, http://tinyurl.com/mpjgrgd. June 18, 2014, http://tinyurl.com/n7w6rh2.
29 Ibid. vention: Goals and Objectives for Action, 54 Black Box warning on Antidepressants
30 michele Berk, et al., Conducting Research U.S. Surgeon General and the National Ac- Raised Suicide Attempts, mSN News, June 19,
on Adolescent Suicide Attempters: Dilemmas and tion Alliance for Suicide Prevention, U.S. De- 2014, http://tinyurl.com/p5wtwon.
Decisions, Behavior Therapy, June 18, 2014, partment of Health and Human Services, Sep- 55 Ibid.
pp. 65-69, http://tinyurl.com/ooa7qb4. tember 2012, p. 94, http://tinyurl.com/8o56lst. 56 Report to Congress: Garrett Lee Smith Youth
31 David A. Brent, et al., Protecting Adolescents 44 Report of the Secretarys Task force on
Suicide Prevention Program, op. cit., p. 43.
from Self-Harm: A Critical Review of Interven- Youth Suicide. volume 1: Overview and Rec- 57 Ibid., pp. 44-47.
tion Studies, Journal of the American Academy ommendations, U.S. Department of Health and 58 Editorial: Bill is a modest proposal to re-
of Child & Adolescent Psychiatry, December Human Services, 1989, http://tinyurl.com/nt8h5cc. duce suicide, The Sacramento Bee, Aug. 18,
45 Sally Spencer-Thomas and Danielle R. Jahn,
2013, p. 1260, http://tinyurl.com/kjteyda. 2014, http://tinyurl.com/kqhybdz.
32 David A. Brent, et al., The Treatment of Tracking a movement: U.S. milestones in Sui- 59 Thomas Insel, Directors Blog: A New Re-
Adolescent Suicide Attempters Study (TASA): cide Prevention, Suicide and Life-Threatening search Agenda for Suicide Prevention, Na-
Predictors of Suicidal Events in an Open Treat- Behavior, february 2012, p. 82, http://tinyurl. tional Institute of mental Health, feb. 5, 2014,
ment Trial, Journal of the American Academy com/mwzjhs2. http://tinyurl.com/lsxsrfj.
Kushner, Howard I., Self-Destruction in the Promised Report to Congress: Garrett Lee Smith Youth Suicide
Land: A Psychocultural Biology of American Suicide, Prevention Program, Substance Abuse and Mental Health
Rutgers University Press, 1989. Services Administration, February 2014.
A historian of medicine traces the history of suicide. Government-funded suicide prevention programs have
trained thousands, but improvements can be made, the
Articles agency says.
Berk, Michele, et al., Conducting Research on Adolescent Screening for Suicide Risk in Adolescents, Adults, and
Suicide Attempters: Dilemmas and Decisions, Behavior Older Adults in Primary Care: U.S. Preventive Services Task
Therapy, June 18, 2014, http://tinyurl.com/qx8f4g5. Force Recommendation Statement, Annals of Internal
Research is urgently needed on effective treatments for ado- Medicine, May 20, 2014, http://tinyurl.com/oarz6vm.
lescents who attempt suicide, but conducting randomized An independent task force of health-care professionals
controlled trials is challenging, say six experienced researchers. concludes that current evidence is insufficient to assess the
balance of benefits and harms of regular screening for sui-
Black Box Warning on Antidepressants Raised Suicide cide risk in adolescents, adults and older adults in a primary-
Attempts, MSN News, June 19, 2014, http://tinyurl.com/ care setting.
p5wtwon.
media mischaracterizations of suicide-risk warnings on anti- Caterino, Jeffrey M., et al., Evaluating Current Patterns
depressant labels may have led to a decline in prescriptions of Assessment for Self-harm in Emergency Departments:
and a small increase in suicide attempts. A Multicenter Study, Academic Emergency Medicine,
August 2013, http://tinyurl.com/paoofhn.
Dewey, Caitlin, Suicide contagion and social media: The many hospital emergency department patients who inten-
dangers of sharing Genie, youre free, The Washington tionally harm themselves, including attempting suicide, are
Post, Aug. 12, 2014, http://tinyurl.com/l444b3r. going undetected.
Improper media coverage of celebrity suicides may lead to
an increase in suicide attempts and deaths. Katz, Cara, et al., A Systematic Review of School-Based
Suicide Prevention Programs, Depression and Anxiety,
Jones-Duke, Alison, Mass Layoffs May Trigger Teen Suicide, May 3, 2013, http://tinyurl.com/njymd7l.
futurity.org, Aug. 15, 2014, http://tinyurl.com/lhgnone. A team including researchers from the University of manitoba
mass layoffs are associated with an increase in suicidal be- reviewed the literature on 16 school-based suicide prevention
havior among teenage girls and adolescent blacks. programs.
Sanger-Katz, Margot, The Science Behind Suicide Con- Lu, Christine Y., et al., Changes in antidepressant use by
tagion, The New York Times, Aug. 13, 2014, http://tinyurl. young people and suicidal behavior after FDA warnings
com/ogtewwn. and media coverage: a quasi-experimental study, BMJ
media must follow reporting guidelines about suicide to (formerly the British Medical Journal), June 2014, http://
avoid contributing to suicide contagion, experts say. tinyurl.com/n7w6rh2.
After widespread media coverage of fDA-required suicide
Schimelpfening, Nancy, Can the Internet Cause Teens warnings on antidepressant labels in 2004, antidepressant use
to Commit Suicide?, Liberty Voice, Oct. 31, 2013, http:// significantly declined.
tinyurl.com/qzzu248.
The Internet can provide support for depressed teens but Pompili, Maurizio, and Mark J. Goldblatt, Psychopharma-
also increase the suicide risk among vulnerable youths. cological Treatment to Reduce Suicide Risk, Psychiatric
Times, April 2, 2012, http://tinyurl.com/om52sg9.
Reports and Studies Research into the direct impact of psychopharmacological
drugs on suicidal behavior is slim, according to two psy-
2012 National Strategy for Suicide Prevention: Goals chiatrists who have studied suicide.
766 CQ Researcher
The Next Step:
Additional Articles from Current Periodicals
Legislation Guerra, Kristine, Social media raises fear of suicide
contagion, The Indianapolis Star, May 3, 2013, http://
Gilliland, Donald, How effective teen suicide prevention tinyurl.com/q5y3qb2.
in Pennsylvania was derailed, Patriot-News (Harrisburg, Adults must intervene immediately if they see signs of sui-
Pa.), April 28, 2014, http://tinyurl.com/pbcdgqr. cidal behavior among teens posting online on social media.
A proposed Pennsylvania law aimed at preventing teen suicide
stalled in a House committee due to Republican-led opposition. Raison, Charles, Screening for suicide: A psychiatrists
take, CNN, April 29, 2013, http://tinyurl.com/oju2rs8.
Higgs, Robert, Supporters of law aimed at reducing The U.S. Preventative Services Task force recommends that
teen suicides expect training in schools to increase this doctors ask patients about specific suicide risk factors, rather
fall, The Plain Dealer (Cleveland), Aug. 20, 2013, http:// than universally screening patients for suicide risk.
tinyurl.com/m5hayxj.
Ohio became the 11th state to pass the Jason flatt Act, which Treatment
requires school staff to receive suicide-prevention training.
Carey, Benedict, Study Questions Effectiveness of Ther-
Wood, Benjamin, Committee approves bill clarifying apy for Suicidal Teenagers, The New York Times, Jan. 8,
school suicide-prevention statutes, Deseret News, Nov. 20, 2013, http://tinyurl.com/cm5nz8r.
2013, http://tinyurl.com/p2lpada. fifty-five percent of suicidal teenagers had received therapy
A Utah legislator presented a bill clarifying what suicide prior to considering, planning or attempting suicide.
risk-related questions faculty and administrators are permitted
to ask students following confusion over language in several Painter, Kim, High antidepressant dose linked to self
state suicide-prevention laws passed in 2013. harm in youth, USA Today, April 28, 2014, http://tinyurl.
com/mzw5fkq.
Prevention Young people who suffer from depression are twice as
likely to harm themselves when prescribed higher doses of
Khadaroo, Stacy Teicher, Teen suicide: Prevention is con- antidepressants, according to a study published in the journal
tagious, too, The Christian Science Monitor, Dec. 8, 2013, JAMA Internal Medicine.
http://tinyurl.com/m5373wc.
The number of teen suicide-prevention strategies and pro- Price, Rita, Training aims at dealing with the loss of
grams has increased sharply over the past decade, according suicide, The Columbus Dispatch, June 26, 2014, http://
to an American foundation for Suicide Prevention official. tinyurl.com/oft7r5v.
The national Local Outreach to Suicide Survivors (LOSS)
Shah, Ruchi, Destigmatizing mental disorders key to program sends teams of volunteers to the scene of a suicide
teen suicide prevention, says advocate mom, Fox News, to provide support to families and friends.
Aug. 1, 2014, http://tinyurl.com/ndb4mhg.
Parents of a teenage boy who died by suicide say spread- CITING CQ RESEARCHER
ing awareness of mental illness and removing its associated
Sample formats for citing these reports in a bibliography
stigmas are keys to preventing teen suicides.
include the ones listed below. Preferred styles and formats
Taylor, Daniel, Guns in the home raise the suicide risk vary, so please check with your instructor or professor.
for all, The Philadelphia Inquirer, Oct. 27, 2013, http://
tinyurl.com/ltpd22e. mLA STYLE
Teens whose families keep firearms in the home are at a Jost, Kenneth. Remembering 9/11. CQ Researcher 2 Sept.
much greater risk of suicide, according to an associate pro- 2011: 701-732.
fessor at the Drexel College of medicine in Philadelphia.
APA STYLE
Screening Jost, K. (2011, September 2). Remembering 9/11. CQ Re-
Dvorak, Petula, Summit addresses mental health of searcher, 9, 701-732.
teens, The Washington Post, June 19, 2014, http://tiny
url.com/puhwmh3.
CHICAGO STYLE
A panel of Northern virginia high school students said parents Jost, Kenneth. Remembering 9/11. CQ Researcher, Sep-
should reach out more to high-stress students in competitive tember 2, 2011, 701-732.
school districts who may be at risk of suicide.
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