Suicide Attempts-2
2005:
https://www.cdc.gov/injury/images/lc-charts/10lc_overall_2005b-a.pdf Population Netflix
drama '13 Reasons Why' blamed for inspiring teen girls'
attempted suicide The two girls are now recovering after teachers found them at the last minute. There have been calls in Austria for 13 Reasons Why, a Netflix drama which tells the story of an American high school student who kills herself, to be banned in the wake of the incident. But despite widespread claims the series had inspired the two girls, a spokesman for the local school board told the Telegraph there was no conclusive evidence of a link. “We can’t say it it’s true. All I can tell you is that a lot of the children at the school have said they believe there is a connection,” Karl Steinparz said. Based on a 2007 novel of the same name, 13 Reasons Why tells the story of an American teen who commits suicide and leaves behind a series of cassette recordings explaining why. The show has been accused of glamourising suicide and attracted controversy over its graphic depiction of issues such as rape. The two girls, who have not been named under child protection laws, are students at the local Gymnasium in the small town of Bad Ischl. Last week they informed a teacher they would be absent from the class during the afternoon and gave him what they claimed was a letter giving them time off school. But the teacher sensed something was wrong and opened the letter to find it was a suicide note. He immediately raised the alarm and staff searched the school. The two girls were found in a toilet. A teacher trained in first aid had to resucitate one of them. They were both rushed to hospital and are now out of danger. The school is still trying to discover why they attempted suicide, Mr Steinparz said. “One of the girls is an exemplary pupil with no problems we know of. The other did have some problems recently but most of them had been cleared up.” Austrian police are investigating whether there is any link to the attempted suicide of a third girl in the small town, who tried to kill herself after arguing with her mother. “All three are alive, thank God,
so our investigation is limited to whether there was any
foul play or third party involved,” David Furtner, a
spokesman for the police, said. “There is no evidence
of any third party who encouraged them to attempt suicide.
It appears this is a case of adolescent problems.” Suicide - Frequently Asked Questions This could be one article during September Suicide is a significant cause of death in many western countries, in some cases exceeding deaths by motor vehicle accidents annually. Many countries spend vast amounts of money on safer roads, but very little on suicide awareness and prevention, or on educating people about how to make good life choices. Attempts at suicide, and suicidal thoughts or feelings are usually a symptom indicating that a person isn't coping, often as a result of some event or series of events that they personally find overwhelmingly traumatic or distressing. In many cases, the events in question will pass, their impact can be mitigated, or their overwhelming nature will gradually fade if the person is able to make constructive choices about dealing with the crisis when it is at its worst. Since this can be extremely difficult, this article is an attempt to raise awareness about suicide, so that we may be better able to recognize and help other people in crisis, and also to find how to seek help or make better choices ourselves. The information here is updated periodically, and is intended to be informative rather than authoritative. A call for anecedotes Here are a number of frequently asked questions to help raise awareness and dispel some of the common myths about suicide:
1. Why do people attempt suicide? People usually attempt suicide to block unbearable emotional pain, which is caused by a wide variety of problems. It is often a cry for help. A person attempting suicide is often so distressed that they are unable to see that they have other options: we can help prevent a tragedy by endeavoring to understand how they feel and helping them to look for better choices that they could make. Suicidal people often feel terribly isolated; because of their distress, they may not think of anyone they can turn to, furthering this isolation. In the vast majority of cases a suicide attemptor would choose differently if they were not in great distress and were able to evaluate their options objectively. Most suicidal people give warning signs in the hope that they will be rescued, because they are intent on stopping their emotional pain, not on dying. 2. Aren't all suicidal people crazy? No, having suicidal thoughts does not imply that you are crazy or mentally ill. People who attempt suicide are often acutely distressed and the vast majority are depressed to some extent. This depression may be either a reactive depression which is an entirely normal reaction to difficult circumstances, or may be an endogenous depression which is the result of a diagnosable mental illness with other underlying causes. It may also be a combination of the two. The question of mental illness is a difficult one because both of these kinds of depression may have similar symptoms and effects. Furthermore, the exact definition of depression as a diagnosable mental illnesses (i.e. clinical depression) tends to be somewhat fluid and inexact, so whether a person who is distressed enough to attempt suicide would be diagnosed as suffering from clinical depression may vary in different peoples opinions, and may also vary between cultures. It's more helpful to distinguish between these two types of depression and treat each accordingly than to simply diagnose all such depression as being a form of mental illness, even though a person suffering from a reactive depression might match the diagnostic criteria typically used to diagnose clinical depression. For example, Appleby and Condonis[1] write: The majority of individuals who commit suicide do not have a diagnosable mental illness. They are people just like you and I who at a particular time are feeling isolated, desperately unhappy and alone. Suicidal thoughts and actions may be the result of life's stresses and losses that the individual feels they just can't cope with. In a society where there is much stigma and ignorance regarding mental illness, a person who feels suicidal may fear that other people will think they are "crazy" if they tell them how they feel, and so may be reluctant to reach out for help in a crisis. In any case, describing someone as "crazy", which has strong negative connotations, isn't helpful and is more likely to dissuade someone from seeking help which may be very beneficial, whether they have a diagnosable mental illness or not. People who are suffering from a mental illness such as schizophrenia, bipolar or clinical depression do have significantly higher suicide rates than average, although they are still in the minority of attemptors. For these people, having their illness correctly diagnosed can mean that an appropriate treatment can begin to address it. 3. Doesn't talking about suicide encourage it? It depends what aspect you talk about. Talking about the feelings surrounding suicide promotes understanding and can greatly reduce the immediate distress of a suicidal person. In particular, it is OK to ask someone if they are considering suicide, if you suspect that they are not coping. If they are feeling suicidal, it can come as a great relief to see that someone else has some insight into how they feel. This can be a difficult question to ask, so here are some possible approaches:
The most appropriate way to raise the subject will differ according to the situation, and what the people involved feel comfortable with. It's also important to take the persons overall response into consideration when interpreting their answer, since a person in distress may initially say "no", even if they mean "yes". A person who isn't feeling suicidal will usually be able to give a comfortable "no" answer, and will often continue by talking about a specific reason they have for living. It can also be helpful to ask what they would do if they ever were in a situation where they were seriously considering killing themselves, in case they become suicidal at some point in the future, or they are suicidal but don't initially feel comfortable about telling you. Talking exclusively about how to commit suicide can give ideas to people who feel suicidal, but haven't thought about how they'd do it yet. Media reports that concentrate solely on the method used and ignore the emotional backdrop behind it can tend to encourage copy-cat suicides. 4. So what sort of things can contribute to someone feeling suicidal? People can usually deal with isolated stressful or traumatic events and experiences reasonably well, but when there is an accumulation of such events over an extended period, our normal coping strategies can be pushed to the limit. The stress or trauma generated by a given event will vary from person to person depending on their background and how they deal with that particular stressor. Some people are personally more or less vulnerable to particular stressful events, and some people may find certain events stressful which others would see as a positive experience. Furthermore, individuals deal with stress and trauma in different ways; the presence of multiple risk factors does not necessarily imply that a person will become suicidal. Depending on a person's individual response, risk factors that may contribute to a person feeling suicidal include:
Significant losses:
Perceived abuse:
5. How would I know if someone I care about was contemplating suicide? Often suicidal people will give warning signs, consciously or unconsciously, indicating that they need help and often in the hope that they will be rescued. These usually occur in clusters, so often several warning signs will be apparent. The presence of one or more of these warning signs is not intended as a guarantee that the person is suicidal: the only way to know for sure is to ask them. In other cases, a suicidal person may not want to be rescued, and may avoid giving warning signs. Typical warning signs which are often exhibited by people who are feeling suicidal include: Withdrawing from friends and family. Depression, broadly speaking; not necessarily a diagnosable mental illness such as clinical depression, but indicated by signs such as:
Source: pediatrics.aappublications.org/content/early/2016/06/24/peds.2016-1420 Suicide Warning Signs The following factors have been found to be related to the presence of suicidal behavior. No single risk factor can be used to fully assess risk.
Source: www.therapistaid.com/worksheets/suicide-warning-signs.pdf This list is not definitive: some people may show no signs yet still feel suicidal, others may show many signs yet be coping OK; the only way to know for sure is to ask. In conjunction with the risk factors listed above, this list is intended to help people identify others who may be in need of support. If a person is highly perturbed, has formed a potentially lethal plan to kill themselves and has the means to carry it out immediately available, they would be considered likely to attempt suicide. 6. I'm a bit uncomfortable about the topic; can't it just go away? Suicide has traditionally been a taboo topic in western society, which has led to further alienation and only made the problem worse. Even after their deaths, suicide victims have often been alienated by not being buried near other people in the cemetery, as though they had committed some utterly unforgivable sin. We could go a long way to reducing our
suicide rate by accepting people as they are, removing the
social taboo on talking about feeling suicidal, and telling
people that it is OK to feel so bad that you'd think about
suicide. A person simply talking about how they feel greatly
reduces their distress; they also begin to see other
options, and are much less likely to attempt suicide. 7. So what can I do about it? There usually are people to whom a suicidal person can turn for help; if you ever know someone is feeling suicidal, or feel suicidal yourself, seek out people who could help, and keep seeking until you find someone who will listen. Once again, the only way to know if someone is feeling suicidal is if you ask them and they tell you. Suicidal people, like all of us, need love, understanding and care. People usually don't ask "are you feeling so bad that you're thinking about suicide?" directly. Locking themselves away increases the isolation they feel and the likelihood that they may attempt suicide. Asking if they are feeling suicidal has the effect of giving them permission to feel the way they do, which reduces their isolation; if they are feeling suicidal, they may see that someone else is beginning to understand how they feel. If someone you know tells you that they feel suicidal, above all, listen to them. Then listen some more. Tell them "I don't want you to die." Try to make yourself available to hear about how they feel, and try to form a "no-suicide contract": ask them to promise you that they won't suicide, and that if they feel that they want to hurt themselves again, they won't do anything until they can contact either you, or someone else that can support them. Take them seriously, and refer them to someone equipped to help them most effectively, such as a Doctor, Community Health Center, Counselor, Psychologist, Social Worker, Youth Worker, Minister, etc etc. If they appear acutely suicidal and won't talk, you may need to get them to a hospital emergency department. Don't try to "rescue" them or to take their responsibilities on board yourself, or be a hero and try to handle the situation on your own. You can be the most help by referring them to someone equipped to offer them the help they need, while you continue to support them and remember that what happens is ultimately their responsibility. Get yourself some support too, as you try to get support for them; don't try to save the world on your own shoulders. If you don't know where to turn, chances are there are a number of 24 Hour anonymous telephone counseling or suicide prevention services in your area that you can call, listed in your local telephone directory. This Web Site also lists a number of Internet resources which provide support for people in crisis. 8. Help? Counseling? But isn't counseling just a waste of time? Certainly it is true that counseling is not a magic cure-all. It will be effective only if it empowers a person to build the sort of relationships they need for long-term support. It is not a "solution" in itself, but it can be a vital, effective and helpful step along the way. 9. Talk, talk, talk. It's all just talk. How's that going to help? While it's not a long-term solution in itself, asking a person and having them talk about how they feel greatly reduces their feelings of isolation and distress, which in turn significantly reduces the immediate risk of suicide. People that do care may be reluctant to be direct in talking about suicide because it's something of a taboo subject. In the medium and longer term, it's important to seek help to resolve the problems as soon as possible; be they emotional or psychological. Previous attemptors are more likely to attempt suicide again, so it's very important to get unresolved issues sorted out with professional help or counseling as necessary. Some issues may never be completely resolved by counseling, but a good counselor should be able to help a person deal with them constructively at present, and to teach them better coping skills and better methods of dealing with problems which arise in the future. 10. How do telephone counseling and suicide hot-line services work? Different services vary in what they offer, but in general you can speak, chat or text anonymously with a counselor about any sort of problem in a no-pressure context that's less threatening than a face-to-face session. Talking the situation over with a caring, independent person can be of great assistance whether you're in a crisis yourself, or worried about someone else who is, and they usually have connections with local services to refer you to if further help is required. You don't have to wait until the deepest point of crisis or until you have a life-threatening problem before you seek help. Demand for telephone and text services vary, so the most important thing to remember is that if you can't get through on one, keep trying several until you do. You should usually get through straight away, but don't give up or pin your life on it. Many people that feel suicidal don't realize that help can be so close, or don't think to call at the time because their distress is so overwhelming.
It's quite likely that some people that read this will one day attempt suicide, so here's a quick suicide prevention exercise: think of a list of 5 people who you might talk to if you had no-one else to turn to, starting with the most preferred person at the top of the list. Form a "no-suicide contract" with yourself promising that if you ever feel suicidal you will go to each of the people on this list in turn and simply tell them how you feel; and that if someone didn't listen, you'd just keep going until you found someone that would. Many suicide attemptors are so distressed that they can't see anywhere to turn in the midst of a crisis, so having thought beforehand of several people to approach would help. This is extremely important for Suicide Survivors. 12. How does suicide affect friends and family members? Suicide is extremely traumatic for the friends and family members that remain (the survivors), even though people that attempt suicide often think that no-one cares about them. In addition to the feelings of grief normally associated with a person's death, there may be guilt, anger, resentment, remorse, confusion and great distress over unresolved issues. The stigma surrounding suicide can make it extremely difficult for survivors to deal with their grief and can cause them also to feel terribly isolated. Survivors often find that people relate differently to them after the suicide, and may be very reluctant to talk about what has happened for fear of condemnation. They often feel like a failure because someone they cared so much about has chosen to suicide, and may also be fearful of forming any new relationships because of the intense pain they have experienced through the relationship with the person who has completed suicide. People who have experienced the suicide of someone they cared deeply about can benefit from "survivor groups", where they can relate to people who have been through a similar experience, and know they will be accepted without being judged or condemned. Most counseling services should be able to refer people to groups in their local area. Survivor groups, counseling and other appropriate help can be of tremendous assistance in easing the intense burden of unresolved feelings that suicide survivors often carry. 13. Hang on; isn't it illegal though? Doesn't that stop people? Whether it is legal or not makes no difference to someone who is in such distress that they are trying to kill themselves. You can't legislate against emotional pain so making it illegal doesn't stop people in distress from feeling suicidal. It is likely to merely isolate them further, particularly since the vast majority of attempts are unsuccessful, leaving the attemptor in a worse state than before if they're now a criminal as well. In some countries and states it is still illegal, in other places it's not. 14. But don't people have the right to kill themselves if they want to? Each of us is responsible for our own actions and life choices. In a sense then, an individual may have the right to do as they wish with their life, including to end it if they so desire. Western societies in particular tend to emphasise individual rights over communal rights and responsibilities. However, every person exists as part of a larger network of relationships of various types which set the context in which an individual's rights and responsibilities exist. People who feel lonely, isolated, distressed and hopeless about their future can find it extremely difficult to recognize supportive relationships which may exist around them. This often causes them to grossly underestimate both the degree of support which could be gained from those around them, and the impact that their suicide would have should they complete it. Discussions regarding rights can become emotive, particularly when there is a conflict between individual and communal rights and responsibilities. For example, people who have been emotionally devastated by the suicide of someone close to them could equally assert their right not to be as understanding by someone else's suicide attempt. It should be reiterated however that a person contemplating suicide is more likely to need understanding than a lecture on their responsibilities to other people. Ultimately, helping people to deal
with their problems better, see their options more clearly,
make better choices for themselves and avoid choices that
they would otherwise regret empowers people with their
rights rather than taking their rights away.
11. What about me; am I at risk? It's quite likely that some people that read this will one day attempt suicide, so here's a quick suicide prevention exercise: think of a list of 5 people who you might talk to if you had no-one else to turn to, starting with the most preferred person at the top of the list. Form a "no-suicide contract" with yourself promising that if you ever feel suicidal you will go to each of the people on this list in turn and simply tell them how you feel; and that if someone didn't listen, you'd just keep going until you found someone that would. Many suicide attemptors are so distressed that they can't see anywhere to turn in the midst of a crisis, so having thought beforehand of several people to approach would help. This is extremely important for Suicide Survivors. 12. How does suicide affect friends and family members? Suicide is extremely traumatic for the friends and family members that remain (the survivors), even though people that attempt suicide often think that no-one cares about them. In addition to the feelings of grief normally associated with a person's death, there may be guilt, anger, resentment, remorse, confusion and great distress over unresolved issues. The stigma surrounding suicide can make it extremely difficult for survivors to deal with their grief and can cause them also to feel terribly isolated. Survivors often find that people relate differently to them after the suicide, and may be very reluctant to talk about what has happened for fear of condemnation. They often feel like a failure because someone they cared so much about has chosen to suicide, and may also be fearful of forming any new relationships because of the intense pain they have experienced through the relationship with the person who has completed suicide. People who have experienced the suicide of someone they cared deeply about can benefit from "survivor groups", where they can relate to people who have been through a similar experience, and know they will be accepted without being judged or condemned. Most counseling services should be able to refer people to groups in their local area. Survivor groups, counseling and other appropriate help can be of tremendous assistance in easing the intense burden of unresolved feelings that suicide survivors often carry. 13. Hang on; isn't it illegal though? Doesn't that stop people? Whether it is legal or not makes no difference to someone who is in such distress that they are trying to kill themselves. You can't legislate against emotional pain so making it illegal doesn't stop people in distress from feeling suicidal. It is likely to merely isolate them further, particularly since the vast majority of attempts are unsuccessful, leaving the attemptor in a worse state than before if they're now a criminal as well. In some countries and states it is still illegal, in other places it's not. 14. But don't people have the right to kill themselves if they want to? Each of us is responsible for our own actions and life choices. In a sense then, an individual may have the right to do as they wish with their life, including to end it if they so desire. Western societies in particular tend to emphasise individual rights over communal rights and responsibilities. However, every person exists as part of a larger network of relationships of various types which set the context in which an individual's rights and responsibilities exist. People who feel lonely, isolated, distressed and hopeless about their future can find it extremely difficult to recognize supportive relationships which may exist around them. This often causes them to grossly underestimate both the degree of support which could be gained from those around them, and the impact that their suicide would have should they complete it. Discussions regarding rights can become emotive, particularly when there is a conflict between individual and communal rights and responsibilities. For example, people who have been emotionally devastated by the suicide of someone close to them could equally assert their right not to be as understanding by someone else's suicide attempt. It should be reiterated however that a person contemplating suicide is more likely to need understanding than a lecture on their responsibilities to other people. Ultimately, helping people to deal
with their problems better, see their options more clearly,
make better choices for themselves and avoid choices that
they would otherwise regret empowers people with their
rights rather than taking their rights away. The Six Reasons People Attempt Suicide Source: www.happinessinthisworld.com/2010/04/25/the-six-reasons-people-attempt-suicide/#.WSpfouvyvIU Though I’ve never lost a friend or family member to suicide, I have lost a patient (who I wrote about in a previous post, The True Cause Of Depression). I have known a number of people left behind by the suicide of someone close to them, however. Given how much losing my patient affected me, I’ve only been able to guess at the devastation these people have experienced. Pain mixed with guilt, anger, and regret makes for a bitter drink, the taste of which I’ve seen take many months or even years to wash out of some mouths. The one question everyone has asked without exception, that they ache to have answered more than any other, is simply: why? Why did their friend, child, parent, spouse, or sibling take their own life? Even when a note explaining the reasons is found, lingering questions usually remain: yes, they felt enough despair to want to die, but why did they feel that? A person’s suicide often takes the people it leaves behind by surprise (only intensifying survivor’s guilt for failing to see it coming). People who’ve survived suicide attempts have reported wanting not so much to die as to stop living, a strange dichotomy but a valid one nevertheless. If some in-between state existed, some other alternative to death, I suspect many suicidal people would take it. For the sake of all those reading this who might have been left behind by someone’s suicide, I wanted to describe how I was trained to think about the reasons people kill themselves. They’re not as intuitive as most think. In general, people try to kill themselves for one of six reasons: They’re depressed. This is without question the most common reason people commit suicide. Severe depression is always accompanied by a pervasive sense of suffering as well as the belief that escape from it is hopeless. The pain of existence often becomes too much for severely depressed people to bear. The state of depression warps their thinking, allowing ideas like “Everyone would all be better off without me” to make rational sense. They shouldn’t be blamed for falling prey to such distorted thoughts any more than a heart patient should be blamed for experiencing chest pain: it’s simply the nature of their disease. Because depression, as we all know, is almost always treatable, we should all seek to recognize its presence in our close friends and loved ones. Often people suffer with it silently, planning suicide without anyone ever knowing. Despite making both parties uncomfortable, inquiring directly about suicidal thoughts in my experience almost always yields an honest response. If you suspect someone might be depressed, don’t allow your tendency to deny the possibility of suicidal ideation prevent you from asking about it. They’re psychotic. Malevolent inner voices often command self-destruction for unintelligible reasons. Psychosis is much harder to mask than depression—and arguably even more tragic. The worldwide incidence of schizophrenia is 1% and often strikes otherwise healthy, high-performing individuals, whose lives, though manageable with medication, never fulfill their original promise. Schizophrenics are just as likely to talk freely about the voices commanding them to kill themselves as not, and also, in my experience, give honest answers about thoughts of suicide when asked directly. Psychosis, too, is treatable, and usually must be for a schizophrenic to be able to function at all. Untreated or poorly treated psychosis almost always requires hospital admission to a locked ward until the voices lose their commanding power. They’re impulsive. Often related to drugs and alcohol, some people become maudlin and impulsively attempt to end their own lives. Once sobered and calmed, these people usually feel intensely ashamed. The remorse is usually genuine, and whether or not they’ll ever attempt suicide again is unpredictable. They may try it again the very next time they become drunk or high, or never again in their lifetime. Hospital admission is therefore not usually indicated. Substance abuse and the underlying reasons for it are generally a greater concern in these people and should be addressed as aggressively as possible. They’re crying out for help, and don’t know how else to get it. These people don’t usually want to die but do want to alert those around them that something is seriously wrong. They often don’t believe they will die, frequently choosing methods they don’t think can kill them in order to strike out at someone who’s hurt them—but are sometimes tragically misinformed. The prototypical example of this is a teenage girl who—suffering genuine angst because of a relationship with a friend, boyfriend, or parent—swallows a bottle of Tylenol not realizing that in high enough doses Tylenol causes irreversible liver damage. I’ve watched more than one teenager die a horrible death in an ICU days after such an ingestion when remorse has already cured them of their desire to die and their true goal of alerting those close to them of their distress has been achieved. They have a philosophical desire to die. The decision to commit suicide for some is based on a reasoned decision often motivated by the presence of a painful terminal illness from which little to no hope of reprieve exists. These people aren’t depressed, psychotic, maudlin, or crying out for help. They’re trying to take control of their destiny and alleviate their own suffering, which usually can only be done in death. They often look at their choice to commit suicide as a way to shorten a dying that will happen regardless. In my personal view, if such people are evaluated by a qualified professional who can reliably exclude the other possibilities for why suicide is desired, these people should be allowed to die at their own hands. They’ve made a mistake. This is a recent, tragic phenomenon in which typically young people flirt with oxygen deprivation for the high it brings and simply go too far. The only defense against this, it seems to me, is education. The wounds suicide leaves in the lives
of those left behind by it are often deep and long lasting.
The apparent senselessness of suicide often fuels the most
significant pain survivors feel. Thinking we all deal better
with tragedy when we understand its underpinnings, I’ve
offered the preceding paragraphs in hopes that anyone
reading this who’s been left behind by a suicide might
be able to more easily find a way to move on, to relinquish
their guilt and anger, and find closure. Despite the abrupt
way you may have been left, those don’t have to be the
only two emotions you’re doomed to feel about the one
who left you. -------------------------
Suicide, defined as intentionally ending one's life, can be committed for varied, complex, and deeply personal reasons, though there are a number of common factors usually involved. Like cannibalism and incest, suicide is taboo in most societies, though cultural perceptions of suicide do vary greatly from nation to nation. The reasons behind a person's suicide often determine how his or her suicide is viewed by the people of a particular society or culture. Reasons People Commit Suicide According to Dr. Alex Lickerman, people end their lives for one or more of six reasons both intentionally and unintentionally:
Depression is the reason most people associate with suicide, and it is also the most common reason for attempted and completed suicides. Feelings of hopelessness, worthlessness, and despair become pervasive in severely depressed individuals, and they see suicide as the only means to relieve suffering. They typically plan their suicides weeks or even months in advance, often without the knowledge of family or loved ones. Additionally, family and friends of people who are suicidal may be in denial that someone they love dearly is at risk to commit such an extreme and often violent act. Depression can be successfully treated with talk therapy and medication. Psychosis, particularly schizophrenia, is another major cause of suicide. Though often manageable with medication, many medicated schizophrenics are unable to fulfill their pre-psychotic potential, which can lead to depression. People who are psychotic often hear voices commanding them to either harm others or harm themselves. Psychosis must be treated with medication, and may require hospitalization in the worst situations. Approximately 1% of the world's population is known to suffer from schizophrenia. Impulsivity, a common trait among those suffering from addiction, bipolar disorder, and borderline personality disorder, is often linked with self-harm, a precursor to the act of taking one's life. People who experience mental illness have a heightened risk of addiction, and drug and alcohol use increases the user's lack of inhibition and impulsivity towards high risk behavior. Sometimes an "impulsive" suicide may be committed in the spur of the moment after weeks or months of planning. Though people who attempt or complete the act of suicide tend to be more impulsive than the overall population, most suicides are planned rather than impulsive acts. People who attempt suicide as a means to seek help for emotional suffering do so with the belief that their attempt will not be lethal. Sometimes the person attempting suicide does so to inflict guilt or shame on someone who has harmed him or her in some way, be it real or perceived. This kind of suicide attempt is considerably more common in adolescents and young adults and can cause unintended permanent damage or even death Some people dying from terminal illnesses commit suicide to alleviate suffering in their last months, weeks, or days of life. Depending where they live, assistance may be provided by a health care professional. A person may kill him - or herself by mistake, through an accidental gunshot wound, oxygen deprivation (used to get high or to achieve sexual arousal, as in the case of erotic asphyxiation), or an unintentional drug or alcohol overdose. Reasons NOT to Commit Suicide What to do if you feel suicidal (in
the non-euthanasia context)? Suicide is a permanent solution to a temporary problem. Ask for help. Reach out. Call a suicide hotline 1-800-273-8255 or text "SOS" to 741741 Get to a hospital and tell them you are feeling suicidal. Tell a therapist or doctor. Call 911. You can recover. There is help and hope. YOU ARE WORTH IT!!! Demographics More than 32,000 people commit suicide each year in the United States. Additionally, there are more than half a million unsuccessful suicide attempts. Nearly 1 million people commit suicide worldwide annually, and the estimated number of suicide attempts ranges from 10 million to 20 million. Males commit suicide at nearly four times the rate of females, while females attempt suicide at three times the rate of males. In the United States, boys aged 10-14 commit suicide at twice the rate of girls their age. At ages 15-19, males commit suicide at five times the rate of same-age females. By ages 20-24, the ratio increases to six times. Suicide is the 8th leading cause of death among males in the U.S. and the 16th leading cause of death among females. In terms of ethnicity, non-Hispanic whites and Native Americans have the highest rates of suicide in the United States, while non-Hispanic blacks, Asians, Pacific Islanders, and Hispanics have the lowest. People in rural areas and western states have higher incidences of suicide than their counterparts in urban areas and eastern states. Worldwide, former Eastern bloc European nations have the highest rates of suicide and countries in South America have the lowest. These patterns reflect current trends and change over time. Methods Nearly 60% of suicides in the U.S. are committed with firearms, and older people are more likely to use a firearm when killing themselves than young people.
Some have taken extreme measures when committing suicide, including intentional starvation, self-immolation, decapitation, drowning, and lying on a train track as an oncoming train approaches. Risk factors According to the National Institute of Mental Health, risk factors for suicide include:
People diagnosed with borderline personality disorder (BPD) are particularly vulnerable to suicide, and people with the disorder are more likely to succeed than individuals with any other psychiatric disorder. Approximately 10% of people with the BPD commit suicide, compared to 6% of people with mood disorders. The rate of suicide for people with BPD is more than 50 times greater than that of the general population. Individuals with BPD tend to suffer from rapid and intense mood swings, impulsivity, and negative self-image and emotional experiences, all factors contributing to suicidal behavior. Additionally, BPD often co-occurs with substance abuse, another major risk factor for suicide. Euthanasia Jack Kervorkian became famous and infamous in the 1990's after inventing a so-called "suicide machine" to administer lethal doses of substances, hastening the deaths of mostly terminally ill clients. The media-dubbed "Doctor of Death" helped more than 130 people end their lives, and spent eight years in a Michigan prison after being convicted of second-degree murder in March 1999. The widow and brother of his terminally ill client supported Kervorkian during his trial. In November 1998 the voters of Michigan defeated a ballot initiative that would have legalized physician-assisted suicide by a wide margin. Laws authorizing physician-assisted suicide were passed in Oregon in 1994, Washington in 2008, and Montana in 2009. The Oregon law, known as the Death with Dignity Act, was enacted in 1997 and upheld by the U.S. Supreme Court in 2006. Since going into effect, an average of 40 people per-year in Oregon have obtained lethal prescriptions from their doctors and ended their lives following the completion of a waiting period. In 2009, 60 individuals ended their lives by physician-assisted suicide. Warning Signs There are certain common signs that a person is planning to kill him- or herself. Those signs include making a will, getting his or her affairs in order, suddenly visiting friends and family members, purchasing instruments of suicide (including a gun, rope, or pills), sudden and significant changes in mood, talking about death or suicide, or writing a suicide note. MedicineNet lists the following risk factors for suicide:
Treatment Widespread treatment is available for people at risk for suicide. Comprehensive inpatient and outpatient treatment plans can be devised by mental health professionals to address an individual's needs. Talk therapy, including cognitive behavioral therapy (CBT), has been shown to be effective in helping patients better understand their thoughts, emotions, and behaviors, and how the three affect and feed each other. Pharmacology is also used to treat mood-related symptoms of suicidality. Mood stabilizers, such as lithium and lamictal, and anxiety medications, including chozpine (Clozaril), risperidone (Risperdal), and aripiprazole (Abilify), have been effective in relieving depression, mania, and/or anxiety-related symptoms in patients exhibiting suicidal behavior. Historical Context of Suicide Though the earliest instances of suicide are not known, and the act of suicide likely originates long before any written history. The practice of intentionally ending one's life was known to ancient Egyptians, who viewed suicide as an acceptable means of dealing with unbearable physical or emotional suffering. Killing oneself as a form of martyrdom was also as acceptable when done to escape or protest perceived civil, religious, or political persecution. Though Socrates opposed the act of suicide, believing human life was the property of the gods, the Greek philosopher was forced to carry out his own execution by consuming the poisonous plant hemlock after being found guilty of impiety and corrupting the youth. Seppuku, or hara-kiri, was a form of ritual suicide practiced by the samurai and daimyo of Japan from the 12th to 19th centuries, and was seen as a heroic and dignified act to avoid shame. During World War II, Japanese pilots, known as kamikazes, intentionally flew their explosives-laden aircraft into enemy aircraft and warships. Such actions were viewed as honorable and those unwilling to sacrifice themselves for their nation and emperor were often viewed as cowards. Adolf Hitler and his wife Eva committed suicide in 1945 as Soviet troops descended upon the German capital of Berlin. Adolf killed himself with a gunshot wound to the head as a means to either avoid being captured by Allied forces or executed publicly in a humiliating manner similar to his WWII ally, Italian dictator Benito Mussolini. His wife, Eva, died after ingesting a cyanide capsule. In recent decades, suicide has been glorified in Muslim countries as a means of political protest with the goal of killing as many other individuals as possible, particularly Israelis and people in the West. The 9/11 attacks on the World Trade Center and Pentagon involved the suicide of the terrorists who perpetrated them. Those attacks were celebrated in parts of the Muslim World. The suicide of Mohamed Bouazizi was the catalyst for the Arab Spring protests of 2010 and 2011 in North Africa and the Middle East. The 26 year-old street vendor set himself ablaze in protest of mistreatment at the hands of Tunisian officials in December 2010, dying from injuries sustained in the burning 18 days later. His suicide sparked outrage in the Muslim world and led to the overthrown of several governments, including those in Tunisia, Egypt, and Libya. Cultural Beliefs Around Suicide Through History. People throughout history have committed the act of suicide in order to avoid religious persecution. Early Christians often chose to be martyrs for their beliefs rather than renounce their faith. After Jewish authorities forbade eulogies or public mourning for those who willfully ended their own lives, suicide began to be stigmatized throughout the Judeo-Christian world. St. Augustine's denouncement of suicide as a sin in the 4th century was the first significant public condemnation of the act by a Christian leader, and came in reaction to the high number of suicides by Christians at that time. In the 13th century, Italian priest Thomas Aquinas denounced suicide as an unforgivable sin for which there was no repentance. His views on the matter inspired criminal and civil laws that heavily discouraged the act of taking one's life. Suicide was further stigmatized in The Middle Ages as more European societies enacted laws criminalizing suicide. During this time, perpetrators of suicide were not allowed proper burials and their bodies were often disgraced in public. One common practice was to drag the bodies of the dead who died by their own hands in public and deface them. Other common practices were the confiscation of the deceased's property and possessions, leaving the bodies for animals to consume, and publicly shaming or even (ironically) executing those unfortunate enough to survive their suicide attempts. The stigma of suicide began to wane during the Renaissance and Reformation periods, as long-held assumptions were examined and often challenged. Many of William Shakespeare's plays dealt with suicide; English poet John Donne defended the act of suicide during times of intense personal crisis and suffering; and French philosopher Voltaire wrote in support a person's right to commit suicide in certain circumstances. In the 19th century, the burgeoning fields of psychology and sociology examined the role society and external influences played in the decision-making processes of people who committed suicide. Societal stressors, while not the sole cause of a person's suicidal behavior, was considered a contributing factor for the first time. Early psychologists such as Theodule-Armand Ribot, Pierre Marie Felix Janet, and Sigmund Freud connected suicide with mental illness, a medical condition requiring treatment by professionals rather than stigma and condemnation. Laws prohibiting suicide were repealed in most western nations during the 19th and 20th centuries. Suicide has become increasingly destigmatized in the late 20th and early 21st centuries, and laws allowing for assisted suicide's often referred to as "right to die" law's have been enacted in several nations, including the United States, the Netherlands, Switzerland, and Luxembourg. Current trends suggest more liberal attitudes towards assisted suicide in certain circumstances, such as severe physical limitations or terminal illness, will continue to be adopted in countries throughout the world. Suicide in Popular Culture Suicide has been addressed in popular throughout history. In recent decades, it has been the subject of numerous films, television episodes, and songs. Films that have included suicide in their storylines include:
"The Reasons Why" by The Cure "She's Already Made Up Her Mind" by Lyle Lovett "Then She Did" by Jane's Addiction "Tourniquet" by Evanescence "William's Last Words" by The Manic Street Preachers
The cover of the debut album by Rage Against the Machine features a photograph of Thich Quang Duc, a Buddhist monk who burned himself to death in 1963 in protest of the Vietnamese government's suppression of the Buddhist religion. The musical duo Suicide has been making music since 1970, and the punk/thrash band Suicidal Tendencies has been recording and touring for over three decades.
Famous people who have committed suicide include:
Iris Chang (author) Kurt Cobain (leader of the band Nirvana) Ian Curtis (lead singer of Joy Division) Brad Delp (lead singer of Boston) Spalding Gray (author and poet) Ernest Hemingway (author) Sylvia Plath (author) Freddie Prinze (comedian and actor) Junior Seau (NFL linebacker) Hunter S. Thompson (author) David Foster Wallace (author) Virginia Woolf (author)
Sources:
"Kamikaze - Suicide Pilots of World War II." English-Online. Web. 03 August 2012. Tanaka, Yuki. "Japan's Kamikaze Pilots and Contemporary Suicide Bombers: War and Terror." The Asia-Pacific Journal: Japan Focus. Web. 03 August 2012. Szczepanski, Kallie. "What is Seppuku?" About.com. Web. 03 August 2012. Lickerman, MD, Alex. "The Six Reasons People Attempt Suicide." Psychology Today. 29 April 2010. Web. 02 August 2012. Cloud, John. "The Mystery of Borderline Personality Disorder." Time magazine. 08 January 2009. Web. 02 August 2012. Smith, M.S., April R. Witte, M.S.,Tracy K. Teale, M.S., Nadia E. King, J.D., Sarah L. Bender, M.S., Ted W. Joiner, Ph.D., Thomas E. "Revisiting Impulsivity in Suicide." National Center for Biotechnology Information. Web. 08 August 2012. Salters-Pedneault, PhD, Kristalyn. "Suicidality in Borderline Personality Disorder." About.com. 05 April 2008. Web. 02 August 2012. Dryden-Edwards, MD, Roxanne. Conrad Stoppler, Melissa. "Suicide." MedicineNet. 10 February 2011. Web. 02 August 2012. "Suicide in the U.S.: Statistics and Prevention." National Institute of Mental Health. 27 September 2010. Web. 02 August 2012. Knickerbocker, Brad. "Jack Kevorkian drove the debate on physician-assisted suicide." The Christian Science Monitor. 03 June 2011. Web. 02 August 2012. Johnson, Dirk. "Kevorkian Sentenced to 10 to 25 Years in Prison." The NY Times. 14 April 1999. Web. 02 August 2012. Related Conditions-disorders Articles Eating Disorders Mood Disorders Anxiety Disorders Somatoform Disorders ADAA Excellence Award 2011 Fetal Alcohol Syndrome (FAS) Codependency Self Harm Codependent Behavior Aspergers Syndrome
More >> More Related PTSD Alcohol and Depression Manic Depression Postpartum Depression SSRI Antidepressants Major Depressive Disorder Help and Support For Depression Mental Health Services Self Injury and Cutting Depression Eating Disorders Mood Disorders Anxiety Disorders Somatoform Disorders ADAA Excellence Award 2011 Fetal Alcohol Syndrome (FAS) Codependency Self Harm Codependent Behavior Aspergers Syndrome Melatonin and the Sleep Cycle Insomnia Suicide Suicide Delirium Gender Identity Disorder attention-deficit-hyperactivity-disorder dementia Dialectical Behavioral Therapy Mental Illness and Society Dementia with Lewy Bodies More >> PTSD Alcohol and Depression Manic Depression Postpartum Depression SSRI Antidepressants Major Depressive Disorder Help and Support For Depression Mental Health Services Self Injury and Cutting Depression Clinical Depression Bipolar Disorder Wellbutrin SNRI Antidepressants Celexa Effexor Lexapro Paxil Zoloft Conditions and Disorders Underearners Anonymous Sources: http://www.happinessinthisworld.com/2010/04/25/the-six-reasons-people-attempt-suicide/#.WSpfouvyvIU ---------------------- 11 Facts About Suicide Welcome to DoSomething.org, a global movement of 5.5 million young people making positive change, online and off! The 11 facts you want are below, and the sources for the facts are at the very bottom of the page. After you learn something, do something! Find out how to take action here. intro_image Nearly 30,000 Americans commit suicide every year. In the U.S., suicide rates are highest during the spring. Suicide is the 3rd leading cause of death for 15 to 24-year-olds and 2nd for 24 to 35-year-olds. On average, 1 person commits suicide every 16.2 minutes. Each suicide intimately affects at least 6 other people. Feeling Down? Talk to a trained crisis counselor. Text “DS” TO 741-741. Free, 24/7, Confidential.
About 2/3 of people who complete suicide are depressed at the time of their deaths. Depression that is untreated, undiagnosed, or ineffectively treated is the number 1 cause of suicide. There is 1 suicide for every 25 attempted suicides. Males make up 79% of all suicides, while women are more prone to having suicidal thoughts. 1 in 65,000 children ages 10 to 14 commit suicide each year. There are 2 times as many deaths due to suicide than HIV/AIDS. Over 50% of all suicides are completed with a firearm. Sources https://www.dosomething.org/us/facts/11-facts-about-suicide ------------------------------------- Suicide claims more lives than war, murder, and natural disasters combined.
General
In 2015 (latest available data), there were 44,193 reported suicide deaths. Currently, suicide is the 10th leading cause of death in the United States. A person dies by suicide about every 11.9 minutes in the United States. Every day, approximately 121 Americans take their own life. Ninety percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death. There are 3.5 male suicides for every female suicide, but three times as many females as males attempt suicide. 494,169 people visited a hospital for injuries due to self-harm, suggesting that approximately 12 people harm themselves for every reported death by suicide. Suicide was the second leading cause of death for adults between the ages of 10 and 34 years in the United States. Depression
25 million Americans suffer from depression each year.
Over 50 percent of all people who die by suicide suffer from major depression. If one includes alcoholics who are depressed, this figure rises to over 75 percent. Depression affects nearly 5-8 percent of Americans ages 18 and over in a given year. More Americans suffer from depression than coronary heart disease, cancer, and HIV/AIDS. Depression is among the most treatable of psychiatric illnesses. Between 80 percent and 90 percent of people with depression respond positively to treatment, and almost all patients gain some relief from their symptoms. But first, depression has to be recognized. The best way to prevent suicide is through early detection, diagnosis, and treatment of depression and other mental health conditions.
Be part of The Overnight and walk with thousands - over 16 miles, from dusk till dawn - to raise funds and awareness for one of our nation's most important causes.
Find more facts at afsp.org or call 888-333-AFSP.
Figures from the Centers for Disease Control and Prevention Understanding Suicide: Fact Sheet for 2015.
If you are a member of the media and would like to speak with experts on suicide prevention or would like to do a story on suicide prevention or the Out of the Darkness Overnight Walk please contact pr@ afsp.org or (347) 826-3577. https://www.theovernight.org/?fuseaction=cms.page&id=1034 ----------------------------------------- Grief Speaks After a Suicide Attempt It is very important that family and friends know what to do and what to be alert for after someone they care about has had a suicide attempt. It is a very scary time for both the person and those who care for the person. I receive a lot of calls from people asking me how to help the person who may have just been released from the hospital or how to help their teenager cope with a recent attempt by one of their friends. Research shows that in the days, weeks and months immediately following an attempt is the time when the person needs a lot of support and that is a time that he is most at risk of suicide. Below please find some helpful links for family and friends. Only 10% of the people who attempt suicide will go on to complete and die by suicide. But 80% of those who die by suicide have made a previous attempt. So while chances are that this person won't attempt again, he or she is also at an increased risk for dying by suicide. The first six months after a hospitalization are especially critical to the suicide attempt survivor, and the person remains at an elevated risk for the entire first year. Also know that research shows that 90% of those who die by suicide had a diagnosable mental illness at the time of death. (depression, bipolar disorder, anxiety, substance abuse, eating disorders, yet most people with a mental illness do not die by suicide).
Try not to focus only on the act itself. What else was going on in the person's life that may have precipitated the attempt? Do they abuse alcohol or drugs? Do they gamble? these are some issues that are often associated with attempts. Support is available for these issues. http://www.griefspeaks.com/id121.html -------------------------------- In The Aftermath Of Suicide
Helping Communities Heal
{blog-author_related:title} Mary Glenn
Photo by Vitaly
“Student committed suicide, please call ASAP”.
The text flashed across my phone while I was sitting in my Tuesday night Bible study. It’s the kind of text I have received countless times before, and it’s never easy to read. A 14-year-old boy killed himself after school. As the local senior police chaplain, I was called in to provide support, grief care, and help to school personnel who were dealing with this trauma.
When I arrived at the school the next morning, I was asked to meet in the vice-principal’s office with the student’s teachers and guidance counselors. These staff members were in shock, wrestling with grief and guilt. They asked the “What if” questions; What if I missed something? What if I could have stopped him from doing this? What if I would have known the pain he was in?
One of the student’s teachers stated, “There is nothing you can say that will convince me that it isn’t my fault. I missed the signs. I could have stopped it.” What someone feels in that moment is real—as real as it can get. I can’t talk someone out of feeling guilt, but what I can do is listen with care, offer compassion, and help people understand some of the dynamics of suicide.
As youth leaders, mentors, and those invested in young people, suicide rates should concern us. Why are so many kids killing themselves, and how can we begin to understand the complexities of this issue? When kids commit suicide, the community is left with questions, grief, and anger. What can we do to help communities heal from this trauma?
Suicide Rates Remain Too High
Young people are killing themselves at alarming rates. For ages 10-24, suicide is the third leading cause of death. In fact, “More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease, combined!”
We need to be concerned not just about completed suicides, but also about suicide attempts. Teens attempt suicide more often than complete it. A nationwide survey of youth in grades 9–12 in public and private schools found that “16% of students reported seriously considering suicide, 13% reported creating a plan, and 8% reporting trying to take their own life in the 12 months preceding the survey. Each year, approximately 157,000 youth between the ages of 10 and 24 receive medical care for self-inflicted injuries at Emergency Departments across the U.S.” All teens are at risk, but boys are the most likely to die from suicide attempts. While girls are more likely to report attempting suicide, 80% of suicide deaths are boys. Culture also plays a role in who attempts and completes suicides. Among our most at-risk teens are Native American/Alaskan Native youth (who have the highest rate of suicide-related fatalities) and Latino youth (who are more likely to report attempting suicide than their non-Latino peers). 1
Why Are So Many Kids Killing Themselves?
We will never know exactly why a student took their life, but there are ways to recognize and identify if a teen may be in trouble. Potential teen suicide risk factors include: 1
access to lethal methods depression/mental illness divorce/family changes drug/alcohol abuse, alcoholism in the home exposure to domestic violence family history of suicide feeling that their life doesn’t matter, lack of self-worth/value feeling that people don’t know/care for them history of previous suicide attempts identity issues incarceration lack of community/isolation loss/grief moving to a new/different community physical, sexual abuse or emotional neglect stressful event victim of bullying The top three methods used in the suicides of young people include firearms (45%), suffocation (40%), and poisoning (8%). 1 I have found this to be true in my own experience, as the majority of youth suicide cases I’ve responded to involved a firearm, usually belonging to a parent.
Several factors can put a young person at risk for suicide. However, having these risk factors does not always mean that suicide will occur. One of the most significant risk factors for teen suicide is depression. As the Los Angeles Department of Mental Health states, “It is estimated that depression increases the risk of a first suicide attempt by at least 14-fold. Over half of all kids who suffer from depression will eventually attempt suicide at least once.” Further, fifty-three percent of young suicide deaths involve substance abuse.
One study revealed that teens under 18 who lost a parent to suicide were three times more likely to commit suicide than children and teens with parents living. After the 2008 economic downturn, several parents in my community took their own lives due to the financial stress they were facing. I have responded to teen suicides where the young persons’ death was preceded by one of their parents taking their own life. When a teen loses a parent, their vulnerability increases greatly.
Finally, untreated and undiagnosed trauma contributes to feelings of hopelessness that can lead to suicidal actions. Teens are being exposed to trauma at concerning rates. Movies, video games, TV shows, and violent life experiences imprint images on the brains of young people. Our eyes and minds process and record trauma (what we have seen and experienced) in our memory. As a result of this trauma, teens can struggle with flashbacks and disturbing memories and emotions, which if left undiagnosed and untreated, may result in teen suicide.
Suicide Is A Complex Reality
After a suicide, we may find ourselves asking many “why” questions: Why did this happen? Why couldn’t I stop it? Why didn’t I see the signs? We are looking for explanations. Sometimes it’s helpful to keep reminding one another that suicide is one person’s decision. We may feel responsible and blame ourselves, and at the same time be angry that this teenager didn’t even give us a chance to help them. Anger is part of the grief process and a normal reaction to teen suicide. We may be plagued with a complex mixture of emotions such as guilt, anger and lack of closure. All are valid and real.
In the majority of attempted suicide attempts, there were signs. However, it is almost impossible to discern unless you are the person contemplating committing suicide. People mask their emotions. The “What if?” questions won’t bring the person back. Replaying of the last conversations and interactions we had with the student won’t change the reality. One person’s suffering, sadness, and decisions have repercussions that reach deeply into the community.
The Deep And Ongoing Impact Of Suicide
I was a youth pastor for 15 years and have served as a police chaplain for almost 15 years. My first police chaplain call was to give a death notification to the family of an 18-year-old (the only son in the family) who committed suicide. The parents were confused, sad, and devastated. Their lives were turned upside down on hearing the news.
Suicide can also expose us to trauma as those who help in the aftermath. Trauma is a result of exposure to a critical incident or distressing experience and, if left untreated, it can result in PTSD (Post Traumatic Stress Disorder) or other issues. We can’t control when tragedy happens, but we can help lessen the impact. This is called trauma care. As those who work with young people, we need to care for ourselves so that we can help offer care to others. This may mean finding a safe place to process our own traumatic stress from being part of the situation.
We all grieve differently. It is important that we give ourselves and each other space and time to grieve. Grieving collectively (e.g., funerals) plays a key role. Together we can remember our lost loved one. Sometimes one death can bring up previous loss and grief. While I was talking with one of the teachers of the 14-year-old who committed suicide, she was filled with grief not just from the recent student suicide but also from an accidental student death ten months previous. Both of the students were in her class. She was feeling the loss of the first student as she was processing the reality of the second student’s death.
Best Practices For Healing
The loss of suicide brings permanent changes. In the aftermath of death, we enter into what is sometimes called the “new normal.” We long to return to the days of old, before this loss. The reality is, we can’t. We must step into the new normal and find ways to deal with the loss. Grief is an important part of this process, and it is imperative that we grieve well. (Learn more about healthy grief in this article by Kimberly Williams, “Good Grief”) In the article “A New Normal: Ten Things I’ve Learned about Trauma”, Catherine Woodiwiss offers several best practices in dealing with trauma and grief, including 2:
Be present with people Healing takes time Grieving and healing are both social experiences Don’t offer cliches or comparison Allow people to tell their own stories Recovering from teen suicide certainly takes time. But we are not guaranteed that we will be stronger after this, or that we will find full healing. Be careful not to make promises to yourself or anyone else that this will be the case.
Below are some additional guidelines that will help us find healing for ourselves as well as those around us who are struggling with the grief following teen suicide:
Ministry of presence. We can embody the peace and presence of God by being present with others, sitting with people in the midst of their pain. During our own grief we need not isolate ourselves, but rather invite community to journey with us. It’s not okay, but it won’t always be this way. Clichés we use on ourselves and with others can bring more pain. The fact that this student was in pain and took their own life changes us all forever. Yet things won’t always be this way. Eventually we can begin to rebuild life after loss. Face down the guilt, shame, and anger. We may feel like we could have done something. Going down that road won’t bring them back. The teen we loved made a decision and took their own life. They are gone and we can’t change that. But the emotions we feel are real, and we need to create healthy space for feelings to be expressed. We can’t change the fact that a teen took their life, but we can lessen the impact of the death on our community. Participating in group processes like CISM (Critical Incident Stress Management) debriefs can mediate the impact because they offer opportunities to talk through the loss with others. CISM is a process by which we discuss what happened, what we saw, felt, experienced, etc. in a group setting with others who are going through this with us. This isn’t equivalent to professional therapy, but is a way to lessen the intensity of the loss by giving a safe space in a group guided by a facilitator. Professional therapy, pastoral counseling, and grief counseling can also assist in community healing. Be sure to be prepared with referrals of local helpers for young people and their families. Acknowledge the impact of the death imprint. When we see or experience something traumatic, our brain takes a picture of what we see or what we can imagine. That death imprint stays with us. Smells, sights, and sounds might cause the memory and pain from that event to be recalled. Be patient and sensitive with yourself and with others when this happens. God is with us. In the midst of the loss and pain, we must remember that God is always with us. In Psalm 32:7 we are reminded that God keeps and surrounds us: “You are my hiding place; You shall preserve me from trouble; You shall surround me with songs of deliverance.” Feeling alone with our grief can overwhelming. But we are promised that God is with us. 3 Cling to hope! Even when we don’t feel it, hope is there. In the midst of losing our loved one, hope helps us to see what is ahead and to look to the future rather than being stuck in the present and past. Action Steps
Assess your own grief process and management in dealing with loss and death. What are your best self-care practices? Read an article or book on loss and grief. Discuss it with your small group or in community with other leaders. How does your ministry handle loss and death well? What could you put in place to respond better? Begin building (or revisit and strengthen) a database of local caregivers who can help after tragedies like suicide or other deaths. Learn more about suicide prevention and warning signs. Part 2 of this article will provide more tips for prevention. Additional Resources
American Academy of Child and Adolescent Psychiatry (AACAP) www.aacap.org
American Association of Suicidology (AAS) www.suicidology.org
American Foundation for Suicide Prevention www.afsp.org
Glover, Beryl S. and Glenda Stansbury. The Empty Chair: The Journey of Grief After Suicide.
Hsu, Albert Y. Grieving a Suicide: A Loved One’s Search for Comfort, Answers, and Hope.
Lewis, C.S. A Grief Observed.
National Alliance for the Mentally Ill (NAMI) www.nami.org
National Mental Health Association (NMHA) www.nmha.org
National Suicide Prevention Lifeline www.suicidepreventionlifeline.org
New Hope Grief Support Community www.newhopegrief.org
Shaw, Luci. God in the Dark: Through Grief and Beyond.
Steel, Danielle. His Bright Light: The Story of Nick Traina. Delacorte Press, 1998.
Suicide Prevention Resource Center www.sprc.org
The Centering Corp (Grief Resources): www.centering.org
Yancey, Philip. The Question That Never Goes Away (Why).
Read Part 2 of this series.
1. See http://www.cdc.gov/violenceprevention/pub/youth_suicide.html
2. Catherine Woodiwiss, “A New Normal: Ten Things I’ve Learned About Trauma,” SOJO Blog, January 13, 2014.
3. See Jude Tiersma Watson’s helpful article for FYI on different ways we view God in the midst of tragedy and loss: “Your Pain: Six Lenses to Help” https://fulleryouthinstitute.org/articles/in-the-aftermath-of-suicide -------------------------------------------------------------- Aftermath of Suicide: Help for Families
FacebookTwitterGoogle+PinterestLinkedIn In the wake of a loved one’s death by suicide, families often disintegrate, unable to deal with the intense grief and the difficult, painful, and often unanswerable question of “Why?” For every suicide, it is estimated that at least six persons are affected. These include family members, co-workers, neighbors, classmates and close friends. Beyond grief and the fruitless search for answers, survivors of suicide also grapple with crippling emotions.
Emotions can Derail Suicide Survivors’ Healing
The waves of emotions that flow through the minds of suicide survivors can be so devastating that they cause the person to no longer be able to function. Life just seems to stop for them, now that their loved one has died by suicide. These emotions may occur singly, or in clusters, come fleetingly or stay for lengthy periods of time. They all need to be dealt with in order for healing to begin.
• Shock – Most survivors of suicide feel shock as an immediate reaction, along with physical and emotional numbness. This reaction is the temporary way for the person to screen out the pain of what just happened, to allow time to comprehend the facts, and take things in smaller and more manageable steps.
• Anger – Loved ones and family members often express anger, or suppress it, at the waste of human life. Anger is another grief response, and may be directed toward the person who died by suicide, to themselves, another family member, or a therapist.
• Guilt – Following death by suicide, surviving family members rack their brains trying to think of what clues they missed, how they may have been able to prevent the suicide. This self-blame includes things they said (or didn’t say), their failure to express love or concern, things they planned to do (but never got around to) – anything and everything in a never-ending kaleidoscope.
• Fear – If one family member committed suicide, perhaps another will make an attempt. The surviving family member may even fear he or she is in jeopardy.
• Relief – When the deceased died by suicide after a protracted illness filled with intense physical pain, long decline into self-destructive behavior, or ongoing mental anguish, surviving family members may feel a sense of relief. Finally, the loved one’s suffering is over.
• Depression – Nothing seems worth an effort anymore to many suicide survivors. This manifests itself in sleeplessness or disturbed sleep, changes in appetite, fatigue, and loss of joy in life.
Grief experts say that most of these intense feelings will diminish over time, although there may be some residual feelings that may never truly go away. In addition, some questions may forever remain unanswered.
Surviving Suicide
It sounds trite, but it’s true. You can survive suicide. It is, however, a long and often painful (and painfully difficult) journey. Here are some strategies to help individuals survive suicide:
• Stay connected with other family members – The last thing you need is to be isolated and alone. You need other people at this time more than any other. Contact with others is particularly important in the first six months following a loved one’s suicide. For others, maintaining contact with others will take longer, almost as a lifeline of support. In any case, other family members are in most need of contact, even if they express a wish to be left alone. Not everyone grieves in the same way. Some people are unable to open themselves up and say what they feel. They may need more time to be able to offer you any consolation, but this doesn’t mean they don’t desperately need it themselves. Talk openly with other family members about your feelings about the suicide and ask them for help. But only do so if you feel ready to speak about it.
• Give children special attention – Children, especially, may have a more difficult time with the intense emotions they are experiencing. It is important to remind them that these are normal grief reactions. They need, above all, to know that you still love them and will be there for them always. Share how you feel with them, and encourage them to speak from their heart when they are ready.
• Holidays are stressful times – Be aware that holidays, birthdays, anniversaries and other special days are very stressful times for suicide survivors. Plan to meet the family’s emotional needs – as well as your own – during these times.
How do you Survive Suicide?
Beyond staying connected with other family members, it’s important that suicide survivors reach out and get help. There’s only so much an individual can work out in his or her head without professional help. Fortunately, help is available in a number of ways. These include psychological grief counseling, individual or group meetings, self-help groups, books and literature.
Websites for Suicide Survivors
Listed here are a few websites that may be helpful for suicide survivors:
• For Suicide Survivors – //forsuicidesurvivors.com/index.html, devoted to those who are grieving the loss of a loved one by suicide.
• Suicide Survivors.org – //www.suicidesurvivors.org/, survivors of suicide help and information, Judy Raphael Kletter.
• Survivors of Suicide – //www.survivorsofsuicide.com/index.html
• Surviving Suicide – //www.survivingsuicide.com/cope.htm, provided by the surviving suicide support group of the Central Christian Church.
Suicide Support Groups
The following link to suicide support groups comes from Suicide.org, //www.suicide.org/suicide-support-groups.html. Click on the state to be directed to a list of suicide survivor support groups in that state. There is also a link to suicide support groups in Canada.
The American Foundation for Suicide Prevention (AFSP) also has a directory of suicide support groups for the United States and International locations.
Survival Suggestions
Those who have been through the process are often the best sources for survival suggestions. The following tips are a common theme among various self-help groups, grief counseling and treatment sites.
• It takes time to survive. You may not think you will survive, but you will.
• Lean on your faith to help get you through this crisis. If you aren’t affiliated with any specific religious group, do meditation and bring forth your own higher power to help you heal.
• Laughter is very healing. Be willing to laugh with others and at yourself. It will help you progress.
• Getting past your feelings of anger, shock, fear, guilt, relief, and depression is necessary – but it doesn’t mean you forget. You do need to “wear out” all those feelings, however, before you can begin to heal. Allow yourself to do so.
• “Why” is always important. Give yourself permission to find the answers until you are satisfied. If you can only obtain partial answers, and that is all that will be forthcoming, be satisfied with that so you can move on.
• Acknowledge that all your intense emotions are perfectly normal reactions to grief.
• Take it one day at a time, one moment or one emotion at a time. This way, you will be less likely to be overwhelmed.
• When you need to talk, call someone. And, be a good listener to others who need to talk as well.
• You need time to heal. Don’t expect this to happen in a prescribed period of time. It’s different for everyone.
• Don’t be around people who try to tell you how to feel. Only you know how you feel, and you’ll progress at your own pace through your healing process.
• Expect that there will be setbacks. Not every day will be a step forward. Understanding that will help you get through these times.
• Put off any major decisions, if you can. In the immediate aftermath of suicide is not the time to make important life decisions.
• It is okay – and recommended – to get professional help to deal with your grief.
• Recognize and understand the pain that your family members and others are going through at this time. It’s not all about you and your feelings. Others are suffering as well.
• Learn how to say no. Set limits for yourself.
• Be patient with yourself – and with others. Not everyone understands what you’re going through. Similarly, other family members and loved ones need to process grief at their own pace. Your patience with them will be appreciated and is a loving gesture.
• Accept that you will never be the same again. But this does not mean that you will never enjoy life again. You can, and you will.
Recommended Books for Suicide Survivors
Although the pain you and your family feel over the loss of your loved one to suicide is personal and unique, it helps to know that others have come through a similar experience. That’s why counseling and group support is so important. As an adjunct to personal interaction with other suicide survivors and counselors, then, reading books on the subject is also therapeutic. It is especially helpful for when you are alone, late at night, or when your grief seems insurmountable.
Children have very different needs than adults. For this reason, parents may wish to read how other parents helped their grieving children. Here are some recommended books, but they are by no means all-inclusive. They are featured on the website For Suicide Survivors:
• What Children Need When They Grieve: The Four Essentials: Routine, Love, Honesty and Security, by Julia Wilcox Rathkey.
• Helping Children Grieve: When Someone They Love Dies (Revised Edition), by Theresa Huntley.
• Helping Children Cope With the Loss of a Loved One: A Guide For Grownups, by William C. Kroen and Pamela Espeland.
• Guiding Your Child Through Grief, by James P. Emswiler and Mary Ann Emswiler.
• Grieving Child, by Helen Fitsgerald.
• Breaking the Silence: A Guide to Help Children with Complicated Grief-Suicide, Homicide, AIDS, Violence and Abuse, by Linda Goldman.
Books for children about suicide include:
• After A Parent’s Suicide: Helping Children Heal, by Margo Requarth.
• After A Suicide: A Workbook For Grieving Kids, developed by the Dougy Center for Grieving Children.
• But I Didn’t Say Goodbye: For Parents and Professionals Helping Child Suicide Survivors, by Barbara Rubel.
• Someone I Love Died by Suicide: A Story for Child Survivors and Those Who Care for Them, by Doreen Cammarata.
General guidelines on suicide are covered in the following books:
• After Suicide: A Ray of Hope for Those Left Behind, by E. Betsy Ross and Joseph Richman.
• After Suicide: Help for the Bereaved, by Dr. Sheila Clark.
• Healing After the Suicide of a Loved One, by Ann Smolin and John Guinan.
• Silent Grief: Living in the Wake of Suicide, by Christopher Lucas and Henry M. Seiden.
• Touched by Suicide: Hope and Healing After Loss, by Michael F. Myers and Carla Fine.
• Aftershock: Help, Hope and Healing in the Wake of Suicide, by Candy Neely Arrington and David Cox.
• After Suicide, by John H. Hewett.
Specific survivor guides include:
• My Son…My Son: A Guide to Healing After Death, Loss or Suicide, by Iris Bolton.
• Suicide of a Child, by Adina Wrobleski.
• Do They Have Bad Days in Heaven? Surviving the Suicide Loss of a Sibling, by Michelle Linn-Gust.
• An Empty Chair: Living in the Wake of a Sibling’s Suicide, by Sara Swan Miller.
• No Time to Say Goodbye: Surviving the Suicide of a Loved One, by Carla Fine.
• Before Their Time: Adult Children’s Experiences of Parental Suicide, by Mary Stimming and Maureen Stimming.
Hope for the Future
Whether through the passage of time, prayer, helping others, or finding a new purpose in life – perhaps through and with your children or others in need – you will eventually begin to feel something again. Now, all you feel is pain and numbness, but that will pass. No, it will never be the same as it was. That’s why you need to use any and all available resources to help you navigate these troubled times.
Remember that love is the most powerful healer there is. Express your love for your loved one that you lost to suicide, as well as to those remaining family members who now need you more than ever. Love yourself as well. Give so that you may receive. And, take it one day at a time. Each day, each month will bring you a little closer to inner peace and new hope for the future. https://www.elementsbehavioralhealth.com/mental-health/aftermath-of-suicide-help-for-families/ -------------------------------------------------------- GETTING HELP TO DEAL WITH AFTERMATH OF SUICIDE ATTEMPTS Shame, guilt, anger, denial over a suicide attempt prevent many families from getting the help they need to navigate the crisis.
When a child attempts suicide, these emotions hit families like a Mack truck. Some family members bury their feelings deep inside and refuse to accept the stark reality. Others spring into action and vow never again to let the child who attempted suicide out of their sight. But no matter how a family deals with the aftermath of a suicide, they are forever changed by it.
"The repercussions from a suicide attempt can go on for years," says Daniel Hoover, PhD, a psychologist with the Adolescent Treatment Program at The Menninger Clinic and associate professor in the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine Houston.
Guilt and shame over a suicide attempt prevent many families from getting the help they need to work through the crisis, Dr. Hoover continues. An estimated 30 percent of families of children who attempt suicide seek family therapy, according to a study published in the Journal of the American Academy of Child and Adolescent Psychiatry in 1997, and about 77 percent of families referred to treatment after an adolescent attempts suicide drop out according to a 1993 Journal study.
Many families don't pursue treatment because they deny or minimize their child's suicide attempt. Teenagers who attempt suicide may also not admit they tried to kill themselves.
"Even when you see a young person in the emergency room right after he or she completed an attempt, very quickly the denial kicks in," Dr. Hoover says. "She may say, 'I never meant it,' or 'it was an accident,' or denying she even made an attempt. Families do the same thing because of the intensity of the suicide issue."
Complicating matters, teenagers may attempt suicide while in treatment for mental illness, such as depression or substance abuse. Families are reluctant to put their trust in the mental health system again--feeling it failed them.
Shame, guilt, anger, denial over a suicide attempt prevent many families from getting the help they need to navigate the crisis.That's unfortunate, Dr. Hoover says, because families desperately need support and direction after a child attempts suicide. Depression, which leads to suicidal thinking, affects the entire family unit. To move past the tragedy, families must address the issues that the suicide caused, and continues to cause, in their lives. Chief among the issues is the family's increased sense of responsibility for the child who attempted suicide. Worried about a repeat suicide attempt, family members, and parents in particular, feel that they have to watch their child constantly—in some cases, sleeping at the foot of the child's bed every night to make sure he or she won't attempt suicide.
"Parents feel a huge obligation to watch over their child," Dr. Hoover says, "At first it may seem somewhat comforting to the child, but then the parents become so intrusive in the child's life he or she thinks, 'I can't live like this anymore."
Learn about 4 Circles addiction treatment. Click now. advertisement Helping families reach that middle ground between protecting and smothering their children is a main goal for family therapy at the Menninger Adolescent Treatment Program, which treats adolescents age 12 to 17. Patients in the inpatient treatment program struggle with family, school and social difficulties because of depression, anxiety, or other psychiatric illness or substance abuse. Some patients also have attempted suicide once or multiple times.
Dr. Hoover recommends individual therapy as well as appropriate psychiatric medication for children who attempt suicide, as most are quite depressed and feel hopeless. Their parents and other children in the family may also benefit from individual therapy, especially if they found them after the attempt.
"Often siblings are just as stressed out as the parents because they find the brother after the overdose, or they are the ones in the background while Mom and Dad and the brother are having all of the conflict," Dr. Hoover says. "So they have been traumatized by it and they need their own help."
Working with therapists at Menninger, patients in the Adolescent Treatment Program learn to develop agency, or the ability to take action and exert control, over their mental illness and suicidal feelings. They learn skills to cope, ways to self-soothe and to seek out sources of support other than their parents. They also learn to share their thoughts and feelings with their parents, and to communicate with their parents if they are feeling suicidal.
Parents, in turn, learn how to listen and not overreact.
"When parents witness that their child is handling his or her feelings better, and knows when to seek help, it lowers their anxiety so much," Dr. Hoover says.
Family therapy immediately following a suicide attempt may not be productive, Dr. Hoover says, because emotions are raw, and the suicide attempt is still fresh in the family members' minds. Once the child who attempted suicide learns how to deal with his or her hopelessness and depression, and the parents begin to deal with their own anxieties and guilty or angry feelings, then they may be ready for family therapy. Family therapy helps family members learn how to communicate better with each other and express their feelings more constructively.
more: Detailed info on suicide and how to support a suicidal person
Sources:
Menninger Clinic press release (4/2007) next: Eating Disorders Information For Parents
Last Updated: 19 March 2016 Reviewed by Harry Croft, MD https://www.healthyplace.com/parenting/depression/help-to-deal-with-aftermath-of-suicide-attempts/ ------------------------------------ Real advice for those who’ve attempted suicide, and want to step back into life
Posted by: TED Guest Author January 14, 2014 at 7:00 pm EDT JD-Schramm-QuoteBy JD Schramm*
In my TED Talk, I acknowledged for the first time that, in 2003, I tried to end my life. I wanted to share this in a public setting because 19 out of 20 people who attempt suicide will fail — and those that make the difficult decision to come back to life need openness from their loved ones and a lot of resources. Perhaps that’s what you are in need of right now.
JD Schramm: Break the silence for suicide attempt survivors JD Schramm: Break the silence for suicide attempt survivors My journey cannot be your journey. And while there are probably great gaps in our specific experiences, there is likely some overlap too. In the process of thinking about my experience, a few themes have emerged which I think have a more universal application. If you have others, by all means add them to the list; if some of these do not work for you, then simply attempt the ones which do.
Live Simply. Avoid the material trappings of a fabulous life, but rather find joy in simple things – walks on the beach, instrumental music, or fresh flowers. Choose what works for you. For example I shared an apartment with a roommate, rather than trying to buy a place or live alone to keep my life simpler.
Cultivate Sacred Spaces. Have a corner of your room which is ideal for reading, journaling, praying or meditating. Find a church or temple or park or art gallery where you can go easily in the midst of a pressure-filled day to “recompose” yourself.
Journal Regularly. This has been vital for me; I have a friend who, at the very least, jots down the time he goes to bed. Sometimes he can get another word, or sentence, or paragraph, or page written… but he’s developed a discipline to at least begin. Don’t just journal the bad, but record the joys and the progress. I often paste simple items (ticket stubs, plane tickets, business cards) from the day onto the page facing what I wrote for the day as a visual remembrance.
Create Works of Beauty. Whatever moves you: do it. Throw pottery, weave tapestries, take photos, learn to dance – the medium (or how good you are) doesn’t matter, but find a way to get outside yourself regularly.
Abstain from Substances. Even if addiction is not one of your issues, I’d urge you to eliminate drugs and alcohol from your first year back from an attempt. It dulls the pain, yes, but it also can steal from you the chance to live fully your feelings. Tackle life’s joys and setbacks head on – without the false help a drink, a joint, or a line can provide.
Assemble Your Dream Team. The exact nature of who you need to help you will depend on the issues you are facing. But strive to put a small and committed group of people in your corner to assist you with the physical, social, spiritual, and personal healing which is needed. Be entirely honest with them so that they know your successes as well as your setbacks.
Manage your Primary Illness. Whether it is depression, addiction, bi-polarity, an eating disorder, or something else which brought you to the brink of death, it requires your primary and unwavering focus. If you put anything (a boyfriend or job or volunteer commitment) ahead of managing your primary illness … you will likely lose that very thing you thought was more important.
Find A Caring Community. Seek out others with similar needs and develop a network you can rely on. Those of us who are in recovery can find this in an AA or CMA meeting, you may need to locate a support group, join a small group at church, or seek an online community of others who get the depths and severity of what you face.
Avoid Dating. You need to first get at ease in your own skin before trying to be intimate with another again. If you are already in an intimate relationship, it is often advised to not get out of this relationship until you are stronger. Consider your “relationship bone” to be in a splint and cast for a while. You need to go easy on it until it is strong enough to handle more weight.
Earn a Modest Income. Be sure your basic needs are met, so as not to add financial pressures to your life, but this is not a season to be closing huge deals, seeing great raises, or starting new and demanding jobs. In essence, during this season (likely a year or so) your full-time job is recovering your life. There will be time in the future when you can be more dedicated to a demanding job and/or fulfilling career.
Comply with Prescriptions. This is especially necessary as it regards anti-depressants. Only reduce or increase your meds under the specific guidance of your doctor. There are terrible tales of patients who begin to recover, with the help of today’s psychiatric drugs, and then feel they no longer need them and simply cease using them and weeks later end up suicidal. These meds have helped millions, but are powerful change agents in our life. Use them with care and strict adherence to what your doctor says.
Share your Story Selectively. It is critical that you create trust with others before sharing your story entirely. Certainly be fully honest with your “dream team,” but you may find others (employers, roommates, bowling buddies, even family members) don’t need and don’t want the full details.
Optimize this Time of Strength. Have conversations with loved ones when you are strong and tell them what to watch for if you “backslide.” Give them guidance as to what you may need but not ask for, should a crisis happen in the future. Some patients have actually created advanced directives of what close friends or family can/should do. As Kay Jamison in Night Falls Fast points out:
“Patients who decide, when rational, that if they again become suicidal they wish to be hospitalized or receive antipsychotic medications or undergo electroconvulsive therapy, but who also know that they are unlikely, when ill, to consent to this, may in some areas of the country draw up “Odysseus” arrangements. Based on the mythic character’s request to be strapped to the mast of his ship so that he might avoid the inevitable call of the Sirens, Odysseus agreements (or advanced instruction directives) allow patients to agree to certain treatments in advance.”
Eliminate Easy Access to Destructive Means. Get the pills, guns, and booze out of the house. It is imperative that you clean house (literally) while you are in a place of strength, possibly with a trusted friend helping you. Don’t leave a “back door unlocked” which could undo all your good work later on when things get tough.
Be Gentle With Yourself. Strive for incremental progress, but don’t beat yourself up over a bounced check or missed appointment. The 12 step literature urges “spiritual progress not spiritual perfection.” All of us who are recovering from a serious suicide attempt are doing a remarkable thing as we reclaim our life. Take heart in your progress, celebrate and rejoice in the small victories. For the first year after my attempt, on the 11th of each month, I’d go out and buy a CD for my collection. Typically show tunes … what can I say?
. . *This excerpt is from a longer manuscript I wrote as part of my journey back to life. I hope to publish the entire story of my journey soon, but wanted to get this out to people now. That’s why I chose to put this out as a blog post first. http://blog.ted.com/real-advice-for-those-whove-attempted-suicide/ ------------------------------- Teen suicide: What parents need to know Teen suicide is preventable. Know the risk factors, the warning signs and the steps you can take to protect your teen.
By Mayo Clinic Staff Is your teen at risk of suicide? While no teen is immune, there are factors that can make some adolescents more vulnerable than others. Understand how to tell if your teen might be suicidal and where to turn for help and treatment.
What makes teens vulnerable to suicide?
Many teens who attempt or die by suicide have a mental health condition. As a result, they have trouble coping with the stress of being a teen, such as dealing with rejection, failure, breakups and family turmoil. They might also be unable to see that they can turn their lives around — and that suicide is a permanent response, not a solution, to a temporary problem.
What are the risk factors for teen suicide?
A teen might feel suicidal due to certain life circumstances such as:
Having a psychiatric disorder, including depression Loss of or conflict with close friends or family members History of physical or sexual abuse or exposure to violence Problems with alcohol or drugs Physical or medical issues, for example, becoming pregnant or having a sexually transmitted infection Being the victim of bullying Being uncertain of sexual orientation Exposure to the suicide of a family member or friend Begin adopted Family history of mood disorder or suicidal behavior What role do antidepressants play?
Most antidepressants are generally safe, but the Food and Drug Administration requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. The warnings call attention to the fact that children, teenagers and young adults under 25 might have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed.
Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood.
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Book: The Mayo Clinic Kids’ Cookbook http://www.mayoclinic.org/healthy-lifestyle/tween-and-teen-health/in-depth/teen-suicide/art-20044308 ------------------------------------------------------- What Parents Should Know About Teen Suicide
For a teenager to be so unbearably unhappy that he would choose to kill himself is something that’s almost too painful for a parent to think about. But with the increasing prevalence of teen suicide, no parent can afford to ignore the possibility. Suicide is now the third leading cause of death for high-school students.
Kids look at this world as being more and more hopeless. They have no answer for their pain and despair, so many are choosing suicide as their solution. When I was in high school — a school with 3,000 students — I never knew of any of my peers committing suicide. And even in my work years ago as a director of Young Life , suicide among the teens in our region was a very unusual event that I rarely heard of.
Fact is, before the 1960’s, suicide by adolescents happened only rarely; but today, nearly one in ten teens contemplates suicide, and over 500,000 attempt it each year. While suicide rates for all other ages have dropped, suicides among teens have nearly tripled.
Between the sexes, teen boys are more than four times as likely to commit suicide as girls. But girls are known to think about and attempt suicide about twice as often as boys. The difference is the method; girls attempt suicide by overdosing on drugs or cutting themselves, and thankfully most are found in time and rescued. Boys tend to use more lethal methods, such as firearms, hanging, or jumping from heights.
The Warning Signs Suicide is a teen’s last attempt to ease the pain, to make a statement, or it is just a wrong decision giving a permanent solution to a temporary problem. Teens don’t see the bigger picture; they only see the "right now." They get wrapped up in the emotions of the moment and tend to only think about a week ahead — that’s all. And when you mix immature short-sightedness with feelings of utter hopelessness, some kids think they cannot live with the pain another day. Other kids who contemplate suicide are filled with rage over teasing by their peers or the way they feel they’ve been mistreated by family. They choose suicide as a tragic form of payback.
That reminds me of Kerri. She was the "perfect kid." She loved church, was involved in mission projects, was adored by her brothers, and stayed away from sex, drugs, and alcohol. Her parents allowed their stunning daughter to date at age 16. But on her first date, the guy tried to go too far, and Kerri was shocked and stunned by the encounter. Her parents asked about the date, and she shared what had happened. Kerri’s father, in the heat of the moment, blamed Kerri. His words verbally crucified his daughter. When Kerri stated that what this boy did made her want to commit suicide, her dad said she didn’t have the guts to do it. Feeling devalued and misunderstood, Kerri decided to show her dad how gutsy she really was. She got into her parents’ medicine cabinet and took 30 sleeping pills. Kerri’s parents had no idea what the fight had done to their daughter until dad came upstairs to apologize, found Kerri asleep, and couldn’t wake her. She awoke a few hours later after being rushed to the emergency room and having her stomach pumped. She wasn’t rebellious; she was just sending her dad a message. If she showed her dad that he was wrong about her being too afraid to kill herself, she could also prove he was also wrong about the way she handled her date.
Like Kerri, most teens contemplating suicide give some type of warning to friends or loved ones ahead of time. It can be subtle and or it can be blurted out in a rage. Either way, it's important for parents to watch for those threats or warning signs and take them seriously, so their teen can get the help they need.
Parents should be aware of these other warning signs that their teenager may be having suicidal thoughts:
They may begin to isolate themselves, pulling away from friends or family They may no longer participate in what was their favorite things or activities They may have recently developed trouble thinking clearly They may have changes in their personality (darker, more anxious, or non-caring) They may be experiencing changes in eating or sleeping habits They may talk about suicide or death in general They may express feelings of hopelessness or guilt They may exhibit self-destructive behavior (substance abuse, dangerous driving, recklessness, excessive risk taking) They may have changes in their personal hygiene and appearance They may complain about anxiety-related physical problems (stomachaches, headaches, hives, fatigue, blurred vision) They may have difficulty accepting praise or rewards. If you see any of these signs in your teen, talk to them about your concerns and seek professional help from a physician or a qualified mental health professional. With the support of family and appropriate treatment, teenagers who are suicidal can heal and return to more healthy thinking.
If you ever hear your teen say, "I'm going to kill myself," or "I'm going to commit suicide," always take such statements seriously and immediately seek assistance from a qualified mental health professional. Don't walk away. Don't wait. Get them to a hospital immediately, even if they don't want to go or say they were just fooling with you.
Hospitalization is needed whenever a teen is a danger to himself. Extreme cutting, bizarre behavior, extreme depression, suicidal thoughts, or excessive drug or alcohol use coupled with emotional issues are just a few of the symptoms that might warrant hospitalization. A parent shouldn’t hesitate to hospitalize their child if they fear for their life. It’s better to be safe than sorry.
It's also important to be proactive in regard to making sure that the main tools of committing suicide are not readily available to a suicidal teen. For boys, lock up guns in the house so they are not accessible. For girls, monitor razor blades and make sure drugs like sleeping pills and pain killers are not accessible in your house. You may need to regularly go through her dresser, purse, backpack and closet to make sure she isn't storing any herself that she's bought or gotten from friends. And when a suicidal girl is taking a bath, knock on the door periodically to get a response.
Be Sure to Talk About It If you see mild warning signs, asking your teen if he or she is depressed or thinking about suicide can be helpful. Such questions filled with love and concern will provide assurance that you care and will give them the chance to talk about their problems. Get them to commit to you that if they ever do have those thoughts, they'll let you or someone else know. If your teen doesn't feel comfortable talking with you, suggest a more neutral person, such as another relative, a counselor, a pastor, a coach, or your child's doctor.
It's important to keep the lines of communication open and express your concern, support, and love. If your teen confides in you their loss of hope or control of their life, show that you take those concerns seriously. It's important not to minimize, mock or discount what your teen is going through, as this can increase his or her sense of hopelessness.
Depression Can Lead to Suicide Each year, thousands of at-risk teens are diagnosed with clinical depression. Most of the signs of depression are the same as suicide warning signs, so depression needs your attention. If left untreated or ignored, it can be a devastating illness for the teen and their family and it can lead to suicide.
There are different treatments for depression, but keep in mind that teen depression is often not treated the same as depression in adults. There are medications available to help teens with depression, but typically they are needed only temporarily. Treatment of teen depression must involve regular counseling and close supervision, since some medical treatments can make the depression more severe before they take full effect and begin helping. The good news is that most teens grow out of depression in a few years.
A depressed teen may have been having relational problems at home or is being picked on or bullied at school. But usually severe depression comes from another problem in their life such as an eating disorder, drug addiction, physical abuse, loss, or medical condition. Some teens just need to eat a better diet and get more sleep at night, but depression and suicidal thoughts are not something I'd recommend anyone treat with home remedies. A depressed teen generally doesn't have the ability or strength to solve their own depression. Attempting to help "shake them out of it" can cause the depression and despair to deepen, since it only serves to point out their own failure to improve their life.
What's a Parent To Do? If you are the parent of a depressed or suicidal teen, it’s important that you try to understand them, listen to them and try not to be accusing. Respect your teen’s opinions and problems and avoid blaming them or yourself for their feelings. Being a teenager is hard today and your child is justified in their feelings, even if you may not agree or understand. When you realize this, you can help your child.
Remain in contact; even if you no longer have any control over your child's life. It can make all the difference. Do what you can to bring family members and the friends they've abandoned back into their life. Get out family pictures and videos to show them better times.
No matter what mischief your child is doing in their life, hope is needed more than judgment at this time. So encourage them by getting them out to experience good things that can add abundance to their life. Sometimes it helps to ask a positive-thinking relative to take them into their home for a time to give the teen a change of scenery. Get them on a good diet. Get them outdoors to soak in some vitamin D. Regular exercise really helps. And find a loving pet that they can take care. Having the responsibility for a pet can sometimes cause a teen to think twice before taking themselves out of the picture. It also gives them a "pal" to talk to who is totally loyal and non-condemning. Finally, plan fun events several months in the future that they can look forward to, and keep reminding them of that date. For teenagers, the point is to create a bridge to help them get past this period of hopelessness and into a better mindset.
Please don't be slow in getting professional help. I've seen many hundreds of teenagers who have become different people from medication designed to correct a deficiency in their developing brain. Others are helped by regular counseling to deal with their inner issues, or with treatment for their drug habit or other addictions in their life. Get the help your teen needs, before they become a statistic.
About the Author: Mark Gregston is an author, speaker, radio host, and the founder and executive director of Heartlight, a residential counseling program for struggling adolescents. Mark can also be followed on Twitter @markgregston and at Facebook at /parentingteens.
http://www.oneplace.com/ministries/parenting-todays-teens-weekend/read/articles/what-parents-should-know-about-teen-suicide-12014.html ---------------------------- Practical Strategies for Parenting a Suicidal Teen By Michelle LeRoy, PhD, LP Most parents would panic if they discovered that their teenager was experiencing suicidal thoughts. Sometimes teens disclose to a parent when they are feeling depressed or suicidal. Frequently, parents find out about suicidal thoughts indirectly by reading their teen’s texts or Facebook posts or hearing about it from their teen’s friends, teacher, doctor, or mental health provider. Other parents just “know” when something seems wrong.
Thoughts of suicide, or “suicidal ideation,” are relatively common among teenagers and young adults. A whopping 12.1 percent of American teenagers seriously consider attempting suicide in their lifetime (Nock et al., 2013), and approximately 2 million teens in the United States go on to attempt suicide each year (NAMI).
The following strategies are grounded in clinical experience and research and are designed to help families address teen suicidality together. Parents play a crucial role in teen suicide prevention.
Educate yourself. Know the risk factors for teen suicide. These include: mental health concerns (especially depression); recent loss (e.g., death, divorce, loss of significant relationship); feelings of hopelessness and helplessness; feelings of worthlessness and guilt; previous suicide attempts; alcohol/substance use; impulsive behavior problems; sexual orientation confusion; family history of suicide; history of abuse or neglect; exposure to family violence; social isolation; and bullying.
Be direct. Talk to your teenager directly about suicidal thoughts. Ask her if she has ever wished to be dead or if she has been thinking about hurting herself. Many times, medical attention is not sought after a suicide attempt and parents may not be aware that their teen has attempted suicide. Remember, talking directly and openly about suicide does not increase a person’s risk for suicide. For many teenagers, having a trusted adult who knows how they are feeling helps to decrease suicide risk.
Communicate openly and respectfully. If your teenager shares concerns with you about suicidal thoughts, this shows great strength and trust in your relationship. A good rule of thumb is to listen twice as much as you speak. If your teen shares that something private, show empathy and compassion by telling him you know how hard it was for him to share and you’ll do whatever you can to help solve the problem. Avoid scolding or shaming your teen for sharing something with you, even if the news is scary or difficult for you to hear. Do not dismiss suicidal thoughts as a threat or a cry for attention. Instead, give him hope and reassurance that he will not feel like this forever and discuss what you can do to help.
Be encouraging. Help your teen come up with a list of coping strategies he can do on his own to help him not act on suicidal thoughts. This may include physical exercise, listening to music, reading, watching a funny movie or TV show, doing something creative (e.g., writing, drawing, taking photos), or doing something relaxing (e.g., deep breathing, meditation). Help him make a list of friends and family members (with phone numbers) and other social opportunities that may help take his mind off things.
Promote safety: Know where your teenager and who she is with is at all times. Be familiar with your teen’s friends and their parents. Monitor electronic communication (e.g., Facebook, texting) and be willing to communicate with your teen via text. Keep track of the alcohol coming in and out of your home. While it is common for teenagers to experiment with alcohol and drugs, substance use is a risk factor for teen suicide.
Limit access to lethal means. Restrict access to firearms by storing guns and ammunition separately in locked cabinets. Consider removing guns from the home, at least temporarily, if your teenager is having thoughts of suicide. Use a lock-box for prescription medications and dispose of old and unused medications. Monitor your teen’s medication on a daily basis and enlist the school nurse to administer medication during the school day if needed. For your teenager’s safety, do not put him in charge of his own medication if there is a concern about suicide.
Create a safety plan. Together with your teen, make a list of trusted family members or friends (with phone numbers) to call in a crisis. Encourage your teen to save the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) in her cell phone or carry the number in her wallet. Instruct her to call 911 or go to the nearest Emergency Department if she is feeling suicidal and cannot keep herself safe.
Seek help from a professional. Let teens know that professional help is available and that you support them in getting help. Both you and your teenager should actively participate in your teen’s therapy - tell the mental health provider that you want to be involved and receive updates at the end of each session regarding your teen’s safety. If the provider is not a good fit, find someone else you and your teenager feel comfortable with. Teach teens that therapy is not a punishment or something to be ashamed of, and discourage others from teasing your teen about going to therapy.
Get support for yourself. Lead by example and engage in healthy ways to manage stress including getting enough sleep, eating well, exercising, asking for help from others, and engaging in enjoyable activities. Seek professional help for yourself if needed. It can be overwhelming to find out that your teenager is dealing with suicidal thoughts. As parents, we may feel angry at ourselves or guilty that our teen is struggling so much. Above all else, we feel terrified for their safety and well-being. A qualified mental health professional can provide support to parents and help navigate the sometimes difficult balance between respecting your teen’s privacy and keeping them safe.
More information is available from the American Psychological Association Source: http://www.huffingtonpost.com/michelle-leroy-phd-lp/teen-suicide-prevention_b_5958356.html ------------------------ Teen Suicide is Preventable Teen suicide is a serious problem. But there are signs to watch for, and sources for help. What the Research Shows Teen suicide is a growing health concern. It is the second-leading cause of death for young people ages 15 to 24, surpassed only by accidents, according to the U.S. Center for Disease Control and Prevention. According to experts Michelle Moskos, Jennifer Achilles, and Doug Gray, causes of suicidal distress include psychological, environmental and social factors. Mental illness is the leading risk factor for suicide. Suicide risk factors vary with age, gender, ethnic group, family dynamics and stressful life events. According to a 2016 fact sheet distributed by the National Institute of Mental Health, research shows that risk factors for suicide include depression and other mental disorders, and substance-abuse disorders (often in combination with other mental disorders). More than 90 percent of people who die by suicide have these risk factors. The risk for suicide frequently occurs in combination with external circumstances that seem to overwhelm at-risk teens who are unable to cope with the challenges of adolescence because of predisposing vulnerabilities such as mental disorders. Examples of stressors are disciplinary problems, interpersonal losses, family violence, sexual orientation confusion, physical and sexual abuse and being the victim of bullying. National suicide prevention efforts have focused on school education programs, crisis center hotlines, media guidelines (suicide prevention strategies that involve educating media professionals about the prevalence of copycat suicides among adolescents, in an effort to minimize the impact of news stories reporting suicide) and efforts to limit firearm access. Referrals can be made for treatment, and treatment can be effective when signs are observed in time. Intervention efforts for at-risk youth can put them in contact with mental health services that can save their lives. Suicide is a relatively rare event and it is difficult to accurately predict which persons with these risk factors will ultimately commit suicide. However, there are some possible warning signs such as: Talking About Dying: any mention of dying, disappearing, jumping, shooting oneself or other types of self harm. Recent Loss: through death, divorce, separation, broken relationship, self-confidence, self-esteem, loss of interest in friends, hobbies or activities previously enjoyed. Change in Personality: sad, withdrawn, irritable, anxious, tired, indecisive, apathetic. Change in Behavior: can't concentrate on school, work or routine tasks. Change in Sleep Patterns: insomnia, often with early waking or oversleeping, or nightmares. Change in Eating Habits: loss of appetite and weight, or overeating. Fear of losing control: acting erratically, harming self or others. Low self esteem: feeling worthless, shame, overwhelming guilt, self-hatred, "everyone would be better off without me." No hope for the future: believing things will never get better, or that nothing will ever change. What the Research Means One in five teenagers in the U.S. seriously considers suicide annually, according to data collected by the CDC. In 2003, 8 percent of adolescents attempted suicide, representing approximately 1 million teenagers, of whom nearly 300,000 receive medical attention for their attempt; and approximately 1,700 teenagers died by suicide each year. Currently, the most effective suicide prevention programs equip mental health professionals and other community educators and leaders with sufficient resources to recognize who is at risk and who has access to mental health care. How We Use the Research Stop a Suicide Today is a school-based suicide prevention program that has experienced success with a documented reduction in self-reported suicide attempts. Developed by Harvard psychiatrist Douglas Jacobs, MD, Stop a Suicide Today teaches people how to recognize the signs of suicide in family members, friends and co-workers, and empowers people to make a difference in the lives of their loved ones. It emphasizes the relationship between suicide and mental illness and the notion that a key step in reducing suicide is to get those in need into mental health treatment. National Suicide Prevention Lifeline 1-800-273-TALK or visit their website. The National Suicide Prevention Lifeline's mission is to provide immediate assistance to individuals in suicidal crisis by connecting them to the nearest available suicide prevention and mental health service provider through a toll-free telephone number: 1-800-273-TALK (8255). It is the only national suicide prevention and intervention telephone resource funded by the Federal Government. Resources Berman, A., Jobes, D., & Silverman, M., (2006) Adolescent suicide: Assessment and intervention (2nd ed.) Washington, DC: American Psychological Association, 456 pp. How to Tell When a Kid is Struggling Emotionally (APA/National PTA Webinar, May 5, 2014) National Suicide Prevention Lifeline or 1-800-273-TALK Suicide Awareness Voices of Education (SAVE) or call: (800) SUICIDE Talking to kids when they need help (APA Help Center) Cited Research Center for Disease Control Suicide Fact Sheet Gould, M., Greenberg, T., Velting, D., Shaffer, D. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry. 42(4):386-405. Achilles, J., Gray, D., Moskos, M. (2004). Adolescent Suicide Myths in the United States. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 25(4):176-182. Beautrais, A. (2005). National strategies for the reduction and prevention of suicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention.26(1);1-3 Source: http://www.apa.org/research/action/suicide.aspx ----------------------------------------------- Suicide and Suicide Attempts in Adolescents Benjamin Shain, COMMITTEE ON ADOLESCENCE Article Figures & Data Info & Metrics Comments Download PDF Abstract
Suicide is the second leading cause of death for adolescents 15 to 19 years old. This report updates the previous statement of the American Academy of Pediatrics and is intended to assist pediatricians, in collaboration with other child and adolescent health care professionals, in the identification and management of the adolescent at risk for suicide. Suicide risk can only be reduced, not eliminated, and risk factors provide no more than guidance. Nonetheless, care for suicidal adolescents may be improved with the pediatrician’s knowledge, skill, and comfort with the topic, as well as ready access to appropriate community resources and mental health professionals.
Abbreviations: AAP — American Academy of Pediatrics FDA — Food and Drug Administration NSSI — nonsuicidal self-injury PHQ — Patient Health Questionnaire Introduction
The number of adolescent deaths that result from suicide in the United States had been increasing dramatically during recent decades until 1990, when it began to decrease modestly. From 1950 to 1990, the suicide rate for adolescents 15 to 19 years old increased by 300%,1 but from 1990 to 2013, the rate in this age group decreased by 28%.2 In 2013, there were 1748 suicides among people 15 to 19 years old.2 The true number of deaths from suicide actually may be higher, because some of these deaths may have been recorded as “accidental.”3 Adolescent boys 15 to 19 years old had a completed suicide rate that was 3 times greater than that of their female counterparts,2 whereas the rate of suicide attempts was twice as high among girls than among boys, correlating to girls tending to choose less lethal methods.4 The ratio of attempted suicides to completed suicides among adolescents is estimated to be 50:1 to 100:1.5
Suicide affects young people from all races and socioeconomic groups, although some groups have higher rates than others. American Indian/Alaska Native males have the highest suicide rate, and black females have the lowest rate of suicide. Sexual minority youth (ie, lesbian, gay, bisexual, transgender, or questioning) have more than twice the rate of suicidal ideation.6 The 2013 Youth Risk Behavior Survey of students in grades 9 through 12 in the United States indicated that during the 12 months before the survey, 39.1% of girls and 20.8% of boys felt sad or hopeless almost every day for at least 2 weeks in a row, 16.9% of girls and 10.3% of boys had planned a suicide attempt, 10.6% of girls and 5.4% of boys had attempted suicide, and 3.6% of girls and 1.8% of boys had made a suicide attempt that required medical attention.7
The leading methods of suicide for the 15- to 19-year age group in 2013 were suffocation (43%), discharge of firearms (42%), poisoning (6%), and falling (3%).2 Particular attention should be given to access to firearms, because reducing firearm access may prevent suicides. Firearms in the home, regardless of whether they are kept unloaded or stored locked, are associated with a higher risk of completed adolescent suicide.8,9 However, in another study examining firearm security, each of the practices of securing the firearm (keeping it locked and unloaded) and securing the ammunition (keeping it locked and stored away from the firearm) were associated with reduced risk of youth shootings that resulted in unintentional or self-inflicted injury or death.10
Youth seem to be at much greater risk from media exposure than adults and may imitate suicidal behavior seen on television.11 Media coverage of an adolescent’s suicide may lead to cluster suicides, with the magnitude of additional deaths proportional to the amount, duration, and prominence of the media coverage.11 A prospective study found increased suicidality with exposure to the suicide of a schoolmate.12 Newspaper reports about suicide were associated with an increase in adolescent suicide clustering, with greater clustering associated with article front-page placement, mention of suicide or the method of suicide in the article title, and detailed description in the article text about the individual or the suicide act.13 More research is needed to determine the psychological mechanisms behind suicide clustering.14,15 The National Institute of Mental Health suggests best practices for media and online reporting of deaths by suicide.16
Adolescents at Increased Risk
Although no specific tests are capable of identifying a suicidal person, specific risk factors exist.11,17 The health care professional should use care in interpreting risk factors, however, because risk factors are common, whereas suicide is infrequent. Of importance, the lack of most risk factors does not make an adolescent safe from suicide. Fixed risk factors include: family history of suicide or suicide attempts; history of adoption18,19; male gender; parental mental health problems; lesbian, gay, bisexual, or questioning sexual orientation; transgender identification; a history of physical or sexual abuse; and a previous suicide attempt. Personal mental health problems that predispose to suicide include sleep disturbances,20 depression, bipolar disorder, substance intoxication and substance use disorders, psychosis, posttraumatic stress disorder, panic attacks, a history of aggression, impulsivity, severe anger, and pathologic Internet use (see Internet Use section). In particular, interview studies showed a marked higher rate of suicidal behavior with the presence of psychotic symptoms.21 A prospective study found a 70-fold increase of acute suicidal behavior in adolescents with psychopathology that included psychosis.22 By definition, nonsuicidal self-injury (NSSI) does not include intent to die, and risk of death is deliberately low. Nonetheless, NSSI is a risk factor for suicide attempts23,24 and suicidal ideation.25 More than 90% of adolescent suicide victims met criteria for a psychiatric disorder before their death. Immediate risk factors include agitation, intoxication, and a recent stressful life event. More information is available from the American Academy of Child and Adolescent Psychiatry26 and Gould et al.11
Social and environmental risk factors include bullying, impaired parent–child relationship, living outside of the home (homeless or in a corrections facility or group home), difficulties in school, neither working nor attending school, social isolation, and presence of stressful life events, such as legal or romantic difficulties or an argument with a parent. An unsupported social environment for lesbian, gay, bisexual, and transgender adolescents, for example, increases risk of suicide attempts.27 Protective factors include religious involvement and connection between the adolescent and parents, school, and peers.26
Bullying
Bullying has been defined as having 3 elements: aggressive or deliberately harmful behavior (1) between peers that is (2) repeated and over time and (3) involves an imbalance of power, for example, related to physical strength or popularity, making it difficult for the victim to defend himself or herself.28 Behavior falls into 4 categories: direct-physical (eg, assault, theft), direct-verbal (eg, threats, insults, name-calling), indirect-relational (eg, social exclusion, spreading rumors), and cyberbullying.29 The 2013 Youth Risk Behavior Survey of students in grades 9 through 12 in the United States indicated that during the 12 months before the survey, 23.7% of girls and 15.6% of boys were bullied on school property, 21.0% of girls and 8.5% of boys were electronically bullied, and 8.7% of girls and 5.4% of boys did not go to school 1 day in the past 30 because they felt unsafe at or to or from school.7 Studies have focused on 3 groups: those who were victims, those who were bullies, and those who were both victims and bullies (bully/victims).30
Reviewing 31 studies, Klomek et al29 found a clear relationship between both bullying victimization and perpetration and suicidal ideation and behavior in children and adolescents. Females were at risk regardless of frequency, whereas males were at higher risk only with frequent bullying. A review by Arseneault et al31 cited evidence that bullying victimization is associated with severe baseline psychopathology, as well as individual characteristics and family factors, and that the psychopathology is made significantly worse by the victimization. Being the victim of school bullying or cyberbullying is associated with substantial distress, resulting in lower school performance and school attachment.32 Suicidal ideation and behavior were greater in those bullied with controlling for age, gender, race/ethnicity, and depressive symptomology.33 Suicidal ideation and behavior were increased in victims and bullies and were highest in bully/victims.34 Similar increases in suicide attempts were found comparing face-to-face bullying with cyberbullying, both for victims and bullies.35
Bullying predicts future mental health problems. Bullying behavior at 8 years of age was associated with later suicide attempts and completed suicides,36 although among boys, frequent perpetration and victimization was not associated with attempts and completions after controlling for conduct and depressive symptoms. Among girls, frequent victimization was associated with later suicide attempts and completions even after controlling for conduct and depressive symptoms. High school students with the highest psychiatric impairment 4 years later were those who had been identified as at-risk for suicide and experiencing frequent bullying behavior. Copeland et al30 found that children and adolescents involved in bullying behavior had the worst outcomes when they were both bullies and victims, leading to depression, anxiety, and suicidality (suicidality only among males) as adults. Assessment for adolescents with psychopathology, other signs of emotional distress, or unusual chronic complaints should include screening for participation in bullying as victims or bullies.
Internet Use
Pathologic Internet use correlates with suicidal ideation and NSSI.37 Self-reported daily use of video games and Internet exceeding 5 hours was strongly associated with higher levels of depression and suicidality (ideation and attempts) in adolescents.38 A more specific problem is that adolescents with suicidal ideation may be at particular risk for searching the Internet for information about suicide-related topics.39 Suicide-related searches were found to be associated with completed suicides among young adults.40 Prosuicide Web sites and online suicide pacts facilitate suicidal behavior, with adolescents and young adults at particular risk.37
A number of factors diminish the exposure of prosuicide Web sites. Web site results from the search term, “suicide,” are predominantly of institutional origin, with content largely related to research and prevention. Although there are a substantial number of sites from private senders (these sites are often antimedical, antitreatment, and pro-suicide,41 including sites that advocate suicide or describe methods in detail42), suicide research and prevention sites tend to come up in searches more commonly. Clicking on links within each site keeps the reader in the site, strengthening the site’s position. Methods sites and overtly prosuicide sites are more isolated, decentralized, and unfocused; these are less prevalent among the first 100 search results, perhaps related to a recent and deliberate strategy by the internet search engines (eg, search engine optimization).41
Learning of another's suicide online may be another risk factor for youth.43 Exposure to such information is through online news sites (44%), social networking sites (25%), online discussion forums (15%), and video Web sites (15%). Social networking sites have particular importance, because these may afford information on suicidal behavior of social contacts that would not otherwise be available. Fortunately, exposure to information from social networking sites does not appear related to changes in suicidal ideation, with increased exposure mitigated by greater social support. Participation in online forums, however, was associated with increases in suicidal ideation, possibly related to anonymous discussions about mental health problems. For example, suicide attempts by susceptible individuals appear to have been encouraged by such conversations.44,45
Interviewing the Adolescent
Primary care pediatricians should be comfortable screening patients for suicide, mood disorders, and substance abuse and dependence. Ask about emotional difficulties and use of drugs and alcohol, identify lack of developmental progress, and estimate level of distress, impairment of functioning, and level of danger to self and others. Depression screening instruments shown to be valid in adolescents include the Patient Health Questionnaire (PHQ)-9 and PHQ-2.46 If needed, a referral should be made for appropriate mental health evaluation and treatment. In areas where the resources necessary to make a timely mental health referral are lacking, pediatricians are encouraged to obtain extra training and become competent in providing a more in-depth assessment.
Suicidal ideation may be assessed by directly asking or screening via self-report. Self-administered scales can be useful for screening, because adolescents may disclose information about suicidality on self-report that they deny in person. Scales, however, tend to be oversensitive and underspecific and lack predictive value. Adolescents who endorse suicidality on a scale should be assessed clinically. Screening tools useable in a primary care setting have not been shown to have more than limited ability to detect suicide risk in adolescents,47 consistent with the findings of an earlier review.48 Instruments studied in adolescent groups with high prevalence of suicidal ideation and behavior showed sensitivity of 52% to 87% and specificity of 60% to 85%; the results are only generalizable to high-risk populations.49,50 Suicide screening, at least in the school setting, does not appear to cause thoughts of suicide or other psychiatric symptoms in students.51,52
One approach to initiate a confidential inquiry into suicidal thoughts or concerns is to ask a general question, such as, “Have you ever thought about killing yourself or wished you were dead?” The question is best placed in the middle or toward the end of a list of questions about depressive symptoms. Regardless of the answer, the next question should be, “Have you ever done anything on purpose to hurt or kill yourself?” If the response to either question is positive, the pediatrician should obtain more detail (eg, nature of past and present thoughts and behaviors, time frame, intent, who knows and how they found out). Inquiry should include suicide plans (“If you were to kill yourself, how would you do it?”), whether there are firearms in the home, and the response of the family. No data indicate that inquiry about suicide precipitates the behavior, even in high-risk students.51
The adolescent should be interviewed separately from the parent, because the patient may be more likely to withhold important information in the parent’s presence. Information should also be sought from parents and others as appropriate. Although confidentiality is important in adolescent health care, for adolescents at risk to themselves or others, safety takes precedence over confidentiality; the adolescent should have this explained by the pediatrician so that he or she understands that at the onset. Pediatricians need to inform appropriate people, such as parent(s) and other providers, when they believe an adolescent is at risk for suicide and to share with the adolescent that there is a need to break confidentiality because of the risk of harm to the adolescent. As much as is possible, the sequence of events that preceded the threat should be determined, current problems and conflicts should be identified, and the degree of suicidal intent should be assessed. In addition, pediatricians should assess individual coping resources, accessible support systems, and attitudes of the adolescent and family toward intervention and follow-up.53 Questions should also be asked to elicit known risk factors. Note that it is acceptable and, in some cases, more appropriate for the patient to be referred to a mental health specialist to access the degree of suicide intent and relevant factors such as coping mechanisms and support systems.
Care in interviewing needs to be taken, because abrupt, intrusive questions could result in a reduction of rapport and a lower likelihood of the adolescent sharing mental health concerns. This is especially true during a brief encounter for an unrelated concern. Initial questions should be open-ended and relatively nonthreatening. Examples include “Aside from [already stated non–mental health concern], how have you been doing?” “I know that a lot of people your age have a lot going on. What kinds of things have been on your mind or stressing you lately?” “How have things been going with [school, friends, parents, sports]?” When possible, more detailed questions should then follow, particularly during routine care visits or when a mental health concern is stated or suspected.
Suicidal thoughts or comments should never be dismissed as unimportant. Statements such as, “You’ve come really close to killing yourself,” may, if true, acknowledge the deep despair of the youth and communicate to the adolescent that the interviewer understands how serious he or she has felt about dying. Such disclosures should be met with reassurance that the patient’s pleas for assistance have been heard and that help will be sought.
Serious mood disorders, such as major depressive disorder or bipolar disorder, may present in adolescents in several ways.54 Some adolescents may come to the office with complaints similar to those of depressed adults, having symptoms, such as sad or down feelings most of the time, crying spells, guilty or worthless feelings, markedly diminished interest or pleasure in most activities, significant weight loss or weight gain or increase or decrease in appetite, insomnia or hypersomnia, fatigue or loss of energy, diminished ability to think or concentrate, and thoughts of death or suicide. The pediatrician should also look for adolescent behaviors that are characteristic of symptoms (Table 1).54 Some adolescents may present with irritability rather than depressed mood as the main manifestation. Other adolescents present for an acute care visit with somatic symptoms, such as abdominal pain, chest pain, headache, lethargy, weight loss, dizziness and syncope, or other nonspecific symptoms55 Others present with behavioral problems, such as truancy, deterioration in academic performance, running away from home, defiance of authorities, self-destructive behavior, vandalism, substance use disorder, sexual acting out, and delinquency.56 Typically, symptoms of depression, mania, or a mixed state (depression and mania coexisting or rapidly alternating) can be elicited with careful questioning but may not be immediately obvious. The American Academy of Pediatrics (AAP) provides more information about adolescent bipolar disorder and the role of the pediatrician in screening, diagnosis, and management.57
View inline View popup TABLE 1 Depressive Symptoms and Examples in Adolescents54
At well-adolescent visits, adolescents who show any evidence of psychosocial or adaptive difficulties should be assessed regularly for mental health concerns and also asked about suicidal ideation, physical and sexual abuse, bullying, substance use, and sexual orientation. Depression screening is now recommended for all adolescents between the ages of 11 and 21 years of age in the third edition of Bright Futures.58 The AAP developed a resource, “Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit,” which is available for a fee.59 The AAP also developed a Web site that provides resources and materials free of charge.60 Identification and screening at acute care visits, when possible, is desirable, because mental health problems may manifest more strongly at these times.
Management of the Suicidal Adolescent
Management depends on the degree of acute risk. Unfortunately, no one can accurately predict suicide, so even experts can only determine who is at higher risk. Intent is a key issue in the determination of risk. Examples of adolescents at high risk include: those with a plan or recent suicide attempt with a high probability of lethality; stated current intent to kill themselves; recent suicidal ideation or behavior accompanied by current agitation or severe hopelessness; and impulsivity and profoundly dysphoric mood associated with bipolar disorder, major depression, psychosis, or a substance use disorder. An absence of factors that indicate high risk, especially in the presence of a desire to receive help and a supportive family, suggests a lower risk but not necessarily a low risk. Low risk is difficult to determine. For example, an adolescent who has taken 8 ibuprofen tablets may have thought that it was a lethal dose and may do something more lethal the next time. Alternatively, the adolescent may have known that 8 ibuprofen tablets is not lethal and took the pills as a rehearsal for a lethal attempt. In the presence of a recent suicide attempt, the lack of current suicidal ideation may also be misleading if none of the factors that led to the attempt have changed or the reasons for the attempt are not understood. The benefit of the doubt is generally on safety in the management of the suicidal adolescent.
The term “suicide gesture” should not be used, because it implies a low risk of suicide that may not be warranted. “Suicide attempt” is a more appropriate term for any deliberately self-harmful behavior or action that could reasonably be expected to produce self-harm and is accompanied by some degree of intent or desire for death as well as thinking by the patient at the time of the behavior that the behavior had even a small possibility of resulting in death. In a less-than-forthcoming patient, intent may be inferred by the lethality of the behavior, such as ingesting a large number of pills, or by an affirmative answer to a question such as, “At the time of your action, would you have thought it okay if you had died?”
Adolescents who initially may seem at low risk, joke about suicide, or seek treatment of repeated somatic complaints may be asking for help the only way they can. Their concerns should be assessed thoroughly. Adolescents who are judged to be at low risk of suicide should still receive close follow-up, referral for a timely mental health evaluation, or both if they should have any significant degree of dysfunction or distress from emotional or behavioral symptoms.
For adolescents who seem to be at moderate or high risk of suicide or have attempted suicide, arrangements for immediate mental health professional evaluation should be made during the office visit. Options for immediate evaluation include hospitalization, transfer to an emergency department, or a same-day appointment with a mental health professional.
Intervention should be tailored to the adolescent’s needs. Adolescents with a responsive and supportive family, little likelihood of acting on suicidal impulses (eg, thought of dying with no intent or plan for suicide), and someone who can take action if there is mood or behavior deterioration may require only outpatient treatment.17 In contrast, adolescents who have made previous attempts, exhibit a high degree of intent to commit suicide, show evidence of serious depression or other psychiatric illness, engage in substance use or have an active substance use disorder, have low impulse control, or have families who are unwilling to commit to counseling are at high risk and may require psychiatric hospitalization.
Although no controlled studies have been conducted to prove that admitting adolescents at high risk to a psychiatric unit saves lives,17 likely the safest course of action is hospitalization, thereby placing the adolescent in a safe and protected environment. An inpatient stay will allow time for a complete medical and psychiatric evaluation with initiation of therapy in a controlled setting as well as arrangement of appropriate mental health follow-up care.
Pediatricians can enhance continuity of care and adherence to treatment recommendations by maintaining contact with suicidal adolescents even after referrals are made. Collaborative care is encouraged, because it has been shown to result in greater reduction of depressive symptoms in a primary care setting.61 Recommendations should include that all firearms are removed from the home, because adolescents may still find access to locked guns stored in their home, and that medications, both prescription and over-the-counter, are locked up. Vigorous treatment of the underlying psychiatric disorder is important in decreasing short-term and long-term risk of suicide. Although asking the adolescent to agree to a contract against suicide has not been proven effective in preventing suicidal behavior,17 the technique may still be helpful in assessing risk in that refusal to agree either not to harm oneself or to tell a specified person about intent to harm oneself is ominous. In addition, safety planning may help guide a patient and his or her family in what steps to take in moments of distress to ensure patient safety.
Working with a suicidal adolescent can be very difficult for those who are providing treatment. Suicide risk can only be reduced, not eliminated, and risk factors provide no more than guidance. Much of the information regarding risk factors is subjective and must be elicited from the adolescent, who may have his or her own agenda. Just as importantly, pediatricians need to be aware of their personal reactions to prevent interference in evaluation and treatment and overreaction or underreaction.
Antidepressant Medications and Suicide
The Food and Drug Administration (FDA) directive of October 2004 and heavy media coverage changed perceptions of antidepressant medications, and not favorably. The FDA directed pharmaceutical companies to label all antidepressant medications distributed in the United States with a “black-box warning” to alert health care providers to an increased risk of suicidality (suicidal thinking and behavior) in children and adolescents being treated with these agents. The FDA did not prohibit the use of these medications in youth but called on clinicians to balance increased risk of suicidality with clinical need and to monitor closely “for clinical worsening, suicidality, or unusual changes in behavior.”62 The warning particularly stressed the need for close monitoring during the first few months of treatment and after dose changes.
The warning by the FDA was prompted by a finding that in 24 clinical trials that involved more than 4400 child and adolescent patients and 9 different antidepressant medications, spontaneously reported suicidal ideation or behavior was present in 4% of subjects who were receiving medication and in just half that (2%) of subjects who were receiving a placebo. No completed suicides occurred during any of the studies. In the same studies, however, only a slight reduction of suicidality was found when subjects were asked directly at each visit about suicidal ideation and behavior, which was considered a contradictory finding. The method of asking directly does not rely on spontaneous reports and is considered to be more reliable than the spontaneous events report method used by the FDA to support the black-box warning.63 In addition, a reanalysis of the data including 7 additional studies and using a more conservative model showed only a trivial 0.7% increase in the risk of suicidal ideation or behavior in those receiving antidepressant medications.64
Subsequent studies have addressed the validity of the black-box warning and suggest that, for appropriate youth, the risk of not prescribing antidepressant medication is significantly higher than the risk of prescribing. Gibbons et al65 conducted a reanalysis of all sponsor-conducted randomized controlled trials of fluoxetine and venlafaxine, which included 12 adult, 4 geriatric, and 4 youth studies of fluoxetine and 21 adult trials of venlafaxine. Adult and geriatric patients treated with both medications showed decreased suicidal thoughts and behaviors, an effect mediated by the decreases of depressive symptoms with treatment. No significant treatment effect on suicidal thoughts and behaviors was found with youth treated with fluoxetine, although depressive symptoms in fluoxetine-treated patients decreased more quickly than symptoms in patients receiving placebo. There was no overall greater rate of suicidal thoughts and behaviors in the treatment groups versus the placebo groups. The finding of increased suicidal ideation and behavior in the treatment groups that formed the basis of the FDA black-box warning on antidepressant use in children and adolescents was not found in this reanalysis of the fluoxetine studies. More importantly, these reanalyses demonstrated the efficacy of fluoxetine in the treatment of depression in youth. Patients in all age and drug groups had significantly greater improvement relative to patients in placebo groups, with youth having the largest differential rate of remission over 6 weeks—46.6% of patients receiving fluoxetine versus 16.5% of those receiving placebo.66
Suicidal ideation and behavior are common, and suicides are vastly less common, which makes it difficult to relate a change in one to a change in the other.63 Examining all available observational studies, Dudley et al67 found that recent exposure to selective serotonin reuptake inhibitor medications was rare (1.6%) for young people who died by suicide, supporting the conclusion that most of the suicide victims did not have the potential benefit of antidepressants at the time of their deaths. The study suggests that whether antidepressants increase suicidal thoughts or behaviors in adolescents, few actual suicides are related to current use of the medications.
Several studies showed a negative correlation between antidepressant prescribing and completed adolescent suicide. The 28% decrease in completed suicides in the 10- to 19-year-old age group from 1990 to 2000 may have been at least partly a result of the increase in youth antidepressant prescribing over the same time period. Analyzing US data by examining prescribing and suicide in each of 588 2-digit zip code zones showed a significant (P < .001) 0.23-per-100?000 annual decrease in adolescent suicide with every 1% increase in antidepressant prescribing.68 A second study analyzed county-level data during the period from1996 to1998 and found that higher selective serotonin reuptake inhibitor prescription rates significantly correlated with lower suicide rates among children and adolescents 5 to 14 years of age.69 Using a decision analysis model, Cougnard et al70 calculated that antidepressant treatment of children and adolescents would prevent 31.9% of suicides of depressed subjects, similar to findings in the adult (32.2%) and geriatric (32.3%) age groups.
The FDA advisory panel was aware that the black-box warning could have the unintended effect of limiting access to necessary and effective treatment63 and reported that prescriptions of antidepressants for children and adolescents decreased by 19% in the third quarter of 2004 and 16% in the fourth quarter compared with the year before.71 Claims data for Tennessee Medicaid showed a 33% reduction of new users of antidepressants 21 months after the black-box warning.72 US national managed care data showed reduced diagnosing of pediatric depression and a 58% reduction of antidepressant prescribing compared with what was predicted by the preadvisory trend.73 Decreased antidepressant prescribing was also seen with chart review.74 Most of the reductions in diagnosing and prescribing were related to substantial reductions by primary care providers, with these reductions persisting through 2007.75 Studies differed as to whether there was76 or was not73,74 a compensatory increase of psychotherapy treatment during the same time period.
Concern was expressed that the reduction of antidepressant prescribing may be related to the increase in US youth suicides from 2003 to 2004 after a decade of steady declines.77 Gibbons et al78 found that antidepressant prescribing for youth decreased by 22% in both the United States and the Netherlands the year after the black-box warnings in both countries and a reduction in prescribing was observed across all ages. From 2003 to 2004, the youth suicide rate in the United States increased by 14%; from 2003 to 2005, the youth suicide rate in the Netherlands increased by 49%. Across age groups, data showed a significant inverse correlation between prescribing and change in suicide rate. The authors suggested that the warnings could have had the unintended effect of increasing the rate of youth suicide.78 Examining health insurance claims data for 1.1 million adolescents, 1.4 million young adults, and 5 million adults, the rate of psychotropic medication poisonings, a validate proxy for suicide attempts, was found to have increased significantly in adolescents (21.7%) and young adults (33.7%), but not in adults (5.2%), in the second year after the FDA black-box warning, corresponding with decreases in antidepressant prescribing (adolescents, –31.0%; young adults, –24.3%; adults, –14.5%).79
Regardless of whether the use of antidepressant medications changes the risk of suicide, depression is an important suicide risk factor, and careful monitoring of adolescents’ mental health and behavioral status is critically important, particularly when initiating or changing treatment. Furthermore, despite the aforementioned new information, the FDA has not removed or changed the black-box warning; the warning should be discussed with parents or guardians and appropriately documented. The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry recommended a monitoring approach63 that enlists the parents or guardians in the responsibility for monitoring and individualizing the frequency and nature of monitoring to the needs of the patient and the family. This approach potentially increases the effectiveness of monitoring and provides greater flexibility, thus reducing a barrier to prescribing. Warning signs for family members to contact the prescribing physician are listed in Table 2.63
View inline View popup TABLE 2 Treatment With Antidepressant Medication: Warning Signs for Family Members To Contact the Physician
Summary
Adolescent suicide is an important public health problem.
Knowledge of risk factors, particularly mood disorders, psychosis, and bullying victimization and perpetration, may assist in the identification of adolescents who are at higher risk.
It is important to know and use appropriate techniques for interviewing potentially suicidal adolescents.
Mood disorders predisposing adolescents to suicide have a variety of presentations.
Management options depend on the degree of suicide risk.
Treatment with antidepressant medication is important when indicated.
Advice for Pediatricians
Ask questions about mood disorders, use of drugs and alcohol, suicidal thoughts, bullying, sexual orientation, and other risk factors associated with suicide in routine history taking throughout adolescence. Know the risk factors (eg, signs and symptoms of depression) associated with adolescent suicide and screen routinely for depression. Consider using a depression screening instrument, such as the PHQ-9 or PHQ-2, at health maintenance visits from 11 to 21 years of age and as needed at acute care visits.46
Educate yourself and your patients about the benefits and risks of antidepressant medications. Patients with depression should be carefully monitored, with appropriately frequent appointments and education of the family regarding warning signs for when to call you, especially after the initiation of antidepressant medication treatment and with dose changes. Recent studies suggest that, for appropriate youth, the benefits of antidepressant medications outweigh the risks.
Recognize the medical and psychiatric needs of the suicidal adolescent and work closely with families and health care professionals involved in the management and follow-up of youth who are at risk or have attempted suicide. Develop working relationships with emergency departments and colleagues in child and adolescent psychiatry, clinical psychology, and other mental health professions to optimally evaluate and manage the care of adolescents who are at risk for suicide. Because mental and physical health services are often provided through different systems of care, extra effort is necessary to ensure good communication, continuity, and follow-up through the medical home.
Because resources for adolescents and physicians vary by community, become familiar with local, state, and national resources that are concerned with treatment of psychopathology and suicide prevention in youth, including local hospitals with psychiatric units, mental health agencies, family and children’s services, crisis hotlines, and crisis intervention centers. Compile the names and contact information of local mental health resources and providers and make that information available to patients/families when needed.
Because there is great variation among general pediatricians in training and comfort with assessing and treating patients with mental health problems, as well as in access to appropriate mental health resources, consider additional training and ongoing education in diagnosing and managing adolescent mood disorders, especially if practicing in an underserved area. Pediatricians with fewer resources still have an important role in screening, comanaging with mental health professionals, and referring patients when necessary (as recommended in Bright Futures, Fourth Edition).
During routine evaluations and where consistent with state law, ask whether firearms are kept in the home and discuss with parents the increased risk of adolescent suicide with the presence of firearms. Specifically for adolescents at risk for suicide, advise parents to remove guns and ammunition from the house and secure supplies of prescription and over-the-counter medications.
Lead Author
Benjamin Shain, MD, PhD
Committee on Adolescence, 2014-2023
Paula K. Braverman, MD, Chairperson
William P. Adelman, MD
Elizabeth M. Alderman, MD, FSHAM
Cora C. Breuner, MD, MPH
David A. Levine, MD
Arik V. Marcell, MD, MPH
Rebecca F. O’Brien, MD
Liaisons
Laurie L. Hornberger, MD, MPH – Section on Adolescent Health
Margo Lane, MD, FRCPC – Canadian Pediatric Society
Julie Strickland, MD – American College of Obstetricians and Gynecologists
Benjamin Shain, MD, PhD – American Academy of Child and Adolescent Psychiatry
Staff
Karen Smith
James Baumberger, MPP
Footnotes
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
FINANCIAL DISCLOSURE: The author has indicated he does not have a financial relationship relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
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