Adolescent Suicide

Adolescent Suicide: An Overview of Nursing Interventions
Despite the idea that adolescents are in the prime of life, adolescence is one of the most fraught periods of development, at least within the context of contemporary Western culture. Adolescent suicide was an acknowledged mental health risk even before reliable statistics were kept on this issue, and the numbers continue to be sobering. According to Bloch (2016), suicide is the second most common cause of death for adolescents ages 10–19 and even more adolescents contemplate suicide, an estimated one in every 7; one in every 13 make a so-called unsuccessful attempt (p.1). Even more sobering is the fact that rates are apparently increasing; adolescent suicides have increased by 25% in the past 15 years (Bloch, 2016). The reasons for this are unclear and continue to be debated. Regardless, the act of an adolescent forcibly taking his or her own life through extraordinary means must remain a public health priority. Furthermore, the degree to which it is a feminist or female issue must be considered, given that the spike in suicides among females has been particularly dramatic: a 75% increase over the past 15 years (Bloch, 2016, p.1).
Factors Contributing to Adolescent Suicide
History of Mental Illnesses
According to a British Medical Journal study of 2399 Norwegian adolescents published by Strandheim (et al., 2014), a history of anxiety and depression had been previously been strongly correlated with suicide, suicide attempts, and suicidal ideation. Conduct disorder, attention deficit hyperactivity disorder (ADHD) obsessive compulsive disorder (OCD), and other psychological issues were also associated with suicide, albeit to a lesser degree. The study itself found that the adolescents it surveyed with a history of anxiety and depressive symptoms, attention and conduct problems, were all twice as likely to experience some type of suicidal behaviors. This suggested that an even broader view of mental illnesses contributing to depression should be undertaken when evaluating adolescents for suicidal risk factors. Not only illnesses presumed to be associated with suicidal and depressive behaviors by their very nature (as suicidal thinking is often considered a symptom of depression in and of itself). Initially non-suicidal self-harm has also, in other studies, been associated with increased suicidal behavior later on (Bloch, 2016).
The study also found a weaker but still present association between obesity (compulsive overeating, which is now classified as a medical disorder), smoking (a form of substance abuse), and suicidality. The one surprising finding of the Strandheim (et al., 2014) study was that binge drinking was not associated with a higher risk of suicidal behavior, but noted that given that the study was exclusively on Norwegian teens, who often binge drink socially, the social aspects of the drinking may have had a protective effect. Social isolation has been associated with greater risk of suicidal behaviors. All of these findings point to the need for greater awareness and vigilance of suicidal behavior in any adolescent with other mental health issues, including but not exclusively anxiety and depression.
Bullying and Social Media Use
Heavy use of social media use has also been strongly associated with depressive symptoms and corresponding suicidality, according to the American Academy of Pediatrics. (AAP) This has often been called the Facebook effect, or the sense that individuals are leading much cooler, better existences based upon their carefully curated online lives. But social media use overall, not just Facebook, Instagram, and sites that allow for public sharing of personal information, has been associated with greater suicidality (both ideation and attempts) as well as higher levels of depression: self-reported use of video games and simply being online more than five hours a day increases an adolescent’s risk (Shain, 2016). Whether this is due to a correlation or causative factors is unclear, as adolescents with social problems and who are socially withdrawn from their peer group may be more apt to seek refuge in video games and online.
The AAP study found other Internet-related factors may contribute to the association. The Internet allows depressive teens to search forums related to suicide, including ways to commit suicide. These may include pro-suicide websites and online suicide pacts or materials geared to individuals with serious illnesses, which still provide adolescents with potential tips to commit suicide and normalize the behavior. The Internet can also intensify the copycat effect of suicidality for adolescents, given that teens who learn about suicide online may be more apt to replicate the behavior (Shain, 2016).
The Internet can also provide a forum for bullying in and of itself. Online behavior of teens is unregulated in a manner that interactions during the school day are not. Teens can engage in social aggression directed at their peers in a fairly free manner, often without any oversight from adults, and adults may poorly understand the degree to which teen’s social lives revolve around the computer. Certain teens may be more apt to find themselves the target of bullying, particularly LGBT teens, who are at a higher risk of suicidal behavior already.
Antidepressant Use
Use of antidepressants is positively associated with a higher risk to adolescents. Once again, in regards to this particular factor, the question of correlation versus causation arises. Teens who are on antidepressants may be presumed to be suffering at depression at a higher rate than the general adolescent population. On the other hand, the increased risk of taking certain kinds of antidepressants for teens has been strong and demonstrable enough for the FDA to issue a specific black box warning regarding the subject (Shain, 2016). It should be noted that the warning, which has existed since 2004 and the specific rise of prescribing the new class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), does not prohibit the prescription of the flagged antidepressants for adolescents but highlights the need for greater monitoring of teens who are taking these medications (Shain, 2016).
Problems Caused By Adolescent Suicide in Society
First and foremost, adolescent suicide is a clear problem for the individual. Greater adolescent impulsivity can cause the teen to take actions that are irreversible. Secondly, this is a problem for individuals around the teen, including parents and friends, who may experience psychological fallout themselves, out of guilt. Thirdly, on a societal issue, as noted previously, there is the risk of copycat suicides and suicide clustering, both within communities and now, with the availability of online media, via publicity teens are able to become more aware of suicide, which they may view as glamorous, even if the media purports to condemn it.
Role of the Psychiatric/Community Health Nurse
Primary Interventions
Nurses can seek to foster better mental health in patients before suicidal ideation begins. On a level of primary care, the nurse has a role of being an advocate for high-risk populations such as young women, LGBT teens, and teens with other mental health issues. Nurses must be aware of programs in the community which may support self-esteem. This will not be the same for every teen—for example, for girls experiencing self-confidence issues, sports and additional academic programs may be of assistance. For LGBT teens, supportive groups for themselves and their families may be helpful. The nurse can also work with existing community institutions such as schools and parents to minimize negative behaviors, such as belittling language in the home or excessive internet use.

Secondary Interventions
For teens already exhibiting depressive and/or suicidal behaviors, nurses can help connect teens and their parents with supportive services. Nurses can help families negotiate the best, evidence-based approaches for treatment, depending on the needs of the teens. Cognitive-behavioral therapies have been found to be particularly useful for teens suffering from depression, OCD, substance abuse, self-harm, and eating disorders in the trained therapist’s identification of irrational thinking patterns and commitment to replacing them with rational ones. According to Driessen & Hollon (2010), cognitive behavioral therapy has been found to be equally or more effective than standard antidepressant treatment for moderate depression. Given concerns about adolescents taking antidepressants, this is particularly relevant.
Regardless, nurses should be aware of the variety of options open to teens and discuss the pros and cons of different treatments with families. They may also need to discuss community-based interventions in the school for teens whose psychological issues are being exacerbated by bullying, prejudice, and other external factors.
Tertiary Interventions
For teens who have attempted suicide, many of the suggested secondary interventions are still relevant, but inpatient settings for severely depressed teens at risk of self-harm may be necessary. Readjusting teens’ medications may need to be discussed. Nurses should bring up guidelines regarding self-harm and confidentiality issues, if this is a concern of the teen regarding therapy (i.e., when confidentiality can be broached if the teen is perceived as being at risk to him or herself).

Community Groups
Resources such as the Suicide Prevention Hotline can provide immediate 24/7 assistance to anyone contemplating committing suicide. Although this is only a first step in seeking assistance, it is important to remind adolescents that help is always available, even if they wish to remain anonymous and feel uncomfortable seeking assistance face-to-face. Groups such as The Trevor Project provide assistance to high-risk population groups such as LGBT teens who may have additional issues exacerbating suicidal ideation, such as bullying at school or fears of rejection from their parents.
Ethical Issues
Teens may also be initially unwilling to seek help because of fears a healthcare provider will tell their parents about their suicidal impulses. Mental health professionals have a duty, often a legal one, to report concerns that a patient is a danger to him or herself (“Mental Health Professionals’ Duty to Warn,” 2018). Providers offering assistance should make patients aware of this fact, so adolescents do not feel betrayed if it is necessary to break the patient’s confidence. In some instances, a pact not to engage in self-harm may be discussed between provider and patient, to give the patient a sense of security about what can and cannot be discussed by the provider outside of treatment.
Gender, Culture, and Other Issues
Psychiatric nurses should be aware that different cultures may have varying levels of acceptance for mental health treatment, and not all may be equally enthusiastic about their adolescent receiving assistance. Additionally, certain cultures may frown upon LGBT teens’ acceptance of themselves, or unmarried female sexual behavior. Nurses do not have to endorse these views—for example, if a teen expresses discomfort coming out to conservative parents, the nurse can support the teen—but should be aware that not all teens have the same cultural context at home of acceptance of the psychiatric treatment they may receive.


References
Bloch, M. (2016). Reducing adolescent suicide. Journal of Child Psychology and Psychiatry,
and Allied Disciplines, 57(7), 773–774. Retrieved from: http://doi.org/10.1111/jcpp.12585https://www.ncbi.nlm.nih.gov/pmc/articles/PMC49758 56/pdf/nihms792469.pdf
Driessen, E., & Hollon, S. D. (2010). Cognitive behavioral therapy for mood disorders: Efficacy,
moderators and mediators. The Psychiatric Clinics of North America, 33(3), 537–555. Retrieved from: http://doi.org/10.1016/j.psc.2010.04.005
Mental health professionals’ duty to warn. (2018). National Conference of State Legislatures
(NCSL). Retrieved from: http://www.ncsl.org/research/health/mental-health- professionals-duty-to- warn.aspx
Shain, B. (2016). Teen suicide: a closer look at three key factors. American Academy of
Pediatrics (AAP). Retrieved from: http://www.aappublications.org/news/2016/06/27/Suicide062716
Strandheim A, Bjerkeset O, Gunnell D, Bjornelv, S., Lingaas T., & Bentzen, N. (2014). Risk
factors for suicidal thoughts in adolescence-a prospective cohort study: the Young- HUNT study. BMJ. Retrieved from: https://bmjopen.bmj.com/content/4/8/e005867
Suicide Prevention Hotline. (2018). Retrieved from: https://suicidepreventionlifeline.org/
The Trevor Project. (2018). Retrieved from:
https://www.thetrevorproject.org/resources/#sm.0000x4oppzfipe05tpv1sbs0nu2x2