Adolescent Suicide: Nursing Interventions and Risk Factors

Introduction

Despite the idea that adolescents are in the prime of life, adolescence is one of the most fraught periods of human 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 the 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 seven; one in every thirteen makes a so-called unsuccessful attempt (p. 1). Even more troubling is the fact that rates are apparently increasing: adolescent suicides have risen by 25% over the past 15 years (Bloch, 2016).

The reasons for this increase are unclear and continue to be debated. Regardless, the act of an adolescent taking his or her own life must remain a public health priority. Furthermore, the degree to which this is a gendered 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 Illness

According to a BMJ study of 2,399 Norwegian adolescents published by Strandheim et al. (2014), a history of anxiety and depression had 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 adolescents with a history of anxiety and depressive symptoms, as well as attention and conduct problems, were all twice as likely to experience some type of suicidal behavior. This suggested that a broader view of mental illnesses contributing to suicidal risk should be taken when evaluating adolescents—extending beyond illnesses presumed to be associated with suicidal and depressive behaviors by their very nature (given that 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, now classified as a medical disorder), smoking (a form of substance abuse), and suicidality. One surprising finding was that binge drinking was not associated with a higher risk of suicidal behavior; the authors noted, however, that because the study was conducted exclusively on Norwegian teenagers—who often binge drink socially—the social aspects of the drinking may have had a protective effect. Social isolation has been associated with a greater risk of suicidal behaviors. All of these findings point to the need for greater awareness and vigilance regarding suicidal behavior in any adolescent with other mental health issues, including but not limited to anxiety and depression.

Bullying and Social Media Use

Heavy 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"—the sense that other individuals are leading far more exciting, fulfilling lives based on their carefully curated online personas. Social media use overall, not just Facebook and Instagram, 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 correlation or causation is unclear, as adolescents who are socially withdrawn from their peer group may be more likely to seek refuge in video games and online environments.

The AAP study found that other Internet-related factors may also contribute to the association. The Internet allows depressed teens to search forums related to suicide, including methods of self-harm. These may include pro-suicide websites, online suicide pacts, or materials originally geared toward individuals with serious illnesses that nonetheless provide adolescents with potential tips and normalize suicidal behavior. The Internet can also intensify the copycat effect of suicidality, given that teens who learn about suicide online may be more apt to replicate the behavior (Shain, 2016).

The Internet can additionally provide a forum for bullying. Online behavior among teens is far less regulated than interactions during the school day. Teens can engage in social aggression directed at peers in a relatively unrestricted manner, often without oversight from adults who may poorly understand the degree to which teens' social lives revolve around digital communication. Certain teens may be more likely to be targeted by bullying—particularly LGBT teens, who are already at a higher risk of suicidal behavior.

Antidepressant Use

Use of antidepressants is positively associated with elevated risk in adolescents. Once again, the question of correlation versus causation arises: teens who are prescribed antidepressants may be presumed to be suffering from depression at a higher rate than the general adolescent population. On the other hand, the increased risk associated with certain antidepressants has been strong and demonstrable enough for the FDA to issue a specific black-box warning on this subject (Shain, 2016). It should be noted that the warning—which has existed since 2004 and the rise of prescribing the class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs)—does not prohibit the prescription of these medications to adolescents, but highlights the need for greater monitoring of teens who are taking them (Shain, 2016).

Problems Caused by Adolescent Suicide in Society

First and foremost, adolescent suicide is a clear tragedy for the individual. Greater adolescent impulsivity can cause a teen to take actions that are irreversible. Secondly, suicide devastates those around the teen—including parents and friends—who may experience profound psychological fallout, including guilt. Thirdly, on a societal level, there is the risk of copycat suicides and suicide clustering, both within communities and, with the availability of online media, across wider audiences. Teens can become more aware of suicide through publicized cases and may, despite media condemnation, come to view it as glamorous or as a solution to their own problems.

Role of the Psychiatric and Community Health Nurse

Primary Interventions

Nurses can seek to foster better mental health in patients before suicidal ideation begins. At the level of primary care, the nurse serves as an advocate for high-risk populations such as young women, LGBT teens, and teens with other mental health issues. Nurses must be aware of community programs that may support self-esteem. These will not look the same for every teen: for girls experiencing self-confidence issues, sports programs and academic enrichment may be beneficial; for LGBT teens, supportive groups for themselves and their families may be helpful. Nurses can also work with existing community institutions such as schools and parents to minimize harmful 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 families with supportive services and guide them toward the best evidence-based approaches for treatment. Cognitive-behavioral therapy (CBT) has been found to be particularly useful for teens suffering from depression, OCD, substance abuse, self-harm, and eating disorders, as it focuses on identifying irrational thinking patterns and replacing them with rational ones. According to Driessen and Hollon (2010), CBT has been found to be equally or more effective than standard antidepressant treatment for moderate depression—a finding that is particularly relevant given concerns about adolescents taking antidepressants.

Regardless, nurses should be aware of the variety of treatment options available to teens and should discuss the pros and cons of different approaches with families. They may also need to address community-based interventions within the school for teens whose psychological issues are being exacerbated by bullying, prejudice, or other external factors.

Tertiary Interventions

For teens who have already attempted suicide, many of the secondary interventions remain relevant; however, inpatient settings may be necessary for severely depressed teens at imminent risk of self-harm. Medication adjustments may also need to be discussed. Nurses should review guidelines regarding self-harm and confidentiality, particularly if the teen expresses concern about what can and cannot be shared by the provider outside of the therapeutic relationship.

Community Resources

The Suicide Prevention Lifeline provides immediate 24/7 assistance to anyone contemplating suicide. Although this is only a first step in seeking help, it is important to remind adolescents that assistance is always available, even if they wish to remain anonymous or feel uncomfortable seeking help face-to-face. Organizations such as The Trevor Project provide targeted support to high-risk populations—particularly LGBT teens—who may face additional stressors such as bullying at school or fear of rejection by their parents.

References

Bloch, M. (2016). Reducing adolescent suicide. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 57(7), 773–774. http://doi.org/10.1111/jcpp.12585

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. 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 Open. Retrieved from https://bmjopen.bmj.com/content/4/8/e005867

Suicide Prevention Lifeline. (2018). Retrieved from https://suicidepreventionlifeline.org/

The Trevor Project. (2018). Retrieved from https://www.thetrevorproject.org/