Suicide and Suicidal Behavior in Adolescents and Young Adults

David A Brent

Candice Biernesser

Suicide is the third leading cause of death in both adolescents and young adults (AYAs) aged 18 to 25 years.¹ In this chapter, we first offer standard definitions for different types of self-destructive behavior, describe some of the most commonly used models of suicidal risk, provide a framework for the assessment of key domains of suicidal risk and determination of imminent suicidal risk, identify some special populations of AYAs who are vulnerable to suicidal behavior, and provide guidelines for clinical management.

DEFINITIONS

The following set of definitions follow the widely accepted Columbia Classification Algorithm for Suicide Assessment²:

A suicide attempt is a self-inflicted injury with stated or inferred intent to die.
Suicide is a suicide attempt that results in a fatal outcome.
Suicidal ideation is present when the patient has thoughts of his or her own death without actually engaging in suicidal behavior. Ideation can range from “passive ideation,” in which the patient thinks about his or her death, without any plan, to “active” suicidal ideation with an explicit plan and intent to act on suicidal thoughts. Intermediate to ideation and attempt are “aborted” and “interrupted” attempts.
“Aborted attempts” occur when a person begins to make a suicide attempt but stops him or herself before experiencing injury.
“Interrupted attempts” occur when the person is engaging in preparatory behavior of a suicide attempt, and another party intervenes prior to the occurrence of injury.
Nonsuicidal self-injury (NSSI) refers to purposeful, often repetitive or stereotyped self-injury with a motivation other than death, such as relief from emotional pain, self-punishment, or to gain attention.³

EPIDEMIOLOGY

Suicidal Ideation and Behavior

The incidence of suicidal ideation and suicidal behavior increases markedly after puberty and peaks in incidence during adolescence. The lifetime prevalence of suicide attempts in one recent survey of adolescents was 4.1%, with 4.0% having experienced suicidal ideation with a plan, and 12.1% having experienced any suicidal ideation.⁴ The Youth Risk Behavior Survey⁵ found somewhat higher 1-year incidences with 17.0% seriously considering suicide, 13.6% having a suicidal plan, and 8.0% having attempted suicide. The 1-year incidence of the spectrum of suicidal ideation and behavior is higher in females compared to males, Hispanics as opposed to other racial and/or ethnic groups, and younger versus older adolescents.⁵ In the 2014 National College Health Association National College Health Assessment,⁶ 8.1% of students seriously considered suicide (one-fourth under the influence of alcohol) and 1.3% made a suicide attempt.

Suicide

Suicide, that is, a suicide attempt that results in death, is much rarer than nonfatal suicide attempts.

Age: Among US youth aged 10 to 14, 15 to 19, and 20 to 24 years, the suicide rates per 100,000 in 2009 were 1.3, 7.8, and 12.5, respectively.
Gender: Suicide in males is twice as high as the rate in females in those 10 to 14 years old, 4 times as high in 15- to 19-year-olds, and five times higher in 20- to 24-year-olds.⁷
Ethnicity: The suicide rate among Native Americans/Native Alaskans is 2.5 times higher than the rest of the population, and peaks in young adulthood, whereas suicide in most other ethnic groups tends to increase with age.⁷
Method: The most common method for suicide in the US among 10- to 14-year-olds is hanging, but older AYAs most commonly use firearms to kill themselves.

MODELS OF SUICIDAL RISK

Diathesis Stress Models

This model hypothesizes that suicide and suicidal behavior are a result of a vulnerability to suicidal behavior, based on a tendency to act impulsively in the face of intolerable emotional distress. This vulnerability combined with stressors such as low mood, hopelessness, or loss lead to suicidal behaviors.⁸ A variation of this model is the potential imbalance between distress (e.g., such as increased depression) and decreased restraint (e.g., loaded gun or intoxicated state).⁹

Interpersonal Theory of Suicide

This theory posits that suicide behaviors are a result of the convergence of perceived burdens, thwarted belongingness, and acquired capability for suicide.¹⁰ According to this theory, NSSI leads to desensitization to physical pain and injury, which then results in an increased willingness to consider and to engage in suicidal behavior.

ASSESSMENT

Assessment of Suicidal Behavior Risk Factors

The most significant risk factors for suicidal behavior include past and current suicidal ideation and behavior, psychopathology, medical comorbidity, psychological traits, family and environmental factors, and availability of lethal agents.

Past Suicidal Ideation and Behavior

Past suicidal ideation and behavior are both risk factors for future suicide and suicide attempts.

In adolescents, around 29% of those with suicidal ideation will make a suicide attempt within one year, whereas 56% of those with suicidal ideation with a plan will make an attempt during this time frame.⁴
Among those with suicidal ideation, predictors of eventual suicide and suicide attempts are the most severe lifetime occurrence of suicidal ideation, as well as the frequency, intensity, and duration of current ideation.
In those who have actually attempted suicide, the strongest predictors of suicide reattempt are regret about having survived and evidence of high suicidal intent, the latter of which refers to behavior indicative of a wish to die.¹¹ For example, evidence of high suicidal intent includes prior planning, arranging the attempt so as not to be discovered, and expressing or thinking that the goal of the attempt was death. Conversely, AYAs with strong reasons for living are less likely to engage in suicidal behavior, even in the face of strong suicidal risk.¹²

Motivation

AYAs often engage in suicidal behaviors for reasons other than to die, such as to escape psychological pain or painful circumstances, to get attention, to express hostility, or to try to get someone to change their mind about a relationship breakup or a punishment.⁹ Precipitants for the suicidal behavior or ideation are important to ascertain, because part of the assessment for safety is determining if the precipitant is likely to recur. Table 70.1 provides common precipitants to suicidal behavior in children, younger adolescents, and older AYAs.

NSSI is usually motivated by a desire to relieve negative affect or a sense of numbness, but can also be a means to escape a stressful social or academic situation, or to engage in self-punishment.³ Although the characteristics of those with NSSI are different than those who engage in suicide attempts, both behaviors share difficulties in emotion regulation and high levels of negative affect. Consequently, NSSI is a strong eventual predictor for a suicide attempt, perhaps even stronger than a previous suicide attempt.¹³

Psychopathology

Almost any psychiatric disorder can increase the risk for suicidal ideation and behavior.⁵,¹¹ Of all the disorders, depression is the most strongly associated with suicidal ideation. Suicidal behavior seems to occur as a result of a confluence of ideation related to depression or hopelessness; increased distress related to conditions such as panic disorder or posttraumatic stress disorder; and greater disinhibition that can occur with insomnia, alcohol and drug abuse, or behavioral disorders.⁴,¹¹ In AYAs, depression and especially bipolar disorder pose the highest risk for completed and attempted suicide. In later adolescence and young adulthood, eating disorders, psychotic disorders, alcohol and substance abuse, and impulsive aggressive personality traits increase the risk for completed and attempted suicide, especially when comorbid with mood disorders.¹¹

TABLE 70.1 Precipitants for Suicidal Behavior

Most Common Precipitants for Suicidal Behavior by Age-Group
Older AYAs	Conflicts with peers and/or romantic partners
Younger adolescents	Conflicts with parents
Very young children	Child abuse

Medical Comorbidity

The following medical conditions have been associated with an increased risk for suicidality.¹¹,¹⁴,¹⁵,¹⁶:

Symptoms of insomnia
Symptoms of pain
Medical conditions that affect the central nervous system, such as epilepsy and migraine
Conditions that have an inflammatory component, such as asthma, inflammatory bowel disease, or obesity
Traumatic brain injury, particularly in military populations

Psychological Characteristics

The following psychological conditions have been associated with an increased risk for suicidality:

Hopelessness or pessimism about the future predicts treatment nonadherence, dropout, higher suicidal intent, and repetition of suicidal behavior.¹¹
Impulsive aggression or a tendency to engage in hostility or actual aggression in response to frustration or provocation is a strong predictor of suicidal behavior, is a precursor for mood disorder, and may explain some aspects of the familial transmission of suicidal behavior.
Neurocognitive tests show that suicide attempters are more impulsive, less effective at generating alternatives solutions when faced with problems, and less able to engage in delayed gratification.¹¹

Association with Health Risk Behaviors

Suicidal behavior is associated with a range of other health risk behaviors (e.g., having unprotected sex, weapon carrying), in part due to the common denominators of poor impulse control, difficulties with delayed gratification, and impaired ability to consider the longer-term consequences of behavior.¹¹

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