Suicide is the eighth leading cause of death for all persons regardless of age, sex or race; the third leading cause of death for young people aged 15 to 24; and the fourth leading cause of death for persons between the ages of 10 and 14. The rates of youth suicide had been declining since 1994, but the numbers are rising dramatically. Are the good intentions of the FDA to blame?
Each year, there are approximately 12 suicides for every 100,000 adolescents. A recent CDC study reported that 27% of high school students said they had thought seriously about killing themselves during the past year. 8% said they had actually tried to kill themselves.
Although suicide is considered the most preventable cause of death, not all suicides are preventable. It is inevitable that all law enforcement officers will be called to the scene of a completed suicide. Welfare check calls related to a subject's suicide risk are routine. After working as a psychiatric nurse for well over two decades, I have learned there are two types of therapists: those who have lost a client to suicide and those who will. It just feels different when it is a kid.
What to Look For
Nine out of ten adolescents who commit suicide give clues before the suicide attempt. Most teenagers will display one or more of the following risk factors and/or warning signs:
- A mental health disorder such as depression; alcohol or substance abuse; or behavior/conduct disorders (chronic runaways, incarcerations). A combination of any of these increases the risk.
- Communication of thoughts of suicide, death, dying, reunion with the dead
- Expression of sadness, boredom, negativity
- Impulsivity, aggression, frequent rage
- Exposure to someone else's completed or attempted suicide
- Giving away prized possessions; making a will
- A recent severe stressor (pregnancy, sexual orientation issues, loss of a relationship, a significant failure)
- Family instability/conflict
- An effort to punish oneself or others --the ultimate revenge
- Undue shame or guilt
- A victim or perpetrator of sexual, physical or emotional abuse
- Accessibility to lethal methods, especially guns
For a teen, suicide is viewed as a way to escape from an uncomfortable situation, emotional pain or unacceptable feelings. Most adolescent suicide attempts are precipitated by interpersonal conflicts; the intent is often not to kill themselves, but to change the behaviors or attitudes of others. It gives a teen a sense of control, when they feel out of control with the rest of their world. Most adolescent suicides occur in the teen's home, after school hours.
Compared to adults, adolescent suicides are often more impulsive, related to anger or irritation, romantically or idealistically driven, and motivated by revenge. Attempts may indeed be manipulative, but only a professional psychiatrist or clinician should make that determination.
Treatment: Therapy, Medication (and the Black Box)
Thoughts of suicide span a lifetime; they are very common. These thoughts may be in relation to a situational crisis, or they may be the hallmark of a mental illness. Anytime anyone verbalizes suicidal intent, they should be referred to a mental health professional. Treatment typically includes psychotropic medications and therapy. When a child or teen has a mild depression, the first line of treatment is therapy: individual, behavioral, cognitive, group and/or family. When the depression is moderate to severe, a psychiatrist may prescribe an antidepressant. Currently only Prozac, a SSRI (selective serotonin reuptake inhibitor) antidepressant, is FDA approved to treat depression in children and adolescents. Additionally, Prozac and three other antidepressants have been FDA approved for pediatric obsession compulsive disorder: Zoloft, Anafranil, and Luvox.
Suicide rates for adolescents declined from 1994-2003, but increased 18% the following year. This increase coincided with the publicity of research (recently determined to be contradictory at best, and essentially flawed at worst) related to an increased suicide risk between antidepressant treatment and suicide risk in children and adolescents. In 2004, these concerns resulted in a FDA black box warning:
Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need..."
An increase of 18% raises the rate to over 14 suicides for every 100,000 adolescents. Antidepressants can save lives; untreated depression will kill. The outcry is being heard throughout the media and the medical community; maybe the FDA will listen. However, the possibility of repealing the FDA black box warning will not be determined until after their review of the national 2005 suicide statistics, which will be released in December 2007. Previously, the FDA has only repealed one black box warning.
What Does This Mean For an LEO?
It is essential that you are aware of the warning signs and risk factors related to teenage suicidality. If the subject is in imminent danger of hurting themselves, they should be transported for further evaluation to a hospital on a 72 hour psychiatric application. If they do not meet this criterion, but present with symptoms of a mental illness, encourage the subject and parents to seek a professional assessment as soon as possible, and to be open to all treatment options, including antidepressant therapy.
Professionally, the youngest completed suicide I have been called to was for a twelve year old boy who had hung himself. Although there were numerous contributing factors to the act, including family conflict and a history of being bullied by peers, the strongest predictor of this suicide was the parents' decision to discontinue psychotropic medication without consulting their son's psychiatrist. This tragedy affected me and my law enforcement partners as well. I suppose this incident served as the impetus for my current soapbox.
I was recently at a sheriff's promotion and awards ceremony in San Diego. Every deputy who was recognized for life-saving at that event had saved the life of a suicidal subject. Here is a quote from the Talmud I hope you will always remember, "He who saves one life saves the world entire." As a law enforcement officer, you can and do make the difference every day.
Tips for Caregivers and Patients Taking SSRIs
- Antidepressants are prescribed for pediatric and adult patients with moderate to severe depression and obsessive compulsive disorder. They are also prescribed to treat adults with a severe anxiety disorder, panic attacks, chronic pain, eating disorders, and post-traumatic stress disorder.
- Suicide ideation can occur during the course of antidepressant therapy. This is often seen at the onset of treatment, when the medication starts to kick in, usually after a couple of weeks. At this point, the patient may have more energy, focus, and concentration to complete a suicidal act. It is also seen if the patient stops his/her medication abruptly. It is essential to continually observe for suicidal thoughts and/or behaviors in anyone taking antidepressant medications.
- In general, SSRI medications are considered to be an improvement over older antidepressant medications. They have fewer side effects. Additionally, they are less likely to be lethal or harmful if taken in an overdose, an issue for patients with depression already at risk for suicide.
- The most common side effects of SSRIs include headache, dry mouth, tremor, nausea, nervousness, insomnia, and agitation. These effects are usually seen at the beginning of treatment, are transient, and will usually go away. There is a risk of sexual dysfunction related to SSRIs in both genders. Your doctor can give you tips for coping with side effects.
- SSRI medications include Prozac, Zoloft, Celexa, Luvox, Effexor, and Paxil. If there has been no improvement in symptoms, it is time to consult with your provider and try a different antidepressant. Recent studies have demonstrated a 70% failure rate for first time antidepressant patients. If changing to a different SSRI medication is not effective, there are other classes of antidepressants that may be include tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and serotonin/norepinephrine reuptake inhibitors (SNRIs). Remember, depression is a treatable disease.
- Consult with your doctor about your medication, double check with your pharmacist; seek a second opinion if you have concerns. What other medications are you taking? What has your response to previous antidepressants been? Which antidepressants have been effective for you or immediate family members? Get tips on how to cope with side-effects. Don't rely on television ads promoting only one antidepressant; newer is not necessarily better.
- Never stop taking an antidepressant without consulting the doctor for instructions on how to safely discontinue the medication. Antidepressants are not habit-forming, however discontinuing them may result in withdrawal symptoms.
- Know when to call your physician, clarify how to reach him/her. Any significant or unusual change in mood, behavior, or suicide ideation indicates an immediate call. Call 911 if you suspect suicide is imminent.
- Resources are available to help you.
- Adolescent Suicide Hotline: 800-261-4000
- National Suicide Hotlines: 800-SUICIDE and 800-273-TALK
- TTY Suicide Hotline: 800-799-4889