Suicidal Ideation Research in Hospital Settings: A Systematic Review

Predicting Hospitalization Versus Discharge of Suicidal Patients Presenting to a Psychiatric Emergency Service

Suicide is a major public health concern accounting for 800 000 deaths globally each year. Although there have been many advances in understanding suicide risk in recent decades, our ability to predict suicide is no better now than it was 50 years ago. There are many potential explanations for this lack of progress, but the absence, until recently, of comprehensive theoretical models that predict the emergence of suicidal ideation distinct from the transition between suicidal ideation and suicide attempts/suicide is key to this lack of progress. The current article presents the integrated motivational–volitional (IMV) model of suicidal behaviour, one such theoretical model. We propose that defeat and entrapment drive the emergence of suicidal ideation and that a group of factors, entitled volitional moderators (VMs), govern the transition from suicidal ideation to suicidal behaviour. According to the IMV model, VMs include access to the means of suicide, exposure to suicidal behaviour, capability for suicide (fearlessness about death and increased physical pain tolerance), planning, impulsivity, mental imagery and past suicidal behaviour. In this article, we describe the theoretical origins of the IMV model, the key premises underpinning the model, empirical tests of the model and future research directions.

A Suicide-Specific Diagnosis – The Case Against

Help Seeking and Perceived Need for Mental Health Care Among Individuals in Canada With Suicidal Behaviors

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessLong-Term Study Backs Link Between Smoking, SuicidalityJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:15 Apr 2005https://doi.org/10.1176/pn.40.8.00400052While Americans worry about whether cigarette smoking will cause lung cancer, perhaps they should also pay attention to a lesser-known risk factor for the habit—suicide. Epidemiological studies going back at least a quarter century have linked cigarette smoking with suicide. And now another large epidemiological study does as well.This latest investigation was headed by Naomi Breslau, Ph.D., a professor of epidemiology at Michigan State University. Results appeared in the March Archives of General Psychiatry.In 1988, Breslau and her colleagues selected some 1,000 young adults to participate in their study. All were members of a health maintenance organization in the Detroit area. All were interviewed at baseline and at three, five, and 10 years after the study started. During each interview, their psychiatric health, smoking habits, and occurrence of suicidal thoughts and of suicidal attempts since the last interview were ascertained.As it turned out, subjects reported only 19 suicide attempts during the 10-year study period. Since 19 suicide attempts were not enough for a meaningful statistical analysis, Breslau and her team decided to lump suicidal attempts and suicidal thoughts together. Combining these gave 17 suicide attempts with the reporting of suicidal thoughts; two suicide attempts without the reporting of suicidal thoughts; and 130 suicidal thoughts without suicide attempts, for a total 132 suicidal thoughts and/or attempts.Breslau and her colleagues then attempted to see whether smoking at baseline, at the three-year assessment, and at the five-year assessment could be statistically linked with the combined number of suicidal thoughts or attempts during the subsequent study periods.The answer was yes. Compared with subjects who had never smoked, current smokers (those who had smoked during the past 12 months) were at a statistically significant increased risk of suicidal thoughts or attempts. In contrast, past daily smokers were not at increased risk for subsequent occurrence of suicidal thoughts or attempts.Moreover, this link between current cigarette smoking and suicidal thoughts or attempts held even when potentially confounding factors—prior suicidal thoughts or attempts, current or past major depression, and current or past substance abuse—were taken into consideration.And even though the study results did not find current cigarette smoking to be as grave a risk factor for suicidal thoughts or attempts as prior suicidal thoughts or attempts, or current or past major depression, they do suggest some practical implications.“Clinical psychiatrists should always be concerned and inquire about suicidality, self-destructive thoughts, et cetera,” Glenn Davis, M.D., a professor of psychiatry at Michigan State University and one of the study authors, said in an interview. “But with added knowledge that there is a connection between smoking and risk for suicidal behavior, they should be particularly sensitive to smoking history in their evaluation of patients.”“By highlighting current smoking, [this study further reinforces] the benefits of smoking cessation,” Donald Klein, M.D., a professor of psychiatry at Columbia University, pointed out to Psychiatric News.How current cigarette smoking might trigger suicidal thoughts or attempts is not known. Yet if it does play a causal role, Breslau and her team suspect that it may do so via an intermediary culprit—the enzyme monoamine oxidase (MAO), which is found in the liver and the central nervous system. It is crucial to the functions of the neurotransmitter serotonin. Low levels of MAO have been found in blood cells of current cigarette smokers, but not in those of ex-smokers, and low blood-cell levels of MAO in turn have been linked with violence and suicide.This investigation has several advantages over past ones on the subject. It took major depression, a well-established risk factor for suicide, into consideration, and it was quite sophisticated in design. Klein explained that it “incorporated major methodological advances by using prospective multiwave longitudinal psychiatric diagnoses in estimating whether smoking independently increases suicide-related behaviors.”The study had a weakness, however, which Breslau and her group acknowledged in their report: The researchers did not gather data about subjects' completed suicides, only about their suicidal thoughts and attempts.The study was funded by the National Institute of Mental Health.An abstract of “Smoking and the Risk of Suicidal Behavior” is posted online at<http://archpsyc.ama-assn.org/cgi/content/abstract/62/3/328>.▪ Arch Gen Psychiatry 2005 62 328 ISSUES NewArchived

A Suicide-Specific Diagnosis – The Case For

The association between suicidality and treatment with Selective Serotonin Reuptake Inhibitors in older people with major depression: a systematic review

Variability in terms and definitions to describe suicidal behaviours and ideation may have led researchers to duplicate their efforts in suicidology thereby possibly wasting valuable resources in a field where funding is scarce. Published nomenclatures appear not to reach a global use. This situation pushed some scholars to advocate for the use of a common nomenclature and a common classification to describe suicidal behaviour that would appeal to the majority of users, whatever their background and whichever their country. A first step towards a universal nomenclature could be to assess the variability of use of definitions and terms. The aims of this dissertation are to describe the published background in the field of nomenclatures, definitions and classifications, and provide a historical and cultural context to the use of terms and definitions to describe suicidal behaviours and ideation. The experimental part of this research consists in a worldwide study of definitions and terms for suicidal behaviours, the results of which were used to elaborate a universal English-language nomenclature of suicidal behaviours. A systematic literature review of contemporary English language nomenclatures found them to be logically organized according to outcome and intent. It appeared that the range of the nomenclatures was fundamental in how the nomenclature were logically organized. A systematic review of terms and definitions was performed based on the four most common characteristics of the definition of suicide found in the literature, i.e. outcome, intent, knowledge of the consequences of the act, and agency (self- or other-inflicted). These four characteristics appeared to cover the vast majority of the concepts underpinning existing definitions, enabled an explanation of the variability of published definitions and were considered for use as tool for research. Intent to die in the definition of suicide was quite agreed upon. However, some authors suggested that intent should refer to something other than death. A systematic review of contemporary classifications of suicidal behaviour revealed they were becoming increasingly precise and operational for clinical and research purposes. On the other hand, the development of new classification systems despite lack of international consensus on definitions and terms related to suicidal ideation and behaviour could potentially lead to an increased level of confusion. An examination of historical context revealed that the term ‘suicide’ appeared in Europe in a period of deep moral change during the seventeenth century, when attitudes toward suicide became more tolerant. A review in the Pacific Islands suggested that local traditional terms often referred to a method having close ties with the cultural context. The methodology of the Worldwide Study of Definitions and Terms for Suicidal Behaviors© (WSDTSB) was then described. The study rationale was to overcome the confusing landscape and poor agreement among authors of nomenclatures, definitions, terms, and classifications in the field of suicidology. The study questionnaire was developed on the basis of the four main criteria of the definition of suicidal behaviour: outcome, intent, knowledge (of the consequences of the act), and agency (self- or other-inflicted). Two types of participants were invited in the study. ‘Experts’, each representing a country, were recruited through international organizations. IASP members that were not national representatives comprised the comparison sample. Methodological limitations were that the study was conducted in the English-language only, and ‘experts’ were designated among IASP national representatives and in six cases among other international associations; in some cases, it is possible that these persons did not have more expertise than IASP members. The results of the WSDTSB were then analysed. Levels of agreement to statements enabled comparison between responses of samples (‘experts’ vs. IASP members), and countries’ language and income background groups, occupation and professional background groups. Regarding the definition of suicide, the highest levels of agreement and similarities between samples and groups were found for fatal outcome, non-clear-cut statements regarding intent and knowledge, and self-infliction. Regarding non-fatal suicidal behaviour and ideation, the highest levels of agreement and similarities between samples and groups were found for definitions of ‘suicide attempt’, ‘suicidal ideation’, ‘death wishes’, ‘suicide plan’, and ‘interrupted suicide attempt’. The results of the WSDTSB were discussed and a nomenclature of suicidal behaviours and ideation was proposed as a baseline for further steps towards a universal classification of suicidal behaviours and ideation. Other limitations of this study were a relatively low participation rate and the low representation of low- and middle-income countries, especially those of the African continent. The necessity to go further in the search of a universal nomenclature was discussed. It was suggested that further research should move on with the aim of elaborating a universal classification of suicidal behaviours possibly based on the results of the present study. Suggestions were made regarding further steps to take.

The study aimed to explore the suicidal process, suicidal communication and psychosocial situation of young suicide attempters in a rural community in Hanoi, Vietnam. Semi-structured interviews were conducted, in a community setting, with 19 suicide attempters aged 15-24 who had been consecutively hospitalized in an intensive care unit. In 12 of 19 cases, the first pressing, distinct and constant suicidal thoughts appeared less than one day before the suicide attempt in question. However, distress and mild, fleeting suicidal thoughts had been present up to six months before the suicide attempt in 16 cases. Five respondents had a suicide plan one to three days before attempting suicide. Altogether, 13 engaged in some form of suicidal communication before their attempt. This communication was, however, difficult for outsiders to interpret. Twelve of the respondents were victims of regular physical abuse and 16 had suffered psychological violence for at least one year before attempting suicide. Eighteen of the respondents used pesticides or raticides in their suicide attempts. None sought advice or consultation in the community despite long-standing psychosocial problems. The strategy of reducing the availability of suicide means (e.g., pesticides or raticides) in Asian countries should be complemented with a long-term suicide-preventive strategy that targets school dropouts and domestic violence, and promotes coping abilities and communication about psychological and social problems as well as recognition of signs of distress and suicidal communication.

Ed Shneidman reports on his 1971 analysis of the suicides that had occurred in the Terman Gifted Children Study. Begun in the 1920s at Stanford University, Professor Lewis Terman identified 1,528 high-IQ California students and, over the years, they have been continuously followed. Today, the remaining subjects (about 100) have a mean age of 93. In his uniquely Shneiderian manner, Ed relates how, in 1971, he utilized a psychological autopsy approach to accurately predict the suicides of a small subsample of the 20 suicides that had occurred to date among the 857 male participants. Almost 35 years later, he shares with us his slightly revised view of those factors that he believes play significant predictable roles in the eventuality of suicide. Jeremy Kisch et al. report on analyses from the Spring 2000 National College Health Assessment Survey (NCHA), sponsored by the American College Health Association. This is the largest and most comprehensive survey to date (15,977 college students) that provides a replication of the CDC's 1995 National College Health Risk Behavior Survey (NCHRBS). This study investigates the relationship between suicidal behavior and depressed mood, as well as other risk factors which increase vulnerability to suicidal behavior. Of particular note is that less than 20% of college students reporting suicidal ideation or attempts were receiving treatment (psychotherapy and/or medications). Adolescent suicide continues to be a major focus of much research as evidenced by the number and range of studies published in SLTB over the years. Researchers have appropriately focused on identifying critical risk factors associated with suicidal behaviors. Thompson et al. explored the roles of anxiety, depression, and hopelessness as mediators between known risk factors and suicidal behaviors among 1,287 potential high school dropouts. As a step toward theory development, a model was tested that posited the relationships among these variables and their effects on suicidal behaviors. The results showed direct effects of depression and hopelessness on suicidal behaviors for males, and direct effects of hopelessness, but not depression, for females. For both males and females, anxiety was directly linked to depression and hopelessness; drug involvement had both direct and indirect effects on suicidal behavior. Lack of family support showed indirect influences on suicidal behaviors through anxiety for both males and females as hypothesized. As the authors point out, for mental health professionals, school personnel, and prevention scientists working with at-risk or suicidal youth, the findings make evident the need to address multiple co-occurring problem behaviors such as drug involvement, emotional distress, and suicidal behaviors. Over the years, SLTB has published data emanating from the CDC's Youth Risk Behavior Survey (YRBS), which is conducted biannually. (see SLTB 30: 304–312; 32: 321–323). The four questions that measure suicidal ideation and attempts are ordered along an implicit continuum of development and severity from seriously considering suicide, to planning, to actually attempting suicide, and, finally, to requiring medical attention for a suicide attempt. As presented by Victor Perez, this process assumes a straightforward sequence of suicidal thought and action and is the underpinning of the content and order of the YRBS questions. However, the assumed ordinal properties of the four questions had never been empirically tested. Brener, Krug, and Simon (SLTB 30: 304–312) found discrepancies in the trends of responses to the questions measuring suicidal activity in their analysis of the YRBS from 1991–1997. Specifically, they showed that although the percentage of students who reported having seriously considered or attempted suicide in the past 12 months had declined steadily since 1991, the percentage of students requiring medical attention for an injurious suicide attempt had increased. They concluded that injurious suicide attempts might not be linked to seriously considering or planning a suicide attempt. Perez examines the assumed ordinal relationship in the 1999 Youth Risk Behavior Survey by constructing a trajectory that identifies all possible response patterns among the four questions measuring suicidal activity. Significant differences between means of dependent variables at each level of the normative trajectory supported the hypothesis that frequency of risk behaviors increases monotonically with successive suicidal thought and behavior. Research on the relationship between schizophrenia and suicidal behaviors has languished until recently (see SLTB 30: 34–49; 34: 66–76; 34: 76–86; 34: 311–319). Camilla Haw et al. identify the risk factors for deliberate self-harm (DSH) in schizophrenia. They provide an explanation and reference to their use of the broader (European) term DSH, rather than attempted suicide. Although there are several published review articles on risk factors for suicide and suicidal behavior in schizophrenia, there are few reviews which make any mention of risk factors for DSH, and there is an assumption that the risk factors for DSH and suicide are the same. Haw et al. examined cohort and case-control studies of patients with schizophrenia or related diagnoses that reported DSH as an outcome. Five variables (past or recent suicidal ideation, previous DSH, past depressive episode, drug abuse or dependence, and higher mean number of psychiatric admissions) were associated with an increased risk of DSH, while one (unemployment) was associated with a reduced risk. In a continuing series of studies (see SLTB 27: 153–163), Eric Blaauw et al. focus on the prevention of suicide in jails and prisons. This current study aims to identify combinations of characteristics (demographic, psychiatric, and criminal) that are capable of identifying potential suicide victims. Characteristics of 95 suicide victims in the Dutch prison system were compared with those of a random sample of 247 inmates in ten jails. Combinations of indicators for suicide risk were also tested for their capability of identifying 209 suicides in U.S. jails and 279 prison suicides in England and Wales. A combination of two demographic characteristics (age over 40, homelessness), two criminal characteristics (one prior incarceration, violent offense), and two indicators of psychiatric problems (history of psychiatric care, history of hard drug abuse) proved capable of identifying 82 percent of the suicide victims in the Netherlands at a specificity of .82 in the general inmate population. Less powerful combinations correctly classified 53% of the U.S. suicides and 47% of the U.K. suicides. Blaauw and colleagues conclude that a small set of demographic and criminal characteristics and indicators of psychiatric problems is useful for the identification of suicide risk in jails and prisons. They point out that the characteristics can easily be incorporated in a screening device that can be administered during the intake process for new inmates. Some risk factors for suicidal behavior are similar to those often studied in the field of criminology. The link between suicide and crime is most apparent when there is a homicide followed by suicide. People who kill others rarely kill themselves afterward. When they do, they are more likely to have killed someone with whom they are intimately involved—an intimate partner or a child. A review of the literature on this phenomenon in Australia, Canada, and the United States showed that, in all three countries, the majority of those who commit suicide after a homicide are male partners or ex-partners of female victims. Using data on over 700 intimate femicides, Myrna Dawson examined the role of premeditation in cases of intimate femicide-suicide compared to killings that do not culminate in a suicide. Her results show that premeditation is more likely to occur in cases involving the offenders' suicide, but that evidence of premeditation varies depending on the type of suicidal killer. Michel Préville et al. present the results of a psychological autopsy investigation of 101 adults aged 60 years and older who died by suicide in Quebec in 1998–1999. The study looks at a number of variables from proxy survivor interview data, including health- and mental health-related behaviors, mental health diagnoses, and social and demographic variables. In this study, 42.6% of the suicide cases presented with mental disorders at the time of their death (mainly depression), and nearly 44% of the suicide cases had no current or pre-existing psychiatric condition. Only 27.7% of the cases did not express any idea of death during the 6-month period preceding their suicidal death. Interestingly, 53.5% of the suicide cases consulted a general practitioner or specialist during the 2-week period preceding their death. The authors suggest that family members and friends could play an important role in preventing elderly suicide attempts by encouraging their parents to discuss their suicidal thoughts with their general practitioner. The results show some similar and some disparate results compared to other studies of elderly suicides, indicating the need for research that examines the complex causal nature of the relationship between mental disorders and suicide among the elderly. Adding to his studies of homeless veterans who abuse substances (SLTB 33:430–432), Brent Benda studied 315 male and 310 female homeless military veterans in a V.A. inpatient program designed to treat substance abusers, many of whom also suffer psychiatric disorders. The study examined gender differences in factors associated with the odds of having suicidal thoughts, and of attempting suicide, in comparison to being nonsuicidal. Childhood and current sexual and physical abuses, depression, fearfulness, relationship problems, limited social support, and low self-esteem were more strongly associated with suicidal thoughts and attempts for women than for men veterans. Extent of alcohol and other drug abuse, aggression, resilience, self-efficacy, combat exposure, combat-related PTSD, and work problems were more strongly associated with suicidal thoughts and attempts for men than for women. While anticipating the release of the CDC's final 2002 national suicide death numbers and rates, there have been different explanations offered for the apparent slow, but steady decline in national suicide rates over the last years. In 1996 the rate was 11.52/100,000; 11.23 in 1997; 11.13 in 1998; 10.47 in 1999; 10.43 in 2000, and 10.69 in 2001. By the time you receive this issue, we will know whether the trend is heading downward or beginning to climb back up. Recently, my attention was drawn to an Editorial originally published on July 30, 1904, in the Journal of the American Medical Association, entitled, “The Increase in Suicide.” I have excerpted portions as follows: The increase of suicide has come to be such a marked feature of social statistics in this country that physicians must be made to realize the possibilities there may be of bringing about a decrease in this unfortunate matter by more care and prevision. Suicides are somewhat more than twice as frequent now as they were ten years ago. … Carefully collected statistics show that there was a constant increase from 3,531 suicides in 1891 to 6,600 in 1897, then a drop in 1898 to 5,920, and in 1899 to 5,340. In 1900 there were 6,755 suicides, an increase of over 150 above the figures for 1897, the highest previous number, and there has been a constant increase since, in 1903 the number of suicides being very close to 8,600. During the last thirteen years—that is, since 1891, there have been altogether 77,617 cases of suicide reported in the newspapers of this country. The decrease in the number of suicides during 1898 and 1899 is not surprising, if we remember the conditions that prevailed in the commercial world at that time. After a period of hard times there was the wave of prosperity and a decided reaction in men's feelings that made the future look bright enough for everyone. Curiously enough, the statistics, however, do not show that city life is so much harder on the people than country life. During the last ten years, the suicide rate in fifty cities of this country has about doubled. That is, however, only in proportion to the suicide rate throughout all the rest of the country and does not especially condemn the high pressure of large city life as a disturbing factor of mentality. The most serious thing about the statistics is the fact that, though suicides are more common among men than women in all countries, the difference is gradually growing less, and in recent years, this has been quite marked. (43: 333–334) The 1890 census data from some states was partially destroyed by a fire in 1921; however, the federal records indicate an 1890 U.S. census of 62,116,811. Using this number, the rates are as follows: 5.68/100,000 in 1891, 10.63 in 1897, 9.53 in 1898, and 8.60 in 1899. The official U.S. census in 1900 was 74,607,225. In 1900, there were 6,755 suicides, yielding a rate of 9.05/100,000. In 1903, there was a significant increase in the number of suicides to approximately 8,600. Using the 1900 census, the suicide rate rose to 11.53/100,000. During the 13-year period between 1891–1903 there were 77,617 suicides, or approximately 5,971/year. This yields a roughly estimated rate of 9.61/100,000 for this 13-year period. Taken as a whole for the years surrounding the turn of the 20th century, the rate hovered around 9–10/100,000. One hundred years later, we continue to grapple with similar rates and similar risk factors.

A Global Call for Action to Prioritize Healthcare Worker Suicide Prevention During the COVID-19 Pandemic and Beyond.

In this editorial, we discuss how mobile phone technology has the potential to move the field forward in terms of understanding suicide risk as well as laying foundations for the development of effective treatments/interventions. We have focused on mobile health technology given the rapid growth of mobile health approaches in suicide prevention (De Jaegere & Portzky, 2014; Mishara & Kerkhof, 2013) and psychological research more generally (Myin-Germeys et al., 2009; Nock, Prinstein, & Sterba, 2009; Palmier-Claus et al., 2011) and because mobile phone use is ubiquitous, with 75% of the world having access to a mobile phone (Kay, 2011). (aut. ref.)

After completing this article, readers should be able to: Most youth occasionally experience the blues, feel sad, or become irritable. Nevertheless, it is important to consider the possibility of a depressive disorder when a depressed or irritable mood is more than temporary, occurs in conjunction with other symptoms, or interferes with daily functioning. Major depressive disorder (MDD) is manifested by a depressed or irritable mood or diminished interest or pleasure that lasts for at least 2 weeks. This is accompanied by changes in cognitive and physical functioning. Dysthymic disorder (DD) is a less severe type of depression that involves chronic symptoms and lasts for at least 1 year. These specific types of depressive disorders are the focus of this article.Depressive disorders can be identified in children of all ages, but they become increasingly prevalent during adolescence. In fact, the peak ages of depressive symptom onset in lifespan studies are 15 to 19 years and 25 to 29 years. The sharpest rise in prevalence occurs among girls during adolescence and early adulthood. Approximately 2% of school-age children and 4% to 6% of adolescents struggle with MDD at any one point in time. Lifetime prevalence rates by late adolescence range between 20% and 25%.Prior to puberty, there is about a 1:1 gender ratio for depressive disorders. After puberty, this shifts to a 2:1 ratio of females to males, which continues throughout adulthood. A combination of hormonal and social changes during puberty may explain the differing rates of depression among males and females.Depression has a complex genetic and environmental basis. Adoption, twin, and family studies all point to the impact of genetic factors, which seem to establish a young person's biologic vulnerability for depression. The onset of a depressive episode, however, often is precipitated by difficult life events or stressful experiences such as a parental divorce, school change, or relationship breakup. Other environmental risk factors include maltreatment (sexual abuse, physical abuse, or neglect). The pathways to depression are complex and variable. Some depressive disorders are more biologic; others are more situational.The symptoms of MDD and DD, as outlined in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV; American Psychiatric Association, 1994), include changes in physical, cognitive, and emotional domains (Tables 1 and 2).In 1996, the World Health Organization ranked depression among the most disabling of all diseases in the world, leading all other disorders in "years lived with disabilities." The reasons for this are apparent when one considers the course of depressive illness. Approximately 70% of youth who have MDD experience another depressive episode within 5 years, and youth who have depressive disorders have a fourfold risk of an adult depressive disorder. Approximately 50% of children and adolescents who have MDD can be expected to have adult recurrences. Early onset and recurrences also have been described as a cause of treatment-resistant depression in later life, leading to multiple episodes that last longer, become more severe, and become more difficult to treat. These tend to be associated with more hospitalizations, job absenteeism, and impaired work performance.Depressive disorders in youth are associated with impaired functioning in several areas of daily living. These include strained family and peer relationships, school attendance difficulties, and academic performance problems. Affected youth often experience suicidal thoughts and are at increased risk for attempted and completed suicide.Early-onset bipolar disorder (BD) often presents as depressive symptoms, which can make it difficult to distinguish between bipolar and unipolar depression. BD is characterized by alternating periods of mania and depression. The inflated self-esteem, excess energy, and poor judgment that characterize a manic phase often result in dangerous activity and substantial social problems. Rapid cycling and mixed symptom states occur in subtypes of BD. Approximately 20% to 40% of children who have MDD eventually develop BD. Some clues to the risk for developing a manic or hypomanic episode include psychosis, psychomotor retardation, or a family history of BD.Another potential diagnostic dilemma occurs when a child or adolescent is abusing alcohol or drugs. Youth are not always forthcoming about such abuse, which may be associated with declining school performance, withdrawal from usual social activities, sleep disturbance, and negative moods. Careful questioning of the youth and parent/guardian is necessary to identify a substance use disorder in youth presenting with depressive symptoms. It can be equally challenging to identify a depressive disorder in youth initially identified for services because of problems related to alcohol or substance abuse.Most children and adolescents who are depressed also have a history of some other psychiatric or alcohol/drug use disorder. For example, 25% to 75% of depressed youth have one or more anxiety disorders, such as separation anxiety disorder or social phobia. Disruptive behavior disorders, such as attention-deficit disorder or oppositional defiant disorder, are also common, and substance abuse or dependence characterizes a significant minority of youth who are depressed. A gender difference exists in patterns of comorbidity. Girls more commonly have comorbid anxiety conditions; boys are more likely to have comorbid conduct disorders or substance use disorders.Children and adolescents rarely seek professional treatment. Thus, parents, teachers, pediatricians, and others who have regular contact with youth play critical roles in recognizing youth who are depressed. Few youth use the word "depressed"; even fewer report to someone that they may be experiencing a clinical depression. Therefore, it is helpful to ask youth about experiences of feeling down, "bad," miserable, bored, or irritated. Signs of clinical depression that often initially are visible to others include withdrawal from activities, decline in school performance, change in sleep patterns, and sadness or irritability.The United States Preventive Services Task Force recently recommended the use of two questions in screening for depression among adults: "Over the past 2 weeks, have you ever felt down, depressed, or hopeless?" and "Have you felt little interest or pleasure in doing things?" The Task Force concluded that evidence is inconclusive regarding the effectiveness of routine screening of children and adolescents, but these two questions may help clinicians detect primary symptoms of depression. More comprehensive screening instruments and diagnostic tools or a referral to a mental health professional should be considered if indicated. The Reynolds Adolescent Depression Inventory (RADS) and the Children's Depression Inventory (CDI) are screening tools used in some school and mental health clinics.Clinical interviews are the cornerstone of a comprehensive assessment and should include, at a minimum, interviews with the youth as well as the parent or guardian. In addition to gathering a complete history of presenting problems (onset, chronicity, severity, prior history of symptoms, and treatment), a full psychiatric interview is conducted to obtain information about possible comorbid conditions. For example, it is critical to ascertain whether psychotic features, disruptive behavior disorders, anxiety disorders, or substance abuse problems are present. Information also is gathered about the youth's medical, developmental, social, and educational histories as well as the family psychiatric history.Important sources of information may include school academic and attendance records; teacher reports; and appropriate biomedical, psychological, or other test findings. Standardized self-report questionnaires may permit youths to answer questions about current symptoms without directly verbalizing the extent of their emotional distress to an adult. This approach sometimes can facilitate honest reporting of the number and severity of depressive symptoms. If noted in a self-report questionnaire, critical items always should be followed up with direct inquiry by the clinician (eg, if a youth reports suicidal ideation).The initial goals of treatment are to ensure the youth's safety and develop an effective therapeutic alliance with the youth and parents. This alliance will facilitate ongoing communication and continuation of care. Consultation with teachers and other caregivers also is important. A focus on patient and family education and a collaborative approach to treatment planning can enhance the youth's adherence to treatment recommendations.Psychoeducation is a key component of the treatment. Beyond this, perspectives on the first line of treatment vary. The choice of whether to begin with psychotherapeutic or psychopharmacologic interventions or a combination depends on depression severity and chronicity, prior history of depressive episodes, likelihood of adherence, previous response to treatment, patient and family motivation for treatment, and availability of resources. Because of the psychological, environmental, and social problems associated with depression and its treatment, pharmacotherapy usually is not sufficient as the sole treatment. Attention to parental mental health and family stress as well as to strategies for helping parents manage the youth's irritability, isolation, or other problems should be included in psychotherapeutic interventions. These systemic concerns affect treatment adherence and ultimate outcomes.Psychoeducation addresses the signs and symptoms of depression; the importance of psychotherapy and psychiatric medication; and common misconceptions about the illness, therapy, or medications. It also is helpful to address the impact that depression has on school, social, and family functioning and the ways in which parents and teachers may aid in recovery. Parent and family education may increase adherence and reduce self-blame. Education of parents can help them identify their own mood disorders and potential treatment needs as well. Education also can reduce blame for symptoms such as irritability and anhedonia that may affect others.Controlled studies have documented the short-term effectiveness of cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) for depressed youth. Both generally are time-limited therapies that involve collaboration or guided discovery between the therapist and adolescent. CBT focuses on self-understanding of negative mood states and on the identification and modification of negative, distorted thought patterns. It also emphasizes problem-solving skills, communication skills, and the development of more adaptive behavior patterns. IPT strives to improve the youth's interpersonal functioning by improving self-understanding, problem-solving, communication, and coping in the realm of relationships. It focuses on a chosen interpersonal problem such as grief, a difficult role transition, an interpersonal conflict or role dispute, social skill deficits, or issues in step-parent families. Although randomized, controlled clinical trials have not been conducted for psychodynamic therapy with depressed youth, this approach may be useful. Family therapy is an important supplement to any of these approaches if difficulties in family communication and support are identified. Goals of family therapy may include improving family affective communication, increasing adaptive behaviors, and changing both interpersonal and family functioning.Selective serotonin reuptake inhibitors (SSRIs) are the antidepressants of choice for youth who require pharmacotherapy (American Academy of Child and Adolescent Psychiatry, 1998). The efficacy of the SSRI fluoxetine in reducing depressive symptom severity in children and adolescents has been demonstrated in two double-blind, randomized, placebo-controlled trials. Paroxetine also has demonstrated efficacy compared with imipramine and placebo in a double-blind, placebo-controlled comparison. Other antidepressant medications are not well studied. Dosing guidelines recommend starting with 10 mg fluoxetine and increasing to 20 mg. The maximum dose is 40 mg to 80 mg. When treating a child younger than 8 years of age, clinicians may want to start with 4 to 8 mg elixir of fluoxetine. However, the efficacy and safety data have been demonstrated only down to age 8 years. If there are problems with insomnia, appetite loss, or restlessness, paroxetine is a more sedating SSRI, and dosing guidelines are identical to those for fluoxetine. SSRIs should be discontinued if symptoms of mania appear. However, youth may benefit from treatment with an SSRI for an extended period before BD develops.An adequate trial of SSRIs is at least 4 to 6 weeks. If no or only minimal improvement is observed, a dose increase should be considered and medication continued for at least 4 to 6 additional weeks. If no improvement has been observed, alternative strategies should be considered, including a referral to a psychiatrist in cases of treatment-resistant depression. Additionally, if the pediatrician is not comfortable in the prescriber role, a psychiatric consultation or referral to a physician experienced in the use of medication is recommended. Frequent medication adjustments are ill-advised, and tapering of medications that have shorter half-lives (eg, paroxetine) is recommended. Obtaining serum levels rarely is necessary unless concerns arise about toxicity or compliance. Studies among adults suggest that the same doses used to treat MDD are efficacious for DD.Tricyclic antidepressants (TCAs) are not considered a first-line treatment for children and adolescents who are depressed, but they may be helpful in treating youth who have comorbid attention-deficit/hyperactivity disorder, enuresis, and narcolepsy as well as for augmentation purposes.In contrast to TCAs and monoamine oxidase inhibitors, SSRIs have a relatively safe adverse effects profile, are easily used (once daily), are suitable for long-term maintenance, and have a low lethality after overdose. Additional information on adverse effects, medication interactions, and the treatment of comorbid conditions is available in reviews of practice recommendations published by the American Academy of Child and Adolescent Psychiatry.ECT can be a useful adjunct for individuals whose depression is severe or life-threatening, who have not responded to other treatments, who cannot take antidepressant medications, and who may have psychotic depression. The decision to use ECT must be made carefully and usually requires the recommendation of more than one psychiatrist as well as a substantial discussion with the child's parent or guardian.Unless there are significant adverse effects, medication should be continued for 6 to 12 months if it is believed to help in the remission of depressive symptoms. The pharmacotherapy should be monitored monthly during this continuation phase. Psychotherapy is helpful during this phase to bolster coping skills and to address antecedents, stressors, and interpersonal conflicts that may have contributed to the onset of depression. Medication adherence also may be improved by psychotherapy.Once the patient's symptoms have remitted for 6 to 12 months, the maintenance phase of treatment may last from 1 year to indefinitely. The goals are to facilitate healthy development and to prevent relapse or recurrence. These may be accomplished through monthly or quarterly visits, depending on the severity and chronicity of the present episode, frequency of previous episodes, comorbid disorders, the patient's motivation, and contextual factors (eg, support systems, family stress, and psychopathology).The presence of comorbid conditions often predicts a poorer response to psychopharmacologic and psychosocial treatments. These conditions, such as anxiety, disruptive behavior, and substance use disorders, often persist after remission of the depressive symptoms and require targeted treatments. Because of time, cost, or the incompatibility of treatments, addressing all conditions simultaneously may be impossible. Hence, the clinician often must prioritize treatment goals and the sequence of interventions.A depressive disorder may be "treatment-resistant" because of an inadequate dosage or duration of medication trial, inadequate duration or "fit" with a particular psychotherapy, poor treatment adherence, complicating comorbidity, undetected BD, chronic or severe life events, misdiagnosis, or mistreatment. Psychopharmacologic strategies to address treatment-resistant depression should be applied systematically in conjunction with family education and support and include optimization, switching, augmentation, or combination. Consultation with a psychiatrist always is advised with treatment-resistant cases.If BD is present or is a possibility, a mood-stabilizing agent (eg, lithium carbonate, valproate, or carbamazepine) may be warranted, especially because antidepressants may induce mania in youths at risk for BD. Approximately 30% to 50% of adults experience modest antidepressant effects with mood stabilizers alone. Antidepressants may be useful adjuncts in such treatments. Psychotic depression may require a combination of antidepressants with antipsychotics or ECT. Neuroleptics should be tapered after psychotic symptoms remit due to the risk of tardive dyskinesia. Atypical antipsychotic medications may be preferred. However, the long-term effects of these medications have not been studied in youth.Suicide is the third leading cause of death among children and adolescents (National Center for Health Statistics, CDC, 2000). The suicide rate for ages 15 to 24 years is 11.1 per 100,000, which is much higher than the rate for youth between the ages of 5 and 14 years (0.8 per 100,000). The suicide rate for males in the 15- to 19-year age group is markedly higher than that for females (Table 3). Rates differ by racial and ethnic group. African-American youth have lower suicide rates than Caucasian youth, with the lowest adolescent suicide rate being that of African-American females. The highest suicide rate is that of Native American males.Although many youth who report suicidal thoughts or attempt suicide do not become suicide victims, these categories overlap substantially. For instance, having frequent thoughts of suicide is the best predictor of suicide attempts, and most youth who attempt suicide report a history of suicidal ideation. Furthermore, greater severity of reported suicidal thoughts increases the likelihood of a suicide attempt within the next year. Approximately 35% to 45% of adolescents who complete suicide have a positive history of suicide attempt. The prevalences of both self-reported suicidal ideation and suicide attempts are higher for adolescent females than for adolescent males (Table 3).Risk factors for completed suicide and suicidal behavior are similar in most respects. There are a few exceptions, however, such as the more specific relationship between availability of firearms and completed suicide. In this section, we review the primary risk factors for completed suicide (Table 4).A history of prior suicidal behavior is the strongest predictor of future suicidal behavior. Nonlethal suicidal gestures or self-inflicted harm, which sometimes are thought to be manipulative or attention-seeking, should not be taken lightly. Youth often can be poor judges of lethality, and what is believed to be a gesture actually may be accompanied by significant suicidal intent. It also may result in substantial physical harm or even suicide because of an error in knowledge or judgment (eg, potential lethality of acetaminophen overdose).Approximately 80% of youth who attempt suicide and 90% of youth suicide victims have histories of identifiable psychiatric or mental disorders. The most common types of psychopathology in these youth are depressive disorders, alcohol or substance abuse, conduct disorder or patterns of aggressive behavior, and anxiety disorders. Increased suicide risk is associated with conditions that often are refractory to treatment or present management problems. These include BD, a chronic depressive disorder comorbid with alcohol or substance abuse, and psychotic presentations.Depressive disorders are linked with increased risk for suicidal ideation, suicide attempts, and completed suicides (Table 5). In fact, suicidal ideation and behavior are common and often unrelenting problems among youth who have depressive disorders. Eighty-five percent of depressed youth report significant suicidal ideation, and 32% of depressed youth report one or more suicide attempts prior to adulthood. Retrospective studies have found that about 50% of adolescent suicides involve the consumption of alcohol, which increases impulsivity, impaired judgment, and mood changes.Environmental or family stress, especially a history of neglect or physical, emotional, or sexual abuse, are considered significant risk factors for suicidal behavior. Interpersonal conflict and loss (eg, fights, break-ups, deaths) also are risk factors. Additionally, hopelessness, impulsivity, aggressive behavior, and agitation are psychological characteristics associated with increased risk for suicidal behavior.Gay, lesbian, and bisexual adolescents are at increased risk for suicidal behavior. Recent general population surveys indicate that of these youth experience suicidal ideation, and have made one or more suicide attempts during the past year. of the risk factors in these youth are the same as those for youth. such as comorbid substance abuse and however, are more common among youth who have a In risk factors such as and are specific to those who negative within risk for anxiety, and suicide increases when a youth someone who suicide. In these at and and and social as well as at identification with the suicidal behavior are recommended. of suicide may suicide are to possible to reduce and to parents and to of youth to such are found more commonly in the of suicide victims than in the of other youth, including those of suicidal youth. The importance of suicidal youth's to firearms is by documented between more and in suicide as or should be from the of suicidal youth or monitored by parents and that if adolescents will suicidal and previous suicidal behavior. questions should address whether children or adolescents they not if they ever have thought about or to if they ever have thought about or to and if they have or such a in It is important to that an adolescent about suicidal thoughts or will not such or or increase the risk for suicidal behavior. inquiry regarding the chronicity, and of such thoughts is Standardized self-report such as the may permit the youth to answer without direct which can facilitate If critical items related to or planning and items significant of chronicity, severity, or always should be followed up with direct Other sources of information include reports from parents, teachers, or others who may have suicidal or such as with the assessment of depressive disorders, a comprehensive that from the youth and parent or is psychiatric or may be necessary for found to be at suicide generally are and and attempts that have significant lethality and that include taken to indicate as well as knowledge and planning and should be taken Furthermore, to safety requires of the child's and caregivers should be advised to especially firearms and medications, from the by young children should not be as For example, when a child it may not be behavior should be carefully for associated mood or other or are used in many The patient is to not to attempt suicide. Furthermore, the patient is to to contact the or other adult if or a suicidal or experiences suicidal intent. on these have the past with an increasing on the as an assessment The may current suicidal intent. It also information about the patient's to and to helpful It is useful to review what positive coping the youth and parent take in the of a suicidal This an for problem-solving and can the of some youth and to or the risk of suicidal behavior. It should be however, that not support the that such prevent they are not for comprehensive for a suicidal youth, suicide risk factors, including suicidal and behaviors, are monitored at of when with suicidal youth next at up on and information to the youth and parent or about easily management and regular patient with guidelines for to in population of suicidal youth is in of primary psychiatric comorbid conditions, the presence of complicating psychosocial and Therefore, the treatment should be on a comprehensive of psychopathology more suicide risk and factors.

The impact of types of social connectedness-family, other adult, and school-on suicide ideation and attempts among all youth, the relative impact of each type, and effect modification by sexual orientation was assessed. Data were from the 2007-2009 Milwaukee Youth Risk Behavior Surveys. Multivariable logistic regression analyses calculated the risk of suicide ideation and attempts by sexual orientation, types of social connectedness, and their interaction. Among all youth, each type of connectedness modeled singly conferred protective effects for suicide ideation. Family and other adult connectedness protected against suicide attempts. When modeled simultaneously, family connectedness protected against ideation and attempts. Sexual orientation modified the association between other adult connectedness and suicide ideation. Findings suggest that family connectedness confers the most consistent protection among all youth and sexual orientation does not generally modify the association between connectedness and suicidal behavior.

Suicide is a leading cause of death in the US. Suicide-specific cognitive behavior therapy (CBT) is effective for reducing suicide attempts but is difficult to implement. To evaluate the efficacy of a smartphone-based digital therapeutic intervention designed to deliver suicide-focused CBT in reducing suicidal behavior among patients hospitalized for a suicide attempt or suicidal ideation. This multisite, double-blind, randomized clinical trial was conducted in 6 psychiatric inpatient units across the US. Adult patients admitted with elevated suicide risk from April 2022 to April 2024 were included. Participants completed a baseline assessment and were randomly assigned to either the digital therapeutic group or control application group. The trial was stopped early by the Data Management Safety Board because it surpassed the prespecified futility boundary for the primary end point. Statistical analysis followed the intention-to-treat principle. The digital therapeutic intervention includes 12 sessions of smartphone-based educational modules (lasting 10-15 minutes each) drawn from CBT for suicide prevention. The active control is a 12-session smartphone-based application that delivers safety planning and psychoeducation about suicide. For both interventions, the first session was completed prior to hospital discharge and the remaining self-paced sessions could be completed after discharge. All participants also received treatment as usual, which included suicide risk assessment, supportive listening, crisis resources, clinician assessment, safety planning, and referral to outpatient treatment. The primary end point was time (days) to first actual suicide attempt during follow-up. The secondary end points were change in suicidal ideation from baseline to week 24 (quantified as a change in the Scale for Suicide Ideation total score) and clinician-rated clinical improvement at week 24. The nonprespecified sensitivity analysis end point for suicide attempts was the rate of suicide attempts (actual, aborted, and interrupted). Prespecified subgroup analyses were also conducted to examine treatment effects among patients with vs without prior suicide attempts. A total of 339 participants (mean [SD] age, 27.9 [10.7] years; 224 females [66.1%]) were included. Follow-up data were available from 266 participants (78.5%). Time to first actual suicide attempt, the primary end point, was not significantly different across treatment groups (log-rank χ21 = 3.6; P = .06). Among the 170 participants with prior suicide attempts, nonprespecified sensitivity analyses indicated that the adjusted rate of follow-up suicide attempts was 58.3% lower in the digital therapeutic group than the control application group (0.70 vs 1.68 attempts per person-year; rate ratio [RR], 0.42 [95% CI, 0.18-0.95]; P = .04), and the odds of clinical improvement were higher in the digital therapeutic group than the control application group (97.9% vs 87.5%; odds ratio, 7.59; 95% CI, 1.14-153.62; P = .04). Trajectories of suicidal ideation significantly differed between the digital therapeutic and control application groups (F3,206 = 2.9, P = .04), with decreased suicidal ideation through week 24 in the digital therapeutic group, but in the control application group, suicidal ideation decreased through week 12 and then increased at week 24. Nonprespecified dose-response analyses indicated the suicide attempt rate among patients with a prior suicide attempt decreased by 14.0% for every digital therapeutic module completed (adjusted RR, 0.86; 95% CI, 0.76-0.98; P = .02). In this randomized clinical trial, the digital therapeutic intervention did not change the time to first actual suicide attempt but helped to sustain reductions in suicidal ideation among inpatients with elevated suicide risk. However, among patients with prior suicide attempts, the digital therapeutic intervention helped reduce recurrent suicide attempts and increased the percentage of inpatients with clinician-rated clinical improvement. ClinicalTrials.gov Identifier: NCT05144685.