Attempted suicide

Suicide attempts in adolescents are at least twice as common in females as males (see Fig 1 and Fig..2). Considerable ethnic variation is seen in the United States, with, for unknown reasons, Hispanic high-school students having twice the rate of black or white teenagers. (2.9)

mood lability, with paranoid ideas and disorder. Many of

Fig. 1 Youth risk behaviour survey: prevalence of suicidal ideation in teenagers in the previous 12-month period (1997) broken down into gender and ethnicity. (Data from Centers for Disease Control.(29))

from Centers for Disease Control.(29))

Aetiology Completed suicide Psychiatric disorders

The most important risk factor for suicide is a psychiatric disorder.(3) Controlled studies of completed suicide suggest similar risk factors for boys and girls, (33.9 but with marked differences in their relative importance(3,4 and 5 (Table 1). In girls, major depression is the most powerful risk factor, which, in some studies, increases the risk of suicide 12-fold; followed by a previous suicide attempt, which increases the risk approximately threefold. In boys, a previous suicide attempt is the most potent predictor, increasing the rate over 30-fold. It is followed by depression (12-fold increase), disruptive behaviour (twofold increase), and substance abuse (increasing the rate by just under twofold).(3)

Table 1 Psychiatric diagnoses in child and adolescent suicides

Psychosocial stressors

Stressful life events often precede a suicide and/or suicide attempt. (12> They are rarely a sufficient cause in suicide, and their importance seems to lie in their action as a precipitant of stress in young people who are at risk by virtue of their psychiatric condition. Family discord, lack of family warmth, and a disturbed parent-child relationship are commonly associated with types of child and adolescent psychopathology, but these factors do not play a more important role in suicide. (12>

Cognitive factors

Perceptions of hopelessness, negative views about one's own competence, poor self-esteem, a sense of responsibility for negative events, and the immutability of these distorted attributions may contribute to the 'hopelessness' repeatedly found to be associated with suicidality. (l8,:!i>

Biology

Biological factors, specifically dysregulation of the serotonergic system, are common in adult suicides. (31> Dysregulation is manifested by low levels of serotonin metabolites in central nervous system fluids, low concentrations of presynaptic serotonergic receptors, and dense concentrations of postsynaptic receptors. Such serotonin abnormalities have been localized to the ventrolateral prefrontal cortex and brainstem of suicide victims and attempters (in postmortem positron-emission tomographic studies as well as in in vivo biological challenges). (32> Serotonin may inhibit extreme fluctuations of mood and reactivity, and the vulnerability to suicide of individuals with these biological abnormalities may be mediated by impulsivity and emotional volatility. As the ventral prefrontal cortex plays a role in behavioural inhibition, it is conceivable that serotonin irregularities in this area make it more difficult for a suicidal individual to control his suicidal impulses. (32> The frequency with which these biological findings occur in adolescent suicide attempters is not yet clear, and studies to demonstrate the precise behavioural correlates of serotonin dysregulation profiles are still lacking. Nordstrom et al.(33) have suggested that knowing the biological status of suicide attempters may have a practical value, in that low 5-hydroxyindole acetic acid concentrations in cerebrospinal fluid examined shortly after a suicide attempt may differentiate between suicide attempters who will commit suicide or repeat the attempt within a year and those who will not.

Imitation

Evidence has accumulated indicating that suicide in vulnerable teenagers can be precipitated by exposure to real or fictional accounts of suicide, such as intense media coverage of a real suicide or the fictional representation of a suicide in a popular film or television programme. The risk is especially high in the young, and lasts for approximately 2 weeks/,!,3* The phenomenon of suicide clusters is also presumed to be related to imitation.

One hypothetical model for how biological and social factors fit together is illustrated in Fig 3.

Fig. 3 How do suicides occur and how can they be prevented?

In a longitudinal study of a large African-American community in the United States, Juon and Ensminger (34> found risk factors for suicidal behaviour in African-Americans to be very similar to those found in Caucasians (depression, substance use, and a number of family variables).

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