Published by CQ Press, an Imprint of SAGE Publications, Inc. www.cqresearcher.

com

Teen Suicide
Do suicide-prevention programs work?

S
uicide is the second-leading cause of death among 13-

to 19-year-olds, after unintended injury and before

homicides, and the teen suicide rate has risen recently.

Yet researchers and mental health professionals cannot

pinpoint why the rate has climbed, and they know little about

what causes someone thinking about suicide to attempt it. more-

over, the ability to predict who is at immediate risk is limited. As

a result, suicide screening tools are of limited effectiveness, and

most school-based suicide-prevention programs may not reduce

Steve Stuban visits the grave of his son Nick, 15, who
teen suicides. Yet researchers are hopeful that new studies, includ- took his own life in 2011 after getting into trouble at
school. He was one of several students at Woodson
High School in Arlington, Va., who apparently have
ing large trials of three kinds of psychotherapy in adolescents, will died by suicide in the past three years. Teen suicide
recently reached a 13-year high of
increase understanding of teen suicide and lead to better identifi- 6.7 deaths per 100,000 teens.

cation and treatment of high-risk teens. meanwhile, a growing

number of states are requiring educators to be trained to recognize

and respond to potentially suicidal youths. Additionally, researchers

have begun delving into physical brain characteristics that might

N
I THIS REPORT
be connected to teen suicide. THE ISSUES ....................747
S
BACKGROUND ................753
I
CHRONOLOGY ................755
D
E
CURRENT SITUATION ........760
CQ Researcher Sept. 12, 2014 www.cqresearcher.com AT ISSUE........................761
Volume 24, Number 32 Pages 745-768
OUTLOOK ......................763
RECIPIENT Of SOCIETY Of PROfESSIONAL JOURNALISTS AwARD fOR
EXCELLENCE AmERICAN BAR ASSOCIATION SILvER GAvEL AwARD
BIBLIOGRAPHY ................766
THE NEXT STEP ..............767
 TEEN SUICIDE
THE ISSUES
Should all teens be
747 screened for suicide risk?
Do school-based suicide-
prevention programs work?
Can suicidal teens be ef-
fectively treated?
BACKGROUND
No Longer a Crime
753 Attitudes toward suicide
evolved over time.
The Prevention Movement
756 Crisis hotlines were busy
from the start.
Pharmacology and Suicide
758 few studies have been done
on the direct impact of drug
therapy on suicide.
CURRENT SITUATION
Federal Legislation
760 Advocates are pushing for
more research funding
State Legislation
762 Teacher-training requirements
are increasingly common.
Neurobiology of Suicide
763 Scientists are searching for
answers inside teen brains.
OUTLOOK
Telling Stories
763 Suicide-attempt survivors are
speaking up.
SIDEBARS AND GRAPHICS
748 Suicide: Myth vs. Fact
misunderstandings abound.
749 Youth Suicide Rate Reached
13-Year High in 2011
most recent data show
6.7 suicides per 100,000.
Cover: Getty Images/The Washington Post/Linda Davidson
746 CQ Researcher
752 Suicide No. 2 Cause of
Teen Deaths
Only injury is more
prevalent.
Suicide-Attempt Rate Rises
753 In 2013, 8 percent of high-
schoolers said they attempted
suicide.
754 Warning Signs That Some-
one is Suicidal
Recognizing the signs can
help save a life.
Chronology
755 Key events since 1897
Media, Schools Can Help
756 Reduce Copycat Suicides,
Experts Say
If it is not a celebrity, the
story should not be on the
front page.
Internet Can Provide
759 Support, Information
In some ways it did save
my life.
At Issue:
761 Should doctors universally
screen teen patients for suicide
risk?
21 States Require Suicide-
762 Prevention Training
Seventeen encourage but do
not require training for school
personnel.
FOR FURTHER RESEARCH
765 For More Information
Organizations to contact.
Bibliography
766 Selected sources used.
The Next Step
767 Additional articles.
Citing CQ Researcher
767 Sample bibliography formats.
Sept. 12, 2014
Volume 24, Number 32
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 Teen Suicide
BY BARBARA MANTEL

THE ISSUES
aitlin Coleman first ex-
Last year, 17 percent of high
school students in the national
Youth Risk Behavior Survey,
coordinated by the Centers for

C perienced depression
when she was 15, but
her doctor discontinued her
Disease Control and Prevention
(CDC), said they seriously had
considered attempting suicide
antidepression medication be- during the prior 12 months;
cause it seemed to make the almost 14 percent said they had
drug she was taking for epilep- made a plan; 8 percent re-
sy less effective. Coleman says ported having attempted sui-
she was OK in high school cide one or more times over
and during her first year of that period; and just under 3
college, but her depression percent said they had made
worsenedin the beginning of an attempt that led to treat-

Livethroughthis.org/DeseRae L. Stage
her sophomore year, when ment by a doctor or nurse. 1
she was 19. Completed suicide among
I couldnt get up in the adolescents is rare. The sui-
morning. I became increas- cide death rate for those age
ingly isolated from my fam- 13 through 19 was 6.74 per
ily, she says. If I could put 100,000, for a total of 2,014
my clothes on, that was a teens, in 2011, the last year of
good day. available government data. 2
Coleman stopped taking That compares with 16.36 per
her epilepsy pills. She 100,000 for those 20 and older.
thought she would have a Nevertheless, it was the second-
seizure in the middle of the Suffering from depression, Caitlin Coleman attempted leading cause of death among
street, get hit by a car and suicide during her sophomore year of college. Now 31 adolescents in the United States
and working in New York City as a food server,
then no one could be mad bartender and sometime singer and pianist, she has that year, after unintended in-
at me for dying by suicide found stability. But, she says, Its a journey. Definitely jury and before homicide. 3
because it would look like an the first year or two were really, really hard. Yet mental health profes-
accident, she says. sionals know little about what
Around Christmas that year, Cole- pression. Suicide is one of the lead- causes someone who is thinking about
man took an overdose of the accu- ing causes of death among Americans suicide to attempt it. And the ability to
mulated pills and ended up in inten- age 13-19. Yet screening tools to iden- predict who is at immediate risk in
sive care. After several weeks, she tify teens at high risk of attempting the next day, week or month is frus-
transferred to the hospitals psychiatric suicide are not very effective, and tratingly limited. The government and
ward, where doctors put her back on those showing promise need more suicide-prevention organizations list sui-
an antidepressant; later, she entered a evaluation, say many suicide experts. cide risk factors, such as depression,
day program, where she participated Suicide-prevention programs in schools anxiety, past suicide attempts and a fam-
in individual, group and art therapy. may raise awareness, but the evidence ily history of suicidal behavior, as well
Now, at age 31, Coleman lives in that they increase mental health refer- as more immediate warning signs, such
New York City, working as a food serv- rals and reduce suicide rates is mixed. as hopelessness and anger. (See box, p.
er and bartender, and is a sometime medications often are effective at treat- 754.) But most people in these cate-
singer and pianist. But her return to ing the mental health disorders that fre- gories never try to take their life. more-
stability didnt happen overnight. Its a quently underlie suicidal behavior, yet over, such lists of risk factors typically
journey. Definitely the first year or two research on whether antidepressants help dont differentiate by age.
were really, really hard, she recalls. suicidal youths is scarce. And to date, we are just realizing that those risks
Like Coleman, the overwhelming only small studies have examined the and warnings signs are for suicidal
majority of suicidal teens have a men- efficacy of psychotherapy, including cog- ideation. But most people who think
tal health disorder, most often de- nitive behavior therapy, for suicidal teens. Continued on p. 749

www.cqresearcher.com Sept. 12, 2014 747

 TEEN SUICIDE

Suicide: Myth vs. Fact

The American Foundation for Suicide Prevention, a nonprofit research and advocacy organization, has
compiled a list of common myths and facts about suicide. If you or somebody you know may be at risk of
suicide, the group urges a call to the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).
Myth: Suicide cant be prevented. If someone is set on taking their own life, there is noth-
ing that can be done to stop them.
Fact: Suicide is preventable. The vast majority of people contemplating suicide dont really want to
die. They are seeking an end to intense mental and/or physical pain. Most have a mental illness. Inter-
ventions can save lives.
Myth: People who take their own life are selfish, cowards, weak or are just looking for
attention.
Fact: More than 90 percent of people who take their own life have at least one treatable mental illness
such as depression, anxiety, bipolar disorder, schizophrenia and/or alcohol and substance abuse. With
better recognition and treatment, many suicides can be prevented.
Myth: Asking someone if they are thinking about suicide will put the idea in their head
and cause them to act on it.
Fact: When you fear someone you know is in crisis or depressed, asking them if they are thinking
about suicide can actually help. By giving someone an opportunity to open up and share their troubles,
you can help alleviate their pain and find solutions.
Myth: Teenagers and college students are the most at risk for suicide.
Fact: The suicide rate for this age group is below the national average. Suicide risk increases with age.
Currently, as an age group, the highest suicide rate in the United States is among those between the ages
of 45 and 64. Taking into account race and sex, the suicide rate is highest among white men over the
age of 65.
Myth: Barriers on bridges, safe firearm storage and other actions to reduce access to
lethal methods of suicide dont work. People will just find another way.
Fact: Limiting access to lethal methods of suicide is one of the best strategies for suicide prevention.
Many suicides can be impulsive and triggered by an immediate crisis. Separating someone in crisis
from a lethal method (e.g., a firearm) can give them something they desperately need: time time to
change their mind, resolve the crisis, or for someone to intervene.
Myth: Someone making suicidal threats wont really do it, they are just looking for attention.
Fact: Those who talk about suicide or express thoughts about wanting to die are at risk for suicide and
need your attention. Most people who die by suicide give some indication or warning. Take all threats of
suicide seriously. Even if you think they are just crying for help a cry for help is a cry for help so help.
Myth: Talk therapy and/or medications dont work.
Fact: Treatment can work. One of the best ways to prevent suicide is by getting treatment for mental
illnesses such as depression, bipolar illness and/or substance abuse and learning ways to solve problems.
Finding the best treatment can take some time, and the right treatment can greatly reduce risk of suicide.
Source: Understanding Suicide: Myth vs. Fact, American Foundation for Suicide Prevention, Sept. 6, 2013, http://tinyurl.com/qx3d2eg

748 CQ Researcher
Continued from p. 747
about suicide do not attempt it, says
David Klonsky, a psychology professor
at the University of British Columbia.
Some scientists are studying the ado-
lescent brain for clues to the biology
of suicide in hopes of better identify-
ing and treating suicidal youths.
Knowledge about the causes of sui-
cide lags far behind our knowledge of
many other life-threatening illnesses
and conditions. In part, this is because
the stigma surrounding suicide has lim-
ited societys investment in suicide re-
search, according to the New York-based
American foundation for Suicide Pre-
vention, which provides up to $5 million
a year in research grants, making it the
nations largest nonprofit supporter of sui-
cide research. 4 The National Institute of
mental Health (NImH) funds $40 million
a year in suicide research, a fraction of
its annual budget of $1.5 billion. 5
I think one of the indicators that
we dont understand suicide well
enough is that rates of suicide have
not meaningfully decreased and in
some demographics or areas have in-
creased over the last many years, even
though suicide prevention has gotten
a lot more attention, says Klonsky.
The suicide death rate for young peo-
ple between 13 and 19 fell, somewhat
erratically, between 1999 and 2007, from
6.39 to 5.26 per 100,000. It then steadi-
ly increased until 2011, when it slightly
surpassed the 1999 rate. That pattern
holds for both boys and girls, although
the suicide death rate for boys each year
is three or four times greater than for
girls. 6 Even though girls are much more
likely to attempt suicide, boys more
often use the most lethal method: guns.
According to case reports, 85 per-
cent of those who attempt suicide with
a firearm die, compared with 69 per-
cent who try suffocation, 2 percent
who overdose and 1 percent who cut
themselves. 7
Some racial and ethnic groups have
higher suicide rates than others. Ameri-
can Indian and Alaskan Native teenagers
www.cqresearcher.com
Youth Suicide Rate Reached 13-Year High in 2011
Teen suicide reached 6.74 deaths per 100,000 teenagers in 2011,
according to the latest data. The rate had dipped to 5.26 in 2007.
(No. of suicides Suicides per 100,000 People
per 100,000)
8 Ages 13-19, 1999-2011
7
6
5
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Sources: Fatal Injury Reports, National and Regional, 1999-2011, Web-based
Injury Statistics Query and Reporting System (WISQARS), Centers for Disease
Control and Prevention, http://tinyurl.com/8xl3mrt
have the highest rate of death by sui- step in prevention, yet there seem to be
cide, followed by white teenagers, Asian many missed opportunities. Nearly 90 per-
and Pacific Islanders and then blacks, ac- cent of suicidal youths saw their primary
cording to government data. 8 care physician in the year before they
Its difficult to pinpoint why suicide died. 12 forty percent of those who die
death rates have risen recently among by suicide visited an emergency depart-
teenagers. Kelly Posner, a professor of ment within the previous year, most for
medical psychology at Columbia Uni- non-psychiatric complaints. 13
versity, says possibilities include a growth So some suicide experts recommend
in social media and cyberbullying; a casting a wide net and screening all
drop in antidepressant use after the teens to find those who might be sui-
U.S. food and Drug Administration cidal. But others disagree, worrying
(fDA) in 2004 required antidepressant that existing tools, such as the Suicide
labels to carry a warning of possible Ideation Questionnaire, the Beck Scale
suicide risk for children and adolescents; for Suicidal Ideation, and the Columbia-
and the weak economy. 9 Suicide Severity Rating Scale (C-SSRS),
In fact, a recent Duke University are not accurate enough when used
study of national data found that a for universal screening.
states job losses were associated with we should be asking these ques-
an increase in girls suicidal thoughts tions the way we monitor for blood
and plans and with an increase in the pressure, says Posner, who co-created
thoughts, plans and suicide attempts the C-SSRS, designed to measure the
of non-Hispanic black adolescents. 10 severity of suicidal thinking and be-
Economic hardship appears to deepen havior. The brief screening version in-
the psychological problems of some cludes questions about death wishes,
vulnerable youth, the authors said. 11 suicidal thoughts, suicide plans and in-
Against this backdrop, here are some tent to carry them out. It also asks
of the questions about teen suicide about past suicide attempts and current
that advocacy groups, researchers, clin- behavior, such as collecting pills, buy-
icians and survivors of suicide at- ing a gun and writing a suicide note.
tempts are asking: But most doctors dont screen teenage
patients for suicide risk. And when they
Should all teens be screened for do screen, some use formal screening
suicide risk? tools and others dont, says Daniel Rei-
Identifying suicidal teens is the first denberg, executive director of minnesota-
Sept. 12, 2014 749
 TEEN SUICIDE
based Suicide Awareness voices of Edu-
cation, (SAvE), a national organization
promoting suicide awareness and edu-
cation.
In a survey of maryland doctors,
fewer than one in four primary care
pediatricians or family practice physi-
cians said they frequently or always
screened adolescents for suicide risk. 14
In the largest study to date examining
emergency room practices for identify-
ing patients who harm themselves, just
a quarter of all patients were assessed
for suicidal thinking, suicide attempts
and nonsuicidal self-injury. 15
Those assessments typically quick
questions by triage nurses identified
only 2.7 percent of emergency room
patients as having those thoughts or be-
haviors. This is in contrast to the known
high burden of mental illness in the
[emergency department] population,
the researchers said, and may indicate
that self-harm is going undetected. 16
But the researchers were not sure
that screening all emergency room pa-
tients is the answer. Thats because the
one emergency department in the study
that questioned 95 percent of its pa-
tients did no better, identifying only
2.4 percent of its patients as intentional-
ly harming themselves in some way. 17
In fact, it remains unclear whether
universal screening of teens and adults
for suicide risk is a good idea. The Amer-
ican medical Association recommends
that doctors routinely ask all adolescents
about thoughts and behaviors that could
indicate serious depression or suicide
risk. But in may the quasigovernmental
U.S. Preventive Services Task force, which
weighs evidence and makes recom-
mendations about the effectiveness of
preventive services, concluded that the
evidence on screening for suicide risk
in primary care is insufficient and that
the balance of benefits and harms can-
not be determined. 18 Such harms might
include distress caused by being asked
questions about suicide and side effects
from any resulting treatment. The task
force said more research is needed to
750 CQ Researcher
determine whether identifying people who
are thinking about suicide would actual-
ly lead to fewer suicide attempts. 19
Alan Berman, the former executive
director of the washington-based Amer-
ican Association of Suicidology, the na-
tions oldest suicide-prevention orga-
nization, says screening tools that rely
on questions about suicidal thinking
have two problems. first, the associa-
tion of suicidal thinking with death by
suicide is weak, he says. many peo-
ple with suicidal thoughts never at-
tempt or die by suicide.
Second, its likely that most kids at
risk are going to deny having suicidal
thoughts even when they do have them,
says Berman. They may be embarrassed,
consider suicide sinful, believe that no
one can help, fear being judged, worry
about being hospitalized against their
will, or not want their suicide plans in-
terrupted, according to Berman. 20
Nevertheless, Berman says emer-
gency departments and schools should
screen all teens coming through their
doors. with parental permission for
minors, kids who are flagged can then
be assessed more thoroughly by a pro-
fessional in a face-to-face interview.
There is no harm in that, says Berman.
Klonsky isnt so sure. Because sui-
cide attempts are rare, even a highly
accurate screening measure is going
to produce a very large number of
false positives, he says, and that can
have costs. Limited resources are de-
voted to people who dont need the
help, and there is also the risk, es-
pecially with teens, that if you mis-
understand them, you can hurt rap-
port and reduce the chance that they
will come to you when they really
need it, says Klonsky.
Reidenberg says universal screen-
ing is too flawed at the moment to
be pursued. Not only do kids tend to
deny having suicidal thoughts, says Rei-
denberg, but screening can give adults
a false sense of security. Lets say
were going to screen all the kids at
the beginning of the school year, he
says. Someone might seem fine, but
two months later they might be re-
ally depressed and suicidal, he says,
and no one would know.
Both Berman and Klonsky say
screening tools can be improved.
Berman would like tools to incorpo-
rate measures of more immediate risk,
like insomnia, hopelessness, agitation,
withdrawal and uncontrolled rage.
Experts also say that teens might be
willing to answer those questions
more honestly than direct questions
about suicidal thoughts and attempts.
Klonsky would like to see a two-
step screening process that incorpo-
rates measures of the capability to hurt
oneself a fairly new research area
pioneered by Thomas Joiner, a psy-
chology professor at florida State Uni-
versity. we are wired to avoid injury,
avoid death, avoid pain, says Klon-
sky, yet some people overcome that
fear and become capable of suicide.
for example, they may have access to
and comfort with guns. They may
have a personality that is more toler-
ant of pain. Or they may have be-
come used to pain, through a histo-
ry of cutting, an eating disorder or
drug abuse, he says.
Do school-based suicide-prevention
programs work?
Because teens spend the largest
part of their waking hours in school,
many suicide-prevention programs put
their focus there, even though evidence
of success is mixed.
many school administrators are un-
comfortable screening students. In one
small study, principals thought many
parents would object, and they them-
selves believed that asking students if
they are depressed or suicidal is the re-
sponsibility of parents, not schools. 21
However, the principals were com-
fortable with educating the student
body about suicide risks and warning
signs and with training school staff. 22
Its no surprise then that these two ap-
proaches are the most common.
 A february report to Congress by a
private consultant found that counties
that implemented government-funded
youth suicide-prevention programs pre-
sented significantly lower youth suicide
rates the year following the training im-
plementation compared with similar
counties that did not conduct training. 23
But a 2013 review of 16 studies
many of them randomized controlled
trials, the gold standard for research
showed that while individual school-
based suicide-prevention programs can
raise awareness and change attitudes,
only a few reduce suicide attempts
and none have been shown to reduce
death rates. 24
In fact, none of the studies includ-
ed in that review tried to gauge the
impact of prevention programs on sui-
cide deaths. Its not that these pro-
grams havent had an impact on death
rates. Its just that it is extremely dif-
ficult to measure that impact, says
psychiatrist Christine moutier, chief med-
ical officer at the American founda-
tion for Suicide Prevention.
Thats because suicide in a small pop-
ulation such as a school is relatively rare.
To detect any change in the suicide rate,
a study would have to span many schools
and school districts. That would be cost-
ly and difficult to organize.
The primary training program for
school staff, such as teachers, adminis-
trators and counselors, is Question, Per-
suade, Refer (QPR). The 60- to 90-minute
program trains them to recognize warn-
ing signs of suicide, offer a student hope
and refer them to professional help.
Its very basic, and thats the prob-
lem with it, says Reidenberg of SAvE.
But, its better than nothing.
Two randomized controlled stud-
ies found that school staff trained in
QPR had more knowledge about sui-
cide and more positive attitudes to-
ward prevention compared with con-
trol groups. But QPR did not increase
the number of referrals to mental
health services or the use of those
services. 25
www.cqresearcher.com
many teachers are not comfortable Hills, mass.,-based company behind
talking with kids about their emotional SOS. Using video and discussion, the
needs, and a gatekeeper training pro- hour-long program teaches students
gram is not going to change that, says how to identify in themselves or their
madelyn Gould, a professor of epidemi- friends the symptoms of depression
ology in psychiatry at Columbia Univer- and whether someone is suicidal, and
sity. A lot of people have been realiz- encourages them to seek help from
ing that the gatekeepers who are trained adults. Confidential screening is sup-
need to be more targeted and selective. posed to follow. Each student gets a
If youre going to do training, you response card that says, Based on the
first have to deal with the mental health video and/or our discussion, I feel I
community within schools, and then need to or I do not need to talk to
Getty Images/The Boston Globe/Jessica Rinaldi
Mourners leave the funeral of Roee Grutman, a high school junior in Newton,
Mass., who died by suicide Feb. 6, 2014. He was the third high school student
in the Boston suburb to take his own life since October 2013. Suicide
accounted for 17 percent of teen deaths in the United States in 2011, making it
the second-highest cause of teen deaths, after unintentional injuries.
also with the mental health community an adult about myself or a friend,
to whom referrals will be made if in- explains Porter. Unfortunately, screen-
deed somebody is thought to be at risk, ing doesnt often happen.
says Berman of the American Associa- A randomized study of SOS in five
tion of Suicidology. most school coun- high schools found that it significantly
selors, nurses and school psychologists increased students knowledge about
are poorly trained in suicide prevention, suicide but made no difference in sui-
he says. cidal thinking or help-seeking behav-
One of the most popular education ior compared with a control group. But
programs for teens is SOS Signs of the program did reduce the number
Suicide, designed for middle and high of self-reported suicide attempts, the
school students. weve distributed it only one of 15 programs in the review
to well over 10,000 schools since the aimed at middle and high schoolers to
program started in 2001, says Can- do so. However, those results could
dice Porter, executive director of Screen- be affected by the self-report design
ing for mental Health, the wellesley of the study, noted the reviewers. 26
Sept. 12, 2014 751
 TEEN SUICIDE
for the longest time, suicidal kids were
Suicide No. 2 Cause of Teen Deaths left out of studies, says clinical psy-
Suicide accounted for 17 percent of U.S. teen deaths in 2011, second chologist Guy Diamond, director of the
Center for family Intervention Science
only to unintentional injuries, at 39 percent. Homicides accounted for
at Childrens Hospital of Philadelphia.
about 15 percent, followed by cancerous tumors (7 percent). Only four small, randomized controlled
trials of treatments to reduce re-attempts
(No. of deaths) Leading Causes of Deaths, U.S.,
5,000 among suicidal teens have shown sta-
39.4%
Ages 13-19, 2011 tistically significant results. 30
4,000 (% of all teen deaths) Yet such research is urgently needed,
3,000
say mental health experts. As many as a
2,000 17.2% third of teenagers who have attempted
16.7%
14.6%
1,000 3.2% 2.3%
suicide try again within a year, and the
6.8%
0 risk of dying by suicide is significantly
Unintentional Suicide Homicide Cancerous Heart Birth Other elevated with multiple attempts. 31
injury tumors Disease Defects
But conducting randomized controlled
Source: 10 Leading Causes of Deaths, United States, 2011, All Races, Both Sexes, trials of suicidal teens is challenging. The
Ages: 13-19, Web-based Injury Statistics Query and Reporting System (WISQARS), ethics boards that supervise clinical trials
Centers for Disease Control and Prevention, http://tinyurl.com/cwofnqf get very scared and anxious that youre
going to have people die in the study,
mental health experts say one of the foundation for Suicide Prevention. Imag- says Berman of the American Association
most promising programs is one that ine if we really put our efforts into that. of Suicidology.
doesnt directly target suicide or teenagers. In addition, it is difficult to recruit kids
The Good Behavior Game is a program Can suicidal teens be effectively in crisis because they and their families
for early elementary school students. Chil- treated? are reluctant to relinquish control over
dren are grouped into teams, each with Treating children and teens for un- treatment. In one study, researchers tried
an equal number of unruly students. The derlying mental health disorders using to randomly assign adolescents who had
teacher posts the rules for acceptable stu- established medications and psy- made a suicide attempt within 90 days to
dent behavior, and the teams that accu- chotherapies may be the best way to either psychotherapy, medication man-
mulate the least infractions are reward- reduce suicide rates, say mental health agement or a combination of the two.
ed. The game has been shown to reduce experts. But such treatment doesnt al- But to recruit enough participants, re-
aggressive and disruptive behaviors, which ways prevent a young person from searchers had to change the study design
are risk factors for suicide. becoming suicidal. In one study of and allow the teenagers and their parents
first-grade students in 41 different more than 6,000 adolescents, more than to choose. most selected the combined
classrooms across 19 schools partici- 80 percent of those who were iden- medication/psychotherapy treatment. 32
pated in a two-year randomized con- tified as suicidal had received mental Randomized trials that do manage to
trolled trial of the game. Evaluated health services, often before they start- recruit suicidal teens also require a high
later as teenagers and young adults, ed contemplating suicide. 28 level of commitment from the research
those who played the Good Behavior The authors said they dont know team to manage the patients suicide risk.
Game were half as likely to experi- how many of the healthy adolescents members of your treatment team are on
ence suicidal ideation, or thoughts, as were prevented from becoming suici- call all the time, says Christianne Espos-
the control group and were less likely dal because of mental health treatment. ito-Smythers, a professor of psychology
to attempt suicide, after controlling for It is clear, though, that treatment does at George mason University in fairfax,
gender and depression. 27 not always succeed and the data con- va. At the same time, team members
whats amazing is that the study is firm the difficulty of reducing suicidal need to balance concerns for the safety
just of first- and second-graders. [The re- thoughts and behaviors among ado- of the patient with the scientific needs
searchers] didnt even continue the game lescents, they wrote. 29 of the study, a group of experienced re-
into third and fourth grades, and yet At the moment, there is no fDA- searchers wrote this year in a guide to
they showed a huge impact by the time approved drug for reducing the risk of the dilemmas of suicide research. 33
the kids were 19 and 21, says clinical suicidal behavior, and, so far, research Despite the hurdles, NImH is funding
psychologist Jill Harkavy-friedman, vice on psychotherapy for young people three large randomized controlled trials
president of research at the American who have attempted suicide is scarce. of promising treatments in adolescents.

752 CQ Researcher
Esposito-Smythers is leading one study,
of cognitive behavioral therapy for sui-
cide prevention. The therapy consists of
individual therapy sessions for the teenag-
er, individual sessions for the parents
and family sessions.
The therapy targets common beliefs
and behaviors of suicidal teens and their
parents. Teens and parents work on skills
such as solving problems and regulat-
ing emotions, and families together learn
how to communicate better and create
contracts for desired behavior.
Problems could include skipping
school and beliefs could include a teen
who thinks she is unloved or a parent
who thinks he has failed his child. we
know parents blame themselves, and we
think these thoughts are often not very
true, says Esposito-Smythers. The ther-
apist will help the parent examine that
belief. . . . whats the evidence, what do
you do well as a parent? maybe you are
actually a really good parent and your
kid is just struggling with depression.
A second NImH-funded trial is study-
ing whats known as dialectical behav-
ior therapy, a modified form of cogni-
tive behavioral therapy that emphasizes
validation. The therapist and the patient
work on accepting uncomfortable
thoughts, feelings and behaviors rather
than struggling with them, according
to the virginia-based National Alliance
on mental Illness, a grassroots mental
health organization. Once that happens,
the process of change no longer ap-
pears impossible. 34
The third NImH-funded randomized
trial is examining attachment-based fam-
ily therapy, which is rooted in the be-
lief that strong family relationships can
provide a buffer against adolescent de-
pression or suicide and that ruptured
family relationships can be repaired.
Diamond, who is leading that trial,
says attachment-based family therapy dif-
fers from cognitive behavioral therapy
in a crucial way. Its more about chang-
ing the environment and less about
changing the way kids think, he says.
we dont think that the kids have
www.cqresearcher.com
Teen Suicide-Attempt Rate Rises
A larger share of U.S. high school students said they attempted suicide
in 2013 (8 percent) than in 1991 (7.3 percent). However, the
proportion of students who said they had seriously considered
attempting suicide dropped from 29 percent in 1991 to 17 percent
in 2013, while the share of students who made plans to attempt
suicide dropped 5 percentage points.
Suicide-Related Behaviors, U.S. High School Students
29% (by percentage, 1991-2013)
1991
17% 18.6%
2013
13.6%
7.3% 8%
1.7% 2.7%
Seriously
considered Planned to
attempt Attempted
attempting suicide Required
suicide suicide
medical
treatment
Source: Trends in the Prevalence of Suicide-Related Behavior, National Youth Risk
Behavior Survey: 1991-2013, Centers for Disease Control and Prevention,
http://tinyurl.com/pt2wxqo
these negative ingrained thought pat- proposals, says clinical psychologist Jane
terns . . . we think the stress is real, Pearson, chair of the Suicide Research
says Diamond. most of the kids we Consortium at NImH. maybe we need
see with depression or suicide live in to get investigators from other areas in-
families with a lot of trauma, and that volved, such as genetics and bioinfor-
could be abuse, alcoholism, divorce matics. we need to build the field.
or parents who are harsh and reject-
ing or intrusive and controlling.
Attachment-based family therapy tries
to recalibrate family relationships, tak-
ing families that are out of kilter and
BACKGROUND
helping them to have an appropriate
balance of warmth and structure so No Longer a Crime
that troubled teens can trust and con-
fide in their parents, says Diamond. n most of colonial America, suicide
These trials are a good start, men-
tal health researchers say, but they
I was considered a sin and a crime.
Property could be forfeited and Chris-
would like to see more research into tian burial denied. But as decades passed,
the basic understanding of suicide, its juries became increasingly reluctant to
causes and effective treatments. rule a suicide a crime and instead al-
when there are good proposals, lowed evidence of melancholy to
they get funded. we need more good form the basis for a plea of insanity.
Sept. 12, 2014 753
 TEEN SUICIDE
ization and the accompanying loosening
Warning Signs That Someone Is Suicidal of community ties for tipping vulnerable
Recognizing the signs that a friend or relative may be suicidal can individuals toward self-destruction. Physi-
help save a life, experts say. cians administering a growing number of
asylums for the insane came to believe
Warning signs that someone is in imminent danger: that mental and physical health resulted
Talking about killing themselves, having no reason to live, from the interaction of environment and
being a burden to others, seeking revenge or feeling trapped. individual constitution.
A suicidal patient would be sent to
Increased use of alcohol or drugs.
a rural asylum, treated with sedatives
Researching methods for killing themselves; hoarding pills or
or stimulants and given laxatives and
buying a gun. tonics to improve digestion. 37
Acting recklessly. In 1897, french sociologist Emile
Withdrawing from activities. Durkheim published his groundbreaking
Sleeping too much or too little. book Suicide: A Study in Sociology. After
Saying goodbye to people. studying the higher suicide rates of men
Giving away prized possessions. versus women, single versus married
Experiencing panic attacks. people, soldiers versus civilians and Protes-
tants versus Catholics, Durkheim con-
Risk factors that increase the chance that a person may
cluded that certain groups were better
attempt suicide: able to integrate into society and were
Mental health problems. therefore less prone to suicide.
Alcohol and drug abuse. But as Durkheim was writing, the
Previous suicide attempts; a family history of suicide attempts. new germ theory of physical disease
Being bullied or bullying others. spurred in part by the work of Louis
Access to pills or firearms. Pasteur was leading neurologists to
Barriers to accessing mental health services. search for the pathological origins of men-
tal illness, and by extension, suicide. They
Factors that can mitigate the risk of suicidal behavior: viewed environmental explanations of
Good problem-solving skills. the etiology of suicide as unscientific and
Strong connections to family, friends and the community. as unworthy of serious consideration,
Restricted access to lethal means of suicide. wrote Kushner. 38
Access to mental health services. By the early-20th century, a con-
Cultural or religious beliefs that discourage suicide. sensus had developed among Ameri-
can psychiatrists that mental health dis-
Source: Nadine Kaslow, Teen Suicides: What Are the Risk Factors? Child Mind orders characterized by distorted notions
Institute, May 2013, http://tinyurl.com/leefd9k; Warning Signs and Risk Factors, of reality, such as schizophrenia, were
American Foundation for Suicide Prevention, undated, http://tinyurl.com/lgo24gn neurological in origin but that emo-
tional disorders, such as melancholia
By the mid-18th century, most coro- cide cases, and, eventually, legislatures and suicide, were psychological. Even
ners jurors in massachusetts had come recognized this turn in public opinion. if social factors did play a role in sui-
to believe what many English physicians During the American Revolution, virginia cide, it was thought that the emphasis
had argued since the 17th century, that became the first jurisdiction to do away should be on changing the patient rather
melancholy was a disease. And, as a with forfeiture of a suicide victims prop- than society, and psychiatrists began to
disease, melancholy could not be used erty. By the late 18th century, jurisdic- adopt individual psychotherapy.
as evidence of criminal intent, wrote tions from massachusetts to virginia, Psychiatrists were particularly recep-
historian of medicine Howard I. Kush- whether by statute or practice, had come tive to the psychoanalytic theories of
ner in Self-Destruction in the Promised to accept the notion that suicide was an Austrian neurologist Sigmund freud,
Land: A Psychocultural Biology of Amer- act whose commission was itself suffi- who asserted suicide was the result of
ican Suicide. 35 cient punishment, wrote Kushner. 36 internal psychopathologic conflicts,
Juries in other colonies also began to In the 19th century, as the United States wrote Kushner. 39
routinely allow pleas of insanity in sui- industrialized, social critics blamed urban- Continued on p. 756

754 CQ Researcher

1890s-1960s
Field of suicidology is estab-
lished; first crisis center opens.
1897
Groundbreaking study by french
sociologist Emile Durkheim exam-
ines the different suicide rates
among groups, such as men ver-
sus women and Catholics versus
Protestants.
1957
American psychologists Edwin
Shneidman and Norman farberow,
in landmark Clues to Suicide, say
no suicide is a rational act.
1958
The countrys first suicide-prevention
center opens in Los Angeles.
1962
Actress marilyn monroes apparent
suicide prompts a surge in calls to
the Los Angeles crisis center.
1967
The National Institute of mental
Health creates the Center for Studies
of Suicide Prevention with Shneid-
man at its helm.
1968
Shneidman founds the American
Association of Suicidology.
1970s-1990s
Families touched by suicide
form grassroots organizations;
Congress passes resolutions
calling suicide prevention a
national priority.
1976
American Association of Suicidology
establishes its crisis center certifica-
tion program.
www.cqresearcher.com
Chronology
1987
families affected by suicide and sci-
entists form the American foundation
for Suicide Prevention.
1989
Adina wrobleski, whose daughter
died by suicide, forms Suicide
Awareness voices of Education, to
prevent suicide and reduce stigma
through public awareness and edu-
cation. . . . first federal government
report on youth suicide, prepared
by the Task force on Youth Suicide,
cites a need for more research on
youth suicide and more evaluations
of prevention programs.
1993
Shneidman publishes influential
Psychache: A Clinical Approach to
Self-Destructive Behavior, concluding
that suicide is the result of intoler-
able psychological pain.
1997
Congress passes resolutions recogniz-
ing suicide as a national problem
and prevention as a national priority.
1998
Grassroots organizations and the
Centers for Disease Control and
Prevention organize a national
suicide summit in Reno, Nev.
2000s-Present
Congress creates a grant program
for youth suicide-prevention pro-
grams. . . . Food and Drug
Administration (FDA) requires
controversial warnings on
antidepressants about their
suicide risk.
2001
Substance Abuse and mental Health
Services Administration (SAmHSA)
establishes a national network of
certified crisis call centers, now
called the National Suicide Preven-
tion Lifeline. . . . federal govern-
ment publishes The National Strat-
egy for Suicide Prevention,
designed to transform attitudes,
policies and services.
2002
SAmHSA creates Suicide Prevention
Resource Center, a registry of evi-
dence-based practices and programs.
2003
Clozapine for schizophrenia becomes
the first fDA-approved drug for use
with suicidal patients.
2004
The Garrett Lee Smith memorial Act
is adopted to provide grants for
youth suicide-prevention programs.
. . . fDA requires black-box warning
labels on antidepressants saying that
children and adolescents taking the
drugs are at increased risk of suicidal
thinking and behavior.
2005
American psychologist Thomas
Joiner, in Why People Die by Suicide,
says suicide results from thwarted
feelings of belonging and percep-
tions of being a burden, combined
with the acquired capability to in-
flict lethal self-injury.
2007
fDA extends the warnings on anti-
depressants to include young adults;
prescriptions for antidepressants de-
cline over the next several years.
2012
The National Strategy for Suicide
Prevention is revised to include an
emphasis on community involvement.
2014
wyoming becomes the 13th state
to pass the Jason flatt Act, which
typically requires middle and high
school educators to receive suicide
awareness and prevention training.
Sept. 12, 2014 755
 TEEN SUICIDE

media, Schools Can Help Reduce Copycat Suicides, Experts Say

If it is not a celebrity, the story should not be on the front page.
month after actor and comedian Robin williams died from coverage after the lone suicide. There were more news

A by suicide, the tabloid press continues to dissect his

last days in articles and photographs. But perhaps the
most iconic and, to suicide experts, most disturbing image might
have been an Academy of motion Pictures Arts and Sciences
tweet posted the day williams was found dead. It contained a
still shot from the Disney animated film Aladdin, in which the
main character is hugging a smiling Genie, voiced by williams,
against a starry sky. The caption reads, Genie, youre free.
If it doesnt cross the line, it comes very, very close to it,
said Christine moutier, chief medical officer at the American
foundation for Suicide Prevention, because the tweet treated
suicide as a release from pain. Suicide should never be pre-
sented as an option. 1
Experts worry that the wrong kind of media coverage can
encourage copycat suicides among vulnerable individuals al-
ready at risk for suicide. The vulnerable individual will identi-
fy with the persons problems and the persons solution, says
madelyn Gould, a professor of epidemiology in psychiatry at
Columbia University.
Theres an exception, Gould points out. when the person
who died by suicide is very, very close, people know how
hurtful it is to those who remain, and so it doesnt seem to
have as much of an influence, she says.
Gould and several colleagues recently published a journal
article in The Lancet Psychiatry about their study of suicide
clusters in young people aged 13 to 20 years. (Clustering is
more common among youths than in the general population,
according to Goulds previous research.)
The researchers compared the clusters to communities in
which only one suicide occurred. They found that newspaper
coverage after the first suicide of a cluster was quite different
stories, and the articles were more likely to be on the front
page, to describe the suicidal act in detail, and to have a head-
line containing the word suicide or the method used. 2
If it is not a celebrity, the story should not be on the front
page. There should not be multiple stories. There should not be
the word suicide in the headline or details about the suicidal act
itself, says Gould. And she says reporters should include the Na-
tional Suicide Prevention Lifeline number, community resources,
and the risk factors and warning signs for suicide.
But heres the problem for journalists, blogged Kelly mcBride,
vice president of academic programs at the Poynter Institute in
St. Petersburg, fla., which trains new and experienced jour-
nalists. Those are the devices of good story-telling and effec-
tive headline writing. Suicides are tragic events. And when you
decide a story is interesting enough to tell, you want to pack
it full of emotional punch. mcBride, who was initially skepti-
cal about the role of media coverage in suicide contagion,
wrote that Goulds study persuaded her that some coverage
can make suicide more likely. 3
Gould points journalists to The Recommendations for Re-
porting on Suicide, developed by leading suicide prevention
experts in collaboration with journalists and media organiza-
tions, including Poynter. 4
following the 1994 suicide of grunge rock musician Kurt Cobain
of Nirvana in Seattle, calls to suicide crisis lines in the region
surged, but there was no significant increase in suicides. Re-
searchers who studied the aftermath of Cobains death hypothe-
sized that the lack of copycat suicides in the area might have
been due, in part, to the local media coverage, which focused
on the pain his suicide caused family members and included dis-
cussions of mental health disorders and their treatment. 5

Continued from p. 754
Prevention Movement
y the mid-20th century, an esti-
B mated 16,000 Americans took their
lives each year. 40 Yet medical litera-
ture and books on suicide were rare.
That changed in the 1950s with the
emergence of the suicide-prevention
movement and the field of suicidolo-
gy the formal, multidisciplinary study
of the nature, causes and prevention
of suicide.
In 1949, clinical psychologist Edwin
Shneidman began to research suicide
after finding hundreds of suicide notes
at the Los Angeles County coroners
office. In 1957, Shneidman and fellow
psychologist Norman farberow pub-
lished Clues to Suicide. Shneidman
and farberow concluded, based on a
study of the suicide notes, that no sui-
cide was a rational act. 41
One year later, the two psychologists
opened the first U.S. suicide-prevention
center, in Los Angeles, with funding
from the U.S. Public Health Service. Psy-
chiatrist Robert Litman was its director.
The staff of three soon was overwhelmed
with requests for services, and Litman
hired and trained eight volunteers.
As an experiment, staff and volun-
teers stayed after working hours to see
whether the need for service persisted
throughout the night. Thus began the
first suicide prevention crisis line, ac-
cording to a history of the center. In the
early 1960s, the coroners office began
to ask the center staff to help investigate
deaths with uncertain cause, and, in 1962,
Litman led the investigation into the
death of actress marilyn monroe at age
36. monroes death from an overdose of
barbiturates, ruled a probable suicide,
prompted a surge in calls to the center.
Throughout the 1960s, other crisis-
intervention centers were established, and

756 CQ Researcher
 Suicide clusters are actually quite rare, says Gould, account-
ing for no more than 10 percent of all completed suicides among
teenagers, for example. But we think it [suicide clusters] can be

Getty Images/Frank Micelotta

prevented, she says. Sensitive media coverage is important, ex-
perts say, but so is the way schools handle a suicide death.
franci Crepeau-Hobson, a professor of school psychology
at the University of Colorado Denver, says sometimes schools
that have experienced a cluster of suicides make the mistake
after the initial suicide of not talking about it at all, while oth-
ers go to the opposite extreme. Im on a couple of different
crisis-response teams that have been called into school districts
after a rash of suicides and where, for example, they had a
huge memorial after the first one and called all this attention After the 1994 suicide of Nirvana frontman Kurt Cobain in
to the deceased, she says. That kind of attention can unin- Seattle, researchers hypothesized that the lack of copycat
tentionally glorify suicide, she says. suicides locally might have been due, in part, to
Crepeau-Hobson says all schools should: media coverage focusing on the pain his death
Adopt policies on student memorials; caused family members.
Establish a crisis team ready to react to a student suicide; know a peer attempted can be helpful, says Crepeau-Hobson,
Avoid glorifying or vilifying the dead student; and but its really, really hard.
Provide support and counseling to at-risk students par- Barbara Mantel
ticularly vulnerable to contagion.
Just as completed suicides can affect suicidal thoughts and 1 Caitlin Dewey, Suicide contagion and social media: The dangers of sharing
behaviors of teenage friends and acquaintances, so can suicide Genie, youre free, The Washington Post, Aug. 12, 2014, http://tinyurl.com/l444b3r.
attempts. In fact, Crepeau-Hobson and colleagues found in a 2 madelyn Gould, et al., Newspaper coverage of suicide and initiation of

recent study of the impact of youth suicidal behavior on peers
that the impact of suicide attempts may be even greater. Do
we know exactly why? No, she says. But she speculates that
it could be because schools often are not aware of a students
suicide attempt while friends are, and so the school has no
chance to provide support and counseling.
I think making it safe for kids to let adults in a school set-
ting know when they have attempted suicide or when they
suicide clusters in teenagers in the USA, 1988-96: a retrospective, population-
based, case-control study, The Lancet Psychiatry, June 2014, http://tinyurl.
com/os59o8x.
3 Kelly mcBride, Can journalists prevent suicide clusters, Poynter Institute,
updated may 9, 2014, http://tinyurl.com/q85h6dv.
4 The Recommendations for Reporting on Suicide, undated, http://reporting
onsuicide.org.
5 Jennifer michael Hecht, Stay: A History of Suicide and the Philosophies
Against It, 2013, p. 171; margot Sanger-Katz, The Science Behind Suicide
Contagion, The New York Times, Aug. 13, 2014, http://tinyurl.com/ogtewwn.

in 1967 the National Institute of mental
Health created the Center for Studies of
Suicide Prevention, with Shneidman at
its helm. After observing the limited
amount of available data, Shneidman
founded the American Association of
Suicidology in 1968 to study suicide. The
association developed a certification pro-
gram for suicide crisis centers and cer-
tified its first center in 1976. 42
These early efforts were expanded
upon in the 1980s with the support and
passion of individuals who had been
bereaved by suicide loss, according to
a report from the U.S. Surgeon Gener-
al. with limited funding and formal or-
ganization, these individuals and their
grassroots organizations set out to place
suicide on the national agenda. 43 They
were especially concerned with rising
suicide rates among adolescents. The
suicide death rate for 15- to 19-year-
olds, for instance, rose from 8.62 per
100,000 in 1981 to 11.14 in 1990. *
In 1987, a group of families touched
by suicide joined with scientists to
form the American foundation for Sui-
cide Prevention to fund research, ed-
* Rates before and after 1999 should be com-
pared cautiously because of changes in method-
ology.
ucate professionals and the public, and
provide resources for family and friends
and for people at risk. Two years later,
Adina wrobleski, whose daughter died
by suicide, founded Suicide Awareness
voices of Education, or SAvE, to pro-
vide public awareness and education.
Other grassroots groups were formed
over the next decade.
In 1989, a government Task force
on Youth Suicide published a report
that found:
Knowledge about youth suicide
was limited;
Acquiring this knowledge required
in-depth research;

www.cqresearcher.com Sept. 12, 2014 757

 TEEN SUICIDE
Suicide-prevention methods need-
ed evaluation; and
Effective approaches to preven-
tion must include committed individ-
uals in health, mental health, educa-
tion and social services in both the
public and private sector. 44
In 1993, Shneidman published Sui-
cide as Psychache: A Clinical Approach
to Self-Destructive Behavior, in which
he posited that individuals with a low
threshold for psychological pain are
the most vulnerable to suicide. 45
Responding to citizen-led groups,
Congress in 1997 passed two resolu-
tions recognizing suicide as a national
problem and suicide prevention as a
national priority. The next year, citizen
groups and the Centers for Disease
Control and Prevention jointly spon-
sored a national conference on suicide
prevention in Reno, Nev., viewed as the
founding event of the modern suicide
prevention movement, according to the
Surgeon Generals report. 46
These efforts culminated in the 2001
release of the National Strategy for Sui-
cide Prevention, produced by experts
from the private and public sectors and
coordinated by the U.S. Department of
Health and Human Services. It was meant
to serve, in its words, as a catalyst for
social change, with the power to trans-
form attitudes, polices and services. 47
Goals included promoting awareness;
supporting prevention; reducing access
to lethal means; training teachers, po-
lice officers, doctors, nurses and men-
tal health care providers to recognize
suicide risk; improving access to men-
tal health and substance-abuse services;
and supporting research. 48
In 2002, the federal Substance Abuse
and mental Health Services Adminis-
tration (SAmHSA) established a na-
tional network of local, certified crisis
call centers, now called the National
Suicide Prevention Lifeline. It serves as
a central switchboard, currently con-
necting a caller to the closest of 165
crisis centers across the country, 24 hours
a day, seven days a week.
758 CQ Researcher
Three years later, the Garrett Lee Smith
memorial Act was signed into law, the
most important legislative accomplishment
in the field of youth suicide prevention
in the past decade, according to the 2012
National Strategy for Suicide Prevention,
a revision of the 2001 strategy. The act
was named for the son of former Sen.
Gordon Smith, R-Ore., a college student
who died by suicide in 2003.
Through the act, the only federal pro-
gram that specifically targets teen suicide,
the federal government gives states and
Indian tribes $30 million annually to de-
velop and implement early intervention,
assessment and treatment services; in-
formation and awareness campaigns; train-
ing programs for service providers and
child care professionals; and tools to eval-
uate these programs. Another $20 mil-
lion funds other programs, including ser-
vices and outreach on college campuses
and the Suicide Prevention Resource
Center, which maintains a registry of
evidence-based practices and programs
for suicide prevention and interventions.
meanwhile, theories of suicide con-
tinued to evolve. In 2005, florida State
Universitys Joiner published Why Peo-
ple Die by Suicide. According to Join-
er, perceptions of not belonging and of
being a burden can lead to a desire to
die by suicide, and, combined with an
acquired capability to lethally injure one-
self, can result in serious suicide at-
tempts and deaths by suicide. 49
Pharmacology and Suicide
esearchers have undertaken nu-
R merous medical trials to study the
impact of pharmaceutical drugs on psy-
chiatric conditions such as depression,
bipolar disorder and substance abuse,
which often accompany suicidal thoughts
and behavior.
Robust treatment of the underlying
psychiatric illness has been the most
effective antisuicide approach, wrote
doctors maurizio Pompili and mark J.
Goldblatt in a review of the history of
drug therapy. Yet tens of thousands of
U.S. teens and adults continue to die
by suicide each year, and there have
been few studies of the direct impact
of these drugs on suicide. 50
One exception was the International
Suicide Prevention Trial, a randomized
trial that compared the antipsychotic
medications clozapine and olanzapine
in patients with schizophrenia and
schizoaffective disorder at high risk for
suicide. Suicide attempts, hospitaliza-
tions and rescues were significantly de-
creased in patients on clozapine. As a
result, in 2003 clozapine for schizo-
phrenia became the first fDA-approved
medication indicated for use with sui-
cidal patients. 51
A recent meta-analysis of data on the
long-term use of the mood stabilizer
lithium in bipolar disorder or other major
mood disorders showed an 80 percent
reduction in the risk of suicide attempts
and suicides.
But Pompili and Goldblatt wrote,
Evidence that antidepressant treatment
decreases suicide risk or suicide at-
tempts is mixed. 52 most studies look-
ing at antidepressant use and suicide
are correlational, that is, they compare
suicide rates over time with prescrip-
tion rates for antidepressants. Thats
not as robust a study as a random-
ized controlled trial, where one group
receives the drug being tested and an-
other group receives treatment as
usual or a placebo. But there have
been no randomized trials examining
antidepressants alone compared with
other treatments or placebos in peo-
ple at high risk of suicidal behavior,
in part because it has proved difficult
to recruit suicidal patients.
Nevertheless, there has been con-
cern that antidepressants could actu-
ally increase suicide risk in young peo-
ple. In 2002, reports surfaced that a
small percentage of children in trials
of the drug Paxil showed signs of sui-
cidal behavior. The fDA ordered its
own review of 25 antidepressant drug
Continued on p. 760
 Internet Can Provide Support, Information
In some ways it did save my life.
hen University of British Columbia student Ameera Ladak, dal thoughts, but hearing about suicides through online forums

w now 20, was diagnosed with depression and became

suicidal last year, she turned to the Internet for help.
During the worst of the crisis, I was very secretive. The In-
was associated with an increase in suicidal thinking. 5
we interpreted that to mean that social networking sites pro-
vide support, just like friends and family, says study co-author
ternet gave me anonymity, recalls Ladak, who made two suicide Daniel Romer, director of the Adolescent Communication Insti-
attempts, but aborted both and checked herself into a hospital. tute of the Annenberg Public Policy Center at the University of
Teenagers who intentionally harm themselves spend more Pennsylvania. But it appears information from anonymous online
time on the Internet than other kids, research shows. 1 Often forums is not so helpful, not as supportive as friends and fam-
they are looking for support, as Ladak was. She says she prob- ily and people they know on facebook, says Romer.
ably would have tried to kill herself more than twice if it hadnt
been for the Internet, where she looked up crisis center hot-
lines and used the live chat function to reach out some-
times, typing was easier than talking on the phone. In some
ways it did save my life, she says. They talked me down.
Online, Ladak was able to find explanations of her condition.
I couldnt really make sense about what I was feeling, she says,
and so she visited the official websites of suicide-prevention or-
ganizations. I really trusted those sources.
A study by Swedish researchers of websites about suicide
that were found through a Google search determined that pages
of organizations predominate, providing information about re-
search and prevention. However, there are also a substantial
number of private pages, often anti-medical and characterized

Courtesy Ameera Ladak

by dialogue, confessions and narratives, and to a higher degree,
an alternative pro-suicide stance, the authors wrote. 2
In one highly publicized case four years ago, a 24-year-old
user of the suicide discussion section of Reddit announced his
intention to kill himself and then carried out his plan. many
of the comments he had received were sympathetic and offered
advice, but others encouraged him to take his life. 3
Ladak says she avoided negative websites. If you are in a
vulnerable place, it is so easy to get caught up in that negative
stuff, she says.
University of Oxford researchers reviewed more than a dozen
studies dealing with teen Internet use, suicide and self-harm
and found, not surprisingly, that the Internet can provide sui-
cidal teens with much-needed support, but can sometimes push
vulnerable youths over the edge. 4 my takeaway message is
that clinicians and families need to ask kids about their Inter-
net usage, says review co-author Paul montgomery, a professor
of psycho-social intervention.
Researchers have found that social networking sites and on-
line discussion forums affect vulnerable youths differently. In
one study, researchers interviewed hundreds of young people
ages 14 to 24 and then re-interviewed them one year later,
asking if they knew of people who had died by suicide, how
they heard about it and whether they themselves had suicidal
thoughts or feelings of hopelessness. It turned out that hear-
ing about someones suicide through social networking sites,
such as facebook, was not associated with increases in suici-
Suicide-prevention chat sites helped university student
Ameera Ladak find support when she was feeling suicidal.
They talked me down, she says.
most government and organization websites provide infor-
mation but dont allow discussion. Says Romer, we should
have more sites online that young people can go to where
they can talk about their suicidal ideation issues and why theyre
feeling that way and that can help them cope.
Barbara Mantel
1 Kate Daine, et al., The Power of the web: A Systematic Review of Studies
of the Influence of the Internet on Self-Harm and Suicide in Young People,
PLOS One, Oct. 30, 2013, p. 4, http://tinyurl.com/przapej.
2 michael westerlund, et al., The Representation of Suicide on the Internet:
Implications for Clinicians, Journal of Medical Internet Research, Sept. 26,
2012, http://tinyurl.com/nrtklnr.
3 Sally m. Dunlop, et al., where do youth learn about suicides on the In-
ternet, and what influence does this have on suicidal ideation?, Journal of Child
Psychology and Psychiatry, June 10, 2011, p. 1074, http://tinyurl.com/nxgwzls.
4 Nancy Schimelpfening, Can the Internet Cause Teens to Commit Suicide,
Liberty Voice, Oct. 31, 2013, http://tinyurl.com/kml8cpu.
5 Sally m. Dunlop, op. cit.

www.cqresearcher.com Sept. 12, 2014 759

 TEEN SUICIDE
multaneous, small increases in suicide
attempts, although no change in much
rarer completed suicides.
I do think some kids are suffering
because they just arent getting the right
treatments. And for many thats med-
ication combined with some type of
therapy, said Louis Kraus, chief of child
and adolescent psychiatry at Chicagos

Getty Images/Frazer Harrison

Rush University medical Center. Kraus
is not connected to the study. 54
However, some researchers ques-
tioned how Lu and colleagues mea-
sured suicide attempts and, as a re-
sult, their conclusions. In addition, the
fDA said it plans no changes in its
black-box warning.
Clark Flatt, left, president of the Jason Foundation, and supporters announce the At this time nothing indicates a need
foundations teen suicide awareness and prevention campaign, in Beverly Hills, for change in the Boxed warning on
Calif., on Sept. 18, 2002. From all appearances . . . my son loved life. But on these drugs, which urges attention to
July 16th in 1997, everything changed. Jason became a statistic of the Silent
patients starting treatment, which the
Epidemic of youth suicide. . . . I will never hug my son again. But I can and will
work alongside you . . . perhaps to save your friend, your neighbors child, a relative fDA feels is still good advice, fDA
or even your own son or daughter, Flatt writes on the foundations website. spokeswoman Sandy walsh said in an
email to NBC News. The warnings do
Continued from p. 758 Despite this inconclusive evidence, not suggest avoiding the drugs. The
trials, which found evidence of an the fDA advisories and the boxed fDA has not tried to discourage the
increase suicide risk for children and warnings received repeated and wide- use of antidepressant drugs in people
adolescents taking the drugs. spread media coverage in major news- who may benefit from them. 55
After an fDA-sponsored public hear- papers and television networks, wrote
ing, in which a parent of a 13-year- Harvard medical School researcher
old boy who died by suicide while
on Zoloft testified, the agency in Oc-
Christine Y. Lu and colleagues in a
June 2014 journal article. 53 CURRENT
tober 2004 required a black-box warn-
ing on the labels of all antidepres-
sants. The warning said that children
and adolescents taking these drugs
Research studies have shown a marked
decline in the diagnosis of depression
in children and substantial reductions in
prescriptions of antidepressants after the
SITUATION
were at increased risk of suicidal think- black-box warnings and subsequent
ing and behavior. * Two-and-a-half years media attention. And after declining in Federal Legislation
later, the fDA extended the warning to the 1990s and again in the first half of
the 2000s, the suicide rate for individu- dvocacy groups are urging Con-
include young adults. However, the fDA
review was of previous drug trials that
were not designed to measure suicide
als ages 10 to 19 began to rise, erasing
the progress made earlier in the decade.
A gress to reauthorize the Garrett
Lee Smith memorial Act, which, among
risk, and the majority of harmful events But any number of factors could be other things, would increase authoriza-
involved suicidal thinking, not suicide at- behind increasing youth suicide rates, tion for youth programs by $2 million
tempts or suicides. There were no com- including a worsening economy. To get a year to $32 million through fis-
pleted suicides in the studies. a better sense of what happened, Lu cal 2016.
and colleagues looked at data from 19 It is an incremental increase, which
* A black-box warning is the most serious warn- health care organizations and found a we would be happy to get, says John
ing placed on prescription medication labels. The substantial reduction in antidepressant madigan, vice president of public pol-
warning on antidepressants did not ban physi- use among adolescents and young adults icy at the American foundation for
cians from prescribing those medications to chil- after widespread media coverage of the Suicide Prevention. The bill has been
dren and adolescents. fDA warnings. They also found si- Continued on p. 762

760 CQ Researcher
 At Issue:
Should doctors universally screen teen patients for suicide risk?
yes
KELLY POSNER
FOUNDER AND DIRECTOR, CENTER FOR
SUICIDE RISK ASSESSMENT AT COLUMBIA
UNIVERSITY; PRINCIPAL INVESTIGATOR OF
THE FDA/COLUMBIA SUICIDE ASSESSMENT
PROJECT
WRITTEN FOR CQ RESEARCHER, SEPTEMBER 2014
s
yes no
uicide is one of societys greatest public health crises,
and the magnitude of its global disease burden is under-
recognized yet it is preventable. Every 13 minutes,
someone in this country dies by suicide, and it is the second-
leading cause of death among 10- to 24-year-olds. Nearly 10 per-
cent of high school students report having attempted suicide in
the past year, and this is likely a gross underestimate.
In order to make an impact on these sobering statistics, we
need to change the way we think and talk about suicide, and
the best place to start is at the doctors office. why? fifty percent
of people who die by suicide see their primary-care provider
within the month before they die, making doctor visits an
ideal opportunity for prevention. many adolescent attempters
come to the emergency room for non-psychiatric reasons, so
if we do not screen we will not find teens who need help.
we should be asking about suicide like we monitor for blood
pressure but assessment of depression and suicide is typi-
cally not part of medical examinations. Evidence has shown
that screening is highly effective in identifying at-risk adoles-
cents, and that screening in primary care contributes to more
accurate diagnosis and better treatment of adolescent depression,
and actually reduces rates of suicide.
why isnt screening the universal norm? Partly due to fear
that screening can have an iatrogenic effect (i.e., asking about
suicide might put the idea in someones head), which has been
specifically studied and clearly debunked as a myth.
Additionally, some are concerned about the burden of such
general screening. However, from a cost-benefit standpoint, it
should be an easy decision. Standardized screening takes a
few seconds, is freely available and actually decreases eco-
nomic and systemic burdens by reducing unnecessary inter-
ventions (such as ER overuse), all while helping to save lives.
meanwhile, the price of losing a loved one to suicide is in-
comprehensibly high.
while no one approach will be the magic solution to the
crisis of suicide, screening is an essential tool in the prevention
repertoire. many expert organizations already advocate for
primary-care screening, including the National Action Alliance
for Suicide Prevention, American Academy of Child and Ado-
lescent Psychiatry, American Academy of Pediatrics, and Ameri-
can medical Association. If we do not screen, we will not find
the teens suffering in silence.
no
www.cqresearcher.com
LLOYD I. SEDERER
MEDICAL DIRECTOR, NEW YORK STATE
OFFICE OF MENTAL HEALTH; ADJUNCT
PROFESSOR, COLUMBIA MAILMAN SCHOOL
OF PUBLIC HEALTH; AUTHOR, THE FAMILY
GUIDE TO MENTAL HEALTH CARE
WRITTEN FOR CQ RESEARCHER, SEPTEMBER 2014
s
uicide is the third-leading cause of death in young adults
and the second-leading cause in younger teenagers. The
need to reduce the incidence of suicidal behaviors is,
thus, greater than it has ever been in youths as well as
adults. So, I unequivocally support strategies that reduce suicide
risk. But screening alone is not one of them.
Depression affects one in six people in their lifetime. It is
one of the greatest causes of medical morbidity and long-term
disability. Depression, as well, is found as an active condition
in the vast predominance of adults who take their lives. for
youths, the data are not as clear but depression is common.
Screening for medical conditions has become an essential
part of good medical care. Think of diabetes, hypertension,
colon cancer and many other conditions. Depression needs to
be detected in primary care and once found effectively treated;
we dont just screen for high blood pressure, we treat it when
it appears.
The same is true for depression: we first must find it and
then treat it. If we dont have proven methods of delivering
effective care, and supplying the resources needed, we
should not (yet) screen. (In the may 2014 issue of JAMA
Psychiatry, I described the circumstances and interagency
partnership that permitted the launch of a New York State
initiative to fully integrate behavioral health care into ambula-
tory primary-care resident training sites, including the essen-
tial elements, implementation challenges and what must be
done for sustainability.)
Effective depression detection and treatment for adults in
primary care has been achieved in more than 60 replication
studies. The work is beginning for youths: while promising,
it is not quite ready for prime time. we should not try to
install depression screening in youths until we know that
depression can be effectively treated in a medical, primary-
care environment.
we should not screen for suicide (as opposed to depression)
risk in youths because of how remarkably infrequently it will
be found. moreover, as already stated, if suicide risk were
found, we would then need to detect its primary driver(s),
including depression, and be able to care for that illness in
primary-care settings. we are not there yet. Some great teams
are working on making depression care for youths happen in
general medical settings the sooner the better.
Sept. 12, 2014 761
 TEEN SUICIDE
fore the death rate by suicide will de-
21 States Require Suicide-Prevention Training cline. Other programs point the way, he
Five states require school personnel to receive annual suicide- says. we charted the increase in re-
search funding in breast cancer, and we
prevention training, 16 require training on a non-annual basis and
charted the decrease in mortality. It is
17 encourage but do not require training. clearly related. The $2 million to $5 mil-
Suicide-Prevention Training Laws for School Personnel, by State lion his organization awards each year
to researchers is divided into small grants
Wash. Mont. N.D. N.H.
Minn.
Vt.
and is only seed money, he says.
Wis. Maine
S.D.
Ore. Idaho Wyo.
Iowa
Mich. N.Y. Mass. State Legislation
Neb. R.I.
Pa.
Ill. Ind. Ohio he Jason foundation, a training and
Calif.
Nev. Utah Colo. Kan. Mo.
Ky.
W.Va.
Va.
Conn.
N.J.
Del.
T advocacy group in Tennessee, has
lobbied for seven years for the Jason
Okla. Tenn. N.C.
Ariz. Ark. Md. flatt Act, now law in 13 states. The law,
N.M. S.C. D.C.

Texas
Alaska
Hawaii
Source: State Laws: Suicide Prevention Training for School
Personnel, American Foundation for Suicide Prevention,
June 2014, http://tinyurl.com/q4k3pfd
Continued from p. 760
in committee in both houses of Con-
gress since last year.
Congress has never reauthorized the
act since President George w. Bush
signed it into law 10 years ago. Instead,
lawmakers appropriate funds each year,
never increasing the amount. funding
was $50 million at the start and its
$50 million now, says madigan.
According to a report to Congress
released in february, between Octo-
ber 2005 and September 2012 the youth
suicide-prevention programs run by
states and tribes have trained 490,000
community members, teachers, fire
fighters, college students, professors,
parents and others in suicide preven-
tion; screened tens of thousands of
youths for suicide risk and steered
many to services; and promoted col-
laboration among public and private
agencies. 56
Yet more work needs to be done,
according to the report. Among other
things, the report found that:
La.
Miss.
Ala. Ga.
Fla.
training
many at-risk youths are not fol-
lowing through to obtain services, often
because they fail to bring in parental
permission forms;
19- to 24-year-olds not in college
are being neglected;
more targeted prevention programs
are needed for youths involved in the
juvenile-justice and foster care systems
and those seen in emergency rooms; and
Suicide awareness training should
be targeted to adults who demonstrate
a capacity for effectively relating to
youths. 57
Suicide-prevention organizations are
also lobbying for the Sprint Act, short
for Suicide Prevention Research Inno-
vation Act, introduced in both the Sen-
ate and the House in february and now
in committee. It would double the amount
of money the National Institute of men-
tal Health devotes to suicide research
from $40 million to $80 million a year.
Even so, madigan calls it a drop in
the bucket and says much more gov-
ernment research funding is needed be-
named after a 16-year-old who died by
Require annual suicide in 1997, usually requires two
training hours of training of school personnel
Require to recognize and respond to suicidal
non-annual
training youths. Some states require annual train-
Encourage but ing, others every two, three or five years.
do not require Under Californias version of the law the
Have no training training is voluntary and up to each
law school district.
Although the foundation has online
training seminars and DvDs, the law
never mandates that the foundations
materials be used. President Clark flatt,
Jasons father, says teacher training, no
matter who provides it, doesnt need
to cost the state a penny. His group
provides free training materials to states
that have passed the act, as do other
mental health organizations.
flatt is working to pass the Jason flatt
Act in Texas and North Carolina and
says he has been contacted by interest-
ed people from Georgia and montana.
In the past, the law has met with
initial skepticism from teachers. The
first time we presented it to the teachers
union or association in all 13 states,
they said, we dont support it. what
it boiled down to is that we used the
word mandate, says flatt. But after ex-
plaining that many state child-abuse laws
already hold teachers responsible for
reporting emotional and physical abuse,
even when self-inflicted, and that train-
ing does not try to turn teachers into
suicide counselors, flatt says, the foun-

762 CQ Researcher
dation convinced teacher groups to
support the law.
Other state laws call for training school
personnel in suicide prevention. In total,
five states require annual training; 16
mandate less frequent training; 17, like
California, encourage training; and 12
have no training law. (See map, p. 762.)
Some states have recently embraced
a more comprehensive approach to sui-
cide prevention, says Nicole Gibson, se-
nior manager of state advocacy at the
American foundation for Suicide Pre-
vention. Pennsylvania this year adopt-
ed legislation requiring not only train-
ing of school personnel but also
development of formal school suicide-
prevention policies and student educa-
tion; Oklahoma adopted legislation en-
couraging such training and policies.
Gibson says she cant think of any
state legislation that requires or en-
courages screening students for sui-
cide risk. Parents and guardians are
concerned about their child being la-
beled and making sure that they are
asked for permission, she says.
Training legislation aimed at other
professionals is also running into ob-
jections from trade associations. In 2012,
washington state passed the matt Adler
Suicide Assessment, Treatment, and man-
agement Act, the first law in the coun-
try to require that certain licensed health
care professionals obtain continuing ed-
ucation in the assessment, treatment and
management of suicide risk. It went into
effect this January. But a similar bill in
California faces opposition.
That legislation would require psy-
chologists, marriage and family coun-
selors and social workers to take a
one-time, six-hour continuing educa-
tion course. And it would require 15
hours of course work in suicide pre-
vention for students in these fields. It
passed both houses of the California
legislature this year and is backed by
mental health organizations. But the
associations representing psychologists,
counselors and social workers object
that such training might be redundant
www.cqresearcher.com
and that setting professional standards
is best left to licensing boards.
Democratic Gov. Edmund G. (Jerry)
Brown Jr. will decide the bills fate. In
2011, Brown vetoed a similar bill that
would have required licensed health care
professionals to take a continuing edu-
cation course on caring for lesbian, gay,
bisexual and transgendered people.
I believe that respective licensing
boards are better suited than the Leg-
islature or the Governor to decide these
matters, Brown wrote at the time. 58
Neurobiology of Suicide
hile researchers have identified
w factors that lead to a lifetime risk
of suicide, clinicians remain ill-
equipped to discern which children are
going to attempt to kill themselves, says
Lisa Pan, a psychiatry professor at the
University of Pittsburgh. we really cant
explain right now why of two adoles-
cents with similar stressors and similar
mental health conditions, one will at-
tempt suicide and one wont, she says.
Clinicians also are not very good
at predicting who is at immediate risk,
she says, and even when at-risk teens
are identified, some dont respond to
standard treatments.
So researchers have been trying to
understand the neurobiology of teen
suicide to identify markers that might
better predict suicide risk and lead to
improved drug and psychotherapy treat-
ments. Some have found anomalies in
the brains of teens who have died by
suicide.
Pan has been pursuing two other
tracks. In the first, she uses functional
magnetic resonance imaging, or fmRIs,
to scan the brains of three groups: teens
with depression who attempted suicide;
teens with depression who never at-
tempted suicide, and healthy control
subjects. She found differences in brain
structure, blood flow and communica-
tion between areas of the brain in the
brains of suicide attempters compared
with the other groups when showing
them pictures of faces.
In particular, Pan found that when
adolescents who have attempted sui-
cide are processing negative emotion,
the area of the brain needed to pay
attention to process emotion is re-
quiring more activity, and then its
communicating less with another area
of the brain that tells you what the
emotion means to you, she says.
Pan also found that the area of the
brain important for understanding social
cues is smaller in adolescents who have
attempted suicide. So they may not be
good at reading social and emotional cues
in other people and then understanding
what those emotions mean in their own
life, she says. So far, this research has
not yet translated into clinical practice.
Pan has also studied the spinal fluid
of 21 depressed and suicidal teens and
young adults resistant to standard
medication. In research not yet pub-
lished, she has found that two-thirds
have some kind of metabolic disorder
compared with healthy control sub-
jects. She did publish a case study of
one such young man, who is now on
a supplement to replace the protein he
is missing and is no longer suicidal or
on antidepression medication.
my metabolic research is in its in-
fancy, says Pan.
OUTLOOK
Telling Stories
or decades, most advocates for sui-
f cide awareness, prevention programs
and research have been clinicians, sci-
entists or family members of someone
who died by suicide. But in the past few
years, an increasing number of survivors
of suicide attempts are speaking up, break-
ing a long-held taboo against sharing
their stories for fear that doing so might
be harmful to them and others.
Sept. 12, 2014 763
 TEEN SUICIDE
Their stories are featured on websites
such as LiveThroughThis.org and
TalkingaboutSuicide. Traditional suicide
prevention organizations are getting on
board. The nations oldest such group,
the American Association of Suicidology,
sponsors the blog attemptsurvivors.com.
we as a field need to hear these
stories, said John Draper, director of the
National Suicide Prevention Lifeline, and
not just to study them, but to ask how
they found a way to cope and connect:
what did family and friends and doc-
tors do that helped, and what did not?
Suicide has proven stubbornly dif-
ficult to understand, to predict and to
prevent, Thomas Insel, director of the
National Institute of mental Health
(NImH), wrote this year. He discussed
a plan, prepared by a public-private
task force, to prioritize research on sui-
cide prevention. The stated goal of A
can use to identify children and ado-
lescents at immediate risk for suicide and
to develop methods to assign at-risk
youths to appropriate interventions.
And those interventions themselves
will be supported by better research,
experts say.
In the next five to 10 years, I defi-
nitely think we will have a lot more data
on what interventions work for kids who
are suicidal, says Esposito-Smythers of
George mason University, from the large,
NImH-funded adolescent suicide studies
looking at intensive cognitive behavior
therapy, dialectical behavior therapy and
attachment-based family therapy.
These three studies will redefine ado-
lescent therapy for suicidal ideation and
attempts, says Diamond of Childrens
Hospital of Philadelphia.
Esposito-Smythers says smaller re-
search studies already have led to a
Notes
1 Trends in the Prevalence of Suicide-Related
Behavior, National YRBS: 1991-2013, Centers
for Disease Control and Prevention, http://tiny
url.com/pt2wxqo.
2 fatal Injury Reports, National and Regional,
1999-2011, wISQARS, Centers for Disease Con-
trol and Prevention, http://tinyurl.com/8xl3mrt.
3 Leading Causes of Death Reports, National
and Regional, 1999-2011, wISQARS, Centers
for Disease Control and Prevention, http://tiny
url.com/cwofnqf.
4 Key Research findings, American founda-
tion for Suicide Prevention, undated, www.afsp.
org/understanding-suicide/key-research-findings.
5 Estimates of funding for various Research,
Condition, and Disease Categories, National In-
stitutes of Health, march 7, 2014, http://report.
nih.gov/categorical_spending.aspx.
6 fatal Injury Reports, National and Regional,
1999-2011, op. cit.
7 Lethality of Suicide method, Harvard School

Prioritized Research Agenda for Suicide
Prevention: An Action Plan to Save Lives
is to reduce the incidence of all suicides
by 20 percent in five years and 40 per-
cent in the next 10. 59
One of the priorities for future re-
search will be understanding short-term
risk for suicide. How will we know
when [a suicidal] person is sitting in
front of us? Honestly, just asking them,
Have you ever thought about it or have
you made an attempt? is not going to
more comprehensive approach in psy-
chotherapy. were seeing interventions
that are more comprehensive, that in-
clude individual sessions, parent ses-
sions and family sessions, she says.
But even as suicide attempt survivors
help inform research, research priorities
are adjusted and larger studies are fund-
ed, suicidal teens must have access to
quality mental health care if suicide death
rates are to decline, prevention special-
ists say. we are woefully in trouble and
of Public Health, 2001, http://tinyurl.com/kxk
muth; firearm Access is a Risk factor for Sui-
cide, Harvard School of Public Health, un-
dated, http://tinyurl.com/q6toapz.
8 fatal Injury Reports, National and Regional,
1999-2011, wISQARS, Centers for Disease Con-
trol and Prevention, http://tinyurl.com/8xl3mrt.
9 for background, see Thomas J. Billitteri, Pre-
venting Bullying, CQ Researcher, Dec. 10, 2010,
pp. 1013-1036, updated may 31, 2012; and
Thomas J. Billitteri, Cyberbullying, CQ Re-
searcher, may 2, 2008, pp. 385-408.
10 Anna Gassman-Pines, et al., Effects of

tell you the answer to that, says Harkavy-
friedman at the American foundation
for Suicide Prevention.
To support that research agenda, NImH
asked researchers to submit applications
to develop and test screening ap-
proaches that emergency departments
understaffed in this country when it comes
to psychiatrists, especially child and ado-
lescent psychiatrists, says Reidenberg of
SAvE. There is not enough time in the
day that these few providers can pro-
vide all of the things that are needed by
all of the people who need them.
Statewide Job Losses on Adolescent Suicide-
Related Behaviors, American Journal of Pub-
lic Health, Aug. 14, 2014, http://tinyurl.com/
k9r6bbm.
11 Alison Jones-Duke, mass Layoffs may Trig-
ger Teen Suicide, futurity.org. Aug. 15, 2014,
http://tinyurl.com/lhgnone.
12 michael L. Lefevre, Screening for Suicide

Risk in Adolescents, Adults, and Older Adults

About the Author
Barbara Mantel is a freelance writer in New York City. She
was a 2012 Kiplinger Fellow and has won several journalism
awards, including the National Press Clubs Best Consumer
Journalism Award and the Front Page Award from the News-
womens Club of New York for her Nov. 1, 2009, CQ Global
Researcher report Terrorism and the Internet. She holds a
B.A. in history and economics from the University of Virginia
and an M.A. in economics from Northwestern University.
in Primary Care: U.S. Preventive Services Task
force Recommendation Statement, Annals of
Internal Medicine, may 20, 2014, p. 720,
http://tinyurl.com/oarz6vm.
13 Jeffrey m. Caterino, et al., Evaluating Cur-
rent Patterns of Assessment for Self-harm in
Emergency Departments: A multicenter Study,
Academic Emergency Medicine, August 2013,
p. 813, http://tinyurl.com/k3yjxyu.
14 Screening for Suicide Risk in Adolescents,
Adults, and Older Adults in Primary Care:

764 CQ Researcher
U.S. Preventive Services Task force Recom-
mendation Statement, op. cit., p. 721.
15 Caterino, et al., op. cit., p. 812.
16 Ibid., p. 813.
FOR MORE INFORMATION
17 Ibid.
American Association of Suicidology, 5221 wisconsin Ave., N.w., washington,
DC 20015; 202-237-2280; www.suicidology.org. Promotes research and training.
18 Suicide Risk in Adolescents, Adults, and

Older Adults in Primary Care: USPSTf Rec-
ommendation Statement, U.S. Preventative Ser-
vices Task force, may 2014, www.uspreven
tiveservicestaskforce.org/uspstf13/suicide/sui
cidefinalrs.htm.
19 Screening for Suicide Risk in Adolescents,
Adults, and Older Adults in Primary Care:
U.S. Preventive Services Task force Recom-
mendation Statement, op. cit., p. 720.
20 morton m. Silverman and Alan L. Berman,
Suicide Risk Assessment and Risk formulation
Part I: A focus on Suicide Ideation in Assess-
ing Suicide Risk, Suicide and Life-Threatening
Behavior, August 2014, pp. 420-431, http://tiny
url.com/ppbuk2p.
21 Stephen D. whitney, et al., Principals per-
ceptions of benefits and barriers to school-
based suicide prevention programs, Children
and Youth Services Review, June 2011, pp. 874-
875, http://tinyurl.com/mnlyzz3.
22 Ibid.
23 Report to Congress: Garrett Lee Smith
American Foundation for Suicide Prevention, 120 wall St., 29th floor, New
York, NY 10005; 212-363-3500; www.afsp.org. funds research.
Jason Foundation, 18 volunteer Dr., Hendersonville, TN 37075; 615-264-2323;
jasonfoundation.com. Provides suicide prevention material for students and teachers.
Live Through This, livethroughthis.org. Profiles survivors of suicide attempts.
National Action Alliance for Suicide Prevention, 1025 Thomas Jefferson St., N.w.,
Suite 700, washington, DC 20007; 202-572-3784; actionallianceforsuicideprevention.
org. Public-private partnership advancing strategies for suicide prevention.
National Suicide Prevention Lifeline, 50 Broadway, 19th floor, New York, NY
10004; 212-614-6309; www.suicidepreventionlifeline.org. Network of 165 crisis centers.
Suicide Awareness Voices of Education (SAVE), 8120 Penn Ave. S., Suite 470,
Bloomington, mN 55431; 952-946-7998; www.save.org. Educates the public about
depressive brain illnesses.
Suicide Prevention Resource Center, 43 foundry Ave., waltham, mA 02453;
877-438-7772; www.sprc.org. maintains database of prevention practices.
of Child and Adolescent Psychiatry, October 2009, 46 2012 National Strategy for Suicide Preven-
pp. 987-996, http://tinyurl.com/pjpxnsz. tion: Goals and Objectives for Action, op. cit.,
33 Berk, et al., op. cit., p. 4.
p. 96.
34 Dialectical Behavior Therapy, National Al- 47 Ibid., p. 97.
liance on mental Illness, february 2013, http:/ 48 National Strategy for Suicide Prevention:

Youth Suicide Prevention Program, SAmHSA,
february 2014, p. 33.
24 Cara Katz, et al., A Systematic Review of
School-Based Suicide Prevention Programs,
Depression and Anxiety, may 3, 2013, http://
tinyurl.com/kr9whu3.
25 Ibid., pp. 1033-1034.
26 Ibid., pp. 1032-1033.
27 Ibid., p. 1035.
28 matthew K. Nock, et al., Prevalence, Cor-
relates, and Treatment of Lifetime Suicidal Be-
havior Among Adolescents: Results from the
National Comorbidity Survey Replication
Adolescent Supplement, JAMA Psychiatry,
march 2013, http://tinyurl.com/mpjgrgd.
29 Ibid.
30 michele Berk, et al., Conducting Research
on Adolescent Suicide Attempters: Dilemmas and
Decisions, Behavior Therapy, June 18, 2014,
/tinyurl.com/p7xd3us.
35 Howard I. Kushner, Self-Destruction in the
Promised Land: A Psychocultural Biology of
American Suicide (1989), p. 28.
36 Ibid., p. 30.
37 Ibid., pp. 39-41.
38 Ibid., p. 53.
39 Ibid., pp. 55-56, 58.
40 Edwin S. Shneidman and Norman L. farberow,
Clues to Suicide (1957), p. vii.
41 Ibid., pp. 3, 40.
42 History of the American Association of
Suicidology, American Association of Suici-
dology, undated, http://tinyurl.com/msb4jmx.
43 2012 National Strategy for Suicide Pre-
vention: Goals and Objectives for Action,
U.S. Surgeon General and the National Ac-
tion Alliance for Suicide Prevention, U.S. De-
partment of Health and Human Services, Sep-
Goals and Objectives for Action, U.S. De-
partment of Health and Human Services, 2001,
pp. 15-16, http://tinyurl.com/ll79jxt.
49 Spencer-Thomas and Jahn, op. cit., p. 82.
50 maurizio Pompili and mark J. Goldblatt,
Psychopharmacological Treatment to Reduce
Suicide Risk, Psychiatric Times, April 2, 2012,
http://tinyurl.com/om52sg9.
51 Ibid.
52 Ibid.
53 Christine Y. Lu, et al., Changes in anti-
depressant use by young people and suici-
dal behavior after fDA warnings and media
coverage: a quasi-experimental study, BmJ,
June 18, 2014, http://tinyurl.com/n7w6rh2.
54 Black Box warning on Antidepressants
Raised Suicide Attempts, mSN News, June 19,
2014, http://tinyurl.com/p5wtwon.
55 Ibid.

pp. 65-69, http://tinyurl.com/ooa7qb4. tember 2012, p. 94, http://tinyurl.com/8o56lst. 56 Report to Congress: Garrett Lee Smith Youth
31 David A. Brent, et al., Protecting Adolescents 44 Report of the Secretarys Task force on
Suicide Prevention Program, op. cit., p. 43.
from Self-Harm: A Critical Review of Interven- Youth Suicide. volume 1: Overview and Rec- 57 Ibid., pp. 44-47.

tion Studies, Journal of the American Academy ommendations, U.S. Department of Health and 58 Editorial: Bill is a modest proposal to re-

of Child & Adolescent Psychiatry, December Human Services, 1989, http://tinyurl.com/nt8h5cc. duce suicide, The Sacramento Bee, Aug. 18,
45 Sally Spencer-Thomas and Danielle R. Jahn,
2013, p. 1260, http://tinyurl.com/kjteyda. 2014, http://tinyurl.com/kqhybdz.
32 David A. Brent, et al., The Treatment of Tracking a movement: U.S. milestones in Sui- 59 Thomas Insel, Directors Blog: A New Re-

Adolescent Suicide Attempters Study (TASA): cide Prevention, Suicide and Life-Threatening search Agenda for Suicide Prevention, Na-
Predictors of Suicidal Events in an Open Treat- Behavior, february 2012, p. 82, http://tinyurl. tional Institute of mental Health, feb. 5, 2014,
ment Trial, Journal of the American Academy com/mwzjhs2. http://tinyurl.com/lsxsrfj.

www.cqresearcher.com Sept. 12, 2014 765

 Bibliography
Selected Sources
Books
Joiner, Thomas, Myths About Suicide, Harvard University
Press, 2010.
A clinical psychologist and suicide researcher demolishes the
myths surrounding suicide.
Kushner, Howard I., Self-Destruction in the Promised
Land: A Psychocultural Biology of American Suicide,
Rutgers University Press, 1989.
A historian of medicine traces the history of suicide.
Articles
Berk, Michele, et al., Conducting Research on Adolescent
Suicide Attempters: Dilemmas and Decisions, Behavior
Therapy, June 18, 2014, http://tinyurl.com/qx8f4g5.
Research is urgently needed on effective treatments for ado-
lescents who attempt suicide, but conducting randomized
controlled trials is challenging, say six experienced researchers.
Black Box Warning on Antidepressants Raised Suicide
Attempts, MSN News, June 19, 2014, http://tinyurl.com/
p5wtwon.
media mischaracterizations of suicide-risk warnings on anti-
depressant labels may have led to a decline in prescriptions
and a small increase in suicide attempts.
Dewey, Caitlin, Suicide contagion and social media: The
dangers of sharing Genie, youre free, The Washington
Post, Aug. 12, 2014, http://tinyurl.com/l444b3r.
Improper media coverage of celebrity suicides may lead to
an increase in suicide attempts and deaths.
Jones-Duke, Alison, Mass Layoffs May Trigger Teen Suicide,
futurity.org, Aug. 15, 2014, http://tinyurl.com/lhgnone.
mass layoffs are associated with an increase in suicidal be-
havior among teenage girls and adolescent blacks.
Sanger-Katz, Margot, The Science Behind Suicide Con-
tagion, The New York Times, Aug. 13, 2014, http://tinyurl.
com/ogtewwn.
media must follow reporting guidelines about suicide to
avoid contributing to suicide contagion, experts say.
Schimelpfening, Nancy, Can the Internet Cause Teens
to Commit Suicide?, Liberty Voice, Oct. 31, 2013, http://
tinyurl.com/qzzu248.
The Internet can provide support for depressed teens but
also increase the suicide risk among vulnerable youths.
Reports and Studies
2012 National Strategy for Suicide Prevention: Goals
766 CQ Researcher
and Objectives for Action, U.S. Surgeon General and
the National Action Alliance for Suicide Prevention, Sep-
tember 2012, http://tinyurl.com/8o56lst.
The government updates its national strategy for preventing
suicide, including emphasizing the need for community in-
volvement.
Report to Congress: Garrett Lee Smith Youth Suicide
Prevention Program, Substance Abuse and Mental Health
Services Administration, February 2014.
Government-funded suicide prevention programs have
trained thousands, but improvements can be made, the
agency says.
Screening for Suicide Risk in Adolescents, Adults, and
Older Adults in Primary Care: U.S. Preventive Services Task
Force Recommendation Statement, Annals of Internal
Medicine, May 20, 2014, http://tinyurl.com/oarz6vm.
An independent task force of health-care professionals
concludes that current evidence is insufficient to assess the
balance of benefits and harms of regular screening for sui-
cide risk in adolescents, adults and older adults in a primary-
care setting.
Caterino, Jeffrey M., et al., Evaluating Current Patterns
of Assessment for Self-harm in Emergency Departments:
A Multicenter Study, Academic Emergency Medicine,
August 2013, http://tinyurl.com/paoofhn.
many hospital emergency department patients who inten-
tionally harm themselves, including attempting suicide, are
going undetected.
Katz, Cara, et al., A Systematic Review of School-Based
Suicide Prevention Programs, Depression and Anxiety,
May 3, 2013, http://tinyurl.com/njymd7l.
A team including researchers from the University of manitoba
reviewed the literature on 16 school-based suicide prevention
programs.
Lu, Christine Y., et al., Changes in antidepressant use by
young people and suicidal behavior after FDA warnings
and media coverage: a quasi-experimental study, BMJ
(formerly the British Medical Journal), June 2014, http://
tinyurl.com/n7w6rh2.
After widespread media coverage of fDA-required suicide
warnings on antidepressant labels in 2004, antidepressant use
significantly declined.
Pompili, Maurizio, and Mark J. Goldblatt, Psychopharma-
cological Treatment to Reduce Suicide Risk, Psychiatric
Times, April 2, 2012, http://tinyurl.com/om52sg9.
Research into the direct impact of psychopharmacological
drugs on suicidal behavior is slim, according to two psy-
chiatrists who have studied suicide.
 The Next Step:
Additional Articles from Current Periodicals
Legislation
Gilliland, Donald, How effective teen suicide prevention
in Pennsylvania was derailed, Patriot-News (Harrisburg,
Pa.), April 28, 2014, http://tinyurl.com/pbcdgqr.
A proposed Pennsylvania law aimed at preventing teen suicide
stalled in a House committee due to Republican-led opposition.
Higgs, Robert, Supporters of law aimed at reducing
teen suicides expect training in schools to increase this
fall, The Plain Dealer (Cleveland), Aug. 20, 2013, http://
tinyurl.com/m5hayxj.
Ohio became the 11th state to pass the Jason flatt Act, which
requires school staff to receive suicide-prevention training.
Wood, Benjamin, Committee approves bill clarifying
school suicide-prevention statutes, Deseret News, Nov. 20,
2013, http://tinyurl.com/p2lpada.
A Utah legislator presented a bill clarifying what suicide
risk-related questions faculty and administrators are permitted
to ask students following confusion over language in several
state suicide-prevention laws passed in 2013.
Prevention
Khadaroo, Stacy Teicher, Teen suicide: Prevention is con-
tagious, too, The Christian Science Monitor, Dec. 8, 2013,
http://tinyurl.com/m5373wc.
The number of teen suicide-prevention strategies and pro-
grams has increased sharply over the past decade, according
to an American foundation for Suicide Prevention official.
Shah, Ruchi, Destigmatizing mental disorders key to
teen suicide prevention, says advocate mom, Fox News,
Aug. 1, 2014, http://tinyurl.com/ndb4mhg.
Parents of a teenage boy who died by suicide say spread-
ing awareness of mental illness and removing its associated
stigmas are keys to preventing teen suicides.
Taylor, Daniel, Guns in the home raise the suicide risk
for all, The Philadelphia Inquirer, Oct. 27, 2013, http://
tinyurl.com/ltpd22e.
Teens whose families keep firearms in the home are at a
much greater risk of suicide, according to an associate pro-
fessor at the Drexel College of medicine in Philadelphia.
Screening
Dvorak, Petula, Summit addresses mental health of
teens, The Washington Post, June 19, 2014, http://tiny
url.com/puhwmh3.
A panel of Northern virginia high school students said parents
should reach out more to high-stress students in competitive
school districts who may be at risk of suicide.
www.cqresearcher.com
Guerra, Kristine, Social media raises fear of suicide
contagion, The Indianapolis Star, May 3, 2013, http://
tinyurl.com/q5y3qb2.
Adults must intervene immediately if they see signs of sui-
cidal behavior among teens posting online on social media.
Raison, Charles, Screening for suicide: A psychiatrists
take, CNN, April 29, 2013, http://tinyurl.com/oju2rs8.
The U.S. Preventative Services Task force recommends that
doctors ask patients about specific suicide risk factors, rather
than universally screening patients for suicide risk.
Treatment
Carey, Benedict, Study Questions Effectiveness of Ther-
apy for Suicidal Teenagers, The New York Times, Jan. 8,
2013, http://tinyurl.com/cm5nz8r.
fifty-five percent of suicidal teenagers had received therapy
prior to considering, planning or attempting suicide.
Painter, Kim, High antidepressant dose linked to self
harm in youth, USA Today, April 28, 2014, http://tinyurl.
com/mzw5fkq.
Young people who suffer from depression are twice as
likely to harm themselves when prescribed higher doses of
antidepressants, according to a study published in the journal
JAMA Internal Medicine.
Price, Rita, Training aims at dealing with the loss of
suicide, The Columbus Dispatch, June 26, 2014, http://
tinyurl.com/oft7r5v.
The national Local Outreach to Suicide Survivors (LOSS)
program sends teams of volunteers to the scene of a suicide
to provide support to families and friends.
CITING CQ RESEARCHER
Sample formats for citing these reports in a bibliography
include the ones listed below. Preferred styles and formats
vary, so please check with your instructor or professor.
mLA STYLE
Jost, Kenneth. Remembering 9/11. CQ Researcher 2 Sept.
2011: 701-732.
APA STYLE
Jost, K. (2011, September 2). Remembering 9/11. CQ Re-
searcher, 9, 701-732.
CHICAGO STYLE
Jost, Kenneth. Remembering 9/11. CQ Researcher, Sep-
tember 2, 2011, 701-732.
Sept. 12, 2014 767
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