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Adolescent Suicide: Epidemiology, Psychological Theories, Risk Factors, and

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52 Current Pediatric Reviews, 2011, 7, 52-67

Adolescent Suicide: Epidemiology, Psychological Theories, Risk Factors,

and Prevention
Mirjami Pelkonen*,1, Linnea Karlsson2 and Mauri Marttunen1,3

1
National Institute for Health and Welfare, Department of Mental Health and Substance Abuse Services, Helsinki,
Finland
2
Turku University Central Hospital, Department of Child Psychiatry, Turku, Finland
3
University of Helsinki and Helsinki University Central Hospital, Department of Adolescent Psychiatry, Helsinki,
Finland

Abstract: Suicide is one of the most common causes of death among young people worldwide. Adolescence is a
developmentally important phase of age due to the growing risk for suicide and prevalence of psychiatric disorders, as
well as due to growing possibilities for prevention and treatments. Research findings in theoretical considerations, in
psychological autopsy studies as well as in selected follow-up studies of clinical populations and suicide attempters
analyzing risk factors for youth suicides are reviewed emphasizing the most recent data. As youth suicides are rare,
research on risk factors for youth suicidal ideation, deliberate self-harm behavior and attempted suicide are also briefly
reviewed. Family-related adversity, precipitating interpersonal problems, and particularly psychiatric disorders constitute
risk factors for adolescent suicide. Mood disorders, substance abuse and prior suicide attempts are strongly related with
youth suicides. However, recent psychological autopsy studies in China have found substantially lower rates of
psychiatric disorders among suicide victims compared with those in the Western countries. Recognition and effective
treatment of psychiatric disorders, e.g. depression are essential in preventing adolescent suicides. As only seldom young
suicide victims have received psychiatric care, broad prevention strategies are needed in health care and social services.
Education of physicians to recognize youth at risk, and restricting access to lethal means are recommended to prevent
suicides. For high-risk youth providing continuity of care is important. Recent treatment studies among suicidal
adolescents have reported promising results on safety planning and increased therapeutic contact early in treatment.
Keywords: Adolescent, deliberate self-harm behavior, psychiatric disorder, psychiatric treatment, risk factor, suicidal behavior,
suicide, theory.

1. INTRODUCTION varies, however, significantly across countries, cultures, and

Completed suicides are a major health problem among
youth worldwide. The latest mean worldwide annual rates of
suicide per 100.000 were 0.4 for females and 1.5 for males
among 5-14-year olds, and 4.9 for females and 22.0 for
males among 15-24-year olds, respectively [1]. There has
been a male preponderance in suicide rates. However, there
is growing concern also on female suicides, as in some coun-
tries, e.g. in rural China [1, 2] recent reports have found even
higher suicide rates among adolescent females compared
with males. Suicide is a leading cause of death worldwide
and the third leading cause of death for adolescents in the
USA [1, 3]. In Finland, youth suicide mortality has declined
by over 20 % from 1990 to 2003, possibly due to better
treatment of depression [4], and actions to prevent suicides
launched throughout the country [5]. However, completed
suicide was a leading cause of death among females and the
second common cause among males at age of 15 – 19 years,
in 2008, in Finland; 27 % of all the deaths in this age group
were suicides [6]. The prevalence of suicidal behaviour
*Address correspondence to this author at the National Institute for Health
and Welfare, Department of Mental Health and Substance Abuse Services,
P.O. Box 30, FI-00271 Helsinki, Finland; Tel: +358 20 6108 213; Fax: +35
89 761307; E-mail: mirjami.pelkonen@thl.fi
racial/ethnic groups around the world [3] .
Despite its high prevalence and known risk factors, suici-
dal thoughts and behaviour in many adolescents are often
undetected by parents, teachers and health care professionals
[7]. It has been estimated that as many as two thirds of sui-
cide attempters are not identified as a danger to themselves
in primary health care clinics, and only few suicide attempt-
ters receive care even after a suicide attempt [7]. In a recent
psychological autopsy study Portzky et al. [8] found that
suicidal communication was less frequently reported by
suicide victims and treatment of psychiatric disorders was
significantly less found in adolescent suicide victims
compared with suicidal adolescents.
Research on risk factors for youth suicide provides the
basis for suicide prevention. Primary prevention of such rare
outcomes as youth suicide faces several problems, and the
effectiveness of preventive efforts in schools, social services
and primary health care has been questioned [7, 9]. Since
most young people committing suicide have suffered from
psychiatric disorders, particularly from depression [10], early
recognition and effective treatment of these disorders are key
issues in the prevention of youth suicide [11, 12]. However,
recent research findings in China have found lower
prevalence of mental disorders in Chinese suicide decedents

1573-3963/11 $58.00+.00 © 2011 Bentham Science Publishers Ltd.

Adolescent Suicide
compared with those in respective Western respective studies
[13]. If further studies confirm the findings on the more
remarkable impact of other risk factors than previously
thought (such as familial adversity, precipitating problems,
cultural factors), theoretical modeling of suicidal behavior
and development of international prevention strategies need
to developed by taking into account these new findings.
Suicidal ideation is defined as one´s wish or threat to die,
suicide attempt/parasuicide as self-injurious behavior with a
non-fatal outcome, deliberate self-harm (DSH) with a history
of intentionally injuring one´s body without apparent
suicidal intention, and suicide as a cause of death on a death
certificate [12, 14]. Completed suicides are rare in children
and young adolescents and their prevalence increase with
growing age [1]. Adolescence and early adulthood are
generally seen as periods in which there is a high risk for
first-onset suicidal behaviour [15]. Due to the growing risk
for suicide with increasing age, adolescents can be regarded
the main target of suicide prevention.
This article first briefly reviews the epidemiology of
completed suicide among adolescents during the last decade.
The main target is to review recent theoretical considerations
and research findings on risk factors and treatment possi-
bilities for adolescent suicide during the last decade. Youth
suicide is a rare phenomenon, and research on risk factors for
youth suicidal ideation, DSH and attempted suicide are also
briefly reviewed. Then, preventive approaches are reviewed.
While depressive disorders are among the most important
psychiatric disorders associated with youthful suicides and
research-based knowledge on adolescent mood disorders
rapidly increases, they are still under-recognised and under-
treated [16, 17]. This paper therefore briefly reviews con-
trolled treatment studies of child and adolescent depressive
disorders. Controlled treatment studies among adolescents
with other psychiatric disorders, as important as they are, are
not included in this review. However, other than depressive
disorders are briefly reviewed in the context of comorbid
psychiatric disorders. Finally, since adolescents with suicidal
ideation or suicide attempts, are in a particularly high risk for
suicide, research on the effects of interventions aiming at
reducing further suicidal behavior among suicide ideators
and attempters are reviewed.
The main focus is to review findings during the last
decade. There are, however, only few recent studies in some
topics (e.g. in adolescent suicide studies using psychological
autopsy-method), and therefore some older studies are also
briefly reviewed.
2. EPIDEMIOLOGY OF ADOLESCENT SUICIDES
According to the WHO statistics [1], the mean worldwide
(countries reporting their mortality data) annual rates of
suicide per 100.000 in 2000 (or latest available year) were
among 15-24 year olds 4.9 for females and 22.0 for males.
There has been a male preponderance in suicide rates world-
wide, and one of the few exceptions were that more females
compared with males committed suicide in rural China [1,
18, 19]. However, recent findings in China show that male-
to-female-ratio for suicide seem to became closer to that in
the West, although it would still be much lower [2] . The
studies from New Zealand, where the rates of female youth
Current Pediatric Reviews, 2011, Vol. 7, No. 1 53
suicide more than doubled from 1977 to 1996, showed that
the increasing rates were due to the growing use of hanging
and vehicle exhaust gas by women [20, 21]. Further
evidence of the role of gender-related method choice may be
found in China, were the higher female rates of suicide is
most likely to be explained be the ready access that Chinese
women have to agricultural pesticides, which are used in
self-poisoning attempts and have high lethality [22]. On the
other hand, the findings from China seem to support a
cultural and /or familial explanation (e.g. a lower social
status in Chinese women than Chinese men), as previously
reported [23].
During the last decade, youth suicide rates have increased
in many countries, and most of the increase is due to more
young men committing suicide [1]. The suicide rates among
young males in Belgium have doubled over the last decade
[24]. For example, suicide rates among adolescents have
increased in USA [3, 25]. In Finland, a country with parti-
cularly high and rising rates of youth suicide until 1991, an
approximately 20 % decline has taken place by 2008 [6].
Total rate of suicides was 18.2 per 100,000 at age of 15-24
years in 2007 in Finland [1].
However, there are large variations in the rates of adole-
scent suicides in countries in different time periods, and
between countries. The background of such secular changes
in youth suicide rates are largely unknown but it has been
suggested that the decline in the rates of youth suicides is
due to restriction of the availability of lethal methods, e.g.
firearms [9, 26, 27], and better treatment of depression [4, 9].
Disparities in the classification of suicide in listing suicide as
the cause of death on death certificates may also contribute
to the international variation. The reliability of international
suicide data is generally considered to be high; however, the
influences of e.g. varying data collection procedures have to
be taken into account in interpreting the findings [3, 28].
3. RISK FACTORS FOR SUICIDE
3.1. Age and Youth Suicide
The incidence rates of suicides increase sharply from
childhood to adolescence [1, 27]. The reasons to explain this
change are largely unknown. The family provides social and
emotional support thereby possibly protecting children from
suicide. Adolescence is often marked by higher levels of
emotional reactivity, increased risk-taking behaviours and
increased strivings for autonomy, which may result in
conflict or a ”pushing away” of previous sources of support,
such as parental figures. Therefore, risks for suicidal beha-
viour may be heightened during adolescence, particularly in
the context of psychiatric disorders associated with increased
emotionality or decreased inhibitions. Alternatively, the risk
for suicidal behaviour during episodes of psychiatric disor-
ders may continue or intensify from adolescence through
young adulthood [29]. Not only the prevalence of suicides
increase with growing age; the reported onset of suicidal
ideation, plans and attempts was highest in the late teens and
early 20s, with the median in the mid-20s [15].
The higher risk for suicide in adolescence may be attri-
buted to the higher prevalence of psychopathology with
growing age [27, 30]. In general, the frequencies of any
54 Current Pediatric Reviews, 2011, Vol. 7, No. 1
psychiatric disorder, particularly mood disorders, substance
abuse and conduct disorder, as well as prior suicide attempts
have been more common in the older than younger adole-
scent suicide victims [18]. Psychopathology may not only be
more prevalent but also convey a higher risk for suicide
among older adolescents [30], however, the finding is not
consistent [31]. Besides studies on suicide victims, one study
found that the relationships between suicide attempts and
with major depression, generalized anxiety disorder, atten-
tion-deficit/hyperactivity disorder, and substance use disor-
ders strengthened as participants came older in a clinical
sample (age 12-19 at admission) [32].
There has been a debate if the underlining structure of
psychiatric disorders is stable with growing age. A recent
study [33] provided evidence of a stable underlying structure
of DSM-IV syndromes across the transition to adolescence.
Further, a general process of psychopathological differentia-
tion is not likely to be responsible for high rates of comor-
bidity in this timeframe. Despite the fact that adolescence is
accompanied by substantial changes in rates of a range of
psychiatric symptoms and disorders, it appears that the
structural organization of those symptoms and disorders is
highly stable [33].
3.2. Theoretical Considerations in Examining Risk
Factors for Suicidal Behaviour
Scientific research in studying risk factors for suicidal
behaviour has previously mainly based on psychological
autopsy studies of suicide victims and follow-up studies of
high-risk adolescents (e.g. suicide attempters, adolescent
clinical populations) [18]. In the recent decade, growing
number of researchers have used theoretical models in order
to examine and understand the relationships between suicidal
behaviour and different risk factors. There are no common
well-investigated and accepted theories thus far, and the
findings may be seen as preliminary. However, they offer
important perspectives for understanding and preventing
youth suicides. We briefly review some of these studies,
which are mostly conducted among non-clinical populations.
Unfortunately, many important theories and findings had to
be excluded from this review, and more comprehensive
reviews on this specific topic are needed.
The development and testing of explanatory models are
challenging in the cause of suicidal behaviour [3]. Although
suicide is a leading cause of death among young people,
suicidal behaviours have a relatively low base rate in the
general population. Studies of suicidal behaviour would
typically require large sample sizes to test the complex
models that will be needed to understand and predict suicidal
behaviour. In addition, concerns about failing to adequately
monitor or treat suicidal behaviour, or about increasing
suicidal behaviour in response to an experimental manipula-
tion, often preclude the use of experimental study designs.
Furthermore, the stigma associated with suicidal behaviours
can lead to underreporting or avoiding research studies. As a
result, although studies of suicidal behaviour have provided
valuable information about the nature of the correlates of
these outcomes, many questions remain about the nature of
these correlations (e.g. what are the mediators and mode-
rators) and about the causal mechanisms through which these
relations exist [3]. Current evidence seems, however, to
Pelkonen et al.
point that there are several different paths to suicidal
behaviour indicating that no one single theory could explain
all heterogeneous forms of suicidal behaviour.
According to Windle [34] most existing conceptual
frameworks of suicidal behaviour, such as “stress model” or
“the mental health model” are predominantly non-develop-
mental. The inclusion of important developmental, age-
normative events (e.g. puberty, dating behaviour) and non-
normative events (e.g. serious injuries, legal encounters) in
conceptual frameworks may facilitate inquiry into the vicis-
situdes of suicidal behaviours among youths, and provide
enhanced understanding of the interrelationship between e.g.
alcohol use and suicidal behaviour. Recent research in
developmental psychopathology emphasizes that multiple
factors influence on disorders and related phenotypes, and
that variables from different levels of analysis (e.g. genetic,
biochemical, physiologic, cognitive, social, neighbourhood)
influence on outcomes. Accordingly, the occurrence, as well
as the nature of expression, of disorders and related factors
may vary across individuals and across time. According to a
multivariate mediation path model, several distant factors
(e.g. difficult temperament, coping motives for drinking,
lower family support, higher percentage of friends using
alcohol) significantly predicted mediators (such as depress-
sion, stressful events, binge drinking), that in turn, predicted
suicidal behaviours [34]. Binge drinking significantly
predicted suicide attempts over and above the influence of
depression and stressful events, whereas higher levels of
alcohol consumption was a more general risk factor for
suicidal behaviours [35].
The stress-diathesis model has been proposed to make
causal sense of the wide range of factors contributing to
suicidal behaviour in psychiatric patients [9]. Diathesis
reflects an increased long-term vulnerability to suicidal
behaviour because of, for example, being more impulsive
and/or aggressive, and therefore more likely to act on sui-
cidal feelings. Critical levels of early-life stress may create
particular vulnerable conditions for enhanced sensitivity of
the hypothalamus-pituitary-adrenal axis, both with biological
and emotional consequences [36]. In line with this theory,
Bruffaerts et al. [37] found in a large nationally represent-
tative sample of 55 299 adolescents that childhood adver-
sities, especially sexual and physical abuse were the stron-
gest risk factors for both for the onset and persistence of
suicidal behaviour, especially during adolescence.
Psycho-educational models are commonly based on the
stress-model [38], and explain suicide as an understandable
and normal response to extreme stress and abnormal situa-
tions. The implementation of stress-model ignores, however,
the much more scientifically supported view of suicidal
behaviour as the consequence of a complex interaction
between social, psychological, biological and psychiatric
characteristics.
Chang et al. [39] tested the mediating and moderating
effects of the cognitive triad (the cognitive theory of dys-
functional views on self, the future and the world by Alford
and Beck [40]) on the relationship between depressive
symptoms and suicidal ideation in a sample of high-school
adolescents in Taiwan. Higher levels of depressive symp-
toms and a negative cognitive triad were related to suicidal
ideation. When the cognitive triad was included as a
Adolescent Suicide
mediator, the effect of depressive symptoms on suicidal
ideation was manifested partially through the cognitive triad.
One study found associations between interpersonal
problem solving, hopelessness, autobiographical memory
and suicidal behaviour among young inpatients [41]. The
importance of extending suicide research to specific indivi-
dual experiences was demonstrated, when suicidal inpatient
female adolescents and those with anorexia nervosa were
reported to evidence of less attraction to life and more
attraction to death as well as more negative attitudes to their
body compared with non-suicidal inpatient females and non-
clinical community controls [42]. Research findings on the
associations between suicidal behaviours and some indivi-
dual variables, such as temperament and personality traits,
coping skills, perceived social support, as well as gender
differences in these variables, have enriched suicide research
[e.g. 19, 25], however, could not be included in this review.
Joiner´s theory of interpersonal-psychological theory of
suicidal behaviour focuses comprehensively on three nece-
ssary, jointly sufficient variables that must be present for an
individual to make a lethal suicide attempt: thwarted belong-
ingness, perceived burdensomeness, and the acquired capa-
bility to enact lethal self-injury. The rationale behind the
concept of acquired capability is that the most direct and
potent means of acquiring the capability for suicide is
attempted suicide and deliberate self-harm behaviour [43].
Recent studies have supported these comprehensive theore-
tical considerations [e.g. 44, 45], however, more research
among adolescents is needed.
Suicidal behaviour runs in families and exposure to
suicidal behaviour may play a role via imitation [46].
However, Burke et al. [47] found that the increase in risk for
suicide attempt in offspring of an attempter parent was not
related to exposure to suicidal behaviour in the family. It
thereby seemed that imitation is unlikely to be sufficient
explanation for the familial transmission of suicidal
behaviour.
Of the biological mechanisms, hampered impulse control
or control of aggression is suggested to be the key under-
lying dimension in suicidal behaviour across diagnostic cate-
gories [48, 49]. There is a reasonable genetic loading and
heritability in suicidal behaviour as shown by the twin and
adoption studies [49] and it could be that low turn over of 5-
hydroxyindoleacetic acid (5HIAA) as measured in the
cerebral spinal fluid is the factor passed on to the next
generation [48]. Moreover, stressful life events and early
adversity increase the risk of suicidal behaviour, possibly via
their influence on child brain structures, stress regulation
systems and, consequently, serotonin levels not only in
childhood but also later in life [50, 51]. These alterations in
homeostasis are then related to e.g. depression, anxiety, and
suicidal behaviour [50, 51]. In a recent review Brent [52]
concluded that familial transmission of suicidal behavior is
mediated by familial transmission of abuse and also appears
to be mediated by the transmission of impulsive aggression
which is suggested to be an endophenotype for suicidal
behavior [53].
In their comprehensive review Goldston et al. [11]
described how awareness of the interface of culture,
adolescent suicidal behaviour, and help-seeking is essential
Current Pediatric Reviews, 2011, Vol. 7, No. 1 55
for culturally competent professionals and an important step
to the development of effective culturally sensitive interven-
tions to reduce suicidal behaviour. Themes on acculturative
stress and protective factors in within cultures, the roles of
religion and spirituality and the family in culturally sensitive
interventions, different manifestations and definitions of
distress in different cultures and community-based intervene-
tions are discussed in this review. Such efforts are only
recently studied, although academic interest in cultural and
social influences on suicidal behaviour dates back at least to
Durkheim´s [54] investigations of the associations between
suicide rates, religion and social integration.
3.3. Risk Factors for Adolescent Suicide
A widely accepted method in research of risk factors for
suicide is studying unselected and representative samples of
suicides using the psychological autopsy. It is a procedure
for reconstructing the life history, behaviour, social and
psychological features of the deceased, as well as the events
preceding the suicide retrospectively by interviews of key
persons who knew the deceased. Usually also data from
different records are collected [55]. The general methodo-
logical problems of psychological autopsy include the
possibility of incomplete and biased information and diffi-
culties in the assessment of psychopathology of the victims
[13]. However, interviewing several informants, using struc-
tured interviews to elicit psychiatric symptoms, and using
explicit diagnostic criteria have reportedly increased the
accuracy of the assessment of psychopathology [55]. Recent
psychological autopsy studies of adolescents are few, and we
therefore also briefly review previous findings. For more
comprehensive and detailed reviews, see e.g. [18, 19, 56].
The prevalence of rare psychiatric disorders, e.g. psy-
chotic disorders, has been low in population-based studies of
suicide using psychological autopsy. Follow-up studies of
clinical adolescent populations and suicide attempters have
provided complementary data of the associations between
suicide and risk factors found in psychological autopsy
studies [57, 58]. Data collection procedures, characteristics
of the samples and the definitions of psychiatric disorders in
different chart-based studies may, however, vary and have to
be taken into account in interpreting the findings [58]. The
following chapters review the most important research on
risk factors for suicide in adolescents. However, completed
adolescent suicide is a rare phenomenon, therefore also
research on risk factors for suicidal ideation, deliberate self-
harm and suicide attempts is briefly reviewed.
3.3.1. Findings in Psychological Autopsy Studies
Previous population-based psychological autopsy studies
of adolescent suicides and follow-up studies of child and
adolescent patients and suicide attempters [18, 19] have
reported parental divorce, non-intact family of origin, family
history of suicide or suicide attempt, parental mental prob-
lems and substance abuse, poor communication with mother
and father, weakened parental support, and parental prob-
lems with the police to be associated with death by suicide.
Individual psychosocial risk factors for young suicides have
included recent disciplinary crisis, interpersonal loss and
school problems.
56 Current Pediatric Reviews, 2011, Vol. 7, No. 1
On the other hand, psychiatric disorders are closely rela-
ted to experiencing negative life events in general and also to
experiencing multiple events with often additive effects. For
example, early adverse events have been found to mediate
the link between current stress and risk for depression later
in life [59]. Respectively, a recent case-control psychological
autopsy study by Portzky et al. [8] investigated psychosocial
and psychiatric risk factors of adolescent suicide among 19
suicide victims and 19 suicidal adolescents. Suicide victims
had been exposed more frequently to suicidal behaviours by
friends and through media and experienced more relational
problems in the past year than the controls. Suicidal com-
munication was less frequently reported by suicide victims
than in controls and when communication did occur, it was
less often directed towards parents. Treatment of psychiatric
disorders was significantly less found in suicide victims.
Portzky et al. [60] likewise showed that the victims had
negative life events and psychosocial problems suggesting
difficulties in coping with stressful psychosocial problems.
Fortune et al. [61] used life-charts of psychological
autopsy information from multiple informants to identify
suicidal process among 27 suicide victims, most of them
males. They found three groups, and one of them was
characterized by longstanding difficulties which spanned the
developmental domains of home, school and peers. The
suicidal process was longstanding, and included deliberate-
self harm prior to the death and direct communication to
friends and family about suicidal ideas and plans. A high
level of distress was evident in this group; many families
were struggling with distressing life events, criminal beha-
viour, illnesses and financial problems. The second group
was characterized by evidence of established psychiatric
disorder, and the third one by the emergence of suicidal
process as an acute response to life events among young
people who appeared to have previously been functioning
well, without apparent mental illness or known self-harm.
However, two of five in this group communicated specific
suicidal intent in the weeks before their death.
These new findings further confirm the strong evidence
that mental disorders constitute the major risk factor for
youth suicide. Psychological autopsy studies in Western
countries have reported mental disorders in 81 % to 95 % of
youth suicides. Approximately 50 % - 75 % of youth victims
have had a mood disorder, most commonly major depression
[18]. In a recent psychological autopsy study by Portzky
et al. [8], 32 informants of 19 young suicide victims were
interviewed, and reportedly all the victims suffered from one
or more mental disorders at the time of their death; almost
half of them were diagnosed with personality disorders, and
adjustment disorders in one fifth of the sample. Only a small
minority was receiving treatment for their disorders. The
suicidal process of suicide victims with adjustment disorder
was short and rapidly evolving without any prior indications
of emotional or behavioural problems [60]. It seems that
albeit patients with AD suffer from short-term stress-related
psychic disorders, adolescent outpatients with severe psy-
chosocial impairment and suicidal behaviour seemed to be in
risk for later suicidal behaviour [62].
Previous findings have further showed that from about
one quarter to two thirds of adolescent victims have received
a diagnosis of substance abuse or dependence. Also
Pelkonen et al.
substance misuse not fulfilling the diagnostic criteria of
substance use disorders has been reportedly associated with
adolescent suicides [18]. In a recent review Giner et al. [56]
found that the role of alcohol use in adolescent and young
adult suicides was high (from 21.4% to 43.7%). Schizo-
phrenic psychoses and personality disorders have been diag-
nosed more commonly in young adult than adolescent
suicides, while disruptive disorders and adjustment disorders
have been more prevalent among younger victims. Also
behavior problems and symptom clusters not fulfilling the
diagnostic criteria of conduct disorder are common among
child and adolescent suicides being reported in 43% - 73 %
of completers, often in combination with depressive symp-
toms and/or substance abuse. Problems with the law are also
overrepresented among youth suicides (16% - 28%). Psy-
chiatric comorbidity is common among young suicide
victims (51% - 81%). The impact of comorbid conditions to
suicide risk is complex and thus far little studied. About one
third of young suicides have a history of prior attempts and
up to two thirds of child and adolescent victims have
verbally communicated their suicidal intent. In controlled
studies the risk for suicide has been estimated to be about
30-fold among youth with a suicide attempt history com-
pared with those without previous attempts [18].
As reviewed above, the relationship between psychiatric
disorders and adolescent suicide is well established.
However, recent suicide research in China has prompted
important debate on the meaning of the findings concerning
the impact of psychiatric disorders for adolescent suicide.
In the case-control psychological autopsy study of 392
young Chinese suicide victims 15-34 years of age, and 416
living comparison subjects, the prevalence of current
psychiatric disorders was 48% for suicide victims and 3.8%
for comparison subjects [2]. They further reported that
mental illness was more prevalent in males than in females
(55.1% vs. 39.3%, respectively). Although psychiatric dis-
orders were strong risk factors for suicide, they were less
prevalent among rural Chinese young people who committed
suicide, particularly females, in comparison with other
populations in China and in the West. However, Zang et al.
[2] did not include personality disorders and disruptive
disorders in their psychiatric interviews, both disorders
common among suicide victims in other studies, and this
may be one reason for different numbers of psychiatric
disorders between studies. Chinese adolescents, especially
females, have reportedly lower risk for alcohol use and
alcohol related problems, and other possible risk factors need
be taken into account (cultural, social and psychological). In
a sub-sample of this study [63], a case-control study was
conducted with 114 suicide victims (at age of 15-24 years)
and with 91 controls who had died of other injuries. Among
suicide victims 24% had attempted suicide, as also pre-
viously reported in Western studies [18]. Of the suicide
victims 45% met a criteria of a psychiatric disorders at the
time of death, however, multivariate logistic models revealed
that it was a risk factor only for the males. Other risk factors
were having experienced severe life events two days before
the death, presence of any depressive symptoms within two
weeks of the death, low quality of life in the month before
death and having an acute stress at the time of death. Prior
suicide attempt was related to suicide in univariate
Adolescent Suicide
comparisons, but could not be included in multivariate
models because no controls had made prior attempts [63].
In discussing the impact of these findings, it has been
suggested that regardless of methodological concerns (e.g. to
use non-psychiatric interviewers) the findings of the pre-
valence of psychiatric disorders in the suicide case-control
psychological autopsy study seemed to be close to actual
rate, albeit somewhat lower compared with an epidemio-
logical study administered by psychiatrists [13]. In addition,
a low proportion of individuals ever receive psychiatric
treatment in China, and unlike in Western studies, the proxy-
based diagnoses cannot be augmented by referring to
information in clinical records [13]. Another concern was the
dichotomous classification of psychiatric disorders in the
suicide studies. Phillips et al. [64] have reported that suicide
risk was linearly related to the severity of depressive
symptoms in China. Probably sub-syndromal symptoms may
be important factors. Manifestations of dysphoric affects
may not match diagnostic criteria in China and other cultures
compared with those in Western countries. Further, the
frequent use of pesticides as a method of self-harm in China
may increase the proportion of suicide decedents without
psychiatric disorder who carried out impulsive acts with little
intention to die [63, 65]. On the other hand, also some pre-
vious psychological autopsy studies have identified suicide
victims with short-term suicidal process as an acute response
to life events among young people who appeared to have
previously been functioning well, without apparent mental
illness or known self-harm [61, 66].
3.3.2. Follow-Up Studies of Child and Adolescent
Psychiatric Patients and Suicide Attempters
Follow-up studies of adolescent psychiatric patients and
suicide attempters have provided complementary data e.g. of
psychotic disorders, which are rare in non-clinical suicide
studies. Recently, Engqvist and Rydelius [57] found sig-
nificantly higher suicide and other mortality rates among
former child and adolescent patients compared with the
general population in a 12-33 year follow-up study. Like-
wise, children and adolescent with psychosis were more
likely than non-psychotic patients to have repeat or multiple
suicide attempts [58]. On the other hand, a recent follow-up
study of a large clinically representative cohort of patients
experiencing their first psychosis found lower suicide rates
than expected. However, the risk for suicide persisted late
into the follow-up (mean 11.5 years), and the risk was
highest soon after the first presentation of psychosis,
indicating the importance of early assessment and treatment
of suicidal behaviour among youth with psychotic disorder
[67]. One study on adolescent outpatients [68] found a high
male mortality rate among former adolescent outpatients
during a 6-year follow-up. Baseline history of suicidal
behavior and severe functional impairment were risk factors
for late suicidality also in a recent follow-up of referred
suicidal adolescents [69].
3.4. Risk Factors for Adolescent Suicidal Ideation,
Deliberate Self-Harm and Suicide Attempts
As youth suicides are rare, much of the knowledge on
risk factors is based on studies of other suicide-spectrum
behaviors, including suicidal ideation or threats, deliberate
Current Pediatric Reviews, 2011, Vol. 7, No. 1 57
self-harm behavior (DSH) and suicide attempts/parasuicides
[14]. Due to variations in the definitions, sample charac-
teristics, and lack of accurate statistics, the prevalence rates
of suicidal ideation and suicide attempts are difficult to be
estimated. According to a comprehensive review of 128
population-based studies including 513,188 adolescents, the
mean of lifetime prevalence of suicide attempts was 9.7%,
with 6.4% reporting suicide attempts in the previous year
[70]. The mean of 13.2% reported lifetime DSH and 26% in
the previous year. The mean proportion of adolescents
reporting lifetime suicidal ideation was 29.9%, with 19.3%
in the previous year. There was a considerable within-group
variation. The proportion reporting lifetime suicide attempts
varied between 2% and 30%, and lifetime suicidal ideation
between 8% and 70%. In most studies suicidal phenomena
were significantly higher among females compared with
males. Suicidal behaviour was more prevalent in studies
using anonymous questionnaires [70]. Most previous reports
have included Western populations, however, recent findings
in rural China have reported respective prevalence numbers
of suicidal behaviours [71].
There are large variations in definitions of variables of
familial and individual risk factors, in methods used and
sample characteristics of suicidal adolescents. In the follow-
ing, we review selected studies in risk factors for non-lethal
suicide-spectrum behavior.
Childhood adversities (especially intrusive or aggressive
adversities) were powerful predictors of the onset and persis-
tence of suicidal behaviours in a nationally representative
sample (n=552,999) in 21 countries worldwide [37]. Like-
wise in a large non-clinical population, drug use, victimi-
zation, risky sexual behaviour and health problems associa-
ted with suicidal behaviour [72]. In a large adolescent non-
clinical population in rural China female gender, older age,
boarding in school, life stress, depression and external locus
of control were significantly associated with increased risk
for suicidal ideation; while older age, life stress, external
locus of control, poor academic performance, depression and
aggression were related to suicide attempts [71].
The meaning of familial risk factors was also studied in
some longitudinal studies. Family history of suicidal
behaviour and childhood sexual abuse increased the risk for
later suicidality [73]. Adolescent suicide attempters in a large
23-year surveillance study among general-hospital treated
suicide attempters, aged 13-19 years, reported that dysfunc-
tional family situation was the commonest underlying reason
for their suicide attempt (in 43.6%), followed by mental
health problems (in 22.8%) [74]. Child and adolescent
offsprings of parental suicide decedents were at high risk for
suicide in a population-based data from national registers in
Sweden [75]. They further found that offspring of suicide
decedents had an especially high risk for hospitalization for
suicide attempt, depressive, psychotic and personality disor-
ders. Child survivors of parental suicide were at particularly
high risk for hospitalization for drug disorders and psychosis
[75].
Families of self-injuring adolescents exhibited less
positive affect, more negative affect and lower cohesiveness
than did control participants [76]. In addition, self-injuring
adolescents exhibited more opposition and defiance and less
58 Current Pediatric Reviews, 2011, Vol. 7, No. 1
positive affect than did control participants during conflict
discussion. Peripheral serotonin was also inversely corre-
lated with the expression of positive affect within dyads.
Furthermore, adolescents´ serotonin levels interacted with
negativity and conflict within dyads to explain 64% of the
variance in self-injury. However, there were no clinical
comparison group, and it is not known if the findings are
specific of self-harm or of general psychopathology; more
sophisticated measures of 5-HT are needed, such as the
fenfluramine challenge tests or in vivo brain imaging
techniques.
Depressive disorder is reportedly the strongest risk factor
for suicidal behaviours [71, 73, 77]. The long-term psychia-
tric outcome for adolescents with persistent or recurrent
internalizing disorder was poor in a longitudinal study of a
large British birth cohort [78]. A longitudinal study of the
Isle of White Study found that not only adolescent worry and
irritability, but also family and experimental adversities were
risk factors for subsequent suicidality [79].
The predictive impact of comorbid psychiatric disorders
has been found in several longitudinal studies. Anxiety
disorders were risk factors for suicidal ideation and suicide
attempts, even after controlling for confounding factors,
however, the risk increased with multiple anxiety disorders
in 25-year follow-up study of a birth cohort in New Zealand
[80]. Further, the Great Smoky Mountains Study, a
representative sample of youth aged 9 to 16 years, were
followed up by Foley et al. [81]. Risk for subsequent suicidal
ideation and/or suicide attempt during the past three months
were greatest for those with current depressive disorder and
anxiety, or depression and disruptive disorder. Severity of
impairment and familial poverty were independent risk fac-
tors, irrespective of psychiatric profile. Moreover, a recent
Finnish longitudinal population-based study reported that
among boys, the strongest predictor of completed suicide or
making a severe suicide attempt by age 24 years was
comorbid conduct and emotional (mostly anxiety) disorder at
age of 8 years [82].
Previous suicidality is one of the most significant risk
factors for later suicidal behaviour [18]. In line with these
findings Nurgham et al. [83] reported that a history of
suicidal acts predicted later suicidality in a follow-up study
of a non-clinical sample. Moreover, suicidal ideation at age
15 years predicted increased risk for suicidal behaviour and
psychiatric disorders compared with non-suicidal adole-
scents [84]. Contrary for previous suggestions, symptoms of
deliberate self-harm behaviour may not be regarded as
transitional and/or non-harmful behaviour [85, 86]. A recent
follow-up study among adolescent outpatients with depress-
sive disorders found that alcohol use and Axis I comorbidity
predicted later suicidality among both those with DSH and
among those with suicidal ideation and/or suicide attempts
[87].
Bullying is reportedly a risk factor for depression and
suicidal ideation [88] and suicide attempts [89]. However, in
a population-based birth cohort [90] longitudinal analyses
revealed that bullying at age 8 years increased odds for
suicide attempts when examined alone, but the association
was not significant after adjusting for conduct disorder and
depression. This suggest that bullying was not causally
Pelkonen et al.
related to suicidal behaviour but instead correlated because
both are consequences of conduct disorder, a known risk
factor for suicidal behaviour, especially among boys. Results
were opposite for girls: victimization, but not bullying was
associated with suicide attempts, even after adjusting for
conduct disorder and depression. According to a recent
review of cross-sectional and longitudinal studies bullying
and peer victimization were risk factors for later suicidality
particularly with psychiatric comorbidity [91].
Some researches have also pointed the importance to
investigate the associations between chronic illness and
suicidal behaviour among adolescents. A recent review by
Greydanus et al. [92] found that approximately one third of
children and adolescents had at least one chronic illness, and
they were vulnerable to biopsychosocial risk factors. In a
cross-sectional study among 15-to 20 year olds 11.4% of the
females and 9.6% of the males had a chronic condition, and
7.7% (3.4% of the controls) of the females versus 4.9% (2%
of the controls) of the males had attempted suicide during the
previous year [93]. According to Haarasilta et al. [94]
subjects who had more than three sick days in the past 6
months and who had respiratory allergies were more likely
to have major depression episodes, and concluded that young
people with chronic illness and symptoms of depression
should be assessed for suicidality. In the same study, it was
observed that depressed subjects also reported poor self-
rated health regardless somatic conditions more frequently
than their non-depressed peers. Greydanus et al. [92]
concluded that suicide risks are seen in adolescents with
chronic illness, and all these young people should be
screened for depression and other risk factors for suicide.
4. PREVENTIVE APPROACHES
Adolescent suicide prevention is an important area of
public health worldwide [12]. Recent reviews have e.g.
assessed suicide prevention strategies [9], suicide screening
procedures [7, 95] and the relationship between youth sui-
cide and access to care [96]. Recommendations or guidelines
for developing and implementing strategies to decrease the
rates of youth suicides are available [1, 26].
Only few preventive efforts for adolescents have been
scientifically evaluated thus far. Prevention in general adole-
scent population includes e.g. programmes in educational
settings. In the school setting, universal screening with the
current tools available has produced a great number of false
positives, which can burden scarce mental health resources.
Universal screening is therefore recommended only when the
screening is part of a larger suicide prevention program with
appropriate access to care [7]. It seems that effective
prevention strategies of adolescent suicide should consist of
identification and appropriate treatment of those in elevated
risk, e.g. those with depression and substance use, and
especially of high-risk youth, e.g. suicide attempters [7]. In
their comprehensive review of suicide prevention strategies,
Mann et al. [9] and Beautrais et al. [26] concluded that
education of physicians and restricting access to lethal means
were found to prevent suicide. Other methods, such as public
education, screening programs and media education need
more testing.
Adolescent Suicide
4.1. Prevention in General Populations
4.1.1. School-Based Programs
The aim of school-based programs has been to increase
suicide awareness of high school students´ through education
and thereby to enhance help-seeking behavior among distur-
bed adolescents. Findings have, however, been contradict-
tory, and education programs to reduce suicidal behavior has
seldom been scientifically evaluated thus far [9]. Ethical and
legal concerns about screening instruments have considered
high number of screening positives, shortcomings in plans
for crisis interventions and problems how the screen positive
youth receive timely and adequate care [95]. Previous find-
ings showed that suicide awareness programs had even
detrimental effects [97], however, a recent randomized
controlled trial in six high schools in USA showed that
screening related questions regarding suicidal ideation did
not cause iatrogenic effects among non-suicidal adolescents
or among suicide attempters [98]. In a subsequent longitu-
dinal study of a suicide screening program, Gould et al. [99]
found promisingly, that nearly 70% of at-risk suicide screen-
ing adolescents, who were recommended to seek treatment,
followed thorough these recommendations.
In a large sample of nine high school students were ran-
domly assigned to SOS suicide prevention program interven-
tion and control group. Self-administered questionnaires
were completed by students three months after the imple-
mentation. Significantly lower rates of suicide attempts and
grater knowledge and more adaptive attitudes about depres-
sion and suicide were observed among students in the inter-
vention group regardless of race/ethnicity, grade and gender.
On the other hand, the intervention was not associated with
increased help-seeking among emotionally troubled youth
[100].
Due to the limitations of school-based suicide awareness
programs, more emphasis has been paid to interventions
aiming at skills training, such as enhancing coping skills and
self-esteem [18, 19]. However, efficacy of psycho-educa-
tional programs is rather conflicting. Portzky and van
Heeringen K [101] examined the effectiveness of psycho-
educational programs with focus on peer-helping to prevent
suicide. 14-18-year-old students were administered struc-
tured questionnaires before and two months after the prog-
ram to assess the effect on knowledge, attitudes, coping and
hopelessness. The findings suggested that a positive effect
on knowledge about suicide could be found, but the program
had no effect on the use of coping mechanisms or levels of
hopelessness. This program did not show any adverse
effects, however, the authors suggest that psycho-educational
programs with peer-helping focus should be implemented as
a part of more comprehensive prevention program. On the
other hand, there are some peer-support suicide prevention
programs aiming at training peers to identify and help
adolescents at risk for suicide [102, 103]. The programmes
were aimed at increasing the sense of social cohesion and
creating the atmosphere that discourages hopelessness and
promotes a positive affect overall. However, most of the
participants did not complete to the program in these studies.
These findings support the view that suicidal adolescents
should never be left alone to peer support, but they should
always be referred to adult health care professionals.
Current Pediatric Reviews, 2011, Vol. 7, No. 1 59
Some school-based adolescent depression education pro-
grammes have been conducted aiming at reduce the risk for
suicidal behaviour through reducing symptoms of
depression. Swartz et al. [104] conducted a 3 hour-education
programme and the results were promising; the knowledge
of depression improved after the curriculum. However,
without a comparison group the results were preliminary.
Sawyer et al. [105] investigated the effectiveness of a uni-
versal intervention to reduce depressive symptoms expe-
rienced by adolescents at high schools, were the students
were randomly assigned either to an intervention or to
comparison group. Despite using an extensive, structured
programme, based on best evidence to increase protective
factors and reduce risk factors at the individual and school
levels, the intervention did not reduce levels in depressive
symptoms in this large three-year study. It was concluded
that implementation of such programmes will require
programs which are perceived by teachers and students as
relevant to educational and learning goals, which can be
effectively delivered in conjunction with other school
programs, and where appropriate access to mental health
care are provided [105].
4.1.2. Crisis Hotlines
Crisis hotlines are widely available for people with
suicidal thoughts. Yet, evidence of their impact in reducing
rates of complete suicide is equivocal [9]. They may be
helpful, however, it seems that hotlines do not reach those
young people, e.g. adolescent males, in greatest need of
personal help. There are reports that disturbed adolescents
prefer to turn to other adolescents, not adults, parents or
professionals when in need of help [18] but those turning to
adults receive help more often than those turning only to
peers [106]. In Australia, a telephone counselling was
conducted between 1997-2000. Changes in suicidality and
mental state among adolescents were found during the
telephone counselling sessions using a reliable rating scale.
Follow-up data were, however, lacking [107]. Recently,
Witte et al. [45] investigated the factor structure of a risk
assessment tool utilized by suicide hotlines, and determined
the predictive validity of the obtained factors. The screening
questions regarding suicidal plans had preliminary more
predictive impact, as well as suicidal ideation albeit not so
significantly. Thereby risk assessment should include both
these aspects also in crisis hotline consultations.
4.1.3. Internet
There are worldwide concerns that pro-suicide web sites
may trigger suicidal behaviours among vulnerable indivi-
duals [9, 49]. In 2006, Australia became the first country to
criminalize such sites. Concerns were expressed that the law
casts the criminal net too widely, inappropriately interferes
with the autonomy of those who wish to die, and has
jurisdictional limitations with off-shore web sites remaining
largely immune. Conversely, proponents point out that the
law may limit access to domestic pro-suicide web sites, raise
awareness of internet-related suicide, mobilize community
efforts to combat it, and serve a powerful expression of
societal norms about the promotion of suicidal behaviour
[108]. On the other hand, modern preventive and treatment
approaches are increasingly using internet-based approaches
with promising preliminary results [109] and, thus, internet
60 Current Pediatric Reviews, 2011, Vol. 7, No. 1
may also be seen as a source of help under appropriate
circumstances.
4.1.4. Media Education
Media influences of reports of completed suicides have
not been evaluated thus far. Some evidence suggests that an
increase in suicides follows after suicide stories in media
[19]. However, media may offer public education for preven-
tion [9, 49]. It has been recommended that media should
avoid e.g. front page coverage on suicide and describe
treatment resources [19]. However, Gould et al. [110]
analyzed by a structured content analysis 151 articles from
newspaper stories of suicides, and found remarkable difficul-
ties in definitions of complex variables. While the majority
of variables (e.g. headline characteristics, pictorial presenta-
tions, event and victim characteristics, textual attitude,
suicide details, attributions to blame, victims´ problems etc)
were very reliable between the raters, in contrast, complex or
equivocal constructs achieved relatively low reliabilities
(such as sensationalizing, glorifying, romanticizing). These
constructs have used in previous media guidelines, and it is
suggested that before effective guidelines and responsible
suicide reporting can ensue, further explication of suicide
story constructs is necessary to ensure the implementation
and compliance of responsible reporting on behalf of the
media [110].
4.1.5. Restriction of Lethal Methods
Methods used in suicide vary by gender and nation. A
large previous international survey of suicides among 15-24
year-olds found that 34% of the suicides were firearm-
related [111]. Based on the lethality and common use of
firearms in male youthful suicides, it has been suggested that
reducing firearm availability would reduce incidence of
suicide [9]. Recently, suicides made by highly lethal
methods, such firearms and pesticides, have decreased after
method restrictions [9]. The critically important meaning of
method restriction were pointed in the studies from New
Zealand, where the rates of female youth suicide more than
doubled from 1977 to 1996, the increasing rates were due to
the growing use of hanging and vehicle exhaust gas by
women [20, 21]. Likewise in China the higher female rates
of suicide is most likely to be explained be the ready access
that Chinese women have to agricultural pesticides, which
are used in self-poisoning attempts and have high lethality
[22]. Gauging the extent which declining overall suicide
rates are directly attributable to restriction in access to
particular means requires consideration of long-term trends
and confounding factors, such as increased antidepressant
use. Limitations of this approach are the difficulty to restrict
many methods (e.g. hanging, drowning, intake of liquids and
solids), and the possibility of method substitution [9]. In
Finland, firearm control legislation is under preparation.
4.1.6. Identification of Adolescents at High Risk for
Suicide
Although the vast majority of adolescent suicides have
had mental problems, and previous suicidal behavior is
common, only about 20 % to 50 % of the victims have
received psychiatric care, and remarkably few (from 5 % to
20 %) have been in psychiatric care at time of suicide [8, 9,
96]. Hence, in primary care, the recognition of those adole-
Pelkonen et al.
scents most at risk of suicide is a major task. Pediatricians
and primary care professionals are in a distinctive position to
help prevent suicide in adolescents [112]. It has been
recommended that primary care clinicians should be trained
in recognizing all known risk factors for suicide. Promising
results were found by Pfaff et al. [113] reporting remarkable
increase in recognizing and responding to suicidal behavior
among adolescents after training primary care physicians.
In addition, children of parents with psychiatric disorders
and/or with suicidal behavior should be thoroughly assessed
and offered appropriate care, if needed. Collaboration with a
psychiatrist and ensuring that adequate and appropriate
treatment is given is essential [9, 96].
4.2. Treatment of Depressed Youth
Psychiatric disorders, particularly mood disorders, are
among the most important risk factors for adolescent
suicides. Recognition and effective treatment of these disor-
ders are cornerstones in clinical prevention of youthful suici-
des. Opinions vary whether psychosocial or pharmacological
interventions, or a combination of them, should be used as
first-line treatment for youth with depressive disorders [114,
115]. This chapter briefly reviews research on the treatment
of diagnosed unipolar depressive disorders among youth as
the most prevalent adolescent psychiatric disorder assocating
with the risk for various dimensions of suicidality.
4.2.1. Psychosocial Treatment of Youth with Depressive
Disorders
In treatment of adolescent depression, no psychotherapy
is shown to be superior to another [114, 115]. It seems,
however, that the use of systematic and evidence-based
approaches by itself is associated with higher efficacy and
increases the probability of positive response [116]. In
general, youths in treatment groups reach symptomatic
recovery faster and more often than in control groups.
However, the treatment trials have been relatively short in
duration and also intervention studies comprise relatively
short follow-up periods. It seems that the good results
obtained in the acute phase treatment [117, 118] are not
sustained over longer periods of time [114, 115], and sugges-
tions for longer treatments, active treatment approach espe-
cially in the early phases of depression, sufficient follow-up
and maintenance treatment have been put forward [119-121].
Combining different approaches (e.g. psychotherapy and
medication) has been reported to be both more effective
[122] and equally effective [123] in the acute phase when
compared with monotherapy but very little data exist on its
longer term effects [121, 124]. Maintenance treatment has
also been little studied [125].
Overall, research on Cognitive-Behavioral Psychotherapy
(CBT) shows, that CBT is effective in the acute treatment of
adolescent depression with no observed difference between
group and individual treatments [114]. In a meta-analysis
where four studies on adolescent CBT with a total of 168
patients were analyzed, it was estimated that remission of
depressive disorder was three times likely in treatment
groups than in comparison groups [126]. The number needed
to treat (NNT) was 4 indicating that four depressed adole-
scents need to be treated for one to reach remission. In other
meta-analyses comprising individual and group CBTs the
Adolescent Suicide
effect sizes (ES) of 1.27 [127], 1.02 [117], and 0.53 [118] in
relation to comparison treatments have been calculated.
The efficacy of Interpersonal Psychotherapy for adole-
scents (IPT-A) in the treatment of adolescent major depres-
sion has been studied in three well-conducted randomized
controlled trials. In a study of 24 IPT-A patients a higher
recovery rate was reported in comparison with 24 controls
(75% vs. 46%) [128]. Improvement in psychosocial func-
tioning has also been reported in a study comprising 34 and
29 adolescents in IPT-A and control treatment groups, res-
pectively [129]. In another trial [130] 71 adolescent outpa-
tients with MDD or dysthymia were randomized to CBT,
IPT-A, and to a waiting list. According to self-reports, both
IPT-A and CBT significantly reduced depressive symptoms
when compared with the waiting list condition. Finally,
according to a meta-analysis comprising 27 child and
adolescent psychotherapy studies, IPT-A was evaluated to be
effective in the treatment of adolescent depression [131]. A
group therapy modification as well as preventive interven-
tion using IPT-A methods, has been developed but currently
little data exist on their efficacy [132-134].
In cases where family conflict plays a major role in
adolescent depression, systematic family therapy has been
suggested to be one treatment alternative. However, while
there are data on the positive effects of the therapy on family
relations [135], data on its efficacy on reducing symptoms of
depression or increasing the likelihood of recovery is less
encouraging [136]. The role of family-centered approach
might be more beneficial in younger adolescents [137] and it
should be noted that family conflict has been identified as a
significant mediator of treatment effect [138]. The need for
research and development of family interventions are further
underlined by recent findings from several intervention
studies which indicate that parental depression or parent-
adolescent conflicts influence the outcome of adolescent
depression [121, 134, 139, 140] and that interventions targe-
ted at these interpersonal conflicts may be superior to those
not including these aims [134].
Taken the relatively high response rates in adolescents
receiving “relatively inactive treatments” in controlled psy-
chotherapy trials, it has been suggested that brief supportive
intervention could be used as the first line treatment of mild
youthful depressive disorders [127, 141]. Although psycho-
dynamic psychotherapy is widely used in clinical practice,
no controlled trials on its efficacy in youthful depressive
disorders have been published. A retrospective chart review
of child and adolescent outpatients who had received either
psychoanalysis or intensive psychoanalytic therapy [142],
found that 40 % of the depressed patients had no diagnosis
and were functioning well, and in 62 % reliable improve-
ment in psychosocial functioning was observed at the end of
treatment. Moreover, a randomized clinical trial with 72 9-
15-year-old patients concluded that short-term (16-30
sessions) focused individual psychodynamic therapy was
effective in the treatment of depression [143]. These find-
ings, encouraging research reports among adult patients
[144] and clinical experience suggest that also psychody-
namic therapy may be of value in treating adolescent
depressive disorders. Creative therapies (e.g. music and art
therapy) are also applied in the treatment of adolescent
Current Pediatric Reviews, 2011, Vol. 7, No. 1 61
depression but no controlled trials are available on their
efficacy.
4.2.2. Biological Treatment of Youth with Depressive
Disorders
One of the first meta-analyses on antidepressant
medication in adolescent depression [145] included five
published and seven unpublished trials of serotonin reuptake
inhibitors (SSRIs) and venlafaxine. The authors conclude
that only fluoxetine had a favourable risk-benefit profile.
Other meta-analyses [146 - 148] also have noted that SSRIs
as a group are superior to placebo, while of individual drugs,
only fluoxetine show a consistent treatment effect over
placebo Furthermore, SSRIs seem to be more efficacious in
adolescent than in childhood depression [148]. While the
data on the efficacy of fluoxetine is most consistent, some
studies [149, 150] have reported also sertraline superior over
placebo in adolescent MDD. Age-grouped analyses of RCTs
on escitalopram [151], paroxetine [152, 153] and venlafaxine
[154] suggest efficacy in treating MDD in adolescents but
not in children. Approximately 10 – 20 % of adolescent
patients may be expected to experience adverse effects when
taking SSRIs. A disconcerting finding has been that SSRIs
may increase the risk for suicidal behaviour particularly
during the first weeks of treatment [155].
The most comprehensive meta-analysis to date included
27 RCTs of SSRIs and other new antidepressants i.e.
fluoxetine, paroxetine, sertraline, citalopram, escitalopram,
nefazodone, mirtazapine, venlafaxine, fluvoxamine [149].
The authors estimated risk differences for response and for
suicidal ideation or attempts in child and adolescent depres-
sion (15 studies), obsessive-compulsive disorder (6 studies)
and non-OCD anxiety disorders (6 studies) and found pooled
risk differences for response in favour for antidepressant
compared with placebo in all three indications. In adolescent
MDD, NNT 10 and NNH for suicidality 112 were calcu-
lated. Careful assessment of response and possible adverse
effects are warranted.
Tricyclic antidepressants are not currently recommended
due to low efficacy and their side effect profile [156]. In
unipolar depression, mood stabilizers can be considered as
augmentation treatment. It has been reported, that among
adolescents who initially failed to response to a monotherapy
with an SSRI, those who received mood stabilizer augmen-
tation earlier in the course of the treatment had better
outcome than those continuing with monotherapy or
receiving the augmentation later on [121].
4.2.3. Summary
Current evidence shows that both certain psychosocial
and psychopharmacological treatments are efficacious in the
acute treatment of adolescent MDD. Of psychotherapies, the
evidence is strongest for individual and group CBT and
individual IPT-A in the acute phase treatment of adolescent
depression. Research on the psychopharmacological treat-
ment of adolescent MDD suggests that SSRIs are useful
while TCAs should not be used as first line medication. Of
individual compounds, the results generally support the use
of fluoxetine as a first choice medication.
In all, good quality data on treatments of adolescent
depression are relatively scarce, especially when compared
62 Current Pediatric Reviews, 2011, Vol. 7, No. 1
with data base of depression in adults. Most trials cover only
the acute phase, and studies comprising longer follow-ups
suggest that relapse and recurrence rates are relatively high,
and that initial differences between treatment modalities tend
to disappear. In addition, treatment trials often exclude
youths with most severe depressions, severe suicidality and
comorbid conditions. Other methodological factors possibly
affecting the results are heterogeneity of study samples, dose
of medication, duration of the trials, instrumentation, con-
comitant other treatments, and definition of treatment res-
ponse and recovery. Issues requiring additional research are
the efficacy of continuation and maintenance treatment in
preventing recurrence of adolescent depressive disorders and
the management of treatment resistant depression in adole-
scents. Finally, effectiveness studies are needed to find out
how results of efficacy studies generalize to routine clinical
practice.
While a relatively high proportion of subjects respond to
psychotherapeutic or antidepressant treatment a markedly
lower proportion gain remission. The results of research on
combining psychotherapeutic and psychopharmacological
treatments seem mixed. There may be some particular
patient subgroups for which a combination treatment may be
most beneficial. Switching to another treatment in case the
first one fails is also beneficial for many [157]. Psycho-
therapy – when needed - should be as readily available as
pharmacological treatment among adolescent psychiatric
patients. Obviously, large studies with longer follow-ups are
needed. Research on side effects of SSRIs indicate need to
weigh the expected gains and harms of antidepressants and
for careful and systematic monitoring of treatment response
and side effects. The impact of family conflict and/or paren-
tal depression on the treatment of adolescent´s mood disor-
der should be actively taken into account. Finally, efforts in
defining as clearly as possible etiologically different sub-
types of depression enabling more individualized treatment
should continue [158, 159].
4.3. Treatment of Suicidal Youth
4.3.1. Psychosocial Treatment of Suicidal Patients
Treatment of suicidal adolescents is complicated by high
rates of treatment refusal and drop-out, and low treatment
engagement [160 - 162]. Therefore, one of the areas of inte-
rest is to develop methods to increase adherence to treatment
and to develop interventions which reach suicidal adole-
scents as effectively as possible [161]. It has been suggested
that effective interventions should focus on specific aspects
of psychopathology (e.g. depression, conduct disorders) as
well as parental attitudes towards the treatment [160].
Emergency unit interventions involving family members
have also been recommended [161]. However, there are few
ED interventions for suicidal patient and none have assessed
cost-effectiveness [162, 163].
Generally, while some treatments have been shown to be
effective in treating the underlying psychiatric disorder or
reducing suicidal ideation, it has been more difficult to find
an intervention successful in decreasing the actual frequency
of attempted suicide [49] or reattempts of suicide [164].
While there is no clear consensus on which of the several
risk factors behind suicidal behaviour should be targets for
Pelkonen et al.
interventions [19], it has been suggested that treatment could
be targeted on the development of distress tolerance and
emotion regulation, and enhancement of protective elements
in family and school [165] and not to be limited to the acute
phase only [166]. Interventions taking into account multiple
risk and protective factors and the natural ecology of the
adolescent, such as multisystemic therapy (MST), seem also
promising [166].
Of various psychotherapies, cognitive-behavioral therapy
(CBT) approaches have been mostly studied in the treatment
of suicidal adolescents [165, 167] as well adolescents
deliberately harming themselves [168] although intervention
studies in this high risk groups are scarce. A specific, CBT-
based and manualized method for adolescents at high risk for
repeated suicide attempts has been developed and shown to
be feasible among adolescent psychiatric patients in the US
[167] but further studies have to be performed on its efficacy
on prevention of reattempted suicide as well as feasibility in
health care systems outside USA. Moreover, Dialectical
Behavior Therapy (DBT), has been shown to be effective in
the treatment suicidal behaviour especially in the context of
borderline personality disorder [169] while studies in adole-
scent populations are scarce. In a study of 62 adolescent
psychiatric inpatients, it was observed that DBT was feasible
to implement and conduct and significantly reduced suicidal
behavioural incidents in one-year follow-up [170].
Also other than individual therapies have been developed
for suicidal youth. Attachment-based family therapy
(ABFT), a manualized family therapy specifically designed
to target family processes associated with depression and
suicide, emerges from interpersonal theories suggesting that
depression and suicide can be precipitated, exacerbated or
buffered against by the quality of family relationships [171,
172]. Group therapy was found to be effective in reducing
self-injurious behaviour among adolescents [173], however,
a recent attempt to replicate this effect by the same group
yield the opposite result: those in the group therapy
condition were more likely compared with the controls to
have engaged in self-injury after the intervention [174].
It may well be that the treatment approach and results
achieved also vary by the underlying psychopathology and
that in many cases adolescents, and especially those suffer-
ing from conduct disorders, could benefit from intensive
treatment integrated into their natural ecology. There might
also be differences in the underlying mechanisms between
amelioration of depressive symptoms or suicidal ideation
and the diminishing of actual suicidal behaviour. Interven-
tions that succeed in reducing the rate of suicide attempts
could also have beneficial impact on various phenomena
often co-occurring or following suicide attempts (e.g. quality
of life, mental health costs, psychosocial adversity) [166].
4.3.2. Biolocigal Treatment of Suicidal Youth
Psychopharmacological treatment or ECT is mainly
directed by the underlying psychopathology. Suicidal beha-
vior is one of the severity indicators when the adolescent
psychiatric diagnostic assessment is performed. Safety mea-
sures have to be taken into account when prescribing medi-
cation to a suicidal adolescent: careful and frequent follow-
up and limitation of the amount of medication prescribed at
one time point. Psychopharmacological treatment is always
Adolescent Suicide
given in the context of treatment alliance and engagement to
treatment is needed for medication to be effective and safe.
Of specific preparations lithium possibly reduces suicidal
behavior in adult bipolar depression [175] and clozapine in
schizophrenia [176].
4.4. Postvention
After a suicide of a child or adolescent, postventive crisis
interventions among the survivors, e.g. at school has been
commonly recommended [177]. In a qualitative study of the
psychosocial consequences for the surviving family, ten
families of 88 suicide victims were interviewed [178]. Teen-
age suicide was found to be a devastating trauma for the
surviving family with sustainable explanations for the
suicide. A prolonged social and psychological isolation of
the families was found. Post-suicide support was reportedly
badly timed and insufficient, especially for younger siblings
[178]. In a systematic review of interventions for people
bereaved through suicide, McDaid et al. [179] found only
eight studies, one of which was scientifically sound. There
was some evidence of some benefit from interventions for
people bereaved by suicide, but further research is needed in
order to confirm whether interventions are helpful, and if so,
for whom.
CONCLUSIONS
Youth suicide is a major public health concern world-
wide. Prevention of suicide in young people is highly impor-
tant. In order to be successful, youth suicide prevention
cannot be restricted to e.g. psychiatric care but action needs
to be taken at different levels in the society. Suicide is a
complex phenomenon with psychological, social, biological,
cultural and environmental factors involved. The consistent
finding is that less than half of adolescent suicides have
received psychiatric care. Physician education in depression
recognition and treatment and restricting access to lethal
methods have reportedly reduced suicide rates [9]. All
expressions of suicide intent have to be taken seriously and
indicate assessment of the adolescent's development and life
circumstances.
The main target of effective prevention of youthful suici-
des is to reduce suicide risk factors. Psychiatric morbidity,
particularly mood disorders, antisocial disorders, and subs-
tance abuse are strongly related with youth suicide. In the
treatment of child and adolescent depression, both psycho-
social treatments and SSRIs have proved to be useful and
efficacious. Research on adolescent psychosocial and psy-
chotherapeutic interventions should address suicidal beha-
vior actively. Treatment of parental mood and other psy-
chiatric disorders is of high importance.
Different treatment modalities are useful in the treatment
of suicidal youth. For high-risk youth providing continuity of
care is important. Recent treatment studies among suicidal
adolescents have reported promising results on safety plan-
ning and increased therapeutic contact early in treatment.
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Received: January 03, 2011 Revised: February 02, 2011
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Accepted: February 09, 2011