Elliott Weiss Martin G.

Wolfish
Suicide Attempts
SUMMARY:
Suicide is a leading cause of death among
North American adolescents. Drugs are the
commonest method used, and are most
frequently those found in the home.
Common factors such as frequent moves,
marital difficulties of the parents, and a
family history of depression occur in these
patients. In 47 cases seen at a Toronto
hospital, 22 patients were admitted. Of
these, 20 had made suicidal gestures; two
had made serious attempts. Most were of
lower or middle class background. There is
often a long-standing problem in the
history, plus a triggering event. Knowledge
of risk factors can help family physicians
identify high risk patients. Hospitalization
of teenagers with suicidal intent is
obviously preferable, especially since it
convinces patient and family that the
attempt or intent has been taken seriously.
(Can Fam Physician 1982; 28:773-780).
in the Adolescent
SOMMAIRE
Le suicide est l'une des principales causes de dec's
chez les adolescents nord-americains. Les
medicaments, en particulier ceux que l'on retrouve
dans les foyers, constituent la methode de suicide la
plus utilisees. Les demenagements frequents, les
difficultes conjugales des parents et un passe
medical familial ponctue de depression sont au
nombre des raisons susceptibles d'entrainer un
suicide. Des quarante-sept cas releves par un hopital
de Toronto, vingt-deux patients ont ete admis a
l'hopital. De ce nombre, vingt avaient attente a leur
vie et deux avaient failli reussir. La plupart de ces
cas etaient de famille de classe inferieure ou
moyenne. On remarque souvent un probleme de
longue date et un evenement decisif. La
connaissance des facteurs peut aider les medecins de
famille a depister les patients les plus susceptibles
de se suicider. L'hospitalisation des adolescents qui
ont des intentions de suicide est evidemment
souhaitable parce qu'elle sert a convaincre le patient
ainsi que ces parents que la tentative ou l'intention
n'a pas ete prise 'a la legee.

Mr. Weiss is presently a final
year medical student at the
University of Toronto. Dr. Wolfish
is chief of pediatrics at North York
General Hospital. Reprint requests
to: Dr. M. Wolfish, North York
General Hospital, 4001 Leslie St.,
Willowdale, Ont. M2K lEl.
UICIDE ATTEMPTS and other
bforms of self-destructive behavior
are endemic among the adolescent
North American population. In fact,
accidents and suicides are the two
main causes of death in teenagers and
young adults today. ' While the major-
ity of suicidal acts are unsuccessful,
the morbidity is significant both in
terms of self-inflicted physical harm
and the emotional scars the adolescent
must bear as a result. Thus, early re-
cognition and treatment of teenagers
CAN. FAM. PHYSICIAN Vol. 28: APRIL 1982
after a self-destructive act is a prime
medical and psychiatric priority.
When a teenager has attempted self-
harm, suicide is a major concern, yet
self-destructive behavior can have a
variety of intents ranging from acts of
low lethality to more serious actions.
This contrasts with the suicidal act
which is "done in desperation to mod-
ify an intensely painful state".2 Often
it is difficult to determine the true in-
tent of the act. While the teenager may
deny the seriousness of the attempt, no
self-destructive act should automati-
cally be considered benign.
Suicidal behavior can range through
threats to a suicidal gesture, to a
serious attempt. The suicidal threat
may be written or verbalized and can
be expressed directly or in more subtle
ways. Both the suicidal gesture and the
serious attempt are actual attempts at
self-harm. They differ in many ways
including the intent, level of planning,
the degree of psychopathology pres-
ent, and the youth's concept of
death.3
Of adolescents who gesture suicide,
females outnumber males three to one.
Drug intoxication is the most fre-
quently used method.2 These teen-
agers do not truly wish to die-rather
the gesture is an attention-seeking de-
vice or a plea for help, directed com-
monly at parents or friends.' These
teenagers are often mildly to modera-
tely depressed and the attempt is
usually poorly planned.
Males are more frequently involved
in serious suicide attempts. These are
often carefully planned and they may
have attempted suicide in the past. The
ability to communicate with others is
more severely compromised as the at-
tempts become more serious. 1 Suicidal
tendencies in adolescents can be quite
variable: awareness of the wide range
of behaviors that the suicidal adoles-
773
Berotec® fenoterol hydrobromide
Prescribing Information
INDICATIONS AND CLINICAL USES: Berotec is indicated for
the symptomatic relief of bronchial asthma and other condi-
tions in which reversible bronchospasm is a complicating fac-
tor, such as chronic bronchitis or emphysema.
CONTRAINDICATIONS: Like other sympathomimetic amines,
Berotec should not be used in patients with tachyarrhythmias
or in those with known sensitivity to sympathomimetic
amines.
3-blocking agents, e.g., propranolol, effectively antagonize
the action of Berotec. Their concomitant use is therefore con-
traindicated.
WARNINGS: Special care and supervision is required in pa-
tients with thyrotoxicosis, cardiac arrhythmias and idiopathic
hypertrophic subvalvular aortic stenosis, when an increase in
the pressure gradient between the left ventricle and the aorta
may occur causing increased strain on the left ventricle.
Use In Pregnancy: The safety of Berotec in pregnancy has not
been established.
Use In Children: There is insufficient data at this time to
establish the safety and efficacy of Berotec in children.
PRECAUTIONS: Berotec should be used with care in
asthmatic or emphysematous patients who also have systemic
hypertension, coronary artery disease, acute and recurring
congestive heart failure, diabetes mellitus, glaucoma or
hyperthyroidism.
Care must also be exercised in the concomitant use of Berotec
with other sympathomimetic amines or MAO inhibitors.
As with all sympathomimetic aerosol drugs, failure to respond
to a previously effective dose usually indicates a significant
deterioration in the patient's asthmatic conditic:i. He should
be instructed to contact his physician immediately in these
circumstances, and on no account should he exceed the re-
commended dose of aerosol. Occasional patients have been
reported to have developed severe paradoxical airway resis-
tance with repeated use of sympathomimetic inhalant prepa-
rations. Fatalities have been reported following excessive use
of aerosol preparations containing sympathomimetic amines,
the exact cause of which is unknown.
ADVERSE REACTIONS: Berotec Inhaler: The following ad-
verse reactions have been reported at therapeutic dosage
levels (1-2 whiffs): tremor, restlessness, palpitations, dizzi-
ness, headache, nausea, lightheadedness and weakness.
Other occasional reactions include vomiting, heartburn,
sweating, nervousness, bad taste, fatigue, prickling and
tingling sensations over the body, and agitation.
Berotec Tablets: The most frequently observed adverse reac-
tions reported at therapeutic dosage levels (2.5 mg b.i.d.
-5 mg t.i.d.) were tremor and nervousness. Other adverse
effects in decreasing order of frequency are: palpitations,
headache, nausea, tachycardia, insomnia and muscle
cramps. Other rare reactions included irritability, weakness,
stomach pains, anxiety, dizziness, rash, tiredness, vomiting,
coughing, numbness in hands and legs, and dry mouth.
SYMPTOMS AND TREATMENT OF OVERDOSAGE: The symp-
toms of overdosage are those of excess beta stimulation listed
under Adverse Reactions. The use of a beta-blocker should be
considered in cases of severe overdosage.
DOSAGE AND ADMINISTRATION: Berotec Inhaler: A single
dose of one or two inhalations (0.2-0.4 mg) to control bron-
chospasm. If required, this dose of 1 or 2 inhalations may be
repeated up to 4 times daily. With repeated dosing, drug
should not be given more often than every 4. hours. Patients
should not exceed a total of 8 inhalations per day (See Pre-
cautions).
Berotec Tablets: The recommended starting dose is 2.5 mg
twice daily. If a greater therapeutic effect is desired, the
dosage may be increased up to a maximum of 5 mg 3 times
per day. The maximum single dose is 5 mg and this should
not be administered more often than every 6 hours. The maxi-
mum daily dose should not exceed 15 mg.
AVAILABILITY: Berotec Inhaler: Each valve depression
delivers 0.2 mg of Berotec as a micronized powder. Each In-
haler Unit contains 200 doses of 0.2 mg Berotec.
Berotec Tablets 2.5 mg: Round, white, flat, bevelled edge,
compressed tablets, engraved with the symbol: j,
9
The reverse side is scored with each halft
engraved as follows: B.
Supplied in amber glass bottles of 100 and 500 tablets.
Berotec Solution: Supplied as an aqueous solution in amber
screw cap glass vials with internal dropping assembly. Each
20 mL vial is supplied in an individual carton with a package
insert of detailed instructions for use. Berotec 0.1%: Con-
tains fenoterol hydrobromide 1 mg/mL solution.
For further information, consult the Berotec Product Mono-
graph or your Boehringer Ingelheim representative.
REFERENCES: 1. Anderson, S.D. et al.: J. Allergy Clin. Im-
munol. 64:612, 1979. 2. Anderson, S.D. et al.: Aust. N.Z.J.
Med. 5:554, 1975. 3 Leife, N and Wittig, H.J.: Ann.
Allergy 35:69, 1975. 4. Weinberg, E.G. et at.: Med. Proc.
18:73, 1972. 5. Wettengel, R. and Fabel, H.: lot. J. Clin.
Pharmacol. 4(Suppl):96, 1972.
Boehrlnger Ingelhelm (Canada) Ltd. PA
g2,,97 Century Drive
(i) CP
'-j- Burlington, Ontario L7LS5J8
cent can present is extremely impor- conscious level.6' I In an attempt to
tant in managing these youths. seek love, the child turns to suicide.
Psychodynamic theories examine
Epidemiology the developmental changes adoles-
The frequency of suicide increases cents must cope with as they approach
with age in the pediatric and adoles- adulthood. Having to deal with new
cent population. Few cases of suicide feelings of sexuality and aggressive
have been reported under age five. impulses, rejection of one's parents
Children aged five to nine years may and the quest for new challenges in
threaten but rarely attempt or suc- life, the developing adolescent may be
ceed.2 Amongst adolescents, the com- unable to cope with these stresses.'
monest method of attempted suicide is The youth sees the world as less pro-
drugs such as ASA, alcohol, barbitu- tective and feels more isolated, lonely
rates, diazepam and antidepressants.' and sad. He may defend against these
The source of the toxic substance is conflicts by acting out. This is compli-
usually the home.' Although less fre- cated by the fact that the adolescent
quent in the adolescent population, vi- may not have developed an adult per-
olent suicide attempts usually involve spective that things do get better.2 It is
males and are understandably asso- therefore understandable that suicidal
ciated with a higher mortality. behavior occurs in the adolescent
Factors common amongst teenagers years.
who turn to suicide include broken Considering suicidal behavior as an
homes, unemployed breadwinners and isolated event may not be totally ap-
a high frequency of family moves.4 propriate. Rather, it may suggest an
underlying psychiatric disorder. In a
Accordingly, adolescents from lower
socioeconomic backgrounds are more recent study, Crumley8 placed psy-
likely to attempt suicide than their chiatric diagnoses on 40 adolescents
counterparts in the higher socio- who attempted suicide. Of these pa-
economic groups.4 As one moves up tients, two-thirds had an affective dis-
the socioeconomic ladder, the relative order, and substance abuse was also
proportion of suicidal gestures de- frequently diagnosed. Personality dis-
clines-but serious attempts increase.4 turbance occurred in 62%, most fre-
Other associated factors include mari- quently a borderline personality dis-
tal discord, alcoholism, child abuse order.
and a family history of suicide and Mattsson9 has proposed a classifica-
death.2'
24 tion system for suicidal intent, to con-
Clearly these are numerous predis- sider the teenagers' state at the time of
posing and associated factors common the act rather than the predisposing
to teenagers who attempt suicide. psychiatric causes (see Table 1). In
Knowledge of these factors in a teen- any case, simply labelling a suicide at-
ager's history may be helpful in identi- tempt as a reactive disorder is clearly
fying the teenager at risk. unwarranted. Psychiatric intervention
may not only prevent further attempts,
Psychopathology but also improve longterm manage-
Attempts to analyze suicidal behav- ment.
ior have ranged from psychoanalytic TABLE 1
theories, such as Freud's "classical External and Internal
theory of melancholia", to dynamic Precipitating Suicidal Factors9
changes that explore the developmen- Loss of a love object followed by
tal changes of adolescence.5 In the 1. acute grief
"expendable child theory", Gould 2. "The badprolonged
or
me": self-depreciating pa-
postulated that all developing children tients
have an intense need for, and constant 3. The final "cry for help" directed
fear of losing, love.6 When a child is beyond immediate family
rejected, the need for love increases as 4. The revengeful angry teenager
the child attempts to fight the loss. Be- 5. The psychotic adolescent
cause the child has an omnipotent 6. The suicidal game
image of his parents, the feelings of
anger and rage he has towards his re-
jecting parents are directed inwards. Suicide Attempts in
Subsequently, the child develops a The Toronto Area
"sense of expendability"' which may Because suicide attempts are rela-
be manifested explicitly or on an un- tively common in the adolescent years,
775
the results are frequently seen in the
hospital emergency department. In one
particular study conducted during four
months in 1977, the emergency de-
partment at North York General Hos-
pital in Willowdale, Ontario, reported
47 cases of teenage suicide attempts
(Table 2).10 Just less than half were
admitted to hospital. The remainder
were sent home for a variety of rea-
sons, usually because they or their
families rejected hospital admission.
The hospitalized group were classified
as having made a gesture or a serious
attempt, depending on whether the at-
tempt was communicated to family or
friends. The majority of the hospital-
ized group came from middle or lower
class backgrounds and the most com-
mon methods involved ingestion of
ASA, diazepam, acetominophen, vari-
ous sedatives, and alcohol. Half of
those admitted were repeat attempts.
TABLE 2
Records of Attempted Suicide in
Teenagers at a Toronto Hospital
Emergency room cases 47
22
Admitted to peds. Ipsychiatry
Females 17
5 ADVERSE REACTIONS: Gasro-intestinal-Diarrhea has been reported
Males
Serious attempts 2 ties.9 In reviewing a number of adoles-
Suicidal gestures 20
10
-communicated with friends
-communicated with parents 10
Average age at admission 15
(range 12-19)
Socioeconomic background
-lower and middle class 17
-upper middle class 5 others)
Discharged by casualty officer 25
(Refused admission, outpatient
follow up arranged, casualty officer
felt admission was unwarranted)
Predisposing and precipitating fac-
tors were also examined: parents' mar-
ital difficulties, conflicts with parents, type of clinical picture. However, the
and alcohol/cannabis abuse were fre-
quent themes. Obviously the make-up
of teenagers who attempt suicide can
vary from one locale to the next. Fur-
ther, it has been estimated that as few
as one in 100 suicide attempts actually psychiatric difficulties.8
receive medical attention.1" However,
this study does at least provide a sam- Case Histories
pling of adolescent suicide attempts in Case I
the Toronto area.
The Clinical Presentation
The teenager who presents with sui- she showed up at a girlfriend's home
cidal behavior almost certainly has had and collapsed.
difficulties in the past. In fact, the sui-
cidal act may be the climax of a long attempt was a final school exam in a
series of struggles in the adolescent's course she felt she was unable to pass.
776
life, including difficulties in interper-
sonal and family relationships.2 There
may also be recent increases in new
problems, with fewer perceived solu-
tions. How these teenagers at risk react
under these stresses is similar.
Prior to the attempt, these adoles-
cents are commonly depressed and
show signs of increased tension such
as restlessness, irritability and over-
sensitivity .2' 12 They may have experi-
enced difficulty in school, including
truancy, and show a general decrease
in social behavior and functioning.
Symptoms include feelings of sadness,
emptiness and lack of energy. More
specific complaints include changes in
sleep and eating, boredom, and loss of
interest in school and social activites.
There may be a previous history of a
suicide attempt or other forms of self-
destructive behavior.
The specific event that triggers a
suicide attempt can vary from a seem-
ingly harmless incident to a highly
traumatic experience. Often it may not
be clear. Conflicts between the child
and his parental figures are a common
precipitating stress, as are grief reac-
tions, loss of loved people or things,
sexual conflicts and school difficul-
cent suicide attempts, Scheer and Kay
divided the precipitating stresses into
six main areas:'3
1. Disclosure of a forbidden activity
(i.e. alcohol)
2. Separation from parents (and
3. Defiance
4. Restriction
5. Criticism
6. Exclusion
The vast majority of teenagers who
exhibit suicidal behavior share this
occasional youth may demonstrate
more severe psychopathology, such as
thought disturbances and hallucina-
tions beyond the acute episode, and
may have a history of longstanding
S.A., a 15 year old girl, attempted
suicide by ingesting 24 ounces of
vodka. There were no witnesses, but
The major stress at the time of the
.(n.u8X cephalexin
DESCRPfO: Keflex is a semisynthetic cephalosporin antibiotic
intended for oral administration. It is 7-(D-a-amino-a-phenylaceta-
mido)-3-methyl-3-cephem-4-carboxylic acid monohydrate.
ACTO: Cephalexin is bactericidal against many gram-positive and
gram-negative organisms. In vitro tests demonstrate that the cephalo-
sporins are bactericidal through their inhibition of cell-wall synthesis.
INDICAT S: Keflex may be indicated in the treatment of bacterial
infections of the respiratory tract, including otitis media, genitourinary
tract, bones and joints, skin and soft tissue when the infection is
caused by susceptible organisms.
CONTRNDICAlTIMS: Keflex is contraindicated in patients with
known allergy to the cephalosporin group of antibiotics.
PRECAUTIS: Antibiotics, including Keflex, should be administered
cautiously to any patient who has demonstrated some form of allergy.
particularly to drugs.
In penicillin-allergic patients, cephalosporin antibiotics should be
used with caution. There is some evidence of partial cross-allergenicity
of the penicillins and the cephalosporins. Of 7.450 clinical trial
patients, 291 had histories of penicillin allergy. Nineteen of them
(about 6.5 percent) were among those in whom possible allergic
reactions to cephalexin were observed.
Patients should be followed carefully so that any side-effects or
unusual manifestations of drug idiosyncrasy may be detected. If an
allergic reaction to Keflex occurs. the drug should be discontinued and
the patient treated with the usual agents (e.g., epinephrine or other
pressor amines, antihistamines, or corticosteroids).
Prolonged use of Keflex may result in overgrowth of non-suscep-
tible organisms. Careful observation of the patient is essential. If
superinfection occurs during therapy, appropriate measures should be
taken.
Keflex should be administered with caution in the presence of
markedly impaired renal function. Under such conditions, careful
clinical observation and laboratory studies should be made because
safe dosage may be lower than that usually recommended.
If Keflex is to be used for long term therapy, periodic monitoring of
hematology, renal and hepatic functions should be done. Indicated
surgical procedures should be performed in conlunction with antibiotic
therapy: e.g., the incision and drainage of abscesses.
Safety of this product for use during pregnancy has not been
established.
Positive direct Coombs tests have been reported during treatment
with the cephalosporin antibiotics. In hematologic studies or in trans-
fusion cross-matching procedures when antigkobulin tests are per-
formed on the minor side or in Coombs testing of newborns whose
mothers have received cephalosporin antibiotics before parturition. it
should be recognized that a positive Coombs test may be due to the
drug.
In patients being treated with Keflex. a false-positive reaction for
glucose in the urine may occur with Benedict's or Fehling's solutions
or with Clinitest tablets, but not with Tes-Tapeo.
in only 1.5 percent of 7.450 clinical trial patients. It was very rarely
severe enough to warrant cessation of therapy. Nausea. vomiting,
dyspepsia and abdominal pain have also occured.
Hypeensity-Allergies (in the form of rash, urticaria and angio-
edema) have been observed. These reactions usually subsided upon
discontinuation of the drug.
Other reactions have included genital and anal pruritus, genital
moniliasis. vaginitis and vaginal discharge, dizziness, fatigue, and
headache. Eosinophilia, leucopenia due to neutropenia, and slight
elevations in SGOT and SGPT have been reported.
SYMPTOMS AND TREATMENT OF ORERDOSAGE: No information is
available on the treatment of overdose with Keflex. There is no
specific antidote.
MICROBIOLOGY: Keflex is active against the following organisms in
vitro:
Beta-hemolytic and other streptococci (many strains of entero
cocci; e.g.. Streptococcus faecalis, are resistant)
Staphylococci. including coagulase-positive, coagulase-negative.
and penicillinase-producing strans (a few strains of staphylococci are
resistant to cephalexin)
Diplococcus pneumrrniae Hemophilus influenzae
Escherichia coli
Klebsiella pneumoniae
Proteus mirabilis
Neisseria catarrhalis
Keflex is not active against most strains of Enterobacter sp., Pr,
morganii. and Pr. vulgaris. It has no activity against Pseudomonas or
Herellea species. When tested by in vitro methods, staphylococci
exhibit cross-resistance between Keflex and methicillin-type
antibiotics.
DOSAGE AND ADMINISTRATION: Keflex is administered orally. The
adult dosage ranges from I to 4 g daily in divided doses. The usual
adult dose is 250 mg every six hours. For more severe infections or
those caused by less susceptible organisms, larger doses may be
needed. If daily doses of Keflex greater than 4 g are required.
parenteral cephalosporins. in appropriate doses should be considered.
The recommended daily dosage for children is 25 to 50 mg per kg
divided into four doses.
Kelfex Su_psion
Child's Weight 125 mg/5 ml 250 mg/5 ml
10 kg (22 lb.)
20 kg (44 lb.)
r to tsp. q.i.d.
I to 2 tsp. q.i.d.
-
I? to I tsp. q.i.d.
40kg (88 lb.) 2 to 4 tsp. q.i.d. Ito 2 tsp. q.i.d.
In severe infections. the dosage may be doubled.
In the therapy of otitis media, clinical studies have shown that a
dosage of 75 to 100 mg per kg per day in four divided doses is
required,
In the treatment of beta-hemolytic streptococcal infections, antibi-
otic therapy should be administered for at least ten days.
To obtain maximum peak levels, cephalexin should be administered
o,i an empty stomach.
DOSAGE FORMS:
Tablets Keflex. equivalent to 250 mg cephalexin (No. 1894), Identi-
Code 057. are supplied in bottles sf 100. and 500.
Tablets Ketlex. equivalent to 500 mg cephalexin (No. 1095). Identi-
Code 049. are supplied in botlIes sf 100. and 250.
Keflen. for Oral Suspension, equivalent to 125 mg cephaleorn per
5 ml teaspoonful. is supplied In a 100 ml size packeage INs. M-201),
Identi Code W21.
Ketlex. for Oral Suspension, equivalent to 250 mg cephaleorn per
5 ml teaspoonful. Is sapplred in a 100 ml size packtage (No. M-202).
idpvi, Curie W6o
CAN. FAM. PHYSICIAN Vol. 28: APRIL 1982
Her father was described as strict. She
had a history of running away from
home, when neither parent was able to
locate her for a week. She had pre-
viously requested a psychiatric referral
from her family doctor, but was told to
see her high school guidance counsel-
lor. History of alcohol consumption
was unknown.
This patient has clearly made a sui-
cidal gesture, communicating the ac-
tion to friends. Although she was un-
conscious when she arrived at the
emergency room, she did not in retro-
spect truly wish to die; the act was im-
pulsive and likely attention-seeking.
The precipitating cause concerned dif-
ficulty in school and her parents' reac-
tion to it. Little is known about this
girl's past, but the episode of running
away and a strict home environment
suggest longstanding family difficul-
ties. The patient demonstrates good in-
sight into her problems, since she has
attempted to obtain help in the past.
Case 2
R. D., a 16 year old girl, attempted
suicide by acetaminophen ingestion.
After taking the pills, she revealed the
ingestion to her father and told him she
did not really want to die. Before the
attempt she was noted to be sleeping
more, binge eating with recent weight
gains, and had suicidal thoughts.
The patient had been depressed for
six weeks before the attempt and said
that "the pressures were too much".
Previously a high achiever, her perfor-
mance in school had recently been fall-
ing. Several weeks before her attempt,
her parents told her they were consid-
ering separation.
The family history includes manic-
depressive illness in the paternal
grandmother, and depression and a
previous suicide attempt by the
mother.
This patient's history is more com-
plete than the previous case, so both
acute and chronic stresses are more
clearly identifiable. Her parents' mari-
tal difficulties are important factors, as
is the six week history of depression
with changes in sleep and eating.
There is a strong family history of de-
pressive illness on both sides of the
family. It is extremely important to
note the patient's mother had at-
tempted suicide in the recent past.
Both cases, which are taken from
the records of the Adolescent Unit,
North York General Hospital, show
that longstanding difficulties and more
CAN. FAM. PHYSICIAN Vol. 28: APRIL 1982
recent stresses are a common finding emphasizing losses, the home situa-
in adolescent suicide attempts. Ob- tion, lifestyle, school, traumatic expe-
viously not all teenagers under similar riences, sexuality and drug use. Signs
stresses would act out in this way, but of depression and symptoms of psy-
they could easily be considered at high chosis should be thoroughly assessed.
risk for self-harming behavior. Both pre- and post-suicidal adoles-
cents are in some degree of distress.
The Clinical Assessment This may range from mild anxiety to
moderate depression to severe person-
Following a suicide attempt, the ad-
olescent is in a crisis state. Resuscita- ality disorganization. The distress
tion is an immediate concern, but once scale (Table 3) can be used to measure
the patient is stable the psychiatric as- the seriousness of the underlying pa-
sessment should not be delayed. In as- thology and as a guide to manage-
ment.2
sessing the teenager, a warm and sup-
portive relationship is important. In The seriousness of the attempt can
addition to a full history of the at- be assessed from the lethality of the
tempt, it is worthwhile checking the method and the strength of the desire
medical and psychiatric history- to die. This can range from attention-
r
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779
seeking threats to clearly lethal actions munication difficulties that can clearly depressive disorders, good ability to
with a strong intent on dying (Table influence initial and longterm manage- communicate and a supportive and un-
4).4,14 Also important is the actual ment. derstanding family are good prognos-
risk to the teenager's life: this may not tic factors. Supportive treatments can
coincide with the intended lethality of Management include medications such as antide-
the attempt. Obviously, when there is any threat pressants. When used, these are sup-
A "psychological biopsy" devel- to an adolescent's health or safety, ad- plementary to other treatments such as
oped by McIntire and Angle14 has mission to hospital is strongly recom- individual and family counselling.
been used as a semi-objective means mended.1 Psychotic individuals and
of evaluating the suicide attempt. The those with significant behavioral dis- Conclusion
"biopsy" includes a narrative outline turbances must also receive inpatient Suicide is a common occurrence
of the event, the home situation, in- care. However, as a set protocol, rou- amongst teenagers today. Longstand-
teractions and the teenager's concept tine admission for all suicidal adoles- ing difficulties with the addition of
of death. The following areas of en- cents is debatable.2' 11 Youths in mild new stresses are usually present. Rec-
quiry are focused on: distress and with low levels of intent ognition of their difficulties and the in-
1. the lethality of the event. may receive adequate treatment as out- itiation of appropriate treatment are
2. prior self-destructive behavior. patients. On the other hand, the hospi- immediate priorities. The ultimate
3. depression. tal milieu does remove the patient goal is to rebuild a healthy and trusting
4. hostility. from a highly stressful situation and a relationship between the patient, fam-
5. stress. therapeutic plan can be initiated ily members and friends. Good com-
6. reaction of the parent. early.1 Hospitalization clearly demon- munication is a necessity. The overall
7. loss of communication. strates to both patient and parent that aim of treatment is to restore to the pa-
8. lack of resources. the situation cannot be taken too tient the sources of emotional sub-
9. extremes of parental expectations lightly. The decision to treat as an out- stance on which all of us depend for
and controls. patient is an individual one, based on our survival. 12
One important application for this the requirements of the patient and his References
type of assessment is to distinguish be- or her family.
tween a serious attempt, suicidal ges- 1. Garfinkel BD, Golombek H. Suicide
In the therapeutic plan, it is impor- and depression childhood and adoles-
ture and other forms of self-destructive tant to assess the family's psychosocial cence. Can MedinAssoc J 1974; 110: 1277&
behavior. The biopsy may also resources, the patient's level of dis- 1281.
identify serious problems such as com- tress, and the lethality of the act. Mild 2. Curran BE: Suicide. Pediatr Clin North
Am 1979; 26:737-746.
3. Mclntire MS, Angle CR, Wikoff RL, et
TABLE 3 al: Recurrent adolescent suicidal behavior.
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4. Mclntire MS, Angle CR., Schicht MI:
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Adv Pediatr 1977; 24:291-309.
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and adolescents. Am J Psychotherapy
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5. As in 4, plus marked feelings of hopelessness and worthlessness- 7. Sabbath JC: The suicidal adolescent-
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6. Unusual personality disturbance; not easily understood in how he Psychology 1969; & 272- 289.
8. Crumley FE: Adolescent suicide at-
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ing; unable to function emergency. Arch Gen Psychology 1969;
20:100-108.
10. Ligate L, Wolfish MG: Attempted sui-
cide in teenagers presented to the Cana-
TABLE 4 diati Paediatric Society, Montreal, June
Lethality Scale 29, 1977.
11. Cohen-Sander R, Berman AL Diag-
1. Threatens to commit suicide to control others nosis and treatment of childhood depres-
2. Threatens to commit suicide, feelings of depression, worthlessness sion and self-destructive behavior. J Fam
Pract 1980; 11:51-58.
3. Threatens to commit suicide with a clear plan 12. Eisenberg L Adolescent suicide: On
4. Takes a non-lethal action in an attempt to control others taking arms against a sea of trouble. Pedi-
5. Takes a non-lethal action because of depression; then asks for help atrics 1980; 66:315-320.
6. Takes a non-lethal or questionably lethal action in a planned or impul- 13. Schneer H, Kai, P: Events and con-
scious idealism leading to suicidal behav-
sive manner and is accidentally found ior in adolescenice. Psychiatry Q 1961;
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8. Takes a clearly lethal action after some thought, and is accidentally 14. Mchntire MS, Angle CR Evaluation of
discovered suicide risk in adolescence. J Fain Pract
1975; .2:3t39-341 .
780 CAN. FAM. PHYSICIAN Vol. 28: APRIL 1982