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Am Fam Physician. 2002;65(9):1931-1932

Most depressed patients do not commit suicide, and the prevalence of suicide in the general population is low. However, suicidal ideation is prevalent in teenagers. Zametkin and colleagues review factors contributing to suicide in teenagers, efficacy of various pharmacotherapeutic agents, and issues relating to screening for depression in this population. Because of the relative rarity of the event, physicians should be aware of the risk factors and warning signs of suicidality in teenagers. A family history of suicide and a parent with a psychiatric disorder are the two most common familial risk factors for suicide in teenagers. Various studies have looked at the inheritance patterns of suicide and concluded that there is a polygenic pattern. There are not yet any clinically useful and specific markers for suicidality. Other risk factors in adolescents are shown in the accompanying table.

Girls think about and attempt suicide more often than boys, but older adolescent boys are 5.5 times more likely to succeed in their suicide attempts. Precipitating factors include psychosocial stressors, which are highly common in most teenagers' lives. Various interventions have been studied in suicidal teenagers, including hospitalization, psychotherapy, and medication. Although immediate hospitalization is the norm when a teenager has contemplated or attempted suicide, there is no evidence in adults that hospitalization prevents suicide, at the time or in the future (studies have not been performed in teenagers).

Specific factors
Previous suicide attempt
Mood disorder (major depressive disorder)
Substance abuse disorder (particularly in males) 16 years or older, male, and living alone
History of physical or sexual abuse
Less specific, but alarming factors
Recent dramatic personality change
Psychosocial stressor (trouble with family or friends, or a disciplinary crisis)
Writing, thinking, or talking about death or dying
Altered mental status (agitation, hearing voices, delusions, violence, intoxication)

Similarly, behavioral and psychotherapeutic treatments have not been shown to reduce rates of suicide in teenagers who have attempted suicide. This may be because teenagers tend to be noncompliant with psychiatric treatment, with one study finding that 40 percent of teenagers were discharged from treatment for failure to attend therapy sessions. Treatment of a known conduct disorder or substance abuse disorder also has not been shown to reduce suicidality. Suicide hotlines and other community-based interventions have not been shown to be effective in reducing suicidal behavior.

Although depressive and bipolar disorders in adolescents are similar to those in adults, and selective serotonin reuptake inhibitors (SSRIs) are clearly efficacious in adults in terms of reducing symptoms of depression, it has been difficult to establish the effectiveness of these antidepressants in teenagers. One reason for this is the high placebo response rate in this group of patients. Of note, however, is the discovery that suicide rates in the United States plateaued in the years after SSRIs came into widespread use. Lithium augmentation has also been studied in adults and has been found to reduce suicide rates. Similar studies have not focused on teenagers, and there is no evidence that lithium is useful in reducing suicide in this group.

Awareness of the risk factors and symptoms of depression is important. Teenagers should be screened by asking about suicidal ideation, presence of firearms in the home, and substance abuse. Past history of suicidality and family history should also be noted. Family physicians who have not had specialized training or expertise in dealing with suicide prevention should ensure a referral to a mental health professional. If the family physician chooses to treat the suicidal teenager, a verbal contract (such as might be made with an adult) should not be relied on. SSRIs are the treatment of choice in suicidal teenagers because there is less chance of a lethal overdose with these agents than with tricyclic antidepressants. Medication therapy should not be discontinued when target symptoms decline but should be continued, sometimes for a period of years.

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