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Am Fam Physician. 2005;71(3):592-594

When adolescents have suicidal thoughts, the idea typically is transient and precipitated by a specific stressful event. Suicidal thoughts are common in high-school–age children, with a higher rate of ideation and attempts in girls than in boys. About 2,000 adolescents successfully commit suicide annually in the United Sates, making this the third leading cause of death among persons 15 to 24 years of age. The rate of suicide attempts increased between the 1960s and the 1980s because of access to guns and increased substance abuse in this age group. The recent decline in suicide rates is probably because of decreased substance abuse and the widespread use of antidepressant medication. Ingestion of over-the-counter medicines is the most common suicide attempt method, and firearms are the most common cause of completed suicide.

Kennedy and associates reviewed the literature to identify risk factors and management plans for adolescents who try to commit suicide. Risk factors include psychiatric conditions (i.e., depressive disorders, substance abuse, and disruptive disorders); previous suicide attempts; family history of psychiatric disorder; history of physical or sexual abuse; and gay, lesbian, or bisexual orientation.

By law, the assessment and management of suicide attempts in the emergency department can be performed without parental consent. Because safety is the first consideration, patients should be searched on arrival, and clothes should be removed to prevent the patient from unexpectedly leaving the emergency department. The evaluation should be performed compassionately and in a timely manner, with close attention to family members who are present. Adolescents who feel that they are well treated are more likely to adhere to future outpatient treatment. The patient's suicidal intent should be assessed, with the understanding that discussions of suicide will not increase the likelihood of future attempts. Positive thoughts should be reinforced. Information also should be gathered from family, friends, and whoever is close to the patient. Suicidal scales may be useful in determining the likelihood of another attempt, but predictive values for these scales have not been tested.

A physical examination should cover all systems, especially vital signs, level of consciousness and orientation, and signs of toxic syndromes. Evidence of physical trauma or abuse should be noted. Ancillary studies that might be useful include urine toxicology, pregnancy test, specific drug levels (if overdose is suspected), and other tests, depending on the specific situation. Organic causes for psychiatric conditions should be evaluated. The treatment goal includes immediate and long-term safety of the patient. Short-term needs can be handled in the emergency department or in the hospital. Long-term needs require family involvement and psychotherapy when necessary, along with a plan the patient can follow to deal with suicidal feelings without resorting to suicidal behavior.

The authors conclude that disposition depends on the evaluation of suicide risk, the mental health resources available in the emergency department, and the health institution's policies about management of suicidal adolescents. Inpatient care is advisable for adolescents with psychiatric disorders, substance abuse, inability to establish a trusting relationship with a medical caregiver, serious medical issues, multiple suicide attempts, or poor social support. Although it is not absolutely necessary, an attempt should be made to obtain parental consent for hospitalization. Outpatient treatment should be considered only for the minority of adolescents with low levels of suicidality who have strong supervision and support at home. Follow-up must be arranged with an appropriate mental health professional. Prescription medication treatment should be avoided in the emergency department situation.

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