Because at least 50% of individuals who die by suicide meet criteria for psychiatric disorders, a logical approach is to treat the associated disorder using medication appropriate for that disorder.4 Depression and antidepressant treatments are common in suicidal/self-harming youths. Other common diagnostic presentations in youths include: bipolar disorder, borderline personality disorder/features, substance abuse, emerging psychoses, anxiety, and traumatic stress. Comorbidities, co-occurring problems, potential lethality of medications, and side effects also need consideration when developing a treatment plan.
The FDA-directed black box warnings regarding a possible increase in the risk of suicidal thinking and behavior in children, adolescents, and young adults (<25 years) treated with antidepressant medications, led to decreased antidepressant prescribing.16 These warnings were based on evidence reviews indicating a small increase in rates of SI and SAs following antidepressant treatment. Analyses of risk differences for “clinical response” and for “suicidal ideation and attempts,” however, suggest that benefits of antidepressant treatment are greater than risks of SI and SAs, with 4% to 11% more depressed youths benefiting from antidepressants versus experiencing a suicidal event.16 Finally, in contrast to the clinical trials that generally excluded patients with high suicide risk, results of larger and more representative pharmacoepidemiologic studies point to a protective effect of antidepressant treatment, with several studies indicating lower suicide rates with higher antidepressant use.16
Given the collective evidence, the American Academy of Child and Adolescent Psychiatry recommends treatment for depression using medication and psychotherapy treatments supported by the evidence. As well, based on the evidence, it supports combined medication and psychotherapy treatment as the most efficacious option.17 Similarly, the Society for Adolescent Medicine (SAM) supports appropriate use of antidepressant medications in the treatment for adolescents with depression and the need to balance the risk of suicidality and clinical need.18
Results on community-based, school-based, and health system approaches to prevention are also promising. The Garret Lee Smith Memorial Youth Suicide Prevention Program (GLS) is a major US initiative that funded multiple community-based suicide prevention programs across the nation. Although programs used diverse components (eg, training, community partnerships, infrastructure for improved service linkage, crisis hotlines), gatekeeper training in which teachers/others with frequent youth contact were taught to identify and refer suicidal youths was a core feature, and served as an indicator of program exposure in the evaluations. Comparisons of data from counties with GLS programs with those for similar/control counties indicated both significantly lower rates of suicide deaths and nonfatal SAs in GLS counties.19 School-based prevention programs that offer skills and work to reduce stigma associated with help seeking have also shown promise for reducing SAs.20 The Zero Suicide initiative in the US aims to support health systems in making system-wide commitments to suicide prevention using a continuous quality improvement process to identify, treat, and provide care for at-risk patients using evidence-based tools and strategies (https://zerosuicide.sprc.org/toolkit). This approach stems from promising results from the Henry Ford Health System indicating that when the health system organized around the zero suicide goal and delivery of “perfect depression care,” a decline in suicide rates was observed.4
We now have psychotherapeutic and prevention strategies with demonstrated benefits for reducing SH and SAs, effective medication treatments for disorders associated with suicide risk, and emerging care process and triage models for improving emergency evaluation and care for youths presenting with suicide and SH risk. A combination of evidence-based psychotherapy augmented by medication as appropriate when a psychiatric disorder is present is likely to be beneficial. The variation in risk and protective processes across individual youths and the complexity of pathways to suicidal behavior present challenges and highlights the importance of personalizing approaches to care to match individuals to care strategies that will be most beneficial and to time interventions optimally. Combining clinical wisdom, skill, and knowledge gained from our science offers a way forward and may allow us to shift the trend toward increasing suicide rates, successfully prevent SAs and premature deaths in our youth, and provide care that helps youths build lives they want to live.
Dr Asarnow is Professor; Dr Fogelson is Clinical Professor; Ms Fitzpatrick is Clinical Research Coordinator; Psychiatry and Biobehavioral Sciences, University of California, Los Angeles; Dr Hughes is Assistant Professor, Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX. Dr Asarnow reports that she is a consultant/receives funding from the NIMH, the Substance Abuse and Mental Health Services Administration, the American Psychological Association, the American Foundation for Suicide Prevention, and the Klingenstein Third Generation Foundation. Drs Fogelson and Hughes and Ms Fitzpatrick report no conflicts of interest concerning the subject matter of this article.
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