INTRODUCTION

Suicide is one of the commonest causes of death among young people. The latest mean worldwide annual rates of suicide per 100,000 are 0.5 for females and 0.9 for males among 5-14-year-olds, and 12.0 for females and 14.2 for males among 15-24-year-olds. Suicide is the sixth leading cause of death among children aged 5-14 years, and the third leading cause of death among all those 15-24 years old. In most countries, males outnumber females in youth suicide statistics. There are far more suicidal attempts and gestures than actual completed suicides. One epidemiological study estimated that there were 23 suicidal gestures and attempts for every completed suicide. Though female teens are much more likely to attempt suicide than males, male teens are more likely to actually kill themselves. The suicide rate among young teens and young adults has increased by more than 300% in the last three decades.

RISK FACTORS FOR SUICIDE

Contrary to popular belief, suicide is not an impulsive act but the result of a three-step process: a previous history of problems is compounded by problems associated with adolescence; finally, a precipitating event, often a death or the end of a meaningful relationship, triggers the suicide. The major, empirically proven risk actors for suicide among adolescents are detailed below.

PERSONAL CHARACTERISTICS

Psychopathology: More than 90% of youth suicides and around 60% of younger adolescent suicide victims have had at least one major psychiatric disorder. The most prevalent disorder in adolescent suicide victims is depressive disorders. Depression that seems to quickly disappear for no apparent reason is a cause for concern, and the early stages of recovery from depression can be a high risk period. Substance abuse, conduct disorder, posttraumatic stress disorder and panic attacks are the other disorders found to be common in this population.

Previous suicide attempts: A history of prior suicide attempts is one of the strongest predictors of completed suicide, especially in boys. One quarter to one third of teen suicide victims have made a previous suicide attempt.

Cognitive and personality factors: Hopelessness, poor interpersonal problem solving ability and aggressive impulsive behaviour have been linked with suicidality.

Biological factors: Some teens are at greater risk for suicide because of their biochemical makeup. Abnormalities in the function of serotonin, a neurotransmitter, have been associated with suicidal behaviour.

FAMILY CHARACTERISTICS

Family history of suicidal behaviour: Teens who kill themselves have often had a close family member who attempted or committed suicide.

Parental psychopathology: High rates of parental psychopathology, particularly depression and substance abuse, have been found to be associated with completed suicide and suicidal ideation and attempts in adolescents. Moreover, family cohesion has been reported to be a protective factor for suicidal behaviour among adolescents.

ADVERSE LIFE CIRCUMSTANCES

Stressful life events: Life stressors such as interpersonal losses and legal or disciplinary problems are associated with completed suicide and suicide attempts in adolescents. The anniversary of a loss can also evoke a powerful desire to commit suicide.

Physical abuse: Childhood physical abuse has been found to be associated with increased risk of suicide attempts in late adolescence and early adulthood.

SOCIOECONOMIC AND CONTEXTUAL FACTORS

School and work problems: Difficulties in school, neither working nor being in school, dropping out of high school and not attending college pose significant risks for completed suicide.

Contagion/Imitation: Teens are more likely to kill themselves if they have recently read, seen, or heard about other suicide attempts. Evidence continues to amass from studies of suicide clusters and the impact of the media, supporting the existence of suicide contagion. The impact of suicide stories on subsequent competed suicides appears to be greatest for teenagers.

PREVENTION STRATEGIES

Youth suicide prevention strategies have primarily been implemented within three domains - school, community, and health are systems. This article reviews the school-based programs.

SCHOOL-BASED SUICIDE PREVENTION PROGRAMS

School based suicide prevention programs include both curricula components to teach students about these warning signs and what to do, as well as non-curricula components such as peer groups, hot lines, intervention services and parent training. Prevention includes education efforts to alert students and the community to the problem of teen suicidal behavior. Intervention with a suicidal student is aimed at protecting and helping the student who is currently in distress. Postvention occurs after there has been a suicide in the school community. It attempts to help those affected by the recent suicide. In all cases it is a good idea to have a clear plan in place in advance. It should involve staff members and administration. There should be clear protocols and clear lines of communication. Careful planning can make interventions more organized, and effective.

The goals of school based suicide prevention programs are to:

* Increase awareness
* Promote identification of students at high risk of suicide and suicide attempts
* Provide knowledge about the behavioral characteristics ("warning signs") of teens at risk for suicide.
* Provide information to students, teachers and parents on the availability of mental health resources
* Enhance the coping abilities of teenagers

Education: Education may be done in a health class, by the school counselor or outside speakers. Education should address the factors that make individuals more vulnerable to suicidal thoughts. Education regarding the ill effects of drug and alcohol abuse would be useful. PTA meetings can be used to educate parents about depression and suicidal behavior. Parents should be educated about the risk of unsecured firearms in the home. Outside mental health professionals can discuss their programs so that students can see that these individuals are approachable. Education on the following topics will be useful:

Warning signs of suicide:

* Preoccupation with death and dying
* Signs of depression
* Taking excessive risks
* Increased drug use
* The verbalizing of suicide threats
* The giving away of prized personal possessions
* The collection and discussion of information on suicide methods
* The expression of hopelessness, helplessness, and anger at oneself or the world
* Themes of death or depression evident in conversation, written expressions, reading selections, or artwork
* The scratching or marking of the body, or other self-destructive acts
* Acute personality changes, unusual withdrawal, aggressiveness, or moodiness
* Sudden dramatic decline or improvement in academic performance, chronic truancy or tardiness, or running away
* Physical symptoms such as eating disturbances, sleeplessness or excessive sleeping, chronic headaches or stomachaches, menstrual irregularities, apathetic appearance

Sudden changes in behavior that are significant, last for a long time, and are apparent in all or most areas of his or her life (pervasive) are more specific than presence of isolated signs. However, it should be noted that many completed suicides had only a few of the conditions listed above, and that all indications of suicidality need to be taken seriously in a one person to another person situation.

Signs of depression in teens:

* Sad, anxious or "empty" mood
* Declining school performance
* Loss of pleasure/interest in social and sports activities
* Sleeping too much or too little
* Changes in weight or appetite

Factors associated with repeated self harm:

* Previous self harm
* Personality disturbance
* Depression
* Alcohol or drug misuse
* Chronic psychosocial problems and behaviour disturbance
* Disturbed family relationships
* Alcohol dependence in the family
* Social isolation
* Poor school record

How to support a student with suicidal thoughts and a low self-esteem?

* Listen actively. Teach problem-solving skills
* Encourage positive thinking. Instead of saying that he cannot do something, he should say that he will try.
* Help the student write a list of his or her good qualities.
* Give the student opportunities for success. Give as much praise as possible
* Help the student set up a step-by-step plan to achieve his goals.
* Talk to the family so that they can understand how the student is feeling.
* He or she might benefit from assertiveness training
* Helping others may raise one's self-esteem.
* Get the student involved in positive activities in school or in the community.
* If appropriate, involve the student's religious community.
* Make up a contract with rewards for positive and new behaviors.

What can be done to help someone who may be suicidal?:

1. Take it seriously. Myth: "The people who talk about it don't do it." Studies have found that more than 75% of all completed suicides did things in the few weeks or months prior to their deaths to indicate to others that they were in deep despair. Anyone expressing suicidal feelings needs immediate attention. Myth: "Anyone who tries to kill himself has got to be crazy." Perhaps 10% of all suicidal people are psychotic or have delusional beliefs about reality. Most suicidal people suffer from the recognized mental illness of depression; but many depressed people adequately manage their daily affairs. The absence of "craziness" does not mean the absence of suicide risk. "Those problems weren't enough to commit suicide over," is often said by people who knew a completed suicide. You cannot assume that because you feel something is not worth being suicidal about, that the person you are with feels the same way. It is not how bad the problem is, but how badly it's hurting the person who has it.

2. Remember: suicidal behavior is a cry for help. Myth: "If someone is going to kill himself, nothing can stop him." The fact that a person is still alive is sufficient proof that part of him wants to remain alive. The suicidal person is ambivalent - part of him wants to live and part of him wants not so much death as he wants the pain to end. It is the part that wants to live that tells another "I feel suicidal." If a suicidal person turns to you it is likely that he believes that you are more caring, more informed about coping with misfortune, and more willing to protect his confidentiality. No matter how negative the manner and content of his talk, he is doing a positive thing and has a positive view of you.

3. Be willing to give and get help sooner rather than later. Suicide prevention is not a last minute activity. Unfortunately, suicidal people are afraid that trying to get help may bring them more pain: being told they are stupid, foolish, sinful, or manipulative; rejection; punishment; suspension from school; written records of their condition; or involuntary commitment. You need to do everything you can to reduce pain, rather than increase or prolong it. Constructively involving yourself on the side of life as early as possible will reduce the risk of suicide.

4. Listen. Give the person every opportunity to unburden his troubles and ventilate his feelings. You don't need to say much and there are no magic words. If you are concerned, your voice and manner will show it. Give him relief from being alone with his pain; let him know you are glad he turned to you. At times everyone feels sad, hurt, or hopeless. You know what that's like; share your feelings. Let the child know he or she is not alone. Avoid arguments and advice giving. If the child's words or actions scare you, tell him or her. If you're worried or don't know what to do, say so.

5. ASK: "Are you having thoughts of suicide?" Myth: "Talking about it may give someone the idea." People already have the idea; suicide is constantly in the media. If you ask a despairing person this question you are doing a good thing for them: you are showing him that you care about him, that you take him seriously, and that you are willing to let him share his pain with you. You are giving him further opportunity to discharge pent up and painful feelings. If the person is having thoughts of suicide, find out how far along his ideation has progressed.

6. If the person is acutely suicidal, do not leave him alone. If the means are present, try to get rid of them. Detoxify the school or home.

7. Urge professional help. Persistence and patience may be needed to seek, engage and continue with as many options as possible. In any referral situation, let the person know you care and want to maintain contact.

8. No secrets. It is the part of the person that is afraid of more pain that says "Don't tell anyone." It is the part that wants to stay alive that tells you about it. Respond to that part of the person and persistently seek out a mature and compassionate person with whom you can review the situation. Distributing the anxieties and responsibilities of suicide prevention makes it easier and much more effective.

Interventions with a suicidal student:

Schools should have a written protocol for dealing with a student who shows signs of suicidal or other dangerous behavior. The following steps may be effective in dealing with a student who expresses active suicidal intent.

1. Calm the immediate crisis situation. Do not leave the suicidal student alone even for a minute. Ask whether he or she is in possession of any potentially dangerous objects or medications. If the student has dangerous items on his person, be calm and try to verbally persuade the student to give them to you. Do not engage in a physical struggle to get the items. Call administration or the designated crisis team. Escort the student away from other students to a safe place where the crisis team members can talk to him. Be sure that there is access to a telephone.

2. The crisis individuals then interview the student and determine the potential risk for suicide. a. If the student is holding on to dangerous items, it is the highest risk situation. Staff should call an ambulance, the police and the student's parents. Staff should try to calm the student and ask for the dangerous items. b. If the student has no dangerous objects, but appears to be an immediate suicide risk, it would be considered a high-risk situation. If the student is upset because of physical or sexual abuse, staff should notify the appropriate school personnel and contact the police. If there is no evidence of abuse or neglect, staff should contact parents and ask them to come in to pick up their child. Staff should inform them fully about the situation and strongly encourage them to take their child to a mental health professional for an evaluation. The team should give the parents a list of telephone numbers of crisis clinics. If the school is unable to contact parents, and if the police cannot intervene, designated staff should take the student to a nearby emergency room. c. If the student has had suicidal thoughts but does not seem likely to hurt himself in the near future, the risk is more moderate. If abuse or neglect is involved, staff should proceed as in the high-risk process. If there is no evidence of abuse, the parents should still be called to come in. They should be encouraged to take their child for an immediate evaluation. d. Follow-Up: It is important to document all actions taken. The crisis team may meet after the incident to go over the situation. Friends of the student should be given some limited information about what has transpired. Designated staff should follow up with the student and parents to determine whether the student is receiving appropriate mental health services. Follow-up is crucial, because most suicides occur within three months of the beginning of improvement in depressive symptoms, when the youth has the energy to carry out plans conceived earlier. Regularly scheduled supportive counseling should be provided to teach the youth coping mechanisms for managing stress accompanying a life crisis, as well as day-to-day stress.

Role of the teachers:

Teachers play an especially important part in prevention, because they spend so much time with their students. Along with holding parent-teacher meetings to discuss teenage suicide prevention, teachers can form referral networks with mental health professionals. They can increase student awareness by introducing the topic in health classes.

Some schools have automatic expulsion policies for students who engage in illegal or violent behavior. It is important to remember that teens who are violent or abuse drugs may be at increased risk for suicide. If someone is expelled, the school should attempt to help the parents arrange immediate and possibly intensive psychiatric and behavioral interventions.

Role of the peers:

Peers are crucial to suicide prevention. According to one survey, 93% of the students reported that they would turn to a friend before a teacher, parent or spiritual guide in a time of crisis. Peers can form student support groups and, once educated themselves, can train others to be peer counselors.

Adolescents often will try to support a suicidal friend by themselves. They may feel bound to secrecy, or feel that adults are not to be trusted, and this may delay needed treatment. Ideally, a teenage friend should listen to the suicidal youth in an empathic way, but then insist on getting the youth immediate adult and professional help.

Role of the parents:

Parents need to be as open and as attentive as possible to their adolescent children's difficulties. The most effective suicide prevention technique parents can exercise is to maintain open lines of communication with their children. Sometimes teens hide their problems, not wanting to burden the people they love. It is extremely important to assure teens that they can share their troubles, and gain support in the process. Parents are encouraged to talk about suicide with their children, and to educate themselves by attending parent-teacher or parent-counselor education sessions and from nearby libraries or the internet. Once trained, parents can help to staff a crisis hotline in their community. Parents also need to be involved in the counseling process if a teen has suicidal tendencies. These activities may both alleviate parents' fears of the unknown and assure teenagers that their parents care.

Postvention/crisis intervention:

The rationale for school-based postvention/crisis intervention is that a timely response to a suicide is likely to reduce subsequent morbidity and mortality in fellow students, including suicidality, the onset and exacerbation of psychiatric disorders, and other symptoms related to pathological bereavement.

The school should have plans in place to deal with a suicide or other major crisis in the school community. The administration or the designated individual should try to get as much information as soon as possible. He or she should meet with teachers and staff to inform them of the suicide. The teachers or other staff should inform each class of students. It is important that all of the students hear the same thing. After they have been informed, they should have the opportunity to talk about it. Those who wish should be excused to talk to crisis counselors. The school should have extra counselors available for students and staff who need to talk. Students who appear to be the most severely affected may need parental notification and outside mental health referrals. Rumor control is important. There should be a designated person to deal with the media. Refusing to talk to the media takes away the chance to influence what information will be in the news. One should remind the media reporters that sensational reporting has the potential for increasing a contagion effect. They should ask the media to be careful in how they report the incident. Media should avoid repeated or sensationalistic coverage. They should not provide enough details of the suicide method to create a "how to" description. They should try not to glorify the individual or present the suicidal behavior as a legitimate strategy for coping with difficult situations.

It is imperative for crisis interventions to be well planned and evaluated; otherwise, not only may they not help survivors, but they may potentially exacerbate problems through the induction of imitation.

CONCLUSION

Suicide attempts and completed suicides among adolescents are problems of increasing significance. School staff, parents, and health professionals should be sensitized about the risk factors and warning signs of suicide, and about the ways to deal with suicidal adolescents.

FURTHER READING

* Gould, M.S., Greenberg, T., Velting, D.M. & Shaffer, D. (2003) Youth suicide risk and preventive interventions: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 4, 386-405.
* Hawton, K. & James, A. (2005) Suicide and deliberate self harm in young people. British Medical Journal, 330, 891-894.
* www.depts.washington.edu/hiprc/practices/topic/suicide
* www.baltimorepsych.com/suicide.htm
* www.metanoia.org/suicide/

Dr. Shahul Ameen, M.D., is a psychiatrist based in Ranchi, India. He edits http://www.psyplexus.com/ (a portal for mental health professionals) and http://www.mind.in/ (a portal on mental health for the consumers).