GUIDELINES FOR TEEN SUICIDE PREVENTION Dr. C. J. John, Chief Psychiatrist, Medical Trust Hospital, Kochi Email: drcjjohn@hotmail.com What WHO Says??? World wide suicide is among top five causes of mortality in the 15 to 19 year age group. In some countries it occupies first or second position. Suicide methods vary from country to country. Adolescents died from violent causes some of them intentional. Database The data of Completed suicides are from National Crime Records Beauro NCRB Attempted Suicide No reliable data Issues of under reporting Stigma Also issues of over reporting homicide to suicide shifts NCRB has less than 15 years group and 15-29 yr group only; and hence misses out exact number in teenage group. Data from Bangalore City (1996, 1997 & 1998) Total number of completed suicides 3718 Below 15 yr 2.6% 75% females (95% in 10-14 yr group) 15 to 19 yr 15% 68.8% females TOTAL 17.6% (Mohan Isaac & Gururaj 2001) Analysis of 1260 attempted suicides at Bangalore City Below 15 yr 2.8 % 60% females 15 to 19 yr 20 % 63.6% females TOTAL 22.8% (Mohan Isaac & Gururaj 2001) [1]
Possible motives or reasons underlying self harm To die To escape from unbearable anguish To change the behaviour of others To escape from a bad situation To show desperation to others To get back at other people or make them feel guilty To gain relief from tension To seek help Features of self harm that suggest high suicidal intent Conducted in isolation. Timed so that intervention is unlikely (for example, after parents have gone to work). Precautions to avoid discovery. Preparations made in anticipation of death (for example, leaving indication of how belongings to be distributed). Adolescent told other people beforehand about thoughts of suicide. The act had been considered for hours or days before hand. Suicide note or message. Adolescent did not alert others during or after the act. Family pattern and negative life events during childhood Parental psychopathology, with the presence of affective and other psychiatric disorders. Alcohol and substance abuse or antisocial behaviour in the family. A family history of suicide and suicide attempts. A violent and abusive family (including physical and sexual abuse of the child) Poor care provided by parents/guardians, with poor communication within the family. Frequent quarrels between parents/guardians, with tension and aggression. Divorce, separation or death of parents/guardians. Frequent moves to a different residential area. Very high or very low expectations on the part of parents/guardians. Parents/guardians inadequate or excessive authority. [2]
Parents/guardians lack of time to observe and deal with the child s emotional distress and a negative emotional environment featuring rejection or neglect. Family rigidity. Adoptive or foster family. Cognitive style and personality Unstable mood, angry or aggressive behavior. Antisocial behavior, acting-out behavior. High impulsivity, irritability. Rigid thinking and coping patterns Poor problem-solving ability when difficulties arise. An inability to face realities. A tendency to live in an illusory world. Fantasies of greatness alternating with feelings of worthlessness. A ready sense of disappointment. Anxiety particularly at signs of mild physical ailment or minor disappointment. Feelings of inferiority and uncertainty that may be masked by overt manifestations of superiority, rejection or provocative behavior towards schoolmates and adults, including parents. Uncertainty concerning gender identity or sexual orientation. Ambivalent relationships with parents, other adults and friends. Associated Psychiatric Disorders Some form of mood disorder in 2/3rd of suicide : Girls- uncomplicated major depression Boys- depression associated with Comorbid Conduct Disorder/Substance Abuse, irritable, impulsive, volatile, prone for aggression. ¼ to 1/3rd had anxiety disorder performance & anticipator anxiety. 1/3rd to ½ had conduct or oppositional disorder boys/older ones. Substance or alcohol abuse older boys Risk situations and events that may trigger suicide attempts or suicide Situations that may be experienced as injurious (without necessarily being so when evaluated objectively) [3]
Family disturbances Separation from friends, girl/boyfriends, classmates, etc. Death of a loved one or other significant person Termination of a love relationship Interpersonal conflicts or losses Legal or disciplinary problems Peer-group pressure or self-destructive peer acceptance Bullying and victimization Disappointment with school results and failure in studies High demands at school during examination periods Unemployment and poor finances Unwanted pregnancy, abortion, sexual abuse Serious physical illness Natural disasters. Adolescent Suicide & Media Death of a student - a six part German television series depicted railway suicide of a young man at the start of each episode. Effects of this studied (Schmidts & Hofner 1988) Eliminated alternative explanations FINDINGS Railway suicides by ADOLESCENT males increased 175% during the series to 21 from an average of 7.63 of same period during previous five years and two subsequent years Among 15-19 years, railway suicide rose to 86% for males and 75% for females. Suicide by other methods did not increase. Number of television networks carrying a suicide story was positively correlated with size of increased adolescent suicide (Philips & Carstenson 1986). American adolescent suicide rate increase demonstrated after most heavily published television news stories (Hessler, Downey, Stipp, M. Kvsky 1981). Children & Suicide Literacy [4]
Our observation in a group of 10-13 yr old children 26 out of 40 gave suicide as an option people choose in crisis, half of them felt it is acceptable. Canadian study on children they were asked : What does suicide mean? Why should someone commit suicide? (Mishara 1997) Learned at very early stage From media & peers Knew how one would kill oneself An option when faced with humiliation Protective Factors Family Patterns Good relationships with family members Support from family. Cognitive Style and Personality Good social skills Confidence in oneself and one s own situation and achievements Seeking help when difficulties arise, e.g. in school works. Seeking advice when important choices must be made Openness to other people s experiences and solutions Openness to new knowledge Cultural and Suicide Demographic factors Social integration, e.g. through participation in sport, church associations, clubs and other activities. Good relationships with schoolmates Good relationships with teachers and other adults Support from relevant people [5]
Levels of Intervention Vulnerability + Stress Emotional Distress Suicidal Ideation Threats Plans No Plans No Ideation shows retributive rage impulsive behaviour Execute Do not Execute Succeed Fail Objectives of Suicide prevention in teenagers is not merely reduction of incidence of teen suicide. It should also aim at imparting life skills that will empower them to handle life and crises as they grow. Suicide Prevention (A) General prevention targeting all teenagers: Positive mental health approach - building self esteem - imparting life skills - promoting emotional expression. (B) Intervention when risk is identified Parent Peer School - Pediatricians and Primary care Physicians focused programmes. [6]
Common Warning Signs SUICIDE THREATS Writing about suicide Direct threats ( I am going to kill myself ) Indirect threats ( I am as well be dead ) PREOCCUPATION WITH DEATH Making final arrangements Giving away prized possessions Talking about death Reading or writing about death Creating artwork about death Ruminating about a dead person CHANGES IN BEHAVIOUR Social withdrawal, isolation, loss of resources Less involvement in interests and activities Increased risk-taking, misconduct in classrooms Abuse alcohol or drugs Decreased work or academic performance Frequent lateness Unexplained absences, truancy Crying easily Abrupt changes in appearance Recent weight or appetite change Sleeplessness or sleepiness Lethargy, exhaustion Increased absences due to unexplained or minor illnesses Inability to concentrate or think rationally Exaggerated fears of disease Low self esteem Hopelessness or helplessness Increased irritability or anger Moodiness, not communicating Extreme anxiety [7]
Be Aware Of Feeling CANNOT Think properly make decisions see any way out get out of depression stop pain make sadness go away see a future without pain see themselves worthwhile get someone s attention seem to get control Assessment Of Risk Current suicide plan Prior suicidal behaviour Availability of means or methods Non availability of resources or support Approaches Be direct. Talk openly and in a matter-of-fact way about suicide Be willing to listen. Allow expressions of feelings. Accept feelings. Be non judgmental. Do not debate about if suicide is right or wrong, feelings good or bad etc. Do not lecture over value of life. Become available. Show interest and support. Do not act shocked. This will put distance between you. Offer hope that alternatives are available. Get help from persons or agencies that offer intervention in suicide Main Issues in Assessment of Adolescents Who Have Self-Harmed Events surrounding the overdose or self harm. Degree of suicidal intent and other reasons for the act. The adolescent s current problems. Possible psychiatric disorder. Family and personal history. [8]
History of psychiatric disorder or self harm. The nature of the adolescent s resources and supports. Risk of further self harm and suicide. Attitude towards help. Assessment of Families of Young People Who Seriously Self- Harmed Family structure and relationships. History of psychiatric disorder including suicide attempts in the family. Recent life events, especially losses. Assessment of Family s Support and Problem Solving Ability Inquire about the circumstances of the self harm, events leading up to it and how it has affected the family. Inquire about how the family has tackled serious problems in the past. Treatment Options for Adolescent Self Harm Individual Problem solving. Cognitive behavioral therapy. Treatment of underlying psychiatric disorder (such as antidepressants) Treatment of drug or alcohol abuse. Anger management. Family Family therapy (such as problem solving or structural or systemic therapy). Group Group therapy (including problem solving, cognitive behavioural therapy and dealing with developmental concern and emotions) Others Environmental changes (such as temporary alternative accommodation) [9]
Educational Programmes To heighten awareness of the problem To promote indirect case finding To promote disclosure of suicidal intentions or ruminations To provide teachers and students as to information about mental health resources Training students Empowering children with life skills Stress management for students Identifying suicidal children, facts and myths about suicide Helping the suicidal Supported by role plays, teachers can help teenagers and parents. Recommendations for Teachers Identify students with personality disturbances and offer them psychological support. Forge closer bonds with young people by talking them and trying to understand and help. Alleviate mental distress. Be trained in the early recognition of suicidal communication through verbal statements / behavioral changes. Support less-skilful students with their school work Be observant of truancy. Avoid stigmatizing mental illness Help to eliminate abuse of alcohol and drugs. Refer students for treatment of psychiatric disorders and alcohol and drug abuse. Restrict students access to means of suicide - toxic and lethal drugs, pesticides, other weapons etc. Give teachers and other school personnel means of alleviating their stress at work. [10]
Factors Associated With Repeated Self Harm Previous self harm. Personality disturbance. Depression. Alcohol dependence in the family. Social isolation. Poor school record. [11]