Suicidal Threats in Teens: What would you do?

A 14-year-old girl is referred by the principal of her school because she made comments about suicide to her teacher after a recent fight and breakup with her boyfriend. She indicated that she had been thinking of taking an overdose of acetaminophen unless she and her boyfriend got back together. She has a bottle of 100 acetaminophen tablets in her purse. A screening evaluation for depression and substance abuse is negative. She has made no previous overdose attempts and has no family history of depression, although her mother states that her daughter is often very impulsive.

Even though the reason for this patient’s suicidal thoughts may not appear to be very serious, the risk of suicide may be high. Teenagers often regard themselves as invincible and may be both emotionally labile and impulsive, which can be a lethal combination. Her behavior could well result in an outcome other than the intended one of reconciling with her boyfriend. Death is not necessarily the goal, but it may be the consequence. Teenagers sometimes romanticize suicide, imagining a large funeral that will be attended by those who have been nasty or uncaring and are now filled with remorse and sadness. Some teenagers also imagine that they will be reunited with others who have died. Such romanticization can increase the risk of suicide.

The assessment of suicidal thoughts or behavior and its management are topics relevant to all clinicians, not just mental health professionals. Up to two thirds of patients who commit suicide have seen a professional in the month before their death. Many patients who kill themselves do so by taking an overdose of prescribed medications, and physicians sometimes unwittingly provide the means for suicide in a single prescription. Few patients spontaneously report their suicidal thoughts and intentions so the clinician must be alert to signals that a patient may be at risk for suicide. Although the patient may not volunteer his or her suicidal intentions, the visit itself can be a cry for help. This is an important point, because the visit may provide the opportunity for a lifesaving intervention.

Never be afraid to ask: "Have you had thoughts about death, or about killing yourself?" If significant risk of suicide exists, this flow chart can be followed.

(Hirschfeld R. Assessment and treatment of suicidal patients. N Eng J Med 1997; 337(13):910-915)

COMMENT: The take home messages here are:

• maintain a high index of suspicion for suicidal ideation in adolescents

• don’t be afraid to ask about suicidal thoughts and plans

• act decisively to secure the individual’s immediate safety and early treatment.

Depression is very treatable if recognized. — R.A.