Presentation by Drs. Gabriel Kaplan and Bennett Silver presented at the 11th annual Sage-NAA Conference

1. Adolescent Suicidal Behavior
Evaluation and Treatment
Considerations
Gabriel Kaplan, M.D.
Bennett Silver, M.D.

2. Conference Agenda
Dr. Gabriel Kaplan
•Epidemiology
Dr. Bennett Silver
•Psychopathology
Dr. Gabriel Kaplan
•Risk Assessment
•Pharmacological Approach
Dr. Bennett Silver
•Psychosocial Approach and Prevention Programs

3. Bennett Silver, MD
ACADEMIC CREDENTIALS
•Board Certified Adult Psychiatrist
▫ American Board of Psychiatry and Neurology, INC
•Child Psychiatrist
▫ Mt. Sinai School of Medicine Trained Specialist
•Director of Residency Training
▫ Bergen Regional Medical Center
•Three decades of clinical work with suicidal patients
PUBLICATIONS/PRESENTATIONS
•Editor,
▫ Child and Adolescent Psychiatry Alerts national newsletter
•Editor,
▫ Psychiatry Drug Alerts national newsletter
•Presentations to physicians, school personnel, professional associations,
parent groups, on the topic of suicide

4. Gabriel Kaplan, MD
ACADEMIC CREDENTIALS
•Board Certified Child Psychiatrist, American Board of Psychiatry and Neurology, INC
•Distinguished Fellow, American Psychiatric Association
•Clinical Associate Professor of Psychiatry, University of Medicine and Dentistry of New Jersey
PUBLICATIONS/RESEARCH/SYMPOSIA
•Kaplan G.
▫ Co-Investigator. New York Hospital Research Grant Follow-up Suicidal Adolescents. 1986-1988
•Pfeffer C., Newcorn J.H., Kaplan G., et al.
▫ Suicidal Behavior in Adolescent Psychiatric Inpatients. J American Academy of Child Adolesc Psychiatry. 1988;
27:357-361
•Pfeffer, C., Newcorn J.H., Kaplan G., et al.
▫ Subtypes of Suicidal and Assaultive Behaviors in Adolescents J Child Psychology and Psychiatry, 1989; 1:151-163
•Kaplan, G., Oquendo, M., Escobar, J., and Marin, H.
▫ Assessment and Management of Depression Symposium 2006 APA
•Kaplan, G., Oquendo, M., Escobar, J., and Marin, H.
▫ Assessment and Management of Suicidal Behavior across the Life Cycle Symposium 2007 APA
•Greydanus D. and Kaplan G.
▫ Strategies to Improve Medication Adherence in Youths: Approaches During the Active to Maintenance Transition.
Psychiatric Times pp 14-16 July, 2012
•Kaplan G.
▫ What is New in Adolescent Psychiatry? A Literature Review and Clinical Implications Adolescent Medicine: State of
Art Reviews (AM:STARs). Spring 2013 (in Press)

5. Epidemiology
Gabriel Kaplan, MD

6. Definitions
Suicidal Ideation Thoughts of harming or killing oneself.
Suicidal Communications Direct or indirect expressions of suicidal
ideation or of intent to harm or kill self,
expressed verbally or through writing, artwork,
or other means.
Suicidal Threats A special case of suicidal communications, used
with intent to change the behavior of other
people.
Suicide Attempt A non-fatal, self-inflicted destructive act with
the explicit or inferred intent to die.
Suicide Fatal self-inflicted destructive act with explicit
or inferred intent to die.
Suicidality All suicide-related behaviors and thoughts
including completing or attempting suicide,
suicidal ideation or communications.
Goldsmith SK, Pellmar TC, Kleinman AM, et al. Reducing Suicide: A National Imperative. Washington, D.C.: National Academy Press; 2002.

7. Trends in Suicide Rates Ages 10 Years and
Older, by Sex, 1991–2009
Centers for Disease Control:
www.cdc.gov/ViolencePrevention/suicide/statistics/

8. Rates have increased since 2004
• Influence of internet social networks
• High suicide among young U.S. troops
• Higher rates of untreated depression in the wake of
recent “black box” warnings on antidepressants—a
possible unintended consequence of the medication
warnings, required by the FDA in 2004

9. Percentage of Suicides Ages 10 Years and
Older, by Sex and Mechanism, 2005–2009
Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/

10. Leading Causes of Death by Age

11. Youth Risk Behavior Surveillance System
(YRBSS)
• The YRBSS was developed by the Centers for Disease Control
(CDC ) in 1990 to monitor priority health risk behaviors that
contribute markedly to the leading causes of death, disability,
and social problems among youth and adults in the United
States
• The YRBSS includes national, state, territorial, tribal
government, and local school-based surveys of representative
samples of 9th through 12th grade students. These surveys are
conducted every two years, usually during the spring
semester.

12. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

13. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

14. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

15. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

16. H S Students Considering, Planning, or
Attempting Suicide in Past 12 Months 2009
Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/

17. Suicide Rates Ages 10–24 Years, by
Race/Ethnicity and Sex, 2005–2009
Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/

18. Risk Assessment
Gabriel Kaplan, MD

19. Common school suicidal situations
• A note is found
• A student overhears another student
• A student confides in a guidance counselor
• A student threatens during school day
• A parent confides in a teacher/counselor
• A teacher discovers student’s self mutilation
• A student “does not look well” and is asked
• Student is absent, parents confide
• Routine suicide school screening
• A student who is bullied expresses suicide ideas

20. Risk Factors
• History of depression or other mental illness
▫ Psychiatric disorder is present in up to 80-90% of adolescent
suicide victims and attempters
 Most common psychiatric conditions are mood, anxiety, conduct, and
substance abuse disorders.
• History of previous suicide attempts
• Family history of suicide
• Stressful life event or loss
• Easy access to lethal methods
• Exposure to the suicidal behavior of others
• Incarceration
• Bullying (victims and perpetrators)
• Hopelessness/guilt

21. What to do?
• A plausible suspicion must be assessed immediately
▫ A usually happy go lucky 7 year old crying “I want to
die” because another student took a toy away does not
need an emergent evaluation.
▫ Keep in mind risk factors/age discussed here
• While rare, every suicide is “one too many”
▫ Thus, when in doubt, err on the side of caution and
refer a.s.a.p.

22. Evaluation
• Adolescent suicidal behavior is a medical emergency that
must be assessed by highly qualified professionals:
▫ Child Psychiatrist,
▫ Psychiatrist,
▫ Non-MD with training and experience in the
assessment of suicidal behavior
• If an adolescent actively threatens suicide, an assessment
must be conducted asap in the Emergency Room setting

23. Expert evaluation
• Comprehensive psychiatric examination
• Includes medical history
• Patient, family, teacher input required
• Evaluation focused on determining potential risk and
disposition
• May include rating scales

24. Expert will assess
• Presence of mental illness
▫ Large majority of patients who suicide suffer from
mental illness
▫ All psychiatrically ill adolescents are high risk
• Presence of aggravating circumstances
▫ Loss, bullying, substance abuse
• Suicide continuum stage

25. Suicide Continuum
Passive
Death
Wish
Suicidal
Ideation
without
method
Suicidal
Ideation
with
method
Self-
Injurious
behavior
with
unclear
intent
Attempt Completion

26. Focused assessment of continuum
• It is vital to assess what the adolescent is thinking
• In order to determine strengths and weaknesses, difficult
questions must be asked centered on degree of desire to
die
• Questions must be very specific. Trying to assess
suicidality without asking about death is like trying to
determine appendicitis without asking “does it hurt
here?”
• There is ample evidence that asking about suicide does
not “put” ideas in any adolescent’s mind

27. Examples of Suicide Continuum
• Passive death wish
▫ I wish God took me away
• Ideation without method
▫ I feel bad and have thought about killing myself
• Ideation with a method
▫ I am thinking about shooting myself

28. Attempt vs. Gesture
• SUICIDE GESTURE:
▫ Self-injury in which there is unclear intent to die but instead an intent to
give the appearance of a suicide attempt in order to communicate with
others (Nock & Kessler Journal of Abnormal Psychology 2006, Vol. 115, No. 3, 616 – 623)
• SUICIDE ATTEMPT:
▫ Potentially self-injurious behavior with a nonfatal outcome, for which
there is evidence (either implicit or explicit) that the person intended at
some level to kill self (Goldsmith SK, Pellmar TC, Kleinman AM, et al. Reducing Suicide: A National Imperative. Washington, D.C.: National Academy Press; 2002).
• There is evidence that these two groups differ but there is also evidence that
those who engage in suicide gestures also carry a higher risk of completion.
• Those who “gesture” must be taken seriously

29. High Risk
• 16 year old male
• Abuses alcohol
• Treated for bipolar disorder
• History of suicidal ideas
• Recent loss of mother due to medical illness
• Father is a hunter
• Broke up with GF and stated he wants to kill self

30. Medium Risk
• 17 year old female
• History of self mutilation without intent to die
• Family history of completed suicide
• Doing poorly in school, ostracized by peers
• Attends therapy regularly
• Has good relationship with parents
• During an argument with peer in school was
overheard voicing wish to die

31. Low Risk
• 9 year old male
• Parents recently separated
• Stays with grandmother very often
• Doing well in school and liked by peers
• No family history of psychiatric problems
• After watching a movie showing a suicide, told
grandmother nobody likes him and he wishes to
die

32. Risk And Disposition
• High Risk
▫ Inpatient treatment
▫ If condition relapses, next time discharge to structured
setting, possibly a therapeutic day school
• Medium Risk
▫ If new condition, Partial Care Program
▫ If condition is chronic, structured setting advisable,
possibly a therapeutic day school
• Minimal Risk
▫ Traditional Outpatient Treatment

33. Psychopathology of Suicide
Bennett Silver, MD

34. How it Happens
Alex was a 17 year old high school senior. He was a
warm, sensitive, quiet young man; a high honor roll
student and a gifted young writer. He had been accepted
to an excellent college, and a promising, successful
future seemed assured. Yet one late afternoon in April,
upon returning home from work, his horrified mother
discovered him on the floor of his bedroom. Alex had
killed himself with a gunshot to the head.
How is it possible that this young man, who seemed to
have everything to live for, would take his own life?

35. Why it Happens
In order to understand why tragedies like this occur, we
must understand the psychopathology from which it
stems.

36. Suicide as a Symptom
• Suicide is to the psychiatrist as cancer is to the internist
• The psychiatrist may provide optimal care, yet the patient may die
by suicide nonetheless
• Suicide is best viewed as a symptom of an underlying disease rather
than a disease per se
• The underlying disease is usually some type of depression, or
another psychiatric disorder and therefore is highly treatable

37. Causes of Depression
• Depression has no single cause. Genetics/Biology definitely play a role (family history)
• The environment: stressful situations, abuse, family issues, physical illness, loss, romantic
breakups, conflict over sexual orientation
• Anxiety and behavior problems increase chances for depression
• Predisposing personality traits: perfectionism, inhibition, isolation, supersensitive
• Drug and alcohol dependency
• Head injuries (e.g., football, soccer, car accidents), lead to disinhibition, depression and
suicide
• Sometimes no clear triggering event
A bio-psycho-social model provides the best understanding of depression

38. Biological Theories About Suicide
• Genetic factors predispose to suicide – clusters of families with both mood
disorders & suicides and clusters with mood disorders without suicide,
indicates independent inheritance of mood disorders and suicidal behavior
• Biological theories about suicide linked to studies of depression-the mental
state most often underlying suicide
• Deficiency of neurotransmitters like norepinephrine/ serotonin at critical
sites in brain resulting in depression
• Many studies indicate a lower level of serotonin in brains of those
who suicided and in cerebrospinal fluid of depressed individuals who
have attempted suicide than in depressed patients who are not suicidal

39. Low Brain Serotonin, Impulsivity and Suicide
• More violent suicide attempters/completers(guns, jumping) lower levels of
serotonin than those using less violent means (e.g., pills)
• Studies have found decreased serotonin levels for gamblers/fire-
setters/impulsive individuals, compared to control populations
• This non-specificity links lower serotonin levels with poor impulse control
which increases suicidal behavior.
• Alcohol lowers serotonin at same sites in brain as seen in depressed
patients. Alcohol is a disinhibiter that increases impulsivity and greatly
increases risk of suicide in depressed patients.
• One third of adolescents who suicide are legally intoxicated at the time of
death

40. Biopsychosocial Theories
• Stress plays a role in development of depression, addiction and other
psychiatric disorders
• Corticotrophin releasing factor (CRF), a key brain hormone in the stress
response, is implicated in the physiology of both depression & Substance
use disorders (SUDs)
• Elevated CRF concentrations found in the brains of suicide victims
• Early life stress (physical/sexual abuse/neglect) and chronic stress cause
sustained elevations of CRF, causing long term damage to brain pathways
(neuroadaptation) which increases susceptibility to depression and
substance use
• This provides the biological underpinnings of the well-established
relationship between early life adversity and depression, suicide and SUDs
in adolescents and adults

41. Suicidal Behavior
• More than 90% of all completed suicides in adolescents (and
adults) are individuals with psychiatric disorders:
• Mood Disorders (most common): Major Depression, Bipolar Dis
• Schizophrenia
• Alcoholism
• Drug Dependence
• Conduct Disorders
• Borderline Personality Disorder
• Panic Disorder
• Substance Abuse Disorders and Anxiety Disorders appear more
important as cofactors rather than primary in themselves. Co-
existent high anxiety, panic, or substance use, accompanying major
depressive disorder or schizophrenia markedly increase suicide risk

42. The Suicidal Crisis
• Often, a crisis situation, what one author called a “state
of perturbation,” occurs in a vulnerable adolescent with a
psychiatric disorder and that crisis converts a state of
potential risk into an actual suicidal act
• The most common precipitating events are break-ups,
episodes of perceived humiliation, academic or
extracurricular failures, school disciplinary/legal
problems, or sexual assaults

43. Mood Disorders and Completed Suicide
60-70% of suicide victims were suffering from a significant
clinical depression at the time of their deaths
Completed Suicide Lifetime Suicide
Attempt
Bipolar Disorder 10-20% 29%
Major Depression 5-12% 16%
General Population <.0002%
(16/100,000)
.02%
Any Psychiatric
Disorder
4%

44. Some Facts About Bipolar Disorder
• Prevalence in America of approx 1% to 4%
• Equally in men and women
• 60% onset before age 20
• 10%-15% of adolescents with recurrent major depression
go on to develop Bipolar Disorder
• Residual symptoms between episodes common, and 60%
experience chronic interpersonal and school difficulties
between episodes
• Strong genetic influence-one of most familial psychiatric
disorders

45. Characterized by Recurrent Mood Episodes
• Major Depressive Episode
• Manic Episode
• Mixed Episode
• Hypomanic Episode

46. Manic Episode
A. Distinct period of persistently elevated, expansive, or irritable
mood –causes marked impairment in functioning
B. During period of mood disturbance at least 3 of the following:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative, pressured speech
4. Flight of ideas or racing thoughts
5. Distractibility
6. Increased in goal-directed activity (social, school work, sexual) or
psychomotor agitation
7. Excessive involvement in activities with high potential for negative
consequences (e.g., buying sprees, sexual indiscretions)

47. Mixed and Hypomanic Episodes
• During a Mixed Episode manic and depressive
symptoms may occur simultaneously or in quick
succession.
• During a Hypomanic Episode, symptoms
same as during Manic Episode, but less severe -
do not cause marked impairment in functioning.

48. Suicide Risk in Bipolar Disorder and Major
Depression

49. Other Factors That Increase Suicidal Acts
in Depressed and Bipolar Patients
• Severity of depression
• Age of onset (younger age)
• Severity of ideation
• Number of prior attempts
• Stable levels of hopelessness
• Transition points: first week of hospitalization,
incarceration, bereavement, victimization/abuse

50. Comorbid Substance Abuse
• Prevalence of comorbid substance abuse in bipolar I and
bipolar II disorder is as high as 61% and 48%
respectively
• This is greater than the prevalence of substance abuse
seen with any other psychiatric conditions, including
schizophrenia, panic disorder, dysthymia and unipolar
depression
• Comorbid substance use increases the risk for suicide in
mood disorders

51. Accurate Diagnosis and Early Intervention
• Bipolar Disorder is difficult to diagnose in adolescence, due to
nature of adolescent moodiness, and similarities with conditions
such as ADHD, Schizophrenia, and Addiction
• Bipolar Disorder has a spectrum of severity and milder forms often
missed or misdiagnosed.
• Misdiagnosis leads to delayed or incorrect treatment
• Early intervention/treatment improves long – term outcome,
reduces suicidal risk for teens

52. Major depression in adults and adolescents
At least 5 of these symptoms must be present to the extent that they interfere with daily functioning over
at least 2 weeks
Adults Adolescents
Depressed mood most of the day Irritable mood; preoccupied with song
lyrics that suggest life is meaningless
Decreased interest/ enjoyment in activities Loss of interest in sports, video games, activities with
friends
Significant weight loss /gain Failure to gain normal weight ; anorexia
or bulimia; frequent complaint
of physical illness
Insomnia or hypersomnia Excessive late night TV or computer; refusal to wake up
for school in morning in morning
Psychomotor agitation/ retardation Running away from home
Fatigue or loss of energy Persistent boredom
Low self-esteem; feelings of guilt Oppositional and/or negative behavior
Decreased ability to concentrate; indecisive Poor performance in school; frequent absences
Recurrent Suicidal ideation or behavior Recurrent suicidal ideation or behavior (writing
about
death ; giving away favorite objects or possessions

53. Signs and Symptoms of Covert Depression
Often Seen in Adolescents
• The quiet, perfectionistic “good boy” who never gets into
trouble but who cannot maintain the level of perfection that
he or others expect of him
• Boys with conduct disturbances who become depressed and
act out impulsively
• Boys who abruptly develop conduct disturbances as their way
of expressing depression
• Changes in school performance or friends
• Beginning to abuse substances

54. Relapse is Common in Major Depression
• After one episode 50%
• After two episodes >70%
• After three epsodes >90%
• Relapse is more common when first episode is before
the age of 20 years

55. Symptoms and Signs of Psychiatric Illness
Are Present Prior to Suicide
Although the bereaved parents of adolescent
suicide victims frequently insist that their child
was totally free of any symptoms prior to the
suicide, this appears rarely true on closer
examination, and may reflect the parents’ denial
or their inability to recognize the signs of
depression

56. Pharmacological Approach
Gabriel Kaplan, MD

57. Pharmacology is just One of Many Tools
within a Comprehensive Approach
• Individual psychotherapy
• Group psychotherapy
• Family therapy
• School Interventions
• Medication
• Therapeutic school placement such as New Alliance Academy
which can utilize all of above approaches

58. Medication Classes Used in Suicide
• Antidepressants
• Antipsychotics
• Mood Stabilizers
• Only one medication has been proven to decrease suicide in adult
schizophrenia and is FDA approved specifically for suicide
▫ Clozapine (antipsychotic)
• There is ample evidence for other medications in adults
▫ Lithium (mood stabilizer)
▫ Antidepressants

59. Antidepressants
Serotonin Enhancers -SSRI’s
• Prozac (Fluoxetine)
• Zoloft (Sertraline)
• Lexapro (Escitalopram)
• Celexa (Citalopram)
• Paxil (Paroxetine)
Serotonin/Norepinephrine Enhancers- SNRI’s
• Effexor (Venlafaxine)
• Pristiq (Desvenlafaxine)
• Cymbalta (Duloxetine)
Dopamine/Norepinephrine Enhancers
• Wellbutrin (Bupropion)

60. Side-effects of Antidepressants
Most adolescents do not have side-effects. If they do
occur they are usually mild and transient.
▫ Headaches
▫ Upset stomach
▫ Decreased appetite
▫ Flushing and sweating
▫ Mild sedation
▫ Jitteriness
▫ Abnormal dreams
▫ Rash
▫ Sexual
▫ BLACK BOX WARNING

61. Antidepressants Are Compatible With
Student Performance in School
• Low incidence of side-effects
• Usually not sedating
• Once daily dosing (morning or nighttime)
• Usually compatible with other medications

62. How Effective Are Antidepressants ?
In an important recent study funded by the NIMH
(TADS) on adolescents with moderate to severe
depression :
 71% of adolescents who received combination treatment
(medication + therapy) improved significantly
 61% of those receiving medication alone (fluoxetine)
improved
 Combination treatment was nearly twice as effective in
relieving depression as the placebo or psychotherapy alone
March J. TADS JAMA. 2004 Aug 18;292(7):807-20.

63. Do Antidepressants make people suicidal?
• 2003 the maker of Paxil disclosed that clinical trial data had found an
increased risk of suicidality in youth.
• FDA concluded that for every 100 treated patients, 1 to 3 patients might be
expected to have an increase in suicidality.
• 2004 FDA required all antidepressants carry a black box warning
• The data did not indicate any completed suicides, thus, the identified
suicidality increase referred to ideas and behaviors but not deaths.
• 2007 FDA expanded the warning to include patients up to age 24.
• There are only two FDA approved agents indicated for use in adolescent
depression: fluoxetine (Prozac) and escitalopram (Lexapro).

64. Black Box Controversy
• Data from the CDC show that between 1992 and 2001, the rate of suicide
among American youth ages 10 – 19 declined by more than 25%
• The dramatic decline in youth suicide rates correlates with the increased
rates of prescribing antidepressant medication (particularly SSRI’s) to
young people
• Since the black-box suicide warnings appeared on the labels of
antidepressants, antidepressant use among teens plummeted. At the same
time, the suicide rate among U.S. teens rose sharply – bucking a decades
long trend
• There are no statistical data yet linking the black box to increased
suicidality but suspicion is high amongst academicians that this may have
been an unintended consequence of the warning

65. Data Reanalyses
• FDA studied only short term data
• Data were reanalyzed adding longitudinal information, extending the
observational period beyond the short term study end point timeframes
assessed by the FDA.
• For adult and geriatric patients medication actually decreased suicidal
thoughts and behavior. The protective effect was mediated by decreases in
depressive symptoms with treatment.
• For youths, however, although depression also responded to treatment, no
significant effects of treatment on lowering suicidal thoughts and behavior
were found, although reassuringly, there was no evidence of increased
suicide risk in those receiving active medication.
Gibbons RD, Brown CH, Hur K, Davis J, Mann JJ.
Suicidal Thoughts and Behavior With Antidepressant Treatment: Reanalysis of the Randomized Placebo-Controlled Studies of Fluoxetine and Venlafaxine.
Arch Gen Psychiatry. 2012 Jun;69(6):580-7.

66. Mood Stabilizers
• USED FOR BIPOLAR DISORDER
• LITHIUM:
▫ Lithium Carbonate (Eskalith,Lithobid)
• ANTICONVULSANTS:
▫ Valproic Acid (Depakote)
▫ Carbamazepine (Tegretol)
▫ Lamotrigine (Lamictal)

67. Lithium
• Oldest mood stabilizer
• Improves depression and mania
• Helps prevent future episodes
• Narrow dosage range (blood levels required)
• Very dangerous in overdose
• Side – effects: drowsiness, weakness, nausea,
fatigue, hand tremor, increased
thirst, increased urination,
thyroid underactivity,
weight gain

68. Anticonvulsants
• Improve depression and mania
• Lamictal especially good for depressive episodes
• Help prevent future episodes
• Narrow dosage range (blood levels required)
• Work better than Lithium for rapid cyclers and mixed
states
• Side – effects: Nausea, headache, double
vision, sedation, liver enzyme
elevation, weight gain, hormone
changes in women (Depakote, e.g.,
absence of menstruation)

69. Antipsychotics
• TYPICAL
▫ Haloperidol (Haldol) Less sedating, muscle rigidity, Tardive Dyskinesia
▫ Chlorpromazine (Thorazine) Sedating, low blood pressure, TD
• ATYPICAL
▫ Aripiprazole (Abilify) –weight neutral, less sedating
▫ Risperdone (Risperdal) – Moderate weight gain, increases prolactin
▫ Quetiapine (Seroquel) – Moderate weight gain, sedating, may have antidepressant
properties
▫ Olanzapine (Zyprexa) – Very effective, but significant weight gain, metabolic
effects (blood sugar, cholesterol)
▫ Ziprasidone (Geodon) – Weight neutral, less sedating
▫ Clozapine (Clozaril) – Most effective, weight gain, metabolic effects, risk for severe
white blood cell suppression requires regular blood tests. Used when other
medications fail.

70. Antipsychotics
• Improve depression (as add on) and mania (combined or
monotherapy)
• Control delusions & hallucinations (psychosis)
• No blood levels required
• Side – effects: sedation, weight gain (some),
elevated blood sugar, diabetes,
restlessness, muscle spasms
• Monitor weight, blood sugar, cholesterol

71. Bennett Silver, M.D.
Psychosocial Approach and
Prevention

72. Getting the Right Help Can Prevent Suicide
• > 80% of adolescent suicide attempters/completers communicate suicidal
ideation prior to the attempt
• Majority of youth suicide attempters/completers have seen a doctor/mental
health worker in 3 months prior to the suicidal behavior
• Few individuals with Major Depressive Disorder receive adequate treatment
for depression before and after a suicide attempt
• Only 20-40% of suicidal patients continue outpatient treatment after
psychiatric hospitalization-treatment dropout another suicide risk factor
• Recent Study of 102 people who killed themselves revealed more than half had
visited mental health specialist during the year prior to death
• Only 5% had contact with addiction services, even though 2/3 suffered from
substance abuse as well as depression - need better integration of mental
health and addiction services

73. Psychotherapy for Suicidal Patients
• Short-term, group, behavioral, interpersonal,
psychoanalytically oriented, and multiple other
psychotherapy approaches have all been employed with
reported success
• However, Cognitive Behavioral Therapy (CBT) by far the
largest evidence base of its effectiveness
• Dialectical Behavioral Therapy (DBT) particularly
effective with suicidal Borderline Personality Disorder
patients

74. Cognitive Therapy
• Cognitive theory emphasizes the psychological significance of
people’s beliefs about themselves, their personal world (including
the people in their lives), and their future – the “cognitive triad”
• Maladaptive emotional distress linked to biased beliefs about this
cognitive triad of self, world, and future
• E.g., clinically depressed people may believe that they are incapable
and helpless, view others as judgmental, and the future as bleak and
unrewarding
• Cognitive therapy modifies these maladaptive beliefs to help the
person gain a more objective view of their problems and their
potential solutions

75. Thinking Patterns Targeted by Cognitive Therapy
• Dichotomous (black-white) thinking
• Cognitive rigidity and constriction
• Perfectionistic standards of self/others, high self-criticism
• Over-general autobiographical memory - past experiences
cannot be used as references for effective coping strategies
• Impaired problem solving
• Hopelessness/helplessness-negative expectations about the
future
• “locked-in” to current perceptions, unable to imagine
alternatives
• View death in a favorable light
• Have difficulty generating reason for living

76. Critical Role of Early Intervention and
Parent Education
• The earlier the intervention in the course of suicidality,
the greater the potential for success
• Importance of parent education of suicidal youth – e.g.,
17% of parents keep firearms even after their child’s
suicide attempts (more lethal methods with repeat
attempts)
• Parents are 3 times more likely to take protective actions
when parent education is provided

77. Bullying and Suicide
• Recent bullying related suicides and school shootings in the US and
in other countries have drawn attention to the connection between
bullying and suicide/homicide
• Too many adults see bullying as “just part of being a kid”
• Bully victims 2 to 9 times more likely to consider suicide
• 30% of students are either bullies or victims of bullying and
160,000 kids stay home daily due to fear of bullying
• Types of bullying- physical, emotional, cyber, sexting
• Being a bully also linked to an increased rate of suicide

78. New Jersey Anti-Bullying Bill of Rights Act
• 2011, toughest in country-extension of original anti-bullying law enacted
in 2002
• Defines bullying: any harmful action towards another student or any
action that creates a hostile school environment or infringes on a
student’s rights at school.
• Includes cyber bullying and bullying both on and off school grounds
• All cases bullying/teasing must be reported to the State
• Written report within 2 days, families, superintendent notified,
investigation within 10 days of incident
• All schools a plan to address bullying, teachers/ administrators trained
to identify/respond to bullying
• All schools anti-bullying specialist/school safety team

79. How to Deal with a Suicidal Adolescent
• First, a person in crisis needs someone to listen and hear what they
are saying
• All suicidal talk should be taken seriously
• Do not be afraid to ask directly if the person has thoughts of suicide
– it will do no harm-most individuals relieved and feel given
permission to talk about it
• Do not be misled by the suicidal person’s comment that he is alright
and past the crisis – follow-up is crucial to insure good treatment

80. How to Deal with a Suicidal Adolescent - 2
• Be firm but supportive – give the impression that you
know what you are doing and that you intend to do
everything possible to prevent him from taking his life
• Evaluate the resources available – inner psychological
resources such as intellectualization that can be
strengthened & outer resources such as counselors,
relatives, clergy and others who can be called in

81. How to Deal with a Suicidal Adolescent - 3
• Act Specifically – do something tangible, parents must be called in,
arrange for him to see someone else, or if necessary, have the person
brought to an emergency room for evaluation
• School staff cannot assume that a student’s family will take positive
steps to respond to the situation, especially in dysfunctional families
and must insure that at risk students receive the necessary services
• Don’t be afraid to ask for assistance and consultation – call upon
whomever is needed. Don’t try to handle everything alone

82. Postvention in the School Setting
• Prevention measures implemented after a traumatic event to reduce risk
to those who have been affected by the tragedy
• The suicide, violent or unexpected death of a student, teacher, even a
celebrity can increase risk of suicide for vulnerable young people -
“copy-cat suicides”
• Postvention includes grief counseling for students/staff,
identification/support of vulnerable students, and families
• Work with the media-ensure news coverage does not
dramatize/romanticize, leading to additional suicides
• Establish school- based suicide prevention programs & crisis response
plans including educational activities that encourage students to
recognize and find help for emotional issues

83. National Suicide Prevention Strategy
• Sept 10, 2012, U.S. announced $55.6 million in new grants for suicide
prevention programs
• First new national strategy plan in over a decade
• Promotes new Facebook service-users can report suicidal comments
they see online from friends-website sends the potential victim an email
urging a call to hotline/chat online with a counselor
• New technologies-mobile apps to connect people with counseling
resources
• Plan highlights the 23 million veterans (17,754 veteran suicide attempts
last year- 48 per day) and efforts to identify soldiers at risk, reduce
stigma and encourage them to seek help

84. Elements of the National Strategy
• Health professionals are not adequately trained for proper assessment, treatment and
management of suicidal individuals, or know how to refer them properly for
specialized assessment/treatment
• Provide targeted education for suicide identification and referral to key gatekeepers
such as teachers, guidance counselors, doctors, clergy, social workers, psychologists
• Improve marketing of community-level educational
• Incorporate screening for depression, substance abuse and suicide risk as a minimum
standard of care for assessment in primary care settings, schools, and colleges
• Limit access to lethal methods of self-harm -firearms, lethal doses of medicines,
drugs, alcohol by underage youth, and dangerous settings such as bridges/rooftops
• For example, improvements and changes in car exhaust emissions have resulted in a
decrease in deaths by carbon monoxide poisoning

85. Other Broad-Based Strategies
• Develop strategies to reduce stigma for consumers of
mental health/substance abuse/suicide prevention
services
• Increase community linkages with mental health and
substance abuse services
• Improve portrayals of suicidal behavior, mental illness/
substance abuse in entertainment/news media- avoid
dramatization to reduce suicide contagions
• Promote/support research on suicide/suicide prevention

86. Suicide Prevention Checklist for Schools
• Does school provide information to staff about the impact/prevalence of
adolescent suicide?
• Does school have policies and procedures in place concerning suicide
issues?
• Does it have support from superintendents/principals/teachers for suicide
prevention program?
• Does school have links to the community to help with a suicidal student and
are staff educated about how to contact them?
• Does your school have a crisis response plan/team that meets on a regular
basis?
School-Based Youth Suicide Prevention Guide of University of South Florida

87. Suicide Prevention Checklist for Schools
• Does school provide parents with list of community resources if they
suspect their child is considering suicide?
• Does school inform parents about risk factors and restricting access to
lethal means (firearms)?
• Is school staff aware of legislation on liability for suicidal behavior in
students?
• Is school aware that while students are in school, the school must act in loco
parentis, or as reasonably as a concerned parent?
School-Based Youth Suicide Prevention Guide of University of South Florida

88. Traditional Treatment Model for Depressed,
Suicidal, Vulnerable Adolescents

89. Integrated School Model
New Alliance Academy
The most effective treatment for these emotionally fragile adolescents
requires a highly integrated (under one roof), multi-pronged treatment
team approach in order to prevent poor or tragic treatment outcomes