Youth Suicidality: Assessment and Interventions

Suicidality is increasing among youth, as shown by multiple national and international studies (e.g. Center for Disease Control & Prevention, 2023; Sapien Labs, 2022). Too many young lives are spiraling down into psychache (the intolerable psychological pain described by Shneidman (1993)).

Across the globe, concern is being voiced in popular media as well as scholarly journals about the mental health of youth. For example, Shpancer (2023) in a popular American magazine, calls today’s youth more “emotionally fragile,” basing this conclusion on several large studies. The Center for Disease Control and Prevention (CDC) reported worsening trends from 2011-2021 in sadness/hopelessness, serious consideration of suicide, making a suicide plan, and attempted suicide (CDC releases the Youth Risk Behavior Survey Data Summary and Trends Report: 2011-2021. https://www.cdc.gov).This report highlighted persistent sadness/hopelessness in 60% of female students and 70% of LGBQ students. A large study by Sapien Labs (2022) looked at youth across the world (64 countries, N = 400,000+) finding nearly half (46%) of youth ages 18-24 were emotionally distressed, and 5 times more likely to have mental health challenges compared to their grandparents’ generation.

Proposed etiologies of increased suicidality

Older literature (e.g. Spirito & Overholser, 2003) identified factors placing adolescents at high risk of suicidality (e.g. homelessness, incarceration, LGBTQ, abusing substances, experiencing a situational stressor such as romantic breakup). A history of child maltreatment also significantly increases risk of suicidal behavior (Zelazny et al., 2019). Newer literature also brings into prominence the devastating life disruptions created by the COVID-19 pandemic and the pervasive negative influence of social media (Shpancer, 2023).

Social media fosters anxiety, stress, and envy (Shpancer, 2023). Horrifying cyberbullying (including messages from peers to “kill yourself”) and livestreaming of suicidal behavior did not exist when many psychiatric clinicians received their training. In a recent address to graduate students currently in training, psychiatric nurse researcher Jamie Zelazny suggested careful evaluation of an adolescent client’s social media usage. Is the adolescent using social media excessively, instead of engaging in physical exercise or healthy social interactions? Does their use of social media leave them feeling bad in comparison to peers? In her own research, comparing suicide attempters and non-attempters, she found that social media experiences differed; attempters reported more negative experiences (Zelazny, 2023).

Suicide prevention interventions

Prediction of suicidal behavior remains challenging, with no existing clinical tools to detect imminent risk; standard clinical interviews do not fully determine future risk (Auerbach et al., 2023). Technology is now being mobilized in prevention interventions. Auerbach’s research team uploaded an app on smartphones of 103 adolescents (ages 13-18) that measured their daily mood and weekly suicidal ideation severity for six months. Participants in the study reported depression, anxiety, and/or substance use disorder at baseline, and 62% had suicidal ideation when the study began. Weekly suicidal ideation scores sorted the study participants into high-risk, medium-risk, and low-risk groups. For the high-risk and medium-risk adolescents, mood disturbance during the preceding week predicted clinically significant suicidal ideation. This longitudinal study demonstrated the feasibility of using this smartphone monitoring approach, but before it could be widely implemented in other settings, systems must be in place for rapid intervention when youth are exhibiting severe suicidal ideation.

Intervening with suicide attempters

Youth who survive a suicide attempt are often hospitalized on a psychiatric inpatient unit Therefore, psychiatric nurses and other service providers have a unique opportunity to extend empathy and support to these young people and help them to forge a path to the future. Helping them to recognize reasons for living, develop a safety plan, and connect to outpatient care are essential. The risk for suicidal behavior after hospitalization is high, especially within the first few weeks after discharge, and many adolescents and their families do not follow through with recommendations such as outpatient cognitive behavioral therapy.

A promising smartphone app (BRITE) was piloted by Kennard et al. (2018) with 66 adolescents who had been hospitalized for suicide ideation or attempt. While they were inpatients, those randomly assigned to the “As Safe as Possible” (ASAP) intervention were taught about emotional regulation and safety planning. For example, youths were taught to catch themselves when ruminating and activate positive affect. Self-soothing techniques were taught to manage painful feelings, After discharge, the smartphone app prompted them to rate their emotional distress daily and implement personalized strategies for emotional regulation and safety planning. A large percentage of the study participants (70%) used the smartphone app and reported satisfaction with both the ASAP intervention and with the BRITE app, although a statistically significant effect on subsequent suicide attempt was not found. A limitation of the study was the predominately female Caucasian sample. Our troubled world must continue aggressive prevention efforts to prevent the loss of young people experiencing intolerable psychological pain. Your contributions to the empirical and clinical literature on youth suicidality are urgently solicited. Replication of the study by Kennard et al. (2018) with a larger, more diverse sample would be useful. Qualitative research would be useful to ask adolescents what it is like to report their mood every day (and their suicidal ideation every week). Does this monitoring reassure them or could it possibly trigger them? What school-based and family interventions are proving effective during this time of increased suicidal ideation and behavior? Answers to these questions are urgently needed.