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Preventing Teen Suicide a Tough Challenge

Spotting it, stopping it a tall order for health-care professionals, experts say

WEDNESDAY, Dec. 27, 2006 (HealthDay News) -- Suicide is the third leading cause of death among teens, but doctors are far from figuring out how to spot and treat teens who might try to take their own lives.

Making a mistake can cost a life, warn two perspective pieces in the Dec. 28 issue of the New England Journal of Medicine.

Even when suicide risk is recognized, in the current climate of confusion over what antidepressants can or cannot do for young people, treatment becomes another major hurdle, the authors note.

"Suicidal behavior almost always occurs in psychiatric cases, but not all psychiatric cases commit suicide," explained Dr. David Brent, a professor of psychiatry at the University of Pittsburgh School of Medicine and co-author of the first article. "We're trying to figure who is at risk and understand more of the causes for treatment and prevention. Identification of risk is not helpful unless we can do something about it."

Weighing many of the traditional risk factors -- mood disorders, alcohol abuse, recent loss of a loved one, and family history of suicidal behavior -- may not be enough.

The key, Brent argued, could be a trait called "impulsive aggression," defined as "the tendency to respond to provocation or frustration with hostility or aggression."

"A tendency to be impulsive-aggressive in combination with depressed mood increases the risk for suicide behavior," Brent said. "The treatment [in this case] may be different than the treatment for depression."

Impulsive aggression has been associated with suicidal behavior even within groups of patients with similar diagnoses. Impulsive aggression increases the likelihood that a person will act on suicidal thoughts. These youngsters have difficulty assessing risks and generating appropriate alternatives when facing problems. And the tendency to such behavior often runs in families.

More successful treatments would improve people's ability to generate these alternatives or better assess risks and benefits.

But the considerable complexity of each individual case must be considered within the current treatment climate, the second NEJM article points out.

In 2004, the U.S. Food and Drug Administration slapped a "black box" warning on popular selective serotonin reuptake inhibitor (SSRI) drugs such as Prozac, Paxil, Celexa and Zoloft, warning of the possible risk of suicidality in pediatric users.

In July 2005, the FDA issued a public health advisory raising the possibility that the risk also applied to adults taking SSRIs, after several studies pointed that way.

Those actions have been followed by conflicting research on the risk of these drugs, with some studies showing an increased risk for suicidality and others showing a reduced risk.

And while the FDA did not prohibit the use of antidepressants in this age group, instead advising more follow-up, there has been an unintended consequence to the new directive.

According to the second article, after the initial advisory was issued, prescriptions for antidepressants for children and adolescents plunged by nearly 25 percent, while the rate of appropriate follow-up care showed no improvement.

For every 10,000 children and adolescents who begin taking antidepressants, about six will die by suicide during the next six months and another 30 will be hospitalized after a serious suicide attempt, the article stated. Some 3,000 will stop taking their medication within a few weeks, 4,000 will never return for a follow-up visit, and 6,000 will not recover from depression during the next six months, the article noted.

But the picture is not all bleak.

"The suicide rate, until recently, was decreasing in adolescents, so something was going well," Brent said. "It may have had to do with the treatment of depression and difficulty getting access to guns. People are also more aware and willing to get help. That is reason for hope, but the rate is still too high and there are things we can do."

More information

The U.S. National Institute of Mental Health has more on treating mental disorders in children.

SOURCES: David Brent M.D., professor, psychiatry, University of Pittsburgh School of Medicine; Dec. 28, 2006, New England Journal of Medicine
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