Adolescent Substance Abuse and Suicide

More and more substance abuse counselors, mental health professionals, and justice system officers are observing adolescents who present with a history of suicidal ideation and attempts. An important issue in examining this population involves exploring the interrelationship between adolescent suicide and substance use.

The National Center for Injury Prevention and Control reports that in 2000, there were 3,994 suicides in the United States by people under the age of 25; 1,621 of those victims (41%) were 19 years old and younger, while 300 were between the ages of 10 and 14. In 2000, suicide ranked as the third leading cause of death among persons ages 15 to 24 in the United States.1

A significant increase in suicide rates among American teenagers over the past 50 years coincides with enormous changes in drug use among youths. However, the relationship between suicide and drug use in adolescents is not a simple, linear one. Rates of adolescent substance use and abuse have fluctuated in recent decades.2 Research findings on adolescent suicide and substance abuse have been confounded by changes in diagnosed adolescent substance abuse disorders, a lack of prospective studies, changes in the treatment of adolescent substance abuse (including dual diagnoses), and failure to investigate the presence of substance use in earlier studies of adolescent suicidal behavior.

Research estimates the prevalence of adolescents who are at risk for suicide to be as high as 1 million.3 Adolescent girls attempt suicide three to four times more frequently than do boys. However, they generally use less lethal means (e.g., substance overdose) and consequently have a significantly higher survival rate.4

In a detailed review of the literature published before 1990, Crumley concluded that substance abuse in adolescents appeared to be associated with a greater frequency and repetitiveness of suicide attempts, more medically lethal attempts, an increased seriousness of intent, and greater suicidal ideation.5 Yet the presence of substance use or a substance use disorder in an adolescent with suicidal behavior does not offer a complete explanation for the behavior. As Crumley stated, the frequent presence of substance use in studies of adolescents with suicidal behavior may point toward an association between adolescent suicide and substance abuse, but does not prove that substance abuse caused the behavior.

In the research studies and review papers referenced in this article, rates of substance abuse in adolescents with suicidal behavior vary widely. Multiple factors may interact with the presence of substance use in youth, which may increase the risk for suicide. Some of these factors were examined in a comprehensive review by Brent et al, which examined psychopathologic risk factors for adolescent suicide and suicidal behavior.6

A comprehensive search of PsyInfo psychology databases (1990-95) identified a list of major risk factors associated with adolescent suicide and suicide attempts.7 These include absence of a maternal figure, access to firearms, an alcoholic family, conduct disorder, depression, dissatisfaction with family relationships, external locus of control, a gender identity crisis (gay, lesbian, bisexual, or transgender issues), and hopelessness. Other risk factors include a lack of reasons for living, a lack of social support, loneliness, low self-esteem, physical or sexual abuse, previous psychiatric inpatient treatment, previous suicide attempt, serious early childhood losses, and substance use.

Depression has been found to be the most frequently reported risk factor associated with adolescent suicide or suicide attempts. An examination of depression and its relationship to the other identified risk factors revealed that it was significantly correlated with suicidal ideation and attempts and most of the other identified risk factors.

Assessment and treatment considerations

Regarding assessment and treatment for adolescents with substance abuse and suicidal ideation, Rowan suggests that the frequency and consequences of drug use are important for the professional to consider.8 The adolescent may experience legal, educational, interpersonal, family, work-related, or medical consequences. Stressors such as an arrest for driving while intoxicated, school failure, loss of friends, or family discord can significantly affect an adolescent's emotional well-being.

Comorbid psychiatric/behavioral issues such as depression or attention-deficit/hyperactivity disorder often constitute the presenting problem, but one should assess for the presence of multiple coexisting disorders, including social phobia, other anxiety disorders, bipolar disorder, or a psychotic disorder. Inquiry into the presence of a firearm in the home or access to a weapon is necessary. Sometimes consultation with a clinician who specializes in substance abuse disorders, or referral to a drug treatment program to evaluate a drug problem, are options to be considered.

In treatment, the most severe and life-threatening issues should be addressed first. Initially, the clinician must determine whether the adolescent poses an acute risk to self. The adolescent initially may require an inpatient hospitalization or day treatment program. Treatment must be individualized to address the many potential diagnoses and problems facing the adolescent. Residential drug treatment, dual-diagnosis day treatment, and after-school drug treatment programs combined with individual therapy by a child psychiatrist or psychologist constitute some potential treatment venues.

There is frequently a need for multi-modal treatment including group, family, individual, and milieu therapy, as well as crisis-oriented interventions. Remedial education is often required. Treatment of adolescents with suicidal behavior, substance abuse, and comorbid psychopathology often requires extensive resources.

Bell and Clark suggest a variety of possible prevention and intervention strategies. These include crisis centers and hotlines, general suicide education, school and community gatekeeper training programs and peer support programs, hospitals and police as community gatekeepers, intervention after a suicide in the community, and screening programs.9

Conclusion

Suicidal thoughts and behavior ultimately can result in years of potential life lost to an adolescent as the result of premature death. It is critical for behavioral health programs serving adolescents not to assess only for suicidal ideation, but also to consider substance abuse as a factor involved in the adolescent's decision making.

References

1. Berman AL, Jobes DA, Silverman MM Adolescent Suicide: Assessment and Intervention. Washington D.C.:American Psychological Association; 2005.
2. Johnston L, O'Malley P, Bachman J. Monitoring the Future Survey 1975-1998. Ann Arbor Mich.:University of Michigan Institute for Social Research; 1999.
3. Straus M. Violence in the Lives of Adolescents. New York City:W.W. Norton and Co.; 1994.
4. Bagley C, Durie D, Hall R, et al. Facing the Facts! Suicide in Canada (brochure). Ottawa:Suicide Information and Education Center; 1990.
5. Crumley F. Substance abuse and adolescent suicidal behavior. JAMA 1990; 263:3051-6.
6. Brent D, Kolko D, Allan M Suicidality in affectively disordered adolescent inpatients. J Amer Acad Child Adol Psych 1990; 29:586-93.
7. Pagliaro AM, Pagliaro LA. Substance Use Among Children and Adolescents: Its Nature, Extent, and Effects from Conception to Adulthood. John Wiley and Sons; 1996.
8. Rowan A. Adolescent substance abuse and suicide. Depress Anxiety 2001; 14:186-91.
9. Bell C, Clark D. Adolescent suicide. Pediatr Clin North Am 1998; 45:365-80.