In this group of 250 confirmed episodes of suicidal behavior randomly selected from cases identified in a cohort of adolescents treated with antidepressant agents, >85% of the cases involved ingestion of medications. Approximately one-half of the confirmed cases had previous suicide attempts. Early adolescents differed from late adolescents in terms of the methods used, presence of psychotic disorders, history of sexual abuse, and presence of hallucinations. In addition, the 2 groups differed in terms of the agents ingested during episodes of suicidal behavior. This study is one of the first to describe differences in suicidal behavior between early and late adolescents. These differences warrant further study in larger and more heterogeneous adolescent populations but suggest potential targets for suicide screening and prevention that have important implications for health care providers and public health scientists.
Many adolescent suicide attempts occur impulsively in the setting of a crisis with little or no warning.25
However, suicidal behavior may also be a serious manifestation of adolescent depression. It is likely that some of the differences between early and late adolescent suicidal behavior described in this study reflect the developmental differences between the 2 groups. Adolescence is a dynamic period characterized by rapid physical, social, and cognitive growth.26
Adolescent development is also characterized by increasing independence and shifting in the relative importance of relationships with parents, other family members, and peers.26
Cognitively, adolescence is characterized by the progression from concrete (“here and now”) thinking to abstract thinking and the ability to consider alternatives and consequences to proposed actions.27
These changes may provide insight into the differences observed between early and late adolescent suicidal behavior in this study. For example, early adolescents were more likely than late adolescents to use hanging as a means of suicide. As concrete thinkers, early adolescents may be less likely to recognize a larger array of options for means of suicide and may not appreciate the physical and emotional consequences of violent methods to themselves and others. It is also possible that access to means of suicidal behavior is more limited for early adolescents relative to late adolescents.
Historical risk factors for adolescent suicidal behavior are likely to be particularly important for clinicians and public health officials. Consistent with other studies showing that suicidal behavior is an important risk factor for later suicide attempts,1,2,5
about one-half of the medical records of early and late adolescent suicidal behavior in this study included documentation of previous suicidal behavior. In addition, nearly 1 in 4 subjects in this study reported either physical or sexual abuse, which is 20 times the reported national average.28
This finding is consistent with previous research demonstrating a strong correlation between child and adolescent abuse and suicidal behavior.16,21,29–31
Abuse during childhood and adolescence has also been associated with poor development in areas of cognition, emotion, and social networks, which may vary with developmental stage. This maladaptation may lead to poor academic performance, fewer coping strategies, increased aggressive and uncontrolled behavior, low self-esteem, social isolation, and inappropriate peer relationships, which are all known risk factors for suicidal behavior.32–34
The range of psychiatric symptoms, including reported hallucinations in early adolescents, may reflect the trauma of previous abuse.
Changes in family and social relationships related to adolescent development are likely to explain some of the differences in precipitating events observed before suicidal behavior. Interpersonal conflict, particularly with parents, was the most common precipitant reported for all adolescents and was more common in early adolescents.35,36
Relationships with parents during early adolescence may be particularly tumultuous as the adolescents seek to develop identity and autonomy and there is growing importance of the influence of peers. The increasing significance of romantic relationships throughout adolescence parallels our study's finding of a higher occurrence of conflict with a romantic partner as a precipitant of suicidal behavior in late adolescents than in early adolescents.37,38
In this study of youth who were prescribed antidepressant medications, depressed and/or irritable mood was almost universally documented as a precedent symptom of suicidal behavior for both early and late adolescents. Hopelessness, anxiety, rage, and hallucinations, although documented less frequently, were still relatively common symptoms preceding suicidal behavior. The presence of hallucinations was more frequently documented as a symptom in early than late adolescent suicidal events. A growing body of literature suggests that hallucinations and other symptoms of psychosis are common in psychiatric illnesses during adolescence and that symptoms are predictive, but not pathognomonic, of future psychotic illness.39
Although additional research is needed, the report of hallucinations, particularly among early adolescents, may have important short- and long-term implications for youth and warrant additional investigation by clinicians.
Our study has important limitations. The study population consisted of adolescents enrolled in TennCare and may not be generalizable to other adolescents. However, during the study period, TennCare covered ~30% of Tennessee children, which represents an important population at-risk for medical and mental health disorders.40
Nationwide, ~20% of children are enrolled in Medicaid programs. The study cohort consisted of patients who filled prescriptions for antidepressant agents, which may limit its generalizability to the larger population of adolescents. However, given the increasing use of antidepressant agents in all children,41,42
understanding the characteristics of suicidal behavior among antidepressant users is important. We only included adolescents with medically treated suicide attempts; thus, adolescents with suicidal behavior who did not enter the health care system were not included. Some of the differences between early and late adolescents in characteristics and potential risk factors for suicidal behavior represent small actual numbers and should be interpreted with caution. Finally, the majority of patients seeking care for suicidal behavior were evaluated in acute care settings where the treating clinicians are less likely to have a relationship with the patient and may not have access to previous medical records. The strengths of the study include the relatively large sample size and the structured chart review and adjudication of suicidal behavior.