REVIEW
Suicide in Adolescents: A Worldwide Preventable Tragedy
Donald E. Greydanus,1, 2 Flora Bacopoulou3 and Emmanuel Tsalamanios3

Pediatrics & Human Development, Michigan State University College of Human Medicine,Michigan State University, Michigan, USA
2
Kalamazoo Center for Medical Studies, Michigan, USA
3
Centre for Health and Prevention in Adolescence, “Aghia Sophia” Children’s HospitalFirst Department of Paediatrics, Athens University, Athens, Greece

1(Received for publication on October 21, 2008)(Accepted for publication on January 15, 2009)

Abstract
The tragedy of suicide in adolescents is experienced by all countries of the world with as
many as 200,000 youth and young adults ending their life in the prime of their life because
of self-murder each year. Such a tragedy should be unacceptable to clinicians of the world
and this article examines factors leading to such death in our youth with recommendations
on how to prevent such a worldwide carnage. A major issue in suicide prevention is toscreen all children and adolescents for depression and other factors that may trigger suicide
in adolescence. (Keio J Med 58 (2) : 95－102, June 2009)

Keywords: suicide, adolescents, causes, prevention
Introduction(i.e., thinness or obesity), and drug abuses (i.e., smoking
and alcohol consumption). Suicide rates for male Japanese youth 15 to 19 years of age increased from 5 per
100,000 in 1990 to 9 per 100,000 in 2003 while the rate
for females increased from 3 to 5 in the same time period.3 Suicide rates for young adults, 20 to 24 years of age,are double or more that noted for the adolescent population.

The tragedy of suicide in adolescents is experienced by
all countries of the world with as many as 200,000 youth
and young adults ending their life in the prime of theirlife because of self-murder each year.1 Such a tragedy
should be unacceptable to clinicians of the world andthis article examines factors leading to such death in ouryouth with recommendations on how to prevent such aworldwide carnage. A major issue in suicide prevention
is to screen all children and adolescents for depression
and other factors that may trigger suicide in adolescence.

United States
Suicide rates in adolescents and young adults in the
United States have varied in the 20t h century and werereflective of greater societal forces. For example, rates
were highest in the 1930s in partial response to major
economic crises in the adult population; these rates
dropped in the 1940s and 1950s only to double from1960 to the early 1990s. 4, 5 Suicide rates in youth
dropped somewhat from the 1990s to 2001, then increasing in 2005. Proposed reasons for the drop from 1990 to2003 was the increased use of selective serotonin reuptake inhibitors (SSRIs) to combat depression. A United

Adolescent Suicide
Japan
The National Plan for Maternal and Child Health for2001 to 2010 in Japan has listed suicide prevention as amajor priority for health care providers in Japan.2 Other
national priorities include reduction in rates of abortion,
sexually transmitted diseases, unhealthy body weights

Presented at the 1580th meeting of The Keio Medical Society in Tokyo, September 2, 2008.
Reprint requests to: Donald E. Greydanus, M.D., Pediatrics & Human Development Michigan State University College of Human Medicine, Pediatrics Program Director Michigan State University/Kalamazoo Center for Medical Studies, 1000 Oakland Drive Kalamazoo, MI 49008-1284, USA, Tel:
+1-269-337-6450, Fax: +1-269-337-6474, E-mail: Greydanus@kcms.msu.edu
95

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96

States government warning was issued in 2003 about thepotential worsening of suicidal ideations of those taking
antidepressants, leading to a drop in SSRI prescriptions
by primary care clinicians, possibly leading to an increase in suicide rates.1
Reports from the Centers for Disease Control and Prevention (CDC, Atlanta, Georgia, USA) noted that approximately 20 to 25% of American high school students(ages 13 to 18) seriously consider suicide, 15% have an
overt suicide plan, 8 to 10% have attempted suicide, andonly 3% actually received medical care for the attempt.6-8 Suicide represents 12% of deaths each year in
the American 15 to 19 year age cohort (Table 1). It is thethird leading cause of mortality in 15 to 19 year oldyouth and the fifth in the 10 to14 year old group.

Methods of Suicide in the United States
Common suicide methods for adolescent males include
firearms (guns), hanging, and a motor vehicle accident,
while adolescent females typically use a drug overdoseor self-cutting.1 3, 1 5 However, comparing the mid-90s tocurrent times, adolescent females now tend to use more
deadly methods, such as firearms.1 5 Methods of suicide
for adolescents ages 10 to 19 years of age are noted inTable 2. Hanging is more common than firearms in 10 to
14 year old adolescents and data notes a reduction in gun
suicides of 0.9 in 1992 to 0.4/100,000 from 1992 to 2001;
during this same time, there was an increase in suicide byhanging from 0.5 to 0.8.6, 16 Data on 15 to 19 year olds noted a decrease in suicide by guns from 7.3 in 1992 to 4.1 in2001 while hanging suicide increased from 1.9 to 2.7.

Table 1 Causes of death in 15-24 year olds in 2000 1,8,15
Unintentional Injuries
Homicide
SuicideMalignant Neoplasms
Cardiac Disorders
All Causes

14,113
4,939
3,994
1,713
1,031
31,307

A review of published data reveals that in 2002, 31,655
15 to 24 year olds died in the United States from various
causes that included approximately 2000 deaths fromsuicide in the 15 to 19 year age cohort and approximately 2000 from suicide in the 20 to 24 year age cohort.9
The overall prevalence of suicide was 11 per 100,000 in
the American adolescent population in 2002, nearly 15 inmales and 3 in females.8 Careful review of this datanotes that more American adolescents and youth diefrom suicide each year than from the combined deathcauses of cancer, HIV/AIDs, chronic lung disease, pneumonia, influenza, birth defects, strokes, birth defects, andheart disease.1
It is difficult to estimate the ratio of suicide attempts toovert suicide in youth because the methods of attemptedsuicide vary from country to country and even withindifferent regions in the same country. There is no national suicide registry in the U.S. and no registry in theworld. One key study noted 6,200 suicide attempts resulting in 13 deaths in American adolescent males with aratio of 1:470; in females, there were 3 deaths in 11,200
suicide attempts resulting in a ratio of 1:3,700.11 In the
U.S., there is a 3 to 1 ratio of suicide attempts to death infemales to males while three to five times more males
complete suicide than females in 15 to 19 year olds.12, 13
Deaths from suicide attempts are higher in females inother countries, such as India or China, because of morelethal means of suicide attempts, such as jumping into
deep wells.14

Table 2 Methods of suicide in 10-19 year olds 1, 27
Firearms
Suffocation (mostly hanging)
Poisoning
Miscellaneous*

49%
38%
7%
6%

*Running into traffic, motor vehicle accidents, burning, others

Adolescent Suicide in Europe
In the United Kingdom, suicide is one of the leading
causes of death and in France, it is the second cause of
mortality, among 15 to 24 year-olds.17, 18 Greece has oneof the lowest suicide rates in Europe. Protective countrysociological characteristics that contribute to low suicide
rates in Greece are associated with low isolation, lowalienation, and increased cohesion reflective in families.
tight family relationships, fairly short distances between
communities, a long country history, and a stable national identity.19
Global Statistics
Approximately 2 million human beings die annually
because of suicide or homicide and in 2002, it was estimated that nearly 900,000 suicides occurred in theworld.2 0-2 2 Data from the World Health Organization(WHO) suggests that 90,000 or more adolescents (10-19
years of age) are victims of suicide annually out of over4 million suicide attempts.14, 23 Suicide is among the top
three causes of death in adolescents around the world
and rates have increased the fastest in adolescents than inother age cohorts.24, 25 If one looks at both the adolescentand young adult cohorts (to age 24 years), then WHO
suggests that up to 200,000 annual suicides occur in thisgroup.9, 26-30
In developed or industrialized countries, males kill

Keio J Med 2009; 58 (2):95－102

themselves via suicide at a rate that is 4 times that of females. Though suicide was more common in adolescentmales of European heritage in New Zealand, Australia,
and the United States, this ratio has changed. Suicide is
now at least the same and sometimes more common, in
those of minority or indigenous status in the UnitedStates (African-American and Native American), New
Zealand (Pacific Islanders), and Australia (Torres
Straight Islanders and Aboriginal peoples).1
A wide range of adolescent suicide rates are reported
in different countries, ranging from under 6.5 per
100,000 in Middle East countries and Latin America toover 30 in the Russian Federation, Slovenia, New Zealand, Lithuania, Finland, and Latvia.9 Table 3 presents
various rates as reported to WHO. Underreporting of suicide rates occurs in some countries because they may be
categorized as accidents or not listed at all. The willingness of countries to accept and deal with self-murder of
their adolescents and young adults varies and is dependent on numerous local ethnic, religious, and socioeconomic influences.14, 26, 27
Table 3 1996 Global suicide rates (per 100,000) 15 to 24 year
olds*Country
Males
Females
Greece3.8
0.8
Portugal
4.3
2.0
Italy
5.7
1.6
Spain
7.1
2.2
Netherlands
9.1
3.8
Sweden
10.0
6.7
Japan
10.1
4.4
Israel11.7
2.5
United Kingdom
12.2
2.3
Germany
12.7
3.4
Denmark
13.4
2.3
France14.0
4.3
Bulgaria
15.4
5.6
Czech Republic
16.4
4.3
Poland
16.6
2.5
Ukraine17.2
5.3
Hungary
19.1
5.5
Austria
21.1
6.5
Ireland21.5
2.0
United States
21.9
3.8
Belarus24.2
5.2
Canada
24.7
6.0
Switzerland
25.0
4.8
Australia
27.3
5.6
Norway28.2
5.2
Estonia
29.7
10.6
Finland33.0
3.2
Latvia35.0
9.3
Slovenia
37.0
8.4
New Zealand
39.9
6.2
Russian Federation
41.7
7.9
Lithuania
44.9
6.7* World Health Organization: http://www.unicef.org/pon96/insu
icid.htm

97

Repeat Suicide
In a survey of over 13,000 adolescents in high school(ages 13 to 18) by the Centers for Disease Control andPrevention (CDC), it was noted that one suicide attemptlead to a 15 times increase in another attempt; 30% had
2 or 3 suicide attempts a year and 17% had 4 or more attempts in a year.15 In another survey, 5% of adolescentsnoted more than one suicide attempt in a year and further
probing revealed that factors inducing repeat suicide attempts include depression (13 fold rise), sexual assault(7 fold rise), violent behavior in males, weight gain infemales, and substance abuse disorder in both sexes.31
The practitioner should inquire about all these risk factors in order to establish if there is a continuing risk ofsuicide. High suicidal intent is suggested by the following: planning in advance, precautions to avoid discovery,
dangerous methods and a “final act” such as a suicide
note. The adolescent should always be asked whether
they still intend to die. It is important that the suicide risk
is reassessed regularly, as it is not static, but changes
over time.32
Pathophysiology
Depression is a major factor in the etiology of suicide,and other precipitants to suicide are listed in Tables 4
and 5.13, 14, 33-38 As many as 33% of adolescent disability is due to mental disorders, of which depression is amajor component.39 Major or severe depression is noted
in 9 of 1,000 preschool children, 20 of every 1,000
school age children (ages 6 to 11), and almost 50 of
1,000 in adolescents (ages 12 to 18); the latter rate issimilar to severe depression in adults.7, 4 0, 4 1 In adolescents and adults, there is a 1 to 2 male to female ratiowith regard to depression. Depression can have many
adverse results, including academic dysfunction, increased arguments with family members, and suicide(Table 6). The status of adolescent mental health aroundthe world has worsened over the past generation with increase in severe depression, school drop-out, refusal toleave home (hikikomori), substance abuse, violence, andsuicide.42-44
Table 4 Biological factors of suicide
Low cerebrospinal fluid levels of 5-hydroxy-indolacetic acid
(5-HIAA)
Low platelet imipramine binding sites
Non-suppressed plasma cortisol after the Dexamethasone
Challenge Test
Abnormal hypothalamic-pituitary-adrenal (HPA) axis
Abnormal sleep EEG with decreased REM (rapid eye movement)

Greydanus DE, et al: Suicide in Adolescents: Current Concepts

98

Table 5 Risk factors for suicide and suicide attempts
Depression
Bullying in School
Homosexuality in Males
History of completed suicide in the family
History of violence in males (as conduct disorder withaggression)
Psychosis with suicidality
Severe agitation or irritability
History of a previous attempt (s)Severe personality disorder (borderline or antisocial)
Academic dysfunction or failure
History of sexual or physical abuse
Substance abuse disorder
Easy access to lethal methods (as firearms, knives or hanging)
Ethical or moral acceptance of suicide as an option for
overwhelming distress
Severe chaos in one’s local community or country
Failure to comply with mental health management
recommendations
Living on the streets
Chronic illness
Exposure to war situations

Table 6 Possible consequences of depression 1
SuicideSocial isolation (hikikomori)
Academic failure
Loss of girl or boyfriend
Substance abuse experimentation and disorders
Abuse (sexual and/or physical)
Sexual promiscuity ( with high risk for sexually transmitted
diseases and unwanted pregnancy)
OthersResearch reveals that as many as half of depressed adolescents eventually attempt suicide and up to 10% of
teenagers with major depressive disorder are dead fromsuicide within 15 years of their psychiatric diagnosis.4 5
One study looked at 2,012 adolescent males admitted toa hospital because of a suicide attempt, revealing that
1.3% were dead from suicide at an average of 3.6 years
follow-up.46
One review considered several studies that involved
1,265 depressed adolescents in which 60% revealed apositive history for suicidal ideation and an attemptedsuicide occurred in 30%; in a review of 466 adolescents
who were treated for depression, 24% were identified
who had attempted suicide.4 7 In another study of 112
teenage suicides, a history of one or more suicide attempt was identified in 50% of the females and 28% of
the males.4 8 Various psychiatric diagnoses were identified in a study of 121 youth hospitalized after a suicide
attempt, as listed in Table 7.47

Table 7 Diagnoses in 31 adolescent males, 90 females withsuicide attempt 47
DisorderMajor depression/dysthymia
Disruptive behavior disorder
Drug abuse/dependence
Alcohol abuse/dependence
Anxiety disorder
Adjustment disorder
Eating disorderSome type of psychiatric disorder

Males (%)
71
32.3
29
19.4
9.7
6.5
0
87.1

Females (%)
64.5
12.2
13.3
14.4
18.9
10
3.3
77.8

One method of seeking causes for adolescent suicide is
to obtain a careful review of issues related to a specificsuicide; this review is identified as a Psychological Autopsy. In this method, various people in the deceased
youth’s life are thoroughly reviewed in an attempt to uncover the reason (s) that lead to the individual’s completed suicide. One well-known study, the New York Psychological Autopsy Study, analyzed 173 teen suicides revealing that a previous attempt was the most critical factor in males; other important precipitants in males were ahistory of severe depression and substance use disorder.4 9, 5 0 Major precipitants in females who completedsuicide include severe depression and drug abuse.4 9, 5 0
Though a positive family history for depression is a
non-specific finding, family history of completed suicide
is a major factor, in which this leads to a 5 times higher
suicide risk in males and 3 times in females.49, 50
Suicide in Absence of Psychiatric Co-Morbidity
Suicide ideation, attempt, and completions may occur
in the absence of underlying overt psychiatric disorders.
A state of hopelessness (which includes difficulty in believing that there are non-suicidal alternatives to life
problems) has been reported to be more predictive of
suicide than is depression. Everyone has a pain thresholdbeyond which they cannot function. Just before a suicidal act, the individual’s adaptive threshold is breached andthey may resolve their pain by committing suicide.13
When youth find themselves in the midst of a major
life crisis without any way out that is known to them,suicide may become an option as a solution to their overwhelming problems. Adolescents are undergoing intense
central nervous system changes and may have the understanding that their problems are manageable. They may
not have the experience or encouragement from others
that their issues can be resolved one way or another. For
example, their life may become overwhelmed by school
failures (complicated by parental pressure to succeed),bullying, concerns with thoughts or feelings of homosexuality, personality conflicts, severe traits of narcissism, easy access to firearms, and others.51 Some youth,Keio J Med 2009; 58 (2):95－102

when overwhelmed by their society, may withdraw fromsociety by staying in their homes (i.e., hikimori) whileothers runaway from home or commit suicide.
Research in the United States notes that being bisexualor homosexual in a climate that is extremely hostile tosuch sexual orientations leads to a high suicide risk; forexample, as many as 42% of homosexual males attempt
suicide in the United States, especially between 15 and17 years of age.2 6, 5 2 Chronic illness can increase risks
for suicide attempts by precipitating depression or inducing central nervous system injury because of complications of infection, chemotherapy, epilepsy, or trauma. In
the U.S., as many as 50% of deaths in teenagers fromsuicide and motor vehicle accidents are complicated byuse of alcohol or other drugs.53-55
There are many extremely stressful situations that confront the youth of the world that may lead to suicide attempts and completions. For example, there are 3 million
annual cases of abuse that are reported in the UnitedStates, with many more that go unreported; approximately 15% are sexual abuse, 26% are physical abuse, 53%
are neglect, and 5% are categorized as emotional
abuse.5 6-5 8 There are over 800,000 youth in some typeof incarceration in the United States, whether in detention centers, jails, or other facilities.59-61
As many as 140 million adolescents are affected by
war in the world, whether as refugees, civilians, or solders.14 Many children and youth are sexually abused bysoldiers in these war situations. The World Health Organization estimates that as many as 170 million children
and adolescents live on the street away from their families, including 40 million in Latin America, 30 million in
Asia, 10 million in Africa, and several hundred thousandin the United States.9, 6 2-6 8 Untold numbers of children
and adolescents are sold into prostitution in the world.
For example, approximately 40% of prostitutes in India
are under 18 years of age while the average age of female beginning prostitution in Moscow (Russian Federation) is 16 years of age. The mental and physical effects
on these children and youth is staggering and suicide is amajor consequence.68-71
Risk of Suicide and Use of Medications
The Food and Drug Administration (FDA) in the U.S.
released a statement on March 22, 2004 that children,
adolescents, and adults who are placed on anti-depressant medication may develop an increased risk for “suicidality”—suicide thinking or ideation; the warning wasthat patients placed on these medications should beclosely observed for increased depression and suicidal
thinking. It was stimulated by one pharmaceutical company (GlaxoSmithKline) giving the FDA evidence of
their research on 1,385 7 to 18 year olds who were taking the SSRI paroxetine; there was double the number99

who developed crying, mood changes, and suicidality —3.4% vs 1.2% for the placebo group.72 The warning has
included all antidepressants, including selective serotonin reuptake inhibitors and now other medications,such as anticonvulsants, the anti-acne medication Accutane, and others. Though the use of antidepressants haverarely, if ever, led to a actual suicide, the effect of suchan FDA warning has been a reduction in SSRI prescriptions in the United States and an increase in suicide as
well. The reduction in suicide from 1990 to 2003 hasbeen linked to an increase in SSRI prescription duringthat time.73
A recent meta-analysis7 4 concluded that antidepressants may cause a small short-term risk of suicidal eventsin adolescents with major depression. However, according to the results of the Treatment for Adolescents with
Depression Study (TADS),7 5 the benefits of the SSRI
fluoxetine in adolescent moderate to severe depression
still outweigh the risks, which could be minimized byadditional provision of cognitive behavior therapy.
Prevention of Suicide
Primary prevention is the ideal method of protection
and involves preventing members of a population frombecoming suicidal. It is important to reduce suicide risk
factors, such as depression, substance abuse, violence infamilies, availability of firearms, social isolation, andpoverty; also, clinicians can promote protective factors
such as physical health, proper exercise, proper diet, andadequate sleep.13
The main step in dealing with suicide in adolescents isto prevent them from reaching a point in their life where
suicide seems to be the only option to overwhelming
problems. The key to this prevention is regular evaluations of the adolescent where the youth can be asked
about various issues in their lives, including depression,suicidal thoughts, conflicts at school (such as bullying),
problems at home, girlfriend or boyfriend conflicts, andother issues.76-78
Interventions should be directed toward increasing
coping skills in adolescents, increasing community andparent awareness of adolescent suicide, and restricting
access to suicidal means. Because of barriers to adolescents receiving specialty mental health services, primarycare settings have become the de facto mental healthclinics for this population. Guidelines for adolescent depression management in primary care have been developed by researchers from the United States, Canada, andthe United Kingdom and work has already begun to implement them in pediatric practices.79 It is recommended
that residents in pediatric training be provided with education in interview skills to learn how to communicate
with teenagers.
Secondary prevention refers to the early detection andGreydanus DE, et al: Suicide in Adolescents: Current Concepts

100

treatment of suicidal individuals. Most suicidal youth are
relieved to be able to communicate with a professional
about their suicidality and learn about help that will prevent them from self-murder. Providing help to the youth
and helping them learn that there are options for thembesides suicide is a major step in lowing suicide rates inany country. The role of medical practitioners is underlined by the finding that half of young people under 25
years of age who committed suicide had contacted a general practitioner in the 3 months before death.80
For suicidal youth, the provision of open access to professional help has produced positive, but not statisticallysignificant results.8 1 Though there are indications for
hospitalizing a suicidal youth (Table 8), hospitalization
per se does not actually prevent overt suicide unless theunderlying problems are resolved.49, 50 Suicidality itself
is not a diagnosis but is reflective of underlying conflicts
that must be corrected to remove the youth’s suicidal
ideation and eventual suicidal attempt. The clinician
should never be concerned that asking youth about possible suicidal thoughts precipitates suicide, but is a preventive step in this regard.82
Table 8 Reasons to hospitalize a youth with suicidal ideation
Psychosis
Severe agitation
Manic state
Intoxicated state (as with a drug overdose)
Patient is a male (10-fold increase in risk of suicide)
Family history for completed suicide (2-fold increase)
Failure of intense outpatient management
History of previous suicide attempts (15-fold increase)
History of severe aggression
Severe substance abuse disorder
Limited care or supervision in the home
Method of providing the family with education about helping theadolescent
Miscellaneous Medical-legal issues

Also, medication (as antidepressants) does not prevent
acute suicide but may be useful over time in managing
some cases of depression in youth. Youth who are psychotic and suicidal may benefit from the use of antipsychotic medication to improve the psychosis. Adolescent’s suicidal behavior can also be influenced by the widersocial context, i.e., societal taboos, role models in thecommunity, and media coverage.3 2 Media portrayal ofdeliberate self-harm has been associated with an increased risk of hospital attendance following deliberate
self-poisoning.83 Careful follow-up of any suicidal youth
is important and research suggests that the majority ofsuch youth may not receive adequate follow-up management that then increases the risk of eventual suicide.1, 50, 84-88

Summary
Suicides are among the three leading causes of death
for adolescents in the world and rates are rising faster inteens than in other age groups; at least 90,000 adolescents commit suicide each year in the world in the context of 4 million suicide attempts each year. Suicide rates
globally are underreported because they may be classified as accidents or not classified at all. The ratio of suicide attempts to completed suicides is 3 to 1 (female tomale) while three times as many males vs. females complete the suicide. Chronic illness, gender orientation concerns, and abuse are other risk factors for suicide. Clinicians caring for adolescents must be aware of the risk ofteen death from suicide and must be prepared to screen
all their patients for this potentially tragic but preventable phenomenon.
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