Psychotherapeutic Treatments
Suicidal children and adolescents report feelings of intense emotional distress involving depression, anger, anxiety, hopelessness, and worthlessness and an inability to change problematic, frustrating circumstances or to find a solution to their problems (Kienhorst et al., 1995; Ohring et al., 1996). They feel so distraught that they often respond impulsively to their despair. Psychotherapeutic techniques aim to decrease such intolerable feelings and thoughts and to reorient the cognitive and emotional perspectives of the suicidal child or adolescent (Kernberg, 1994; Spirito, 1997).

Cognitive-behavioral therapy (CBT) may be a useful intervention, considering that suicidal children and adolescents often experience negative cognitions about themselves, their environment, and their futures. Recent research suggests that CBT may be more effective than systemic behavior family therapy or individual nondirective supportive therapy in reducing depressive symptoms associated with suicidal ideation (Brent et al., 1997). Such treatment can focus on re-attribution of precipitating issues for suicidal behavior and enable the suicidal child or adolescent to rank stresses and to consider avenues of problem-solving (Rotheram-Borus et al., 1994; Brent et al., 1997; Spirito, 1997).

Interpersonal conflicts are important stresses related to the risk imparted by poor social adjustment of potentially suicidal children and adolescents. Treatment of interpersonal strife may significantly reduce suicidal risk. Recent research into the efficacy of interpersonal psychotherapy of depressed adolescents suggests beneficial effects (Kaslow & Thompson, 1998); it is a treatment that may be modified to address the risk factor issues related to interpersonal loss, conflicts, and need for restitution often reported by children and adolescents with suicidal tendencies.

A significant class of risk factors for suicide involves family discord, which is characterized by poor communication, disagreements, and lack of cohesive values and goals and of common activities (de Long, 1992; Miller et al., 1992; Wagner, 1997). Suicidal children and adolescents often feel that they are isolated within the family, exhibit problems in independence, and view themselves as expendable to the family, a perception that is a motivating force for self-annihilation (Sabbath, 1969; Pfeffer, 1986; Miller et al., 1992). Family intervention with suicidal children and adolescents is an important method to decrease such problems and to enhance effective family problem-solving and conflict resolution, so that blame is not directed toward the suicidal child or adolescent. Cognitive-behavioral approaches with suicidal children and adolescents and their families aim to reframe their understanding of family problems, alter the family style of maladaptive problem-solving techniques, and encourage positive family interactions (Rotheram-Borus et al., 1994). Time-limited home-based intervention to reduce suicidal ideation in children and adolescents and to improve family functioning has been reported to have limited efficacy for children and adolescents without major depressive disorder (Harrington et al., 1998). Psychoeducational approaches to reduce the extent of expressed anger may be helpful in lowering risk for suicidal behavior in children and adolescents (Fristad et al., 1996).

Psychopharmacological Treatments
There is a dearth of research on the efficacy of pharmacological treatments for reducing suicidal thoughts or preventing suicide in children and adolescents. Most of the research on pharmacotherapies has been conducted in adults. In depressed adults, SSRIs have been found to reduce suicidal ideation (Letizia et al., 1996; Wernicke et al., 1997) and to reduce the frequency of suicide attempts in nondepressed patients who had previously made at least one suicide attempt (Verkes et al., 1998). In a controlled trial of the experimental neuroleptic drug flupenthixol, researchers noted a significant reduction in suicide-attempt behavior in adults who had made numerous previous attempts (Montgomery & Montgomery, 1982). Similar studies have yet to be conducted on adolescents, although trials of SSRIs in depressed adolescents suggest that these drugs are effective for treating depression and for reducing suicidal ideas also in this age group (Emslie et al., 1997; Ryan & Varma, 1998). Because placebo-controlled, methodologically appropriate studies of tricyclic antidepressants have failed to find a significant effect in depressed children and adolescents (Ryan & Varma, 1998), it is reasonable to regard SSRIs as a first-choice medication in treating depressed suicidal children and adolescents (also see American Academy of Child and Adolescent Psychiatry, 1998). In contrast to tricyclic antidepressants, SSRIs have low lethal potential when taken in overdoses (Ryan & Varma, 1998).

In adults with major depressive disorder, controlled research suggests that lithium reduces suicide risk (Thies-Flechtner et al., 1996), but this has not yet been demonstrated in children and adolescents. Clinicians should be cautious about prescribing medications that may reduce self-control, such as the benzodiazapines, amphetamines, and phenobarbital. These drugs also have a high lethal potential if taken in overdose (Carlsten et al., 1996).

Intervention After a Suicidal Death of a Relative, Friend, or Acquaintance
The suicidal death of a relative or acquaintance may increase the risk for childhood or adolescent suicidal behavior and other dysphoric states (Brent et al., 1992, 1994; Pfeffer et al., 1994, 1997; Clark & Goebel, 1996). Major depression, post-traumatic stress disorder, and suicidal ideation often occur after the death of an adolescent friend or acquaintance and relative (Brent et al., 1992, 1994, 1996).

The goal of the clinician is to decrease the likelihood that a child or adolescent comes to view the suicidal behavior of the deceased as a coping strategy in dealing with adversity (Brent et al., 1997). Psycho- educational counseling may reduce the risk for suicidal behavior in these circumstances. Intervention is also needed to decrease the child’s or teen’s personal sense of guilt, trauma, and social isolation. This treatment can be given in individual meetings, at group sessions with other teens, or in conjunction with parents who need help to support the adaptive capacities of their children and adolescents. School professionals sometimes offer programs of this kind and can be invaluable in identifying grieving friends who may need help.

Community-Based Suicide Prevention
The principal public health approaches to suicide prevention have been (1) crisis hotlines⁸; (2) restrictions covering access to suicide methods; (3) media counseling to minimize imitative suicide; (4) indirect case-finding by educating potential gatekeepers, teachers, parents, and peers to identify the warning signs of an impending suicide; (5) direct case-finding among high school or college students or among the patients of primary practitioners by screening for conditions that place teens at risk for suicide; and (6) training professionals to improve recognition and treatment of mood disorders. As discussed below, the level of evidence for these strategies varies. There is more support for direct case-finding and improved recognition and treatment of mood disorders than for the other strategies.

Crisis Hotlines
Although crisis hotlines are available almost every- where in the United States, research has failed to show that they reduce the incidence of suicide (Bleach & Clairborn, 1974; Apsler & Hodas, 1976; Miller et al., 1984; Shaffer et al., 1990a, 1990b). Possible reasons for this are that actively suicidal individuals (males and individuals with an acute mental disturbance) do not call hotlines because they are acutely disturbed, preoccupied, or intent on not being deflected from their intended course of action (Shaffer et al., 1989). Hotlines are often busy, and there may be a long wait before a call is answered, so that callers disconnect; the advice individuals get on calling a hotline may be stereotyped, inappropriate for an individual’s needs, and perceived as unhelpful by the caller. Gender preferences in seeking help result in the large majority of callers being females, whereas males are at greatest risk for suicide. While each of these deficiencies is potentially modifiable, there have been no systematic attempts to do so.

Method Restriction
Method preference for suicide varies by gender and by nationality. In the United States, the most common method for committing suicide is by firearms, and it has been suggested that reducing firearms availability will reduce the incidence of suicide (Moscicki, 1995). However, a natural experiment in Great Britain suggests this is unlikely. The favored suicide method, self-asphyxiation with coal gas, became impossible after the introduction of natural gas. This resulted in a marked but short-lived decline in the suicide rate. Within a decade, the suicide rate had returned to previous levels, and suicides were being committed by other means (Farberow, 1985). Although reducing access to firearms with gun-security laws reduces accidental deaths from firearms (Cummings et al., 1997), there is no evidence to date that such laws have a significant impact on suicides attributable to firearms.

Media Counseling
Even though it appears prudent for reporters and editors to minimize coverage of youth suicide in general and attention to individual suicides (O’Carroll & Potter, 1994), there is as yet no evidence that these guidelines, issued by the Centers for Disease Control and Prevention, are effective in reducing the suicide rate.

Indirect Case-Finding Through Education
Controlled studies have failed to show that classes for high school students about suicide increase students’ help-seeking behavior when they are troubled or depressed (Spirito et al., 1988; Shaffer et al., 1991; Vieland et al., 1991). On the other hand, there is evidence that previously suicidal adolescents are upset by exposure to such classes (Shaffer et al., 1990a, 1990b), even though this does not necessarily lead to a suicide attempt. Such educational programs seem, therefore, to be both an ineffective mode of case-finding and to carry with them an unjustified risk of activating suicidal thoughts

Direct Case-Finding
Judging from the high response rate to surveys about suicidal attempts and ideation (National Center for Health Statistics, 1997), adolescents will provide accurate information about their own suicidal thoughts and/or behaviors if asked directly in a nonthreatening way. A sensible approach to suicide prevention that needs further study, therefore, is to screen systematically 15- to 19-year-olds (the age group at greatest risk) for (1) previous suicide attempts; (2) recent, serious, suicidal preoccupations; (3) depression; or (4) complications of substance or alcohol use. Clearly, screening programs need to go beyond identifying a teen with a high-risk profile. Youth identified in this way should be referred for evaluation and, if necessary, treatment. Contingency arrangements may need to be made to assist uninsured adolescents with help if it is needed (Shaffer & Craft, 1999).

Aggressive Treatment of Mood Disorders
Preliminary and as yet unreplicated studies in Sweden (Rihmer et al., 1995) suggest that education of primary medical practitioners to better identify the characteristics of mood disorders and to treat these effectively produced a significant reduction in suicide and suicide-attempt rates. Although the optimal treatment of adolescent depression is not yet as well understood as that of adult depression, this is an option that may prove to be useful.

Air Force Suicide Prevention Program—A Community Approach
Combining many of the approaches for adolescents described above, the Air Force Surgeon General developed and implemented a community approach to suicide prevention for older adolescents and young adults on active duty. The program involved education on suicide risk awareness, reducing barriers to mental health services, and stigma-reducing efforts.⁹

⁸ Crisis hotlines are only one of the services offered through crisis services, a topic discussed subsequently.

⁹ In 1995, prior to implementation, suicide rates were almost 16 per 100,000; following 3 years of exposure to the program, suicide rates fell to below 2 per 100,000 (Air Force Surgeon General, personal communication, 1999)