Incidence
Etiology/Assessment
Management
Pharmacologic Management

Adolescents with cancer tend to fight to live rather than succumb to death, either natural death or suicide. Suicide in the absence of a major mental disorder is as rare among adolescents as it is for adults.[1] Refusal of treatment by adolescents has not been found to be a means of attempting suicide. Rather, noncompliance is associated with the belief that life and death are determined by fate, luck, or God. The adolescent believes that his or her disease is outside of the realm of control and is in the hands of God or some other force.

In the general pediatric population, about 2,000 adolescents in the United States die by suicide each year. Suicide consistently ranks as the second or third leading cause of death for persons between the ages of 15 and 34 years. One author suggests that before puberty, children are less vulnerable to suicide because of their cognitive immaturity, which makes planning and implementing a lethal attempt difficult. Even accounting for underreporting, it is evident that the youth suicide rate has more than doubled during the period from 1956 to 1993. The increasing youth suicide rate has been attributed to the increase in and prevalence of adolescent alcohol abuse; chronic and acute illnesses were not described as major factors contributing to suicide.[1]

The suicide rate for male adolescents is 4 times as high as the rate for females. The suicide rate for white adolescents is about twice as high as the rate for blacks and Hispanics. In one study, 53% of 380 high school students had thought about killing themselves, with 9% of this group having attempted suicide. In another study, a representative sample of 11,631 high school students reported that 27% of the students had seriously considered suicide, with 16% having a plan in mind, 8% having made an attempt, and 2% making attempts that required medical attention. The authors of this study extrapolated from these results that 276,000 high school students make suicide attempts requiring medical attention.[1] To date, little is known about the actual prevalence of suicidal thinking and suicide attempts in childhood cancer.

Because little is known about suicide risk factors specifically in childhood cancer, one could assess the risk factors for the general pediatric population with the following:[2]

1. Biologic factors include family history of psychiatric disorders such as depression, schizophrenia, alcoholism, drug dependence, and conduct disorder. Genetic predisposition to low levels of serotonin are associated with depression.



2. Predisposing life events include an early family history of parental abuse, negative life event such as loss of a parent, childhood bereavement, and disturbed, hostile interfamilial relationships. Many psychosocial factors and negative life events have not been found to cause subsequent suicidal behavior.



3. Psychosocial factors include the very nature of adolescence itself, with its concurrent desire to experiment with drugs and alcohol. Conflict or confusion about sexual orientation can be a factor in adolescent suicide. In addition, characteristics such as perfectionism, impulsivity, inhibition, and isolation all contribute to the likelihood of the adolescents having thoughts of suicide.



4. Psychiatric disorders are found in 95% of all completed suicides in adolescents. The following disorders are seen in most suicides: major depressive illness, schizophrenia, alcoholism, drug dependence, and conduct disorder. However, most individuals with psychiatric disturbances do not commit suicide.



5. Contagion is an expression that describes the phenomenon of young people identifying with the suicidal behavior of others. Those who are in a vulnerable state may imitate suicidal behavior. A completed suicide in a childhood cancer setting should lead to support and monitoring of the victim's peers.



6. The availability of lethal weapons such as a gun in the house can precipitate suicide.



7. Precipitating events such as a diagnosis of cancer can change a state of potential risk to actual suicide. In this instance there is usually:
   • A preexisting psychiatric disorder.
   
   
   
   • A number of current life stressors.
   
   
   
   • An upsetting event such as academic failure.
   
   
   
   • Life-threatening disease.
   
   
   

One author describes the hopelessness that may be felt by cancer survivors as being instrumental in acts of suicide. She asserts that when an adolescent cannot determine reasons to live, hopelessness occupies the thought process and suicide presents a reasonable solution.[3]

The management of suicide is carried out through the careful evaluation and assessment of a child with cancer and his or her family. The multiple factors that make life intolerable for some children need to be addressed. Suicide prevention must include:

• Individual assessment.



• Referral to appropriate health professionals.



• Appropriate drug management.



• Individual psychiatric therapy coupled with family therapy.

The evidence of continuity of childhood and adolescent depression and of familial transmission of this disorder from parent to child would seem to argue that the same agents used for adults would be effective in childhood. The efficacy of antidepressants in children and adolescents has not been established.[4]

Refer to the PDQ summary on Pediatric Supportive Care for more information.

References

1. Clark DC: Suicidal behavior in childhood and adolescence: recent studies and clinical implications. Psychiatr Ann 23 (5): 271-83, 1993. 
   
   
2. Callahan J: Blueprint for an adolescent suicidal crisis. Psychiatr Ann 23 (5): 263-70, 1993. 
   
   
3. Perrone J: Adolescents with cancer: are they at risk for suicide? Pediatr Nurs 19 (1): 22-5, 1993 Jan-Feb.  [PUBMED Abstract]
   
   
4. Ryan ND: The pharmacologic treatment of child and adolescent depression. Psychiatr Clin North Am 15 (1): 29-40, 1992.  [PUBMED Abstract]
   
   

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