GRAND ROUNDS
Suicide in Teenagers
Assessment, Management, and Prevention
Alan J. Zametkin, MD
Marisa R. Alter, BS
Tamar Yemini, BA
CASE PRESENTATION
Marie, a 16-year-old white girl, had
no academic or social problems until
the sixth grade. Her prenatal, birth,
and perinatal periods were uncompli-
cated, and her medical and psycho-
logical development were normal,
according to her parents and school
records. Marie was the oldest of 3
children. Both her parents had suc-
cessful careers, and there were no
acute or chronic stressors in her fam-
ily. Her mother characterized her as a
youngster who wanted to try all
sports and performing arts and was
academically precocious.
Marie was diagnosed with Osgood-
Schlatter disease in the sixth grade. Be-
cause of Marie’s restricted physical ac-
tivity, her mother’s concern about
depression, and Marie’s telling a sixth-
grade friend that she wished to die, she
was seen by a psychologist 5 times.
Careful evaluation found no evidence
of neglect, domestic violence, abuse (in-
cluding sexual), or early traumas. No
diagnosis was made. The patient de-
veloped cold-induced asthma at 12
years of age and occasionally was
treated with inhalers. Between the 6th
and 12th grades, Marie was not treated
by a psychologist or psychiatrist. Be-
tween the seventh and ninth grades, she
gained excessive weight, but in the
months preceding her death, she had
lost 9 kg. No evidence of any type of
eating disorder was noted by any fam-
See also pp 3089 and 3126
and Patient Page.
3120 JAMA, December 26, 2001—Vol 286, No. 24 (Reprinted)
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At the Clinical Center of the National Institutes of Health
Adolescents who kill themselves invariably have an underlying psychiatric
disorder. Biological markers are not yet clinically useful for identifying ado-
lescents at risk, and there is a paucity of research data on the effectiveness
of behavioral intervention for suicidal teenagers. A case of a 16-year-old scholar
and athlete is presented to illustrate how multiple risk factors and a family
diathesis often go undetected, resulting in tragic consequences. Psychiat-
ric, familial, genetic, and social risk factors of adolescent suicide are re-
viewed, and the efficacy of lithium and antidepressant pharmacotherapy in
reducing suicide rates is discussed. The importance of screening adolescent
patients for depression is emphasized. Although teenage suicide is rare and
hard to predict, identifying and treating adolescents at risk is essential to
further reduce teenage suicide.
JAMA. 2001;286:3120-3125 www.jama.com
ily member. During the 6 months be- the months before her death. She was
fore her death, her parents were un- given a flu shot by her family physi-
aware of any thoughts she might have cian 1 month before her death. Accord-
had of hopelessness or worthlessness ing to her parents, the patient was us-
or any suicidal ideation or suicide at- ing a nonprescription caffeine product
tempts. In retrospect, her mother real- to stay awake and complete more
ized that her daughter had almost all schoolwork.
the symptoms of major depression On the morning of her death, she ar-
(B OX 1). 1 Marie’s diary entries re- gued on the telephone with a male
flected that her concentration was de- friend who lived in another city and
teriorating and that she had visited an with whom Marie was not romanti-
apartment rooftop on one occasion. cally involved. This friend was well
There was no evidence of periods of ma- known to the family. By all observers’
nia, hypomania, thought disorder, or accounts, she was heterosexually ori-
illegal substance abuse, although she ented. She e-mailed a suicide note to the
may have abused caffeine. male friend, but by the time he re-
The family history included major
depression successfully treated in Ma- Author Affiliations: Mood and Anxiety Disorders Pro-
rie’s biological mother, and her pater- gram (Dr Zametkin) and Geriatric Psychiatry Branch
(Mss Alter and Yemini), National Institute of Mental
nal great aunt died in circumstances Health, Bethesda, Md. Dr Zametkin is also a commis-
suggestive of suicide. sioned officer on active duty in the United States Pub-
During the weeks before the sui- lic Health Service.
Corresponding Author and Reprints: Alan J. Zamet-
cide, Marie had significantly impaired kin, MD, National Institute of Mental Health, 3N238
sleep. However, her sleep patterns were Bldg 10, 9000 Rockville Pike, Bethesda, MD 20892
(e-mail: zametkin@mail.nih.gov).
not characteristic of mania, in which pa- Grand Rounds at the Clinical Center of the National
tients sleep only 2 to 4 hours per night. Institutes of Health Section Editors: John I. Gallin, MD,
Marie had skipped several days of the Clinical Center of the National Institutes of Health,
Bethesda, Md; David S. Cooper, MD, Contributing Edi-
school because of an upset stomach in tor, JAMA.
©2001 American Medical Association. All rights reserved.

ceived it and called the family, it was
too late. Marie’s only previous recent
verbalization regarding suicidal think-
ing (6 weeks before her death) was to
a former camp counselor, who failed to
relay the information to the parents.
On the day of her death, shortly af-
ter sending the suicide message, Ma-
rie climbed to the roof of a neighbor-
ing apartment building and jumped off.
DISCUSSION
The loss of a talented, bright, and
highly motivated 16-year-old high-
lights the insidious nature of the indi-
vidual risk factors that affected this
adolescent’s life. Both the patient’s sex
and the lethality of the method are
noteworthy in this case.
Marie’s parents, both professionals
and 1 in treatment for depression, were
never informed by the camp coun-
selor of suicidal ideation. The adoles-
cent was driven and accomplished but
was incapable of sharing her thoughts
with her parents or family physician.
The immediate stressor, interpersonal
loss, is a well-known risk factor but is
typical of the average 12th-grade ado-
lescent. The 2 most common familial
risk factors, positive family history of
suicide and a parent with a psychiatric
disorder, were present. Postmortem
toxicologic analysis revealed no evi-
dence of drug abuse or pregnancy.
Our review highlights how this case
is typical and atypical and why suicide
in teenagers may be difficult to pre-
dict or prevent. Many risk factors may
not be identified in advance. Suicide in
teenagers occurs even in the most sup-
portive family environment, such as that
of the family described, in which an ex-
cellent scholar-athlete was given both
parental attention (the family ate din-
ner together every night) and indepen-
dence.
CLINICAL CONTEXT
The rate of suicide among adolescents
has significantly increased in the past
30 years. In 1998, 4153 young people
aged 15 to 24 years committed suicide
in the United States, an average of 11.3
deaths per day. Suicide is the third lead-
©2001 American Medical Association. All rights reserved.
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ing cause of death in this age group and
accounts for 13.5% of all deaths.2 Cen-
ters for Disease Control and Preven-
tion data show that females contem-
plate and attempt suicide at much
higher rates than males. However, older
male adolescents complete suicide 5.5
times more often than female adoles-
cents.3 This incongruence is believed to
be due to the tendency of males to use
more lethal means for suicide. Chil-
dren younger than 10 years are less
likely to complete suicide, and the risk
appears to increase gradually in chil-
dren between 10 and 12 years of age.
However, on average, 170 children 10
years or younger commit suicide each
year. Exact figures in the youngest age
group are probably underestimates be-
cause of lack of recognition of suicide.
CLINICAL CHARACTERISTICS
A number of facts exacerbate the diffi-
culty clinicians face in identifying sui-
cidal patients: (1) the low prevalence
of suicide (0.01%) in the general popu-
lation; (2) the large percentage (99.9%)
of depressed patients who do not com-
mit suicide, despite a 10-fold increase
of suicide in adult patients with depres-
sion 2 ; and (3) the high percentage
(27%) of suicidal ideation in the gen-
eral teenaged population.4 Rare events
are hard to predict. In an attempt to
guide clinicians, a large body of evi-
dence has been collected on risk fac-
tors, with criteria for assessing risk.
Adolescent Risk Factors
Previous attempt is a major risk factor.
Major depressive disorder and other
mood disorders, such as bipolar disor-
der, are most often cited as a risk factor
for suicide (BOX 2). In one study, Shaf-
fer et al5 reported that 52% of subjects
who committed suicide met criteria for
major depressive disorder, whereas in
total, 61% met criteria for a mood dis-
order (eg, manic depressive disorder and
major depression). Substance abuse dis-
order, conduct disorder (delinquency),
and anxiety disorder are also risk fac-
tors. Impulsivity and aggressiveness are
personality traits frequently seen in per-
sons who attempt suicide. A patient with
(Reprinted) JAMA, December 26, 2001—Vol 286, No. 24 3121
SUICIDE IN TEENAGERS
Box 1. Risk Factors
for Suicide
Specific Factors
Previous suicide attempt
Mood disorder (major depressive
disorder)
Substance abuse disorder
(particularly in males)
Aged 16 years or older, male, and
living alone
History of physical or sexual abuse
Less Specific Alarming Factors
Recent dramatic personality
change
Psychosocial stressor (trouble with
family or friends or a
disciplinary crisis)
Writing, thinking, or talking about
death or dying
Altered mental status (agitation,
hearing voices, delusions,
violence, intoxication)
a history of a suicide attempt, however
minor (so-called gestures), is at an in-
creased risk of a repeated attempt. Fam-
ily history of suicide also increases risk.6
Finally, one of the distinguishing fea-
tures of adolescent suicide is that it may
be precipitated by a psychosocial
stressor, such as a recent loss, rejec-
tion, or disciplinary crisis.3 However,
these events are common in a normal
adolescent’s life.
The Inheritance of Suicide
Although suicide may run in families,
this observation does not in itself prove
a genetic basis for this behavior. Both
familial and genetics studies will be re-
viewed.
Familial Findings. Brent et al6 ex-
amined 58 adolescent suicide pro-
band subjects and 55 similar control
subjects. The rate of suicide attempts
in the first-degree relatives of suicide
proband subjects was increased com-
pared with that of the control sub-
jects, even after the increased rates of
psychiatric disorders in the families of
suicide attempters was considered.
Tishler et al7 reported that 22% of ado-
lescents treated at an emergency de-
SUICIDE IN TEENAGERS
Box 2. Signs of Clinical
Depression and Mania*
Depression
Depressed mood most of the time
Loss of interest or pleasure in
activities
Weight loss or gain
Insomnia or hypersomnia
Loss of energy
Feelings of worthlessness
Hopelessness toward future
Lack of concentration
Recurring thoughts of death
Complaints of psychosomatic
symptoms
Mania
Elated or irritable mood
Inflated self-esteem, grandiosity
Decreased need for sleep
Pressured speech
Racing thoughts
Distractedness
Excessive participation in
multiple activities
Hypersexuality, impulsive
spending, uninhibited
remarks
*See reference 1.
partment after attempting suicide had
at least 1 family member who had ex-
hibited suicidal behavior.
Although some familial factors as-
sociated with suicide may be identical
to those responsible for psychiatric dis-
orders, such as mood disorder, some are
independent of the mood disorder. For
example, in their study of depression
and suicide in Old Order Amish com-
munities, Egeland and Sussex8 docu-
mented clusters of suicides in 4 fami-
lies that also exhibited heavy loading
for mood disorders. However, their
study also identified families who were
heavily loaded for mood disorders yet
had no history of suicide. This finding
led them to hypothesize that mood dis-
orders and suicidal behavior were in-
herited independently.
Genetic Factors. In adoption stud-
ies in a Danish population,9 12 of 269
biological relatives of adoptees who had
committed suicide had themselves com-
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mitted suicide, whereas only 2 of 269
biological relatives of adoptees who had
not committed suicide had killed them-
selves. In this study, no adopting rela-
tives had died by suicide. In a separate
study, Papadimitriov et al 10 inter-
viewed patients with a history of mood
disorders and suicidal behavior and
their relatives. Using computational
analysis, the authors concluded that sui-
cidality is most compatible with poly-
genic inheritance.
In support of this finding, studies of
twins have revealed that monozygotic
twins have a 13.2% concordance for sui-
cide, whereas dizygotic twins have only
a 0.7% concordance for suicide.11 A
separate study 12 demonstrated that
monozygotic twins were no more likely
than dizygotic twins to attempt sui-
cide when one twin had died of causes
other than suicide. The heritability of
serious suicide attempts was recently
estimated at 55%.13 Despite growing
knowledge about genetic factors, no
specific marker provides clinical use-
fulness yet.
The Serotonin Hypothesis
Studies have linked serotonin with the
control of impulsivity, aggression, self-
mutilation, and depression. Most stud-
ies comparing suicide attempters with
nonattempters have found lower lev-
els of 5-hydroxyindoleacetic acid (5-
HIAA), a metabolite of serotonin, in the
cerebrospinal fluid (CSF) of suicide at-
tempters.14 Arango et al15 reported de-
creased serotonin and 5-HIAA levels in
the brain stems of suicide attempters.
Genetic studies have suggested that sui-
cidal acts16 and low CSF 5-HIAA lev-
els17 are related to a polymorphism in
the TPH gene, which codes for trypto-
phan hydroxylase, the rate-limiting en-
zyme in the synthesis of serotonin.
These studies suggest that low CSF
5-HIAA levels are due to low central se-
rotonin turnover, which is caused by
a reduced capacity to hydroxylate tryp-
tophan in the synthesis of serotonin.
The authors speculate that the pres-
ence of a certain allele of the TPH gene
might lead to this reduced capacity.
Although several groups have re-
©2001 American Medical Association. All rights reserved.
ported an association between the TPH
gene and suicide, the literature dis-
agrees about which allele is associated
with this behavior.17-20 Further, other
studies21,22 did not reveal a significant
difference in the TPH polymorphism yet
did reveal one in the serotonin trans-
porter gene of suicide completers.
Several researchers have reported
physiological changes in the serotonin-
ergic system of suicide completers: in-
creased serotonin 1A15 and serotonin 2A
receptors23,24 and decreased serotonin
transporters25 in the prefrontal cortices
of suicide completers. It is unclear, how-
ever, whether these changes are caused
by a certain genotype or whether they
are the result of low levels of serotonin,
exposure to psychotropic medications,
or another mitigating factor. One such
factor is chronic stress or psychologi-
cal trauma. Attempts to identify clini-
cally useful biological markers are un-
der way, but at present no biological
measures are clinically useful.
INTERVENTIONS
Hospitalization
There are no evidence-based data that
psychiatric hospitalization prevents im-
mediate or eventual suicide, despite
overwhelming clinical consensus that
immediate hospitalization is a critical
component in preventing both adult and
teenaged suicidal patients from com-
pleting suicide. In one study that inves-
tigated the efficacy of hospitalization,26
parasuicidal adult patients were ran-
domized to home or a hospital. No sig-
nificant difference was found in out-
come as measured by subsequent suicide
or general functioning. In a separate con-
trolled trial of adult suicide attempters
who were randomized to admission or
discharged home, no significant differ-
ence in repetition rate was noticed af-
ter 16 weeks of follow-up.27 This study
has not been done in teenagers.
Behavioral or Psychotherapeutic
Treatment
No treatment program has reduced sub-
sequent attempts in adolescent sui-
cide attempters.26 In addition, no con-
trolled studies have demonstrated that

treating conduct disorder or sub-
stance abuse reduces the number of fu-
ture suicide attempts, which is due to
the lack of established treatments with
proved long-term efficacy for these dis-
orders.26
Adolescents are generally not com-
pliant with psychiatric treatment. One
study28 found that 40% of suicidal teen-
agers are removed from treatment for not
attending therapy. A separate 3-month
follow-up study29 of 62 adolescents dis-
charged from an emergency depart-
ment after a suicide attempt found that
52% of them failed to attend more than
2 sessions of therapy, and 16% of pa-
tients never attended outpatient therapy.
Suicidal and nonsuicidal children
dropped out of treatment, but the sui-
cide attempters ended therapy earlier
than nonsuicidal children.30
In a review of 4 novel approaches to
intensive outpatient care, Greenhill and
Waslick26 determined that none of the
follow-up or treatment programs was su-
perior to the others. The studies in-
volved adults, and there are no compa-
rable controlled trials in adolescent
suicide attempters. Only one study31 of
cognitive behavior therapy included ado-
lescent suicide attempters, and this study
demonstrated modest effects compared
with those of a brief, problem-oriented
therapy.3,26 For multiple reasons, it is
highly problematic to assume that the
cognitive behavior therapy performed on
adult study subjects can be transferred
to adolescents, given the critical role of
family factors in adolescent life and the
fact that, developmentally, this age group
might be incapable of using this ap-
proach. Nevertheless, without a clear-
cut solution, a prudent approach ap-
peared to be conscientious clinical
follow-up of teenagers to ensure that they
were engaged in treatment.26
Unless the general practitioner, inter-
nist, or pediatrician has particular inter-
est, training, or expertise in suicide pre-
vention, teenagers with suicidal ideation
or multiple risk factors or who have
attempted suicide should be referred for
a complete mental health evaluation and
careful treatment. In areas with few psy-
chiatrists available, careful communi-
©2001 American Medical Association. All rights reserved.
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cation between physicians and psy-
chologists or psychiatrists is essential.
Pharmacotherapy
Both older and newer selective seroto-
nin reuptake inhibitor (SSRI) antide-
pressants unequivocally reduce symp-
toms of major depression and generalized
anxiety in adults. There is also clear-cut
and overwhelming evidence that the de-
scriptive phenomenology of unipolar and
bipolar disorders in adolescents is es-
sentially identical to that in adults.32
However, historically, experts in adoles-
cent depression have had difficulty dem-
onstrating that antidepressants reduce
symptoms of major depression and gen-
eralized anxiety in this age group. They
cite the high placebo response rate in
teenagers as a methodologic hurdle to
demonstrating efficacy in this subpopu-
lation. Recent studies33,34 have emerged
with more definitive positive results of
the efficacy of antidepressants in a teen-
aged population.
Despite the evidence base for the ef-
ficacy of antidepressants in depression,
little evidence exists that antidepres-
sants significantly lower suicide rates in
adult patients treated with antidepres-
sants.4 Tondo et al35 state, “Despite broad
clinical use and intensive study of anti-
depressants for four decades, evidence
that they significantly alter suicidal be-
havior, or reduce long term suicidal risk,
remains meager and inconclusive.” The
introduction of SSRIs and other mod-
ern antidepressants that are much less
toxic in acute overdose than older drugs
appears not to have been associated with
a decrease in suicide rates. It is there-
fore safe to say that there are no evi-
dence-based data to suggest that tricy-
clic antidepressants or SSRIs prevent
suicide in teenagers. However, suicide
rates began to plateau in the 1990s, start-
ing with the widespread introduction of
SSRIs in the United States.36
Benefits of lithium augmentation for
depression have been reported in 2 stud-
ies37,38 in adolescents, although less than
half the subjects seemed to respond to
this additional treatment. There is
strong and conclusive evidence that in
adults with bipolar disorder, lithium as
(Reprinted) JAMA, December 26, 2001—Vol 286, No. 24 3123
SUICIDE IN TEENAGERS
part of long-term treatment provides
“substantial protection against suicide
attempts and fatalities” (relative risk
reduction ratio of 7.18 in a meta-
analysis of 22 studies).35 In addition, “[a]
recent international collaborative study
found that discontinuation of lithium
maintenance was associated with sharp
increases in suicidal risk in a large
sample of Bipolar I and Bipolar II
patients.”35 This study found that rates
of suicide completions and attempts
increased 20-fold after lithium use was
discontinued.
Bipolar illness commonly presents in
adolescence with classic adult fea-
tures (grandiosity, pressured speech,
decreased sleep, agitation, intense
irritability). Much academic contro-
versy exists about the identification of
bipolar illness in very young adoles-
cents and prepubertal children. Lithium
has not been subjected to large-scale
studies in adolescents with childhood
depression, and where it has been stud-
ied, clear-cut effects have been noted
on aggression but not mood. There is
no evidence on lithium’s effectiveness
in reducing suicide in teenagers, but the
evidence in adults is strong.
The possibility that pharmaco-
therapy, especially SSRIs, may increase
suicidal thinking or behavior is re-
viewed in a meta-analysis of 17 studies
(of adults) by Beasley et al.39 They could
not show any evidence that suicide rates
were different between patients treated
with SSRIs (fluoxetine), tricyclic antide-
pressants, or a placebo. No evidence ex-
ists that the results would be different in
teenagers.
As summarized by Goodwin and
Ghaemi,40 only 2 studies of adults ad-
dress the impact of anticonvulsants
(mood stabilizers) on suicide. Despite
the effectiveness of carbamazepine and
valproate in controlling acute manic
episodes, one study showed that car-
bamazepine was less effective than
lithium in preventing adult suicide. No
data exist for valproate.40 Psychosis as
part of bipolar illness, psychotic de-
pression, or adolescent-onset schizo-
phrenia clearly is associated with in-
creased suicidal behavior in adults, and
SUICIDE IN TEENAGERS
the use of antipsychotic drugs in ado-
lescent psychosis is clearly efficacious
for psychotic symptoms.
Community-Based Suicide
Prevention Programs
The practice parameters of the Ameri-
can Academy of Child and Adolescent
Psychiatry3 summarized the limited em-
pirical data on the measurable effects
of school-based programs and hot-
line crisis services on suicidal behav-
ior. “Early studies . . . failed to show that
hotlines reduce the incidence of sui-
cide . . . and their value remains un-
tested. . . . Suicide awareness pro-
grams in schools . . . have not been
shown to be effective either in reduc-
ing suicidal behavior or in increasing
help seeking behavior.”3
Future Directions
The prevalence of suicide has leveled
off in the United States during the past
10 years,2 a trend that correlates with
significant increases in the use of an-
tidepressant medications in adoles-
cents and young adults.36 However, the
effects of widespread use of these newer
antidepressants on suicide rates of teen-
agers and whether the leveling-off trend
will continue have yet to be ascer-
tained. Further, there are no clear cri-
teria for hospitalizing and discharging
a patient at moderate risk for suicide,
and community-based suicide preven-
tion programs have not yet been clini-
cally proved to have an effect on sui-
cide rates. It also is unclear what type
of psychotherapy efficaciously pre-
vents suicide attempts. Surprisingly,
there are no data to indicate that the
treatment of a patient’s underlying con-
dition (eg, conduct disorder or sub-
stance abuse) prevents suicidal behav-
ior. Anecdotal reports have not shown
that the penetration of managed care
has increased the number of teenaged
suicides, yet it is uncertain whether
closer scrutiny of patient admissions
and pressure for early discharge will
affect the rate of suicide attempts and
completions. Finally, the biological ba-
sis of suicidal behavior remains un-
clear despite the large body of litera-
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ture discussing it. The surgeon general
noted41 that increased support for evi-
dence-based treatment and preven-
tion was needed. The Public Health Ser-
vice42 further identifies ways in which
investment in clinical research, profes-
sional training, and evidence-based
community prevention should lead to
reductions in suicide rates in the United
States.
CONCLUSIONS
Although much clinical practice is
based on limited research, incomplete
knowledge, and extrapolations from
adult studies, several recommenda-
tions can be made to physicians faced
with the task of assessing and treating
suicidal teenagers and preventing sui-
cide. Physicians should know the symp-
toms of depression and the risk fac-
tors for suicide in teenagers and inquire
about these symptoms during an of-
fice visit. Physicians should also ask
about firearms and other lethal means
that might be found in the home and
should always screen for substance
abuse, conduct disorder, and poor
school performance. Physicians should
pay particular attention to patients who
were recently hospitalized or those with
multiple hospitalizations for suicidal be-
havior3 and should obtain a family his-
tory of depression and suicide.
Physicians who choose to treat sui-
cidal teenagers should not rely on con-
tracts (ie, a verbal agreement between
patient and physician that the patient
will not attempt suicide). They should
also be aware that suicide risk seems
highest at the beginning of depressive
episodes, so expeditious treatment or
referral is crucial. Hospitalization may
be required for suicidal teenagers with
altered mental status such as psycho-
sis or thought disorder, who have ac-
tively abused substances or have at-
tempted suicide, who experience
hopelessness or impulsivity, or who
have a lack of adequate parental super-
vision, among many other factors. Phy-
sicians should prescribe SSRIs instead
of tricyclic antidepressants for safety
reasons, since SSRIs are much less likely
to be lethal in an overdose. In general,
©2001 American Medical Association. All rights reserved.
adult doses may be used in older teen-
agers, but teenagers and family should
be counseled about adverse effects, in-
cluding sexual dysfunction. In addi-
tion, parents should be warned about
manic activation when antidepressant
medication is used. Although the data
regarding the precipitation of suicidal
ideation by SSRIs in adolescents are not
at all clear, “the wisest course of ac-
tion for the practitioner during the early
stages of . . . treatment . . . is to system-
atically inquire about suicidal ide-
ation before and after treatment is
started, especially . . . if SSRI treat-
ment is associated with the onset of aka-
thisia [motor restlessness, active or sub-
jective].”3 Physicians should also not
instruct their patients to discontinue
medication use when target symp-
toms subside. They should provide
careful follow-up after medication use
is discontinued. Some patients will re-
quire many years of continuous phar-
macotherapy and follow-up, since de-
pression is a chronic and recurring
illness. If faced with a denial for treat-
ment by an insurer, physicians should
emphasize to the managed care orga-
nization that the patient is suicidal. For
further recommendations, physicians
should review the American Academy
of Child and Adolescent Psychiatry
practice parameters.3
If a patient commits suicide, the phy-
sician should counsel the victim’s fam-
ily, friends, and community. In addi-
tion, physicians should be aware of the
risk of related suicides and how to guide
the media to prevent “glorification” of
suicide.
Finally, if suicidal thinking and be-
havior are signs of psychiatric disor-
der, then symptomatic relief or ame-
lioration of common risk factors and
underlying psychiatric illness should re-
duce suicide in teenagers. If health care
professionals vigilantly screen for the
constellation of factors that lead teen-
agers to commit suicide, then this rare
but tragic behavior will be reduced.
Acknowledgment: Monique Ernst, MD, PhD, and
Robert Cohen, MD, PhD, provided critical review, and
Jessica Kirkland, Jill Barents, and Suzanne Muson, BA,
provided editorial assistance.

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