EVIDENCE-BASED RESOURCE GUIDE SERIES Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youths Acknowledgments This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) under contract number HHSS283201700001/ 75S20319F42002 with SAMHSA. Donelle Johnson served as the contracting officer representative. Disclaimer The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of SAMHSA. Nothing in this document constitutes a direct or indirect endorsement by SAMHSA of any non-federal entity’s products, services, or policies, and any reference to non-federal entity’s products, services, or policies should not be construed as such. Public Domain Notice All material appearing in this publication is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA. Electronic Access This publication may be downloaded from http://store.samhsa.gov Recommended Citation Substance Abuse and Mental Health Services Administration (SAMHSA): Treatment for Suicidal Ideation, Self-harm, and Suicide Attempts Among Youth. SAMHSA Publication No. PEP20-06-01-002 Rockville, MD: National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental Health Services Administration, 2020. Originating Office National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857, SAMHSA Publication No. PEP20-06-01-002. Nondiscrimination Notice SAMHSA complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. SAMHSA cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, ni edad. Publication No. PEP20-06-01-002 Released 2020 Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth Acknowledgments I MESSAGE FROM THE ASSISTANT SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES As the U.S. Department of Health and Human Services Assistant Secretary for Mental Health and Substance Use at the Substance Abuse and Mental Health Services Administration (SAMHSA), I am pleased to present this new resource: Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth. In response to the charge of the 21st Century Cures Act to disseminate information on evidence-based practices and service delivery models, the National Mental Health and Substance Use Policy Laboratory developed the Evidence-Based Resource Guide Series focused on the prevention and treatment of substance use disorders and mental illnesses. With this specific guide, SAMHSA’s goal is to inform healthcare professionals, healthcare system administrators, teachers and school administrators, parents, community members, policy makers, and others of the strategies for treating suicidal ideation, self-harm, and suicide attempts among youth. Suicide is the second leading cause of death for youth in the United States. The suicide rate for youth aged 10 to 24 increased 56 percent from 6.8 per 100,000 in 2007 to 10.6 per 100,000 in 2017.1 Many factors contribute to thoughts of suicide in this population, including depression, hopelessness, low self-esteem, peer and parental relationship problems, academic difficulties, and substance use. Suicide is preventable, suicidal thoughts and behaviors are treatable, and interventions are available and should be accessible to any young person who needs help. This guide discusses the prevalence of suicide among youth, effective treatment programs, implementation considerations and strategies, and examples of the successful use of programs in clinical and community- based settings. I encourage you to use this guide to identify treatment programs you can implement to address suicidal ideation, self-harm, and suicide attempts among youth in your communities. Elinore F. McCance-Katz, MD, PhD Assistant Secretary for Mental Health and Substance Use U.S. Department of Health and Human Services 1 Curtin, S. C. & Heron, M. (2019). Death rates due to suicide and homicide among persons aged 10-24: United States, 2000-2017. National Center for Health Statistics, Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf. Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth Message from Assistant Secretary for Mental Health and Substance Use II Evidence-Based Resource Guide FOREWORD Series Overview The Substance Abuse and Mental Health Services A priority topic for SAMHSA is ensuring the availability Administration (SAMHSA), and specifically, its of effective treatment for youth with suicidal ideation National Mental Health and Substance Use Policy or who have attempted suicide or engaged in self-harm. Laboratory (Policy Lab), is pleased to fulfill the charge This guide reviews the related literature and science, of the 21st Century Cures Act to disseminate information examines emerging and best practices, identifies gaps in on evidence-based practices and service delivery models knowledge, and discusses challenges and strategies for to prevent substance misuse and help people with implementation. substance use disorders (SUD), serious mental illnesses Expert panels of federal, state, and non-governmental (SMI), and serious emotional disturbances (SED) get the participants provide input for each guide in this series. treatment and support they need. The panels include accomplished scientists, researchers, Treatment and recovery for SUD, SMI, and SED can service providers, community administrators, federal and vary based on several geographic, socio-economic, state policy makers, and people with lived experience. cultural, gender, race, ethnicity, and age-related factors Members provide input based on their knowledge of which can complicate evaluating the effectiveness healthcare systems, implementation strategies, evidence- of services, treatments, and supports. Despite these based practices, provision of services, and policies that variations, however, there is substantial evidence to foster change. inform the types of resources that can help reduce Research shows that implementing new programs and substance use, lessen symptoms of mental illness, and practices requires a comprehensive, multi-pronged improve quality of life. approach. This guide is one piece of an overall approach The Evidence-Based Resource Guide Series is a to implement and sustain change. Users are encouraged comprehensive set of modules with resources to to review the SAMHSA website for additional tools and improve health outcomes for people at risk for, with, technical assistance opportunities. or recovering from mental and/or substance use disorders. It is designed for practitioners, administrators, community leaders, and others considering an intervention for their organization or community. Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth Evidence-Based Resource Guide Series Overview 1 Content of the Guide FOCUS OF THE GUIDE Suicide is the second leading This guide contains a foreword and five chapters. The chapters stand alone cause of death for youth and young and do not need to be read in order. Each chapter is designed to be brief and adults in the United States. Factors accessible to healthcare providers, healthcare system administrators, community contributing to thoughts of suicide members, policy makers, and others working to meet the needs of individuals in this population include mental at risk for, experiencing, or recovering from mental and/or substance use health and substance use problems, disorders. low self-esteem, peer and parental relationship problems, and academic The goal of this guide is to review the literature on treatment for suicidal difficulties. ideation, self-harm, and suicide attempts among youth, distill the research Suicidal ideation, self-harm, and into recommendations for practice, and provide examples of how practitioners suicide attempts are higher among can use these practices in their programs. The programs included in this youth than adults. Approximately guide focus on adolescents and young adults who are currently experiencing 17 percent of high school students suicidal ideation, self-harm, and/or suicide attempts, and addresses risk factors reported suicidal ideation in the past unique to this population. The programs can be implemented by mental health year, and 7.4 percent of high school professionals in a variety of settings, including schools, community mental students reported a suicide attempt health centers, residential facilities, or juvenile justice programs. in the same period. The prevalence of suicidal thoughts and behaviors FW Evidence-Based Resource Guide Series Overview is higher in some groups, including LGBTQ+ youth and racial and ethnic Introduction to the series. minorities, particularly American 1 Issue Brief Indian and Alaska Native youth and youth of more than one race. Overview of current approaches and challenges to addressing suicidal ideation, self-harm, and suicide attempts among youth. This guide presents programs and practices that address effective 2 What Research Tells Us treatment of suicidal thoughts, suicidal behaviors, and self-harm Current evidence on effectiveness of the following programs among youth and young adults. included in the guide to treat suicidal ideation, self-harm, and suicide attempts among youth: Dialectical Behavior Therapy Interventions need to be part of a and Attachment-Based Family Therapy. comprehensive approach that seeks to decrease suicide risk factors 3 Guidance for Selecting and Implementing and increase protective factors. Evidence-Based Programs In addition, systemic barriers to Practical information to consider when selecting and effective treatment for youth need to implementing programs and practices to treat suicidal ideation, be addressed, including appropriate self-harm, and suicide attempts among youth. referrals and linkage to treatment services, improved education and 4 Examples of Suicide Treatment Programs training for healthcare professionals, and increased availability of services Examples of programs to treat suicidal ideation, self-harm, and and insurance coverage for diagnosis suicide attempts among youth. and treatment of mental disorders 5 Resources for Evaluation and Quality Improvement and suicidal behaviors. Guidance and resources for implementing programs and practices, monitoring outcomes, and improving quality. Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth Evidence-Based Resource Guide Series Overview 2 The framework below provides an overview of this guide. The review of treatment programs in Chapter 2 of the guide includes specific outcomes, practitioner types, and delivery settings for the programs. Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth Evidence-Based Resource Guide Series Overview 3 Suicide is now the second CHAPTER 1 leading cause of death for adolescents and young adults aged 15 to 24 in the United States, and suicide 1 attempts are significantly higher among youth, compared to adults. 2-3 Issue Brief Suicide, suicide attempts, self-harm, and suicidal ideation significantly increase a youth’s risk of death by suicide9 and are significant public health concerns in young people. often lead to subsequent and more lethal suicide attempts.10 Suicide is now the second leading cause of death for adolescents and young adults aged 15 to 24 in the United Suicide contagion is a process where States,1 and suicide attempts are significantly higher exposure to the suicide or suicidal behaviors among youth, compared to adults.2-3 Suicidal ideation, self- of others influences people who are already harm, and suicide attempts are more common than suicide vulnerable and considering suicide. Exposure death in young people, and are associated with several to suicide by a close friend, family member, or other negative consequences, such as co-morbid mental another person within one’s social network is disorders, poor educational and vocational outcomes, and considered a significant suicide risk factor for premature death due to other causes.4 Studies show that individuals and communities.11 people who attempt suicide in adolescence have a higher likelihood of mental health treatment utilization, mental Suicidal ideation refers to thinking about or planning illness diagnosis, and adult suicide.5 suicide. The thoughts lie on a continuum of severity The impacts of youth suicide extend beyond the from a wish to die with no method, plan, intent, or individual. Research indicates exposure to a suicide behavior, to active suicidal ideation with a specific (e.g., schoolmate’s suicide and personally knowing plan and intent.12 Although suicidal ideation does not someone who died by suicide) predicts suicide ideation include physically harmful behaviors, over one third and attempts.6 The National Longitudinal Survey of adolescents who experience suicidal ideation will of Adolescent Health reveals that for the first year attempt suicide within their lifetimes.13 following a friend’s death by suicide, peers experience Self-harm is behavior that is self-directed and deliberately heightened suicidal ideation and attempts, as well as results in injury or the potential for injury to oneself.8 The higher rates of depression.7 term, also referred to as self-directed violence, encompasses What is Suicide? both suicidal and non-suicidal self-injury (NSSI), and self-harm with unclear intent. NSSI is distinguished from Suicide is a death caused by self-directed injurious a suicide attempt or suicide because it does not include behavior with any intent to die as a result of the behavior.8 suicidal intent.14 NSSI is considered a significant risk factor A suicide attempt is a non-fatal, self-directed, and for both suicide attempts and death by suicide and may or potentially injurious behavior with any intent to die may not accompany suicidal ideation.15 as a result of the behavior.8 Previous suicide attempts Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth Issue Brief 4 (cid:52)(cid:80)(cid:86)(cid:83)(cid:68)(cid:70)(cid:27)(cid:1)(cid:36)(cid:37)(cid:36)(cid:1)(cid:56)(cid:70)(cid:67)(cid:14)(cid:67)(cid:66)(cid:84)(cid:70)(cid:69)(cid:1)(cid:42)(cid:79)(cid:75)(cid:86)(cid:83)(cid:90)(cid:1)(cid:52)(cid:85)(cid:66)(cid:85)(cid:74)(cid:84)(cid:85)(cid:74)(cid:68)(cid:84)(cid:1)(cid:50)(cid:86)(cid:70)(cid:83)(cid:90)(cid:1)(cid:66)(cid:79)(cid:69)(cid:1)(cid:51)(cid:70)(cid:81)(cid:80)(cid:83)(cid:85)(cid:74)(cid:79)(cid:72)(cid:1)(cid:52)(cid:90)(cid:84)(cid:85)(cid:70)(cid:78)(cid:1)(cid:9)(cid:56)(cid:42)(cid:52)(cid:50)(cid:34)(cid:51)(cid:52)(cid:10)(cid:18)(cid:1)(cid:15) Prevalence The suicide death rate for adolescents and young adults has increased in the past two decades. In 2018, the suicide death rates for adolescents and young adults were 2.85 per 100,000 for ages 10 to 14, 11.39 per 100,000 for ages 15 to 19, and 17.4 per 100,000 for ages 20 to 24.1 In all age groups, males have a higher suicide death rate than females. However, from 1999 through 2018, the suicide death rate doubled for females aged 15 to 19 and 20 to 24.For youth aged 10 to 14, the suicide death rate more than tripled from 2001 to 2018.16-17 Explanations for the increase in suicide may include bullying, social isolation, increase in technology and social media, increase in mental illnesses, and economic recession. Suicidal ideation, self-harm, and suicide attempts are significantly higher in youth compared to adults, despite adult suicide death rates being higher.1,3,18 In 2019, approximately 18.8 percent of high school students reported suicidal ideation in the past year, and 8.9 percent of high school students reported a suicide attempt in (cid:52)(cid:80)(cid:86)(cid:83)(cid:68)(cid:70)(cid:27)(cid:1)(cid:19)(cid:17)(cid:18)(cid:26)(cid:1)(cid:54)(cid:79)(cid:74)(cid:85)(cid:70)(cid:69)(cid:1)(cid:52)(cid:85)(cid:66)(cid:85)(cid:70)(cid:84)(cid:1)(cid:58)(cid:80)(cid:86)(cid:85)(cid:73)(cid:1)(cid:51)(cid:74)(cid:84)(cid:76)(cid:1)(cid:35)(cid:70)(cid:73)(cid:66)(cid:87)(cid:74)(cid:80)(cid:83)(cid:1)(cid:52)(cid:86)(cid:83)(cid:87)(cid:70)(cid:90) the past year.3 Rates of high school students reporting purposefully hurting themselves without wanting to die over the past 12 months ranged from 6.4 to 14.8 percent for males and 17.7 to 30.8 percent for females in 2015.19 Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth Issue Brief 5 Prevalence of suicidal thoughts and behaviors is Risk and Protective Factors particularly high in lesbian, gay, bisexual, transgender, Risk factors are characteristics that potentially increase an and questioning or queer youth and youth with other individual’s level of suicide risk, whereas protective factors sexual and gender minority identities (LGBTQ+). are factors that mitigate against risk. Adolescents and young Lesbian, gay, and bisexual adolescents and young adults adults are in a state of transition, facing new independence, are two to four times more likely to report suicidal identity formation, and changing social situations at school ideation, self-harm, and a suicide attempt compared to and home. The significant physical, hormonal, and social their heterosexual peers.3 Transgender youth are four changes of adolescence can increase the likelihood of a to five times more likely to attempt suicide compared young person experiencing anxiety or depression.24 to their peers who exclusively identify as their sex assigned at birth (i.e., cisgender), with about 34.6 Mental and substance use disorders, including depression, percent reporting a suicide attempt in the past year.20 anxiety, bipolar disorders, eating disorders, marijuana use, LGBTQ+ youth often experience unique stressors and alcohol use or misuse, also increase the likelihood and related to their identity, such as discrimination, violence, severity of suicidal ideation,25 as well as risk of suicide trauma, expectations of rejection, concealment of their attempts26 and deaths.27-28 Other individual-level risk identity, and internalized homo- and trans-negativity, that factors include but are not limited to: increase risk for mental disorders and suicide.21 • Previous suicide attempts Some racial and ethnic minority youth also experience • Childhood trauma, such as physical, sexual, and higher rates of suicidal behaviors. In 2017, American emotional abuse Indian and Alaska Native (AI/AN) youth, as well as • Being in the child welfare system • Being a victim or perpetrator of bullying youth of more than one race, reported the highest rates • Experiencing a stressful event of both suicidal ideation and suicide attempts.22 While • Consistent low-level or toxic stress suicide attempt rates decreased among most racial and • Dysregulated sleep ethnic groups between 1991 and 2017, Black youth • Hopelessness experienced an increase in suicide attempts and injury • A sense of losing control by suicide attempt.22 Differences in suicide attempt • Emotional reactivity or pattern of aggressive or rates may be attributed to disparities in access to mental aggressive-impulsive behavior health treatment and other factors that AI/AN and Black • Access to non-secure firearms youth disproportionally experience, including poverty, • Access to lethal means of suicide, including historical trauma, and adverse childhood experiences.22-23 medications11,13,29-31 Importance of Prevention Family-level risk factors include parental depression, suicidal behavior, and substance use disorders.32-33 While the primary focus of this guide is on treatment approaches, it is necessary to highlight the importance of prevention strategies in stopping young people from Marijuana use and depression are associated engaging in suicidal behaviors. This chapter provides with suicidal ideation34 and a greater likelihood context regarding risk and protective factors and some of suicide attempts among adolescents.35-36 core prevention strategies critical to treatment program Adolescents who use marijuana are also at planning and implementation. increased risk of developing depression and suicidal thoughts and behaviors later in life.37 The associations between marijuana, depression, and The association between alcohol use and suicide are growing concerns. Marijuana use, suicidal thoughts and behaviors is of concern, marijuana use disorder, and major depressive since more than 21 percent of youth aged 12 episodes increased among adolescents aged 12 to 17 used alcohol in 2019, and 9.4 percent to 17 between 2016 and 2019. reported past month use.2 Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth Issue Brief 6 Knowledge of risk factors helps clinicians and program Factors that reduce risk for suicidal thoughts, attempts, administrators understand chronic risks clients have. and deaths are referred to as protective factors. Although single risk factors are severely limited in Recognizing them is just as important, if not more so, as their ability to accurately predict suicidal thoughts and understanding factors that increase risk.41 Adolescence behaviors,38 recent studies suggest that combinations offers a period of developmental opportunity to discover of risk factors predict more effectively.39 Nevertheless, new outlooks, form positive relationships, and explore there is considerable heterogeneity among youth at risk one’s identity. It is also a period that can increase for suicide, and risk levels can increase or decrease over resilience when youth overcome challenges and thrive as time. Therefore, there is no one-size-fits-all approach to they develop and mature.42 prevention or treatment.38,40 Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth Issue Brief 7