Mental Health: A Report by the Surgeon General

There is good evidence that over 90 percent of children and adolescents who commit suicide have a mental disorder before their death (Shaffer & Craft, 1999). The most common disorders that predispose to suicide are some form of mood disorder, with or without alcoholism or other substance abuse problem, and/or certain forms of anxiety disorder (Shaffer et al., 1996b). Psychological postmortem studies also show that a significant proportion of suicide victims suffered from an anxiety disorder at the time of their death, but the number of victims has been too small to yield precise odds ratios for the calculation of an effect. Although the rate of suicide is greatly increased in schizophrenia, because of its rarity, it accounts for very few suicides in the child and adolescent age group.

Controlled studies of completed suicide suggest similar risk factors for boys and girls (Shafii et al., 1985; Brent et al., 1988; Groholt et al., 1997), but with marked differences in their relative importance (Shaffer et al., 1996c).

Among girls, the most significant risk factor is the presence of major depression, which, in some studies, increases the risk of suicide 12-fold. The next most important risk factor is a previous suicide attempt, which increases the risk approximately threefold. Among boys, a previous suicide attempt is the most potent predictor, increasing the rate over 30-fold. It is followed by depression (increasing the rate by about 12-fold), disruptive behavior (increasing the rate by twofold), and substance abuse (increasing the rate by just under twofold) (Shaffer et al., 1996c).

Stressful life events often precede a suicide and/or suicide attempt (de Wilde et al., 1992; Gould et al., 1996). As indicated earlier, these stressful life events include getting into trouble at school or with a law enforcement agency; a ruptured relationship with a boyfriend or a girlfriend; or a fight among friends.7 They are rarely a sufficient cause of suicide, but they can be precipitating factors in young people.

Controlled studies (Gould et al., 1996; Hollis, 1996) indicate that low levels of communication between parents and children may act as a significant risk factor. While family discord, lack of family warmth, and disturbed parent-child relationship are commonly associated with child and adolescent psychopathology (violent behavior, mood disorder, alcohol and substance abuse disorders) (Brent et al., 1994; Pfeffer et al., 1994), these factors do not play a specific role in suicide (Gould et al., 1998).

Evidence has accumulated that supports the observation that suicide can be facilitated in vulnerable teens by exposure to real or fictional accounts of suicide (Velting & Gould, 1997), including media coverage of suicide, such as intensive reporting of the suicide of a celebrity, or the fictional representation of a suicide in a popular movie or TV show. The risk is especially high in the young, and it lasts for several weeks (Gould & Shaffer, 1986; Phillips et al., 1989). The suicide of a prominent person reported on television or in the newspaper or exposure to some sympathetic fictional representation of suicide may also tip the balance and make the at-risk individual feel that suicide is a reasonable, acceptable, and in some instances even heroic, decision (Gould & Shaffer, 1986).

The phenomenon of suicide clusters is presumed to be related to imitation (Davidson, 1989). Suicide clusters nearly always involve previously disturbed young people who knew about each other’s death but rarely knew the other victims personally (Gould, personal communication, 1999).

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