Australian Doctor 14th July Issue 14JULY2023 issue | Page 49

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LGBTIQ POPULATIONS LGBTIQ people have higher rates of mental ill-health and suicide or suicidal behaviours and face barriers to accessing services , due to structural ( including legislative ) and everyday experiences of discrimination , stigma and resultant trauma . A recent study indicated that 37.2 % reported suicidal ideation and 3.9 % a suicide attempt within 12 months in Australia . These findings underscore the importance of culturally-safe suicide prevention programs as well as addressing the issue of marginalisation for this group . 72

What GPs say they need to support suicidal teens

Themes that GPs identify in their management of suicidal behaviours are listed in box 3 .

Training on suicide prevention in primary care enhanced by practising interviewing in simulated , standardised patient interactions ( face-to-face and telehealth ) is under investigation . 73

PROGNOSIS

RECURRENT self-harm behaviours among adolescents are common , with 15-25 % of adolescents treated in hospitals returning for treatment within 12 months . 16 , 46 For adolescents treated in hospital , over a third will repeat suicidal attempts within 12 months . 75 , 76 When certain mental health issues , such as borderline personality disorder , are superimposed on suicidal incidents , a substantially higher rate of repeated attempts occur . Three quarters of adolescents with borderline personality disorder are found to have suicidal attempts and they also exhibit

1 . Which THREE socio-demographic factors may increase the risk of suicide ? a Poverty . b Female . c Rural residence . d Migration .

2 . Which THREE psychological factors may predispose to suicidality in children and adolescents ? a Mental health issues . b Acute stress . c Close-knit peer group . d Poor impulse control .

3 . Which TWO are important in the assessment of suicidality in children and adolescents ? a A judgemental assessment approach . b Considering their understanding of the concept of death and its permanency . c Relying solely on the information provided by the young person . d Working collaboratively with the family and any other significant people in the young person ’ s life .

4 . Which ONE is not an area to explore screening for higher rates of extreme levels of selfharm than do adults with borderline personality disorder . 77 Adolescents with prior suicide attempts may have higher school dropout rates and lower scores on educational indicators than their peers . 78 Self-harm behaviours during adolescence may predict more adversity in later life ; males are more likely to be affected than females in terms of unemployment and family-related issues . 79

THE FUTURE

The knowledge about risk factors from research over five decades has not been sufficiently translated into success in reducing suicide rates . 80 This ‘ knowledge-to-practice ’ gap may suggest the need to revisit and scrutinise existing approaches . Using the SUICIDE principle in the assessment to identify predisposing , precipitating , perpetuating and protective factors for suicide should be part of the GP-based management guidelines for children / adolescents with suicidal ideation or attempts . Specifically , factors that predict short-term or even immediate risks such as recent changes in psychiatric symptoms or acute stressful life events require actionable strategies to address immediate needs . Therefore , collaboration between GPs and other first-line responders is important to identify and modify these proximal risk factors . Helping the patient navigate through various types of hospital-based , school-based and

suicidality and self-harm ? a Suicidal ideas . b Suicide history in the family . c Suicidal plans . d Post-suicide attempt .

5 . Which TWO statements regarding the management of suicidality are correct ? a There is no link between selfharm and increased risk for suicide attempts and suicide . b Suicide attempts elevate future suicide risk . c Therapeutic assessment offers no benefit over usual care . d Interpersonal and systemic factors in EDs often prevent effective intervention .

6 . Which THREE are indications for more intensive psychiatric care ? a First suicide attempt . b Ongoing ( pressing ) suicidal thoughts , wishes , intentions , plans . c Psychiatric disorders underlying community-based mental health services , is imperative .

CASE STUDY

GEORGE , 17 , lives with his parents and older brother , a university student . George presents to the local ED following a near fatal suicidal attempt via carbon monoxide poisoning . On the morning of the attempt , he had a school assignment due that he was struggling to complete . In the early morning hours , he went to his mother ’ s car that was parked on the side of the road and attempted suicide . He was found by passers-by who called an ambulance .

There is no prior history or diagnosis of mental illness , although he was seen briefly two years ago by the school counsellor following selfharm by lacerating his arm .

He reports experiencing low mood for the past two years , but during the recent COVID-19 lockdown his mental

Self-harm behaviours during adolescence may predict more adversity in later life .

state deteriorated and his sleep – wake cycle reversed . He used to perform well academically but has now fallen behind , which is a major stressor for him . He has a couple of close friends and gives a history of being bullied from the beginning of high school , although denies any recent issues . He reports a decrease in appetite , low motivation and energy and emergence of suicidal ideation over the past two months , with detailed planning of the attempt for the past few weeks . He had researched different methods and had decided on

SUICIDALITY IN CHILDREN AND ADOLESCENTS

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suicidal ideation and behaviour . d Lack of alternatives for adequate monitoring and treatment .

7 . Which TWO modalities are appropriate in managing suicidality in children and adolescents ? a Safety planning . b Prolonged hospitalisation . c Avoid school attendance . d Psychotherapy .

8 . Which THREE are features of safety planning with the patient ’ s family and friends ? a Identify warning signs and triggers of a worsening mental state . b Identify effective modes of communication . c Emergency professional contacts . d Remove sources of harm .

9 . Which THREE statements regarding suicidality in children

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and purchased the equipment necessary for carrying out his plan . George denies any history of substance use and he has never been romantically involved with anyone . Although there is no history of childhood trauma or abuse , he describes significant parental marital conflict from when he was a young boy and reported that his father had recently left home ( 2-3 weeks before his admission ). George denies that this conflict is causing him distress as he says he is used to his dad leaving home intermittently following fights with his mum .

George is admitted to the adolescent mental health unit given the high suicidal risk in the context of a diagnosis of a major depression . Initially he is very upset that the attempt had failed . On assessment he appears to be disengaged but speaks in a low tone with brief answers .

He is started on fluoxetine and receives CBT for depression . A detailed safety plan is agreed on . Family meetings provide psychoeducation regarding depression and its management , including the safety plan and strategies to address any future distress . The impact of the marital conflict on George ’ s mental state is discussed as is the importance of providing emotional safety for George to discuss his feelings openly with his family . Over the course of the seven-day admission , his sleep – wake cycle improves and he returns to having a routine to his day . His mood improves and he becomes bright and reactive , interacting well with staff and other patients . He is discharged to the care of the community mental health team . His allocated case manager

and adolescents in specific populations are correct ? a Rural areas have higher suicide rates . b Indigenous youth suicide rates are double those of the non-Indigenous population . c Stigma may affect reporting in some culturally and linguistically diverse groups . d LGBTIQ people face barriers to accessing services .

10 . Which THREE statements regarding the prognosis in suicidality in children and adolescents are correct ? a Recurrent self-harm behaviours among adolescents are common . b When certain mental health issues are superimposed on suicidal incidents , a substantially higher rate of repeated attempts occur . c Women who self-harm during adolescence have higher rates of later life family-related issues than do men . d Adolescents with prior suicide attempts may have higher school dropout rates and lower scores on educational indicators than their peers . continues CBT sessions and communication with the school counsellor ensures continuity of care and support at school as well . When reviewed in the clinic six weeks post-discharge he is maintaining the symptom improvement .

This case highlights the importance of timely intense intervention for a suicide attempt as well as the need to identify and address any underlying mental illness and the biopsychosocial precipitating and perpetuating factors .

CONCLUSION

THE prevalence of suicidal ideation and attempts in children and adolescents is underestimated since a proportion do not access mental health services . This highlights the need for first-line responders , including GPs , to identify suicidal behaviours and associated risk factors and provide aftercare . Psychological mechanisms underlying self-harm or suicidal behaviours in children and adolescents are more likely to arise from emotional dysregulation in response to stress ; this occurs because the neurobiological features in children and adolescents are distinct from those in adults .

A good understanding of unique risk and protective factors for youth suicide is thus critically important in the assessment and management . Engagement of families and friends also plays a key role in safety planning . Suicide prevention and intervention for children and adolescents require a collaborative effort and GPs can act as a key liaison to connect various stakeholders while also assisting the co-ordination of different services over the course of recovery .

RESOURCES

• PHQ-9 : Modified for Teens bit . ly / 36bvij7

• PHQ-9 : Modified for Aboriginal people bit . ly / 3GTz3Gw

• Beyond Blue — Beyond Now suicide safety plan app bit . ly / 390SEtD

— The Way Back Support Service bit . ly / 3rTCIju

• Project Air bit . ly / 3sMDL43

• Black Dog Institute iBobbly app bit . ly / 3LHk2LA

• National Rural Health Alliance : Suicide in rural and remote Australia bit . ly / 3s44RVn

• Rural Adversity Mental Health Program bit . ly / 3uWqo4a

• Suicide Prevention Australia : Fact sheet : Suicidality among culturally and linguistically diverse communities 2021 bit . ly / 3Jw7S6D

• Suicide Prevention Australia : Fact sheet : LGBTIQ + suicide prevention 2021 bit . ly / 33wqvrO

• Cornell Research Program on Self-injury and Recovery : The relationship between nonsuicidal self-injury and suicide bit . ly / 3tZJYdp

References Available on request from howtotreat @ adg . com . au