Suicidal and Non-Suicidal Self-Injurious Behavior

Suicide is a preventable public health tragedy and the leading cause of death among youth ages 10-24 in the United States.

A notable proportion of youth experience suicidal thinking or have a history of engagement in suicidal and/or non-suicidal self-injurious (NSSI) behaviors.

• Approximately 22% of US high school students report that they seriously considered making a suicide attempt, while 10% report having made a suicide attempt in the past year (CDC, 2023).
• The past year prevalence of NSSI is also estimated to be high among adolescents (~23% in a non-clinical sample). 

Suicide risk notably increases in the transition into adolescence. There is evidence for an increase in suicide risk among subgroups of adolescents (e.g., biological females, Black and Hispanic youth).

• Additionally, sexual and gender minority youth report elevated suicidal ideation and behaviors and are at particularly high risk for suicide.
• Suicide risk and protective factors span demographic characteristics (e.g., biological sex, gender, age, race/ethnicity), psychopathology (e.g., depression), interpersonal stressors (e.g., peer victimization, social connectedness), as well as a history of self-harm thinking and behaviors.

NSSI includes self-harm behaviors (e.g., cutting, burning) without suicidal intent. Functions of NSSI are varied and may include communication of distress, escape from a situation or emotions, a desire to feel in control, wanting to reduce feelings of numbness, self-punishment, and intent should always be clarified.

Emergency department (ED) visits due to suicide attempts and other suicidal behavior have been climbing in the past few years, especially among girls.

• Notably, ED visits due to self-harm behaviors have notably increased in recent years.
• Among youth, under 19, who died by suicide, approximately 38% and 77% had contact with the healthcare system in the month and year prior to their death, respectively.

Primary care settings present a unique and critical opportunity to identify and intervene with youth at risk for suicide or who are engaging in NSSI.

Resources Mentioned in the Video

• American Academy of Pediatrics, Blueprint for Youth Suicide Prevention: https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/ 
• Zero Suicide: https://zerosuicide.edc.org/ 
• Safety planning: Stanley-Brown Safety Plan https://sprc.org/online-library/stanley-brown-safety-plan/ 
• Counseling Access to Lethal Means (CALM) training course: https://zerosuicide.edc.org/resources/trainings-courses/CALM-course 
• 988 Suicide and Crisis Hotline: https://988lifeline.org/current-events/the-lifeline-and-988/ 

Screening Tools

• Depression: Patient Health Questionnaire (PHQ-9): https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf 
• Suicidality: Ask Suicide Screening Questionnaire (ASQ): https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf 
• Suicidality: Ask Suicide Screening Questions Brief Suicide Safety Assessment (ASQ BSSA): https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/youth-outpatient/bssa_worksheet_outpatient_youth_asq_nimh_toolkit.pdf 
• Suicidality: Columbia Suicide Severity Rating Scale (CSSR-S):  https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdf 
• Nonsuicidal self injury and suicidality: Suicidal ideation; Onset, frequency, and methods; Aftercare; Reasons; and Stage of change (SOARS): https://www.contemporarypediatrics.com/view/soars-model-risk-assessment-nonsuicidal-self-injury 

Other Resources

• MC3 Recordings:
  • Depression and Suicide Screening by: Lia Gaggino, M.D.
  • Suicide Safety Planning by: Lia Gaggino, M.D.
  • Assessment and Management of Youth Self-Harm Behaviors in Primary Care by: Alejandra Arango, Ph.D.
• Pediatric Meltdown Podcast Episodes:
  • Screening Youth For Suicide Risk: Can it be done in a busy pediatric practice? (Episode 8)
  • Self-Injurious Behaviours in Youth: Assessment and Management (Episode 144)
  • Preventing Youth Suicide: Risk Assessment and Management (Episode 158)
  • Youth Suicide Prevention: Safety Planning and Lethal Means Safety Counseling (Episode 159)
• Breaking Down Mental Health Podcast Episodes:
  • What is Suicidal Ideation? Self Injurious Behavior? (Episode 4)
  • Safety Assessment and Planning (Episode 5)

Ahmedani BK, Simon GE, Stewart C, Beck A, Waitzfelder BE, Rossom R, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29(6) 870-877. https://doi.org/10.1007/s11606-014-2767-3 

Centers for Disease Control and Prevention. WISQARS. 10 Leading Causes of Death, United States, 2018-2020. https://wisqars.cdc.gov/data/lcd/home

Centers for Disease Control Prevention. (2023). Youth Risk Behavior Survey Data Summary & Trends , 2011–2021. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf 

Cha CB, Franz PJ, Guzmán EM, Glenn CR, Kleiman EM, Nock MK. Annual Research Review: Suicide among youth–epidemiology, (potential) etiology, and treatment. J Child Psychol Psychiatry. 2018;59(4):460-482. https://doi.org/10.1111/jcpp.12831 

Gaylor EM, Krause KH, Welder LE, Cooper AC, Ashley C, Mack KA, et al. Suicidal thoughts and behaviors among high school students—Youth Risk Behavior Survey, United States, 2021. MMWR supplements. 2023;72(1):45. https://doi.org/10.15585/mmwr.su7201a6 

Haas AP, Eliason M, Mays VM, Mathy RM, Cochran SD, D’Augelli AR, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex. 2011;58(1):10-51. https://doi.org/10.1080/00918369.2011.534038 

Nock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA, Zaslavsky AM, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013;70(3):300-310. https://doi.org/10.1001/2013.jamapsychiatry.55 

Office of the Surgeon General. (2021). Protecting Youth Mental Health: The US Surgeon General’s Advisory [Internet]. surgeon-general-youth-mental-health-advisory.pdf (hhs.gov)

Ward D. Office Practicum, Pediatric Success Series: The Concerning Trend in Behavioral Health Emergency Room Visits for Children and Adolescents. https://www.officepracticum.com/blog/the-concerning-trend-in-mental-health-emergency-room-visits-for-children-and-adolescents/ 

Yard E, Radhakrishnan L, Ballesteros MF, Sheppard M, Gates A, Stein Z, et al. Emergency Department visits for suspected suicide attempts among persons aged 12-25 years before and during the COVID-19 pandemic- United States, January 2019-May 2021. Morbidity and Mortality Weekly Report, 70(24), 888. https://www.cdc.gov/mmwr/volumes/72/wr/mm7226a2.htm?s_cid=mm7226a2_w