Recurrent adolescent suicidal behavior

Suicide is the third leading cause of death among people in the age group 15 to 25 years.1 Self-destructive behavior in children and adolescents is a continuum that ranges from drug intoxications to gestures of low lethality to suicide attempts with high lethality of intent. In our survey of 1,100 self-poisonings in people aged 6 to 18 who were seen at poison control centers we found an incidence of 220 self-poisonings for every fatality.2 This is higher but comparable to other estimates of 50 to 150 suicide gestures for every reported death from suicide in the adolescent.3-6 Suicide attempts may account for 12% of all emergency room visits.7 This represents a public health problem of the first magnitude. It is ironically tragic that many of the adolescent suicide deaths are unintentioned-the victim did not really intend to die. In our collaborative poison study, for example, none of the six deaths could be called intended. The adolescents were not victims of suicide but of pharmacologic roulette. The single best correlate of suicidal risk appears to be lethality of intent. A diagnosis of suicide attempt, as contrasted to a gesture, implies both a lethality of intent coupled with a mature concept of death as an irreversible state. Lethality is defined by Shneidman8 as the probability of an individual's killing himself in the immediate future. In classifying all deaths as intentioned, subintentioned, and unintentioned as contrasted to the traditional classifications of natural, accidental, suicidal, and homicidal he has used the dimension of lethality to cut across the terms attempted, threatened, and completed suicide.