More Than “Teen Angst”: What to Watch For

The incidence of high-risk behavior among teenagers has attracted increased media attention lately. It feels like a new report surfaces every day detailing the death of one or more teens as a result of alcohol, illicit drug use, or speeding. These risky behaviors grab our attention; they are overt and somewhat public. But behaviors that correlate with anxiety and depression, which can in turn lead to suicide or suicidal ideation, are more subtle—and that is what concerns me.

The data on suicide is staggering. On a daily basis, almost 3,000 people worldwide complete suicide, and approximately 20 times as many survive a suicide attempt.¹ Annually, deaths resulting from suicide exceed deaths from homicide and war combined.² In 2013, there were 41,149 suicides in the US—that translates to a rate of 113 suicides each day, or one every 13 minutes.³ Suicide has surpassed homicide to become the second leading cause of death among 10- to 29-year-olds; in 2012, suicide claimed the lives of more than 5,000 people within this age bracket.^4,5 In the 2013 Youth Risk Behavior Survey (YRBS), 17.7% of high school students reported seriously considering suicide during the prior 12 months, and nearly 9% of those students had attempted suicide during that same period.⁶ I wonder how many of those students exhibited telling behaviors that went unnoticed.

What are these subtle signs that are so easily overlooked? Behaviors most might consider “within the norm” of today’s youth—hours playing video games, sending hundreds of texts every day, lack of exercise, and lack of sleep. Research has demonstrated that moderate-to-vigorous physical activity reduces the incidence of depression in adolescents.⁷ A 2014 study of European teens published in World Psychiatry found that the adolescents most at risk for symptoms of depression and anxiety are those who are fixated on media, don’t get enough sleep, and have a sedentary lifestyle.⁸ Hmm... sounds like many US teenagers today. While that doesn’t mean that every teen who lacks sleep, plays video games, or isn’t active is at risk, we do need to pay closer attention to them, because this combination exacerbates risk.

There’s another unhealthy habit that contributes to the risk for teen suicidality: smoking and use of electronic vapor products (EVPs). The 2015 YRBS, which surveyed more than 15,000 high school students, noted that 3.2% smoked cigarettes only, 15.8% used EVPs only, and 7.5% were dual users. Analysis of that data identified associations between health-risk behaviors and both cigarette smoking and EVP use.⁹ Teens who smoked or used EVPs were more likely to engage in violence, substance abuse, and other high-risk behaviors, compared with nonusers. Moreover, compared with nonusers, cigarette-only, EVP-only, and dual smokers were significantly more likely to attempt suicide; cigarette-only smokers were more likely than EVP-only users to attempt suicide.⁹

Smoking, inactivity, sleep deprivation, and social isolation (because texting or face-timing with your friends is not being social) are a recipe for depression and anxiety in an adolescent. Sleep deprivation alone has been linked to depression and may be associated with a decreased ability to control, inhibit, or change emotional responses.¹⁰ Far too often, teens view suicide as the only relief from these feelings.

Awareness of this problem has grown in the past 30 years. The YRBS was developed in 1990 to monitor priority health risk behaviors that contribute to the leading causes of death, disability, and social problems among youth in the US—one of which is suicide.¹¹ In 2001, the Department of Health and Human Services introduced the National Strategy for Suicide Prevention, the first national program of its kind, and released an evidence-based practice guide for school-based suicide prevention plans.¹² The 2002 Institute of Medicine report Reducing Suicide: A National Imperative recognized the need for early recognition and prevention of suicidality.¹³ And yet, we still have the staggering statistics I cited earlier.

Because of their proximity to children and adolescents, schools are frequently viewed as an integral setting for youth suicide prevention efforts. It is encouraging that suicide prevention programs exist in more than 77% of US public schools—but disheartening that it is not 100%.

And what about the rest of us? What can we, as health care providers, do to stem this tide of teen suicide? The importance of early prevention strategies to reduce onset of suicidal thoughts and help identify persons who are at risk for or are currently contemplating suicide cannot be overemphasized. We need more health care practitioners who are trained to assess suicide plans and to intervene with young persons. This involves education in recognizing risk factors and making appropriate referrals, expanding access to social services, reducing stigma and other barriers to seeking help, and providing awareness that suicide prevention is paramount.

It is incumbent on us as health care providers to screen for and ask our teenaged patients about those subtle behaviors. As adults, it is our responsibility to support and watch over our youth. In the words of former Surgeon General David Satcher, “We must act now. We cannot change the past, but together we can shape a different future.”¹⁴

The incidence of high-risk behavior among teenagers has attracted increased media attention lately. It feels like a new report surfaces every day detailing the death of one or more teens as a result of alcohol, illicit drug use, or speeding. These risky behaviors grab our attention; they are overt and somewhat public. But behaviors that correlate with anxiety and depression, which can in turn lead to suicide or suicidal ideation, are more subtle—and that is what concerns me.

The data on suicide is staggering. On a daily basis, almost 3,000 people worldwide complete suicide, and approximately 20 times as many survive a suicide attempt.¹ Annually, deaths resulting from suicide exceed deaths from homicide and war combined.² In 2013, there were 41,149 suicides in the US—that translates to a rate of 113 suicides each day, or one every 13 minutes.³ Suicide has surpassed homicide to become the second leading cause of death among 10- to 29-year-olds; in 2012, suicide claimed the lives of more than 5,000 people within this age bracket.^4,5 In the 2013 Youth Risk Behavior Survey (YRBS), 17.7% of high school students reported seriously considering suicide during the prior 12 months, and nearly 9% of those students had attempted suicide during that same period.⁶ I wonder how many of those students exhibited telling behaviors that went unnoticed.

What are these subtle signs that are so easily overlooked? Behaviors most might consider “within the norm” of today’s youth—hours playing video games, sending hundreds of texts every day, lack of exercise, and lack of sleep. Research has demonstrated that moderate-to-vigorous physical activity reduces the incidence of depression in adolescents.⁷ A 2014 study of European teens published in World Psychiatry found that the adolescents most at risk for symptoms of depression and anxiety are those who are fixated on media, don’t get enough sleep, and have a sedentary lifestyle.⁸ Hmm... sounds like many US teenagers today. While that doesn’t mean that every teen who lacks sleep, plays video games, or isn’t active is at risk, we do need to pay closer attention to them, because this combination exacerbates risk.

There’s another unhealthy habit that contributes to the risk for teen suicidality: smoking and use of electronic vapor products (EVPs). The 2015 YRBS, which surveyed more than 15,000 high school students, noted that 3.2% smoked cigarettes only, 15.8% used EVPs only, and 7.5% were dual users. Analysis of that data identified associations between health-risk behaviors and both cigarette smoking and EVP use.⁹ Teens who smoked or used EVPs were more likely to engage in violence, substance abuse, and other high-risk behaviors, compared with nonusers. Moreover, compared with nonusers, cigarette-only, EVP-only, and dual smokers were significantly more likely to attempt suicide; cigarette-only smokers were more likely than EVP-only users to attempt suicide.⁹

Smoking, inactivity, sleep deprivation, and social isolation (because texting or face-timing with your friends is not being social) are a recipe for depression and anxiety in an adolescent. Sleep deprivation alone has been linked to depression and may be associated with a decreased ability to control, inhibit, or change emotional responses.¹⁰ Far too often, teens view suicide as the only relief from these feelings.

Awareness of this problem has grown in the past 30 years. The YRBS was developed in 1990 to monitor priority health risk behaviors that contribute to the leading causes of death, disability, and social problems among youth in the US—one of which is suicide.¹¹ In 2001, the Department of Health and Human Services introduced the National Strategy for Suicide Prevention, the first national program of its kind, and released an evidence-based practice guide for school-based suicide prevention plans.¹² The 2002 Institute of Medicine report Reducing Suicide: A National Imperative recognized the need for early recognition and prevention of suicidality.¹³ And yet, we still have the staggering statistics I cited earlier.

Because of their proximity to children and adolescents, schools are frequently viewed as an integral setting for youth suicide prevention efforts. It is encouraging that suicide prevention programs exist in more than 77% of US public schools—but disheartening that it is not 100%.

And what about the rest of us? What can we, as health care providers, do to stem this tide of teen suicide? The importance of early prevention strategies to reduce onset of suicidal thoughts and help identify persons who are at risk for or are currently contemplating suicide cannot be overemphasized. We need more health care practitioners who are trained to assess suicide plans and to intervene with young persons. This involves education in recognizing risk factors and making appropriate referrals, expanding access to social services, reducing stigma and other barriers to seeking help, and providing awareness that suicide prevention is paramount.

It is incumbent on us as health care providers to screen for and ask our teenaged patients about those subtle behaviors. As adults, it is our responsibility to support and watch over our youth. In the words of former Surgeon General David Satcher, “We must act now. We cannot change the past, but together we can shape a different future.”¹⁴

The incidence of high-risk behavior among teenagers has attracted increased media attention lately. It feels like a new report surfaces every day detailing the death of one or more teens as a result of alcohol, illicit drug use, or speeding. These risky behaviors grab our attention; they are overt and somewhat public. But behaviors that correlate with anxiety and depression, which can in turn lead to suicide or suicidal ideation, are more subtle—and that is what concerns me.

The data on suicide is staggering. On a daily basis, almost 3,000 people worldwide complete suicide, and approximately 20 times as many survive a suicide attempt.¹ Annually, deaths resulting from suicide exceed deaths from homicide and war combined.² In 2013, there were 41,149 suicides in the US—that translates to a rate of 113 suicides each day, or one every 13 minutes.³ Suicide has surpassed homicide to become the second leading cause of death among 10- to 29-year-olds; in 2012, suicide claimed the lives of more than 5,000 people within this age bracket.^4,5 In the 2013 Youth Risk Behavior Survey (YRBS), 17.7% of high school students reported seriously considering suicide during the prior 12 months, and nearly 9% of those students had attempted suicide during that same period.⁶ I wonder how many of those students exhibited telling behaviors that went unnoticed.

What are these subtle signs that are so easily overlooked? Behaviors most might consider “within the norm” of today’s youth—hours playing video games, sending hundreds of texts every day, lack of exercise, and lack of sleep. Research has demonstrated that moderate-to-vigorous physical activity reduces the incidence of depression in adolescents.⁷ A 2014 study of European teens published in World Psychiatry found that the adolescents most at risk for symptoms of depression and anxiety are those who are fixated on media, don’t get enough sleep, and have a sedentary lifestyle.⁸ Hmm... sounds like many US teenagers today. While that doesn’t mean that every teen who lacks sleep, plays video games, or isn’t active is at risk, we do need to pay closer attention to them, because this combination exacerbates risk.

There’s another unhealthy habit that contributes to the risk for teen suicidality: smoking and use of electronic vapor products (EVPs). The 2015 YRBS, which surveyed more than 15,000 high school students, noted that 3.2% smoked cigarettes only, 15.8% used EVPs only, and 7.5% were dual users. Analysis of that data identified associations between health-risk behaviors and both cigarette smoking and EVP use.⁹ Teens who smoked or used EVPs were more likely to engage in violence, substance abuse, and other high-risk behaviors, compared with nonusers. Moreover, compared with nonusers, cigarette-only, EVP-only, and dual smokers were significantly more likely to attempt suicide; cigarette-only smokers were more likely than EVP-only users to attempt suicide.⁹

Smoking, inactivity, sleep deprivation, and social isolation (because texting or face-timing with your friends is not being social) are a recipe for depression and anxiety in an adolescent. Sleep deprivation alone has been linked to depression and may be associated with a decreased ability to control, inhibit, or change emotional responses.¹⁰ Far too often, teens view suicide as the only relief from these feelings.

Awareness of this problem has grown in the past 30 years. The YRBS was developed in 1990 to monitor priority health risk behaviors that contribute to the leading causes of death, disability, and social problems among youth in the US—one of which is suicide.¹¹ In 2001, the Department of Health and Human Services introduced the National Strategy for Suicide Prevention, the first national program of its kind, and released an evidence-based practice guide for school-based suicide prevention plans.¹² The 2002 Institute of Medicine report Reducing Suicide: A National Imperative recognized the need for early recognition and prevention of suicidality.¹³ And yet, we still have the staggering statistics I cited earlier.

Because of their proximity to children and adolescents, schools are frequently viewed as an integral setting for youth suicide prevention efforts. It is encouraging that suicide prevention programs exist in more than 77% of US public schools—but disheartening that it is not 100%.

And what about the rest of us? What can we, as health care providers, do to stem this tide of teen suicide? The importance of early prevention strategies to reduce onset of suicidal thoughts and help identify persons who are at risk for or are currently contemplating suicide cannot be overemphasized. We need more health care practitioners who are trained to assess suicide plans and to intervene with young persons. This involves education in recognizing risk factors and making appropriate referrals, expanding access to social services, reducing stigma and other barriers to seeking help, and providing awareness that suicide prevention is paramount.

It is incumbent on us as health care providers to screen for and ask our teenaged patients about those subtle behaviors. As adults, it is our responsibility to support and watch over our youth. In the words of former Surgeon General David Satcher, “We must act now. We cannot change the past, but together we can shape a different future.”¹⁴