Why do young people want to take their own lives?
Suicide among young people is not on the decline as it is in other age groups, and the number of suicide attempts is rising sharply. In order to reverse this trend, researchers at Karolinska Institutet are trying to understand the underlying factors. They are also examining different methods of discovering risk individuals and of preventing mental ill-health in young people in general.
"There's no simple reason why young people are becoming more and more depressed, as it's the result of a number of coinciding factors," says Britta Alin Åkerman, psychologist and professor emeritus at the Swedish National Prevention of Suicide and Mental Ill-health (NASP), a department under KI's Department of Public Health Sciences.
Professor Emeritus Åkerman has worked with the mental health of young people since the mid 1960s, and believes that although many of the recent changes that have occurred in society might be largely positive, they have left young people more vulnerable.
There are also a number of signs that mental ill-health amongst young people is on the rise. For instance, the number of young women treated in hospital after an attempted suicide or other self-destructive act is much higher now than it was in the early 1990s, according to the 2009 Public Health Report.
Feelings of severe anguish, worry and anxiety have also tripled amongst young people over the past twenty years. What is the reason for this and why do so many young people try to take their own lives?
To answer these questions, scientists have isolated a number of health and risk factors at an individual, community and social level, no one of which can alone account for a suicide event. The societal factors have changed considerably in recent time for young people; for one, the work climate is tougher, both for young people and their parents, which puts heavier demands on education. Consequently, it is more common for students to feel depressed than it is for young people with a job.
"These days all school pupils are expected to go to an upper secondary school," says Professor Emeritus Åkerman. "But for some young people it is better to enter vocational training. Not everyone has a theoretical bent, and for those who don't, the pressure can give rise to deep feelings of failure."
Fewer school counsellors and psychologists
The pressure has also increased on high-performing students. Another gradual change that has taken place in schools is a decrease in the number of school counsellors and psychologists - the personnel with the most mental health training. School nurses are still present, but having sole responsibility for 1,000 to 1,500 students is not easy, says Professor Emeritus Britta Alin Åkerman.
"Schools have the important task of identifying depressed students and passing them on to the healthcare services," she continues. "But many teachers feel they lack the skills to identify and handle mental ill-health. Our research shows that training in how to handle students in a crisis was twice as common a couple of decades ago than it is today."
Having to handle choice
There is also much to suggest that the greater level of choice in todays society is difficult for young people to cope with.
"I've shown in my research that many young people have trouble prioritising from among all the choices they have to make at school," says Professor Emeritus Britta Alin Åkerman. "They can't differentiate between choices that are important and not so important, and are afraid of making the wrong choices for their future."
While choice is probably good for most people, she argues, it can be very hard to deal with for the most vulnerable individuals. People's vulnerability and ability to cope with pressure and change vary widely.
The link between genes and suicide still a mystery
Professor Danuta Wasserman is head of NASP, and has devoted all her working life to research and education around suicide prevention. She believes that genetic factors go some way to explaining why certain people have a greater propensity for displaying suicidal behaviour.
"There's a big difference between how people respond to similar traumas, and we need to know more about the connection with the individual's genetic and physiological circumstances. The time of life at which the trauma occurs is also important, as some stages of development are more sensitive than others. In this respect it's interesting to study how the influence of genetic factors varies with the different stages of life; we know, for example, that gene expression varies with age and brain development," she says.
To date, the link between heredity and suicide is a rather unstudied field, but Danuta Wasserman believes that genetic differences might also explain differences in suicidal behaviour between the sexes, and in the efficacy of treatment between individuals and age groups. For instance, some young people taking antidepressant drugs (SSRI) run a risk of suicide not seen in the others.
"We don't know the reason for the difference, but it can be genetic," says Danuta Wasserman. "Gene expression in the brain changes with age, although the process is largely a mystery. This doesn't mean, however, that we should stop treating young people with antidepressant drugs. But we must combine their pharmaceutical treatment with psychological treatment and impose very tight controls."
The link between depression, chronic aguish and suicide is a strong one, and roughly seventy-five per cent of fatal suicide attempts have several depressive symptoms, often compounded by chronic anguish. The treatment of depression and anguish is therefore an important preventative measure. In fact, the lower number of suicides in society has coincided with a sharp increase in the use of SSRIs. However, the actual correlation between the decline in suicide rate and SSRI use is still not fully understood.
For young people with depression, the picture is made more complicated by the way that treatment entails an increased risk of suicide for certain individuals. This impelled the American FDA to issue a warning in 2003, and the fear that drugs can trigger suicide in depressed patients has led to a decline in SSRI treatment for young people in America. In Europe and Sweden, the link between suicide rates and SSRI treatment has been less marked.
Danuta Wasserman believes that the lack of effective drug treatment without side effects for young people with depression can be one of the reasons why the suicide rate in this group is not falling; more studies are needed on this, however.
The relationship between suicide and the consumption of antidepressants in young people is also one of the European Medicines Agency's (EMEA) six priority research fields and a similar priority for a network of European research groups led by Danuta Wasserman.
"When preventing suicide in young people, pharmaceutical treatment has to be combined with psychological methods," she says. "Biological treatment methods are important for restoring balance to the central nervous system, but existential problems require psychological and psychiatric methods. We therefore need to study the preventative effects of these treatments more."
An important aspect of suicide prevention is supporting parents in their efforts to give their children a secure upbringing and the chance to develop their self-confidence.
"We had a global financial crisis in the 1990s, which caused a great deal of anxiety and worry," says Danuta Wasserman. "This might have made parents less receptive to their childrens mental health, something which might go some way to explaining the mental ill-health seen in todays young people. There is a risk that the present economic crisis will have the same effect."
Warning signs to take seriously
Reaching depressed young people in time is a critical aspect of suicide prevention. There are a number of warning signs that someone is close to suicide. These signals are especially important to heed and take seriously when observed in young people.
"A young person often lacks life experience and insight into the ups and downs of life that otherwise might help them understand that problems can disappear and difficulties can pass," says Britta Alin Åkerman. "This means that they tend to act on impulse. Suicide or attempted suicide can thus occur more suddenly in young people, and so it's important for others to notice any help those showing signs of mental ill-health as soon as they can." Training school and healthcare staff to identify risk individuals is therefore essential and makes up much of NASP's work.
"Our research shows that training in the prevention of mental ill-health makes it easer for vulnerable pupils to be identified, so such training should be compulsory for all teachers," says Britta Alin Åkerman.
Unfortunately, suicide is still surrounded by myth and taboo, which makes it more difficult for help to be given. One way of combating these notions is, according to the scientists, to speak openly about mental ill-health and suicide.
In order to help create a more open climate in schools around mental ill-health and suicide, NASP has prepared a prevention programme comprising a film and student and staff packs.
In the film, which is called "Love is the greatest kick", four young people talk about their lives and thoughts about suicide. The film has been screened in around 200 schools, and a brief evaluation has shown that more pupils dared to talk openly about suicide and their mental ill-health after having seen the film, compared to those who did not see the film.
There are other similar prevention programmes at work, perhaps the most famous being the USA's Florida Programme, where the number of suicides more than halved when it was tested on over 330,000 school pupils.
However, many Swedish schools do not give matters of mental ill-health priority, and according to one NASP study from 2003, the majority of schools in the country lack a preventative programme and have no prevention training for their. A recent survey carried out by NASP on behalf of the government shows that this is still the case.
"I'm afraid to say that most schools have no contingency plans for dealing with mental ill-health and the will to work preventatively is very low, despite there being a tool to use," says Britta Alin Åkerman.
For example, research shows that there is a clear correlation between bullying and suicidal behaviour, and Swedish law requires all schools to have anti-bullying programmes. But the law is often not complied with. Incorporating suicide prevention measures into such a programme is not difficult to do, says Britta Alin Åkerman, but most schools have no prevention strategies at all.
Better tools to help strengthen young people's self esteem and improve their ability to overcome their negative feelings and destructive behaviour is something else for which Danuta Wasserman sees a need.
"Self-esteem and an ability to handle relations makes it easier for young people to overcome their sense of hopelessness, and thus they constitute a form of protection against suicide," she says. "This applies to shy and withdrawn children as much as it does to extrovert and aggressive children."
According to Danuta Wasserman, suicide prevention is a very neglected field of research, very much because of the prevailing taboos and myths surrounding the subject. However, she believes there has been a positive change in recent years.
"The Swedish government adopted a zero-vision strategy to suicide last year, and one of the things they did in connection with this was to make moves to improve the understanding of suicide and suicide prevention. Also, the EU has earmarked extra funds to research into suicide this year too," she says.
Text: Cecilia Odlind. Published in Medical Science, issue no 4, 2009.