Perspective
Familial Pathways to Suicidal Behavior — Understanding and Preventing Suicide among Adolescents
N Engl J Med 2006; 355:2719-2721December 28, 2006
- Article
A 16-year-old boy whose brother recently committed suicide is seen in the emergency room after slashing his wrists. He reports having felt severely depressed and hopeless since his brother died and has markedly increased his alcohol intake. His depression actually began 4 years ago, after the death of his father, and has continued unabated. The patient has a history of being disciplined for fighting in school, usually after being teased or provoked by his peers. Immediately before his suicide attempt, he had a fight with his girlfriend, his mood plummeted, and he decided that he might as well be dead. His mother reports that the boy's father died of “accidental carbon monoxide poisoning.” The father had had problems with depression, alcohol dependence, and aggression and most likely also committed suicide.
This patient has many of the known risk factors for suicide in a young person: a mood disorder, alcohol abuse, recent loss of a loved one, and a family history of suicidal behavior.1 Although suicide is the third leading cause of death among young people, the vast majority of people who face personal losses, have mood disorders, and abuse alcohol neither attempt nor complete suicide. What additional characteristics might explain why this teenager would do so? We have proposed a stress-diathesis model for adults that, along with the familial transmission of vulnerabilities to suicidal behavior, may help to explain and predict suicide among young people (see diagram
Familial Pathways to Early-Onset Suicidal Behavior.).2 Important stressors that may originate outside the family include the acute despair associated with relationship crises or other personal losses or failures, especially if experienced in the context of a major depression. In combination with such stressors, the inherited diathesis predisposes people to suicidal behavior.Such a model, of course, leaves room for great individual variation in the factors and processes that lead to suicide.2 Many teenagers who attempt suicide show evidence of an inability to regulate their mood or tolerate distress. Faced with an upsetting situation, some vulnerable teenagers focus excessively on suicide as a solution and act impulsively, evincing limited cognitive flexibility, poor problem-solving abilities, and difficulty with inhibiting inappropriate responses. These same factors contribute to a common correlate of suicidal behavior: impulsive aggression, defined as the tendency to respond to provocation or frustration with hostility or aggression. For other young people, hopelessness and depression may play a more critical role. Ultimately, the confluence of multiple risk factors results in the highest risk for suicidal behavior.
The tendency toward such behavior is often familial and most likely has a genetic component. Studies of adopted children and twins show that familial concordance for suicidal behavior is explained by both genetic and environmental factors.3 Although psychiatric disorders also run in families, suicidal behavior appears to be familially transmitted independently of these disorders. For example, among parents with a mood disorder, those who have attempted suicide are more than six times as likely as those who have not to have a child who attempts suicide, even though the offspring of both groups have similar rates of mood disorders.3 Suicidal behavior that begins before 25 years of age is highly familial, and having a greater number of affected family members is associated with an earlier age at appearance of suicidal acts. A better understanding of the mechanisms of familial transmission of suicidal behavior could help us to identify vulnerability factors with greater precision, thereby informing treatment and prevention efforts.
Our knowledge about the sequence of and relation between salient factors leading up to suicidal behavior is incomplete, which limits our ability to build a causal model. However, impulsive aggression seems to be key in the network of relevant factors.2,3 Within groups of diagnostically similar patients, impulsive aggression is strongly associated with suicidal behavior, because it increases the likelihood that a person will act on suicidal thoughts. Impulsive aggressive traits, which are highly heritable, are more severe in patients with greater numbers of family members manifesting suicidal behavior and appear to be transmitted from parent to child along with a tendency toward suicidal behavior. Neurobiologic and neuropsychological investigations seem to support this link.3 Lower levels of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) are found in persons with suicidal behavior or impulsive aggression than in diagnostically and demographically similar controls.
Postmortem and imaging studies of persons who have completed or attempted suicide have identified alterations in the number and function of serotonin receptors in the regions of the prefrontal cortex that are involved in emotion regulation and behavioral inhibition.2 Neurocognitive deficits in executive functioning, working memory, accurate assessment of risk, and problem solving have been found to correspond to these regional alterations in the brain in persons who have attempted suicide. These deficits may underlie the cognitive rigidity seen in our teenage patient: he was unable to think of alternatives to suicide, to weigh the benefits and risks of a suicide attempt, or to redirect his thoughts in order to find relief from his depressed mood. Moreover, in persons prone to suicide, both depression and a family history of suicidal behavior exacerbate difficulties with problem solving.
Early childhood abuse and neglect appear to contribute to the familial transmission of suicidal behavior by compounding genetic vulnerability.1-3 Studies in nonhuman primates show that early neglect by parents results in alterations in serotonin function in the brain, with attendant increases in impulsivity and aggression, especially in those who are genetically vulnerable.2 Parents who attempt suicide often have risk factors, such as impulsive aggression, that not only may be passed on to their children but also may affect the parent's ability to provide an optimal environment for child rearing.
Could bereavement or imitation help to explain the clustering of suicide within families? Our patient apparently did not realize that his father had committed suicide, but his own attempt followed his brother's suicide. His depression and drinking worsened after his brother's death, contributing to his risk of suicide. A suicide of a close friend or sibling, however, does not usually increase the risk of a suicide attempt; such imitation is more likely to be triggered by a suicidal model who is not personally known to the imitator.1,3 Furthermore, studies show concordance for suicidal tendencies between adoptees and their biologic relatives but not their adoptive families, suggesting that familial transmission is more closely linked to genetics than to imitation.
Unfortunately, these findings are insufficient to permit accurate prediction of who will commit suicide, but they do suggest that impulsive aggression, neurocognitive difficulties, and family adversity might be considered potential targets for treatment in persons who have attempted suicide. No one would question the need to treat our patient's depression and alcohol dependence, but his impulsive aggression, difficulties with the regulation of emotion, limited problem-solving skills, and cognitive inflexibility might still confer a significant risk of suicide the next time a crisis occurs. In fact, some promising treatments that reduce the recurrence of suicidal behavior focus on the enhancement of the regulation of emotions, tolerance for distress, and cognitive flexibility in order to improve the efficacy of generating viable alternatives to suicide during a crisis.4 Mood stabilizers, such as lithium, prevent suicide in some populations and, despite their known side effects, deserve further study, since they may positively affect decision making or impulsive aggression.2,5
We believe that future treatment studies should incorporate neurocognitive indicators of risk, as well as interventions aimed at altering these core vulnerabilities. The development of complementary psychosocial and pharmacologic interventions that target emotional and cognitive difficulties common among suicide-prone persons could prove to be a major advance for the treatment of adolescents who attempt suicide and might aid in preventing suicide in those who have a high familial risk.
Dr. Mann reports having received consulting fees from Eli Lilly.
Source Information
Dr. Brent is the academic chief of child psychiatry and director of the Services for Teens at Risk (STAR) Center at the University of Pittsburgh School of Medicine, Pittsburgh; he also holds an endowed chair in suicide studies. Dr. Mann is chief of the Department of Neuroscience and director of research at the New York State Psychiatric Institute and a professor of translational neuroscience at Columbia University College of Physicians and Surgeons, New York.
- References
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Kenneth R. Conner, Annette L. Beautrais, David A. Brent, Yeates Conwell, Michael R. Phillips, Barbara Schneider. (2011) The Next Generation of Psychological Autopsy Studies. Suicide and Life-Threatening Behaviorno-no
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Bibilola Damilola Oladeji, Oye Gureje. (2011) Parental Mental Disorders and Suicidal Behavior in the Nigerian Survey of Mental Health and Well-Being. Archives of Suicide Research 15:4, 372-383
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Nicola Madge, Keith Hawton, Elaine M. McMahon, Paul Corcoran, Diego Leo, Erik Jan Wilde, Sandor Fekete, Kees Heeringen, Mette Ystgaard, Ella Arensman. (2011) Psychological characteristics, stressful life events and deliberate self-harm: findings from the Child & Adolescent Self-harm in Europe (CASE) Study. European Child & Adolescent Psychiatry 20:10, 499-508
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Tina R. Goldstein, Mihaela Obreja, Wael Shamseddeen, Satish Iyengar, David A. Axelson, Benjamin I. Goldstein, Kelly Monk, Mary Beth Hickey, Dara Sakolsky, David J. Kupfer, David A. Brent, Boris Birmaher. (2011) Risk for Suicidal Ideation Among the Offspring of Bipolar Parents: Results From the Bipolar Offspring Study (BIOS). Archives of Suicide Research 15:3, 207-222
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Martie P. Thompson, Laney S. Light. (2011) Examining Gender Differences in Risk Factors for Suicide Attempts Made 1 and 7 Years Later in a Nationally Representative Sample. Journal of Adolescent Health 48:4, 391-397
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Marc T. Swogger, Sungeun You, Sarah Cashman-Brown, Kenneth R. Conner. (2011) Childhood physical abuse, aggression, and suicide attempts among criminal offenders. Psychiatry Research 185:3, 363-367
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M K Nock, I Hwang, N A Sampson, R C Kessler. (2010) Mental disorders, comorbidity and suicidal behavior: Results from the National Comorbidity Survey Replication. Molecular Psychiatry 15:8, 868-876
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J Brezo, A Bureau, C Mérette, V Jomphe, E D Barker, F Vitaro, M Hébert, R Carbonneau, R E Tremblay, G Turecki. (2010) Differences and similarities in the serotonergic diathesis for suicide attempts and mood disorders: a 22-year longitudinal gene–environment study. Molecular Psychiatry 15:8, 831-843
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Linda M. Pirruccello. (2010) Preventing Adolescent Suicide. Journal of Psychosocial Nursing and Mental Health Services 48:5, 34-41
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Martie Thompson, Chinthaka Kuruwita, E. Michael Foster. (2009) Transitions in Suicide Risk in a Nationally Representative Sample of Adolescents. Journal of Adolescent Health 44:5, 458-463
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Shirley Y. Hill, Shuhui Wang, Bryan Kostelnik, Howard Carter, Brian Holmes, Michael McDermott, Nicholas Zezza, Scott Stiffler, Matcheri S. Keshavan. (2009) Disruption of Orbitofrontal Cortex Laterality in Offspring from Multiplex Alcohol Dependence Families. Biological Psychiatry 65:2, 129-136
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Amy Wenzel, Aaron T. Beck. (2008) A cognitive model of suicidal behavior: Theory and treatment. Applied and Preventive Psychology 12:4, 189-201
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Kanita Dervic, David A. Brent, Maria A. Oquendo. (2008) Completed Suicide in Childhood. Psychiatric Clinics of North America 31:2, 271-291
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Stan Kutcher, David M Gardner. (2008) Use of selective serotonin reuptake inhibitors and youth suicide: making sense from a confusing story. Current Opinion in Internal Medicine 7:2, 204-208
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Gwendolyn Portzky, Kees van Heeringen. (2007) Deliberate self-harm in adolescents. Current Opinion in Psychiatry 20:4, 337-342
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Donald E. Greydanus, Joseph Calles. (2007) Suicide in Children and Adolescents. Primary Care: Clinics in Office Practice 34:2, 259-273
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