AACAP Dispatch: "We Don't Have a Model of Care for Suicidal Children that Works"

The crisis of a crisis mentality in the care of suicidal youth

The Frontier Psychiatrists is a Health-themed newsletter. Owen Scott Muir, M.D., writes it. He’s a child psychiatrist. I am reporting from AACAP 2024, the national American Academy of Child and Adolescent Psychiatry meeting. I do quick dispatches from meetings, so this is one of those…This article is about suicide prevention in youth.

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Suicidal adolescents are terrifying. They are terrifying for their families, they are scary for physicians, and they can scare themselves. To be clear, kids want to kill themselves a lot. As I have written previously, I was one of those kids at that age.

How many kids think about killing themselves? Among girls, according to the CDC…

Ahem. Let’s reset the typeface.

1 in 4 girls seriously consider attempting suicide every year.

It may have to do with the fact that 1 in 5 experienced sexual violence in the past year, and more than 1 in 10 had ever been forced to have sex.

Among LGBTQAI youth, just under 1 in 4 attempt suicide every year.

6.6% of boys also attempted suicide in 2021. It is bad.

That is horrifying. Most survive. Many will not. This is a nightmare for parents and kids. It’s about 50 kids thinking about suicide for every kid attempting one setting.¹

I am unclear about what we are doing to change this as a field of medicine or as a society.

At this conference, my colleagues are presenting on non-inpatient care for suicidal youth. To be very blunt, we have ZERO data that inpatient care reduces completed suicide. The risk of completed suicide (not youth-specific data) in a hospital is 50 times higher² than not in a hospital. These individuals are not randomized so they may be at higher risk. But the number doesn’t go down. It goes up. It’s the wrong direction.

After discharge, again across all ages, the numbers are staggeringly bad³:

In this meta-analysis of 100 studies of 183 patient samples, the postdischarge suicide rate was approximately 100 times the global suicide rate during the first 3 months after discharge and patients admitted with suicidal thoughts or behaviors had rates near 200 times the global rate. Even many years after discharge, previous psychiatric inpatients have suicide rates that are approximately 30 times higher than typical global rates.

Again, this is not causal inference data and is at a higher level than youth-specific data, but it is not reassuring.

There are NO CURRENT FDA-APPROVED TREATMENTS for suicidal youth.

So, any hospitals we are admitting children into to help use either medications or therapy or both. The oral medications only have warnings for making suicidal thinking worse — not great data on youth who are already suicidal:

Using “antidepressants” made sense conceptually:

The presence of suicidal thoughts and feelings is one of the criteria pointing toward a diagnosis of depression. Such a diagnosis tends to be followed by a prescription for pharmacotherapy, sometimes in combination with psychotherapy but often only as monotherapy. Because untreated depression is a risk factor for suicide, prescribing an apparently safe drug would seem to be a logical strategy for reducing the number of depression-induced suicides. The perceived safety of the newer antidepressants made it easy for primary care physicians (PCPs) to prescribe them—and they did, in vast amounts.⁴

As a class, all oral antidepressant medicines have a black box warning for MORE suicidal ideation.⁵

Again, I’m not saying these drugs are causing completed suicide in youth. I am saying the hospitals and the drugs we use in them make things WORSE for many or DO NOT CHANGE THINGS FOR THE BETTER in an already adverse disease state. That disease state is wanting to die and being a kid—especially a girl or queer kid. Adults demonstrably act to sexually assault and/or wish death and despair upon the most vulnerable youth.

“There is no data to support psychiatric hospitalization in suicidal youth.”

Some psychotherapies like DBT, MBT, and others have data for effectiveness. I’ve even written a manual on one such therapy (Amazon affiliate link!)

Hospitals do not work⁶. Yet we keep using them. We have no proven effective oral medications in the antidepressant class, at least. Yet we keep using them.

I ask a simple but difficult question:

Why do we keep doing things without evidence that they are helpful?

Where are better treatments? Do kids think we are full of it when we say we want to help? The data on outcomes supports that cynicism.

“Just Asking Questions”

from AACAP, 2023,

—Owen Scott Muir, M.D.

1. Data from UT Southwestern program as presented at AACAP 2024.

2. Chammas F, Januel D, Bouaziz N. Inpatient suicide in psychiatric settings: Evaluation of current prevention measures. Front Psychiatry. 2022 Oct 28;13:997974. doi: 10.3389/fpsyt.2022.997974. PMID: 36386981; PMCID: PMC9650354.

3. Chung DT, Ryan CJ, Hadzi-Pavlovic D, Singh SP, Stanton C, Large MM. Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2017 Jul 1;74(7):694-702. doi: 10.1001/jamapsychiatry.2017.1044. PMID: 28564699; PMCID: PMC5710249.

4. McCain JA. Antidepressants and suicide in adolescents and adults: a public health experiment with unintended consequences? P T. 2009 Jul;34(7):355-78. PMID: 20140100; PMCID: PMC2799109.

5. 19. Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry. 2006;63(3):332–339.

6. Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry. 2006 Mar-Apr;47(3-4):372-94. doi: 10.1111/j.1469-7610.2006.01615.x. PMID: 16492264.