24-Hour Warning Signs for Suicide Attempt

Background

With adolescent suicide rates increasing by 50% since 2001 and approximately 10% of U.S. high school students reporting a suicide attempt within a 12-month period, identifying imminent warning signs is crucial. This PECARN study addresses a critical knowledge gap by examining the 24-hour warning signs preceding adolescent suicide attempts [1].

Study Question

What warning signs in the 24 hours preceding an adolescent suicide attempt can help identify acute risk?

Study Design

  • Design: Case-crossover comparing 24 hours before attempt vs. control period
  • Enrolled 1,094 adolescents (ages 13-18) with suicide risk factors from 14 PECARN emergency departments
  • Study sample: 105 of 1094 who reported a suicide attempt on a text message survey and confirmed intentional self-harm at an interview 
  • Bi-weekly text message surveys for 18 months to identify attempts
  • Included both adolescent +/- parent interviews

Key Findings

The authors identified a myriad of warning signs that were significant based on univariate analysis. That means that these signs, when analyzed alone, differentiated those teens who were at risk for a suicide attempt within 24 hours. This provides a general screening tool for observers, such as family members and friends, who may be unaware of or notice all warning signs.

Fewer warning signs were found to be significant based on multivariate analyses, because this stricter statistical approach examines which warning signs remain independently significant while controlling for all other warning signs. In other words, multivariate analysis helps identify which warning signs stand on their own merit rather than just being correlated with other warning signs. This distinction is clinically important: while any single univariate warning sign could indicate risk and warrant attention, the multivariate warning signs may be particularly powerful indicators of imminent risk.

For example, both adolescents and parents identified withdrawal and suicidal communications as significant in multivariate analysis, suggesting these may be especially important warning signs to monitor. However, the longer list of univariate warning signs – including sleep problems, emotional changes, and negative life events – remains clinically valuable since observers may only notice only 1-2 signs rather than the full constellation of risk factors.

The following are all the significant univariate warning signs, with those that remained significant in multivariate analysis in bold:

Parent-Reported Warning Signs:

  1. Withdrawal from social activities and people
  2. Suicidal communications
  3. Problem with sleep
  4. Risky behavior (including drug use)

Adolescent-Reported Warning Signs:

Behaviors/Events:

  1. Withdrawal from people/activities
  2. Serious conflict with parent
  3. Suicidal communications
  4. Negative romantic event
  5. Problem with sleep
  6. Other negative interpersonal event
  7. Other negative life event

Cognitions:

  1. Suicidal rumination
  2. Perceived burdensomeness
  3. Angry or hostile thoughts
  4. Hopelessness
  5. Could not escape problems
  6. Thwarted belongingness
  7. Failure
  8. Not stop worrying

Feelings/Emotions:

  1. Self-hate
  2. Rush of feelings
  3. Emotional pain
  4. Decreased rage toward others
  5. Down/depressed
  6. Scared
  7. Ashamed
  8. Turmoil in gut
  9. Stirred up inside
  10. Alone
  11. Hollow/empty
  12. Numb
  13. Hurt by someone
  14. Do not have friends that can trust completely

Clinical Applications

Assessment Considerations

  1. Include both parent and adolescent perspectives when possible
  2. Focus on recent changes in behavior, especially social withdrawal
  3. Pay attention to recent interpersonal conflicts, particularly with parents
  4. Note that withdrawal was consistently identified by both parents and adolescents

Safety Planning Implications

  • Educate parents about observable warning signs, particularly:
    • Suicidal communications
    • Social withdrawal
    • Changes in sleep patterns
    • Risky behavior (including drug use)
  • Help families develop specific response plans when warning signs emerge

Study Limitations

  • Retrospective methodology
  • Study population enrolled from academic emergency departments
  • Sample demographics: 81.9% female
  • 64% retention rate for follow-up interviews

Take home messages

  1. Both withdrawal from social activities and suicidal communications emerged as robust warning signs in multivariate analyses from both parent and adolescent reports, suggesting these merit particular attention in acute risk assessment.
  2. The identification of distinct parent-reported versus adolescent-reported warning signs underscores the importance of gathering multiple perspectives during emergency department evaluations of suicidal teens.

Why is this important for patients and caregivers

This research provides concrete, observable signs that may indicate acute suicide risk in adolescents. For families and caregivers, knowing these warning signs is crucial because:

  • They are observable within a critical 24-hour window.
  • Many can be noticed by parents and other caregivers.
  • They differ from longer-term risk factors, which include a family history of suicide, chronic substance use disorder, diagnosed mental health conditions, and history of prior suicide attempt.
  • They can prompt immediate intervention.

The study’s findings emphasize that sudden changes in social behavior, particularly withdrawal, and interpersonal conflicts may signal imminent risk. This knowledge empowers families and healthcare providers to recognize and respond to acute suicide risk more effectively.

Funding: This work was supported by the National Institute of Mental Health (grant number: R01MH113582)

Reference

  1. King CA, Gipson Allen PY, Ahamed SI, et al. 24-Hour warning signs for adolescent suicide attempts. Psychol Med. 2024;54(7):1272-1283. doi:10.1017/S0033291723003112. PMID 37947215
Michelle Lin, MD

Michelle Lin, MD

University of California, San Francisco

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