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Journal of Child Psychology and Psychiatry 59:4 (2018), pp 483–485
Commentary: A time to reap and a time to sow:
reducing the adolescent suicide rate now and in the
future: commentary on Cha et al. (2018)
David Brent
Division of Child and Adolescent Psychiatry, Western Psychiatric Institute and Clinic, Pittsburgh, PA, USA
Cha and colleagues have provided an erudite, lucid,
and comprehensive survey of where research on
adolescent suicide has been, and where it should go.
Their paper provides a broad global picture of the
descriptive epidemiology of adolescent suicide,
describes environmental, psychological, social, and
biological processes likely to be associated with
suicidal risk, reviews extant approaches to the
management of adolescent suicidal behavior, and
makes recommendations for future research. This
editorial will expand on some of their recommenda-
tions, and also remind readers, that, regardless of
how much we still need to learn, we do possess
knowledge that, if applied now, could help to reduce
the adolescent suicide rate in the near term.
Cha and colleagues correctly observe that ages
that span ‘youth’ suicide cover a range of develop-
ment from childhood to near-adulthood, and the risk
factors and mechanisms that lead to suicidal behav-
ior may be quite different in younger and older
adolescents. One point to underscore is that there
has been a very disturbing, poorly understood, and
rapid growth in the rate of suicide in youth aged 10–
14, at least in the United States, particularly in girls.
We know very little about the characteristics of
younger suicide victims and what we do know is
based on psychological autopsy studies that were
conducted over 20 years ago. Psychological autopsy
studies that address the antecedents and profiles of
younger suicide victims are needed so that we can do
a better job of detecting at-risk youth and interven-
ing before it is too late.
A second set of recommendations relate to the
opportunities posed by technology to assess, and
potentially intervene with suicidal youth. Longitudi-
nal data suggest that social media use leads to
depression and suicidal ideation rather than vice
versa, and that these effects were in part mediated by
sleep loss (Hokby et al., 2016). Social media use in
excess of 2 hours a day has deleterious effects on
mental health, including increased suicidal ideation,
but these negative effects can be counteracted by
active parental monitoring of social media use (Reid
Chassiakos, Radesky, Christakis, Moreno, & Cross,
2016). Youth may also have ‘suicidal signatures,’ on
the basis of postings and searches that could be
used to identify and intervene with youth at risk
(Braithwaite, Giraud-Carrier, West, Barnes, &
© 2018 Association for Child and Adolescent Mental Health.
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doi:10.1111/jcpp.12903
Hanson, 2016). Clinicians and researchers should
pay more attention to social media use and its
impact on youth in order to intervene effectively
now and in the future.
Other opportunities to leverage the use of technol-
ogy that may enhance detection and early interven-
tion, such as using data gathered from mobile
phones to monitor activity, voice quality, and fre-
quency of calls, have been used to identify changes
in mental state, including changes in depression and
suicidal risk (Pestian et al., 2017). If increased risk
could be reliably assessed through such means, then
once increased risk was detected, this could trigger
messages sent to notify the adolescent’s clinician,
and could encourage the adolescent about the use of
coping strategies, safety plans, and rapid access to
support, thus providing a potential technological
safety net for at-risk patients.
A third set of recommendations emphasize the
importance of focusing on short-term rather than
lifetime suicidal risk. Clinicians who evaluate suici-
dal patients are being asked to determine their risk
in the short-run, not the long-run, yet as Cha et al.
(2018) point out, there is a paucity of research in this
area. One promising approach uses machine learn-
ing to cull information from electronic health records
and was able to accurately predict suicide attempts
in the next 7 days (Walsh, Ribeiro, & Franklin,
2017). One of the important findings from this study
was that the set of risk factors changed as the
window of time expanded or contracted, and that the
shorter term the prediction, the more salient sub-
stance abuse was as a risk factor. In addition to
studies that attempt to predict suicidal behavior in
the short term, it is also important for studies to
hone in on the events and processes that occurred
during the 24 hours prior to a suicide attempt, given
findings cited in Cha et al. that, in young adult
suicide attempters, the majority of steps involved in
making a suicide attempt take place within 6 hours
of the attempt.
A fourth recommendation has to do with conduct-
ing studies across different levels of analysis. It was
clear from this review that studies of molecules,
genes, and imaging have, with few exceptions, not
made strong connections with psychological models
of suicidal behavior. One promising, but preliminary
study, whose team members included this

484 David Brent
editorialist and two of the authors of this review,
examined the neural signatures of suicidal and
nonsuicidal individuals while thinking about sui-
cide-related, negatively, and positively valenced
words. Machine learning-generated algorithms of
brain activation patterns were able to accurately
discriminate suicidal ideators from healthy controls,
and to identify, among the ideators, who had made a
previous suicide attempt (Just et al., 2017). Such
approaches, by examining the neural processes
associated with thinking about suicide, may help to
bridge the gap between imaging studies and those
that test conceptual psychological models.
In a research review, it is appropriate to look to the
future and consider what advances are needed to
improve assessment and treatment. The recommen-
dations made by the authors are sound. Neverthe-
less, there is an additional category of research that
should be considered, which is the testing of the
public health impact of the dissemination of appar-
ently efficacious interventions on the adolescent
suicide rate. There are four approaches to the
reduction of suicide and suicidal behavior for which
there is some empirical support as summarized in a
recent review about suicide prevention (Zalsman
et al., 2016).
First, preventive approaches, whether delivered in
the classroom or to the family, have been shown to
have long-lasting effects on suicidal ideation and
attempt on follow-up. The Good Behavior Game, a
teacher-led intervention, promotes prosocial behav-
ior and has been shown to reduce suicidal ideation
and behavior even 25 years after the end of the
intervention. The Youth and Mental Health Interven-
tion is a curricula-based intervention for high school
students that has been shown to cut the suicide
attempt rate in half 12 months after its implemen-
tation (Zalsman et al., 2016). Several preventive
interventions designed to augment family resiliency
have been shown to have longer term protective
effects against suicidal ideation and behavior.
Future work could test whether widespread imple-
mentation of such empirically supported programs
could affect the adolescent suicide rate.
Second, improving access to evidence-based men-
tal health care for depression and suicidal behavior
has been shown to reduce regional rates in suicide
and suicidal behavior (Zalsman et al., 2016). Regio-
nal improvements in primary care practitioner iden-
tification and management of depression and
increased use of antidepressants are associated with
regional reductions in suicide (Zalsman et al., 2016).
While Cha and colleagues are correct that the yield
from the study of psychiatric disorder and suicide is
diminishing, our services are still organized around
traditional nosology and improvements in depres-
sion care, however imperfect, can result in reduc-
tions in suicide.
Third, improvements in the ways in which mental
health care is delivered can substantially reduce
14697610, 2018, 4, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.12903 by National Medical Library The Director, Wiley Online Library on [23/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
J Child Psychol Psychiatr 2018; 59(4): 483–5
regional suicide rates. Louis Appleby and his team
have identified several service innovations that
address service delivery risk factors for patient sui-
cide. Implementation of these changes resulted in
21%–29% reductions in suicide in the regions in
which they were implemented (Kapur et al., 2016).
These service changes include implementation of
measurement-based care for depression, availability
of a 24-hour crisis line, availability of dual diagnosis
treatments, assertive outreach for nonadherent
patients, and having a clear policy for transfer of
patient from adolescent to adult services (Kapur et al.,
2016).
Fourth, restriction of access to lethal agents has
been shown to be protective across various methods of
suicide, including detoxification of automobile
exhaust, bridge barriers, safer storage for guns, and
lock boxes for pesticides (Zalsman et al., 2016). For
suicidal adolescents, who may be more impulsive
than older suicidal individuals, restriction of the
availability of lethal agents could be even more signif-
icant.
We owe a debt of gratitude to the clear and
thoughtful review contributed by Cha and col-
leagues. This review is appropriately future oriented,
and yet it calls to mind a poem by the poet Yehuda
Amichai. One may recall that in Ecclesiastes, it
states, ‘to everything there is a season. . . a time to
plant, and a time to pluck that which has been
planted.’ In his poem, ‘A Man Doesn’t Have Time in
His Life,’ Amichai offers a rebuttal to this concept,
writing instead that:
A man doesn’t have time in his life
to have time for everything.
He doesn’t have seasons enough to have
a season for every purpose. Ecclesiastes
Was wrong about that.
A man needs to love and to hate at the same
moment,
to laugh and cry with the same eyes,
with the same hands to throw stones and to gather
them (Amichai, 2013).
To reduce the adolescent suicide rate, we need to
reap and sow at the same time. Let us harvest the
knowledge we already have to make inroads into
youth suicide, and follow Cha et al.’s blueprint to
sow seeds for a better future.
Acknowledgements
The author has declared that he has no competing or
potential conflicts of interest, and thanks Joseph Park
for editorial assistance.
Correspondence
David A. Brent, Division of Child and Adolescent
Psychiatry Western Psychiatric Institute and Clinic,
© 2018 Association for Child and Adolescent Mental Health.

doi:10.1111/jcpp.12903
3811 O’Hara Street, Suite 311, Pittsburgh, PA
15213, USA; Email: BrentDA@upmc.edu
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Accepted for publication: 13 February 2018