Barriers to treatment for suicidal adolescents are generally the same as those discussed throughout this chapter: low access to care, low help seeking behavior, low utilization, problems with clinician detection of suicidality, and problems with referral or adherence to care. The empirical basis of these findings is primarily from studies of adolescent suicide attempters. Extrapolating from studies of suicide attempters to completers is problematic for adolescents because attempters are more likely to be female, whereas completed suicides are more likely to be male. Female adolescents are more likely than males to identify a need for mental health help (Saunders et al., 1994).
Access to mental health care is one of the foremost problems. Adolescents at the highest risk for suicide completion have dropped out of school and are unemployed. Their odds for suicide compared to controls are increased 44-fold (Gould et al., 1996). These adolescents, by definition, would not have access to school-based mental health services or employer supportive services.
Adolescent suicide attempters typically first access care in emergency departments, but up to half receive no formal treatment after their emergency department visit (Spirito et al., 1989). Of those receiving care after a visit, non-adherence is exceedingly common. In an inner city hospital where they had received emergency care, 77 percent of adolescent suicide attempters dropped out of treatment in the outpatient psychiatry clinic. Attempters kept significantly fewer appointments than did nonattempters (Trautman et al., 1993). In a separate study at the same clinic, age was inversely related to treatment adherence in male adolescents: younger males (ages 11–15) were more likely to keep appointments after emergency care than were older male suicide attempters (ages 16–19; Piacentini et al., 1995). The reasons for failure of adolescents to attend treatment are likely to include parent resistance to treatment, repetitive evaluations, long waiting periods, and poor communication in the emergency department (Rotheram-Borus et al., 2000; Rotheram-Borus et al., 1994).
Medication adherence is also low among adolescents, although there appear to be no direct data in suicide attempters or completers. In a study of adolescents discharged from inpatient psychiatric care, only 38 percent were adherent. Substance abuse was a major predictor of non-adherence (Lloyd et al., 1998).
Detection of suicidality is another barrier to treatment. Only 9 percent of teachers and only one-third of high school counselors thought that they could recognize a student at risk (King et al., 1999a; King et al., 1999b). Despite the fact that previous suicide attempt is the strongest predictor of