Preventing youth suicide

The signs that alert us to a risk of suicide are diverse. On the one hand, any verbalization of a negative view of oneself. This translates into expressions such as thoughts like : "I'm worthless," "My life has no meaning," "I'm a burden to my parents," among many other negative ideas.

We must also be alert to changes in behavior that denote a loss of interest in things they previously enjoyed doing, meeting up with friends, or changes, sometimes abrupt, that may draw our attention to that person.

Why do young people commit suicide?

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Some of the most common warning signs are:

• Comments about how to kill oneself or plans to kill oneself or to harm oneself.
• Showing desperation or talking about having no way out, feelings of hopelessness and loneliness.
• To feel a deep pain that does not end and that makes you feel trapped.
• To express that one is a burden to others, that no one cares about oneself, that others would be better off without one...
• Consuming or increasing the consumption of substances such as drugs or alcohol.
• To have anxious or agitated behavior.
• Sleeping too much or too little.
• Abandoning relationships with family, friends, and other important relationships.
• Expressing extreme anger.
• Mood swings, sadness or irritability, demotivation, loss of interest.
• Social and family isolation.

People who talk about suicide aren't doing it for attention. This is a myth that prevents us from taking action. People who talk about suicide are expressing suffering or emotional distress that they don't know how to manage. We must reinterpret this myth: it's a cry for help, an opportunity for those around them to realize they need support.

Pau (fictitious name)

Testimony

Listen to me!

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When someone expresses suicidal thoughts or negative self-talk, such as "I'm worthless," "My life is meaningless," or "I'm a burden to my parents," it's crucial to take it seriously. Seeking professional help is essential, and within the family, it's vital to acknowledge and validate the child's suffering. All threats of suicide are real; this doesn't mean it's imminent, but it's certainly something to be taken seriously.

In general, published studies agree that the transition from suicidal ideation to suicide takes about a year. As always, these studies refer to large samples, so this is a helpful guideline for understanding the overall process. Clinical experience points in the same direction; the young people we treat after a suicide attempt describe processes of months, even years, of suicidal thoughts before acting on them. Unfortunately, all too often, the suicide attempt is the first indication or communication to those around them of this internal process. It has been shown that suicide is not a sudden, impulsive act that we can do nothing about.

If we suspect our son or daughter is thinking about death, we should ask them, even if it's a difficult question. Not doing so is too risky.

We don't know. Therefore, we can't let our guard down. We must act as soon as possible, making it clear that they need help. Please help if anyone mentions their intentions. Let's not wait!

There are various factors or situations that can become risk factors for some young people:

• A real sense of hopelessness about the future.
• Severe depression.
• A previous suicide attempt.
• Some form of psychiatric disorder.
• Alcohol and drug abuse.
• Low self-esteem, which can lead to feelings of guilt or shame.
• A recent loss or grief of someone close.
• Family history of suicide.
• Experiencing another significant suicide (for example, a friend or significant adult).
• Difficulty maintaining social or romantic relationships.
• Persistent bullying or rejection by peers (of the same age).
• Racism.
• Homophobic or LGBTphobic attitudes.
• Easy access to drugs, medication, or other methods.

Many studies have demonstrated the effectiveness of specific interventions in reducing deaths by suicide. It seems clear, therefore, that suicide can be prevented, but it is also evident that to achieve this, many, if not all, of us will need to be involved and committed to this essential goal. Echoing the slogan of the traffic accident prevention advertising we have known and embraced for years: "Zero deaths by suicide."

Diego J. Palao Vidal

Executive Director of Mental Health

Consorci Corporació Sanitaria Parc Taulí de Sabadell

«We can all help prevent suicide deaths»

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There are three levels of prevention depending on the target group. Universal prevention is aimed at the general population, indicated prevention is aimed at a population group at higher risk of developing a problem, for example, people with depression, and selective prevention is aimed at people who have already attempted suicide. Regarding suicidal behavior, when we talk about universal prevention in adolescents, we are referring primarily to universal interventions within the school setting, such as Empowering a Multimodal Pathway Toward Healthy Youth (EMPATHY) or Saving and Empowering Young Lives in Europe (SEYLE).

Regarding targeted and selective suicide prevention, we will discuss interventions that address the essential elements of suicide, such as pain, hopelessness, and attachment, and that help alleviate distress and incorporate personal resources. Examples of these include treatments such as Dialectical Behavior Therapy (DBT ), Cognitive Behavioral Therapy ( CBT ), and Mentalization-Based Therapy (MBT ). These three interventions are not only geared toward treating individuals at risk but are also specifically designed for suicidal ideation and attempts.

If someone is having suicidal thoughts, they need to understand that they're not doing anything wrong, that nothing strange is happening to them that we don't know how to handle, and that their situation isn't irreparable simply because they've thought about death. They should ask for help, talk about it, and know that they're not alone.

It is important to consult a medical or pediatric professional so that they can make a referral to mental health services (Child and Adolescent Mental Health Center (CSMIJ) or Adult Mental Health Center (CSMA)) or, in very urgent cases, consult the mental health emergency services where there are psychiatrists on call who can make an urgent assessment of the case and start treatment or indicate admission, if necessary.

If we detect that our child wants to commit suicide, the immediate actions are parallel. On the one hand, we must implement preventative measures immediately . The essential one in our environment is to lock away all medication in the home so that our child cannot access it. In countries with a high prevalence of firearms, the measure would also include removing all firearms from the house.

In parallel, we also need to seek help from a mental health professional . The procedure for accessing care within the public healthcare system in Spain is to go to your child's pediatrician or primary care physician and inform them of the situation. They will then assess the situation and make a referral to mental health services, which are usually located within the primary care center itself. They will determine whether to address the situation at their center or refer the child to a Child and Adolescent Mental Health Center (CSMIJ, in Catalonia).

In the private or mutual insurance system, you can request a visit with a mental health professional to assess actions to take and steps to follow.

If we find our child in the middle of a suicide attempt or identify that they have just done it, or we consider that we cannot wait for the day of the visit with the referring professional, we must go directly to the emergency room of their reference hospital, both to assess the organic consequences of the attempt if they have carried it out, and if so, their stabilization, as well as for a mental health assessment.

Never tell him: "Don't talk nonsense."

We must avoid saying anything that invalidates or worsens the person's suffering, that poses or is understood as a challenge, that does not take them seriously, or that is a problem for their loved ones.

For example, never say to him/her:

• He just wants attention.
• Don't talk nonsense.
• If he wants to do it, he should do it properly, but he shouldn't bother anyone.
• Nothing's happening.
• Those are his own things.
• That he is in the best moment of his life.
• There are people who are worse off.
• Saying those things to me is going to kill me.
• You're going to kill your father with your things.
• You're just causing trouble.

It will depend on the type of relationship you have with that person to see what is most appropriate, but, in general terms, you should:

• Validate their discomfort: "I understand... it's normal to feel this way" (These are not clichés, this has to be real to reach the person, therefore, before saying this, you have to have listened to them deeply).
• Transmit hope: "We'll get through this together..."
• Strengthen their connection to life: "You know you're not alone, I'm not going to leave you alone, we need you..."

Suicide is not an illness , so there is no specific treatment for someone who wants to commit suicide. However, many treatment approaches have proven effective in suicide prevention, especially those that recognize that suicidal crises require medium- to long-term follow-up.

The World Health Organization Brief Intervention and Contact Program (WHO BIC) has been recognized in a meta-analysis as the intervention with the best results for suicide reduction, surpassing lithium and cognitive behavioral therapy . This intervention consists of a discharge visit and a scheduled follow-up of nine contacts distributed over 18 months (telephone or in-person, distributed weekly and monthly at 1, 2, 4, 7, and 11 weeks, and 4, 6, 12, and 18 months).

Many other therapies have shown benefits in addressing suicidal behavior: Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Transference-Based Therapy (TFP), Multisystemic Family Therapy (MST ), Family-Based Crisis Intervention (FBCI ), and Attachment-Based Family Therapy (ABFT ). Some pharmacological treatments, such as lithium and clozapine, have also demonstrated their effectiveness in suicide prevention.

In the reality of suicide, especially in childhood and adolescence, it is important to tailor treatment to the factors that led the individual to make this decision. But generally speaking, any treatment aimed at increasing life coping skills has the greatest impact on reducing suicide rates in childhood and adolescence.

Suicidal ideation is not an illness and is not recognized as such in any international classification or manual of diseases. This means that suicide cannot be treated with medication; it's not like a wart that can be surgically or chemically removed. This is not to say that medication cannot help. In fact, psychopharmacological strategies for addressing suicidal ideation are primarily aimed at reducing and alleviating the pain or suffering underlying the thoughts of death, by treating the underlying psychiatric disorders and psychiatric symptoms, such as depression, anxiety, or insomnia.

Yes, even now, when we all feel we still have a long way to go in suicide prevention, most people overcome their crises and manage to lead normal lives. What is difficult and inadvisable is trying to avoid, run away from, or escape a life crisis; it's about facing it and resolving it.

Young people going through a life crisis often consider death as the solution to a situation that, as its name suggests, is defined as a crisis—that is, it is characterized as temporary. It's a situation one may feel unable to manage, sometimes because a solution isn't found at the moment. Impatience for its resolution generally increases the pain, with a distorted perception that it will be this way forever. But we know that's not the case; not having found a solution yet shouldn't be understood as meaning it doesn't exist, only as simply that it hasn't been found yet.

Julia (fictitious name)

Testimony

"My message is that everything passes, no problem is permanent."

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These situations have a beginning and an end. If a person can understand that it's a matter of time and has compassion for themselves to allow it, what they perceive as so difficult ceases to be so. We all have the experience of having lived through a situation that seemed overwhelming, impossible to deal with… and the next day, or after a few days, our perception of that situation had already changed.

Yes, there are people who can return to a normal life, and some, of public prominence, have chosen to share their struggles and how they recovered, hoping to help others with their stories. This is the case, for example, with Lady Gaga, Selena Gomez, Adele, Demi Lovato, Sia, Katy Perry, Billie Eilish, Kid Cudi, René Residente, and Kendrick Lamar, among others. But there are still countless anonymous examples all around us.

You've taken an important step by admitting that you feel the same. You should tell this without fear to the professionals who are helping you and to your mother. They may mistakenly think you're better, and if that's not the case, it's important to be honest with those around you: tell them you don't feel any better.

Only with reliable information about how you truly feel can you receive more targeted help, and of course, it will also help your mother. When we're not emotionally well, we think others know or will notice, but no, we're not mind readers. We can sense it, but we can't be certain. If we don't express how we really feel, it's difficult for others to help us.

I was reminded of someone trying to open a jar. They exert a great deal of effort without seeing any progress, thinking they'll never be able to open it. If they had to judge the value of their efforts at that moment, they could only be negative, a waste of time. The jar remains closed, and their understanding, based on past experience, is that they are incapable of opening it. Sometimes, they pass the jar to someone, seemingly less physically strong, and that person opens it immediately without any effort. At that moment, after the initial astonishment, and only then, do they realize that all the previous efforts had been very useful; they had prepared, loosened the pressure, without any apparent progress. At that moment, they promise themselves never again to undervalue the efforts made, those that have not yet proven their worth.

It seems your mother has opened many jars, and she's seen many times that every night, just after the darkest moment, dawn breaks. You can never be a burden to your mother, nor can you tire the professionals, and when they tell you they see you're improving, they already know the jar hasn't been opened yet, but I think what they mean is to acknowledge your efforts to keep going. It seems your mother is also from another era, one where effort was valued more than the result.

If you feel you can't handle this, seek professional help; that's what they're there for, you're not bothering anyone. Trust is fundamental and sometimes hard to find in your own environment, but it's not impossible. You have the right to express your feelings: what you feel and how you feel it. There are people who felt like you, took the step of asking for help, and today they're happy because their lives have changed thanks to that opportunity.

It's very important that you consult a professional if you haven't already, or that you speak with a professional you already know and have spoken to before. We professionals are here to help you ; you'll never bother us by asking for help and sharing your distress. It's our job, and we are fully committed to it. We will be by your side, supporting you through this process so you can feel better . If you don't feel comfortable talking to your family or friends about this, perhaps you could ask them to accompany you or help you find professional help, without going into too much detail when explaining what's happening to you or how you feel. Perhaps this first step will make it easier for you to open up to them and share a little more about what you're going through.

If you've just turned 17 and want to be better by 18, that means you've given yourself a reasonable amount of time to recover. I imagine that, with a year ahead, the most important thing now is precisely to forget about time pressures and not be constantly timing your recovery. After all, it will depend somewhat on what you do during that time, and putting pressure on yourself doesn't seem like the best idea. Therapy, like everything else, depends a bit on your commitment, but at your age, if you're involved, you'll feel better in a year.

You might feel better even without getting involved, but that's not what I recommend. At that age, the fear of staying the same is very common, as common as it is unfounded. You're in a time of constant change, both the changes you want to make and the changes you don't. You're close to seeing a reality that teenagers sometimes don't see: that the adult world is infinitely better than the teenage world.

The recovery processes from suicidal crises are individual, but they also have common elements; we try to address these latter elements in the response.

We understand that suicidal crises occur within the context of a life crisis. Therefore, we know that the risk of suicide remains until the life crisis is resolved . For this reason, we recommend that safety measures be maintained throughout the life crisis and for one year after its resolution.

It is important to incorporate these safety measures into family routines:

• Deprive access to medication (we recommend keeping all medication in the home locked up) and monitor its use and ensure adherence to drug treatment.
• Remain more available and attentive to the presence of potential crises.
• Encourage compliance with her psychological and pharmacological treatment , ensure that she attends follow-up visits, and maintain good communication with her daughter's therapist and with the school (if she is able to attend at this time).
• To give him hope.
• Recognize and explain to her that adolescence is a tough stage, but that everything that comes after is much better, that it's not a problem if she doesn't know what to do in the future, if she doesn't know what she wants, if she's confused, because all those things in adolescence are not a problem, they are precisely the questions that need to be answered in the coming years, not at that moment.
• Let her know that her discomfort will not overwhelm the family , that you are where you want to be, by her side, in good times and not-so-good times.
• Encourage your daughter's involvement in groups, activities, with peers, and within the family.

It's likely that during this process, you'll feel confused and overwhelmed at some point. You might do something you don't think is right, or something your daughter criticizes you for. This is perfectly normal, and she'll need to understand that it's not about doing everything perfectly, that we all make mistakes, but about getting back up with humility, with compassion for yourself, and continuing to try.

When your daughter tells you, "I'm still not okay, I don't feel ready yet," you should tell her, "We know, and we'll be here for you until you are." With her progress, therapy, and your support, she will gradually be able to identify the situations that overwhelm her and increase her resources for coping with them.

Always follow the guidelines and, if in doubt, ask the professionals who care for your daughter; don't hesitate to ask them for guidance.

What helps is reacting with calm, empathetic behavior: letting her know that you understand that self-harm is a reaction when she feels truly overwhelmed and is experiencing a lot of emotional pain. That you are there for her and that it must be a really difficult experience. Above all, it requires a lot of patience; these are processes that can take a long time to recover from.

It's important that you implement safety measures at home, such as keeping all medication locked away or removing objects that could harm your daughter. Close supervision is also crucial; this means being more available and attentive to your daughter's well-being so you can support her throughout this process and let her know you're there for her if she needs anything. Make sure she attends appointments with her caregivers , takes her medication (if applicable), and maintains communication between the family and the professionals.

She needs to feel and see that you are there, close by, ready to listen and help her with whatever she needs. In moments of greater distress, it's crucial to be present, actively listen, help her distract herself with an activity , know where to seek urgent help, or have some rescue medication on hand to help calm her down.

Often, when children self-harm, it's a way to escape, to calm themselves, to disconnect from emotional pain. With professional support, you may also be able to help your daughter find other ways to channel this distress without hurting herself.

You can do a lot, but he might not like everything.

You need to know if your friend is receiving treatment, if their parents are aware of their situation and their distress—in short, if there are already many of you forming a support network. If so, all that's left is for you to befriend someone who sees no reason to live. This means you'll have to take more initiative in the relationship; sometimes you might even have to be a little persistent to make them aware of what they're currently unable to see: that they're not alone, that you care about them and are happy to help, that they're not a burden, that you're aware of the efforts they're making, that they shouldn't worry, and that they shouldn't give in to despair. Remember the importance of connection.

If, on the other hand, you're the one who receives the initial news, the situation is more complicated for you, because at that moment your friend might struggle to see, or agree with, the importance of creating and activating that support network, the importance of their parents knowing about their situation, and the importance of more people being involved in their recovery process. A friendship is based on doing what's best for the other person, not on keeping poisoned secrets . Unfortunately, we've had to deal with kids who kept their friend's secret, and that friend ended up dying by suicide. The guilt these kids feel is immense, even though they don't actually feel guilty; it's not easy to face that situation. We can't deal with this reality alone, because we aren't alone either.

We know that they're more likely to talk to their friends first, perhaps those from school, rather than their parents or teachers. Young people need to feel comfortable talking about these issues and be able to tell a friend they're having suicidal thoughts. It's important not to stigmatize them for what they're saying. You should know that your friend's words reflect emotional suffering. It's not a mental illness, nor is it cowardice, nor is it a desire for attention. Encourage them to seek help, and to talk to their family and those they trust most. It's crucial to listen and offer support in seeking help.

There are behaviors that can show us that perhaps something is wrong: they don't answer WhatsApp messages, perhaps they've changed their photo to one that conveys sadness, they don't answer your calls, or when you're with them, they tell you that nothing is worth it, that they wouldn't get up, they don't want to continue studying or working, that they don't sleep well.

Our first instinct is always to tell them to cheer up. We try to offer advice, including the fact that we're all more or less in the same boat, and in an attempt at empathy, we share our own problems so they realize they're not alone. And we often say that you should always try to see the positive side of things. But all of this might only make them feel more burdened by their own discomfort and pain, and perhaps lead them to think it's better not to say anything more to anyone.

No one has taught us how to deal with emotional pain. We all know how to act in the face of physical pain or a wound, but with emotional wounds, we don't know what "band-aid" might work.

Without invalidating, or underestimating, what they've told us, we can support them with basic things they used to enjoy, simply being there for them without overwhelming them with questions or reflections. It's important to listen to what they say without judgment or criticism: their emotional wounds and pain need to be heard.

We shouldn't take responsibility for the other person's distress; we can't guess, we're not professionals or specialists. For this reason, it's very important to encourage them, with complete conviction, to seek professional help, always offering and conveying hope.

It's a really interesting question, and the concept of "diffusion of responsibility" also plays an important role. It must be easy, on social media, to think that a lot of people are seeing it, so someone will act, someone will do something. I'm going to try to answer by sharing some thoughts, so that everyone can draw their own course of action.

We have mentioned some interventions that have proven effective in preventing suicide and other problems, such as bullying. One such intervention involves working with students: " Know , Support , and Inform ." It aims to empower peers to share responsibility for situations of risk among their classmates , relieving the victim of the burden of having to report the situation and ensuring they don't feel alone.

In my clinical experience, parents always express profound gratitude to those who alerted them to the risks their children faced . It is an act of courage and civic responsibility to prioritize the well-being and life of even a friend, to put it before a misguided sense of loyalty. True commitment to friends lies in mutual care, in knowing that the person will act in your best interest, not in them keeping your secrets and becoming a passive accomplice to your self-destruction.

Schools offer the greatest potential for impact on suicide prevention . They are the place where all the children in a community can be found, making them ideal for implementing universal prevention interventions (for everyone). Most studies evaluating the effectiveness of interventions have been conducted in schools, such as the EMPATHY Study and the SEYLE Study .

The potential is undeniable, but that's true of suicide and most of the difficulties children face (mistreatment, abuse, neglect, etc.). So, from my point of view, what would be questionable is asking teachers to do more than they already do. If I were in the field of education, I wouldn't be satisfied with just being given ideas on how to act; rather, I would invite social workers into my classrooms and have them do what is known to work.

I also recommend consulting the recent "Guide for the prevention and initial approach to suicidal behavior in educational centers in the Balearic Islands", which includes interesting resources and content.

Questions about suicidal thoughts or behavior should always be approached progressively and in a competency-based manner . We would always begin by identifying distress, either actively (observing changes in behavior and expressions of distress) or by responding to a direct request from the child or adolescent.

Once the presence of pain is confirmed, we would begin assessing for the next essential element of suicide: hopelessness. If we find both elements, which we know are sufficient for suicidal ideation, we must ask about it. In some cases, if the child or adolescent says they are thinking about suicide, it would be enough to interrupt the assessment, support them in their distress, and inform them that we will tell their parents about this important matter so they can help them cope with their suffering.

As a practical example , I propose what a conversation with a 12-year-old boy after a training session might be like:

• Coach: "Can I talk to you for a moment? How are you? I've noticed you've been looking downcast and unmotivated for several days now. Is everything alright?"
• Boy: "Yes, yes, I'm fine, nothing's wrong."
• Coach: "Okay, but know that we're a team, not just on the field. You know you can count on us for whatever you need."

A few days later...

• Boy: "Can I talk to you?"
• Coach: "Of course."
• Boy: "It's been a while since..."
• Coach: "Wow... what you're telling me is very tough... What have you thought of doing?"
• Boy: "Nothing, there's nothing that can be done, I'm not capable of doing anything."
• Coach: "With everything you've told me, have you ever thought that life isn't worth living?"
• Boy: "Every day..."
• Coach: "That's normal. Do your parents know about this?"
• Boy: "No, I don't want to worry them."
• Coach: "I can imagine, always so reserved. I already told you we're a team, and we're not going to leave you alone in this. I'll help you talk to them. We'll get through this for sure, but together."

A coach doesn't need to delve deeper; they don't need to know if, in addition to suicidal ideation, there's planning involved, or if there have been previous attempts. It's not within their scope of practice to address suicidal thoughts, work on reasons for living, or develop a safety plan. However, they can identify the suicidal ideation, validate the pain, convey hope, and, very importantly, pass that information on to the next level of staff. A psychologist, on the other hand, must thoroughly explore all of these aspects.

The first step is to acknowledge the distress , validate it, inform the teaching staff of the student's concerns, and involve them in their recovery so that they, in turn, can involve their classmates. We need to identify the source of the distress as much as possible, whether it stems from excessive demands, academic difficulties, or problems with relationships with classmates.

Let us remember that, at 12 or 13 years old, many fronts open up: fitting in with others, fears of rejection, shame, not only that of studies, and that many of them affect the latter.

Make sure they understand that you are going to help them because, for you, their anxieties are important and there is nothing to be ashamed of, that there is no way they can let us down, that we love them with good grades and with bad grades, with fears and without them.

If we can reduce their pain and discomfort by doing this, we will have already prevented the risk of suicidal thoughts arising. Secondly, we must convey hope , that everything will be alright, and that they will have the necessary time to improve the situation once it has been identified.

At the same time, it's important to increase opportunities for social interaction and encourage them to belong to different groups, whether in sports, recreational activities, community centers, etc. Some children base their self-esteem on their performance in areas other than academics, and others rely on friends from their community's leisure center or sports club when they have conflicts with classmates or schoolmates.

Child and youth suicide, like adult suicide, is linked to suffering , therefore, to all those situations that objectively cause it: school bullying, physical and psychological abuse, sexual abuse, witnessing gender violence and a long etcetera.

In the specific case of school bullying, there are two particularities worth highlighting:

• The relationship between bullying and suicide is global; that is, it is linked to suicide both on the part of the bullied person and on the part of the bully.
• The victim is often subjected to two elements that are fundamental to suicide: the pain and suffering generated by the aggressions or humiliations and the detachment from the peer group, which takes on special relevance in adolescence.

We must all be very alert to situations of school bullying and activate the protocols that educational centers have to deal with these situations, aimed especially at the victim, but also at the aggressor.

This student is probably expressing a fear of pain that he thinks he may experience by anticipating situations that are very painful.

These are fears or anxieties that arise in the face of what could be "anticipatory grief" towards situations where there is a risk of breaking an emotional bond with someone, a place or something we have an appreciation or emotional connection to.

As a counselor, and depending on each case, we would recommend talking to the student so they can verbalize their fears. Doing so will make those thoughts less painful. Talking helps everyone; in this case, it's about speaking with them calmly and with respectful curiosity, not as an interrogation. Thank them for their trust . Acknowledge that these are painful situations for them and validate their feelings . Try to offer confidentiality, but don't promise things you can't keep. Involve their support network, parents or legal guardians if possible, and help them understand that professional help, if needed, will help them manage the distress they are experiencing.

Generally, many studies on serious organic diseases are conducted from an oncology perspective. In adolescents and young adults, an increased risk of suicide has been described during the first year after diagnosis. It is also true that, as with all identified risk factors, the predictive power is very poor, but the relationship does seem evident.

We work with young people under the age of eighteen. In our daily practice, we have seen some young people who we knew had chronic illnesses, and that, in some way, might have influenced the overall situation, but even in those few cases, I don't recall any who cited this problem as the main reason for their disengagement from life.

In my experience at Sant Joan de Déu Hospital in Barcelona , where I work, all units dealing with chronic childhood diagnoses have a psychology team. Of course, Oncology has a team of psycho-oncologists, but the Cystic Fibrosis unit also has a psychologist who is part of the multidisciplinary team.

To answer the question directly, my impression is that mental health services offer support to all these units by incorporating psychologists, who are usually part of the hospitals' consultation or liaison teams. And that this psychological support could eventually become an effective selective prevention intervention for those who might be at risk due to their circumstances. This could be the reason why we hardly see any young people with these problems through the suicidal behavior program, because they are already being addressed by these units.

There are also many first-person and family organizations, such as the Spanish Association Against Cancer (AECC), which do immense work in providing psychological support.

The death by suicide of a young person is devastating and a very traumatic experience for family and friends ; it marks us for life.

Socially we may feel questioned and even internalize this feeling, generating feelings of guilt that are very deep, present from the very initial moments of grief for suicide.

It is advisable at the beginning to offer companionship, respecting the needs of the bereaved , helping with the most essential and basic things including self-care; do not make judgments or opinions about the person who died by suicide.

The key is to listen without using phrases like, "I know how you feel" (unless you've been through something similar), "Cheer up for your other children," "Stop crying," or "You have to accept it." These expressions don't help; on the contrary, they cause more pain. Death by suicide, always unexpected and traumatic, is compounded by the experience of a death that comes too soon: parents are never truly prepared to bury their children.

It is recommended to tell children, teenagers, and young adults in the family what has happened as soon as possible. It is important that they are informed by a direct adult, preferably their parents, or siblings if they are involved.

It is helpful and highly recommended to connect with others who have experienced this and who offer support, individually or in groups, for managing the overwhelming emotions and feelings of complex grief. You can find this support through survivor associations, such as After Suicide - Survivors Association or Papageno . On the latter's website, you can find the resource closest to your home.

Friends are advised to discuss their experience with trusted individuals. Talking about what you've been through with someone who knows how to listen is a great help.

Friends or siblings of teenagers may feel guilty, especially those who might have received threatening words or witnessed actions that could have alerted them to or predicted their death. Others may feel anger and resentment, thinking that the person committed such a selfish act. Still others may not know how to express their feelings. Their emotions should be acknowledged and validated.

It is important to convey to young people that there is no right way to feel pain, that it is important to feel it and be able to talk about it, showing our willingness to do so when they feel ready.

For reading and reflection on grief after suicide, I recommend "Grief or Griefs"

Nurses play a vital role in the primary prevention of suicide, as well as in the monitoring and treatment of individuals at risk. For suicide prevention, nurses work in health education and provide individual and family support. Developing a care plan allows us to identify protective factors that need to be addressed. Clinical interviews and suicide risk assessment scales also help us identify individuals who may be at risk.

When someone attempts self-harm, it's because they've used a coping mechanism to deal with anxiety, distress, or maladaptive hopelessness. Therefore, nurses focus their health education on providing adaptive tools and strategies to use if the person is in crisis and may resort to them. Examples include relaxation and breathing exercises, distraction techniques, or rubbing an ice cube on the skin.