Says Dr Alan Apter, director of the Child and Adolescent Division at Schneider Children's Medical Center, Petach Tikva (Israel) and member of ESCAP’s International Scientific Advisory Board. Dr Apter is child and youth psychologist and an expert in suicide and depression. He now researches prevention of adolescent suicide, after having achieved an international reputation in research and treatment of child abuse. Early identification of suicidal behaviour is an important part of his current work.
Apter: “The idea is to try and encourage adolescents and children to feel more free about asking for help. At any age, but usually the real danger begins at early adolescence. It is then when I start to worry about suicidal thoughts. Especially in boys, because in western countries suicide is much more common in males. And males are also much less able to ask for help than girls are.” 

Real men don’t ask for help
“This is due to a very strong cultural factor. I would like to change their male stereotype, where ‘real men don’t ask for help’ in European countries and America. There are many factors that make people depressed and anxious, but the one factor that seems to be critical in determining serious suicide attempting, and that is the ability to communicate the stress.”
“In the west you will find the majority of adolescent suicides are male, while in places like India and China there are actually more young women who commit suicide. And in the Arab community suicide is in fact not common at all, although non-fatal attempted suicide is increasing there lately. Young Arabs who feel oppressed by their environment, for example by being forced to marry. They show this suicidal behaviour to draw attention to this problem, trying to find some way to get out of their impossible situation. All of these patterns clearly show the cultural component.” 

Someone to turn to
“Adolescent suicide is very strongly guided by cultural factors. Behavioural patterns and what the culture allows and what is does not allow. There are many cultures where suicide is very much forbidden – in some religious groups for example – and as a result suicide is not so common. And also in religious communities you will find people who one can turn to, who will comfort you...”
“In terms of life events you will find these ‘impossible situations’ with no way out in every culture. Kids who are trapped. Asking verbally for help could open up a way out in all those situations.” 

Dare to ask the question
“There are a lot of things going on in adolescent suicide that we don’t understand. I think doctors or even psychologists, teachers and parents are afraid to ask these questions directly. They seem to be afraid of putting ideas into their minds. But apparently there is no risk in asking – there was a very important paper published in 2005 by Madelyn Gould, where she showed that Asking teens questions about suicide does not prompt suicidal thoughts or behavior in those who aren't suicidal. So this kind of screening turns out to be safe.” 

Cyber-bullying
With professor Gould (Columbia University and New York State Psychiatric Institute) and professor Robert A. King (Yale Child Study Center), Alan Apter researched the impact of cyber-bullying. “There is definitely a link between cyber-bullying and suicide, which is mediated by depression”, Apter says. “When a depressed adolescent is being bullied, there is a very high risk for suicide. This also is especially common in the west, although I have never really seen any studies on cyber bullying in non-western countries.” 

Taking away the means
An example of a successful suicide prevention programme was conducted in the Israeli army. Apter: “It has been shown that one of the most effective ways to prevent suicide is to remove access to means. In other words: people are as much suicidal, but if they don’t have easy access to the means by which to commit suicide, we can decrease the actual suicides by a large degree. In the Israeli army the soldiers were allowed to take their weapons home. After this was changed, the suicide rates dropped dramatically. A recent study from Switzerland, where they had a similar situation, showed the same results.”
“Civilian situations are different of course, but there are some very good programmes that are similar. There are a lot of kids that kill themselves for example by taking over-the-counter medication. If you do something about the number of tablets in a packet, this is also a very effective intervention against suicide attempts. We try to put this into practice by working together with the ministry of Health on legislation. It would be very helpful if uniform guidelines were developed in this field on an international level as well. As a member of the Scientific Advisory Board of ESCAP I am looking into the possibilities of preparing a symposium at the Madrid 2015 congress on the prevention of suicide in adolescents and the set-up of broadly accepted guidelines.”