Every year, about 300 young people commit suicide, making it the second most common cause of death after road accidents among 16 to 19-year-olds.
And for every youngster who takes his or her own life, many more attempt to do so. A recent Samaritans survey of a group of north London teenagers found that just over 11 per cent had tried to kill themselves, while 40 per cent felt at times that there was "no point in living". And each year, 25,000 young people are admitted to hospital because they've harmed themselves, often by cutting into their arms and legs, or taking poisons.
What all these figures add up to is a lot of teenagers trying to cope with distress, frustration and feelings of hopelessness. How can schools recognise vulnerable students? What can they do to help them? And if the unthinkable does happen, how do they cope with the aftermath?
Are teenagers particularly vulnerable?
Although people of all ages and backgrounds take their own lives, suicide rates and diagnoses of depression in young people have risen steadily since 1970. It is older teenagers who are most at risk; until the age of 14, suicide is relatively uncommon, though there are still around 20 cases every year. One case that made headlines last year was the death of 11-year-old Thomas Thompson, who took an overdose after he told his mother he'd been bullied at his Liverpool school.
The factors are complicated, but some common elements help to suggest why adolescents may be vulnerable. "Teenagers don't have much life experience.
They may perceive a stressful situation as inescapable and turn to short-term avoiding strategies, like drink or drugs," says Rory O'Connor, senior lecturer in health psychology at the University of Stirling. "And they tend to be social perfectionists with unrealistic expectations of themselves. This can leave them feeling a failure."
Suicide may not be linked directly to adolescence, but it is linked to periods of transition. Consider the stresses of changing family relationships, physical development, the discovery of romance and sex, and nervousness about making your own way in the world beyond school.
What causes someone to commit suicide?
Suicide rarely has a single cause. It's usually the result of a complex combination of circumstances, which the Trust for the Study of Adolescence has divided into "primary" and "secondary" risk factors. The primary, or more serious, factors include psychiatric disorder, a previous suicide attempt, serious depression and drug or alcohol abuse. Secondary risk factors include a family history of suicide, the suicide of a friend or a significant blow to self-esteem. "It's incredibly difficult to pin it down," admits Dr John Coleman, the trust's director. "If you look back afterwards, you sometimes could never have known they would do it."
But Dr O'Connor's research has found one common element associated with suicide risk: hopelessness. More than 90 per cent of suicidal people admit to feeling they have no hope for the future. Teenagers who find problem-solving difficult, particularly when it comes to personal issues, often get sucked into feelings of desperation. "They tend to be poor at solving social problems, say a relationship crisis. They have fewer and less appropriate solutions to offer. They begin to feel very alone."
Feelings of isolation are closely linked to depression and suicide.
Increased suicide risks have been seen in teenagers isolated from their families in custody or care, and in gay, lesbian or bisexual young people who have difficulty getting emotional support from their families.
Bullying, too, is an important factor; bullied young people often report feelings of isolation and are in the suicide "at risk" group.
What's the relationship between self-harm and suicide?
Teenagers who self-harm are more than 100 times more likely to go on to commit suicide than those who don't. A 2001 study by the Oxford University Centre for Suicide Research found that 10 per cent of 15 and 16-year-olds had self-harmed at some time, and yet many believe that even these figures underestimate the scale of the problem. "Most people just patch themselves up. They don't want to be recorded," says Lorraine Chandler, who runs the Life Stinks programme aimed at supporting young people with depression, particularly those who self-harm (see resources). She sees a direct link between self-harm and suicide. "People aren't self-harming to get attention, they just want the emotional pain to stop. And, of course, the ultimate way to achieve that is to kill yourself."
As with suicide, self-harm can be triggered by all kinds of factors, but many teenagers who self-harm report feeling lost in a system that doesn't care, where nobody wants to talk to them. "I know of schools where people have formed cutting clubs, to self-harm in groups. It's an enormous problem," says Ms Chandler. So much so that the UK, with France, has the dubious distinction of having the highest adolescent self-harm rates in Europe, more than four times those of the Netherlands, for example.
Boys and girls, north and south
One of the reasons it is so difficult to identify factors in teenage suicide is the huge variation between the rates for young men and those for young women. Fifteen per 100,000 young men (15 to 24-year-olds) in England and Wales kill themselves each year, while the figure for young women is only four per 100,000. In contrast, attempted suicide and deliberate self-harm are more common for girls. There is no definitive reason for the difference, but research has shown that young men may be more affected by unemployment or poor employment opportunities, may find accessing health services more difficult, and may have greater difficulties than young women in talking about their feelings and asking for help.
Young men are also more likely to be involved in drug or alcohol abuse and violence, and have better access to means of violent self-injury, such as firearms. "Young men are not equipped for the changing stresses of modern life," suggests Dr O'Connor. "They are poor at giving and accepting emotional support." When teenage boys do kill themselves, they are much more likely than girls to choose violent methods: to hang or shoot themselves or slit their wrists.
Suicide figures also show big regional variations. In Scotland, youth suicide rates are much higher than they are in England and Wales, rising to 36 young men per 100,000. "In Scotland and Northern Ireland, rates have increased dramatically," says Dr Coleman. "It seems to be linked to poor economic prospects, a lack of access to effective support, particularly in isolated rural communities, and sometimes to political issues."
What are the warning signs?
Because suicidal behaviour is complicated, so too are the warning signs.
"We should be wary about saying what to look out for," says Dr Coleman.
"It's just a case of being sensitive to the kinds of situations that make young people vulnerable." But there are some changes in behaviour that might suggest a teenager is feeling depressed and even suicidal. Someone may become increasingly aggressive or withdrawn, lose their appetite or stop interacting socially. They may dwell on negative thoughts or even begin to joke about suicide. "Joking is often a way of articulating pain," says Simon Armson, chief executive of the Samaritans. "Fear and confusion show up in many ways; feelings need to be taken seriously."
The situation is made more complex by the fact that most checklists of warning signs include such "normal" teenage behaviour as mood swings, inattentiveness in class and irregular attendance at school. Not every failure to hand in homework is a cry for help, but Mr Armson points out that teachers are ideally placed to recognise when a pupil's behaviour is out of the ordinary. "To know if someone is behaving abnormally, you have to know them well in the first place," he says. "That's where teachers have a vital role." Be aware, too, that suicide is more common in winter, particularly after Christmas.
So what can schools do?
Dealing with suicide means treading a fine line between glamorising it and failing to talk about it at all. "We have to be careful," says Mr Armson.
"But we all have a responsibility to offer emotional support." The Samaritans recommend developing general programmes promoting good psychological and emotional health. These might also provide details of where young people can turn for help. A school that suspects a young person to be suicidal should act quickly to get professional advice, from the pupil's GP, from a counselling organisation or from mental health specialists.
The Samaritans have been visiting University College school in London for more than 10 years. Ruth Beedle, head of PSHE, is particularly aware that, in a boys' school such as hers, outside help can reinforce messages about learning to communicate. "If you've been playing football at break for the past five years rather than sitting around talking to each other, which skills will you have developed? We want to help the boys express themselves more confidently and openly."
The Samaritans take hour-long sessions with Year 9 groups, talking about their work and some of the people they help. "Lots of things emerge," says Ms Beedle. "Boys can find it difficult to accept that you get good and bad days. This helps them see the wider picture. And if we can just help one person, it's worthwhile."
"But I'm just a teacher"
Teenagers contemplating suicide may not know where to get help, so they turn to their teachers. But teachers are often wary of the additional responsibility, or frightened of acting wrongly. Lorraine Chandler is understanding, but emphasises the importance of taking action. "People are terrified by suicide. They don't know what to do. But teachers are the sticking plaster, the first-aid until professional help arrives. They may be the one person the child can talk to. We're not asking them to be counsellors, just to take five minutes to get them the help they need.
Formal referrals can take months, and in that time the person may be dead."
Experience shows that teenagers are likely to talk to a teacher on the spur of the moment, and if they don't get an immediate response are unlikely to come back. "Even if it's a busy time for you, make sure you know what the problem is. It may not be able to wait," says Ms Chandler.
"Find them someone to talk to and a safe, private place to go."
Talking the right language
"Sometimes the major hurdle in talking to suicidal teenagers can be getting on the right wavelength," says Simon Armson. The Samaritans have tried a variety of ways to reach young people. They advertise on beer mats, have "branches" in tents at rock festivals, and for 10 years have been experimenting with an email service, officially launched in 2002. They now receive around 300 emails a day and are looking at extending the idea to text messaging. "Young people find it difficult to call helplines, because they're embarrassed, or because they feel their problems aren't severe enough," he says. "People feel more in control of email; they can take time to write it and cope with the response."
Another successful initiative for getting the right help to the right people has been the training of peer mentors. The Oxford University research showed that 41 per cent of potential suicides turned to their friends first, but that most young people had no idea what to do if someone came to them feeling suicidal. Lorraine Chandler's Life Stinks programme trains Year 8 students in listening skills and provides them with information about professional support. "Peer mentoring has already been successful for issues such as bullying," she says. "By training up peer mentors to deal with suicide we can make sure desperate teenagers are not left alone at a critical time. There is somebody there to listen and to care."
Suicide is often described as "contagious"; in the school environment this can mean the problem just keeps getting bigger. Other pupils will often express open admiration for their dead friend's courage. "One of the most worrying aspects for teachers is the catching element," says Dr John Coleman. "You have to find a way of acknowledging copycat behaviour, but it can be scary." It's important to bring powerful reactions into the open and allow others to express grief. "The suicide has to be talked about," he says. "The first instinct is to put a lid on it, but that's not sensible.
Class has to stop. Young people have to be able to express their feelings."
Suicide has now been committed in public through the internet: in January last year, a 21-year-old in Phoenix, Arizona, took an overdose of prescription drugs while live on webcam in front of an internet chatroom audience, who urged him on.
You're not alone...
Procedures for coping with bereavement at school may need to be changed after a suicide. There's still more stigma attached to death by suicide than by accident, and, depending on the school ethos, there may be moral or religious issues. It's also likely the local press will be camped outside the school gates, and there will be no shortage of spectators keen to apportion blame. The police will also be involved. "Schools are a soft target," says one head who recently had to cope with the suicide of a pupil. "The first assumption is that the person must have been bullied; it's not easy to defend yourself against rumours."
Making a suicide prevention plan can help (with a section on what to do if a suicide occurs), and most local authorities and community health professionals will be able to offer advice on putting something together.
The Trust for the Study of Adolescence publishes a training pack with exercises for groups and advice on how to assess risk. And local branches of the Samaritans can organise school visits, with project material for use in the classroom, as well as offering help for staff. "Teachers need support," says Simon Armson. "They can feel very vulnerable."
The best medicine?
As many as 50,000 under-18s are prescribed antidepressants by their GPs.
Known as selective serotonin reuptake inhibitors (SSRIs), these drugs are not officially licensed for use in children, but until late last year doctors were able to prescribe them at their discretion. Since December, however, the Medicines and Healthcare Products Regulatory Agency has advised doctors to stop prescribing all but one, Prozac (fluoxetine), because of evidence that they may cause young people to become suicidal, and the evidence of benefit in children with depression is small.
"It seems that drugs alone don't work," explains Dr Rory O'Connor.
"Evidence suggests that you need a mixed approach, which includes helping teenagers find ways to solve their problems." This might include convincing them that their reactions are normal and setting new goals. "It's not helpful to think suicidal young people must be psychologically ill," he says. "We need to ask how they got to that state and what sort of supportive environment can help them get through it. We need to find the positives in their future, things to keep them alive."
Main text: Steven Hastings. Photographs: PYMCA, Alamy. Additional research: Sarah Jenkins
Next week: Staff sickness