the loss of a patient , particularly an adolescent patient , to suicide is one of the most distressing events a clinician can face . it is imperative that family doctors possess knowledge and understanding of the characteristics of suicidal adolescents in order to more accurately identify and intervene at an early stage . there is a significant gap in services for youth with all types of mental health issues . a recent canadian study showed half of suicidal adolescents had not accessed any mental health services . often the only connection these vulnerable youth have with the health care system is their family doctor . suicide is the third leading cause of death for teenagers in the united states   and the second leading cause of death for canadian adolescents . suicide ideation and attempts are known risk factors for suicide completion [ 510 ] , with an estimated 15 to 20 attempted suicides to every completed suicide . researchers note that the overall low base rate of completed suicide for youth makes it very difficult , even with a good screening tool , to predict the level of risk for completed suicide and for this reason they suggest concentrating on the phenomena associated with suicidal ideation in youth [ 1113 ] . the prevalence of suicidal thoughts among adolescents is quite high , with an estimated 2030% of adolescents reporting them at some point . the rates at which youth present with suicidal ideation , suicide attempts , and suicide are alarmingly stable over the past twenty years . there has been extensive ongoing research [ 610 , 15 , 16 ] into the risk factors and treatments for suicidal ideation and behavior . a systematic review of the literature concluded that there was strong evidence that the following factors are associated with adolescent suicidal phenomena : depression , alcohol abuse , use of hard street drugs , suicidal behavior among friends , living apart from parents , family conflict , unsupportive parents , and a history of abuse . less conclusive but promising evidence also suggests that poor physical health , sexual activity , and physical disability are associated with suicide attempts . unfortunately , there are few representative community studies discussing the use of family doctors and the use of mental health services among adolescents with suicidal ideation . this study investigated the relationship between suicidal ideation and demographic characteristics , health conditions , psychological characteristics and health care utilization patterns among a regionally representative sample canadians aged 15 to 19 . we also report utilization patterns of health and mental health services by canadian adolescents with suicidal ideation . the analyses reported in this paper used the public use data files of the canadian community health survey ( cchs ) conducted in 2000/2001 . the target population of the cchs covered approximately 98% of the canadian population aged 12 or older . the cchs had a response rate of 84.7% after 14 months of collection , which resulted in a final sample of 130,880 respondents . the survey was administrated through in - home face - to - face interviews with 88% of the sample and telephone surveys conducted through home phone numbers for the remaining 12% of the sample . only six provinces ( nova scotia , new brunswick , quebec , ontario , manitoba , alberta ) and one territory ( yukon ) opted for the inclusion of questions on suicidal ideation . thus , of the original 11,081 respondents aged 15 to 19 in the cchs , only 5,788 were asked questions on suicidal ideation . , we present data on several characteristics which were only asked in a sub - sample of the above provinces . thus , self - report of life stress , hours per week watching television , whether the adolescent had ever had sexual intercourse , and levels of social support have smaller sample sizes than the other characteristics reported . these questions , in addition to income level , which had a substantial amount of missing data , were therefore excluded from the logistic regression analyses . the logistic regression analyses included 5,471 respondents who had complete data on all the variables in the analysis . adolescents who reported suicidal ideation in the previous year ( n = 260 ) were compared with their peers who did not ( n = 5528 ) . the frequency of different forms of health care utilization was reported for adolescents who had suicidal ideation . chi - square analyses were conducted for categorical variables and independent t - tests were conducted for interval and ratio level variables comparing teens with and without suicidal ideation . the first analysis included 5 demographic characteristics ( gender , school attendance , race , living arrangement and whether the adolescent reported they sometimes or often did not have enough food to eat due to lack of money ) , 2 health behaviors ( smoking status and alcohol dependency ) and 6 physical health characteristics ( self - perceived health status , whether their activities were prevented by pain , number of chronic conditions and whether the teenager had asthma , back problems or migraines ) . the second logistic regression included all of the above variables and depression . respondents in the cchs were asked two questions on suicidal ideation :  have you ever seriously considered committing suicide or taking your own life .  those who said yes were asked ,  has this happened in the past 12 months ?  therefore , our suicidal ideation variable was dichotomized into considered suicide in the past 12 months versus not . in the bivariate analyses , the following demographic variables were investigated : ( 1 ) gender ; ( 2 ) educational enrolment status ( currently attending school / college or university versus not ) ; ( 3 ) race ( self - report : white versus non - white ) ; ( 4 ) living arrangement ( adolescent lives with two parents , with one parent , unattached , other ) . the household 's financial situation was measured in several ways : ( 5 ) total household income . ( 6 ) income adequacy ( low , medium , high ) was calculated based upon total household income and number of people in the household . ( 7 ) extreme poverty was assessed through the question ,  in the past 12 months , how often did you or anyone else in your household not have enough food to eat because of a lack of money ? smoking status identified those who had never smoked in comparison to those who were former or current smokers . alcohol dependency was based on questions from the composite international diagnostic interview - short form ( cidi - sf ) developed by kessler et al . . if a teenager responded that they had 5 or more drinks at least once a month during the last 12 months , they were asked a series of questions about symptoms of alcohol dependence ( e.g. , being drunk or hungover while at work or school or while taking care of children ; experiencing a persistent desire for alcohol ) . if they reported at least three of these behaviors in the past month , they were classified as self - reported health status was derived from the question  in general , would you say your health is excellent , very good , good , fair , poor . the responses were dichotomized into excellent , very good or good , versus fair or poor . if they responded no , they were asked how many activities their pain or discomfort prevented ( none , a few , some , most ) . the answers were then dichotomized into two categories ( usually no pain or discomfort or pain prevents no activities versus pain prevents few activities , some activities or most activities ) . the number of chronic conditions among the cchs respondents was calculated from summing the number of the following 17 conditions that had been diagnosed by a health professional and that had lasted six months or more : asthma , back problems , migraine headaches , arthritis or rheumatism , fibromyalgia , inflammatory bowel disease , cataracts , chronic bronchitis , emphysema or chronic obstructive pulmonary disease , diabetes , epilepsy , heart disease , cancer , stomach or intestinal ulcers , effects of a stroke , glaucoma , and chronic fatigue syndrome . these responses were summed into three categories ( no chronic conditions , 1 condition , 2 or more conditions ) . only the first three problems were experienced by more than 5% of 1519 year old respondents , and thus further analysis explored the association between each of these conditions and suicidal ideation . those aged 18 and over in several of the provinces were asked about their stress level :  thinking about the amount of stress in your life , would you say that most days are ( not at all stressful , not very stressful , a bit stressful , quite a bit stressful , extremely stressful ) ? the answers were dichotomized with the first three categories classified as  not stressful  and the latter two classified as  stressful  . respondents were diagnosed as depressed if they had a probability of depression of 90% or greater as classified by kessler and mroczek 's scale based on a subset of 21 items from the composite international diagnostic interview ( cidi ) . the questions cover a cluster of symptoms for depressive disorder , which are listed in the 1987 diagnostic and statistical manual of mental disorders of the american psychiatric association . this short - form ( sf ) scale was developed to operationalize criteria a through c of the dsm - iii - r diagnosis of major depressive episode . the sensitivity of the cidi - sf was 89.6% and specificity was 93.9% with the total classification accuracy 93.2% for a major depressive episode in comparison to cidi . in some of the provinces , four types of social support were evaluated using the medical outcomes study social support survey : emotional and informational support ( e.g. , empathic understanding and guidance ) , tangible support ( e.g. , material or behavioural assistance ) , positive social interaction ( e.g. , doing fun things together ) , and affection ( e.g. , love and affection ) . we also investigated the association between suicidal ideation and excessive television viewing ( defined as 20 or more hours per week watching television ) . use of a family doctor was determined through the following question :  not counting when you were an overnight patient in a hospital , nursing home or convalescent home , in the past 12 months , how many times have you seen , or talked on the telephone , about your physical , emotional or mental health with a family doctor or general practitioner ? respondents ' contact with mental health care professionals was determined by the question :  in the past 12 months , have you seen or talked on the telephone to a health professional about your emotional or mental health ? those who answered yes were asked how many times they visited a mental health professional ( coded as no visits , 13 visits , 4 or more visits ) . as shown in table 1 , females had higher rates of suicidal ideation than males ( 4.7% versus 2.9% ; p < .001 ) . only significant findings with p values less than .05 are reported . suicidal ideation was significantly more prevalent among those not attending school or college , unattached individuals and those living in single parent families as opposed to those living with two parents , and those who reported that they did not always have enough food to eat due to lack of money . the average household income of suicidal teenagers was significantly lower than that of their nonsuicidal peers . each of the health risk behaviors ( having had sexual intercourse , type of smoker , and alcohol dependency ) was associated with an elevated prevalence of suicidal ideation . the prevalence of suicidal thoughts was higher among teens who reported poorer health status , those who had two or more chronic conditions , particularly those with migraine headaches and/or back problems , those whose activities were prevented by pain , and those who reported high levels of stress . teenagers who were depressed had approximately ten times higher prevalence of suicidal ideation than the nondepressed ( 23.1% versus 2.1% ) . in comparison to adolescents without suicidal ideation , those who reported suicidal ideation had much lower levels of all four types of social support investigated . teens who spent 20 or more hours a week watching television had almost double the prevalence of suicidal ideation in comparison to teens who did not watch as much television . the first logistic regression analysis ( which did not include the variable on depression ) indicated that women had 54% higher odds of suicidal ideation than men and that teens living in single parent households had 71% higher odds of suicidal ideation in comparison to those in two parent families ( see table 2 , model 1 ) . former or current smokers had five times the odds of reporting suicidal thoughts in comparison to teens who had never smoked . adolescents who were alcohol dependent had more than twice the odds of suicidal ideation in comparison to their peers without alcohol dependency . teens whose activities were prevented by pain had twice the odds of suicidal ideation in comparison to those without any activity limitation . according to the nagelkerke r - square statistic , the variables in the first model explained 12.7% of the variability in suicidal ideation , which increased to 22.9% when depression was added to the model ( please see table 2 , model 2 ) . those who were depressed had nine times the odds of reporting that they had suicidal thoughts in the preceding year when compared with their nondepressed peers . once depression was included in the model , only two other characteristics remained statistically significant : living in a single parent family and smoking status . our univariate analyses of health care utilization indicated that suicidal adolescents were not getting the help they needed : almost three - quarters ( 73% ) of suicidal adolescents had not spoken about mental health issues with any health professional ( including family doctors , psychiatrists , psychologists and/or social workers ) . only 18% of suicidal teens had four or more mental health visits with any health professional . our particular interest was to focus on the use of family doctors by teens with suicidal ideations . although 80% of suicidal adolescents reported that they had seen or spoken on the phone with their family doctor in the preceding year about any issue , only 5% indicated that they had consulted with their family doctor about a mental health issue . the vast majority of suicidal teens were not receiving any mental health services from health professionals . our finding that only 27% of suicidal adolescents had consulted with any mental health professional in the past year is comparable to wilson 's finding that only 1 in 4 adolescents with a mental health problem seek medical care to address the problem . four out of five suicidal teens had seen or talked on the phone with their family doctor in the past year , presenting an important opportunity to discuss mental health concerns . apparently , the majority of adolescents with suicidal ideation did not present these issues : only one in twenty suicidal teens reported that they had spoken to their family doctor about mental health concerns . although general practitioners ( gp ) , such as family practitioners , are often the first point of contact for adolescents seeking health care , barriers to accessing mental health assistance from gps include  limited knowledge about the types of help gps provide ; perceived difficulties in the doctor - patient relationship ; fears about both the process and content of a gp consultation  [ 12 , p. 345 ] ; and difficulties accessing services . literature suggests that parents ' and youth 's perceptions of a mental health problem affect whether youth access mental health services . barriers to service use include beliefs that the mental health problem is not serious enough and a desire to solve the problem oneself . when these barriers can be overcome , research has found that youths are often more comfortable discussing issues with their gp than with a specialist . therefore , it appears that the health professional must take the initiative to investigate potential suicidality among their adolescent patients . a recent study concluded that gps do not routinely ask adolescent patients about suicidal ideation and often lack time to properly screen patients . researchers have proposed that medical practitioners take individualized approaches with clients to focus on their unique strengths , vulnerabilities , and specific circumstances when assessing suicidality . improved knowledge about the characteristics associated with elevated risk of suicidal ideation could improve targeting and outreach efforts by family physicians .   in identifying their most vulnerable teen patients , the findings of our population - based study indicate that doctors may benefit from considering suicidal risk factors in addition to the usual  red flags  of depression   and stress . of particular relevance to family physicians , suicidal ideation was significantly elevated in teens with back problems and / migraine headaches , two or more chronic conditions , and poor self - reported health . other studies have identified chronic illness as a risk factor for adolescent suicidal ideation [ 27 , 28 ] , particularly when comorbid with depression . in a prospective study , migraines have been found to be an independent factor associated with suicide attempts , even in the absence of a major depressive disorder . our finding that those whose activities were prevented by pain had more than triple the prevalence of suicidal ideation in comparison to those without activity limitations ( 12.6% versus 3.5% ) builds on previous research showing positive associations between suicidal ideation and pain intensity   and chronic pain [ 32 , 33 ] , although the link between suicidality and both back pain and activity limitation due to pain have not been as extensively studied in the adolescent population . additionally , women , teens from single parent families , those without adequate food due to financial problems , smokers , and those who were sexually active had a high prevalence of suicidal ideation as did those with low levels of social support . family physicians could target adolescent patients with these mental health , health , and sociodemographic characteristics for sensitive assessment of suicidal risk as an important first step in improving services to these vulnerable and underserved adolescents .   in keeping with the previous research , we found female adolescents had much higher risk of suicidal thoughts than their male peers . the risk ratio in this study was 1.62 , very similar to that found in the average of 5 previous studies on the phenomenon ( 1.58 , 95% c.i . while females have higher risks of suicidal thoughts , plans , and attempts , it is , in fact , adolescent males who have much higher rates of suicide completion .   our findings that 2.9% of males aged 15 to 19 and 4.7% of female adolescents reported suicidal thoughts in the previous year was well below the average found in other studies ( 19.3% , 95% c.i . there are several possible reasons for this : interview surveys ( such as the cchs ) typically report much lower rates of all suicidal phenomena than anonymous questionnaires . furthermore , the vast majority of the previous studies had been school based , not community based . it is probable that adolescents are less likely to report suicidal thoughts when interviewed in their home environment than in a school setting . we found a positive correlation between a number of health risk behaviors and suicidal ideation which had also been identified in other studies . these factors include smoking [ 36 , 37 ] , sexual activity and alcohol dependency . evidence suggests that smoking mediates other psychosocial causes of suicidal ideation ( e.g. , depression ) and is likely not a causal pathway . other researchers have also shown that among adolescent females , sexual activity and sexual risk - taking is associated with increased suicidal ideation and suicide attempts [ 36 , 3843 ] . both male and female adolescents who used alcohol at the time of sexual intercourse were found to have greater odds of considering a suicide attempt . within the adolescent population , sexual risk - taking behavior has been identified as a psychosocial and behavioral risk factor interrelated with suicidal ideation . we found that not attending school was associated with much higher rates of suicidal ideation , a finding that replicated earlier research . depression , however , is also highly correlated with school drop - out and thus it is unclear whether the relationship is direct or indirect . previous research   supports our finding that those who lived with neither parent had higher levels of suicidal ideation than those living in two parent families . however , our finding that adolescents from single parent families had higher suicidal ideation rates than those in two parent families is in keeping with some earlier research for example , , but in contrast to others ( e.g. , ) . we found that suicidal ideation was higher in those with lower household income , measured in dollars , and those with insufficient food due to economic problems . however , when income was divided into low , medium , and high categories , we did not find a significant association with suicidal ideation . the association between poverty and suicidal ideation may result from the increased stress and higher level of hopelessness among those in extreme financial need [ 47 , 48 ] . other studies suggest that it is particularly food insufficiency , and not low income levels in general , which is strongly correlated to dysthymia , suicidal ideation , and suicide attempts . evidence suggests that individuals often use entertainment media when experiencing stress and anxiety , and when feeling lonely . in their nationally representative study , bickham and rich   found that children who spent more time watching violent television alone spent less non - television time with friends . our study indicated a significantly higher prevalence of suicidal ideation among those watching television more than 20 hours per week . our data do not allow us to know if those with excessive television viewing were socially isolated or lonely . in future research on adolescents and suicidality , attention to high levels of media exposure and its potential link to social isolation would be helpful . research suggests the importance of understanding the role of social integration and isolation with suicidal behaviour . a number of studies have found social isolation to be associated with increased risk of suicide attempts   and suicidal ideation [ 55 , 56 ] . adolescents in the present study who reported suicidal ideation had low levels of all four types of social support . this finding supports previous studies that have found social support to be a protective factor against suicidality [ 5759 ] , particularly perceived parental support [ 57 , 58 ] .   in our study , 10.2% of the variability in suicidal ideation was explained by depression , even after a wide range of other risk factors had been included in the analysis . other researchers have also emphasized that presence of a depressive mood disorder is among the most powerful predictors of suicidal ideation and suicide attempt . further elevations in the risk for suicidal behavior occurs when depression or affective disorders are present in combination with substance abuse [ 6164 ] . however , it is positive to note that three quarters of the depressed respondents were not suicidal . future research efforts could focus on reasons why some depressed adolescents are suicidal while the majority are not in order to inform strategies to decrease the prevalence of suicidal ideation . a major limitation of our study was the lack of data in the cchs on several important risk factors for suicidal ideation including homosexuality and bisexuality   and whether the teen had a peer or family member who had attempted suicide . family doctors are suicidal adolescents ' major point of contact with the health care system . although four out of five suicidal teens had met with a family physician in the year preceding the survey , only one in twenty had discussed any mental health concerns with their family doctor . clearly , the onus is on the family doctor to initiate discussions related to depression and suicidal thoughts because teenagers rarely disclose these issues to their doctors without prompting . this study provides a profile of teens most at risk for suicidal ideation , which should improve targeting and outreach to the most vulnerable . in addition to the well - known risk factors of depression and stress , suicidal ideation was highly elevated in adolescents with two or more chronic health conditions , self - reported poor health , migraines , and those whose activities were prevented by pain . other characteristics significantly correlated with suicidal ideation include lower income , smoking , living alone or in single parent families , having lower levels of social support , and watching excessive amounts of television . family physicians should regularly screen for suicidal thoughts in their adolescent patients with these characteristics in order to intervene as early as possible .
introduction . 
 this study investigated the relationship between suicidal ideation and demographic characteristics , health conditions , depression , and health care utilization patterns among adolescents . methods . 
 secondary analysis of the regionally representative canadian community health survey conducted in 2000/2001 ( response rate 85% ) . 
 adolescents aged 15 to 19 who reported suicidal ideation in the previous year ( n = 260 ) were compared with their peers who did not ( n = 5528 ) . 
 the association between suicidal ideation and socio - demographic and health characteristics were investigated . 
 findings . 
 almost three - quarters ( 73% ) of suicidal adolescents had not spoken with any health professional about mental health issues in the preceding year . despite the fact that 80% of suicidal adolescents had regular contact with their family doctor , 
 only 5% had consulted with them about mental health issues . 
 in addition to the well - known risk factors of depression and stress , suicidal ideation was highly elevated in adolescents with two or more chronic health conditions , self - reported poor health , migraines , and back pain and those whose activities were prevented by pain ( p < .05 ) . 
 other characteristics significantly correlated with suicidal ideation included smoking , living in single parent families , and having lower levels of social support . conclusions . 
 family physicians should regularly screen for suicidal thoughts in their adolescent patients with these characteristics .