Adolescent suicide is now responsible for more deaths in people between ages 15 to 19 than cardiovascular disease or cancer (Blackman, 1996). Teen suicide has more than tripled since the 1960's (Santrock, 2003). Despite this alarming increased suicide rate, depression in this age group is largely under-diagnosed and can lead to serious difficulties in school, work, and personal adjustment, which may continue into adulthood. How prevalent are mood disorders and when should an adolescent with changes in mood be considered clinically depressed? Brown (1996) gives the reason why depression is often overlooked in adolescents is that it is a time of emotional turmoil, mood swings, gloomy thoughts, and heightened sensitivity. Adolescence is often a time of rebellion and experimentation. Blackman (1996), observed that the "challenge is to identify depressive symptomatology which may be superimposed on the backdrop of a more transient, but expected developmental storm." (p. 52)

For numerous teens, the symptoms of depression are directly related to low self-esteem stemming from increased emphasis on peer popularity and/or peer isolation. On the other hand for some teens, depression arises from poor familial relationships, including decreased family support and perceived rejection from their parents (Lewis and Lewis, 1996). Oster and Montgomery (1996) stated "when parents are struggling over marital or career problems, or are ill themselves, teens may feel the tension and try to distract their parents" (p 2). This distraction might well include increased disruptive behavior, self-inflicted isolation and even verbal threats of suicide. Many times parents wrapped up with their own conflicts and busy lives fail to see the changes in their teens, or they simply refuse to admit their teen has a problem. In today's society, the family unit can be quite different from the stereotypical one of the 1950's where the father worked and the mother was the homemaker. Today, with single parent families and families where both parents are working full time, the teen may harbor feelings of being "second fiddle" in the hierarchy of importance. Great stress is placed upon teens today starting in early childhood which significantly contributing to the strain and depression they experience. Most enter daycare at an early age and continue into preschool. At one end of the spectrum, teens are pushed by parents to excel in sports and academics and on the other end there are teens that are never given direction or goals by their parents. Those pressured to excel oftentimes become overwhelmed by what is expected of them and succumb to using drugs and alcohol as a form of escape and possibly feel the only way out is that of suicide. Those teens without direction and lack of interest on the part of their parent's also increase the likeliness of drugs and alcohol activity as a means of escape (Lasko 1996). These adolescents might contemplate and even attempt suicide as a way of either drawing attention to themselves or to end their lives because no cares about them anyway.

Regardless of the reason for teen suicide the issue is a reality and no other state has been burdened than Idaho with respect to teen suicide -- especially male teen suicide. Epidemiologically the haunting question is not only why but also what can be done to avert the continuing tragedy?

Male Teen Suicide in Idaho. When most Americans think about Idaho images of open fields, vast national forests, mountains, lakes, and a tranquil lifestyle come to mind. Idaho holds for most individuals the impression of being a magnificently empty natural space, one that depicts rugged Western authenticity. As such the visitor, though media or actual travel, would never think that such an addictively satisfying place would be plagued by a high male teen suicide rate. Yet, Idaho ranks second in the nation with reported adolescent suicide deaths (Idaho Department of Welfare, 2003) and the rate of male suicides in Idaho is four times that of females and the chosen method used to complete the act of suicide is the firearm. In addition a survey conducted by the Idaho Department of Education produced reporting data revealing information that showed 2,330 Idahoans aged 18 and older attempted suicide within a twelve month period in 2001 (Idaho Department of Education. 2001). This in and of it self is staggering knowing that the population of Idaho is roughly 1,293,000. Upon closer inspection data gathered by the CDC (2003) shows that Idaho has four unique populations susceptible to the act of suicide, namely Native American males ages 15-24, teenage males ages 15-17, working age males ages 18-64 and elderly males aged 75 and older. Of these four groups the teen male group (ages 15-17) have the overall highest suicide rate: 22.5 per 100,000 between 1999 and 2001 (CDC, 2003). This is followed by the Native American male group with a reported suicide rate of 21 per 100,000. However, over a ten-year period, 1992-2001, Native American males (15-24) committed suicide more frequently than all other reported groups: 115.8 per 100,000.

Although nationally suicide is the third highest cause of death for teens, in Idaho it is the second highest cause of teen deaths. In addition, between 199 and 2001 15- to 17-year-old teen males completed the suicide act five times higher than female teens of the same age bracket (U.S. Department of Health and Human Services, 2001). However, the same is not true for attempted suicide as females teens in grades 9 through 12 attempted suicide twice as much as male teens (Idaho Department of Education, 2001). Continuing further the collected data supports the fact that of the teen male population in Idaho, Native American males between the ages of 15 and 17 have the highest rated of suicide. Those factors supporting the increase of suicide and suicide attempts can be generally attributed to mental disorders, substance abuse aggressive and impulsive behavior patterns, and easy access to firearms (Idaho Department of Health and Welfare, 2003). Knowing that teen male suicide in Idaho is extremely high by way of national averages the need for preventative programming is crucial.

Preventative Programming. The very first step in establishing a teen preventative program to deal with the suicide phenomenon is the ability to recognize the warning signs and risk factors of possible suicide actions. Most professionals, including those in the State of Idaho, recognize that preventing suicide begins first with recognizing the warning signs presented below followed by an understanding of the risk factor involved:

1. A previous suicide attempt.

2. Very noticeable changes in personality, mood structure, and behavior.

3. Talking to others about suicide.

4. Depression/sadness and feelings of isolation and loneliness.

5. Withdrawal from peer and family activities.

6. Inability to concentrate, changes in eating patterns, and a lack of communication.

7. Loss of interest in activities once enjoyed.

8. Having lost a friend or family member to suicide.

9. Academic performance changes.

10. Self-harming behaviors ("cutters").

The risk factors associated with the aforementioned warning signs are generally agreed to be the following:

1. A relationship breakup with a girlfriend or boyfriend.

2. Failing academically.

3. Feeling humiliated very badly.

4. Loss of a friend or close family member from death or suicide.

5. Divorce between parents.

6. A victim of bullying and harassment.

7. An unplanned pregnancy.

8. A tragic event or the anniversary of a tragic event.

9. Parental abuse -- both physical and emotional.

10. Causing the intended or accidental death of another -- especially a friend or family member.

These risk factors are significantly increased when the teen is confronted with substantive abuse, cultural diversity, lack of social support, and inaccessibility to mental health treatment programs. In order to counteract the rise in teen suicide, especially in teen males, the Idaho Department of Health and Welfare has developed a preventative program called the Idaho's Suicide Prevention Plan; one that includes both developing defensive factors while concurrently reducing risk factors. Although the plan is extensive in goal setting initiatives it falls short in specifically identify how certain "gatekeepers" can effectively deal with the problem; especially with respect to the nursing profession.

Teen Suicide and the Nursing Profession. Knowing that teen suicide is potentially a preventable public health concern, nurse can play a critical role in both identification and treatment situations. Most often nurses are placed in a hospital, health care facility, or schools's frontline and, as such, are generally the first to come into contact with depressed or suicidal teens (Lyon & Morgan-Judge, 2000). In fact, because minority teens are more likely to open-up to someone of their own ethnicity and race, the need for culturally diverse nurses is greatly upheld. Therefore, as the rise in teen suicide continues the need for culturally competent nurses who can be vigilant with respect to potential suicide teens is also strong. Generally speaking all nurses, whether school, clinical, or administrative, must be aware of teen suicide potential. The responsibility of the nurse is briefly presented in outline form below.

1. Actively support substantive and suicide prevention and education programs.

2. Recognize that teens…