The urge to commit suicide used to be regarded as a simple process. It was thought that mental illness (or physical illness, especially in the elderly) could lead to suicidal thoughts, then suicide attempts, followed by actual suicide. In recent years, however, researchers have found that this tragic phenomenon is much more complicated. "This is too simplistic," according to child and youth psychiatrist Dr. Alan Apter, head of the psychological medicine department at Schneider Children's Medical Center in Petah Tikva. Dr. Apter was co-chairman and main speaker at the second international conference on "Understanding Youth Suicide: A Meeting of Different Perspectives," held for three days late last month at Kibbutz Ma'aleh Hahamisha. "We know today of many more possible factors: Impulsive behavior in response to life events can lead to attempted suicide. There are environmental influences on neurodevelopment, such as child abuse, the loss of a parent and low birth weight that can lead to mental illness. There are also risk factors in adulthood - a breakdown in relationships, job loss, poor socioeconomic conditions, religious beliefs or substance abuse can lead to suicidal thoughts," noted Apter. "There are also many facilitation factors such as how acceptable the person is personally and culturally, the effect of the media, cognitive and problem-solving skills, age and gender. Severe mental pain from loneliness and difficulty in communicating may cause suicidal thoughts. On the other hand, there are protective factors such as positive relationships as a child, social support and religious sanctions. Even genes may be involved." Apter urged that the understanding of evidence-based treatments for suicidal behavior be increased. In many European countries, suicide is the leading cause of death among young people - more common than death from road accidents or AIDS. In Israel, about 400 people commit suicide every year, with one-quarter of them under 18, Apter said. The number of suicide attempts - an estimated 10 to 20 times more frequent than actual suicides - is shocking. Some of these were genuinely failed attempts, but usually the people did not intend to take their lives, but only to "draw attention to their problems." Schneider Children's Medical Center alone receives about 100 such cases a year. The conference was addressed at the opening by Eytan Goldberg, whose son committed suicide in the army 10 years ago at the age of 19. "He was a computer freak and not well accepted by his peers. It took me several years to forgive him for what he did to us - but it has taken even longer for me to forgive myself for not being aware of his problems. I decided to do what I could to prevent more such cases." Goldberg set up a voluntary organization called Derech Haim (Path of Life) for this purpose, and it has even sponsored public service ads on TV to increase awareness of the suicide problem. Whether one attempts suicide or succeeds is not only a matter of chance but also of gender and societal influences, notes Apter. In most countries including Israel, females attempt suicide more often than males, who have a higher rate of actually killing themselves. But in China, for example, women are more likely to kill themselves than men, who attempt suicide more often. This is because of the availability of toxic agricultural pesticides, he explains. When Sri Lanka banned the use of strong pesticides, suicide rates plummeted, showing that reducing the means to take life can reduce suicide. Similarly, raising the legal drinking age may reduce the rate of youth suicide, especially in the 18 to 20 group. When teens who attempt suicide are brought to Schneider, the hospital has to use funds from donors to treat them, as mental health services are not yet supplied by the health funds. But as Schneider is owned by Clalit Health Services, there is no subsidy. Various health ministers, including the current Ya'acov Ben-Yizri, have promised that "very soon," mental health care will be provided as part of the basket of health services, but responsibility has not yet been transferred. "I believe there is a very good chance, however, that the ministry will take youth suicide seriously. It has promised funding for a unit aimed at preventing it. As this is the first time something has been promised, we hope it will happen," Apter said. "I pray that mental health care will be in the health services basket like any physical disease. The current situation is terrible, as the health funds don't issue referral slips for such care in the hospital." THERE IS a good suicide prevention program in the Israel Defense Forces, said Apter. "I wish we could have such a program for civilians." Suicide rates are highest in the secular community. He knows of no studies in the haredi community, but research in modern Orthodox communities has shown that in times of dire stress, religion is not a protective factor. "There have been alarming developments in the Arab sector, which traditionally has had very low suicide rates. We know now that the attempted suicide rate among young Arab in the north is higher even than among their Jewish counterparts." Handguns and larger weapons are the most frequent means used for suicide, said Apter. "The availability of weapons is very high, so guns are used much more frequently than drugs, chemicals, hanging, knives or razor blades," he explains. Some in the field argue that screening tests can identify youths at high risk, concluded the Schneider psychologists. "Some say public discussions of suicide minimize its occurrence, but others argue that this increases the phenomenon by making youth more aware of the possibility. I believe that active detection and early treatment of childhood emotional disorders might be a major strategy in prevention, so national prevention programs that promote targeted awareness are definitely worth considering." Prof. David Shaffer of Columbia University in New York, who also served as co-chairman of the conference and is an expert in the epidemiology of youth suicide, said that in the US, attempted suicide is most common between ages 15 and 17. Being generally of lower socio-economic status, blacks should have a higher suicide rate, but in fact is is lower than in whites. A 2005 study showed that about 16.8 percent of Americans aged 15 to 19 admitted having suicidal thoughts, with 8% having attempted suicide, while a smaller percentage needed medical attention. Males were about nine times more likely than females to kill themselves. ALCOHOL ABUSE is definitely a factor in suicide, said Shaffer, as during "Prohibition" between 1920 and 1933, the US suicide rate dropped significantly. It also dropped during World War II, but it is difficult to know whether this was due to patriotism, army service or other factors. "There are theories that in the 1960s, the US suicide rose because large numbers of mothers went out to work instead of staying at home, and there was an increased intake of recreational drugs. The introduction of Prozac for depression a decade ago is credited with bringing down the suicide rate," he said. Meanwhile, a Columbia University expert in "suicide clusters" - in which victims, usually young people, imitate an initial case of suicide - noted that the phenomenon could spread via Web sites such as Myspace, which create virtual communities. Prof. Madelyn Gould noted that media reports usually accompany a rash of suicides occurring in the same geographical area within a few months. "A normal person will be sad if a friend killed himself, but he doesn't become suicidal unless he suffers from existing tension and vulnerabilities. Then it can become contagious." While researchers like Gould have been collecting increasing data on such suicide clusters, they are in the dark about suicide "contagion" in virtual communities on the Internet. She suggested at the conference that research be done to understand how to prevent such clusters of suicides. Suicide clusters in a specific place and within a short time are still relatively rare, comprising only 1% to 5% of all suicides. However, there have been cases in which as many as 11 young people committed suicide in a chain reaction to an initial suicide. Gould studied 53 clusters in which 209 American youths died over about a decade. She and colleagues interviewed friends and relatives of the victims as well and a control group of youths who did not take their own lives. In a third of the cases, the suicide was carried out in front of others, such as at a party or a home, but in more than half of the cases, the victim killed himself (the vast majority were teenage boys) in a public area such as a schoolyard. The number of suicide attempts coming to the attention of Geha Mental Health Center in Petah Tikva dropped when the hospital changed its shower heads so that a rope could not be hung on them and when locks that can be opened from the outside were installed on toilet enclosures, said Dr. Gil Zalsman, director of child and adolescent psychiatry at the association, and who has also been an associate research scientist at Columbia University's neuroscience division. Zalsman said genetic factors are also involved. "It runs in families for biological and environmental reasons. Suicide is four to 12 times more common in families in which someone has committed or attempted suicide, he said. But is it not only conditions in which children area raised; there are also "candidate genes" for depression and suicide such as one named TPH2. He and colleagues studied 211 teens, 65 of them from psychiatric hospital inpatient departments after making attempts; a control group of 95 teens was used as a comparison. Violence and impulsivity were found to be connected to certain gene types, but Zalsman declared that genes do not doom people to suicide. If you had a childhood and adolescence with warm parents and few or no stressful life events or abuse, genes are ot significant, he said. "If you had a bad childhood and adolescence, bad genes can have a big influence. If you had a good life as a youngster, even bad genes can offer a lot of protection against suicide." Famed Israeli rock singer Aviv Geffen - the son of two famous parents (Nurit and Yonatan) who divorced - attempted suicide as a teenager, said Zalsman, and put a tombstone with his name on it on the cover of his first album. "But he changed and has joined the fight against youth suicide. He starred in a videoclip against suicide, and has even been called in twice to persuade young people not to kill themselves." So there is always hope.