New Findings About Youth Suicide

Several recent publications are informative to clinicians on the topic of suicide in children and adolescents. Some of the most salient findings are reviewed here.

Suicide rates

Data from the CDC listed suicide as the second leading cause of death among youths aged 10 to 24 years in the US.¹ The most common methods of suicide were by firearm, suffocation (including hanging), and poisoning (including drug overdose).

[[{"type":"media","view_mode":"media_crop","fid":"38647","attributes":{"alt":"Youth suicide, © Kieferpix/shutterstock.com","class":"media-image media-image-right","id":"media_crop_5034470857402","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3856","media_crop_rotate":"0","media_crop_scale_h":"144","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"© Kieferpix/shutterstock.com","typeof":"foaf:Image"}}]]Data from the period studied (1994-2012) showed that suicide rates by suffocation increased, especially for females-on average, by 6.7% annually compared with 2.2% annually for males. Firearm suicide rates decreased for both males and females, from 10.9 to 5.9 per 100,000 and from 1.5 to 0.8 per 100,000, respectively. For both males and females, suicide by poisoning was less common and decreased among males (from 1 to 0.6 per 100,000) and females (from 0.6 to 0.4 per 100,000).

The increase in suffocation suicide rates was found for all races/ethnicities and geographic regions. Increased use of suffocation as a means of suicide is particularly worrisome, since suffocation has a high lethality rate.

Rural vs urban suicide rates

Fontanella and colleagues² examined trends in suicide rates to determine whether there were differences between adolescents and young adults in rural and urban settings. Data were obtained from the National Center for Health Statistics, National Vital Statistics System from 1996 to 2010. The population studied consisted of youths aged 10 to 24 years who had died by suicide: 66,595 youths died by suicide during that period. The rural suicide rates were nearly twice the suicide rates of the urban settings for both males (19.9 and 10.3 per 100,000) and females (4.4 and 2.4 per 100,000).

This disparity between rural and urban suicide rates increased over time for males. Suicide rates for males declined in urban areas but remained stable in rural areas. Suicide rates for females significantly increased in most urban and rural areas. Although death by firearms decreased in all areas, rates of suicide by firearms for males and females were higher in rural areas than in urban areas. These differences in rural and urban suicide rates remained, even after controlling for sociodemographic, economic, and health care system factors.

What accounts for these disproportionately higher rates of youth suicides in rural compared with urban settings? The researchers suggest that limited availability and accessibility of mental health services, geographic and social isolation, access to firearms, and declining economy in rural settings may be factors. The researchers propose important methods to address mental health provision in rural areas, including integration of psychiatric services in primary care settings, the use of telepsychiatry, and school-based programs.

Hospitalization rates for suicidality

Torio and colleagues³ recently published the annual report on health care that examined national trends in hospital utilization for children who had mental health conditions. Two national data sets (2006 and 2011) supported by the Agency for Healthcare Research and Quality were used for the analyses of children aged 1 to 17 years.

From 2006 to 2011, inpatient hospitalizations for suicide, suicidal ideation, and self-injury increased by 103.9% for youths aged 1 to 17 years. The percentage increases in age-groups were 129.7% for children aged 5 to 9 years; 150.5% for children aged 10 to 14 years; and 81.6% for youths aged 15 to 17 years. Emergency department visits for suicide and self-injury increased by 36.5%. The highest increase in emergency department visits for suicide and self-injury were in children aged 5 to 9 years (87.9%), followed by those aged 10 to 14 years (50.1%) and those aged 15 to 17 years (27.8%).

The authors of this annual report speculated that the economic downturn and the increase in prevalence of childhood mental health conditions may account for the increasing rates of suicide, suicidal ideation, and self-harm leading to inpatient hospitalization and emergency department visits.

Access to firearms

Firearms are the leading means of suicide for adolescents. Limiting access to firearms has been a major focus of suicide prevention strategies. Simonetti and colleagues⁴ examined whether adolescents with mental health risk factors for suicide have less access to in-home firearms than adolescents without suicide risk factors. Data were obtained from the National Comorbidity Survey: Adolescent Supplement, a nationally representative survey of 10,123 US adolescents aged 13 to 18 years who were interviewed between 2001and 2004. The question on the survey related to firearm access was as follows: “How many guns that are in working condition do you have in your house, including handguns, rifles, and shotguns?” Adolescents who reported at least one firearm in the home, were asked the following: “Could you get [the gun/one of the guns] and shoot it right now if you wanted to? Or is either the gun or the ammunition put away where you can’t get it?” Access to a firearm was defined as yes (ie, “could get it”) or no (ie, “could not get it”).

About a third (29.1%) of the adolescents reported one or more functioning firearms in the home to which they had access. Of those with firearm access, 40.9% reported that access was easy and they had the ability to shoot that firearm. Adolescents with firearm access, compared with those without access, were significantly more likely to be older (15.6 vs 15.1 years), male (70.1% vs 50.9%), non-Hispanic white race/ethnicity (86.6% vs 78.3%), and living in high-income households (40.0% vs 31.8%) and in rural areas (28.1% vs 22.6%).

The percentage of adolescents who met criteria for one or more lifetime mental disorders was greater among those with firearm access than among those without access (53.6% vs 49.2%). A greater proportion of adolescents with firearm access had a lifetime or recent history of alcohol abuse and lifetime history of drug abuse than adolescents without firearm access. It is important to note that there were no differences in firearm access between adolescents with and without suicide risk factors.

It is concerning that adolescents with suicide risk factors are as likely to have access to a firearm as adolescents with no suicide risk factors, especially given the educational efforts about limiting firearm access. Further interventions are necessary in clinical practice to strongly recommend that parents remove or, if unwilling, safely store firearms.

Familial suicide transmission

Another area of suicide prevention is identification of individuals at high risk for suicide attempts. Brent and colleagues⁵ sought to identify the pathways by which suicidal behavior is transmitted in families. The sample consisted of 701 offspring of 334 parents with mood disorders, of which 191 (57.2%) parents made a suicide attempt. The offspring aged 10 to 50 years (mean age, 18 years) were followed for a mean of 5.6 years: 44 (6.3%) of the 701 offspring had made a suicide attempt before participating in the study; 29 (4.1%) had made an attempt during study follow-up. Parent suicide attempt was the strongest predictor of offspring suicide attempt (odds ratio = 4.8) even after adjusting for baseline history of mood disorder, baseline history of suicide attempt, and mood disorder at the time of the attempt.

The results of this study are striking in that there was nearly a 5-fold increased risk of suicide attempt in offspring whose parents had attempted suicide, independent of the familial transmission of mood disorder. Children whose parents have attempted suicide should be identified early and receive appropriate intervention to decrease the likelihood of a suicide attempt.

Family and peer invalidation

An interesting area of investigation is the role of perceived family and peer invalidation in adolescent suicidal events.⁶ Emotional invalidation from peers may be overt (ie, bullying) or covert (ie, social rejection). Similarly with family members, there is a rejection of the adolescent’s thoughts and feelings. In this 6-month longitudinal study, 119 adolescents admitted to an inpatient unit for suicide risk and their parents were interviewed and completed self-report assessments.

Weekly ratings of perceived family invalidation and perceived peer invalidation were done over 6 months. Adolescents were asked the following questions to assess perceived family invalidation: “Were there times that you did not feel accepted by your family? Or that you could not express your true thoughts and feelings? Or that if you did express your thoughts and feelings, that you would be dismissed, punished, ignored, or made fun of?” The questions to evaluate perceived peer invalidation were: “Were there times that you did not feel accepted by your classmates? Or that you felt you were being left out? Or that you could not express your true thoughts and feelings? Or if you did express your true thoughts and feelings, that you would be dismissed, punished, ignored, or made fun of? How many friends do you have that you can confide in?”

Perceived family invalidation predicted suicidal events (suicide attempt or emergency interventions to intercede in a suicide attempt) over the follow-up period for boys only. However, perceived peer invalidation predicted self-mutilation for both boys and girls. These findings demonstrate the importance of assessing perceived peer and family invalidation during interviews of youths, particularly those with mood disorders and other risk factors for suicidal behavior.

Disclosures:

Dr Wagner is the Marie B. Gale Centennial Professor and Chair Ad Interim in the department of psychiatry and behavioral sciences and Director of Child and Adolescent Psychiatry at the University of Texas Medical Branch at Galveston.

References:

1. Sullivan EM, Annest JL, Simon TR, et al; Centers for Disease Control and Prevention. Suicide trends among persons aged 10-24 years-United States, 1994-2012. MMWR Morb Mortal Wkly Rep. 2015;64:201-205.

2. Fontanella CA, Hiance-Steelesmith DL, Phillips GS, et al. Widening rural-urban disparities in youth suicides, United States, 1996-2010. JAMA Pediatr. 2015;169:466-473.

3. Torio CM, Encinosa W, Berdahl T, et al. Annual report on health care for children and youth in the United States: national estimates of cost, utilization and expenditures for children with mental health conditions. Acad Pediatr. 2015;15:19-35.

4. Simonetti JA, Mackelprang JL, Rowhani-Rahbar A, et al. Psychiatric comorbidity, suicidality, and in-home firearm access among a nationally representative sample of adolescents. JAMA Psychiatry. 2015;72:152-159.

5. Brent DA, Melhem NM, Oquendo M, et al. Familial pathways to early-onset suicide attempt: a 5.6-year prospective study. JAMA Psychiatry. 2015;72:160-168.

6. Yen S, Kuehn K, Tezanos K, et al. Perceived family and peer invalidation as predictors of adolescent suicidal behaviors and self-mutilation. J Child Adolesc Psychopharmacol. 2015;25:124-130.