Youth Suicide Is Increasing: Modest Actions Taken Now Can Save Lives

Youth Suicide Is Increasing: Modest Actions Taken Now Can Save Lives

August 2, 2019

1 Introduction

Suicide is the second leading cause of death among young people ages 10 to 24, and rates are rising, as they are for the entire population. Each year, about one in six high school students reports thinking of suicide1. More than 150,000 young people are treated in emergency departments annually after engaging in self-harm2. The “collateral damage” of youth suicide is extensive. Family and friends are often greatly affected by grief and guilt, and the effects frequently last for years.

Rarely, but even more traumatically, youth suicide can snowball within schools and communities into “suicide clusters,” in which a single death becomes a kind of contagion fed by relationships and communication, including social media, and leads to others. Although such clusters are rare, they occur most frequently among young people, accounting for an estimated 100 to 200 deaths annually in this group3. These events are devastating for communities.

In a previous publication for this policy series, I discussed recommendations to reduce suicide across the life span4. There has been promising action on several of these recommendations, including accreditation standards with a stronger focus on suicide prevention issued by The Joint Commission and passage of the National Suicide Hotline Improvement Act of 2018. Now it is time to consider steps to decrease youth suicide. The burden of mortality and morbidity (e.g., residual trauma and increased risk for survivors) is high. The gap between what we know and what we do is large—and it is growing, because much more is being discovered about what works. The current level of effort nationally is very small. The only national youth suicide prevention program (created via the Garrett Lee Smith Memorial Act of 2004) has demonstrated its impact, but the program is modest and provides only time-limited support to selected communities. In addition, institutions that are critical to youth suicide prevention (e.g., schools and healthcare systems) have not yet broadly embraced the mission. The uneven adoption of effective suicide prevention methods, especially by schools, is particularly concerning given the impact of youth suicide clusters and the fact that suicidal impulses can trigger mass violence.

Although the risk of any individual suicide by a young person is low, the risk and the potential impact are increased by a “neighborhood” death, whether that neighborhood is defined geographically or by social media boundaries. Thus, the need to act on youth suicide is great. The opportunities are salient because of suicide’s impact, because available tools are significantly improved, and because of several timely national policy opportunities.

Action is needed at the national level and in states and communities. Nationally, increasing concern about youth suicide as well as data showing both the effectiveness and the limited scope of the Garrett Lee Smith Memorial Suicide Prevention Program suggest that the program should be expanded. An ongoing effort is needed, rather than a program that provides time-limited discretionary grants in an unpredictable manner. In addition, as youth suicide rates increase, programs that address school safety and mental health needs must address suicide prevention more explicitly, as highlighted in national suicide prevention recommendations for school systems5.

This policy paper focuses on policy advocacy for national action on youth suicide. Although compelling efforts have been implemented in the private sector, a full inventory is beyond the scope of this paper, and recommendations emphasize actions that could be undertaken by the government.

2 Patterns and Challenges

Thomas Joiner’s interpersonal theory of suicide6 has been influential in changing thinking about suicide and its prevention and helps frame policy choices. Joiner theorized that suicidal thoughts and the desire for suicide are influenced by isolation (“thwarted belongingness”) and by perceptions that one is a burden to others. He suggested that thoughts of or even the desire for suicide are not sufficient to result in suicide; one must acquire the capability to kill oneself—both by overcoming one’s natural fear of death and by acquiring the means to do so.

Research by Millner and colleagues7 explored Joiner’s ideas via in-depth interviews with individuals who had attempted suicide. Results showed that the median time between initial thoughts of suicide and the attempt was long (about 2 years), suggesting that acquiring the capability for suicide is often a lengthy process. This finding also suggests that a long window for productive intervention may often exist—if, and only if, individuals are identified during this period. However, Millner and colleagues found great variability in the “pathways” by which people progressed toward an attempt.

These patterns are even more variable with young people. Teenagers are sensitive to social influence, so “shaming” on social media may result in dangerous pressures on vulnerable youth. Media coverage that sensationalizes suicide or discusses methods of self-harm can make suicide seem more attractive and feasible, and can reduce normal inhibitions against self-harm. Impulsiveness is also a notable developmental challenge for teens, and thus they may be much more likely to progress quickly from thoughts of suicide to an attempt. These factors suggest that approaches to reduce youth suicide must be even more sensitive to social networks than in efforts with adults.

3 Patterns Specific to Youth Suicide

As noted, suicide is the second leading cause of death among young people ages 10–24. Suicide claimed more than 6,000 young lives in the United States in 2016—more than three times as many lives as lost to cancer in this age group and more than 25 times as many as lost to flu and pneumonia. The rate and number of youth suicides—as with suicide deaths generally—have both increased considerably since 2003, following a period of decline after 1990.

The number of suicide deaths among young people only partly illustrates the scope of the problem of self-harm, although the impact of youth suicide on families and the years of life lost are substantial. For every youth suicide death, there are about 25 suicide attempts serious enough to require medical attention. These attempts are also costly and traumatic, and a past suicide attempt increases future risk. This pattern of many nonfatal attempts is true for all age groups, but it is more pronounced for young people. A key issue is the means of self-harm that is used. Attempts with a gun are likely to be fatal, and the lethality of attempts is much greater for individuals with access to a gun (e.g., veterans, police officers, and older men). Therefore, access to firearms is a key suicide prevention issue when young people with their more impulsive mindset are exposed to loss or trauma, such as a suicide in their school.

Prevention efforts should consider several groups of youth who are at elevated risk of suicide. Considering Joiner’s framework, it is likely that the vulnerability of some youth is affected by stigma that reinforces perceptions of being unwanted. For example, sexual minority youth have elevated rates of self-harm and suicide; these patterns are strongest among transgender youth, for whom stigma is powerful. American Indian/Alaska Native youth have the highest rates of suicide among ethnic groups, perhaps driven by historical trauma and loss of cultural identity. For these minority groups, addressing the underlying conditions of discrimination is a challenging but important task. Intervention efforts must also be culturally appropriate, because cultural issues can be the drivers of suicidal thinking and of isolation. Similarly, suicide rates are elevated for youth in the foster care and juvenile justice systems, where many have been exposed to some precursors of suicidal thinking (e.g., trauma) and where stigma and social isolation may also increase risk. This paper does not include specific recommendations for subpopulations of youth at elevated risk. However, an increased focus on identifying suicide risk (such as in healthcare and mental health settings) and providing effective treatment and support is needed.

5 Conclusion

The knowledge needed to prevent youth suicide has evolved, and at the same time rates of death have increased. Applying new knowledge can reverse the trajectory of increased deaths among young people.

Because of growing concern, action now appears possible. We should seize the moment to make these modest changes that can save young lives.

References

  1. Youth Risk Behavior Survey: Data Summary and Trends Report, 2007–2017.  Atlanta, Centers for Disease Control and Prevention, 2017. Available online: https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trendsreport.pdf
  2. Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta, Centers for Disease Control and Prevention, Injury Prevention and Control, 2017. Available online: https://www.cdc.gov/injury/wisqars/index.html
  3. Gould MS as cited in Zenere FJ: Suicide clusters and contagion. Principal Leadersh 10(2):12–16, 2009.
  4. Hogan MF: Suicide Is a Significant Health Problem. Philadelphia, Scattergood Foundation, 2017. Available online: www.thinkbiggerdogood.org
  5. Suicide Prevention in Schools. New York, American Foundation for Suicide Prevention, 2019. Available online: https://afsp.org/our-work/advocacy/public-policy-priorities/suicide-prevention-in-schools/
  6. Walrath C, Garraza LG, Reid H, et al.: Impact of the Garrett Lee Smith Youth Suicide Prevention Program on suicide mortality. Am J Public Health 105:986–993, 2015.
  7. Garraza LG, Walrath C, Kuiper N, et al.: The impact of GLS prevention activities on youth suicide mortality from 2006 to 2015. Presented at the American Association of Suicidology Conference, Washington, DC, April 18–21, 2018.
  8. Gould MS, Lake AM, Galfalvy H, et al.: Follow-up with callers to the National Suicide Prevention Lifeline: evaluation of callers’ perceptions of care. Suicide Life Threat Behav 48:75–86, 2018.
  9. Preventing Suicide: A Toolkit for High Schools. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2012. Available online: https://store.samhsa.gov/product/Preventing-Suicide-A-Toolkit-for-High-Schools/SMA12-4669
  10. Suicide Prevention Programs Overview. Dedham, MA, MindWise Innovations, 2019. Available online: http://mindwise.wpengine.com/what-we-offer/suicide-prevention-programs/
  11. Joiner T: The Perversion of Virtue: Understanding Murder-Suicide. New York, Oxford University Press, 2014.

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