Suicide in Teenagers

Suicide is consistently one of the leading causes of death in the United States each year and unfortunately, teenage suicide is on the rise (Centers for Disease Control and Prevention (CDC), 2018a). Although mental health conditions are often attributed to suicide, there is rarely a single cause. Numerous risk factors often contribute including relationships, access to healthcare, education, interpersonal and problem-solving abilities, level of support from friends and family, gender identity, finances, legal status, substance abuse, housing difficulties, and so on (World Health Organization (WHO), 2018a).

Adolescents exposed to several of these risk factors have a greater potential of being vulnerable to mental health issues. It is important for communities, healthcare systems, government, and suicide prevention organizations to come together in order to increase awareness and focus on the prevention of teen suicide (CDC, 2018a).

Case Definition

A surveillance case definition is a set of uniform criteria used to define a disease for public surveillance and enables health officials to classify and count different cases consistently across reporting jurisdictions (CDC, 2017). Suicide is not among the list of mandatory notifiable conditions and therefore does not currently have a specific case definition. However, the Centers for Disease Control and Prevention (2011) provides a Self-Directed Violence Surveillance publication including definitions and recommended data elements. The goal of the publication is to address the lack of definition uniform and have consistent terminology with standardized definitions to improve communication among researchers, clinicians, and others working in this area (CDC, 2011). Within this publication, suicide is defined as “death caused by self-inflicted injurious behavior with an intent to die as a result of the behavior” (CDC, 2011, p. 23).

Sources of Data

Suicide rates and statistics are available through several sources. Many are found through the Centers for Disease Control and Prevention website. The Web-based Injury Statistic Query and Reporting System (WISQARS) is an online data-base providing fatal and non-fatal injury and the costs of such injury (CDC, 2018b). The National Violent Death Reporting System provides states and communities with clearer information about violent deaths, including suicide, and tracks data over time (CDC, 2018b). Unfortunately, only 40 states participate in this system that links data from law enforcement, coroners, medical examiners, vital statistics, and crime labs to a central database (CDC, 2018b). The National Vital Statistics System is responsible for the registration of vital events including births, marriages, divorces, and deaths. The Youth Risk Behavior Surveillance System (YRBSS) monitors categories of health-related behaviors that contribute to causes of death and disabilities among youth (CDC, 2018b). It is survey based and is conducted through the CDC by state and territory. The World Health Organization is also a resource for suicide rates across the globe.

Determinants

Recognizing at-risk individuals for suicide is important. Determinants of suicide in the community include a wide range of risk factors. Price and Khubchandani (2017) recognize these risks and categorize them into four areas:

Intrapersonal (history of suicidal ideation and attempt, mental illness, low self-esteem), interpersonal (access to firearms, sexual or physical abuse, parents with low levels of education, bullying, low socioeconomic status), community factors (high family disruption, prejudice attitudes towards mental health, inadequate community resources for suicide prevention, inadequate access to mental health care), and society factors (inadequate funding for health programs, inadequate numbers of psychiatrists, lack of population knowledge of suicidal warning signs) (p. 73).

The World Health Organization provides additional health determinates including stress, the pressure to conform to with peers, sexual orientation, quality of home life, health status, sleep patterns, and lack of access to support systems (WHO, 2018a).

Healthcare Costs

Costs related to suicide are substantial and have economic consequences. In 2013, suicide accounted for $50.8 billion of the medical and work-loss costs of fatal injury by intent in the United States (National Institute of Mental Health, 2018). Of the 50.8 billion, male suicides comprised an estimated 82% of the costs, totaling $41.7 billion. The CDC (2015) reported each suicide in the United States in 2013 cost an estimated $1.2 million.

Morbidity and Mortality Rates

Unfortunately, suicide rates are increasing and affecting more American families each year. Since 1999, the CDC reports a 30% increase in suicide for at least half of states (CDC, 2018a), indicating an increased need for awareness and suicide prevention measures. WHO estimates the suicide mortality rate in 2016 for the United States was 15.3 suicide deaths per 100,000 people, with 43% not having a known mental health diagnosis (World Health Organization, 2018c).

Suicide does not only affect the United States. WHO estimates an approximate 800,000 global suicides per year, documenting one suicide per 40 seconds (WHO, 2018b). WHO (2018b) also reports at least 60 countries across the world to have less than one psychiatrist per 100,000 population in 2014.

Rural vs. Urban Suicide Rates

Suicide is a major health concern for those living in rural populations and consistently have a higher suicide rate than urban areas (Handley, Inder, Kelly, Attia, & Kay-Lambkin, 2011). Variable factors can help explain the difference in prevalence of rural areas. A study was completed in Germany to compare rural to urban suicide rates. Data showed rural areas had suicide rates between 12.6 and 13.2 per 100,000 persons, compared to urban areas where rates were between 11.0 and 11.6 per 100,000 persons (Helbich, et al., 2017). Results were indicative that access to healthcare, socioeconomic status, and social isolation do contribute to increased suicide rates in rural areas.

Descriptive Epidemiology

Suicide rates among teenagers are on the rise and in fact, are the highest they have ever been (Price and Khubchandani, 2017). WHO (2018a) estimated 62,000 adolescents died in 2016 as a result from self-harm and is the third leading cause of death amongst teens age 15-19. When studying suicide rates among different populations, it is important to consider several characteristics, and how they affect the population.

Person Characteristics

Teenagers (13-19) are in a crucial developmental stage and maintaining a healthy mental health status is important. Those exposed to multiple risk factors have a greater potential for a negative impact on their mental health (WHO, 2018a). Price and Khubchanani (2017) examined teen suicide and found that males are three times more likely than females to die from suicide. In figure 1, (Price & Khubchanani, 2017, p. 71) explored adolescent suicide by race/ethnicity and gender in 2014.

Figure 1. Adolescent Suicides by Race/Ethnicity and Gender, 2014 (ages 13-19)

Figure 1 data represents the estimated percentages of suicides in different ethnic groups and divides them into genders. Of the 2,145 teen suicides in 2014, 1,601 or 75%, were males and 544, or 25% were females. Among the ethnicities, both white males and females had the highest percentage of suicides, followed by Hispanics and African Americans (Price and Khubchanani, 2017).

Place Characteristics

Research provides evidence there are differences in suicide rates depending on the environment and location of the person. In a study period from 1996-2010, data concluded suicides rates among teenagers were double that of urban areas for both males and females resulting in 19.93 males per 100,000 population and 4.40 female per 100,000 population. For rural areas, it was found suicide by firearm rates were between 2.7 and 3.3 times higher and suicide by hanging/suffocation were between 1.6 and 1.8 times higher than those of urban areas (Fontanella, et al., 2015).

Figure 2 (CDC, 2018, para 3) represents the percentage of increase in suicides per state from 1999- 2016. Nevada was the only state to have a decrease in suicide rates, while North Dakota had the highest increase at 57.6%.

Figure 2. Suicide rates increased in almost every state

Time Characteristics

Suicide among teenagers has risen since 2007 as seen in Figure 3 (Canady, 2017, p.2). According to Canady (2017), the suicide rate for males aged 15-19 has risen 31%, with 14.2 per 100,000 in 2015. Females had a similar pattern, nearly doubling to 5.1 per 100,000 from 2007 to 2015 (Canady, 2017).

Figure 3. Suicide rates for teens ages 15-19 years, by sex United States 1975-2015 (per 100,000 population)

Prevention

Cultural differences among the population can have an effect on suicide rates along with the stigma surrounding mental health care (Crowder & Kemmelmeier, 2018). This creates a barrier to prevention and the possibility for guilt, shame, or embarrassment with those struggling with mental health issues or suicidal thoughts. Many countries display honor cultures and are characterized by the “belief that self-worth is synonymous with reputation” (Crowder & Kemmelmeier, 2018, p. 398). Crowder and Kemmelmeier further discuss this behavior to be more susceptible to suicide, due to maintaining one’s public image (2018).

Historically, African American suicide rates have been significantly lower than those of White Americans. Research links cohesive family relationships, friendships, religiosity, spirituality, and supportive social network to the low suicide rates among this culture, however, more research needs to be completed for further observation of cultural factors (Utsey, Hook, & Stanard, 2007).

Primary Prevention

Teenage suicide will never be completely eliminated, but efforts can be made to reduce the current increasing rates. A person being aware of current life situations would be an important piece for preventing suicide. When a person is attentive of their surroundings and current mental state, persons are able to seek help before symptoms or crises occur. Learning the disease process of suicide and being educated on risk factors and signs and symptoms could save a life.

The CDC (n.d.) recommends reducing risky behaviors, such as alcohol use or drug use, for prevention measures against suicide. Education about these behaviors and how each can contribute to suicide is an important part of awareness in teenagers. WHO (2018a) encourages the promotion of mental health and well-being to build resiliency against different situations and address needs associated with teenagers. To do this, WHO established the mental health Gap Action Program (mhGAP) and which provides evidenced-based guidelines to better identify and support mental health conditions in areas with reduced resources (WHO, 2018a).

Secondary Prevention

Secondary prevention focuses on early detection of a disease and screening assessments. There are several mental health assessments, but the Colombia-Suicide Severity Rating Scale (C-SSRS) is an assessment used to identify suicidal risk. Studies have shown this particular assessment is specific and can help reflect changes in a patient’s condition over time (Oquendo & Bernanke, 2017). Various professionals can administer this assessment including nurses, physicians, psychiatrists, psychologists, and social workers. This assessment has been translated into 114 country-specific languages for use (Oquendo & Bernanke, 2017). By using assessment tools, the hope is to provide early detection of suicidal thoughts to reduce the number of completed suicides.

Summary

Suicide is on the rise in the United States including teen suicide. Multiple factors contribute to mental health status and can be attributed to the increase in teen suicide over the past 30 years (Zametkin, Alter, & Yemini, 2001). Although there are several prevention strategies to incorporate into suicide awareness, suicide will never be completely eliminated. Clinicians, families, and friends are encouraged to learn the warning signs to have early intervention for those struggling with suicidal thoughts.

Upstream social determinants can have a large impact on the mental health status of a person. These include access to healthcare and health insurance, social support or exclusion, knowledge, beliefs, and behaviors. Persons who are involved in risk taking-behaviors, such as alcohol and drug use are more vulnerable to suicidal thoughts and tendencies (WHO, 2018a). Worldwide, the prevalence of heavy drinking among adolescents ages 15-19 was 13.6% and the use of cannabis was 5.6%.

Psychiatric mental health nurse practitioners (PMHNP) have an important role in recognizing the warning signs of suicidality to accurately progress forward in treatment. This might include completing further assessments, considering medication changes, or referring a patient for hospitalization- depending on severity. Practitioners should be educated and aware of the most up to date resources for patients and be able to recommend further treatment if needed. Access to healthcare can be a struggle for patients in rural communities and PMHNP should consider practicing in these areas to increase access. Practitioners should have continuing education and be involved in local government to change policy and procedures to increase mental health services in communities.

While suicide is a difficult, multifaceted health issue, strides can be made to help prevent this problem. Taking steps to increase access to healthcare and improving suicide education is vital to saving lives across the globe.

References:

1. Centers for Disease Control and Prevention. (n.d.). Prevention. Retrieved fromhttps://www.cdc.gov/pictureofamerica/pdfs/picture_of_america_prevention.pdf
2. Centers for Disease Control and Prevention (2011). Self- directed violence surveillance: Uniform Definitions and Recommended Data Elements. Retrieved from https://www.cdc.gov/
3. violenceprevention/pdf/Self-Directed-Violence-a.pdf?fbclid=IwAR3ZxA7Y-qvfArFRo5Mrqt6AISjUkiA2KdvA8XBlgoHD5a3Q73hiEWLPfj0
4. Centers for Disease Control and Prevention. (2015). Estimated Lifetime Medical and Work-loss Cost of Fatal Injuries- United States, 2013. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6438a4.htm?s_cid=mm6438a4_w
5. Centers for Disease Control and Prevention (2017). National notifiable diseases surveillance system: Surveillance Case Definition. Retrieved from https://wwwn.cdc.gov/nndss/case-definitions.html
6. Centers for Disease Control and Prevention. (2018a). Suicide Rising Across the US.
7. Retrieved from https://www.cdc.gov/vitalsigns/suicide/index.html
8. Centers for Disease Control and Prevention. (2018b). Violence prevention: Data Sources. Retrieved from https://www.cdc.gov/violenceprevention/suicide/datasources.html
9. Crowder, M. K., & Kemmelmeier, M. (2018). Cultural differences in shame and guilt as understandable reasons for suicide. Psychological Reports, 121(3), 396-429. Retrieved from https://doi.org.10.1177/0033294117728288
10. Fontanella, C. A., Hiance-Steelesmith, D. L., Phillips, G. S., Bridge, J. A., Lester, N., Sweeney, H. A., & Campo, J. V. (2015). Widening rural-urban disparities in youth suicides, United States, 1996-2010. JAMA Pediatrics, 169(5), 466-473. Retrieved from https://doi.org/10.1001/jamapediatrics.2014.3561
11. Handley, T. E., Inder, K, J., Kelly, B. J., Attia, J. R., & Kay-Lambkin, F. J. (2011). Urban-rural influences on suicidality: Gaps in the existing literature and recommendations for future research. Australian Journal of Rural Health, 19(6), 279-283. Retrieved from https://doi.org/10.111/j.1440-1584.2011.01235.x
12. Helbich, M., Bluml, V., de Jong, T., Plener, P. L., Kwan, M. -P,. & Kupusta, N. D. (2017). Urban-rural inequalities in suicide mortality: a comparison of urbanicity indicators. International Journal of Health Geographics, 16(1), 1-12. Retrieved from https://doi.org/10.1186/s12942-017-0112-x
13. National Institute of Mental Health (2018). Suicide. Retrieved from http://www.nimh.nih.gov/
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17. Price, J. H., & Khubchandani, J. (2017). Adolescent Homicides, Suicides, and the Role of Firearms: A Narrative Review. American Journal of Health Education, 48(2), 67-79. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,sso&db=eric&AN=EJ1133278&site=eds-live&scope=site&custid=s8356098
18. Utsey, S. O., Hook, J. N., & Stanard, P. (2007). A re-examination of cultural factors that mitigate risk and promote resilience in relation to African American suicide: A review of the literature and recommendations for future research. Death Studies, 31(5), 399-416. Retrieved from https://doi.org/10.1080/07481180701244553
19. World Health Organization (2018a). Adolescent mental health: Key Facts. Retrieved from https://www.wno.int/news-room/fact-sheets/detail/adolesent-mental-health
20. World Health Organization (2018b). Global health observatory (GHO) data: Mental Health. Retrieved from http://www.who.int/gho/mental_health/en/
21. World Health Organization (2018c). Suicide: Suicide Mortality Rate. Retrieved from http://apps.who.int/gho/data/node.sdg.3-4-viz-2?lang=en
22. Zametkin, A. J., Alter, M. R., & Yemini, T. (2001) Suicide in teenagers: assessment, management, and prevention. JAMA, 286(24), 3120-3125. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=11754678&site=eds-live

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