Descriptive Epidemiology of Teen Suicide

Teen Suicide

Having a loved one, friend, or even an acquaintance, that choose to take his or her life, is devastating and life altering for those left behind.  According to the Centers for Disease Control and Prevention (CDC), suicide is when death occurs due to self-inflicted harm (2018).  Teen suicide is defined the same way only the person’s age is from 12-18 years old.  In this paper adolescent suicide will be discussed while describing its surveillance case definition, the sources of data that is available regarding teen suicide, the significance of suicide at the national and global level, the known determinants of the injury, the descriptive epidemiology of teen suicide and, finally, known preventions against teen suicide.

Introduction

As stated earlier, the case definition of suicide is “self-inflicted or injures behavior with an intent to die as a result of the behavior” (CDC, 2018).  In 2016 nearly 45,000 people committed suicide in the United States (CDC, 2018).  Suicide has been an issue for many years, in 2007 it was found that suicide was the third greatest cause of youth (ages 15-24) deaths.   (Shaffer, Gould, & Hicks, 2007).  All attempts to commit suicide do not always end in death of the individual however.  A suicide attempt is when a person attempts to harm oneself enough to cause death, but it ends up not being fatal.  Suicide ideation is when a person thinks about, creates a plan or is contemplating suicide (CDC, 2018).  Currently, suicide attempts and ideation have been on the rise.  A 2006 healthy youth survey was done by the Washington State Department.  The representative sample this survey used was 4,447 students in the public school system.  They found that 11% of eighth graders that where surveyed had suicide ideation (Washington State Department, 2006). 

The surveillance case definition that is used by the CDC for suicide is self-directed violence (CDC, 2014).  The World Health Organization defines self-directed violence as: “the intentional use of physical force or power, threatened or actual, against oneself, that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation” (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). 

It is important to be able to tract suicidal behavior, in order create preventative interventions.  The CDC has a way to assess self-directed violence.  If a person goes to the emergency department, after attempting suicide that ended up being non-fatal, the National Electronic Injury Surveillance System-All injury Program is used to keep track of these records (Crosby, Ortega, & Melanson, 2011).  This survey helps monitor the prevalence of this health condition, so that earlier detection, as well as risk factors, can be identified and used to help increase prevention.

Suicide has a large significance in our nation.  In the United States, there were 34,598 deaths reported, making it the 11^th leading causes of death in our nation (Xu, Kochaned, Murphy, Tejada-Vera, 2007).  To get a perspective of what this number means, if one thinks of the outbreak of Ebola in 2016 with the 11,315 confirmed deaths, one can see that death by suicide was three times more than that amount (BBC, 2018). 

Globally suicide among adolescents is a major health concern.  Wasserman, Cheng, & Jiang, found that suicide is considered to be the fourth leading cause of deaths among young men and the third leading cause of death for young women (2005).  This study was done in over 90 countries.  In all of these countries combined over 132,000 deaths occurred for young people and 9% of those were caused by suicide (Wasserman, Cheng, & Jiang, 2005).  This shows that teen suicide is not just a concern for those in the United States, but worldwide.

Because this is such a big concern and problem for the entire human race, it is important that better research and interventions be created to help prevent so many suicidal deaths.  To know more about suicide one needs to be able to research and access the most up to date and current information that is available concerning suicide.  The sources that are available to research suicide and teen suicidal data are; Youth Risk Behavior Surveillance (YRBSS), National Center for Health Statistics, World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), Behavioral Health Risk Assessment, and several psychiatric type journals. 

In 2009, the YRBSS found that “6.3% of students in grades 9 through 12 reported making a suicide attempts in the year prior to the survey. The Survey also found that 10.9% of students made a suicide plan and 13.8% seriously contemplated suicide”(YRBSS, 2009b).  All of these sources are an excellent resource for those in the medical field as well as for the general population.  There is a lot of research that has already been done; however, more of the research has been focused on treatment of mental health disorders, and not preventative measures of suicide (O’Connell, Boat, & Warner, 2009).

The known determinants, or risk factors that have contributed to suicide have been linked to mental illnesses, post-traumatic stress disorder, anxiety, and depression. Firearm availability, sexual or physical-abuse, are also risk factors for suicide (Shaffer et al., 2007). There is also a connection with teenagers and how well each of them could communicate with his or her parents.  Having poor communication with parents seemed to add to the problem when those children where unable to seek out help during crisis.  Marttunen, Hillevi, Henriksson, & Lonnqvist (1991) did a study and found that in 90% of suicides that occurred, had some kind of psychiatric diagnosis or mental disorder.  Substance abuse was one of the risk factors that seemed to have more of an impact on the older teens, two-thirds of this population group where found to have substances in his or her body when autopsies where done (Shafer, Gould, Fisher, Trautman, Moreau, Kleinman & Flory, 1996). 

Suicide is not contagious; however, it does create a loop of risk factors for those associated with people who have committed suicide.  Having a loved-one commit suicide increases the risk of another family member committing suicide as well (CDC, 2018).  For example, if a parent commits suicide, it automatically can put the child into the higher risk category for doing the same.  “Risk factors for suicide are multi-faceted.  Mental health conditions are often seen as the main cause of suicide, but suicide is rarely caused by any single factor” (CDC, 2009b).

Suicide does not just have an emotional impact on families and communities.  There are also financial consequences as well.  A “total lifetime cost associated with nonfatal injuries and deaths caused by self-directed violence in 2000 were approximately $33 billion, including $1 billion for medical treatment and $32 billion for lost productivity”(Corso, Mercy, Simon, Finkelstein, & Miller, 2007).  According to the CDC (2018), suicide costs as well as costs related to self-harm, came to be around $70 billion a year.  These costs also included missed work as well as the medical expenses.  The overall healthcare cost of the disease does not just affect the personal family, but can have a ripple effect into the community and society.  “The annual quantifiable cost of such disorders among young people was estimated in 2007 to be $247 billion” (O’Connell, Boat, & Warner, 2009).

The morbidity and mortality of suicide is something that has increased over time.  The CDC found that “since 2005, life expectancy at birth in the U.S. increased by 1 year; however, the number of persons who died prematurely was relatively constant… Age-adjusted rates declined among all leading causes except deaths attributable to Alzheimer’s disease and suicide (2014).   There has been some improvement and decline in some areas concerning suicide but not enough to make a large difference.  In 1991 it was reported that 7% of the youth had attempted suicide, and then the same survey done in 2009 showed a decline to 6% (YRBS, 2009a).  This amount of change in over almost two decades was not substantial, even though it was a decline in numbers.

The next question to ask is whether suicide rates differ between rural or urban locations.  Singh & Siapush found that there was a “significant rural–urban gradient” and that there was a “rising suicide rate, with increasing levels of rurality” (2002).  This information is important to know so the right resources can be made available based on location of where one lives.  It has not been discovered whether having easier access to lethal weapons in rural areas, (such as the availability of guns for hunting), could be a contributing factor to this gradient.  There has not been enough evidence to prove that different gun laws contribute or deter from teen suicide either.  There was also speculation of whether access to social media and Internet could have played a role in why suicides where happening in rural areas.  Poonai, Mehrotra, Mamdani, Patmanidis, Miller, Sukhera, & Doan discovered that looking up suicide Internet content was not connected to an increase of hospital visits for suicide attempts (2017).    

Interestingly, it was found that “although suicide is more probable for people in rural communities, depression, and anxiety are more prominent in urban areas”(Hauser & Valachy, 2018).  This information can be interpreted to mean that even though rural areas have a higher rate of teen suicide, it does not exclude the fact that urban areas have a greater potential for risk factors such as these mood disorders.  With a mood disorder being one of the highest risk factors for teen suicide, it is possible that rural and urban locations could eventually equal one another. 

Descriptive Epidemiology

Suicide rates can be separated into many subtypes and personal characteristics.  The aggregate group that has been narrowed down for this paper is suicide among adolescents ages 12-18.  Teenage males and females both have high suicidal rates.  Shaffer et al., (2007) found that males seem to have a higher suicide rate than females, and that there is a wider range of differences depending on the age of the individual.  Youth, while in the pre-teen years, have a much smaller suicide rate than when they get older.  The suicide rate is almost equal in males and females at this age.  As each of the youth age, the number of suicides in males and females increase; however,  the suicide rate in males increases significantly more than in females.  Figure 1, (CDC, 2009a) shows the variation among adolescent suicide rates from the years 2000-2006.  One can see the gap and difference of the older male aggregate vs. the older female aggregate.  This shows there is a difference in distribution between age and gender.

   FIGURE 1

(CDC, 2009a).  

Globally “suicide rates were higher in males 10.5/100,000 than in females 4.1/100,000” (Wasserman, Cheng, & Jiang, 2005).  There is also a difference in the way different genders choose to commit suicide.  Males seem to commit suicide more often with the use of lethal weapons as well as hanging.  Females around the globe tend to commit suicide by way of ingestion.  Geographically, the types of ingestion are different among women.  In the United States the use of over the counter medications or medicines are more often used (and are less lethal); however, in Asian countries the use of herbal and poisonous ingestion is used and has been seen to be far more fatal (Shaffer et al., 2007).  

  Race does play a part in suicide.  It is found that American Indians and Alaska natives have the highest suicidal rate.  Asians/Pacific Islanders have the lowest rates (Shaffer et al., 2007). “Minority students are more likely than white students to consider, plan, and attempt suicide. Hispanic students were most likely to consider (15.4%) and plan a suicide attempt (12.2%) than white and black students. Hispanic and black students were more likely to make a suicide attempt (8.1% and 7.9%) than white students (5.0%)” (CDC, 2010).  Personal characteristics and race play a large part in suicidal risk and behavior. 

Socioeconomic status seems to be equal among all populations, however, those that attend college seem to have a lower rate of suicide than those that do not (Shaffer et al., 2007).  Religious beliefs seem to have a large impact on deterring suicidal behavior.  Religious and societal taboos have been found to make some individuals seek help among family or community leaders; instead, of choosing to commit suicide.  Sexual orientation studies have found that youth who identify as being lesbian, gay, or bisexual seem to have higher suicidal ideation and attempts (Shaffer et al., 2007).  It does need to be mentioned that the study that was done by Shaffer et al., was done before laws and the perception of what it meant to be gay, lesbian or bisexual, had been changed.  Occupation and marital status don’t seem to have as much of an impact on adolescent suicide due to the age group.  However, parent’s occupations and marital status can have effect.  Having family discord, parents being out of work, divorce of parents or family trauma, can put the adolescent in the higher risk category for suicide.

 Place characteristics also have an impact on teen suicide.  As discussed earlier, rural areas seem to have a higher rate for teen suicide than urban areas.  The county that has the highest teen suicide rate is the rural Northwest Arctic Borough, in Alaska.  Suicide rate in this county was “estimated to be 51.8%” (Suicide Rate, 2018). The state that has the highest suicide rate in the US is Alaska, “at 35.1% compared to the national average of 8.9%” (Mckinnon, Gariepy, Sentenac, & Elgar, 2016).  The country worldwide that has the highest level of suicide is Lithuania at a rate of 58.1/100,000 (World Health Organization, 2016).  With these statistics it looks as if physical environment, such as that in Alaska and Lithuania and the colder weather, seem to play a role in suicidal rates.  Not all adolescents are employed, but place of work has been found to have impact.  According to Woo et al., (2012) people that have a job that is primarily indoors have a higher suicide rate than a person who can work outside.  

Time characteristics and seasonal influences seem to also have an effect on this disorder.  Weather such as rain, thunderstorms, cloudy skies, and colder weather have shown to add to the risk of suicidal behavior in people (Woo et al., 2012).  Interestingly it was found that during the spring months, there seemed to be an increase in suicides with those suffering from mood disorders  (Postolache, Mortensen, Tonelli, Jiao, Frangakis, Soriano, & Qin, 2010).  It is important to note that people committing suicide in the spring have usually just come out of living for months in a darker, colder, and the cloudier season of winter.  This could effect some of the people that chose to commit suicide.

Prevention

Interventions to prevent this condition come in many forms.  “While its causes are complex and determined by multiple factors, the goal of suicide prevention is simple: Reduce factors that increase risk”(CDC, 2018).  The cultural factors that impact teen suicide are whether there is a negative perspective on suicide or not in that culture.  In some cultures and religious beliefs, suicide is considered a sin or something that could affect one’s chance at a happier afterlife.  These types of beliefs can deter suicide in some teens that might do it otherwise. 

The behavioral factors can be related to choices such as alcohol abuse, street drugs or choices that cause more personal drama or discontent. The environmental factors that have been discussed earlier in this paper of living in a rural area without the medical or community support that is needed can all be risk factors.  There is a need for different types of preventions for those that live in rural areas than those that live in urban areas, especially due to the higher suicide rate that is found in rural areas. “More than 90 percent of people who die by suicide have these risk factors” (Gould, Greenberg, Velting, & Shaffer, 2003). 

Based on these known risk factors, the most effective primary prevention against suicide is education.  Educating teens in the school system, community centers and even in the media has been an effective tool.  Education for health care professionals on different screening tools one could use to identify those at risk sooner is another form of primary and secondary prevention.  “Ideally, prevention addresses all levels of influence: individual, relationship, community, and societal. Effective prevention strategies are needed to promote awareness of suicide and encourage a commitment to social change” (CDC, 2018). 

Another primary prevention that has been implemented for those who feel that he or she is in crisis, are prevention hotlines.  These are set up so one can call in anonymosely and talk to someone.  This prevention can be seen as preventative for suicide, and has been utilized globally.

A secondary prevention is to have teenagers who are currently suicidal, depressed, or who suffer from substance or alcohol abuse, be screened for mental health problems (Shaffer et al., 2007).  By having these screening tools available, it can help healthcare workers identify those individuals that need more education and resources to help prevent suicide from happening. There have been a lot of preventative interventions that have been created to help change or remove the different risk factors people face.  By focusing on different mental and emotional risk factors, one can assist with family dynamics, help with past traumatic experiences as well as ways to deal socially.  Having the primary care provider know the social dynamics of his or her patients can help to create more policies and programs specifically to help promote more resources for that aggregate group.  There is evidence that supports these environmental and individual-level protective factors and preventive interventions (O’Connell et al., 2009). Durlak & Wells (1997) reviewed 177 interventions that focused on reducing behavioral and social problems in youth.  The results that were found showed that those that participated in the changed school environment, transitioned using plans during stressful times and promoted individual mental health programs,  had significant effect and reduction of problems (Durlak & Wells, 1997). 

Conclusion

In conclusion, this paper reviewed adolescent suicide, described its surveillance case definition and the sources of data that is available.  The statistics and significance of suicide on a national and global level was reviewed.  The known determinants and risk factors where explored along with the descriptive epidemiology of suicide in the specific aggregate group of adolescents.  Preventions against teen suicide was then analyzed and considered for primary and secondary interventions.

 In reviewing this information, one can conclude that some of the most impactful upstream social determinants of teen suicide are related to those that are predisposed for untreated mental health disorders as well as those that have lifestyle choices that include substance abuse, family discord, and have access to lethal forms of weapons or materials. 

The best health promotion and prevention practice that is available at this time is education to individuals as well as families on the known risk factors of suicide and given resources for alternative behaviors.  Educating doctors, family nurse practitioners and healthcare providers on the secondary screening tools is another system that can be implemented to help locate those at risk easier and earlier on.  

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