Self-reported suicide attempts rose significantly in African American teens

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Adding to what is known about the growing crisis of suicide among American teens, a team led by researchers at the McSilver Institute for Poverty Policy and Research at New York University have uncovered several troubling trends during the period of 1991-2017, among Black high school students in particular.

The findings were published today (Oct. 14) in the November 2019 issue of Pediatrics, the journal of the American Academy of Pediatrics:

  • Self-reported suicide attempts rose in Black teenagers, even as they fell or saw no significant trend in white, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native teenagers.
  • Self-reported suicide attempts increased at an accelerating rate in Black female teenagers, even as overall female suicide attempts declined.
  • There was a significant increase in injuries from self-reported suicide attempts in Black male teenagers.
  • A surprising dynamic in the relationship between self-reported suicide thoughts (ideation), plans and attempts was revealed: ideation and plans decreased while actual attempts increased.

“It is urgent that we get to the bottom of why the rate of suicide attempts among Black female adolescents is accelerating,” said the lead author of the study, Dr. Michael Lindsey, executive director of the McSilver Institute, and the Constance and Martin Silver Professor of Poverty Studies at NYU’s Silver School of Social Work. “We also need to understand why Black males are increasingly injured in suicide attempts.”

“Youth suicide is very real and must be addressed,” New York State Senator David Carlucci, chair of the NYS Senate’s Mental Health and Developmental Disabilities Committee, said about the research findings.

“The numbers are staggering among Black youth, and just one life lost is one too many. We need a task force to specifically investigate the causes of Black youth suicide.

I thank the McSilver Institute for their partnership and unwavering commitment to bring attention to this once silent crisis.”

“The numbers are staggering among Black youth, and just one life lost is one too many. We need a task force to specifically investigate the causes of Black youth suicide.

I thank the McSilver Institute for their partnership and unwavering commitment to bring attention to this once silent crisis.”

“The number of Black youth who are tragically taking their own lives is rising at an alarming rate, and that is why I sponsored legislation to establish a Black Youth Suicide taskforce here in New York State,” says New York State Assemblywoman Kimberly Jean-Pierre, of the 11th Assembly District.

“It’s vital for us to take action now to improve mental health and suicide prevention services to save these precious lives, and I applaud Dr. Lindsey and his research team at the McSilver Institute for shedding light on this very real issue.”

“The McSilver Institute’s findings of increased suicide attempts and self-injury among Black young adults are important and tremendously concerning, particularly for those of us who work in New York’s child welfare community where Black families are chronically, disproportionately overrepresented,” said Judge Ronald E. Richter, CEO and executive director of JCCA and former commissioner, NYC Administration for Children’s Services.

“We must address Dr. Lindsey’s alarming data with urgency. Further research is critically necessary to determine best practices for our work with the young people who will shape our city’s future.”

“These findings should also push us to expand how we frame suicide prevention from mostly looking at individual-focused efforts and explanations, to societal based changes,” said Gary Belkin, former NYC deputy health commissioner and founder of the Billion Minds Institute.

“Rising suicidality is the tip of an iceberg that should compel us to ask not only what are these children doing to themselves, but ask about the structural and racist violence of our society — what is society doing to them?”

“Further research must be done into why traditional precursors to suicide attempts, such as thinking about it or making plans, are decreasing while actual attempts are going up,” Lindsey said.

“It’s important that we identify the signs before young people attempt to end their lives.”

According to the Centers for Disease Control and Prevention, suicide was the third-leading cause of death in 2017 among Black youth ages 15-19.

The McSilver Institute researchers conducted logistic regression analyses on data from the nationally representative school-based Youth Risk Behavior Survey (YRBS) from the years 1991 to 2017.

In addition to Lindsey, the research team included Arielle H. Sheftall of the Center for Suicide Prevention and Research, Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children’s Hospital and the Department of Pediatrics, College of Medicine, Ohio State University; Yunyu Xiao of the McSilver Institute and Silver School at NYU; and Sean Joe at the George Warren Brown School of Social Work, Washington University in St. Louis.


Suicide is a serious problem worldwide, with an annual global age-standardized suicide rate of 11.4 per 100 000 population [1]. Suicide attempts are also a serious public health problem, with significant tolls on psychiatric and other healthcare services. Hospitalizations for attempted suicides occur at a rate of six to seven times that of completed suicides [2], and are an important predictor of eventual suicide [3].

A review of articles examining suicidal behaviour highlights the importance of definitional clarity [4].

Suicide attempt is defined as a self-inflicted, potentially injurious behaviour with a non-fatal outcome for which there is evidence of intent to die, and it is differentiated from self-harm, where it is evident that there is no intent to die [5], and highlights the importance of suicide intent in differentiating both behaviours [4,5].

A high degree of suicide intent is associated with hopelessness, pessimism [6], a sense of isolation, older age, a history of suicide attempts, and a higher risk for completed suicide [7].

Suicide attempts have been rated in terms of the medical consequences or medical lethality and seriousness of the intent of the individual to die [8]. The Beck Medical Lethality Scale [9] addresses the medical lethality of the suicide attempt but gathers very little other information.

The Suicidal Behaviour Questionnaire [10] asks for a count of previous self-injuries and suicide attempts together with information about the medical treatment for each, but does not include other aspects of the attempt.

Other lethality scales which have been developed more recently are more comprehensive, as they include other dimensions in addition to medical severity, and empirical support has been cited [4,11].

Subjective intent to die has been demonstrated to be of high importance, through empirical studies of multiple samples and advanced statistical analyses [12].

Suicide intent could be measured by the Suicide Intent Scale SIS [13], which includes items on the preparation and manner of execution of the attempt, the setting, prior clues given that could facilitate or hamper intervention or discovery, the attempter’s perception of the lethality of the method, the extent of premeditation, purpose, and expectation of the possibility for rescue.

Factor analysis of the SIS revealed four factors: attitude towards the attempt, planning, precautions against intervention, and communication with others. Subsequent research [14] found that the precautions dimension differentiated between attempters who did and did not ultimately die by suicide, implying that attempters who took precautions against being discovered, such as those who found isolated places and scheduled their attempts at times when discovery was less likely, would be particularly at risk of eventual suicide.

An important component of the nature of suicide is the typical pattern of the index attempt. Those who had taken precautions against discovery at the time of the index attempt might have been more likely to use similar methods at the ultimate attempt. Since precautions would militate against discovery and intervention, this pattern, if repeated, would seem likely to foster a successful suicide.

Suicide intent and lethality may have overlapping features, and most clinicians will assume that high medical lethality suggests high suicide intent.

However, lethality may not be a true reflection of intent [15]. Greater suicide intent increases suicide risk [16], but studies did not consistently show an association between suicide intent and lethality of the suicide attempt.

Some researchers found minimal association between the degree of suicide intent and the extent of medical lethality in suicide attempts [9,17,18]. However, for attempters with accurate expectations about the likelihood of dying from the attempts, medical lethality was proportional to the degree of suicide intent.

Attempters were more likely to make medically severe attempts when they had accurate expectations of the lethality of the method used, and higher suicide intent [17]. A study done in China found a positive correlation between suicide intent and lethality.

Zhang and Xu [19] postulated that the high fatality rate for Chinese females who swallowed poisonous pesticides was a function of strong suicide intent and the well-known lethality of pesticides. In contrast, some studies found that the medical lethality of the chosen method did not match the adolescent attempter’s intent to die, as the adolescent had limited knowledge of the toxicity [20].

It has been suggested that both suicide intent and medical lethality should be assessed when ascertaining the seriousness of the attempt.

Neimeyer and Pfeiffer [21] cited the inadequate assessment of suicide intent as one of the common errors of suicide interventionists. It was suggested that effective assessments should include assessment of suicide intent, lethality of the suicide plan (e.g., by enquiring about precautions against discovery and rescue), and perturbation associated with the suicide plan [7,21].

Issues that have been identified in suicide risk assessment include membership of a high risk group, the acuteness of risk, the need for risk indicators to be clinically relevant, and the recognition that the risk factors are multi-dimensional, intersecting and interacting [22].

Background risk factors include socio-demographic and related indices which are correlated with increased risk for suicide. They can assist the clinician in overall formulation of suicide risk.

Beautrais [23] proposed that in the accumulative risk model, the risk of serious suicide attempts rose dramatically with the risk factor burden to which an individual was exposed.

Four or more risk factors were found to elevate the odds of serious suicide attempts over 120 times more than those with fewer than three risk factors. Risk increases as the risk factors accumulate for a suicidal individual [7].

Suicide risk is also increased with certain combinations of risk factors, for example, patients with bipolar disorder and comorbid alcohol use disorder had twice the suicide risk of those with bipolar disorder but without alcohol use disorder [24].

Substantially higher risks occur among those with history of suicide attempts and psychiatric diagnosis, such as mood disorder and schizophrenia [232527].

When researchers tried to use the commonly recognized suicide risk factors to predict suicide, predictive power was found to be poor with low clinical utility. Pokorny [28] used the 20 best predictors of suicide to identify the 67 subjects who died by suicide in a sample of 4,800 American veterans. Statistical analysis yielded 1,206 false-positive identifications, and had limited usage in a clinical capacity.

Goldney and Spence [29] also found that the predictive ability of six clinical features of suicide was poor. Even in high risk patients with affective disorders, prediction of suicide using the suicide risk factors was poor [30].

Furst and Huffine [31] found that when subjects were asked to predict suicide, the potential for suicidal behaviour was under-estimated. Factors associated with accurate prediction were female gender and presence of a family member who died by suicide.

In summary, there are limitations in the usage of checklists on recognized risk factors, and standardized assessments in assessment of suicide risk and intent. There is insufficient evidence to support a model for accurate prediction of suicide risk.

An investigation of the current practice in clinical assessment of suicide risk, and factors contributing to suicide intent for suicide attempts in the local context would inform efforts in defining best practice in suicide assessment.

A review of relevant literature shows that many risk and protective factors were related to suicide deaths and suicide attempts in both Western and Asian studies, listed in the next two paragraphs. However, there is a lack of large scale research examining prediction of suicide intent and risk using recognized suicide risk and protective factors, and circumstances surrounding the attempt.

This current study aims to explore prediction of medical doctors’ clinical assessment of suicide risk and suicide attempters’ self-report of suicide intent. Based on past evidence in both Western and Asian studies, analysis will be conducted on the following available variables. These variables were collected as part of standard clinical assessment.

The risk factors include: living alone [32], unemployment [3235], financial problem [36], physical illness [36], mental illness [34,35,37], alcohol/ drug use [38,39] interpersonal conflict [34,35,40] protective factors include: presence of dependents [41], emotional support [42], willingness to seek help [43,44], resolution of precipitants [45], religion [46], regret of the attempt [47], and positive future planning [48]. It is hypothesized that their suicide risk and suicide intent will be predicted by the above-mentioned risk and protective factors as well as features of the attempt, e.g., planning, and precautions taken to hide the attempt [8,14].


Source:
NYU
Media Contacts:
Robert Polner – NYU
Image Source:
The image is in the public domain.

Original Research: Open access
“Trends of Suicidal Behaviors Among High School Students in the United States: 1991–2017”. Michael A. Lindsey, Arielle H. Sheftall, Yunyu Xiao, Sean Joe.
Pediatrics doi:10.1542/peds.2019-1187.

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