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Adolescent Suicide: 2009 UpdateLanny Berman, Ph.D.Executive directorAmerican Association of SuicidologyWashington, DC, USA
Academic Meeting WHO Coordinating Center for Research and Training in Suicide PreventionBeijing, 6 March, 2009
Adolescent Suicide: 2009 Update
• American Psychological Association, 2006
• Research summation to 2005
• Clinical practice applications; prevention programming applications
• Some international focus, but mostly a North American bias
• Update questions: From a more global perspective, notably looking at USA and China
Adolescent Suicide: 2009 Update• Objectives:
1. Stress the importance of indigenous research2. Offer a few good research questions based on recent
research findings and hypotheses in need of testing: Why is youth suicide more prevalent in rural settings
in both the USA and China? Is increased or excessive substance use a universal
risk factor? Why do youth suicide rates decline when they do? How can we identify those youth who make nonfatal
attempts? What are the warning signs of youth suicide?
Youth Suicide: Global Trends
•More than 80% of published research on suicide comes from developed countries
•Significant methodological limitations▫Few case-controlled studies▫Over-reliance on clinical samples▫Mixed samples of youth who ideate and
youth who attempt; poor operational definitions to classify samples
Global Trends
•Youth suicide rates vary across the globe•Cross-national comparisons:
▫Difficult as death certification systems vary between countries and even within the same country, therefore great differences in quality and validity of data
▫Difficult due to different cultural and religious attitudes toward suicide, thus severe under-reporting in some countries
Comparison of Suicide in USA and in China
United States• Males > Females• Modal Method: Firearms• Almost 90% with mental
disorder• Less impulsive• Rural > Urban
China• Females > Males• Modal Method: Pesticides • Minority with mental
disorder, especially in female suicides
• More impulsive• Rural > Urban
Global Comparisons
•Youth suicide rates in the US and in China are higher in rural settings
▫The suicide rate for women in rural China is three times the urban rate for both men and women.
▫Rates of youth suicide in the US are
generally highest in the most sparsely populated states.
Suicide rates among persons aged 15-19 years by state -- US, 2000-2004
Rates per 100,000 population
0.0 to 6.41
6.42 to 7.76
7.77 to 10.26
10.27 to 35.15
Source: CDC vital statistics
Wash., D.C.
Also in AustraliaAustralia, Suicides, 2005 -- State and Territory Rates
• NSW 9.7• Vic 10.6• Qld 12.8• SA 12.8• WA 11.6• Tas 15.6
•NT 24.0• ACT 10.1• Total 11.2
Why is Youth Suicide More Prevalent in Rural Areas?
Why Might Rural Suicide Rates be higher? Hypotheses: 1-3
• Risk factors associated with residence in rural areas:
▫Low population density Social and geographic isolation
▫Lower socio-economic status [low educational attainment, poorer economic conditions (more agricultural work, higher unemployment)]
▫More accepting attitudes toward suicide? (Renberg et al, 2008)
Why Might Rural Suicide Rates be higher? Hypotheses: 4-6
▫Culture of individualism/frontier mentality/negative attitudes toward help-seeking
▫Greater availability of modal methods? (firearms in US, pesticides in China)
▫Higher proportion of at risk demographic groups Unmarried, males, whites/Native-Americans (in US)
Rural Suicide Hypotheses: 7-9
▫Greater stigma associated with mental disorders Less tolerance of deviant behavior
▫Lower rates of mental health service utilization? (Renaud et al, 2009)
Fewer available services and fewer health professionals per capita
▫Higher rates of interpersonal violence?
Rural Suicide Hypotheses:10-12
▫Less sophisticated death certification systems (e.g. coroner versus medical examiner in US)
▫Lower rates of nonfatal suicide attempts, thus similar overall prevalence of suicidal behaviors
▫Higher substance use, especially binge drinking?
Is Substance Use a Universal Chronic and Acute Risk Factor?
Fleischmann et al (2005)English language research studies worldwide (N = 894 cases)
Substance Use and Youth Suicidal Behaviors (see Esposito-Smythers and Goldston, 2008)
• Among youth receiving treatment for substance use: 18-36% have a history of suicidal behavior
• SUD is associated with 3- to 4-fold increase in suicide attempts
• Adolescents diagnosed with SUD are 5-13 times as likely to die by suicide
• In US, as many as 50% of adolescents who attempt and those who die by suicide had been drinking at time▫ Independent of depressive symptoms, heavy episodic drinking is
significantly related to self-reported suicide attempts, especially among those younger than 13 (OR = 2.6) (Aseltine et al, 2009)
Substance Use and Youth Suicidal Behaviors
•Common precipitants▫e.g. conflict with parents
•Common vulnerabilities▫e.g. wish to escape conflict or problems
•Common comorbid risk factors▫e.g. history of abuse, PTSD, trouble with
police…
Why Do Youth Suicide Rates Decline When They Do?
New Zealand Youth Suicide Rates
Rates of suicide and open verdicts:England & Wales 1968 - 2007
0
2
4
6
8
10
12
14
16
18
68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 04 06
Year
Ra
te/1
00
,00
0
Males
15-24 yrs
Source: Office for National StatisticsData are for registrations of death in each calendar year
Rates of suicide and open verdicts: England & Wales 1968 - 2007
0
1
2
3
4
5
6
68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 04 06
Year
Ra
te/1
00
,00
0
Females
15-24 yrs
Source: Office for National StatisticsData are for registrations of death in each calendar year
Suicide Rates: 1960-2005, 15-19 Years, USA
0
2
4
6
8
10
12
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
Rate
Working HypothesesRecent Declining Youth Suicide Rates
•Means Restriction Approaches ▫US: Firearms; China: Pesticides?
•Decreased Divorce Rate•Suicide Awareness and Gatekeeper
Programs•Crisis Hotlines•Same Prevalence, Decreased Lethality
▫ Increased ED admission data▫Decreased use of firearms
•Better Management of Mental Disorders▫ Increased antidepressant prescribing (SSRI’s)▫Psychotherapy: CBT, DBT
•Regression Toward Mean
How Can We Identify Youth Who Make Nonfatal Attempts?
Global Comparisons
•There are no national data on attempted suicide in China
Burden of Injury
Hospitalizations
Emergency Dept visits
Events reported on surveys
Unreported events
Deaths
Source: CDC
0
50
100
150
200
250
300
350
400
450
Age Group in years
Ra
te p
er
10
0,0
00
po
pu
lati
on
Males
Females
Self-inflicted injury among all persons by age and sex--United
States, 2005
Source: CDC WISQARS NEISS
Percentage of High School Students Who Actually Attempted Suicide,* 1991 – 2007
1991 1993 1995 1997 1999 2001 2003 2005 20070
20
40
60
80
100
7.3 8.6 8.7 7.7 8.3 8.8 8.5 8.4 6.9
Per
cen
t
* One or more times during the 12 months preceding the survey1 No significant change over time
National Youth Risk Behavior Surveys, 1991 – 2007
Percentage of High School Students Whose Suicide Attempt Resulted in an Injury, Poisoning, or Overdose That Had To Be Treated by a Doctor or Nurse,* 1991 – 2007
1991 1993 1995 1997 1999 2001 2003 2005 20070
20
40
60
80
100
1.7 2.7 2.82.6
2.62.6
2.9 2.3 2
Perc
en
t
* During the 12 months preceding the survey1 No significant change over time
National Youth Risk Behavior Surveys, 1991 – 2007
Comparative Estimates of Nonfatal Suicidal Behaviors among Adolescents, US (5 states)US State (year)
Estimated Hospital Admissions for self-inflicted injury
YRBS: SA requiring medical attention
Ratio: YRBS: Hospital Admissions
Alaska (2005) 149 1,707 (3.2%) 11.5:1
Arizona (2005)
289 13,532 (3.2%) 46.8:1
Florida (2006) 796 24,000 (2.1%) 30:1
Maine (2005) 82 1,380 (1.5%) 16.8:1
Nevada (2005)
123 5,036 (3.3%) 40.9:1
Grand Mean .077% 2.45% 31.8:1
A few definitions of a nonfatal suicide attempt•A thwarted high lethality, intended suicide•An aborted potentially lethal, intended
suicide•An intended suicide, yet low lethality
behavior (misjudged toxicity?, poor judgment?...)
•A low lethality, low intention behavior (e.g. for instrumental purpose)
•A non-suicidal, self-injury behavior viewed by perpetrator as suicidal
What are the Warning Signs of Youth Suicide?
Acute Risk: IS PATH WARM?• I Ideation/threatened or communicated• S Substance Abuse/excessive or increased
• P Purposeless/no reasons for living• A Anxiety, Agitation/Insomnia• T Trapped/feeling no way out• H Hopelessness
• W Withdrawal from friends, family, society• A Anger (uncontrolled)/rage/seeking revenge• R Recklessness/risky acts - unthinking• M Mood changes (dramatic)
Bullying (Kim et al, 2008: Int J Adol Med & Health)
Reviewed 37 case-comparison studies from 16 countries*
• Victim of Bullying▫ Increased risk of SI (OR Range: 1.4-5.6) [12/15 studies]▫ Increased risk of SA and SIB (OR Range: 1.5-5.4) [12/13 studies]▫ Dose-Response relationship: frequent victimization increased risk
• Perpetrators▫ Increased risk of SI (OR Range: 1.4-9.0) [8/10 studies]▫ Increased risk of SA and SIB (OR Range: 2.3-9.9) [2/4 studies]
• Victim-Perpetrators▫ Increased risk of SI (OR Range: 1.9-10.0) [5/5 studies]
* Prior hx of suicidality considered as a covariant in only 1/37 studies
• Increased risk of attempt, self-injurious behavior, and/or ideation also generally found in victims of bullying in special populations: juvenile offenders, LGB, LD, drug abuse…
Impulsive Aggression as Risk Factor•Zhang (2009, this meeting) “dysfunctional
impulsivity”•Spirito et al (2006)
▫Genetic and neurobiologic studies suggest that impulsive aggression may be the mechanism through which decreased serotonic activity is related to suicidal behavior
Insomnia as an Acute Risk Factor• Roane and Taylor (Sleep, 2008)
▫ 4,944 (12-18 year olds: US): 9.4% reported insomnia symptoms – associated with use of alcohol, cannabis and other drugs, depression, suicide ideation and suicide attempts
• Liu et al (Sleep, 2007)▫ 553 adolescents (Hungary)diagnosed with major depressive
disorder: 73% had sleep disturbance (54% insomnia; 9% hypersomnia; 10% both). Sleep disturbance associated with more depressive symptoms and comorbid anxiety symptoms. Those with both, more severely depressed
• Barbe et al (J. Clinical Psychiatry, 2005)▫ Depressed suicidal youth (7-17 years old: US), versus those
depressed but without suicide ideation, presented more frequently with insomnia
Conclusions
•It is very important to expand the scope and depth of suicide research country by country
•It is very important to develop systems that allow for cross-national comparisons
•It is very important to understand how much we have yet to learn and need to better understand to prevent the tragic loss of young lives by suicide
