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Defining Youth Suicide 

Defining Youth Suicide
Chapter:
Defining Youth Suicide
DOI:
10.1093/9780195173642.003.0022
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date: 14 December 2018

SCOPE AND DEMOGRAPHICS

Fifty years ago suicide among young people aged 15–24 was a relatively infrequent event and suicides in this age group constituted less than 5% of all suicides in the United States. As can be seen in Figure 21.1, between the mid-1950s and the late 1970s, the rate of suicide rose markedly among this age group. This increase was observed most dramatically among young males, whose suicide rates more than tripled between 1955 and 1977 (from 6.3 per 100,000 to 21.3). Among females ages 15–24, the suicide rate more than doubled during this same period (from 2.0 per 100,000 to 5.2). By 1980, suicides by 15-to 24-year-olds constituted almost 17% of the approximately 30,000 suicides in the United States (National Center for Health Statistics, n.d.).

Figure 21.1 Rates of suicide for 15-to 19-year-olds and 15-to 24-year-olds, both sexes, all races [source: National Center for Health Statistics]. Rates for 15-to 19-year-olds are not available for pre-1970.

Figure 21.1
Rates of suicide for 15-to 19-year-olds and 15-to 24-year-olds, both sexes, all races [source: National Center for Health Statistics]. Rates for 15-to 19-year-olds are not available for pre-1970.

Rising suicide rates continued, albeit at a slower pace, during the 1980s and early 1990s, reaching a peak rate of 13.6 suicides per 100,000 youth aged 15–24 in 1994. At that point, rates began to steadily decline, decreasing to 9.9 per 100,000 by 2002 (the last year for which national data are currently available), a drop of over 27% (National Center for Health Statistics, n.d.).

Figures available since 1970 (also depicted in Fig. 21.1) show that among the younger subset of youth, those aged 15–19, the suicide rate rose relatively consistently up until 1990 (from 5.9 per 100,000 to 11.1), and has dropped considerably since that time to 7.4 suicides per 100,000 population in 2002. Even with these declines, the overall youth suicide rate remains more than twice what it had been before the marked rise began, and currently constitutes almost 13% of all U.S. suicides (Centers for Disease Control and Prevention [CDC] n.d.a).

Suicide before the age of 12 is rare, but increases with every year past puberty (CDC, n.d.a). In 2002, youth aged 20–24 had a suicide rate of 12.3 per 100,000, compared to the rate of 7.4 among adolescents aged 15–19. A total of 4,010 young people aged 15–24 died by suicide during that one year, 1,513 between the ages of 15–19, and 2,497 between the ages of 20–24. Currently in the United States suicide is the third leading cause of death among youth; only accidents and homicide claim more young lives. Among college students specifically, suicide is the second leading cause of death, surpassed only by accidental injury.

How is one to explain the rise in the rate of youth suicide in the United States during the latter half of the last century? It has been suggested that the increase in the youth suicide rate paralleled an increase in the rate of depression since the 1950s. Documenting an increase in the rate of depression is not easy, however, since clinical studies undertaken prior to the 1980s did not use a standard definition of depression. In addition, such a dramatic rise in suicide in a relatively short time frame is likely to reflect some broad environmental change. Thus, medical and social scientists have sought other explanations (Berman & Jobes, 1995; Gould, Greenberg, Velting, & Shaffer, 2003; Hendin, 1978).

Increased availability of firearms as a contributing factor is suggested by increases in the rate of suicide by firearms among young people in the United States during the 1980s (Boyd & Moscicki, 1986; Brent, Perper, & Allman, 1987; Brent et al., 1991). Similar increases in youth suicide have been seen in countries such as New Zealand and in Europe, however, where firearms are not a common suicide method (World Health Organization, 2003).

The diminishing cohesion of the family observed since World War II has frequently been blamed for a wide range of youth problem behaviors, including both drug abuse and suicide. The psychosocial revolution that swept the Western world beginning in the 1960s, which embraced a greater freedom in sexual behavior, as well as changes in the expectations that young men and women had for themselves and for their relationships, is also thought to have contributed to youth suicide (Hendin, 1978, 1995). A marked and well-documented increase in drug and alcohol exposure took place during that period (Johnston, O'Malley, & Bachman, 2002), and the relationship between substance abuse and suicide has been clearly established in a number of studies of both adults (Barraclough, Bunch, Nelson, & Sainsbury, 1974; Robins, Murphy, Wilkinson, Gassner, & Kayes, 1959) and youth (Marttunen, Aro, Henriksson, & Lonnqvist, 1991; Shaffer et al., 1996).

The question of why youth suicide rates have declined in recent years is equally important. Al though we shall return to this question later in this section, it should be kept in mind that from a historical perspective, the declines we have seen recently are not unique. Twice previously in the 20th century, the rate of suicide among young men declined precipitously: once between 1908 and 1922, when the young male suicide rate went from almost 14 per 100,000 to 6, a drop of over 100%; and again between 1938 and 1944, when the rate fell from almost 9 per 100,000 to 6, a decline of 35%.

Recent decreases have been attributed to efforts to restrict firearms availability among youth (Brent, Baugher, Bridge, Chen, & Chiappetta, 1999; Miller & Heminway, 1999). In the United States the proportion of suicides that involve firearms has decreased somewhat in recent years, although firearms are still used in about 60% of all suicide deaths (CDC, n.d.a). Parallel declines in the youth suicide rate and in the rate of suicide by firearms, therefore, are not surprising. It should also be noted that among older white males, who have the highest suicide rate of any demographic group in the United States, the proportion of suicides that involve firearms has not declined. Furthermore, suicide rates have decreased in other countries where firearms are not a commonly used method.

The decline in the rate of youth suicide has also been linked to the increased use of antidepressant medication in treating young depressed people (Olfson, Shaffer, Marcus, & Greenberg, 2003). Although more precise data than are currently available may well substantiate the link between antidepressant use and suicide deaths, it should be noted that other problem behaviors among youth, notably substance abuse and violent crime, have generally risen and fallen parallel with changes in the suicide rate. And the recent drop in violent crime by young people in recent years seems less likely to be related to increased use of antidepressants.

Improved economic conditions in the 1990s have been credited for the recent decline in youth suicide, just as they were blamed for the high national rates during the depression of the 1930s. The decline in youth suicide has been noted, however, in countries that did not experience the prosperity that occurred in the United States during the last decade of the 20th century.

It is only relatively recently that tracking studies such as the CDC's Youth Risk Behavior Survey (YRBS) have been undertaken to provide accurate data about suicide attempts by young people. Thus, it is not possible to determine whether the increase in youth suicide deaths seen be tween the mid-1950s and 1990 was matched by an increase in suicide attempts among young people. The YRBS data reported since the early 1990s show that among high schools students (the target group for the YRBS), the recent decline in suicide deaths has not been accompanied by a comparable decline in suicide attempts (CDC, n.d.b).

The most current YRBS data (2003) indicate that 8.5 percent of U.S. high school youth surveyed (5.4% of males and 11.5% of females) made one or more suicide attempts in the prior 12-month period; 2.9 percent (2.4% of males and 3.2% of females) required medical attention as a result of a suicide attempt. Seventeen percent of the students indicated that they had seriously considered attempting suicide during the past 12 months. Since youth who are not currently attending school have been found to be at higher risk for suicide attempts and suicide deaths than those who are in school (Gould, Greenberg, et al., 2003; Gould, Fisher, Parides, Flory, & Shaffer, 1996), YRBS high school–based data likely underestimate the extent of these events among young people overall.

Patterns of suicidal behavior vary widely among youth from different demographic backgrounds. Among young people ages 15–24, males die by suicide almost six times more frequently than females. In 2002, the suicide rate among young men ages 15–24 was 16.4 per 100,000, and the rate among young women was 2.9. Although young males die by suicide more often than females, females report suicidal ideation and attempts more often than males (CDC, n.d.b.).

Youth suicide rates also vary widely among different racial and ethnic groups. In 2002, white youth had a suicide rate of 10.6 per 100,000, compared to rates of 6.5 for African Americans, 6.6 for Hispanic youth, 5.3 for Asian Americans/ Pacific Islanders, and 17.9 for American Indians and Alaskan Natives (CDC, n.d.a). The elevated rate of suicide among Native Americans of all ages is substantially accounted for by the particularly high suicide rate of young Native American males (Berlin, 1987; Wallace, Calhoun, Powell, O'Neil, & James, 1996).

Suicide attempt rates appear to be particularly high among young Latinos, surpassing rates among either whites or African Americans, whose attempt rates are similar (CDC, n.d.a). Although these patterns have been relatively stable, the reasons underlying the differential distribution of suicide attempts and suicide completions among racial and ethnic groups in the United States have not yet been adequately explored.

Since the mid-1980s, significant public attention has been focused on youth suicide prevention. During that decade, a proliferation of youth suicide prevention programs were developed and implemented, particularly in schools where they targeted students, parents, teachers, and other school personnel. This coincided with increasing recognition of childhood and adolescent depression, and mental health professionals and medical practitioners likewise began looking for ways to prevent the tragic loss of young lives to suicide. Many of these early youth suicide prevention efforts have not been sustained because of a lack of demonstrable success and/or a lack of funding.

In recent years, renewed attention to the problem of youth suicide has resulted from the National Strategy for Suicide Prevention, developed by the Department of Health and Human Services Administration and the Office of the former Surgeon General, David Satcher (U.S. Department of Health and Human Services, 2001). This initiative called for the development of statewide suicide prevention programs to address youth as well as other priority target populations.

Our primary goal in this section of the book is to examine youth suicide prevention strategies and interventions with an eye toward identifying what works, what does not appear to work, and what research needs to be undertaken to move the field forward. We begin with a review of the multiple factors that have been suggested to put youth at risk for suicide.

ETIOLOGY OF YOUTH SUICIDE

It is generally agreed upon that suicidal behavior is multiply determined. In the following pages, we review the factors that have been identified in the research literature as conveying primary risk for suicide among young people, as well as factors that have been suggested to mediate or protect against suicidal behavior. These risk factors are summarized in Table 21.1. Different aspects of the problem have been addressed in a number of previous reviews (Gould, Greenberg, et al., 2003; Guo & Harstall, 2002; Wagner, 1997; Wagner, Silverman & Martin, 2003) and we have drawn on these in the discussion that follows and throughout the rest of this section.

Table 21.1 Factors Associated with Risk for Suicidal Behavior in Adolescentsa

Psychopathology

Depression

Drug and alcohol abuse

Aggressive-impulsive behavior

Hopelessness

Pessimism

Conduct disorder (male)

Panic disorder (female)

Family and Genetic

Family history of suicidal behavior

Parental psychopathology

Environment

Firearm availability

Diminished family cohesion

Lack of parental support

Parent–child conflict

Negative life events

Child sex abuse

Suicide contagion

Biology

High 5-HT receptor expression in prefrontal cortex and hippocampus

Serotonergic dysfunction

Previous suicidal behavior

Suicide attempts

Sexual orientation

Same-sex sexual orientation

a Factors noted have been found to be associated with increased risk for suicidal behavior individually but overlap and shared underlying factors have not been assessed.

Risk Factors

Although true causation is difficult to establish, a number of factors, or sets of factors, appear, on the basis of existing research, to be primary risk factors for youth suicide. Clearly, there is considerable overlap and mutual reinforcement among these factors, although most studies have considered them separately.

Psychopathology and Substance Abuse

There is overwhelming evidence that psychopathology is the most significant risk factor for both suicide deaths and suicide attempts among adolescents (Brent et al., 1999; Groholt, Ekeberg, Wichstrom, & Haldorsen, 1997; Shaffer et al., 1996). Psychological autopsy studies have determined that the vast majority of adolescents who die by suicide have significant psychiatric problems, including previous suicidal behavior, depressive disorder, substance abuse, and conduct disorder. The initial onset of such problems often precedes the suicide by several years. Suicide risk among adolescents has also been established to increase with the number of psychiatric diagnoses, with comorbidity between affective disorders and substance abuse being of particular importance (Shaffer et al., 1996). One recent analysis (Gould, 2003) has suggested that eliminating psychopathology could prevent 78%–87% of youth suicides.

The psychiatric problems and gender-specific diagnostic profiles of youth who attempt suicide have been found to be similar to those who die by suicide, with relatively more females than males presenting with affective disorder (Brent et al., 1999; Shaffer et al., 1996) and more males than females having substance abuse, particularly among older male adolescents (Gould et al., 1998; Marttunnen, Avo, Henriksson, & Lönnqvist, 1991; Shaffer et al., 1996). Conduct disorder is also prevalent in young males with suicidal behavior, often comorbid with substance use disorders and anxiety and mood disorders (Brent et al., 1993a; Gould et al., 1998; Shaffer et al., 1996).

Panic disorder has been found to be related to suicidal behavior, particularly among girls (Gould et al., 1996, 1998). Among adults, however, no association has been found when controlling for comorbid depression (Warshaw, Dolan, & Keller, 2000). Other anxiety disorders such as posttraumatic stress disorder have not been shown to be associated with suicidal behavior among young people when other comorbid psychiatric conditions are taken into consideration (Wunderlich, Bronisch, & Wittchen, 1998). Some studies have reported a relationship between bipolar disorder and both suicide deaths and suicide attempts among youth (Brent et al., 1988; Brent, Perper, & Moritz, 1993; Marttunnen et al., 1991; Shaffer & Hicks, 1994). Although suicide is relatively common among adults with bipolar disorder, given the relative rarity of the disorder, it accounts for only a small proportion of suicide deaths (Appleby, Cooper, Amos, & Faragher, 1999; Vijayakumar & Rajkumar, 1999). Suicidal ideation appears to be less directly related to psychopathology than either suicide attempts or suicide death (Andrews & Lewinsohn, 1992; Reinherz et al., 1995), perhaps because ideation, while occurring with higher frequency, is less persistent and may be fleeting. Gould et al. (1998) found suicidal ideation to be associated with depression in adolescent females and with depression and disruptive disorders in young males.

Aggressive-impulsive behavior (Apter, Plutchik, & van Praag, 1993; Gould et al., 1998; McKeown, et al., 1998; Sourander, Helstela, Haavisto, & Bergroth, 2001) has an increased association with suicidal behavior, particularly in the context of a mood disorder (Brent, Johnson, et al., 1994; Johnson, Brent, Bridge, & Connolly, 1998). Aggressive-impulsive behavior has been found to discriminate suicide attempters from psychiatric controls, and also appears to be related to familial transmission of suicidal behavior.

Hopelessness has also been implicated as an important factor associated with youth suicidal behavior, although its relationship is not independent of depression and depressed mood (Rotheram-Borus & Trautman, 1988; Rotheram-Borus, Trautman, Dopkins, & Shrout, 1990). Among a depressed subgroup that is at high risk for suicide, hopelessness may be an important marker. Pessimism, a negative cognitive style that may be related to hopelessness, has been found to characterize suicide attempters independent of depression (Lewinsohn, Rhode, & Seeley, 1996).

Previous Suicidal Behavior

Studies among adults have consistently identified previous suicidal behavior to be the most important factor associated with risk of suicide (Hawton & Sinclair, 2003), with repetition of suicide attempts significantly increasing the risk of a fatal outcome (Sakinovsky, 2000). Studies of youth have likewise found previous suicide attempts to be one of the strongest predictors of both subsequent attempts and suicide deaths (McKeown et al., 1998; Shaffer et al., 1996; Wichstrom, 2000). This relationship is particularly strong among youth with mood disorders (Brent et al., 1999; Shaffer et al., 1996). The risk for future suicidal behavior has been estimated to increase 3–17 times when a previous attempt has occurred (Groholt et al., 1997). One study of a high school sample found that half of adolescent suicide attempters had made more than one attempt (Harkavy-Friedman, Asnis, Boeck, & DiFiore, 1987), and this finding is confirmed by data reported by the YRBS (CDC, n.d.b). Overall, it is estimated that one quarter to one third of adolescents who die by suicide had made a previous attempt (Brent et al., 1993a; Groholt et al., 1997; Shaffer at al., 1996).

While prior attempts figure prominently in the histories of many young persons who die by suicide, the nature of the linkage between earlier and subsequent suicidal behavior is less clear. Existing evidence suggests, however, that previous suicide attempts convey an increased risk for suicide death even after controlling for psychiatric risk factors (Brent et al., 1999; Shaffer et al., 1996).

Sexual Orientation

An additional personal factor that has been suggested to be associated with youth suicide is homosexuality. A number of individual studies (Faulkner & Cranston, 1998; Fergusson, Horwood, & Beautrais, 1999; Garofalo et al., 1998; Remafedi, French, Story, Resnick, & Bloom, 1998; Russell & Joyner, 2001; Wichstrom & Hegna, 2003) as well as a comprehensive review article (McDaniel, Purcell, & D'Augelli, 2001) report increased rates of nonlethal suicidal behavior among youth with same-sex sexual orienta tion. Wichstrom and Hegna (2003) found that the suicide attempt rate was higher for those with same-sex orientation regardless of whether they had actually had same-sex sexual contact. They found that those who had had same-sex sexual contact had the highest rate. Stigmatization, victimization, isolation, and parental rejection have been identified as factors in suicidal behavior among gay, lesbian, and bisexual youth (McDaniel et al., 2001).

There is no empirical evidence that links suicide deaths among youth to sexual orientation (Shaffer, Fisher, Hicks, Parides, & Gould, 1995). Research in this area is likely to be limited by methodological challenges, notably inaccuracies in the reporting of sexual orientation or sexual behavior (McDaniel et al., 2001; Russell, 2003).

Biological and Genetic Factors

Some studies have linked youth suicidal behavior to parental psychopathology (Brent et al., 1988; Brent, Perper, et al., 1994; Gould et al., 1996), although others have found rates of family psychopathology among young suicide attempters and completers to be similar to those of other clinical samples (see Wagner, 1997; Wagner et al., 2003). Both suicide and suicide attempts have been found to be increased in families in which a parent has died by suicide or attempted suicide, even when controlling for the impact of parental psychopathology (Brent, Bridge, Johnson, & Connolly, 1996; Brent et al., 2002; Glowinski et al., 2001). This relationship may be mediated by familial transmission of impulsive aggression (Brent et al., 2003).

The mechanisms through which psychopathology and suicidality among parents may influence youth suicidal behavior are not yet clear. Although little is currently known about the genetics of youth suicide, adult studies suggest that biological factors play a significant role in suicide. Neurobiological abnormalities, in particular lower levels of central nervous system serotonin (5-HT), have been implicated in aggressive impulsivity and suicidal behavior in adults (Oquendo & Mann, 2000). Postmortem studies of the brains of adult suicide victims have also shown higher levels of 5-HT receptors than in normal controls (Arango et al., 1990; Mann, Stanley, McBride, & McEwen, 1986).

Postmortem studies of youth who have died by suicide are rare, and therefore the implications of adult findings for understanding youth suicide are not clear. One postmortem study involving 15 teenage suicide victims and 15 normal matched control subjects found significantly higher levels of 5-HT receptor expression in the prefrontal cortex and hippocampus of those who had died by suicide, suggesting that this abnormality may be a marker of adolescent as well as adult suicide (Pandey et al., 2002). These authors noted that higher levels of serotonin receptor expression have been implicated in alterations in emotion, stress, and cognition, which suggests promising avenues of exploration for understanding the neurobiology of youth suicide. Further studies are needed to confirm these findings and to clarify genetic relationships.

Family Environment

The familial expression of suicidality is likely a function of example as well as biology. Certain factors related to the family environment such as lack of family support and parent–child conflict have been found to contribute to risk for youth suicidal behavior (see Wagner, 1997; Wagner et al., 2003 for reviews). Particularly among younger suicide victims, parent–child conflict has been identified as a common precipitant to suicidal behavior (Brent et al., 1999; (Groholt, Ekeberg, Wichstrom, & Haldorsen, 1998).

Negative Life Events

There is considerable evidence that various negative life events contribute independently to youth suicide (see Wagner, 1997; Wagner et al., 2003), over and above other risk factors (Gould et al., 1996; Johnson, Cohen, et al., 2002). Physical abuse, for example, has been demonstrated to increase risk in case–control (Brent, Johnson, et al., 1994; Brent et al., 1999) and longitudinal studies (Brown, Cohen, Johnson, & Smailes, 1999; Johnson et al., 2002; Silverman, Reinherz, & Giaconia, 1996), and has been associated with youth suicidal behavior even after controlling for other contributory factors such as parental psychopathology (see Johnson et al., 2002; Wagner, 1997; Wagner et al., 2003).

Child sexual abuse has also been found to be associated with increased risk for suicidal behavior (Johnson et al., 2002; Silverman et al., 1996), as well as with many other adverse psychological outcomes (Fergusson, Horwood, & Lynskey, 1996.). Some of the suicide risk conferred by child sexual abuse is likely related more generally to parental psychopathology, although one longitudinal study that controlled for many other risk factors (Fergusson et al., 1996) identified a unique contribution of this variable to suicidality.

Stressful life events have been found to be associated with suicide deaths (Beautrais, 2001; Brent, Perper, & Moritz, 1993; Gould et al., 1996; Marttunen, Aro, & Lönnqvist, 1993) and suicide attempts (Beautrais, Joyce, & Mulder, 1997; Fergusson, Woodward, & Horwood, 2000; Lewinsohn et al., 1996). Studies of young suicide attempters suggest that the type of stressor associated with suicidal behavior is age related, with suicidal behavior in younger adolescents most frequently precipitated by conflicts with parents, and in older adolescents by interpersonal loss, in particular the loss of a romantic relationship (Brent et al., 1999; Groholt et al., 1998). Interpersonal loss has also been identified as a significant stressor among youth with substance abuse problems (Brent et al., 1993b; Gould, Greenberg, et al., 2003; Marttunen, Aro, Henriksson, & Lönnqvist, 1994).

Bullying has also been suggested as a precipitant, with at least one study finding both victims and perpetrators to be more likely to engage in suicidal behavior than youth not involved in bullying (Kaltiala-Heino, Rimpela, Marttunen, Rimpela, & Rantanen, 1999). There appear to be commonalities between bullying and other forms of social maligning, such as those reported by gay and lesbian youth. Although media accounts of suicide among young people frequently allude to bullying as a cause, scientific evidence for this is lacking. No studies of bullying have controlled for the presence of other risk factors in suicide victims, in particular psychopathology, and to date in the United States, no systematic suicide prevention efforts have targeted this factor.

Legal or disciplinary problems have been found to precipitate suicidal behavior in youth with conduct disorder and other disruptive disorders (Brent, Perper, & Moritz, 1993; Gould et al., 1996). Academic difficulties have also been found to be associated with increased risk for suicidal behavior. Several studies have demonstrated increased suicidal ideation or behavior among students at risk for dropping out of high school (Beautrais, Joyce, & Mulder, 1996; Thompson & Eggert, 1999; Wunderlich et al., 1998). Gould et al. (1996) also reported that school problems and not being in school or in a work situation pose considerable risk for suicide death.

Contagion

There is evidence that young people are particularly vulnerable to the impact of suicide contagion, whether through media coverage or direct knowledge of a peer's suicide (Gould, 2001; Gould, Jamieson, & Romer, 2003). Research has described outbreaks or clusters of both suicide deaths (Gould, Wallenstein, & Kleinman, 1990; Gould, Wallenstein, Kleinman, O'Carroll, & Mercy, 1990) and attempted suicides (Gould, Petrie, Kleinman, & Wallenstein, 1994) among young people. Having a friend who has attempted suicide has been found to discriminate depressed adolescents who themselves make a suicide attempt from those who do not (Lewinsohn, Rohde, & Seeley, 1994). The causality of the association between a youngster's knowledge of a friend or family member who attempts suicide and the youth's subsequent suicidal behavior has been supported using two waves of data from the National Longitudinal Study of Adolescent Health (Add Health), a nationally representative study of youth in grades 7 through 12 (Cutler, Glaeser, & Norberg, 2001). Despite some research reporting no association between media reporting and subsequent suicides (Mercy et al., 2001), the evidence of the significant impact of media coverage on suicide is ample and continues to grow (see Gould, 2001; Pirkis & Blood, 2001a, 2001b; Schmidtke & Shaller, 2000; Stack, 2000).

Availability of Means

Over half of the 4,000 youths aged 15–24 years who died by suicide in 2002 used firearms (CDC, n.d.a), and there is strong evidence that firearms used for both suicides and unintentional injuries by adolescents are mainly from the home environment (Bailey et al., 1997; Beautrais et al., 1996; Brent et al., 1993d; Grossman, Reay, & Baker 1999; Shah, Hoffman, Wake, & Marine, 2000).

Family firearm ownership has been found to correlate with the youth suicide rate for 15-to 24-year-olds (Birckmayer & Hemenway, 2001). Almost three quarters of youth suicides and suicide attempts have been found to involve the use of a firearm belonging to a household member; in more than half of the cases, a parent's gun was involved (Grossman et al., 1999; Reza, Modzeleski, Feucht, Anderson, & Barrios, 2003). A disproportionate number of parents with guns in the household have been found to leave their guns loaded and not locked up (Coyne-Beasley, McGee, Johnson, & Bordley, 2002; Coyne-Beasley, Schoenback, & Johnson, 2001).

Guns have been estimated to be four to five times more prevalent in the homes of suicide victims compared to controls (Brent et al., 1993d; Kellermann et al., 1992; Shah et al., 2000). There appears to be a gradient of risk, with loaded guns and handguns posing the greatest risk. In a recent review of case–control studies, Brent and Bridge (2003) reported that the odds of a youth dying by suicide was 31.3–107.9 times higher in homes where a gun was present than in homes without guns.

Of note, youth who use firearms for suicide reportedly have fewer identifiable risk factors, such as expressing suicidal thoughts, suicidal intent, psychopathology, and substance abuse, compared to those using other means (Azrael, 2001; Brent et al., 1999; Groholt et al., 1998), and firearm suicides appear to be more impulsive and spontaneous (Azrael, 2001). Thus, to at least some extent, means availability appears to function as a contributing factor to youth suicide, independent of other factors. Among the approximately 10% of youth who died by suicide and had no clear psychiatric diagnosis, the only factor found to discriminate this group from normal controls was the presence of a loaded gun in the home (Brent et al., 1993d; Kellerman et al., 1992).

Despite strong evidence for the role of firearms in youth suicide, it should be noted that restricting access to guns may not always result in a decrease in overall suicide deaths. A study that examined suicide methods used by Australian males between 1975 and 1998 (De Leo, Dwyer, Firman, & Neulinger, 2003) reported a declining rate of firearm suicide among males overall as well as among a subset of males aged 15–24, attributed in part to increased restrictions on weapons purchases. In both samples, however, these declines coincided with an increase in the rate of suicide by hanging. Among young males, the increased rate of hanging coincided with an increase in the overall suicide rate.

Protective Factors

Several factors, identified below, have been suggested as protecting youth against suicidal behavior. In reviewing protective factors, several limitations should be noted, in particular, the likelihood that they are features of psychological health and thus nonspecific for suicidality as opposed to other forms of mental illness. Further, it has not been empirically determined whether patterns and behaviors consistent with psychological health actually protect against mental illness and suicidality, or whether they are manifestations of a lack of mental illness. In addition, conclusions are limited by the fact that studies have not generally examined protective factors in a broader context of risk factors.

Connectedness to Family, School, and Other Institutions

Researchers have found that students who describe their families as emotionally involved and supportive were much less likely to report suicidal behavior than students who described their families as less supportive and involved (McKeown et al., 1998; Resnick et al., 1997; Rubenstein, Halton, Kasten, Rubin, & Stechler, 1998, Rubenstein, Heeren, Housman, Rubin, & Stechler, 1989; Zhang & Jin, 1996). There is limited evidence that family cohesion is independent of the adolescent's levels of depression or life stress (Rubenstein et al., 1989, 1998).

The National Longitudinal Study on Adolescent Health (Resnick et al., 1997) reported that student connectedness to school was also a primary protective factor. Similarly, there is limited evidence that perceived suicide risk is inversely related to religious orthodoxy, particularly among racial and ethnic minorities (Greening & Stoppelbein, 2002).

Social Skills

Jessor (1991) suggested that a range of social skills, including decision making and problem solving, may be protective factors for suicidal behavior, and this relationship has received considerable attention among school administrators. The impact of social skills on youth suicidal behavior has not been directly tested, however, and there is no evidence that students with good decision-making or problem-solving skills are overall less suicidal. Although some studies have found that at-risk students who participated in interventions designed to improve social skills showed decreased depression and suicidal behavior (LaFramboise & Howard-Pitney, 1995; Thompson, Eggert, & Herting, 2000; Thompson, Eggert, Randell, & Pike, 2001), it is not clear that these decreases were accounted for by any increase in acquired social skills.

YOUTH SUICIDE PREVENTION

Given the multiplicity of risk and protective factors that have been related to youth suicide, it is understandable that many different approaches have been taken in the attempt to prevent this behavior. In the next three chapters, we discuss and critique the major preventive strategies and treatment approaches that have been used. Rather than undertaking an exhaustive review of every program that has been identified, we have selected those that have been most fully described in published reports and/or those we feel best illustrate a general type or approach. Reflecting the strategies that have received the widest application, our review focuses primarily on suicide prevention programs targeting groups of youth, rather than on clinical care or evaluation of individual youth who are potentially suicidal.

Before turning to this discussion, we would like to share some observations regarding the accumulated literature on youth suicide prevention. Although many different programs have been developed and implemented, very few have been systematically evaluated for their immediate or long-term efficacy and effectiveness. In contrast to programs addressing other high-risk behaviors such as drug use, few if any youth suicide prevention programs are supported by conclusive empirical evidence of effectiveness.

In part, this is due to the unique impact of ethical considerations on suicide research in general and outcomes evaluation in particular. Such considerations have served to limit participation of suicidal individuals in clinical trials and other interventions, and to restrict the availability of appropriate control groups by discouraging selective offering of potentially helpful interventions (Fisher, Pearson, Kim, & Reynolds, 2002).

Also important to note are the difficulties inherent in attempting to determine the impact of programs implemented among relatively small samples on the statistically rare events of suicide death or attempted suicide. In addition, the application of many suicide prevention strategies and programs in settings in which contact with participants is transitory has limited the ability of such programs to employ longitudinal evaluation designs that might reveal long-term outcomes, including suicide attempts and suicide deaths. In the absence of large-scale, long-term studies, programs have tended to rely on proximal outcomes such as knowledge, attitudes, and referrals to treatment, whose relationship to suicide attempts and suicide deaths has been incompletely established, if at all.

Further, it should be noted that with respect to almost all suicide prevention efforts, reports of effectiveness have been internally produced, typically by the program developers, often using designs, outcomes, effectiveness criteria and measures unique to an individual site. This has limited the degree to which different approaches can be compared. Rather than using a careful before-and-after design in a case–control setting, evaluations have frequently been confined to determining whether a program was found to be interesting or acceptable to a particular target group.

In spite of these limitations, the programs and interventions reviewed in the subsequent chapters suggest a great deal about what appears to work, and what doesn't, in the prevention of suicide among adolescents and young adults.