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Three out of 5 youths who died by suicide between 2010 and 2021 in the US did not have a documented preceding mental health (MH) diagnosis, emphasizing the need for improved detection and connection to MH services among children and adolescents, researchers reported in JAMA Network Open.

Findings from the new cross-sectional study of youth suicide decedents aged 10 to 24 years also show that the odds of having a MH diagnosis were lower among certain groups, including those of racial and ethnic minority groups, those who used firearms, males, and those aged 14 years and younger.

“These findings underscore the need for equitable identification of mental health needs and universal lethal means counseling as strategies to prevent youth suicide,” first author Sofia Chaudhary, MD, of Emory University School of Medicine in Atlanta, and colleagues wrote in the study published online July 30, 2024.

In the US, suicide is the second leading cause of death for children aged 10 to 14 years and the third leading cause of death for adolescents and young adults aged 15 to 24 years, with almost half of suicides among the combined age groups due to firearms, according to the study.

Data from the US Centers for Disease Control and Prevention (CDC) show a nearly 50% increase in annual suicide rates between 2010 and 2021 among US youths aged 10 to 24 years. As rates have increased, disparities have widened. Investigators noted that American Indian and Alaska Native (AI/AN) youths have the highest rate of suicide overall among racial and ethnic groups (41.9 suicides per 100 000 youths in 2020). The rate has increased the fastest among Black youths with an 87% increase between 2010 and 2020. These disparities “widened and persisted” during the first year of the COVID-19 pandemic, with significantly higher rates of suicide documented among boys, children aged 5 to 12 years, youths aged 18 to 24 years, non-Hispanic AI/AN youths, and Black youths, along with more firearm suicides than expected, researchers wrote.

“Despite shifting patterns of MH service use and increased firearm accessibility, few studies have evaluated which population subgroups are most likely to have a known MH diagnosis prior to youth suicide,” Chaudhary and coauthors stated. They conducted the current study to assess the association of documented MH diagnosis with sociodemographic characteristics, suicide mechanism, clinical characteristics, and precipitating circumstances among youth suicide decedents.

Using data from the CDC National Violent Death Reporting System (NVDRS) collected between 2010 and 2021, investigators identified 40 618 youth suicide decedents to include in the analysis. Most participants (58.1%) were aged between 20 and 24 years, male (79.2%), and non-Hispanic White (76.1%). Also, 13.2% of the cohort was Hispanic, 12.7% was Black, 4.2% Asian, Native Hawaiian, or other Pacific Islander, and 2.9% AI/AN.

Overall, 40.4% of the cohort had a documented MH diagnosis and 46.8% died by firearms. Across individual groups, researchers observed that White youths had the highest rate of MH diagnosis (42.8%) and AI/AN youths had the lowest rate (28.0%); slightly more than half of girls (52.4%) had an MH diagnosis compared to 37.3% of boys.

Findings

Racial and ethnic disparities. Compared with White youths, the adjusted odds of having a MH diagnosis were lower among AI/AN (aOR 0.45, 95% CI 0.39-0.51); Asian, Native Hawaiian, or other Pacific Islander (aOR 0.58, 95% CI 0.52-0.64); and Black (aOR 0.62, 95% CI 0.58-0.66) youths. Adjusted odds were also lower among Hispanic youths (aOR 0.76, 95% CI 0.72-0.82) compared with non-Hispanic youths.

To reduce these disparities, researchers noted that prevention efforts for youth from racial and ethnic minorities “should include trauma-informed, culturally sensitive MH services, increased diversity in the MH workforce, and investments in school-based MH services, where Black youths are more likely than White youths to receive care.”

Age and sex disparities. The adjusted odds of having a MH diagnosis were lower among youths aged 10 to 14 years (aOR 0.70, 95% CI 0.65-0.76) compared with those aged 20 to 24 years. The odds were higher among young women (aOR 1.64, 95% CI 1.56-1.73) compared with young men, according to the results.

“This finding is particularly notable because suicide rates have risen to become the second leading cause of death in youths aged 10 to 14 years,” Chaudhary et al stated. “Suicide prevention strategies for young children in primary care and community settings should focus on fostering resilience, promoting peer and family connectedness, and empowering children with strategies to cope with stress and adversity.”

Suicide mechanism. An MH diagnosis was documented for 33.2% of youths who died by firearms, 61.6% of those who died by poisonings, 44.2% of those who died by hanging, strangulation, or suffocation, and 44.8% of those who died by other mechanisms. Among youth suicide decedents with a documented MH diagnosis, the most common mechanism was hanging, strangulation, or suffocation (42.7%). Among those without a documented MH diagnosis, firearms (52.6%) were the most common mechanism used.

Compared with youth suicide decedents who used firearms, those who died by poisonings (aOR 2.78, 95% CI 2.55-3.03); hanging, strangulation, or suffocation (aOR 1.70, 95% CI 1.62-1.78); and other mechanisms (aOR 1.59, 95% CI 1.47-1.72) had higher adjusted odds of having a documented MH diagnosis.

These findings speak “to the need for universal lethal means counseling, delivered in community and school settings, regardless of whether youths have a known MH diagnosis,” investigators stated.

Limitations of the current study include the fact that the NVDRS database is not a nationally representative sample and the use of source records and family member accounts to determine mental health diagnoses may mean some prior diagnoses were unknown or underreported.

“Given the low rates of MH diagnoses among youth suicide decedents, prevention efforts must also address family and life stressors in tandem with MH risk factors. Both increased identification of unmet MH needs and universal, community-based approaches are needed to prevent youth suicide,” researchers concluded.

Reference: Chaudhary S, Hoffmann JA, Pulcini CD, et al. Youth suicide and preceding mental health diagnosis. JAMA Netw Open. Published online July 30, 2024. doi:10.1001/jamanetworkopen.2024.23996