Structural Racism and Suicide Prevention for Ethnoracially Minoritized Youth: A Conceptual Framework and Illustration Across Systems

A unique model of care for youth in crisis: A pilot open trial

Suicide is the second leading cause of death for those ages 10-24 years in the United States, and emergency department (ED) visits due to youth self-injurious thoughts and behaviors (SITB) and increased substantially between 2016 and 2021. Although ED services are essential for an effective system of care, the ED setting is typically not well-suited for the comprehensive, collaborative, and therapeutic evaluation of SITB; treatment planning; and care coordination that youth in a suicidal crisis need. As a result, an urgent care model for mental health designed to provide comprehensive crisis triage and intervention services is needed within outpatient psychiatry. This pilot trial examined the feasibility, acceptability, and preliminary clinical outcomes of a brief, urgent care model, the Behavioral Health Crisis Care Clinic (CCC), designed to provide comprehensive outpatient triage and intervention services aimed at reducing suicide risk for youth in crisis. Participants were 189 youth (ages 10-20; 62.4% females; 58% Caucasian) who had past-week suicidal ideation or behavior and their caregivers. The results demonstrated the CCC model exceeded feasibility and acceptability benchmarks based on the Service Satisfaction Scale (M score > 3.00). CCC care was associated with significant decreases in self-reported suicide risk based on the Collaborative Assessment and Management of Suicidality Suicide Status Form with low levels of ED usage during CCC care (7.7%) and 1-month posttreatment (11.8%). Over 88% of patients without established outpatient care at the time of referral were connected to care during CCC treatment, almost all of whom (95%) continued with ongoing mental health care 1 month after ending CCC care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Structural adverse childhood experiences associated with suicidal ideation, suicide attempts, and repetitive nonsuicidal self-injury among racially and ethnically minoritized youth

INTRODUCTION

High rates of suicidal ideation (SI), suicide attempts (SA), and repetitive nonsuicidal self-injury (NSSI) among some ethnoracially minoritized United States youth populations may be related to adverse childhood experiences (ACEs) with structural roots.

METHODS

Using the 2013-2019 Minnesota Student Surveys, we assessed associations of student-reported structural ACEs (parental incarceration, housing instability, food insecurity, and foster care involvement) with SI, SA, and repetitive NSSI within the past 12 months using multilevel logistic regression stratified by ethnoracial group (American Indian/Alaskan Native [AIAN], Hmong, other Asian, Black Latino, other Latino, Somali, other Black/African American [AA], Native Hawaiian/Pacific Islander [NHPI], and multiracial), and adjusted for sex, grade, ACEs experienced within one's household, mental health treatment, and perceived safety.

RESULTS

Structural ACEs were strongly associated with increasing SI, SA, and NSSI. At ≥2 structural ACEs, repetitive NSSI rates ranged from 7% to 29% (female), 8% to 20% (male); SA rates ranged from 13% to 35% (female), 10% to 22% (male); and SI rates ranged from 31% to 50% (female), 20% to 32% (male). Black Latino, NHPI, AIAN, and Black/AA students most often reported structural ACE exposures.

CONCLUSION

Reducing structural ACEs may reduce SI, SA, and repetitive NSSI among ethnoracially minoritized youth populations. Disaggregating diverse youth groups revealed variations in these outcomes that remain hidden when subpopulations are aggregated.

Adolescent suicide risk factors and the integration of social-emotional skills in school-based prevention programs

Adolescents are considered one of the most vulnerable groups affected by suicide. Rapid changes in adolescents' physical and mental states, as well as in their lives, significantly and undeniably increase the risk of suicide. Psychological, social, family, individual, and environmental factors are important risk factors for suicidal behavior among teenagers and may contribute to suicide risk through various direct, indirect, or combined pathways. Social-emotional learning is considered a powerful intervention measure for addressing the crisis of adolescent suicide. When deliberately cultivated, fostered, and enhanced, self-awareness, self-management, social awareness, interpersonal skills, and responsible decision-making, as the five core competencies of social-emotional learning, can be used to effectively target various risk factors for adolescent suicide and provide necessary mental and interpersonal support. Among numerous suicide intervention methods, school-based interventions based on social-emotional competence have shown great potential in preventing and addressing suicide risk factors in adolescents. The characteristics of school-based interventions based on social-emotional competence, including their appropriateness, necessity, cost-effectiveness, comprehensiveness, and effectiveness, make these interventions an important means of addressing the crisis of adolescent suicide. To further determine the potential of school-based interventions based on social-emotional competence and better address the issue of adolescent suicide, additional financial support should be provided, the combination of social-emotional learning and other suicide prevention programs within schools should be fully leveraged, and cooperation between schools and families, society, and other environments should be maximized. These efforts should be considered future research directions.

Informing Equitable Prevention Practices: A Statewide Disaggregated Analysis of Suicide for Ethnoracially Minoritized Adolescents

The increase in adolescent suicide rates in the United States is a pervasive public health issue, and ethnoracial youth with diverse identities are disproportionately impacted, yet less studied. National planning efforts reinforce state-level approaches to suicide prevention through an equitable lens to prevent adolescent suicide. This study examined disaggregated state-level data over time to determine changes to suicide outcomes based on race/ethnicity, sex, sexual orientation, and the intersection of these identities and determined which sub-groups had higher odds of suicide outcomes. Data from the 1991-2019 Centers for Disease Control and Prevention Youth Risk Behavioral Surveillance System were analyzed for 17,419 ethnoracially minoritized high school adolescents in North Carolina. Descriptive analyses and multinominal logistic regression models were employed. Findings indicated that subgroups within categories of ethnoracial populations, specifically Black female adolescents unsure of their sexual orientation, reported higher rates of suicide attempts. Additionally, Multiracial adolescents reported higher means for suicide consideration and attempts over time. Recommendations for investigating state-level suicide data by focusing on diverse intersecting identities to illuminate areas for potential prevention efforts and support health equity are provided.

Considering the importance of 'Communities of Practice' and Health Promotion Constructs for Upstream Suicide Prevention

Background

Suicide is a serious and growing health inequity for Alaska Native (AN) youth (ages 15-24), who experience suicide rates significantly higher than the general U.S. youth population. In low-resourced, remote communities, building on the local and cultural resources found in remote AN communities to increase uptake of prevention behaviors like lethal means reduction, interpersonal support, and postvention can be more effective at preventing suicide than a risk-referral process. This study expands the variables we hypothesize as important for reducing suicide risk and supporting wellbeing. These variables are: 1) perceived suicide prevention self-efficacy, 2) perceived wellness self-efficacy, and 3) developing a 'community of practice' (CoP) for prevention/wellness work.

Method

With a convenience sample (N = 398) of participants (ages 15+) in five remote Alaska Native communities, this study characterizes respondents' social roles: institutional role if they have a job that includes suicide prevention (e.g. teachers, community health workers) and community role if their primary role is based on family or community positioning (e.g. Elder, parent). The cross-sectional analysis then explores the relationship between respondents' wellness and prevention self-efficacy and CoP as predictors of their self-reported suicide prevention and wellness promotion behaviors: (1) working together with others (e.g. community initiatives), (2) offering interpersonal support to someone, (3) reducing access to lethal means, and (4) reducing suicide risk for others after a suicide death in the community.

Results

Community and institutional roles are vital, and analyses detected distinct patterns linking our dependent variables to different preventative behaviors. Findings associated wellness self-efficacy and CoP (but not prevention self-efficacy) with 'working together' behaviors, wellness and prevention self-efficacy (but not CoP) with interpersonal supportive behaviors; both prevention self-efficacy and CoP with higher postvention behaviors. Only prevention self-efficacy was associated with lethal means reduction.

Conclusions

The study widens the scope of suicide prevention. Promising approaches to suicide prevention in rural low-resourced communities include: (1) engaging people in community and institutional roles, (2) developing communities of practice for suicide prevention among different sectors of a community, and (3) broadening the scope of suicide prevention to include wellness promotion as well as suicide prevention.

Trends in Adolescent Suicide by Method in the US, 1999-2020

Importance

Adolescent suicide in the US is a major public health problem, yet temporal trends in suicide methods by demographics are understudied.

Objective

To examine national trends in suicide mortality by method (firearm, poisoning, hanging and asphyxiation, and all other means) from 1999 to 2020 by demographic characteristics.

Design, Setting, and Participants

This serial cross-sectional study used national death certificate data of adolescent (aged 10-19 years) suicide decedents compiled by the National Center for Health Statistics from January 1, 1999, to December 31, 2020. Data analysis was performed from April 1, 2023, to July 9, 2023.

Exposures

Age, sex, and race and ethnicity.

Main Outcomes and Measures

Trends in age-standardized mortality rates and average annual percent change (AAPC) in rates were estimated by age, sex, and race and ethnicity for each suicide method.

Results

This study assessed data from 47 217 adolescent suicide decedents. From 1999 to 2020, suicide by firearm (AAPC, 1.0; 95% CI, 0.1-1.9), poisoning (AAPC, 2.7; 95% CI, 1.0-4.4), hanging and asphyxiation (AAPC, 2.4; 95% CI, 0.2-4.6), and other means (AAPC, 2.9; 95% CI, 1.2-4.6) increased. Rapidly increasing rates were observed among female adolescents for poisoning (AAPC, 4.5; 95% CI, 2.3-6.7) and hanging and asphyxiation (AAPC, 5.9; 95% CI, 5.0-6.8) suicides. From 2007 to 2020, firearm suicides sharply increased among female (annual percent change [APC], 7.8; 95% CI, 6.0-9.5) and male (APC, 5.3; 95% CI, 4.3-6.3) adolescents. Firearm suicide rates increased among Black adolescents from 2012 to 2020 (APC, 14.5; 95% CI, 9.7-19.5), Asian and Pacific Islander adolescents from 2008 to 2020 (APC, 12.0; 95% CI, 9.7-14.5), American Indian and Alaska Native adolescents from 2014 to 2020 (APC, 10.6; 95% CI, 2.6-19.3), and Hispanic or Latino adolescents from 2011 to 2020 (APC, 10.2; 95% CI, 6.3-13.8). During the study period, Black adolescents had the highest average increase in hanging and asphyxiation suicides (AAPC, 4.2; 95% CI, 3.2-5.2). From 2011 to 2020, poisoning suicide deaths increased (APC, 12.6; 95% CI, 8.5-16.7) among female adolescents.

Conclusions and Relevance

Suicide rates increased across all methods from 1999 to 2020. Differences were noted by sex, age, and race and ethnicity. Increasing suicide rates among racial and ethnic minoritized youth are especially concerning, and effective prevention strategies are urgently needed.

Centering Community Strengths and Resisting Structural Racism to Prevent Youth Suicide: Learning from American Indian and Alaska Native Communities

The persistence of extreme suicide disparities in American Indian and Alaska Native (AI/AN) youth signals a severe health inequity with distinct associations to a colonial experience of historical and on-going cultural, social, economic, and political oppression. To address this complex issue, we describe three AI/AN suicide prevention efforts that illustrate how strengths-based community interventions across the prevention spectrum can buffer suicide risk factors associated with structural racism. Developed and implemented in collaboration with tribal partners using participatory methods, the strategies include universal, selective, and indicated prevention elements. Their aim is to enhance systems within communities, institutions, and families by emphasizing supportive relationships, cultural values and practices, and community priorities and preferences. These efforts deploy collaborative, local approaches, that center on the importance of tribal sovereignty and self-determination, disrupting the unequal power distribution inherent in mainstream approaches to suicide prevention. The examples emphasize the centrality of Indigenous intellectual traditions in the co-creation of healthy developmental pathways for AI/AN young people. A central component across all three programs is a deep commitment to an interdependent or collective orientation, in contrast to an individual-based mental health suicide prevention model. This commitment offers novel directions for the entire field of suicide prevention and responds to calls for multilevel, community-driven public health strategies to address the complexity of suicide. Although our focus is on the social determinants of health in AI/AN communities, strategies to address the structural violence of racism as a risk factor in suicide have broad implications for all suicide prevention programming.

Suicide and Suicide Risk in Adolescents

Suicide is the second leading cause of death for 10- to 24-year-olds in the United States and is a global public health issue, with a recent declaration of a National State of Emergency in Children's Mental Health by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children's Hospital Association. This clinical report is an update to the previous American Academy of Pediatrics clinical report, "Suicide and Suicide Attempts in Adolescents." Because pediatricians and pediatric health care providers are at the front line of care for adolescents amid a child and adolescent mental health crisis, and because of the chronic and severe shortage of mental health specialists, it is important that pediatric health care providers become facile with recognizing risk factors associated with suicidality and at-risk populations, screening and further assessment of suicidality as indicated, and evidence-based interventions for patients with suicidal ideation and associated behaviors. Suicide risk can be mitigated by appropriate screening, bolstering of protective factors, indicated treatment, community resources, and referrals to mental health providers when available.

Measurement Choices for Youth Suicidality

Suicide is among the leading causes of death among individuals ages 10-24, making suicidal thoughts and behaviors (STBs) a serious public health crisis among youth. Suicide risk screening and assessment are vital to addressing this public health crisis. In fact, many youths that screen positive for suicidal ideation do not have known mental health concerns and would have been missed if not asked directly. Medical settings are an optimal setting to detect suicidality early and provide appropriate follow-up monitoring and care as needed. To support effective and efficient screening and assessment of suicidal thoughts and behaviors, providers must choose measures with both strong psychometric properties and clinical utility. While measurement of STBs can vary across health settings, suicide risk screening and assessment typically involves gathering information about current suicidal ideation, suicidal behaviors, and suicidal plans via self-report questionnaires, clinical interviews, and/or computerized adaptive screens. In alignment with measurement-based care efforts, the current manuscript will provide a scoping review of measures of youth suicidal ideation, behavior, plans, and their risk factors. Specifically, the psychometric properties, clinical utility, and other key considerations for screening and assessment of adolescent suicide risk are discussed.

Editorial: Can Mobile Crisis Response Help Mitigate Racialized Disparities in Acute Child Mental Health Care?

Mobile crisis response (MCR) is a community-based intervention designed to provide de-escalation and relief to individuals experiencing a behavioral health or substance use-related crisis wherever they are, including at home, at work, at school, or in the community. Often it is the first, or only, option for youth who experience barriers to accessing traditional mental health care in the community. Elevated rates of mental health needs and suicidality among children and adolescents in the United States make availability of quality MCR increasingly important. Studies suggest that an estimated 70% to 80% of children with mental health disorders do not receive care, and minoritized children are even less likely to access community-based behavioral health care services.1 MCR can act as a bridge for securing treatment for children in acute distress. However, until recently, few studies have demonstrated the outcomes of MCR services for children and adolescents or more specifically for minoritized youth.

Mexican-origin parent and child reported neighborhood factors and youth substance use

Background

Structural oppression affects health behaviors through residence in suboptimal neighborhoods and exposure to community violence. Youth and parents report perceptions of neighborhood factors that can affect youth substance use behaviors. Given that Latinx youth report higher levels of perceived community violence than other racial and ethnic groups, it is imperative to examine how youth- and parent-perceived neighborhood-level factors may relate to youth substance use.

Methods

Data were collected using clinical interviews with family triads (fathers, mothers, and youth) and parent-child dyads (father or mother and youth) enrolled in the Seguimos Avanzando study of 344 Mexican-origin families in Indiana. Neighborhood measures, including perceptions of exposure to violence, neighborhood characteristics, and neighborhood collective efficacy, were included in parent and youth surveys. Self-report measures for past year alcohol and drug use were included in the youth survey only. T-tests were conducted to estimate differences in neighborhood reports among the sample triads. A series of linear regression models were used to estimate the associations between youth-, mother-, and father-reported perceptions of neighborhood factors and youth substance use.

Results

Preliminary results indicate that fathers reported higher levels of exposure to violence than mothers [t(163) = 2.33, p = 0.02] and youth [t(173) = 3.61, p < 0.001]. Youth reported lower negative neighborhood characteristics than mothers [t(329) = 6.43, p < 0.001] and fathers [t(169) = 3.73, p < 0.001]. Youth reported significantly better neighborhood collective efficacy than mothers [t(296) = 3.14, p = 0.002], but not statistically different from fathers. Results from the primary analysis showed that youth exposure to violence was positively associated with youth substance use (b = 0.24, SE = 0.06, p < 0.0001), but the youth's neighborhood characteristics and collective efficacy were not significantly associated with youth substance use. None of the parent-reported neighborhood variables were associated with youth substance use.

Conclusion

The discrepant findings between parent and youth reports of perceived neighborhood characteristics and substance use have important implications for researchers and community stakeholders, and for developing targeted interventions and prevention strategies. Our study highlights the need to address youth experience of community violence and to prioritize creating safe and inclusive neighborhood environments. Potential strategies include improving community resources, strengthening social support networks, promoting open communication about neighborhood risks, and fostering collaborative efforts to address substance use behaviors.

Suicidal thoughts and behaviors in youth seeking mental health treatment in Texas: Youth Depression and Suicide Network research registry

INTRODUCTION

Suicidality in youth is a serious public health problem. The Texas Youth Depression and Suicide Research Network (TX-YDSRN) was initiated in 2020 to create a research registry for youth with depression and/or suicidality in Texas. This report presents baseline clinical/demographic characteristics of the first 1000 participants, focusing on suicidal thoughts and behaviors.

METHODS

The registry includes 8-20-year-old youth receiving treatment for depression, or who screen positive for depression and/or suicidal ideation/behavior. Baseline data include diagnosis, depression/anxiety severity, suicidal ideation/behavior, trauma history, and measures of resilience.

RESULTS

We present baseline data on the first 1000 participants. Most (79.6%) of the sample had a primary depressive disorder. The sample had moderate to severe depression (Patient Health Questionnaire for Adolescents, PHQ-A; 12.9 ± 6.4) and anxiety (Generalized Anxiety Disorder, GAD-7; 11.3 ± 5.9). Nearly half reported ≥1 lifetime suicide attempts and 90% reported lifetime or current suicidal ideation. Participants with past/current suicidality (attempts and/or ideation) had greater illness severity (depression, anxiety, and suicidal thoughts/behaviors), lower resilience, and higher rates of trauma exposure than those without suicidality.

CONCLUSIONS

Baseline data indicate moderate levels of depression, anxiety, and suicidality and their correlates in this cohort. Future reports will determine trajectories of outcomes and predictors, moderators, and social determinants related to these outcomes.

Editorial: Combatting the Intergenerational Trauma of Structural Racism Through Practice, Policy, and Research

Several recent studies have investigated the mental health consequences of structural racism. Structural racism has been defined as "macro-level societal conditions that limit opportunities, resources, and well-being of less privileged groups on the basis of race/ethnicity and/or other statuses, including but not limited to, gender identity, sexual orientation, disability status, social class or socioeconomic status (SES), religion, geographic residence, national origin, immigration status, limited English proficiency, physical characteristics, or health conditions."1 Researchers have hypothesized that the trauma of structural racism transmits across generations through pathways that are physiological (ie, compromised immune systems, activated hormonal stress responses), environmental (ie, limited access to housing, health care, employment, and income), social (ie, domestic violence, substance consumption, criminal justice involvement), and psychological (ie, family histories of depression, anxiety, and traumatic stress-disorders).2.

Intersectional Prevalence of Suicide Ideation, Plan, and Attempt Based on Gender, Sexual Orientation, Race and Ethnicity, and Rurality

Importance

Suicidal thoughts and behaviors (STBs) are major public health problems, and some social groups experience disproportionate STB burden. Studies assessing STB inequities for single identities (eg, gender or sexual orientation) cannot evaluate intersectional differences and do not reflect that the causes of inequities are due to structural-level (vs individual-level) processes.

Objective

To examine differences in STB prevalence at the intersection of gender, sexual orientation, race and ethnicity, and rurality.

Design, Setting, and Participants

This cross-sectional study used adult data from the 2015-2019 National Survey on Drug Use and Health (NSDUH), a population-based sample of noninstitutionalized US civilians. Data were analyzed from July 2022 to March 2023.

Main Outcomes and Measures

Outcomes included past-year suicide ideation, plan, and attempt, each assessed with a single question developed for the NSDUH. Intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) models were estimated, in which participants were nested within social strata defined by all combinations of gender, sexual orientation, race and ethnicity, and rurality; outcome prevalence estimates were obtained for each social stratum. Social strata were conceptualized as proxies for exposure to structural forms of discrimination that contribute to health advantages or disadvantages (eg, sexism, racism).

Results

The analytic sample included 189 800 adults, of whom 46.5% were men; 53.5%, women; 4.8%, bisexual; 93.0%, heterosexual; 2.2%, lesbian or gay; 18.8%, Hispanic; 13.9%, non-Hispanic Black; and 67.2%, non-Hispanic White. A total of 44.6% were from large metropolitan counties; 35.5%, small metropolitan counties; and 19.9%, nonmetropolitan counties. There was a complex social patterning of STB prevalence that varied across social strata and was indicative of a disproportionate STB burden among multiply marginalized participants. Specifically, the highest estimated STB prevalence was observed among Hispanic (suicide ideation: 18.1%; 95% credible interval [CrI], 13.5%-24.3%) and non-Hispanic Black (suicide plan: 7.9% [95% CrI, 4.5%-12.1%]; suicide attempt: 3.3% [95% CrI, 1.4%-6.2%]) bisexual women in nonmetropolitan counties.

Conclusions and Relevance

In this cross-sectional study, intersectional exploratory analyses revealed that STB prevalence was highest among social strata including multiply marginalized individuals (eg, Hispanic and non-Hispanic Black bisexual women) residing in more rural counties. The findings suggest that considering and intervening in both individual-level (eg, psychiatric disorders) and structural-level (eg, structural discrimination) processes may enhance suicide prevention and equity efforts.

The Burden of Not Belonging: A Qualitative Study of the Applicability of the Interpersonal Theory of Suicide Constructs of Belongingness and Burdensomeness to Ethnocultural Minoritized Youth

Guided by the Interpersonal Theory of Suicide (IPTS), this study aims to understand the applicability of the constructs of belongingness and burdensomeness and their relevance to suicide risk and mental health among ethnocultural minoritized youth. A qualitative exploratory study was conducted using five focus groups with 29 self-identified Latinx and Black adolescents aged 13-17 years to explore the meaning they ascribed to belongingness and burdensomeness. Views of social media related to these constructs were also explored. Template analysis was used to analyze the data. Themes highlighted dimensions such as caring, self-worth, and liability, congruent with the IPTS dimensions of belongingness and burdensomeness. Notably, new themes emerged reflecting the distinctive experiences of these populations, such as the importance of being true to themselves, the burden of not belonging to families, and cultural aspects of liability, highlighting dimensions not found in the existing IPTS theoretical constructs. Consideration of the diverse experiences of ethnocultural minoritized youth can strengthen theoretical constructs, clinical practice, and aid in developing intervention strategies to increase protective factors and decrease risk factors for suicide behaviors relevant to such youth.

Demographic predictors of emergency service utilization patterns in youth at risk of suicide

OBJECTIVE

To explore demographic predictors of Emergency Department (ED) utilization among youth with a history of suicidality (i.e., ideation or behaviors).

METHODS

Electronic health records were extracted from 2017 to 2021 for 3094 8-22 year-old patients with a history of suicidality at an urban academic medical center ED in the Mid-Atlantic. Logistic regression analyses were used to assess for demographic predictors of ED utilization frequency, timing of subsequent visits, and reasons for subsequent visits over a 24-month follow-up period.

RESULTS

Black race (OR = 1.45, 95% CI = 1.11-1.92), Female sex (OR = 1.59, 95% CI = 1.26-2.03), and having Medicaid insurance (OR = 1.71, 95% CI = 1.37-2.14) were associated with increased utilization, while being under 18 was associated with lower utilization (<12: OR = 0.38, 95% CI = 0.26-0.56; 12-18: OR = 0.47, 95% CI = 0.35-0.63). These demographics were also associated with ED readmission within 90 days, while being under 18 was associated with a lower odds of readmission.

CONCLUSIONS

Among patients with a history of suicidality, those who identify as Black, young adults, patients with Medicaid, and female patients were more likely to be frequent utilizers of the ED within the 2 years following their initial visit. This pattern may suggest inadequate health care access for these groups, and a need to develop better care coordination with an intersectional focus to facilitate utilization of other health services.

Structural Racism and Adolescent Mental Health Disparities in Northern California

Importance

Understanding how structural racism is associated with adolescent mental health is critical to advance health equity.

Objective

To assess associations between neighborhood privilege, measured by the Index of Concentration at the Extremes (ICE) and adolescent depressive symptoms, suicidality, and related racial and ethnic disparities.

Design, Setting, and Participants

This was a retrospective cohort study using electronic health records of adolescents aged 12 to 16 years who attended well-teen visits between 2017 and 2021. Kaiser Permanente Northern California is an integrated health care delivery system serving 4.6 million members. The cohort included 34 252 individuals born singleton at an affiliated facility from January 1, 2005, to December 31, 2009, and who had completed at least 1 mental health screener during a well-teen visit by November 23, 2021.

Exposures

American Community Survey 2016 to 2021 5-year estimates were used to calculate ICE scores for adolescents' residential census tract at ages 10 to 11. Three ICE measures were used as proxies of structural racism: racial privilege (ICE-race and ethnicity; hereinafter ICE-race), economic privilege (ICE-income), and combined economic and racial privilege (ICE-income plus race and ethnicity; herinafter ICE-income plus race). ICE scores were categorized into quintiles based on California statewide distributions.

Main Outcomes and Measures

Depressive symptoms and suicidality were assessed through self-report screeners during well-teen visits. Depressive symptoms were considered to be present if patients had a score on the Patient Health Questionnaire-2 of 3 or higher (the tool uses a Likert scale to determine the frequency [0 = not at all; 3 = nearly every day] that they had depressed mood and lack of pleasure in usual activities in the past 2 weeks; responses were summed and dichotomized).

Results

Analyses included 34 252 adolescents (12-16 years of age; mean [SD] age, 13.7 [0.8] years; 17 557 [51.3%] male, 7284 [21.3%] Asian or Pacific Islander, 2587 [7.6%] Black], 9061 [26.5%] Hispanic, 75 [0.2%] American Indian or Indigenous, 12 176 [35.5%] White, and 3069 [9%] other or unknown). Risks of depressive symptoms and suicidality generally increased with each level of declining neighborhood privilege. Adjusted risk ratios comparing adolescents from neighborhoods with the least to most racial and economic privilege were 1.37 (95% CI, 1.20-1.55) for depressive symptoms and 1.59 (95% CI, 1.23-2.05) for suicidality. Racial disparities between Black and White youth and Hispanic and White youth decreased after adjusting for each ICE measure, and became nonsignificant in models adjusting for ICE-race and ICE-income plus race.

Conclusions and Relevance

In this cohort study, lower neighborhood privilege was associated with greater risks of adolescent depressive symptoms and suicidality. Furthermore, adjusting for neighborhood privilege reduced mental health disparities affecting Black and Hispanic adolescents. These findings suggest that efforts to promote equity in adolescent mental health should extend beyond the clinical setting and consider the inequitable neighborhood contexts that are shaped by structural racism.

Relationships between internalized stigma and depression and suicide risk among queer youth in the United States: a systematic review and meta-analysis

Background

Queer youth experience high rates of depression and suicidality. These disparities stem from stigma-based stressors, including internalized stigma (i.e., negative social views that minoritized individuals internalize about their own identity). Given the importance of this factor in understanding mental health disparities among queer youth, we completed a systematic review and meta-analysis examining the relationships between internalized stigma and outcomes of depression and suicide risk (i.e., suicidal ideation, non-suicidal self-injury, and suicidal behavior).

Methods

We followed the PRISMA standards. Six bibliographic databases were searched for studies in the United States from September 2008 to March 2022. Dual independent screening of search results was performed based on a priori inclusion criteria.

Results

A total of 22 studies were included for data extraction and review. Most studies examined general internalized homophobia, with few examining internalized biphobia or transphobia. Many studies examined depression as an outcome, few studies examined suicidal ideation or behavior, and no studies examined non-suicidal self-injury. Meta-analyses model results show the association between general internalized queer stigma and depressive symptoms ranged r = 0.19, 95% CI [0.14, 0.25] to r = 0.24, 95% CI [0.19, 0.29], the latter reflecting more uniform measures of depression. The association between internalized transphobia and depressive outcomes was small and positive (r = 0.21, 95% CI [-0.24, 0.67]). General internalized queer stigma and suicidal ideation had a very weak positive association (r = 0.07, 95% CI [-0.27, 0.41]) and an even smaller, weaker positive association with suicide attempt (r = 0.02, 95% CI [0.01, 0.03]).

Conclusion

Implications for clinical practice, policy, and future research are discussed.

Study Preregistration: Does State-level Structural Racism Impact Risk for Suicidal Thoughts and Behaviors Among US Adolescents Across Race and Ethnicity?

In the United States, suicide deaths have disproportionately increased among Black and Hispanic youth over the past 2 decades.1 Despite the critical need for more culturally responsive suicide prevention strategies, there has been only sparse research into unique risk factors commonly experienced among ethnoracially minoritized youth, such as racism-related experiences. Experiences of racial and ethnic discrimination (ie, a behavioral manifestation of racism via unfair treatment predicated on an individual's racial and/or ethnic group affiliation) have been associated with higher rates of suicidal thoughts and behaviors (STBs) in Black and Hispanic adolescents.2,3 This research has largely focused on individual-level racism (ie, interpersonal exchanges) assessed via subjective self-report surveys. Thus, less is known about the impact of structural racism, which is enacted at the system level.

Millennials, the Most Afflicted Generation: Suicide Trends Within Dallas County From 2019 to 2021

ABSTRACT

In the wake of the SARS-CoV-2 (COVID-19) pandemic, mental health has become a pivotal topic of discussion nationwide.1,2 Recognition of mental health disorders, mitigation of psychological distress during times of uncertainty, and abating negative stigma have become a focus of many groups, both internal and external to the medical field. Still, one of the most devastating sequelae of mental health afflictions is suicide.A retrospective review of all cases classified as suicide from January 2019 through December 2021 was conducted using the laboratory information system database within the Southwestern Institute of Forensic Sciences, the county division that performs postmortem examinations of cases under the jurisdiction of Dallas County and some surrounding North Texas counties. A total of 846 cases were retrieved that occurred within Dallas County. This cohort consisted of 659 men and 187 women with an average age of 42.9 years (median, 40 years). This study highlights compelling trends of suicides within a localized portion of North Texas during a 3-year period in which the population endured momentous and unprecedented worldwide events.

Leader and Provider Perspectives on Implementing Safe Alternatives for Teens and Youth - Acute (SAFETY-A) in Public School Districts Serving Racial/ethnic Minoritized Youth

Racial/ethnic minoritized (REM) youth represent a high-risk group for suicide, yet there are striking disparities in their use of mental health services (MHS) even after risk is identified in schools. Prior research suggests that school-based risk assessments and hospitalization encounters can be negatively experienced by REM youth and families, thus deterring likelihood of seeking follow-up care. The Safe Alternatives for Teens and Youth-Acute (SAFETY-A) is a brief, strengths-based, cognitive-behavioral family intervention demonstrated to increase linkage to MHS when implemented in emergency departments. With its focus on strengths and family engagement, SAFETY-A may cultivate a positive therapeutic encounter suited to addressing disparities in MHS by enhancing trust and family collaboration, if appropriately adapted for schools. Thirty-seven school district leaders and frontline school MHS providers from districts serving primarily socioeconomically disadvantaged REM communities participated in key informant interviews and focus groups. First, interviews were conducted to understand usual care processes for responding to students with suicidal thoughts and behaviors, and perspectives on the strengths and disadvantages of current practices. An as-is process analysis was used to describe current practices spanning risk assessment, crisis intervention, and follow-up. Second, focus groups were conducted to solicit perceptions of the fit of SAFETY-A for these school contexts. Thematic analysis of the interviews and focus groups was used to identify multilevel facilitators and barriers to SAFETY-A implementation, and potential tailoring variables for implementation strategies across school districts.

Suicide in Global Mental Health

PURPOSE OF REVIEW

We review recent research on the epidemiology and etiology of suicide in the global context. We focus on data from low- and middle-income countries (LMIC), with the goal of highlighting findings from these under-researched, over-burdened settings.

RECENT FINDINGS

Prevalence of suicide in LMIC adults varies across region and country income-level, but is, on average, lower than in high-income countries. Recent gains in suicide reduction, however, have been smaller in LMIC compared to global rates. LMIC youth have much higher rates of suicide attempts than youth from high-income countries. Females as well as people with psychiatric disorders, those living with HIV, those who are LGBTQ + , and those with poor socioeconomic status are highly vulnerable populations in LMIC. Limited and low-quality data from LMIC hinder clear interpretation and comparison of results. A greater body of more rigorous research is needed to understand and prevent suicide in these settings.

Achieving mental health equity in Black male suicide prevention

Despite a steady decrease in suicide rates in the United States, the rate among Black males has increased in recent decades. Moreover, suicide is now positioned as the third leading cause of death in this population, signaling a public health crisis. Enhancing the ability for future suicide prevention scholars to fully characterize and intervene on suicide risk factors is an emerging health equity priority, yet there is little empirical evidence to robustly investigate the alarming trends in Black male suicide. We present fundamental areas of expansion in suicide prevention research focused on establishing culturally responsive strategies to achieve mental health equity. Notably, we identify gaps in existing research and offer future recommendation to reduce suicide death among Black males. Our perspective aims to present important and innovative solutions for ensuring the inclusion of Black males in need of suicide prevention and intervention efforts.

A Systematic Review of School-Based Suicide Prevention Interventions for Adolescents, and Intervention and Contextual Factors in Prevention

Suicide is the fourth leading cause of death among adolescents, globally. Though post-primary, school-based suicide prevention (PSSP) has the potential to be a key strategy for preventing adolescent suicidal thoughts and behaviours (STBs), there are persisting challenges to translating PSSP research to practice. Intervention and contextual factors relevant to PSSP are likely key to both PSSP effectiveness and implementation. As such, this systematic review aimed to summarise the effectiveness of PSSP for adolescent STBs and highlight important intervention and contextual factors with respect to PSSP. PsycINFO, Medline, Education Source, ERIC, Web of Science, and the Cochrane Central Register of Controlled Trials were searched to identify randomised and non-randomised studies evaluating the effectiveness of interventions located in post-primary, school-based settings targeting adolescent STBs. PSSP effectiveness and intervention and contextual factors were synthesised narratively. Twenty-eight studies were retained, containing nearly 47,000 participants. Twelve out of twenty-nine trials comparing intervention and independent control comparators reported statistically significant reductions in STBs postintervention, and 5/7 trials comparing preintervention and postintervention scores demonstrated significant reductions in STBs over time. Reporting and analysis of intervention and contextual factors were lacking across studies, but PSSP effectiveness and intervention acceptability varied across type of school. Although school personnel commonly delivered PSSP interventions, their input and perspectives on PSSP interventions were lacking. Notably, adolescents had little involvement in designing, inputting on, delivering and sharing their perspectives on PSSP interventions. Twenty out of twenty-eight studies were rated as moderate/high risk of bias, with non-randomised trials demonstrating greater risks of bias and trial effectiveness, in comparison to cluster randomised trials. Future research should prioritise complete reporting and analysis of intervention and contextual factors with respect to PSSP, involving key stakeholders (including adolescents and school personnel) in PSSP, and investigating key stakeholders' perspectives on PSSP. Given the inverse associations between both study quality and study design with PSSP effectiveness, particular consideration to study quality and design in PSSP research is needed. Future practice should consider PSSP interventions with universal components and PSSP which supports and involves key stakeholders in engaging with PSSP.

An Integrated Conceptual Model to Understand Suicidality among Queer Youth to Inform Suicide Prevention

In this article, we apply and combine elements from four theoretical frameworks (i.e., Minority Stress Theory, Person-in-Environment and Risk and Resilience Framework, Interpersonal-Psychological Theory of Suicide, and Intersectionality) to explain the problem of queer youth suicide through our integrated conceptual model, Queer Prevention of Youth Suicidality Model (Queer-PRYSM). The need for this conceptual model is based on the current state of the literature, including mixed empirical findings on factors related to queer youth suicidality, no scholarly consensus on specific contributing factors regarding high rates of suicidality among queer youth (including queer youth subgroups), and the absence of a unifying theory to explain the queer youth suicide risk. To address these limitations in theory, evidence, and scholarship explaining suicidality among queer youth we present our integrated model with growing, current, relevant research with queer youth. Queer-PRYSM includes minority stressors specific to queer youth, mental health problems, interpersonal-psychological factors, socioecological factors (i.e., family, school, peers, and community), and intersectionality concepts. Queer-PRYSM is essential to understanding the relationship of distal and proximal risk and protective factors in queer youth suicide and developing evidence-informed suicide preventive interventions that can be incorporated into practice, policy, and system structures.

A Systematic Review of Music-Based Interventions to Improve Treatment Engagement and Mental Health Outcomes for Adolescents and Young Adults

Mental health disorders and suicidality are rising among adolescents and young adults (A-YA) while rates of treatment engagement remain notoriously low. Emerging research supports the potential of music-based interventions to improve mental health, but their efficacy remains unclear for A-YA. This systematic review evaluates the evidence on music-based psychosocial interventions to improve engagement in treatment and/or mental health outcomes among A-YA. This review was prospectively registered with PROSPERO and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twenty-six studies were extracted. There was heterogeneity of designs, populations, measures, and outcomes. A typology of music-based interventions emerged, which is characterized by combinations of three broad categories: 1) Somatosensory, 2) Social-Emotional, and 3) Cognitive-Reflective. Most interventions are Socio-Cognitive and Holistically Integrated (combines all three) followed by Socio-Somatic. All interventions involved Social-Emotional processes. Results indicate that most studies report significant effects for mental health outcomes related to social and emotional improvements and reductions of internalizing symptoms for adolescents. Few studies targeted young adults and effects on engagement were rarely measured. There is a need for more studies that use rigorous methods. This review illuminated a need for interventions that are developmentally and culturally tailored to subgroups. Finally, the field is ripe from more studies that apply experimental therapeutics to conceptualize, operationalize, and test mechanisms of change to improve the understanding of how and for whom music-based interventions work. Recommendations for embedding these innovative strategies into research and practice for A-YA are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10560-022-00893-x.

Equitable suicide prevention for youth impacted by the juvenile legal system

Suicide is the second leading cause of death for adolescents in the United States. Despite the already alarmingly high rates of suicide attempts among adolescents, youth involved in the juvenile legal system (JLS) are up to three times more likely to have suicide attempts than their peers not impacted by the JLS. This public health crisis is also a matter of health equity, knowing that ethnoracially minoritized youth, mainly Black and Latinx youth, have disproportionate contact with the JLS. In order to disrupt the current elevated rates of suicide among Black and Latinx youth involved in the JLS, there needs to be more concerted efforts to improve assessment and suicide prevention efforts in the JLS. There are various potential touch points of care for suicide prevention and the Sequential Intercept Model (SIM), which outlines community-based responses to the involvement of people with mental and substance use disorders in the criminal justice system, can be used as a strategic planning tool to outline possible equitable interventions across these various touch points. Our purpose is to provide a comprehensive picture of gaps and equitable opportunities for suicide prevention across each intercept of the SIM. We provide recommendations of priorities to promote health equity in suicide prevention for ethnoracially minoritized youth impacted by the JLS.