Alterations in performance and discriminating power of the death/suicide implicit association test across the lifespan

The Death/Suicide Implicit Association Test (d/s-IAT) has differentiated individuals with prior and prospective suicide attempts in previous studies, however, age effects on test results remains to be explored. A three-site study compared performance on the d/s-IAT among participants aged 16-80 years with depression and prior suicide attempt (n = 82), with depression and no attempts (n = 80), and healthy controls (n = 86). Outcome measures included the standard difference (D) score, median reaction times, and error rates. Higher D scores represent a stronger association between death/suicide and self, while lower scores represent a stronger association between life and self. The D scores differed significantly among groups overall. Participants with depression exhibited higher scores compared to healthy controls, but there was no difference between participants with and without prior suicide attempts(F[2,242]=8.76, p<.001). Response times for participants with prior attempts differed significantly from other groups, with no significant differences in error rates. The D score was significantly affected by age (β =-0.007, t = 3.65, p<.001), with slowing of response times in older ages. Results suggest reaction time d/s-IAT D scores may not distinguish implicit thinking about suicide as response times slow with age, but slowed response times may be sensitive to suicide risk potentially indicating basic information processing deficits.

The evaluation of emotional maltreatment's effect on family dynamics and suicidal behaviors

BACKGROUND

Emotional maltreatment and poor family functioning are known risks for youth suicide, but few studies have examined these issues as prospective predictors of future attempts.

OBJECTIVES

Examine family functioning and suicide risk associated with emotional maltreatment in youth with a lifetime history of major depressive disorder (MDD) and the prospective association of emotional maltreatment and family functioning with future suicide attempts.

PARTICIPANTS AND SETTING

Participants included 321 youth aged 12-15 years (251 with emotional maltreatment; 70 with no emotional maltreatment) recruited from a metropolitan children's hospital from 2011 to 2018. Prospective analyses included 280 youths (221 with emotional maltreatment; 59 without emotional maltreatment).

METHODS

Semi-structured interviews and self-reports assessed family functioning and suicidal thoughts and behaviors in youth with and without emotional maltreatment at baseline, 6-month, 1-year, and 2-year follow-up. Multivariate analyses examined whether emotional maltreatment predicted future suicide attempts, beyond the effect of prior suicide attempts.

RESULTS

Emotionally maltreated youth reported significantly lower scores for family adaptability, cohesion, and family alliance, and higher rates of suicidal ideation and suicide attempts, compared to youth without emotional maltreatment. Youth experiencing multiple forms of abuse were significantly more likely to attempt suicide at future timepoints, however this association was attenuated after controlling for prior suicide attempts.

CONCLUSION

Youth who experienced emotional maltreatment had a significantly higher percentage of past suicidal thoughts and behaviors and significantly less favorable scores for family functioning associated with an increased suicide risk. Findings support family-focused suicide prevention strategies as a promising approach to reduce youth suicide.

Association Between Social Determinants of Health and Deliberate Self-Harm Among Youths With Psychiatric Diagnoses

OBJECTIVE

The authors sought to examine the association between adverse social determinants of health (SDoHs) and risk for self-harm among youths.

METHODS

The authors performed a retrospective longitudinal analysis of Ohio Medicaid claims data (April 1, 2016-December 31, 2018) of 244,958 youths (ages 10-17 years) with a primary psychiatric diagnosis. SDoHs were identified from ICD-10 codes and classified into 14 categories, encompassing abuse and neglect, child welfare placement, educational problems, financial problems, exposure to violence, housing instability, legal issues, disappearance or death of a family member, family disruption by separation or divorce, family alcohol or drug use, parent-child conflict, other family problems, social and environmental problems, and nonspecific psychosocial needs. Cox proportional hazards analysis was used to examine the association between SDoHs and self-harm (i.e., nonsuicidal self-injury or suicide attempt). Analyses controlled for demographic characteristics and comorbid psychiatric and general medical conditions.

RESULTS

During follow-up after an index claim event, 51,796 youths (21.1%) had at least one adverse SDoH indicator, and 3,262 (1.3%) had at least one self-harm event. Abuse and neglect (hazard ratio [HR]=1.90, 99% CI=1.70-2.12), child welfare placement (HR=1.32, 99% CI=1.04-1.67), parent-child conflict (HR=1.52, 99% CI=1.23-1.87), other family problems (HR=1.25, 99% CI=1.01-1.54), and nonspecific psychosocial needs (HR=1.41, 99% CI=1.06-1.89) were associated with significantly increased hazard of self-harm.

CONCLUSIONS

Adverse SDoHs were significantly associated with self-harm, even after controlling for demographic and clinical characteristics, underscoring the need for capturing SDoH information in medical records to identify youths at elevated suicide risk and to inform targeted interventions.

Youth Suicide During the First Year of the COVID-19 Pandemic

OBJECTIVE

To identify potential differential changes in youth suicide deaths associated with the coronavirus disease (COVID-19) pandemic to better inform suicide prevention strategies.

METHODS

This cross-sectional study analyzed national suicide data for US youth aged 5 to 24 years from 2015 to 2020. Annual and monthly numbers of suicides were extracted overall and by sex, age, race and ethnicity, and method. Expected suicides were modeled from the trend in monthly deaths before COVID-19 (January 1, 2015-February 29, 2020), by using interrupted time-series analyses with quasi-Poisson regression. Rate ratios (RR) and corresponding 95% confidence intervals (CI) were used to compare expected and observed suicides during the first 10 months of COVID-19 (March 1, 2020-December 31, 2020).

RESULTS

Among 5568 identified youth suicides during the 2020 pandemic, 4408 (79.2%) were male, 1009 (18.1%) Hispanic, 170 (3.3%) non-Hispanic American Indian/Alaska Native, 262 (4.7%) Asian/Pacific Islander, 801 (14.4%) Black, and 3321 (59.6%) white. There was a significant increase in overall observed versus expected youth suicides during the COVID-19 pandemic (RR = 1.04, 95% CI = 1.01-1.07), equivalent to an estimated 212 excess deaths. Demographic subgroups including males (RR = 1.05, 95% CI = 1.02-1.08), youth aged 5 to 12 years (RR = 1.20, 95% CI = 1.03-1.41) and 18 to 24 years (RR =1.05, 95% CI = 1.02-1.08), non-Hispanic AI/AN youth (RR = 1.20, 95% CI = 1.03-1.39), Black youth (RR = 1.20, 95% CI = 1.12-1.29), and youth who died by firearms (RR = 1.14, 95% CI = 1.10-1.19) experienced significantly more suicides than expected.

CONCLUSIONS

Suicide deaths among US youth increased during COVID-19, with substantial variation by sex, age, race and ethnicity, and suicide method. Suicide prevention strategies must be tailored to better address disparities in youth suicide risk.

Black Youth Suicide: Investigation of Current Trends and Precipitating Circumstances

OBJECTIVE

Suicide among Black youth is a significant public health concern, yet research investigating the epidemiology of suicide in this population is limited. This study examines current trends and precipitating circumstances of suicide by sex and age group in Black youth 5 to 17 years of age, using 2 national databases.

METHOD

Data from the Web-based Injury Statistics Query and Reporting System (WISQARS) and the National Violent Death Reporting System (NVDRS) were used to investigate trends and precipitating circumstances of Black youth suicide from 2003 to 2017. We hypothesized suicide rates would increase over time for both sexes and all age groups (5-11, 12-14, and 15-17 years), and precipitating circumstances would differ by sex and age group. Trend analyses were conducted using Joinpoint regression software, version 4.8.0.01 (Surveillance Research Program, National Cancer Institute). Sex and age group comparisons of characteristics and precipitating circumstances were conducted using standard univariate statistical tests.

RESULTS

From 2003 to 2017, Black youth experienced a significant upward trend in suicide with the largest annual percentage change in the 15- to 17-year age group and among girls (4.9% and 6.6%, respectively). Mental health problems, relationship problems, interpersonal trauma and life stressors, and prior suicidal thoughts/behavior were the most common clinical characteristics and precipitating circumstances, with several varying by sex and age group.

CONCLUSION

Increases in Black youth suicide calls for the prioritization of research aimed at identifying specific risk and protective factors as well as developmental mechanisms associated with Black youth suicidal behavior. To implement effective suicide prevention programming, understanding targets for intervention is necessary.

Mortality and Cause of Death Among Youths Previously Incarcerated in the Juvenile Legal System

Importance

More than 50 000 youths are incarcerated in the United States on any given day, and youth incarceration has been linked to lasting adverse outcomes, including early mortality. Improving our understanding of the factors associated with early mortality among incarcerated youths can inform appropriate prevention strategies.

Objective

To examine mortality rates and causes of death among youths previously incarcerated in the juvenile legal system.

Design, Setting, and Participants

This retrospective longitudinal population-based cohort study compared mortality rates between youths aged 11 to 21 years incarcerated from 2010 to 2017 with same-aged nonincarcerated Medicaid-enrolled youths in the state of Ohio. Data from January 2017 to December 2019 were collected from juvenile incarceration, Medicaid, and death certificate information in Ohio.

Exposure

Incarceration in the state of Ohio's juvenile legal system.

Main Outcomes and Measures

Number, characteristics, and causes of deaths. Poisson regression incidence rate ratios (IRRs) compared mortality rates between previously incarcerated and Medicaid-enrolled youths.

Results

Among 3645 incarcerated youths, 3398 (93.2%) were male, 2155 (59.1%) Black, 1307 (35.9%) White, and 183 (5.0%) other race and ethnicity. Overall, 113 youths (3.1%) died during the study period. Homicide was the leading cause of death in formerly incarcerated youths (homicide: 63 [55.8%]; legal intervention [ie, death due to injuries inflicted by law enforcement]: 3 [2.7%]). All-cause mortality rates were significantly higher among previously incarcerated youths than Medicaid-enrolled youths (adjusted IRR [aIRR], 5.91; 95% CI, 4.90-7.13) in every demographic subgroup. Compared with Medicaid-enrolled youths, mortality rates for previously incarcerated youths were highest for homicide (aIRR, 11.02; 95% CI, 8.54-14.22), overdose (aIRR, 4.32; 95% CI, 2.59-7.20), and suicide (aIRR, 4.30; 95% CI, 2.22-8.33). Formerly incarcerated Black youths had a significantly higher risk of homicide (aIRR, 14.24; 95% CI, 4.45-45.63) but a lower risk of suicide (aIRR, 0.18; 95% CI, 0.04-0.89) and overdose (aIRR, 0.31; 95% CI, 0.10-0.99) than White youths who were incarcerated. Previously incarcerated youths aged 15 to 21 years were significantly more likely to die than youths aged 22 to 29 years, irrespective of cause of death (aIRR for youths aged 22-29 years, 0.09; 95% CI, 0.06-0.14).

Conclusions and Relevance

In this study, youths with a history of incarceration were significantly more likely to experience early mortality compared with nonincarcerated Medicaid-enrolled youths. Delinquency and violence prevention strategies that incorporate a culturally informed approach and consider sex and developmental level are critical.

The impact of peer influencing on adolescent suicidal ideation and suicide attempts

OBJECTIVE

The purpose of this study was to examine the role of peer influence on adolescent suicidal ideation and attempts within youth seeking emergency care or outpatient mental health services. We examined whether affiliation with peers reporting suicidal thoughts/behaviors was associated with an adolescent's own suicidal ideation and/or suicide attempt beyond individual risk factors.

METHODS

One hundred and eighteen adolescents, ages 13-18, were recruited from the emergency department and outpatient mental health clinics at a large, metropolitan children's hospital. Adolescents with suicidal ideation in the past six months (ideators, n=19) and with a suicide attempt in the past year (attempters, n=40) were matched with controls with no history of ideation or attempt on age (±1 year), sex, and race. Adolescents and parents completed semi-structured interviews and self-report questionnaires to examine individual and peer associated risk factors.

RESULTS

Both ideators and attempters were more likely to affiliate with peers with suicidal behavior compared to their matched controls. However, affiliation with suicidal peers was only associated with attempter group status after controlling for individual risk factors.

CONCLUSION

Affiliation with peers reporting suicidal thoughts/behaviors was linked to an adolescent's own history of suicide attempt. Through understanding peer affiliation, peers may be an important resource for both identifying and preventing youth suicidal behavior. Evidence-based programs that focus and utilize peer influence may be invaluable for prevention efforts.

Characteristics and Precipitating Circumstances of Suicide Among Children Aged 5 to 11 Years in the United States, 2013-2017

IMPORTANCE

Suicide is the eighth leading cause of death among children aged 5 to 11 years, with rates increasing during the past decade. A better understanding of factors associated with childhood suicide can inform developmentally appropriate prevention strategies.

OBJECTIVE

To examine characteristics and precipitating circumstances of childhood suicide.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study examined restricted-use data from the National Violent Death Reporting System (NVDRS) regarding child suicide decedents aged 5 to 11 years in the US from 2013 to 2017. The NVDRS is a state-based surveillance system that collects data on suicide and violent deaths in 50 states, with restricted-use data available from 37 states. Details and context related to suicide deaths were identified through a content analysis of case narratives from coroner or medical examiner and law enforcement reports associated with each incident.

EXPOSURES

Characteristics and precipitating circumstances associated with suicide cited in the coroner, medical examiner, and law enforcement case narratives.

MAIN OUTCOMES AND MEASURES

Suicide incidence and risk factors for suicide including mental health, prior suicidal behavior, trauma, and peer, school, or family-related problems.

RESULTS

Analyses included 134 child decedents (101 [75.4%] males; 79 [59.0%] White individuals; 109 [81.3%] non-Hispanic individuals; mean [SD] age, 10.6 [0.8] years). Most suicides occurred in the child's home (95.5% [n = 128]), and more specifically in the child's bedroom. Suicide by hanging or suffocation (78.4% [n = 105]) was the most frequent method, followed by firearms (18.7% [n = 25]). Details on gun access were noted in 88.0% (n = 22) of suicides by firearm, and in every case, the child obtained a firearm stored unsafely in the home. Findings revealed childhood suicide was associated with numerous risk factors accumulated over time, and suggest a progression toward suicidal behavior, especially for youth with a history of psychopathology and suicidal behavior. An argument between the child and a family member and/or disciplinary action was often a precipitating circumstance of the suicide.

CONCLUSIONS AND RELEVANCE

This qualitative study found that childhood suicide was associated with multiple risk factors and commonly preceded by a negative precipitating event. Potential prevention strategies include improvements in suicide risk assessment, family relations, and lethal means restriction, particularly safe firearm storage. Future research examining the myriad aspects of childhood suicide, including racial/ethnic and sex differences, is needed.

Health Services Use by Children in the Welfare System Who Died by Suicide

OBJECTIVES

To examine characteristics and health service use patterns of suicide decedents with a history of child welfare system involvement to inform prevention strategies and reduce suicide in this vulnerable population.

METHODS

A retrospective matched case-control design (120 suicide decedents and 1200 matched controls) was implemented. Suicide decedents included youth aged 5 to 21 who died by suicide and had an open case in Ohio's Statewide Automated Child Welfare Information System between 2010 and 2017. Controls were matched to suicide decedents on sex, race, and ethnicity. Comparisons were analyzed by using conditional logistic regressions to control for matching between the suicide and control groups.

RESULTS

Youth in the child welfare system who died by suicide were significantly more likely to experience out-of-home placements and be diagnosed with mental and physical health conditions compared with controls. Suicide decedents were twice as likely to access mental health services in the 1 and 6 months before death, regardless of the health care setting. A significantly higher percentage of suicide decedents used physical health services 6 months before their death or index date. Emergency department visits for both physical and mental health conditions were significantly more likely to occur among suicide decedents.

CONCLUSIONS

Suicide decedents involved in the child welfare system were more likely to use both mental and physical health care services in the months before their death or index date. Findings suggest that youth involved in the child welfare system may benefit from suicide prevention strategies in health care settings.

Depressed Mood Prior to Death

Abstract. Background: Suicide is a leading cause of death among youth in the United States. Multiple factors have been shown to increase risk for suicidal behavior, including depressed mood. Aims: The purpose of this study was to examine individual characteristics and precipitating circumstances of suicide in youth decedents with and without depressed mood at the time of death. Method: Data from the National Violent Death Reporting System (NVDRS) were analyzed for 17 US states from 2003 to 2012. Participants included suicide decedents aged 10–19 years ( N = 4,053). Analyses compared youth suicide decedents with depressed mood at time of death with those without depressed mood using logistic regression. Sex-specific differences in youth with depressed mood were also explored. Results: Youth suicide decedents with depressed mood were more likely than those without depressed mood to exhibit clinical characteristics and precipitating circumstances associated with suicide. Comparison of males and females with depressed mood found unique sex-specific differences. Limitations: Data were limited to 17 states, analyses did not include a control group, and data were collected through postmortem reporting. Conclusion: Findings support a significant association between depressed mood and factors associated with suicidal behavior in youth and offer potential areas to focus prevention strategies.

Trends in Suicide Among Youth Aged 10 to 19 Years in the United States, 1975 to 2016

IMPORTANCE

Suicide is a leading cause of death among youth aged 10 to 19 years in the United States, with rates traditionally higher in male than in female youth. Recent national mortality data suggest this gap may be narrowing, which warrants investigation.

OBJECTIVE

To investigate trends in suicide rates among US youth aged 10 to 19 years by age group, sex, race/ethnicity, and method of suicide.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study using period trend analysis of US suicide decedents aged 10 to 19 years from January 1, 1975, to December 31, 2016. Data were analyzed for periods defined by statistically significant changes in suicide rate trends. Suicide rates were calculated using population estimates.

MAIN OUTCOMES AND MEASURES

Period trends in suicide rates by sex and age group were assessed using joinpoint regression. Incidence rate ratios (IRRs) were estimated using negative binomial regression comparing male and female suicide rates within periods.

RESULTS

From 1975 to 2016, we identified 85 051 youth suicide deaths in the United States (68 085 male [80.1%] and 16 966 female [19.9%]) with a male to female IRR of 3.82 (95% CI, 3.35-4.35). Following a downward trend until 2007, suicide rates for female youth showed the largest significant percentage increase compared with male youth (12.7% vs 7.1% for individuals aged 10-14 years; 7.9% vs 3.5% for individuals aged 15-19 years). The male to female IRR decreased significantly across the study period for youth aged 10 to 14 years (3.14 [95% CI, 2.74-3.61] to 1.80 [95% CI, 1.53-2.12]) and 15 to 19 years (4.15 [95% CI, 3.79-4.54] to 3.31 [95% CI, 2.96-3.69]). Significant declining trends in the male to female IRR were found in non-Hispanic white youth aged 10 to 14 years (3.27 [95% CI, 2.68-4.00] to 2.04 [95% CI, 1.45-2.89]) and non-Hispanic youth of other races aged 15 to 19 years (4.02 [95% CI, 3.29-4.92] to 2.35 [95% CI, 2.00-2.76]). The male to female IRR for firearms increased significantly for youth aged 15 to 19 years (χ2 = 7.74; P = .02 for sex × period interaction). The male to female IRR of suicide by hanging or suffocation decreased significantly for both age groups (10-14 years: χ2 = 88.83; P < .001 for sex × period interaction and 15-19 years: χ2 = 82.15; P < .001 for sex × period interaction). No significant change was found in the male to female IRR of suicide by poisoning across the study period.

CONCLUSIONS AND RELEVANCE

A significant reduction in the historically large gap in youth suicide rates between male and female individuals underscores the importance of interventions that consider unique differences by sex. Future research examining sex-specific factors associated with youth suicide is warranted.

Characteristics and Precipitating Circumstances of Suicide Among Incarcerated Youth

OBJECTIVE

Studies show incarcerated youth are at increased risk for suicidal behavior, yet little is known about factors associated with suicide for this population. Using a nationally representative sample, this study examined characteristics and precipitating circumstances of suicide in incarcerated youth decedents compared with youth suicide decedents in the general population.

METHOD

Data were analyzed for suicide decedents 10- to 24-years-old (N = 10,126) in the United States from 2003 through 2012 from the National Violent Death Reporting System. Logistic regression compared precipitating circumstances of suicide for incarcerated youth decedents and those not in custody. Details on suicide deaths in detained youth were captured from coroner/medical examiner and law enforcement reports associated with each incident.

RESULTS

Most youth suicide decedents were older, white, and male regardless of incarceration status. Incarcerated youth suicide decedents were more likely to die by hanging, strangulation, or suffocation and less likely to disclose suicide intent, leave a suicide note, or exhibit depressive symptoms compared with those not in custody. Additional risk factors for suicide were not significantly different between youth decedents in custody and those not in custody, suggesting that unique aspects of the incarceration environment could be associated with an increased risk of suicide.

CONCLUSION

Study findings highlight the need for early suicide risk detection and developmentally relevant interventions tailored for youth in correctional settings. Future efforts should include evaluation studies to support suicide prevention programs designed for incarcerated youth and research that examines distinctive factors associated with suicidal behavior in youth in custody.