Age and Birth Cohort-Adjusted Rates of Suicide Mortality Among US Male and Female Youths Aged 10 to 19 Years From 1999 to 2017

A Narrative Review of Depression and Suicide in Adolescent Females to Guide Assessment and Treatment Recommendations

STUDY OBJECTIVE

Suicide is a leading cause of death for adolescents. Medical professionals are increasingly being asked to screen for depressive symptoms and suicidal ideation with little training. The purpose of this paper is to review factors related to suicidal thoughts and actions, assessment of symptoms, and initial suggestions for treatment for medical providers.

METHODS

A literature review of risk and resilience factors, assessment measures, and treatment options for depression and suicidal ideation and behavior in adolescent females was conducted.

RESULTS

Given the higher risk of suicidal thoughts and depressive symptoms in adolescent females, accurate and thorough assessment of symptoms is recommended.

CONCLUSION

Medical providers should be aware of symptoms related to depression and suicidal ideation in order to provide more effective assessments. Recommendations for brief assessment measures that can be used in the clinic and possible first line treatments are provided.

The intersection of race, ethnicity, and gender and the prevalence of suicidal thoughts and behaviors

The prevalence of suicidal thoughts and behaviors across distinct intersections of race/ethnicity and gender among adolescents remains understudied. The current study seeks to address this important gap in suicide scholarship using a statewide representative sample of U.S. Florida middle school and high school adolescents. Data drawn from the 2022 Florida Youth Substance Abuse Survey (FYSAS) (N = 41,764) were analyzed to examine disparities in suicidal thoughts and suicide attempts among 26 racial/ethnic and gender subgroups of middle school and high school aged adolescents. Survey-weighted prevalence estimates for both suicidality outcomes were generated, and binary contrasts were used to assess the statistical significance of the differences in the probabilities between members of each subgroup and youth belonging to all other subgroups. Our results indicate that the prevalence of suicidal thoughts and attempts was highly gendered and varied according to racial/ethnic subgroups. Native American girls reported more suicidal thoughts (49.9%) and attempts (16.5%) in the past 12 months than any race/gender group. Other racial/ethnic and gender groups that reported particularly high rates of suicidal thoughts and attempts were West Indian/Caribbean female adolescents (48.8% and 13.4%, respectively), Puerto Rican female adolescents (48.5% and 14.7%, respectively), and Black/non-Hispanic female adolescents (19.9% and 15.6%, respectively). Because certain gender and race/ethnic subgroups are at an increased risk for suicidality, more research is needed to better understand the risk and protective factors to determine which suicide prevention strategies might best serve each group.

Trends in Suicidal Mortality and Motives among Working-Ages Individuals in Japan during 2007-2022

Suicides in Japan consistently decreased from 2009-2019, but increased during the COVID-19 pandemic. To identify causes of increasing suicides, age-dependent and temporal fluctuations of suicide mortality rate per 100,000 (SMRP) in working-age generations (20-59 years) disaggregated by suicidal motives (7-categories; 52-subcategories) and sex from 2007 to 2022, were analyzed by analysis of variance and joinpoint regression, respectively, using the government suicide database "Suicide Statistics". The SMRP of 20-29 year-old males and 20-49 year-old females began to increase in the late 2010s. SMRPs of these high-risk groups for suicides caused by depression (the leading suicidal motive for all groups) began increasing in the late 2010s. Economic-related, employment-related, and romance-related problems contributed to the increasing SMRPs in 20-29 males in the late 2010s. Romance-related and family-related problems contributed to the increasing SMRPs of 20-29 females in the late 2010s. Increasing SMRPs caused by child-raising stress in 20-39 year-old females from the late 2010s was a remarkable finding. In contrast, SMRPs of 30-59 year-old males consistently decreased until 2021; however, in these groups, SMRPs for suicides caused by various motives sharply increased in 2022. The consistent increase in SMRPs of high-risk groups from the late 2010s to the pandemic suggest recent socioeconomic and psychosocial problems in Japan possibly contributed to the increasing SMRPs in these high-risk groups independently of pandemic-associated factors, whereas the SMRPs of males of 30-59 years were probably associated with the ending of the pandemic rather than pandemic-associated factors.

Suicidal Mortality and Motives Among Middle-School, High-School, and University Students

IMPORTANCE

The suicide mortality rate per 100 000 population (SMRP) consistently decreased before the COVID-19 pandemic outbreak in Japan and then unexpectedly increased during the pandemic. However, the underlying mechanisms remain poorly understood.

OBJECTIVE

To identify trends in and factors associated with suicidal mortality and motives among students in Japan from 2007 to 2022.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, data on SMRPs among Japanese middle-school, high-school, and university students were obtained from the government suicide database Suicide Statistics of the National Police Agency.

MAIN OUTCOMES AND MEASURES

Age-dependent and temporal fluctuations in annual SMRPs, disaggregated by suicidal motive (7 categories and 52 subcategories), sex, and school, were analyzed using linear mixed-effect and joinpoint regression models, respectively.

RESULTS

Total suicide numbers from 2007 to 2022 were as follows: 760 male middle-school students, 635 female middle-school students, 2376 male high-school students, 1566 female high-school students, 5179 male university students, and 1880 female university students. The mean (SD) student populations from 2007 to 2022 were as follows: 1 752 737 (81 334) male middle-school students, 1 675 572 (78 824) female middle-school students, 1 648 274 (67 520) male high-school students, 1 614 828 (60 032) female high-school students, 1 652 689 (32 724) male university students, and 1 229 142 (57 484) female university students. Among male students, the leading motives were school-related factors (underachievement and worrying about the future), followed by family-related and health-related motives. Among female students, school-related and family-related motives decreased, but health-related motives showed an age-dependent increase. The SMRPs of middle-school male students and female students were almost equal (mean [SD], 2.7 [1.0] vs 2.4 [1.4]), but the age-dependent increase in SMRPs among male students was pronounced (mean [SD], high-school vs university male students, 9.1 [2.4] vs 19.6 [3.0]; high-school vs university female students, 6.1 [2.4] vs 9.6 [1.8]). However, the incidence of suicide among high-school students associated with health-related motives was greater in female students. The majority of suicides associated with major impactable suicidal motives (school-related, health-related, and family-related motives) began increasing before the pandemic. Changes in SMRP associated with interpersonal relationships, such as conflict with classmates or parents, were not significant, but the rates increased greatly during the pandemic.

CONCLUSIONS AND RELEVANCE

School-related, health-related, and family-related problems were major motives, whereas the impacts of health-related and family-related motives increased and decreased with age, respectively. Notably, most SMRPs associated with major impactable motives (underachievement, conflict with a parent or classmate, and mental illnesses) had already begun increasing in the late 2010s, indicating that recent increasing SMRPs among school-aged individuals were associated with pandemic-related factors and other factors affecting this generation before the pandemic. It may be inappropriate to uniformly apply research findings based on school-aged individuals to school-based suicide prevention programs for students in middle school, high school, and university.

Suicide in young people: screening, risk assessment, and intervention

Suicide is the fourth leading cause of death among young people worldwide and the third leading cause of death among those in the US. This review outlines the epidemiology of suicide and suicidal behavior in young people. It discusses intersectionality as an emerging framework to guide research on prevention of suicide in young people and highlights several clinical and community settings that are prime targets for implementation of effective treatment programs and interventions aimed at rapidly reducing the suicide rate in young people. It provides an overview of current approaches to screening and assessment of suicide risk in young people and the commonly used screening tools and assessment measures. It discusses universal, selective, and indicated evidence based suicide focused interventions and highlights components of psychosocial interventions with the strongest evidence for reducing risk. Finally, the review discusses suicide prevention strategies in community settings and considers future research directions and questions challenging the field.

Relationship between adverse childhood experiences, depression and suicidal behaviors in adulthood among young men who have sex with men: A prospective cohort study

BACKGROUND

Suicidal behaviors have been a crucial public health issue among young men who have sex with men (YMSM). Adverse childhood experiences (ACEs) and depression are important predictors of suicidal behaviors. Few studies have examined the underlying mechanisms. This study aims to examine the mediation mechanism from ACEs to depression and further to suicidal ideation based on a prospective cohort study of YMSM.

METHOD

Study data were derived from 499 YMSM recruited from three cities (Wuhan, Changsha and Nanchang) of China from September in 2017 to January in 2018. ACEs (abuse, neglect and household challenges), depressive symptoms and suicidal behaviors (suicidal ideation, suicidal plan and suicidal attempt) were measured at the baseline, the first wave and second wave follow-up survey, respectively. Mediation modeling analysis was used for data analysis only for suicidal ideation due to the low frequency of suicidal plan and attempt.

RESULTS

An estimated 17.86% of YMSM reported suicidal ideation, 2.27% ever made a suicidal plan and 0.65% of YMSM had a suicidal attempt in the past six months. The effect of ACEs on suicidal ideation was fully mediated through depressive symptoms (indirect effect [95%CI] = 0.011 [0.004,0.022]). Among the three subconstructs of ACEs, childhood abuse and neglect could increase the risk of suicidal ideation in adulthood by increasing depressive symptoms (indirect effect = 0.020 [0.007,0.042] for childhood abuse, and 0.043 [0.018,0.083] for neglect), but not for household challenges (indirect effect = 0.003 [-0.011,0.018]).

CONCLUSIONS

ACEs could affect suicidal ideation through depression, particularly for childhood abuse and neglect. Preventive strategies may focus on the treatment of depression and psychological counseling, especially for YMSM who ever experienced negative experiences in childhood.

The association of weight control attempts with suicidality: The role of objective weight status and weight perception among adolescents of United States

BACKGROUND

The evidence for the association of weight control attempts with suicidality by objective weight status, subjective weight perception, and distorted weight perception among adolescents was limited.

METHODS

Data were extracted from a national representative sample of Youth Risk Behavior Surveys in the United States from 2011 to 2019. Binary logistic regression models with complex sampling designs were used to explore the association of weight control attempts, objective weight status, and weight perception with suicidality.

FINDINGS

The adolescents attempting to lose weight had higher weighted prevalence of suicidal ideation, suicide plan, suicide attempt, and suicide attempt with medical treatment compared with other attempts of weight control. Totally, attempting to lose weight was significantly associated with increased risk of suicidal ideation (OR: 1.17, 95%CI: 1.05-1.30) and suicide attempt (OR: 1.26, 95%CI: 1.10-1.46) when adjusting objective weight status, weight perception and all other covariates. In the subgroup analyses, attempting to lose weight was significantly associated with increased risk of suicidality in the adolescents of normal weight, underweight, perceived normal weight, perceived underweight, right estimation of objective weight status.

LIMITATIONS

Uncertain causal relationship existed because of cross-sectional design.

CONCLUSIONS

The risk of suicidality associated with weight control attempts varied among different subgroups. The findings in this study suggest that not only objective weight status but also weight perception should be with consideration when performing weight control attempts.

The influence of the age-period-cohort effects on male suicide in Brazil from 1980 to 2019

Suicide is a complex and multi-determined phenomenon. Higher rates are observed in men and are related to multiple risk factors, including mental disorders, financial crises, unemployment, and easy access to highly lethal means of perpetration, such as firearms. We studied the effects of age, period, and cohort (APC) on total and firearm-related suicides in men in Brazil and its major regions from 1980 to 2019. Death records were extracted from the Brazilian Ministry of Health's Mortality Information System. Estimable functions were used to estimate APC models, through the Epi library of the R statistical program, version 4.2.1. During the study period, Brazil had an average rate of 10.22 deaths per 100,000 men. Among regions, rates ranged from 8.62 (Northeast) to 16.93 (South). The same profile was observed in suicides by firearms. After estimating the APC models, we observed a temporal trend of increasing total suicides for Brazil and regions, except for the South region, where the trend was stationary. The trend was downward for firearm suicides for all locations. A positive gradient was observed in the mortality rate with advancing age for total suicides; and peak incidence between 20-29 years, with subsequent stabilization, for suicides perpetrated by firearms. There was a reduction in the risk of death for suicides perpetrated by firearms in relation to the reference period (1995-1999) for all locations, except in the North region, where the effect was not significant. The younger generations from the 1960s onwards had a higher risk of death from total suicide and a lower risk for those perpetrated by firearms in relation to the reference cohort (1950-1954). We observed a reduction in the mortality trend for suicides perpetrated by firearms, a reduction in the risk of death in the 2000s and for men born after 1960. Our results suggest reducing the risk of death from suicide by firearms in Brazil and regions. However, there is an upward trend in mortality from total suicides in the study period (1980-2019) and for younger cohorts.

Análisis psicométrico de la escala de ideación suicida de Roberts en universitarios mexicanos

El incremento observado en las tasas de suicidio en jóvenes hace necesario contar con escalas de cribaje para la identificación de personas en riesgo. La escala de ideación suicida de Roberts (EIS) es un instrumento breve que ha mostrado propiedades psicométricas adecuadas en adolescentes mexicanos. El objetivo del presente estudio fue corroborar la estructura de dicho instrumento mediante un análisis factorial confirmatorio (AFC) y analizar sus propiedades psicométricas en estudiantes universitarios. Aplicando un método cuantitativo instrumental, se administró la EIS a 1190 universitarios. Los resultados del AFC corroboran la estructura unifactorial de la EIS; asimismo, la consistencia interna, reportada con el alfa de Cronbach ordinal (αO = 0.813), resultó adecuada. Se concluye que el instrumento muestra una estructura unifactorial y que las características psicométricas de los reactivos fueron adecuadas, resalta que 2.9 % de la muestra obtuvo una puntuación que indica alto riesgo suicida.

Investigating the paradox of increasing obesity and declining heart disease mortality in the United States: Age-period-cohort model

Background

Obesity as a risk factor of heart disease (HD) is confirmed through observational, laboratory, and intervention studies. However, it cannot explain why HD declines, but obesity increases in the United States in recent decades. This study attempted to understand this paradox.

Methods

Annual data of national HD mortality (1999–2018) were derived from Wide-Ranging Online Data for Epidemiologic Research, biannual obesity data (1999–2016) from the National Health and Nutrition Examination Survey, and smoking data (1965–1990) were from the National Health Interview Survey. Age-period-cohort method was used to decompose HD mortality into age, period, and cohort effects, and to estimate age-cohort adjusted mortality rates. To explain the paradox, age-cohort adjusted rates were associated with obesity rates to verify the positive obesity-HD relationship, while smoking rates were associated with cohort effects to explain the current declines in HD mortality.

Results

During 1999–2018, the prevalence of obesity increased while the crude HD mortality rate declined for both sex and all races. After controlling for the curvilinear age effect and consistent declining cohort effect, the age-cohort adjusted HD mortality sustained stable in 1999–2007 and increased thereafter. The age-cohort adjusted rate in 1999–2018 (per 100,000) increased from 189.31 to 238.56 for males, 67.23 to 90.28 for females, 115.54 to 157.39 for White, 246.40 to 292.59 for Black, 79.79 to 101.40 for Hispanics, and 49.95 to 62.86 for Asian. The age-cohort adjusted HD mortality rates were positively associated with obesity rates (r = 0.68 for males, 0.91 for females, 0.89 for White, and 0.69 for Hispanic, p < 0.05), but not significant for Black and Asian. Further, during 1965–1990, the estimated cohort effect showed a decline in HD risk and was positively associated with smoking rates (r = 0.98 for both sex, 0.99 for White, and 0.98 for Black, p < 0.01).

Conclusion

Study findings reveal potential increase of HD risk and support the positive relationship between obesity and HD risk. Declines in HD mortality in the past two decades are primarily due to tobacco use reduction and this protective effect was entangled in the mortality rates as cohort effect.

Role of Foreign-Born Status on Suicide Mortality in Spain Between 2000 and 2019: An Age-Period-Cohort Analysis

Objectives: To examine recent age-period-cohort effects on suicide among foreign-born individuals, a particularly vulnerable sociodemographic group in Spain. Methods: Using 2000-2019 mortality data from Spain's National Institute of Statistics, we estimated age-period-cohort effects on suicide mortality, stratified by foreign-born status (native- vs. foreign-born) and, among the foreign-born, by Spanish citizenship status, a proxy for greater socioeconomic stability. Results: Annual suicide mortality rates were lower among foreign- than native-born individuals. There was heterogeneity in age-period-cohort effects between study groups. After 2010, suicide mortality increased markedly among the foreign-born-especially for female cohorts born around 1950, and slightly among native-born women-especially among female cohorts born after the 1960s. Among native-born men, suicide increased linearly with age and remained stable over time. Increases in suicide among the foreign-born were driven by increases among individuals without Spanish citizenship-especially among cohorts born after 1975. Conclusion: After 2010, suicide in Spain increased markedly among foreign-born individuals and slightly among native-born women, suggesting an association between the downstream effects of the 2008 economic recession and increases in suicide mortality among socioeconomically vulnerable populations.

Contributions of PTSD polygenic risk and environmental stress to suicidality in preadolescents

Suicidal ideation and attempts (i.e., suicidality) are complex behaviors driven by environmental stress, genetic susceptibility, and their interaction. Preadolescent suicidality is a major health problem with rising rates, yet its underlying biology is understudied. Here we studied effects of genetic stress susceptibility, approximated by the polygenic risk score (PRS) for post-traumatic-stress-disorder (PTSD), on preadolescent suicidality in participants from the Adolescent Brain Cognitive Development (ABCD) Study®. We further evaluated PTSD-PRS effects on suicidality in the presence of environmental stressors that are established suicide risk factors. Analyses included both European and African ancestry participants using PRS calculated based on summary statistics from ancestry-specific genome-wide association studies. In European ancestry participants (N = 4,619, n = 378 suicidal), PTSD-PRS was associated with preadolescent suicidality (odds ratio [OR] = 1.12, 95%CI 1-1.25, p = 0.038). Results in African ancestry participants (N = 1,334, n = 130 suicidal) showed a similar direction but were not statistically significant (OR = 1.21, 95%CI 0.93-1.57, p = 0.153). Sensitivity analyses using non-psychiatric polygenic score for height and using cross-ancestry PTSD-PRS did not reveal any association with suicidality, supporting the specificity of the association of ancestry-specific PTSD-PRS with suicidality. Environmental stressors were robustly associated with suicidality across ancestries with moderate effect size for negative life events and family conflict (OR 1.27-1.6); and with large effect size (OR ∼ 4) for sexual-orientation discrimination. When combined with environmental factors, PTSD-PRS showed marginal additive effects in explaining variability in suicidality, with no evidence for G × E interaction. Results support use of cross-phenotype PRS, specifically stress-susceptibility, as a genetic marker for suicidality risk early in the lifespan.

Racial/Ethnic, Sex, Sexual Orientation, and Socioeconomic Disparities in Suicidal Trajectories and Mental Health Treatment Among Adolescents Transitioning to Young Adulthood in the USA: A Population-Based Cohort Study

Suicide is the second leading cause of death for people aged 10-34 years old. Limited research has documented extant heterogeneities in suicide across the life course and among diverse sociodemographic groups. There is also limited research on the influences of mental health utilization on suicidal trajectories across the life course. This study aims to: (1) identify racial/ethnic, sex, sexual orientation, socioeconomic status, and intersectional differences in suicidal trajectories among adolescents transitioning to adulthood; and (2) examine influences of mental health service utilization on disparities in suicidal trajectories. The study included 9421 respondents (Mage = 14.99 [SD = 1.61]) from Waves I-IV National Longitudinal Study of Adolescent to Adult Health (1994-2008). Latent class growth analyses were used to identify trajectories of suicidal ideation and suicide attempts. Multivariate multinomial logistic regression was used to examine the influences of mental health treatment and sociodemographic characteristics on suicidal trajectories. Three suicidal ideation (low-stable, high-decreasing, moderate-decreasing-increasing) and two suicide attempt (low-stable, moderate-decreasing) trajectories were identified. Compared with the low-stable trajectories, the risks of being in high-decreasing suicidal ideation trajectories were higher among females (AOR = 1.45, 95% CI 1.01-2.13) and sexual minorities (AOR = 1.82, 95% CI 1.21-2.74). Sexual minorities (AOR = 2.63, 95% CI 1.69-4.08) and low-SES adolescents (AOR = 1.79, 95% CI 1.08-2.98) were more likely to be in the moderate-decreasing suicide attempt group. Mental health service utilization predicted engagement in high-risk suicidal trajectories. Sociodemographic disparities in suicidal trajectories initiate early and persist over time. Individuals in high-risk trajectories received mental health treatment during adolescence. Suicide prevention should target vulnerable subpopulations and mental health service utilization in the early stage.

Variations in seasonal solar insolation are associated with a history of suicide attempts in bipolar I disorder

Background

Bipolar disorder is associated with circadian disruption and a high risk of suicidal behavior. In a previous exploratory study of patients with bipolar I disorder, we found that a history of suicide attempts was associated with differences between winter and summer levels of solar insolation. The purpose of this study was to confirm this finding using international data from 42% more collection sites and 25% more countries.

Methods

Data analyzed were from 71 prior and new collection sites in 40 countries at a wide range of latitudes. The analysis included 4876 patients with bipolar I disorder, 45% more data than previously analyzed. Of the patients, 1496 (30.7%) had a history of suicide attempt. Solar insolation data, the amount of the sun’s electromagnetic energy striking the surface of the earth, was obtained for each onset location (479 locations in 64 countries).

Results

This analysis confirmed the results of the exploratory study with the same best model and slightly better statistical significance. There was a significant inverse association between a history of suicide attempts and the ratio of mean winter insolation to mean summer insolation (mean winter insolation/mean summer insolation). This ratio is largest near the equator which has little change in solar insolation over the year, and smallest near the poles where the winter insolation is very small compared to the summer insolation. Other variables in the model associated with an increased risk of suicide attempts were a history of alcohol or substance abuse, female gender, and younger birth cohort. The winter/summer insolation ratio was also replaced with the ratio of minimum mean monthly insolation to the maximum mean monthly insolation to accommodate insolation patterns in the tropics, and nearly identical results were found. All estimated coefficients were significant at p < 0.01.

Conclusion

A large change in solar insolation, both between winter and summer and between the minimum and maximum monthly values, may increase the risk of suicide attempts in bipolar I disorder. With frequent circadian rhythm dysfunction and suicidal behavior in bipolar disorder, greater understanding of the optimal roles of daylight and electric lighting in circadian entrainment is needed.

Age, period, and cohort effects on suicide death in the United States from 1999 to 2018: moderation by sex, race, and firearm involvement

The role of sex, race, and suicide method on recent increases in suicide mortality in the United States remains unclear. Estimating the age, period, and cohort effects underlying suicide mortality trends can provide important insights for the causal hypothesis generating process. We generated updated age-period-cohort effect estimates of recent suicide mortality rates in the US, examining the putative roles of sex, race, and method for suicide, using data from all death certificates in the US between 1999 and 2018. After designating deaths as attributable to suicide according to ICD-10 underlying cause of death codes X60-X84, Y87.0, and U03, we (i) used hexagonal grids to describe rates of suicide by age, period, and cohort visually and (ii) modeled sex-, race-, and suicide method-specific age, period, and cohort effects. We found that, while suicide mortality increased in the US between 1999 and 2018 across age, sex, race, and suicide method, there was substantial heterogeneity in age and cohort effects by method, sex, and race, with a first peak of suicide risk in youth, a second peak in older ages-specific to male firearm suicide, and increased rates among younger cohorts of non-White individuals. Our findings should prompt discussion regarding age-specific clinical firearm safety interventions, drivers of minoritized populations' adverse early-life experiences, and racial differences in access to and quality of mental healthcare.

Temporal Trends in Suicidal Ideation and Attempts Among US Adolescents by Sex and Race/Ethnicity, 1991-2019

Importance

Disparities by sex and racial/ethnic group in suicide death rates are present in US adolescents. Whether disparities in suicide death extend to groups targeted for suicide prevention efforts, namely, those with suicidal ideation or nonfatal suicide attempts, is unknown.

Objective

To examine differences in temporal trends between suicidal ideation and suicide attempts in US adolescents from 1991 through 2019 by sex and race/ethnicity subgroups.

Design, Setting, and Participants

A cross-sectional analysis of the national Youth Risk Behavior Survey, weighted to represent US adolescents from 1991 to 2019, included 183 563 US high-school students in grades 9 to 12. Data were analyzed from September 16, 2020, through April 12, 2021.

Exposures

Calendar year, sex, race/ethnicity, and interactions of sex and race/ethnicity.

Main Outcomes and Measures

Survey-weighted prevalence estimates, annual percentage changes (APCs) and average APC in the survey-weighted prevalence of suicidal ideation and nonfatal suicide attempts, constructed from self-reported suicidal ideation, plan, and attempts in each survey year, by sex, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian or Pacific Islander and Native Hawaiian, American Indian/Alaska Native), and their interactions (sex × race/ethnicity).

Results

In 183 563 (unweighted) included adolescents (mean [SD] age, 16.07 [1.23] years; 94 282 females [weighted percentage, 49.4%; 95% CI, 48.8%-50.1%]), the prevalence of suicidal ideation decreased from 1991 to 2019 (from 19.4% to 15.8%; 95% CI, 0.7%-0.9%), whereas the prevalence of nonfatal suicide attempts increased from 1991 to 2019 (from 7.3% to 8.9%; 95% CI, 1.0%-1.4%). Joinpoint regression indicated a -3.1% (95% CI, -3.7% to -2.6%) annual decrease in suicidal ideation between 1991 and 2009, followed by a 3.4% annual increase (95% CI, 1.9% -4.8%) between 2009 and 2019. Decreasing followed by increasing trends in suicidal ideation showed modestly different turning points in female (1991-2009, 2009-2019), White (1991-2009, 2009-2019), Hispanic (1991-2007, 2007-2019), and Black (1991-2005, 2005-2019) adolescents. Although no significant trends were observed in suicide attempts from 1991 through 2019, male (68.4% increase; 95% CI, 0.2% -1.2%) and Black (79.7% increase; 95% CI, 0.1%-1.5%) adolescents had greater increases in the prevalence of suicide attempts. Interaction of sex and race/ethnicity revealed increases in suicidal ideation in White females from 2009 to 2019 (APC, 4.3%; 95% CI, 1.5%-7.1%), Black females from 2005 to 2019 (APC, 3.4%; 95% CI, 1.4%-5.4%), and Hispanic females from 2009 to 2019 (APC, 3.3%; 95% CI, 1.0%-5.6%) and suicide attempts in White females from 2009 to 2019 (APC, 3.1%; 95% CI, 0.3%-6.0%).

Conclusions and Relevance

The findings of this study show apparent sex and racial/ethnic differences in trends in suicidal ideation and suicide attempts. Increases in suicidal ideation since 2009 were observed in female individuals; changes in male and Black adolescents represented the largest increase in the prevalence of suicide attempts between 1991 and 2019. Evidence-based suicide prevention programs need to be tailored by sex and race/ethnicity, calling for greater diversification of health care system, school, and community prevention approaches.

Evaluation of Attention-Deficit/Hyperactivity Disorder Medications, Externalizing Symptoms, and Suicidality in Children

IMPORTANCE

Childhood suicidality (ie, suicidal ideation or attempts) rates are increasing, and attention-deficit/hyperactivity disorder (ADHD) and externalizing symptoms are common risk factors associated with suicidality. More data are needed to describe associations of ADHD pharmacotherapy with childhood suicidality.

OBJECTIVE

To investigate the associations of ADHD pharmacotherapy with externalizing symptoms and childhood suicidality.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, cross-sectional and 1-year-longitudinal associations were examined using data (collected during 2016-2019) from the Adolescent Brain Cognitive Development (ABCD) Study, a large, diverse US sample of children aged 9 to 11 years. Data analysis was performed from November to December 2020.

EXPOSURES

Main and interaction associations of externalizing symptoms (hyperactivity ADHD symptoms, oppositional defiant, and conduct disorder symptoms) and ADHD medication treatment (methylphenidate and amphetamine derivatives, α-2-agonists, and atomoxetine) at baseline assessment.

MAIN OUTCOMES AND MEASURES

Child-reported suicidality (past and present at baseline; current at longitudinal assessment). Covariates were age, sex, race/ethnicity, parents' education, marital status, and concomitant child psychiatric pharmacotherapy (antidepressants and antipsychotics).

RESULTS

Among 11 878 children at baseline assessment (mean [SD] age, 9.9 [0.6] years; 6196 boys [52.2%]; 8805 White [74.1%]), 1006 (8.5%) were treated with ADHD medication and 1040 (8.8%) reported past or current suicidality. Externalizing symptoms (median [range], 1 [0-29] symptom count) were associated with suicidality (for a change of 1 SD in symptoms, odds ratio [OR], 1.34; 95% CI, 1.26-1.42; P < .001), as was ADHD medication treatment (OR, 1.32; 95% CI, 1.06-1.64; P = .01). ADHD medication use was associated with less suicidality in children with more externalizing symptoms (significant symptom-by-medication interaction, B = -0.250; SE = 0.086; P = .004), such that for children who were not receiving ADHD medications, there was an association between more externalizing symptoms and suicidality (for a change of 1 SD in symptoms, OR, 1.42; 95% CI, 1.33-1.52; P < .001); however, for children who were receiving ADHD medication, there was no such association (OR, 1.15; 95% CI, 0.97-1.35; P = .10). The association with medication remained even when covarying for multiple confounders, including risk and protective factors for suicidality in ABCD, and was replicated in 1-year longitudinal follow-up. Sensitivity analyses matching participants with high numbers of externalizing symptoms taking and not taking ADHD medication treatment confirmed its association with less suicidality.

CONCLUSIONS AND RELEVANCE

These findings suggest that ADHD medication treatment is associated with less suicidality in children with substantial externalizing symptoms and may be used to inform childhood suicide prevention strategies.

Age patterns of suicide with different methods for US Whites: APC modelling analysis of the 1999-2017 national data

AIMS

Suicide emerges as a threat to national health of USA with Whites being at extra risk. More information is needed regarding the increased suicide among Whites to improve national suicide prevention strategies. This study aims to characterise the age pattern of suicide among Whites by suicide methods adjusting for time period and birth cohort.

METHODS

Suicide mortality data by age of 15-84 years during 1999-2017 were derived from the Wide-Ranging Online Data for Epidemiological Research, prepared by US Center for Disease Control and Prevention. Mortality data for three common suicide methods, firearms, suffocation and poisoning were analysed using the age-period-cohort (APC) model. Period-cohort adjusted mortality rates by age were estimated based on results from APC modelling.

RESULTS

Period-cohort adjusted rates indicated that the overall age pattern for males contained five phases, including three increasing phases (ages 15-20, 30-50 and 65+), connected by two declining phases (ages 20-30 and 50-65); and the age pattern for females was a parabolic with an increasing phase from 15 years of age up to 50, followed by a declining phase after age 50. Furthermore, the age pattern for different suicide methods differed substantially for males, but did not for females. Among males, suicide by firearms contained two rapid increasing phases, one during adolescence and another in older ages; suicide by suffocation showed a high plateau across an age span from 20 to 55 years; and suicide by poisoning followed a parabolic, increasing by age up to 45 before it declined. Age patterns revealed by the unadjusted crude rates were biased because of significant linear period effect and W-shaped cohort effect.

CONCLUSIONS

This study is the first to quantify the age patterns of suicide by different methods for US Whites using period-cohort adjusted rates. Study findings provide valid evidence supporting precision interventions to reduce the extra suicide mortality among Whites by targeting specific age ranges with different suicide methods.

An Age-Period-Cohort Analysis of Biomarkers of Lifestyle-Related Diseases Using the National Health and Nutrition Survey in Japan, 1973-2018

Studies of biomarkers of lifestyle-related diseases in Japanese cohorts are scarce. This study aimed to analyze trends in risk markers of lifestyle-related diseases using age-period-cohort (APC) analysis. Data on systolic blood pressure and BMI from 1973 to 2018 and serum glucose, triglyceride, and high-density lipoprotein cholesterol levels from 1989 to 2018 available from the National Health and Nutrition Survey were used. Values for each of the risk markers for each age, period, and cohort were estimated using APC analysis. For women, a decrease in all the risk markers of lifestyle-related diseases was observed in individuals born between the 1930s and approximately 1970. Therefore, female individuals born in approximately 1970 were considered to have the lowest risk of developing lifestyle-related and cardiovascular diseases. Meanwhile, the cohort effect on all the risk markers deteriorated for the younger cohorts, and changes in lifestyle behavior are needed for cohorts born more recently. For men, the trends in risk markers across the cohorts differed, and the relative risk of lifestyle-related diseases for each cohort differed according to disease. These results could help understand cohort-specific risks for lifestyle-related disease and enable identification of high-risk populations who could benefit from preventive measures.

Resident Responses to a Wellness Survey and Significant Unreported Distress

Resident well-being is a significant issue affecting our future physicians' abilities to fulfill their potential in training and practice. In the 2017 Council on Resident Education in Obstetrics and Gynecology National Wellness Survey, residents identified many challenges to wellness and had the opportunity to provide free-text responses about these issues. Secondary analysis of these responses revealed clusters of symptoms associated with mood disorders, including high rates of reported anxiety and depression symptoms, and even suicidality. The prevalence of these self-reported symptoms underscores the importance of targeting wellness programming efforts, improving health care work environments, advancing access to care, and destigmatizing mental health concerns for our learners.

Outcomes in 886 Critically Ill Patients After Near-Hanging Injury

BACKGROUND

Near-hanging experiences are life-threatening events about which few data are available.

RESEARCH QUESTION

What are the outcomes and early predictors of hospital mortality in critically ill patients who have undergone a near-hanging experience?

STUDY DESIGN AND METHODS

Adult patients who were resuscitated successfully after suicidal near-hanging injury admitted to 31 university or university-affiliated ICUs in France and Belgium between 1992 and 2014 were studied retrospectively. Patients were identified by searching the hospital databases for International Statistical Classification of Diseases and Related Health Problems, 9th and 10th revisions, codes and hospital charts for hanging. Logistic multivariate regression was performed to identify factors associated vital and functional outcomes at hospital discharge as the primary end points. Secondary outcomes were evaluation of temporal trends and identification of predictors of hospital mortality.

RESULTS

Of the 886 patients (181 women and 705 men; median age, 43 years; interquartile range, 34-52 years), 266 (30.0%) had attempted suicide previously, 600 (67.7%) had a diagnosed mental illness, and 55 (6.2%) attempted hanging while hospitalized. Median time from hanging awareness to unhanging was 0 min (interquartile range [IQR], 0-0; range, 0-82 min). Median Glasgow Coma Scale score was 3 (IQR, 3-5) at ICU admission. Hanging induced cardiac arrest in 450 of 886 patients (50.8%). Overall, 497 of 886 patients (56.1%) were alive at hospital discharge, including 479 of 497 patients (96.4%) with a favorable neurocognitive outcome (defined as a Glasgow Outcome Scale score of 4 or 5). By multivariate analysis, factors associated with hospital mortality were hanging-induced cardiac arrest (OR, 19.50; 95% CI, 7.21-60.90; P < .00001) and findings at ICU admission of glycemia level > 1.4 g/L (OR, 4.34; 95% CI, 1.82-10.81; P = .0007) and of lactate level > 3.5 mmol/L (OR, 9.98; 95% CI, 4.17-25.36; P < .00001).

INTERPRETATION

The findings from this large multicenter retrospective cohort emphasize the very high mortality after hanging injury chiefly because of hanging-induced cardiac arrest. However, patients who survive near-hanging experiences achieve excellent neurocognitive recovery. Studies of early neuroprotective strategies for patients who have undergone near-hanging experiences are warranted.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT04096976; URL: www.clinicaltrials.gov.

Age, period and cohort effects in firearm homicide and suicide in the USA, 1983–2017

Background

Rates of firearm homicide and suicide have varied over time. These variations are due to a number of factors including temporal trends, age, birth year and gender. We sought to conduct an age–period–cohort analysis to understand the intersection of these factors with firearm homicide and suicide.

Methods

We used data on firearm homicide and suicide for the years 1983–2017 from the Centers for Disease Control and Prevention’s Web-based Injury Statistics Query and Reporting System for this analysis. We restricted our analysis on firearm homicide to persons aged 10–44 years and our analysis on firearm suicide to persons aged 50–84 years, as these age groups are most at risk of each outcome. We calculated annual incidence rates for both outcomes per 100 000 population, overall and by gender.

Results

Across all age groups, rates of firearm homicide increased dramatically in the late 1980s and early 1990s. The peak age for firearm homicide varied across cohorts, although it was generally between ages 15 and 29 years. Rates of firearm homicide were substantially higher among men than women, regardless of age, period or cohort. Firearm suicide rates varied significantly by gender. Among men, older cohorts had higher firearm suicide rates, although the rate of firearm suicide increased with age across all cohorts. Among women, firearm suicide rates were also highest among older cohorts; however, firearm suicide rates decreased or remained relatively constant with age.

Conclusion

There are important differences in rates of firearm homicide and suicide with respect to gender, age, period and cohort.

Marijuana legalization and historical trends in marijuana use among US residents aged 12-25: results from the 1979-2016 National Survey on drug use and health

Background

Marijuana is the most commonly used illicit drug in the United States. More and more states legalized medical and recreational marijuana use. Adolescents and emerging adults are at high risk for marijuana use. This ecological study aims to examine historical trends in marijuana use among youth along with marijuana legalization.

Method

Data (n = 749,152) were from the 31-wave National Survey on Drug Use and Health (NSDUH), 1979–2016. Current marijuana use, if use marijuana in the past 30 days, was used as outcome variable. Age was measured as the chronological age self-reported by the participants, period was the year when the survey was conducted, and cohort was estimated as period subtracted age. Rate of current marijuana use was decomposed into independent age, period and cohort effects using the hierarchical age-period-cohort (HAPC) model.

Results

After controlling for age, cohort and other covariates, the estimated period effect indicated declines in marijuana use in 1979–1992 and 2001–2006, and increases in 1992–2001 and 2006–2016. The period effect was positively and significantly associated with the proportion of people covered by Medical Marijuana Laws (MML) (correlation coefficients: 0.89 for total sample, 0.81 for males and 0.93 for females, all three p values < 0.01), but was not significantly associated with the Recreational Marijuana Laws (RML). The estimated cohort effect showed a historical decline in marijuana use in those who were born in 1954–1972, a sudden increase in 1972–1984, followed by a decline in 1984–2003.

Conclusion

The model derived trends in marijuana use were coincident with the laws and regulations on marijuana and other drugs in the United States since the 1950s. With more states legalizing marijuana use in the United States, emphasizing responsible use would be essential to protect youth from using marijuana.