Professor Deborah Winders Davis from the University of Louisville School of Medicine discusses the prevalence, risk factors, and stigma associated with youth mental health and suicide, emphasizing the importance of raising awareness and developing intervention strategies to tackle the critical issues facing young people
Suicide rates for youth and young adults ages 10-24 years in the United States increased 52.2% from 2000 to 2021.(1) However, youth suicide does not just occur in high-income countries. In fact, 73% of suicides worldwide occur in low- and middle-income countries, representing the third highest cause of death in this age group.(2) In addition to deaths, a significant number of children are treated for self-harm, which is a risk factor for subsequent suicide.(2)
In the US, the rate of emergency department visits for self-harm for this age group is almost twice that of adults ages 35-64 years.(1) The World Health Organization has reported that data on suicides and suicide behaviors are lacking in quality.(2-5) Although poor data quality is not unique to suicide, there is more concern for the under-reporting of suicide and suicide behaviors due to the sensitive nature of the act, including stigma associations and legal concerns.(2) Lastly, in 2021, three major pediatric professional organizations in the US jointly released a statement declaring a state of emergency for child and adolescent mental health.(6)
Risk factors
Risk factors for self-harm events, including suicide, are multifaceted.(5, 7-11) These factors include more proximal factors related to the individual, their immediate family and friends, and social environments, as well as more distal factors such as the geographical area in which they live.(5, 8) Geography may play a role in access to mental health treatment, access to firearms, and social norms that may increase the stigma associated with mental health problems such as anxiety and depression.(2-5)
One important risk factor is child maltreatment.(9, 12) Angelakis and colleagues (2020) reported that children who had experienced child abuse or neglect were almost three times more likely to attempt suicide and 2.36 times more likely to experience suicidal ideation than their contemporaries who did not experience maltreatment.(12)
Another risk factor for mental health problems is exposure to bullying.(13, 14) It has been reported that 20-40% of children and youth have experienced bullying.(15) Rates vary by participant demographics and data sources.(15) Bullying has been shown to be associated with severe psychological, emotional, and academic consequences for victims.(16-17) Arango et al.(18) examined characteristics of bullying involvement and social connectedness in relation to suicide ideation and attempts in a sample of youth who reported bully victimization, bully perpetration, and/or low social connectedness. Their results indicated that higher levels of bully victimization, for both in-person and electronic bullying, were significantly associated with increased rates of suicide ideation and attempts.(18) Kim and Leventhal’s systematic review of 37 studies on children and adolescents found that any involvement in bullying increased the risk of suicide ideation and behaviors.(19)
In a more recent study that replicated and extended findings from Sibold and colleagues that used 2013 data,(20) Kerns et al.(14) found the prevalence of youth feeling sad increased from 30% in 2013 to 37.1% in 2017-2021, and attempted suicide rose from 8.2% to 8.9%. Additionally, Kerns et al. found that 62.1% of the bullied students reported feeling sad compared to 51.3% in 2013, and 19.8% reported attempted suicide compared to 18.3% in 2013.(14)
Stigma about mental health problems
Stigma is a particular problem when working with pediatric populations. While adults themselves may have concerns about stigma that may interfere with their own help-seeking behavior,(21-22) when their child has a mental health problem, they are concerned for the stigma aimed at their child, but they are also concerned that they will be blamed for their child’s mental health problems.(3, 23, 24) Stigma has also been shown to interfere with help-seeking behaviors for racial/ethnic minoritized groups. 22, 25, 26)
Media portrayal of suicidal behaviors and mental health problems
In several high-income countries, media portrayal of youth suicide has been shown to be related to suicides, suicidal behaviors, and depressive symptoms.(27-31) However, others have suggested caution,(32, 33) while still others have suggested that the media could serve as a positive influence on help-seeking.(34)
While more research is needed to better understand these differences in findings and nuances in influences on youth behavior and symptoms, caution is warranted in how various media platforms present information that could have a negative influence on youth, especially those who are most at risk.
Prevention
In a recent comprehensive review of factors associated with suicidal thoughts and behaviors in children who were maltreated, Duprey and colleagues propose a complex model that has implications for practice and research.(9) They suggest that there are large gaps in knowledge related to mechanisms, moderators, and mediators that would inform future directions. Their theoretical framework is based on developmental systems theories in which the child’s developmental outcomes are dependent upon dynamic interactions between the child and their environment.(9) Such theories recognize the bidirectional transactions that occur between a child and its proximal and distal environmental influences.(35-38) Duprey and colleagues suggest that the developmental psychopathology framework, systems theories, and suicidology theory together informed their theoretical framework. Although they were only examining suicidal thoughts and behaviors in youth who were mistreated as children, their model may have a larger applicability. Although beyond the scope of this paper to review in depth, their model is a reminder that mental health problems in children, especially suicidal thoughts and behaviors, must consider broader developmental mechanism that influences child outcomes.
Interventions must be developed based on sound theoretical frameworks. These interventions must be individualized based on such factors as child age, sex, gender identity, race/ ethnicity, co-morbidities, history of maltreatment, and other personal characteristics. Additionally, proximal and distal environmental factors such as parent-child relationships, socioeconomic status, family circumstances, neighborhood characteristics, discrimination, and other environmental influences must be considered.
Lastly, much research is needed to test specific interventions. The research needs to examine the efficacy of the intervention, with special emphasis on who it works for, under what circumstances, at what dose, and for how long. Given the complex nature of associated exposures, including mediators and moderators, a ‘one-size-fits-all’ approach will not be effective nor efficient.
In 2024, the U.S Department of Health and Human Services published a National Strategy for Suicide Prevention, which is a ten-year plan with recommendations for addressing gaps in suicide prevention.(1) The plan suggests that suicide prevention should be embedded within communities at the state, local, tribal, and national levels and within healthcare. Included in the strategies are goals to advance suicide-related surveillance, research, evaluation, and quality improvement by improving data collection quality, timeliness, scope, usefulness, and accessibility.(1) In a recent review article, King and colleagues suggested that continued research is urgently needed to refine and tailor interventions for suicide prevention. Moreover, it is equally important that efforts are made to translate the research findings into policy and practice.(39) Implementation efforts will likely need successful collaborations among researchers, healthcare professionals, policymakers, and others in public and private institutions that serve youth.(39)
