1 table, 2 figures omitted
In 2001, suicide was the third leading cause of death among persons
aged 10-19 years.1 The most common method
of suicide in this age group was by firearm (49%), followed by suffocation
(mostly hanging) (38%) and poisoning (7%).1 During
1992-2001, although the overall suicide rate among persons aged 10-19 years
declined from 6.2 to 4.6 per 100,000 population,1 methods
of suicide changed substantially. To characterize trends in suicide methods
among persons in this age group, CDC analyzed data for persons living in the
United States during 1992-2001. This report summarizes the results of that
analysis, which indicated a substantial decline in suicides by firearm and
an increase in suicides by suffocation in persons aged 10-14 and 15-19 years.
Beginning in 1997, among persons aged 10-14 years, suffocation surpassed firearms
as the most common suicide method. The decline in firearm suicides combined
with the increase in suicides by suffocation suggests that changes have occurred
in suicidal behavior among youths during the preceding decade. Public health
officials should develop intervention strategies that address the challenges
posed by these changes, including programs that integrate monitoring systems,
etiologic research, and comprehensive prevention activities.
Annual data on suicides occurring in the United States during 1992-20012 were obtained by using CDC's Web-based Injury Statistics
Query and Reporting System (WISQARS™)1 and
examined by age group (i.e., persons aged 10-14 and 15-19 years) and method
(e.g., firearm, suffocation, and poisoning) for each year and the 10-year
period. To analyze these data, codes were used from the International Classification of Diseases, Ninth Revision (ICD-9) and
the International Classification of Diseases and Related
Health Problems, Tenth Revision (ICD-10), which was implemented in
1999. Although coding of mortality data changed in 1999, the two revisions
have near 100% agreement on classification of suicides by firearm, suffocation,
and poisoning3; thus, the suicide method
was defined consistently during the period analyzed.
For each method of suicide, annual suicide rates (per 100,000 population)
were calculated by age group and overall. Because firearms and suffocation
were the two most common methods of suicide among persons aged 10-19 years,
accounting for approximately 90% of suicide deaths in this age group, trends
for these two methods (Figures 1 and (2) were formally evaluated by using
negative binomial rate regression to account for overdispersion in the data.
Supplemental information on suicides by poisoning (the third most common method)
and suicide by all other methods (e.g., jumping from a height) is provided
for illustration purposes. Annual ratios of suffocation suicides to firearm
suicides were examined as an additional means of assessing changes in the
relative magnitude of these methods over time (Table).
Among persons aged 10-14 years, the rate of firearm suicide decreased
from 0.9 per 100,000 population in 1992 to 0.4 in 2001, whereas the rate of
suffocation suicide increased from 0.5 in 1992 to 0.8 in 2001. Rate regression
analyses indicated that, during the study period, firearm suicide rates decreased
an average of approximately 8.8% annually (p<0.0001), and suffocation suicide
rates increased approximately 5.1% annually (p<0.0001). Among persons aged
15-19 years, the firearm suicide rate declined from 7.3 in 1992 to 4.1 in
2001; the suffocation suicide rate increased from 1.9 to 2.7. Rate regression
analyses indicated that, during the study period, the average annual decrease
in firearm suicide rates for this age group was approximately 6.8% (p<0.0001),
and the average annual increase in suffocation suicide rates was approximately
3.7% (p<0.0001). Poisoning suicide rates also decreased in both age groups,
at an average annual rate of 13.4% among persons aged 10-14 years (Figure
(1) and 8.0% among persons aged 15-19 years (Figure 2). Because of the small
number of suicides by poisoning, these decreases have had minimal impact on
changes in the overall profile of suicide methods of youths.
Among persons aged 10-14 years, suffocation suicides began occurring
with increasing frequency relative to firearm suicides in the early- to mid-1990s,
eclipsing (i.e., ratio >1.0) firearm suicides by the late 1990s (Table).
In 2001, a total of 1.8 suffocation suicides occurred for every firearm suicide
among youths aged 10-14 years. Among youths aged 15-19 years, an increase
in the frequency of suffocation suicides relative to firearm suicides began
in the mid-1990s; however, in 2001, firearms remained the most common method
of suicide in this age group, with a ratio of 0.7 suffocation suicides for
every firearm suicide.
KM Lubell, PhD, MH Swahn, PhD, AE Crosby, MD, Div of Violence Prevention;
SR Kegler, PhD, Office of Statistics and Programming, National Center for
Injury Prevention and Control, CDC.
The findings in this report indicate that the overall suicide rate for
persons aged 10-19 years in the United States declined during 1992-2001 and
that substantial changes occurred in the types of suicide methods used among
those persons aged 10-14 and 15-19 years. Rates of suicide using firearms
and poisoning decreased, whereas suicides by suffocation increased. By the
end of the period, suffocation had surpassed firearms to become the most common
method of suicide death among persons aged 10-14 years.
The reasons for the changes in suicide methods are not fully understood.
Increases in suffocation suicides and concomitant decreases in firearm suicides
suggest that persons aged 10-19 years are choosing different kinds of suicide
methods than in the past. Data regarding how persons choose among various
methods of suicide suggest that some persons without ready access to highly
lethal methods might choose not to engage in a suicidal act or, if they do
engage in suicidal behavior, are more likely to survive their injuries.4 However, certain subsets of suicidal persons might
substitute other methods.5 Substitution
of methods depends on both the availability of alternatives and their acceptability.
Because the means for suffocation (e.g., hanging) are widely available, the
escalating use of suffocation as a method of suicide among persons aged 10-19
years implies that the acceptability of suicide by suffocation has increased
substantially in this age group.
The findings in this report are subject to at least two limitations.
First, because U.S. mortality data include a limited number of variables,
direct testing of whether method substitution is occurring is not possible;
however, no sizeable demographic changes in the composition of youth suicide
decedents have been documented that might explain the changes in methods.1 Second, official mortality data for suicide are
known to reflect some degree of undercount; however, such undercounts do not
appear to affect conclusions about trends over time.6
The findings in this report demonstrate that rapid shifts in youth suicidal
behavior can occur, underscoring the need for early effective suicide-prevention
efforts that focus on suicidal thoughts and pressures. Moreover, statistical
simulations comparing the impacts of different types of suicide-prevention
approaches suggest that widely implemented population-based strategies will
have a greater effect in reducing overall suicide rates than the more traditional
strategies that concentrate on persons at high risk.7 One
of the most common population-based strategies focuses on restricting access
to highly lethal means (e.g., bridge barriers and bubble-packaging for over-the-counter
medications) to diminish the likelihood of death from self-inflicted injuries.8 However, the private nature of suffocation, its
widespread availability, and its high lethality suggest that population-based
prevention efforts addressing access to lethal means also must confront the
underlying reasons for suicidality to avoid the potential for method substitution.
Suicide is a multifaceted problem for which several risk factors exist,
including societal beliefs regarding the acceptability of suicidal behavior,
social isolation and community disintegration, stressful life events, mental
illness, and substance abuse.9 When such
factors combine with widespread availability of lethal means, higher rates
of suicide tend to result.8 The actual effectiveness
of existing population-based prevention approaches in reducing the number
of suicide deaths is unclear. In addition to improving data-collection methods,
public health officials should emphasize the need to evaluate the effectiveness
of current suicide-prevention activities and examine how effective strategies
can be implemented in diverse communities. CDC supports various efforts to
evaluate suicide-prevention programs for youth. Additional information is
available at http://www.cdc.gov/ncipc.
The findings in this report are based in part on contributions by JL
Annest, PhD, Office of Statistics and Programming, National Center for Injury
Prevention and Control, CDC.
Methods of Suicide Among Persons Aged 10-19 Years—United States, 1992-2001. JAMA. 2004;292(4):427-428. doi:10.1001/jama.292.4.427