1 table omitted
Violence is a major cause of morbidity and mortality, particularly among
youths. In the United States, homicide and suicide are the second and third
leading causes of death, respectively, for persons aged 13-19 years.1 Although suicide commonly is associated with anxiety,
depression, and social withdrawal, research suggests a link between violent
behaviors directed at oneself (i.e., suicidal behaviors) and violent behaviors
directed at others among adolescents.2- 6 Certain
students who engage in extreme forms of violence, such as school shootings,
exhibit suicidal ideation or behavior before or during the attack.2,3 However, suicidal behavior also
might be associated with involvement in less extreme forms of violent behaviors,
such as physical fighting, which might be a risk factor for more severe forms
of violence.3 To characterize any potential
association between suicide attempts and fighting, CDC analyzed self-reported
2001 data from a nationally representative sample of high school students
in the United States. The results of that analysis indicated that students
who reported attempting suicide during the preceding 12 months were nearly
four times more likely also to have reported fighting than those who reported
not attempting suicide. Prevention programs that seek to reduce both suicidal
and violent behaviors are needed. Because prevalence of this association was
determined to be highest in the 9th grade, these efforts might be most effective
if implemented before students reach high school.
Analyses were based on data from 11,815 (out of 13,601) nationally representative
high school students in grades 9-12 who participated in the 2001 Youth Risk
Behavior Survey (YRBS) and responded to questions about whether they had attempted
suicide and whether they had participated in physical fighting in the preceding
12 months.7 Participation in YRBS was voluntary,
anonymous, and required parental permission. Students completed a self-administered
booklet consisting of 95 items and recorded responses directly on a computer-scannable
answer sheet. The data were weighted to be representative of students in grades
9-12 in public and private schools in the United States.
The prevalence of reporting a suicide attempt among all students was
8.9% and the prevalence of involvement in any physical fight was 33.2%. Overall,
5.3% of the students reported both attempting suicide and participating in
a fight (females, 6.0%; males, 4.5%). Logistic regression analyses were used
to test whether the prevalence of fighting differed by suicide attempt status
within each demographic population. Students who reported attempting suicide
were more likely to have been in a physical fight than students who reported
not attempting suicide (61.5% versus 30.3%). Results from the stratified models
indicated an association between attempting suicide and fighting for each
demographic population (Table). Higher proportions of both male and female
suicide attempters (77.8% and 54.0%, respectively) reported fighting than
males and females who had not attempted suicide (41.2% and 19.8%, respectively).
Among those who reported attempting suicide, the proportion who reported fighting
was highest among 9th graders (64.5%) and decreased with each subsequent grade.
MH Swahn, PhD, KM Lubell, PhD, TR Simon, PhD, Div of Violence Prevention,
National Center for Injury Prevention and Control, CDC.
The findings of this analysis indicate that one in 20 high school students
reported both suicide attempts and participation in physical fighting in the
preceding year. Moreover, the majority (61.5%) of those students who attempted
suicide also reported physical fighting, compared with less than one third
(30.3%) of those who had not attempted suicide. This analysis extends earlier
study2- 6 of
the link between suicidal behavior and interpersonal violence by documenting
the strength of the association across demographic populations. The findings
indicate that suicide attempt status was associated with involvement in physical
fighting for both males and females; students in grades 9-12; four racial/ethnic
populations; and youths living in urban, suburban, and rural areas.
The observed association between suicide attempts and fighting across
demographic populations suggests that violence prevention programs directed
at reducing both suicide and fighting are likely to be relevant for youths.
However, the mechanisms linking suicidal behavior and interpersonal violence
are unclear; these results do not permit an assessment of the extent to which
suicidal and fighting behaviors are directly associated or the direction of
the association. The two behaviors might be linked because they share common
risk factors. Aggressiveness, impulsivity, substance abuse, depression, and
hopelessness can increase the risk for both suicidal and violent behaviors.8,9 Additional research is needed
to examine these and other factors to better determine the underlying mechanisms
that link suicidal and violent behaviors as well as the overlap between multiple
types of violent behavior.
The findings in this report are subject to at least three limitations.
First, all participants were high school students and do not reflect the experiences
of youths who have dropped out of school. Second, suicide attempts and fights
were self-reported and therefore subject to reporting bias. Finally, the data
do not permit either an assessment of the temporal ordering between suicide
attempts and physical fights or a determination of whether the two behaviors
occurred within a narrower period during the preceding 12 months.
Prevention strategies to reduce both suicide attempts and fighting might
be possible and advantageous to design. Strategies determined effective in
reducing youth problem behaviors (e.g., skill and competence-building programs,
positive youth development, and parent training)10 might
reduce underlying risks and provide the skills and support students need to
avoid fighting and suicidal behavior. Additional research is needed to determine
whether strategies that reduce youth risk for interpersonal violence also
can be implemented to prevent suicidal behavior.
Suicide Attempts and Physical Fighting Among High School Students—United States, 2001. JAMA. 2004;292(4):428-430. doi:10.1001/jama.292.4.428