Trends in Adolescent Suicide by Method in the US, 1999-2020

Key Points Question How did US adolescent suicide rates change over time by method (firearm, poisoning, hanging and asphyxiation, and all other means) from 1999 to 2020 by age, sex, and race and ethnicity? Findings In this cross-sectional study of 47 217 adolescent suicide decedents, suicide by firearm, poisoning, hanging and asphyxiation, and all other means increased from 1999 to 2020. Differences were noted by age, sex, and race and ethnicity in suicide method patterns. Meaning Adolescent suicide is an increasing problem, and implementing effective, tailored prevention strategies is increasingly necessary.


Introduction
Suicide remains one of the leading causes of death among adolescents in the US.3][4][5][6] Although older and male adolescents have historically had higher suicide rates than younger and female adolescents, respectively, 7,8 recent evidence suggests these gaps may be closing as suicide rates are increasing more rapidly for female adolescents than male adolescents. 9,102][13] Race and ethnicity are social constructs; hence, racial and ethnic differences in health may be driven by social determinants, environment, and systems of oppression and marginalization that produce disparities in health and longevity. 14storically, firearms have been the leading means of adolescent suicide mortality; however, asphyxiation is becoming increasingly common. 9,15,16Other common methods of suicide include poisoning and jumping, and methods may vary by demographic characteristics.For instance, among racial and ethnic minoritized male youths, firearms are becoming an increasingly common method of suicide. 8search on temporal trends of the methods of suicide among adolescents remains poorly understood-particularly by age, sex, and race and ethnicity-despite evidence of suicide becoming a burgeoning public health problem and the method of suicide being significantly associated with mortality. 8,13Therefore, elucidation of national trends in adolescent suicide methods by demographic characteristics is urgently needed.This study aimed to comprehensively describe trends in suicide methods (poisoning, firearm, hanging and asphyxiation, and all other means) in the US from 1999 to 2020 among adolescents by sex, age, and race and ethnicity.Findings will highlight disparities in suicide methods and priorities for targeted intervention.

Methods
Information about demographic characteristics and underlying causes of death were obtained from death certificate data compiled by the National Center for Health Statistics from January 1, 1999, to December 31, 2020.Because this cross-sectional study focused on adolescents, we restricted the study to individuals aged 10 to 19 years as defined by the World Health Organization. 17We categorized suicide methods into 4 means: firearm; poisoning; hanging, strangulation, or suffocation (hereafter, hanging and asphyxiation); and all other means (not involving firearm, poisoning, and hanging and asphyxiation [approximately 6.5%]) based on International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes (eTable 1 in Supplement 1).
Because the leading means of suicide death during the 1999 to 2020 period for poisoning was drug poisoning (78.7%) and the most frequent method in all other means was jumping (34.1%), we further examined suicide deaths due to these specific means.We stratified population estimates of each means of suicide deaths by year, age, sex, and race and ethnicity.Race and ethnicity were categorized using death certificate data as Hispanic or Latino, non-Hispanic American Indian and Alaska Native, non-Hispanic Asian and Pacific Islander, non-Hispanic Black, and non-Hispanic White.Death rates among American Indian and Alaska Native individuals were restricted to Indian Health Service Purchased/Referred Care Delivery Areas to increase the sensitivity of American Indian and Alaska Native race determination on death certificates.The National Institutes of Health Institutional Review Board waived approval and informed consent because the study used publicly available,

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Trends in Adolescent Suicide by Method in the US, 1999-2020 deidentified data.This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. 18

Statistical Analysis
We calculated age-standardized mortality rates by age group (10-14 and 15-19 years), race and ethnicity, sex, and type of suicide means of death (method) using SEER*Stat software, version 8.4.1 (National Cancer Institute).All rates were age standardized to the US population in 2000 and presented as per 100 000 person-years.We used the Joinpoint Regression Program to calculate the average annual percent change (AAPC) in mortality rates, representing the summary measure from 1999 to 2020, stratified by sex, race and ethnicity, and suicide means of death.Using Joinpoint regression, we also calculated annual percent changes (APCs).In this analysis, we identified calendar years with significant changes in trajectories and calculated the slope in each segment.We used the parametric method to calculate 95% CIs for the trend.P values were calculated using the permutation distribution of the test statistic (P < .05 was considered statistically significant with a 2-sided test).Data analysis was performed from April 1, 2023, to July 9, 2023.

Results
From 1999 to 2020, 47 217 adolescent suicide deaths were recorded in the US.Firearms (2.2 per 100 000 population) and hanging and asphyxiation (2.2 per 100 000 population) accounted for the highest age-adjusted suicide rates among the total study population (eTable 2 in Supplement 1).On average, death rates for all suicide means increased annually from 1999 to 2020 (Figure 1).Hanging and asphyxiation had the largest absolute increase among male (+1.2 per 100 000 population) and female (+1.3 per 100 000 population) adolescents.

Discussion
In this nationwide analysis of death certificates, we identified increasing rates of suicide deaths by method, sex, age, and race and ethnicity among US adolescents.Despite variations in suicide rates by method, an overall increasing trend was observed across all demographics.For both female and male adolescents, hanging and asphyxiation suicide rates had the largest absolute increase during the study period.However, the highest average annual increases for poisoning and hanging and asphyxiation suicide rates were observed among female adolescents.These findings highlight the importance of considering sex, age, and race and ethnicity in understanding suicide mortality trends and methods among adolescents.
On average, suicide by firearm increased between 1999 and 2020 and was a leading method.
0][31][32][33] Additionally, unsafe gun-storing practices persist as a significant nationwide problem and can prove fatal.[35][36] Consistent with prior research, 21,37,38 American Indian and Alaska Native youth had the highest suicide mortality rates due to firearms from 1999 to 2020.0][41][42] Additionally, the recent, rapidly accelerating rates of firearm suicide among Black, Hispanic or Latino, and American Indian and Alaska Native adolescents are concerning.These findings, which align with previous studies, underscore an increasing suicide epidemic among racial and ethnic minoritized youths 8,12,21 and may be influenced by various determinants.4][45][46][47] In addition, adolescent firearm suicides are more common in neighborhoods with higher concentrations of people living at or below the federal poverty line, which are disproportionately composed of American Indian and Alaska Native, Black, and Hispanic or Latino communities. 48nsequently, there is an urgent need to improve access to mental health services and address socioeconomic inequity among the aforementioned communities.It is imperative to address the discrimination, anti-Black violence, and race-based traumatic stress that are increasingly implicated in increasing suicide rates among racial and ethnic minoritized youth [49][50][51][52][53] -particularly Black youth.

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Concordant with existing literature, [54][55][56] mortality rates for poisoning rapidly accelerated between 2011 and 2020 in the current study, especially among female adolescents.Adolescents attempting suicide by poisoning typically choose easily accessed and less lethal drugs. 57The ominous change in poisoning deaths may suggest adolescents are finding more lethal means of poisonings, contributing to an increase in deaths by suicide.Differences observed between female and male youths may be due to female adolescents' higher likelihood to attempt and die by suicide poisoning. 19,58][10] Although the explanation for this trend is unclear, some have pointed to the proliferation of social media use and access to online resources for lethal self-harm, as well as to easier access to means for hanging and asphyxiation among adolescents. 10,55,59,60Historically, male adolescents had higher rates of asphyxiation suicide mortality compared with their female peers. 58However, previous studies, as well as the current study, observed that rates of asphyxiation suicide among female adolescents are accelerating rapidly, indicating that suicide attempts among female youth may be shifting toward more lethal means. 8,10,28This finding is concerning given female adolescents' higher likelihood of having a suicide plan and their greater rates of suicide ideation and attempts. 58Recent upward trends among female youth may be attributable to the increasing influence of social media and its harmful effects on the mental health of female adolescents. 61 observed a sharp increase in hanging and asphyxiation suicide deaths among Asian and in follow-up care for youth assessed as at risk for suicide, and cultural stigma toward mental health problems as potential contributors to increasing Asian and Pacific Islander youth suicide rates. 63,64e increasing adolescent suicide epidemic requires a multifaceted and demographic-specific approach.Solutions must incorporate policy changes and public health initiatives as well as a recognition of the profound and lasting impact of structural racism, systemic inequities, and social determinants of health on suicide.Improving screening and early identification of suicide risk and treatment is paramount; this can be facilitated in primary care visits, through school-based suicide prevention programs, and with awareness campaigns. 55These improvements are especially crucial for Black youths, as implicit biases in clinical spaces leading to under-recognition, misdiagnosis, and undertreatment of mental health conditions have been cited as barriers to suicide prevention efforts. 65,66For example, Black youth are often mislabeled as having behavioral problems rather than requiring mental health services, which can lead to failures in identifying suicide risk and providing adequate care. 65rsistent high rates of firearm suicide among American Indian and Alaska Native adolescents and increasing rates among racial and ethnic minoritized adolescents require urgent attention as firearms and gun culture in the US continue to cause disproportionate harm. 679][70] However, the effects of stricter gun laws are neither equitable nor equal, with the beneficial impact of gun laws on adolescent firearm deaths attenuating as community social vulnerability increases. 71This outcome is likely to disproportionately affect racial and ethnic minoritized youths. 71Subsequently, focusing on upstream factors to ameliorate structural and neighborhood-level barriers to health (eg, socioeconomic deprivation, residential segregation, systemic racism, underfunded health care systems, and federal infrastructure negligence) is necessary. 71Additionally, improving the identification of children at risk of suicide and ensuring parents of at-risk youth are counseled on gun safety and safe storage practices may reduce youth firearm suicide. 32For American Indian and Alaska Native youth, interventions that use a protective factor framework, which emphasizes cultural continuity and leverages the strengths of American Indian and Alaska Native communities, hold potential in reducing adolescent suicide. 72Restriction strategies to reduce poisoning and drug poisoning suicide, such as disposing of surplus medications, maintaining a home lockbox for all prescription medications, and assessing which medicinal combinations are likely lethal, may be effective. 57,73Blister packing opioids and lethal drugs as opposed to storing in bottles has also been suggested to reduce adolescent suicide risk and access to lethal suicide means. 57Given the difficulty of restricting access to lethal means outside institutionalized settings for hanging and asphyxiation suicides, 28 it is crucial to shift our focus toward understanding the underlying reasons for the increase in hanging and asphyxiation suicides, particularly among Asian and Pacific Islander and female youth.By gaining a deeper understanding of the factors that contribute to these trends, we can develop more effective prevention strategies, such as education, screening, and leveraging support systems for at-risk youth.
A strategy that has had promising results among Indigenous (First Nations) youth in Canada suggests that engaging youth in social justice initiatives (advocacy, protest, and empowerment) along with cultural affirmation markedly reduced suicide risks among adolescents. 74At the time of the study, First Nations youth in Canada had one of the highest rates of youth suicide in the world.In this seminal study, Chandler and Lalonde 74 examined youth suicide rates in 196 First Nation communities between 1987 and 1992 and observed that more than half had no youth suicides in the prior 5 years.They identified 5 markers of advocacy, protest, and empowerment (challenging the federal government of Canada over titles to land, the right of self-governance, control over education, access to health care, and police and fire services) and 1 marker of cultural affirmation (establishing buildings where youth participated in cultural activities).They observed that each of

Figure 1 .
Figure 1.Trends in Age-Standardized Suicide Mortality Rates Among Adolescents by Method, United States, 1999-2020

Figure 2 .
Figure 2. Trends in Age-Standardized Suicide Mortality Rates Among Adolescents by Method and Age Group, United States, 1999-2020