Trends in US Suicide Deaths, 1999 to 2017, in the Context of Suicide Prevention Legislation | Adolescent Medicine | JAMA Pediatrics | JAMA Network
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Figure 1.  Joinpoint Analysis of Changes in Trends of US Suicide Rates of Children and Adolescents Aged 5 to 18 Years, by Sex, United States, 1999-2017
Joinpoint Analysis of Changes in Trends of US Suicide Rates of Children and Adolescents Aged 5 to 18 Years, by Sex, United States, 1999-2017

Figures were prepared with data from the US Centers for Disease Control and Prevention. GLSMA indicates the Garrett Lee Smith Memorial Act.

Figure 2.  Suicide Rates of Children Ages 5 to 18 Years, Stratified by Age Group, United States, 1999-2017
Suicide Rates of Children Ages 5 to 18 Years, Stratified by Age Group, United States, 1999-2017

Figures were prepared with data from the US Centers for Disease Control and Prevention. GLSMA indicates the Garrett Lee Smith Memorial Act.

1.
Burstein  B, Agostino  H, Greenfield  B.  Suicidal attempts and ideation among children and adolescents in US emergency departments, 2007-2015.   JAMA Pediatr. 2019;173(6):598-600. doi:10.1001/jamapediatrics.2019.0464 PubMedGoogle ScholarCrossref
2.
US Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System. https://webappa.cdc.gov/sasweb/ncipc/mortrate.html. Published 2019. Accessed May 20, 2019.
3.
Government of Canada. Tri-Council policy statement: ethical conduct for research involving humans–TCPS 2. https://ethics.gc.ca/eng/policy-politique_tcps2-eptc2_2018.html. Published 2018. Accessed January 21, 2020.
4.
Matsubayashi  T, Ueda  M.  The effect of national suicide prevention programs on suicide rates in 21 OECD nations.   Soc Sci Med. 2011;73(9):1395-1400. doi:10.1016/j.socscimed.2011.08.022 PubMedGoogle ScholarCrossref
5.
Office of the Surgeon General (US); National Action Alliance for Suicide Prevention (US).  2012 National Strategy for Suicide Prevention: Goals and Objectives for Action, A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. Washington, DC: US Department of Health & Human Services; 2012.
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    1 Comment for this article
    EXPAND ALL
    Population HEALTH
    Paul Nelson, M.S., M.D. | Family Health Care, P.C. retired
    Most succinctly, our nation's Population HEALTH is characterized by the worsening events of maternal mortality (for more than 25 years), childhood maltreatment, childhood obesity, adolescent suicide/homicide, teenage pregnancy, substance abuse/mortality, homelessness, mass shootings, mid-life depression/disability, and stagnant longevity at birth (2010-18). As represented above, our nation's healthcare is faced with issues that are likely beyond its direct prevention, mitigation, or amelioration.

    We have all been either directly or indirectly connected with community efforts to mount collaborative efforts to resolve locally identifiable human adversities. The concepts of social cohesion, social capital, and social dilemmas surface repeatedly but without
    a clear and well-defined interconnection with any long-term and broadly supported concept for meaningful change. Admittedly, the entrenched traditions that drive pockets of poverty and "the mindless menace of violence" ( Senator Robert Kennedy 1968) are very complex, generational problems.

    At the same time, our nation's worsening health spending has steadily interfered with our nation's investment in higher education, housing infrastructure, and a resilient safety net for each community. Remember that early childhood education has an ROI (return on investment) of 7:1, disaster mitigation of 4-6:1, and higher education of 3:1. I would add that our nation's health spending problem will not resolve without reducing the daily experience of STRESS by our resident persons afflicted by restricted social mobility and chronic social isolation, community by community. A nationally sanctioned and promoted, locally controlled and implemented strategy will be required. HINT: Look up the Smith-Lever Act passed by Congress in 1914.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    February 17, 2020

    Trends in US Suicide Deaths, 1999 to 2017, in the Context of Suicide Prevention Legislation

    Author Affiliations
    • 1Centre for Research and Intervention on Suicide, Ethical Issues and End of Life Practices, Department of Psychology, Université du Québec à Montréal, Montreal, Quebec, Canada
    • 2Department of Psychology, Université du Québec à Montréal, Montreal, Quebec, Canada
    JAMA Pediatr. 2020;174(5):499-500. doi:10.1001/jamapediatrics.2019.6066

    Burstein et al1 have reported that visits to US hospital emergency departments (EDs) for suicide attempts (SA) or suicide ideation (SI) doubled among youth aged 5 to 18 years between 2007 and 2015. The question remains whether this trend is paralleled by an increase in suicides. The United States has greatly invested in youth suicide prevention during this period. If only ED visits increased but not suicide mortality, this would suggest that prevention activities resulted in more youths seeking help in EDs. However, if suicide had an increase similar to SA/SI, this might suggest that more needs to be done or new approaches need to be undertaken. We examine if suicide rates had increasing trends similar to the increase in SA/SI ED visits.

    Methods

    Using the joinpoint regression, we analyzed age-specific and sex-specific annual suicide rates for youths from 1999 to 2017, using data from the US Centers for Disease Control and Prevention’s Web-based Injury Statistics Query and Reporting System.2 The suicide rates per 100 000 population were coded as X60-X84, Y87.0, or *U03, based on International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. According to the “Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans—TCPS 2” (2018),3 which applies to research conducted in Canada, analyses of national-aggregate, publicly available data with no possibility of identifying individuals do not require ethics board approval or use informed consent procedures, and thus this study did not obtain such approval or consent. We used SPSS version 26.0 (IBM) for analyses, with 2-sided P values less than .05 considered significant. Data analysis occurred from April 2019 to May 2019.

    Results

    From 1999 to 2007, suicide rates for individuals aged 5 to 19 years fell steadily (Figure 1), with an annual percentage change (APC) of −1.98% (95% CI, −3.5% to −0.4%; P = .02). Beginning in 2007, the overall suicide rate increased by an APC of 5.4% (95% CI, 4.2%-6.6%; P < .001). Rates for both male and female individuals started to increase significantly in 2007-2008 (APCs: male youths, 2007-2015, 3.5% [95% CI, 1.9%-5.2%]; P < .001; female youths, 2008-2017, 8.5% [95% CI, 5.7%-11.3%]; P < .001). In 2015, 3 years after the revised National Strategy for Suicide Prevention was released (in 2012), APCs increased further for male youths (APC: 2015-2017, 13.6% [95% CI, 0.8%-28.0%]; P = .04).

    Age-stratified analyses (Figure 2) indicate that the surge in youth suicides between 2007 and 2017 was mostly driven by individuals aged 12 to 15 years (APC: 8.5% [95% CI, 7.0%-9.9%]; P < .001) and 16 to 18 years (APC: 4.7% [95% CI, 3.4%-6.0%]; P < .001). The study by Burstein et al1 reported that nearly half of all SA/SI ED visits were for children aged 5 to 11 years. Our study found a significant increase in this age group in 2012 through 2017 (APC: 14.7% [95% CI, 3.8%-26.7%]; P = .01).

    Discussion

    The deaths of US youths by suicide parallel the increases in ED visits for SA/SI starting in 2007.1 Matsubayashi and Ueda4 suggested that national suicide prevention strategies are most effective among the elderly and youth populations. However, our results did not find a positive outcome on the increasing youth suicide rates. The US National Strategy for Suicide Prevention was implemented in 2001, during a period of steady decreases in suicides. Important legislation on youth suicide prevention, the Garrett Lee Smith Memorial Act, was enacted in 2004,5 a time of declining youth suicide rates. These earlier strategies do not appear to have been sufficient to thwart the rise in youth suicides that started in 2007. The revision of the National Strategy for Suicide Prevention in 2012 was soon followed, in 2015, by an even more dramatic rise in male youth suicide rates.

    It is important to better understand the causes of the increasing US youth suicide rates and why the substantial efforts to reduce suicidal behaviors in US youths have not prevented the significant annual increases in suicide mortality, as well as parallel increases in ED visits for SA/SI. Explanations of the suicide increases are (1) current approaches to youth suicide prevention are ineffective, (2) US suicide prevention strategies have the potential for reducing youth suicides but are not sufficiently implemented to have made a major change in outcome, or (3) despite positive outcomes of current programs, there have been substantial increases in risk factors that are unaffected by current programs, and this has resulted in continued increases in suicidal behaviors despite program benefits. Either current suicide prevention actions need to be increased substantially to reach more vulnerable young people, or current strategies need to be reconsidered to determine how to better prevent youth suicides in the United States.

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    Article Information

    Accepted for Publication: August 21, 2019.

    Corresponding Author: Brian L. Mishara, PhD, Centre for Research and Intervention on Suicide, Ethical Issues and End of Life Practices, Department of Psychology, Université du Québec à Montréal, C.P. 8888, Succ. Centre-ville, Montreal, QC, H3C3P8, Canada (mishara.brian@uqam.ca).

    Published Online: February 17, 2020. doi:10.1001/jamapediatrics.2019.6066

    Author Contributions: Dr Mishara and Mr Stijelja had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Both authors.

    Acquisition, analysis, or interpretation of data: Both authors.

    Drafting of the manuscript: Both authors.

    Critical revision of the manuscript for important intellectual content: Mishara.

    Statistical analysis: Stijelja.

    Supervision: Mishara.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Burstein  B, Agostino  H, Greenfield  B.  Suicidal attempts and ideation among children and adolescents in US emergency departments, 2007-2015.   JAMA Pediatr. 2019;173(6):598-600. doi:10.1001/jamapediatrics.2019.0464 PubMedGoogle ScholarCrossref
    2.
    US Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System. https://webappa.cdc.gov/sasweb/ncipc/mortrate.html. Published 2019. Accessed May 20, 2019.
    3.
    Government of Canada. Tri-Council policy statement: ethical conduct for research involving humans–TCPS 2. https://ethics.gc.ca/eng/policy-politique_tcps2-eptc2_2018.html. Published 2018. Accessed January 21, 2020.
    4.
    Matsubayashi  T, Ueda  M.  The effect of national suicide prevention programs on suicide rates in 21 OECD nations.   Soc Sci Med. 2011;73(9):1395-1400. doi:10.1016/j.socscimed.2011.08.022 PubMedGoogle ScholarCrossref
    5.
    Office of the Surgeon General (US); National Action Alliance for Suicide Prevention (US).  2012 National Strategy for Suicide Prevention: Goals and Objectives for Action, A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. Washington, DC: US Department of Health & Human Services; 2012.
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