A Cycle of Exclusion That Impedes Suicide Research among Racial and Ethnic Minority Youth

Abstract

In the U.S., suicide risk for Black, Indigenous, and People of Color (BIPOC) is most concentrated before age 30, which contrasts with non-Hispanic White groups, for whom the highest risk period is during ages 50–65. The need for a better understanding of the underlying causes of suicidal behavior among BIPOC youth is critical. Cultural considerations were recommended over a decade ago to advance the study of youth suicide prevention and research. Without addressing the barriers to implementing these recommendations in limited-resourced settings, however, the mental health needs of BIPOC youth at risk for suicide will continue to go unmet. In this commentary, we outline structural barriers in research that perpetuate a cycle of exclusion wherein an understudied, though timely, research area faces undue burdens across the research cycle, which impedes the study of suicide risk among BIPOC youth.

Although comprehensive national data on suicide deaths following COVID-19 are not yet available, early evidence among adults indicates that the racial disparities observed in health outcomes related to COVID-19 (Centers for Disease Control and Prevention, 2020a) may extend to suicide. Specifically, statewide suicide data in Maryland and Connecticut show an increase in suicide deaths among Black, Indigenous, and People of Color (BIPOC) populations following the COVID-19 pandemic, whereas suicide deaths among White populations decreased during this same period (Bray et al., 2020; Mitchell et al., 2021). These findings are consistent with national surveys conducted within weeks to months of the start of the pandemic reporting higher rates of suicide ideation among BIPOC groups (Czeisler et al., 2020; Fitzpatrick et al., 2020). The racial disparities in health exacerbated by the COVID-19 pandemic were further compounded by greater attention to racialized violence and injustices that disproportionately burden BIPOC communities, raising our collective awareness of the insidious effects of structural racism. This has prompted a re-examination of the standards and practices across many health fields, including within suicide research and prevention.

In the U.S., suicide risk for BIPOC groups is most concentrated before age 30, with the highest rates among Native American youth, which stands in contrast to suicides among non-Hispanic White individuals, for whom the highest rate is among individuals ages 50-65 (Centers for Disease Control and Prevention, 2020b). Historically, suicide deaths in Black youth populations were low, though potential biases in the misclassification of deaths may be a contributing factor (Ali et al., in press). Recent data, however, suggest suicide rates among Black children ages 5-12 years old are double the rate of White children of the same age (Bridge et al., 2018). Similarly, an examination of trends from the Youth Risk Behavior Survey between 1991 and 2017 suggest increases in suicide attempt rates among Black adolescents over time (Lindsey et al., 2019). Such trends have garnered attention from the largest funding organizations of suicide research – the National Institute of Mental Health and the American Foundation for Suicide Prevention, prompting new priorities that center suicide risk in BlPOC youth and limited-resourced settings. The need for a better understanding of the underlying causes of racial and ethnic disparities in suicide-related risk, particularly in youth, remains critical.

Calls for greater cultural considerations in the study and prevention of youth suicide were made over a decade ago (Goldston et al., 2008; Joe, et al., 2008). Among the recommendations offered were a greater need for consideration of the sociocultural context of youth suicide using phenomenological and other research designs more amenable to community-based approaches, as well as population-level research. In this commentary, we outline several barriers that have impeded the realization of these recommendations. These include barriers related to sampling, lack of available resources, undervalued research designs, and limited publication opportunities, all of which interact to perpetuate a cycle of exclusion wherein an understudied, though timely, research area faces undue burdens across the research cycle. Without addressing these barriers, the mental health needs of BIPOC youth at risk for suicide will continue to go unmet.

Racial and ethnic minority groups, particularly youth, have been largely underrepresented in suicide research (Cha et al., 2018). This problem is not unique to the study of suicide, as it pervades many areas of psychology (Rad et al., 2018). The lack of diversity in samples suggests a larger problem, overall – the current hegemonic state in clinical research and practices, with a constrained definition of what are recognized as scientifically rigorous and valid research approaches and topics (Buchanan & Wiklund, 2020). Further, research in psychology areas where BIPOC youth are more represented (e.g., social psychology, developmental psychology; Roberts et al., 2020) often don’t examine clinical phenomena like suicide risk, creating another missed opportunity.

Researchers working with BIPOC youth face numerous barriers, including mistrust of health professionals and stigma toward mental health and research (Fisher et al., 2002). BIPOC youth at risk for suicide are also less likely to seek mental health services compared to their White peers (King et al., 2019). This is problematic, given that clinical samples of convenience are a significant source of study participants in youth suicide research. Community-based approaches, though fraught with their own challenges, may help address this barrier. Such approaches may include recruitment of participants from minority serving institutions, many of which are public institutions in urban areas (e.g., public hospitals, commuter colleges), with greater representation of BIPOC youth in their populations. However, these settings, which are more likely to hire BIPOC faculty and support work with BIPOC communities, may not have the additional research supports often found in highly-resourced institutions. This makes them less competitive, in the current state of clinical science, to produce research that is deemed scientifically rigorous, compared to highly-resourced institutions. Zayas and colleagues (2009) additionally described various structural barriers they encountered in their community-based approach to studying suicidal behaviors in Latina adolescents. These included difficulties engaging community stake-holders and mental health providers (despite expressed enthusiasm and optimism), overworked and underpaid staff, participant barriers (e.g., commuting and childcare costs), and mistrust toward government agencies and medical systems. A community-based participatory research approach, where community members were trained as interviewers and received supplemental salaries, helped address many of these barriers (Zayas et al., 2009).

Consideration of the aforementioned barriers related to sampling leads us to our next point: studies deemed more scientifically rigorous often involve experimental and/or longitudinal designs. Such research approaches require significant resources (e.g., infrastructure, equipment, labor) that are less available in limited-resourced institutions. Fewer resources are thus available to investigators with greater access to underrepresented populations (e.g., immigrant, low SES, BIPOC youth), who are more often studying topics that are particularly relevant to underrepresented groups (e.g., racial and ethnic discrimination). This is more likely to yield research that is undervalued and deemed lower quality or that is not considered generalizable beyond the targeted groups, which leads the research to be published in lower impact, specialty journals (Roberts et al., 2020) or not published at all. The inability to widely disseminate research findings may result in grant applications that are less competitive and serves as an added barrier to acquire the funding necessary to carry out the type of research that would be more highly valued and impactful. Thus, not only does research with BIPOC youth at risk for suicidal behaviors require additional effort on the part of investigators, the absence of available infrastructure and support to adequately carry out their work leads to difficulties disseminating their work in a way that would allow them to obtain needed resources to conduct the type of research deemed more rigorous by their peers who do not work with BIPOC youth.

Even as journal editors advocate for increased rigor in standards for evaluation of research designs (e.g., the requirement that longitudinal studies examining mediation include at least 3 time points; see De Los Reyes, 2017), such methodological requirements, while laudable in a level playing field, may disadvantage researchers who work with BIPOC communities, given that these designs require substantial resources to attain. In contrast, methodological requirements related to sampling – such as requirements for racial and ethnic diversity in sampling – which might disadvantage researchers who work with predominantly-White communities, have not been similarly implemented. As a result, two things occur in tandem. First, suicide researchers with greater access to and expertise in studying BIPOC communities are unable to meet the methodological requirements of journals where their findings would be more widely disseminated and that would help them secure additional resources to advance theories and research with these communities. Second, predominant suicide theories and research that exclude BIPOC communities are generalized to BIPOC populations and even used as the starting point for adaptation of models and interventions to BIPOC individuals, potentially not adequately meeting the mental health needs of BIPOC youth.

At this point, a cycle of exclusion in research becomes more evident, wherein a lack of resources constrains the type of research that is feasible (and often evaluated as inferior) within limited-resourced settings. This cycle disproportionately impacts certain groups studying topics particularly relevant to underrepresented groups, to produce less competitive grant applications to obtain the necessary funding to advance their research area. Indeed, findings from the National Institutes of Health suggest that research topics and more community- or population-based approaches explained, in part, the lower rates of R01 grants awarded to Black/African American scientists compared to their White counterparts (Hoppe et al., 2019). This becomes more concerning when considering the diversity-innovation paradox (Hofstra et al., 2020). Specifically, researchers used text analysis and machine learning to examine innovation, or scientific novelty, in dissertations or theses from 1977-2015 from over 1 million doctoral-degree holders in the U.S. They found that members of groups underrepresented in the sciences – i.e., women and BIPOC – innovated at a greater level than men and White individuals, respectively, but were less likely to attain faculty positions or sustain a research career. Despite career development initiatives (e.g., F and K awards), structural barriers in these early career stages for women and BIPOC scholars result in the loss of critical knowledge and skills to advance science.

With this commentary, we hope that the gatekeepers of scientific knowledge about youth suicide risk, including grant reviewers and journal editors, broaden their views of scientific merit to further advance the timely and understudied research area of suicide risk among BIPOC youth. To be clear, we are not advocating that lower methodological standards be applied to research with BIPOC youth. Just as early advances in suicide research began by examining the available evidence, drawing initial conclusions from studies with European or European-American samples using methods that were better designed to inform the state of knowledge at that time and to guide future research, advances in suicide research with BIPOC youth can also build upon the available evidence using designs and methods that are feasible within limited-resourced settings.

It is increasingly evident that current youth suicide research and practices continue to overlook the mental health needs of BIPOC individuals. Attaining the highest standards and best practices in youth suicide research will require attending to issues of diversity, equity, and inclusion (Buchanan & Wiklund, 2020). Such efforts would further inform suicide risk in other marginalized populations that are also at elevated risk for suicidal behaviors (e.g., LGBTQ, Military), as well as majority populations. It behooves us all to better understand the underlying causes of the well-documented racial and ethnic disparities in youth suicide-related risk. Simply applying established theories and research practices to a different population does not sufficiently address these structural barriers. Changes at every level of the scientific process and research cycle are necessary for systemic change to occur.