What’s Behind the Increased Risk of Suicidal Behavior in Black Girls?

Suicide is the second leading cause of death among youths 10–24 years of age in the United States. According to the Centers for Disease Control latest statistics (1), the overall suicide rates have shown an alarming increase by 37% between 2008 and 2018, which decreased by 5% between 2018 and 2020 and increased again after the pandemic and peaked in 2022. The suicide rates have increased by about 62% in youth aged 10–24 years between 2007 and 2021 and have tripled for those between 10 and 14 years of age between 2007 and 2018 (2). While the suicide rates for males aged 10–14 and 15–24 years have declined between 2020 and 2022, there were no change in suicide rates in females (3). The overall age-adjusted suicide rate showed the highest relative percent change among non-Hispanic American Indian or Alaska Native (AI/AN) (26%), non-Hispanic Black (19.2%), and Hispanic (6.8%) individuals during the 2018–2021 period (4). Among youth aged 10–24 years, suicide rates increased significantly by 36.6% among Black youth during the same period. These statistics highlight the overall suicide problem in the United States and the especially increased suicide rates in youth, female, and Black individuals.

Against this backdrop in suicide rates, Cooper and colleagues (5) highlight the similarly increased risk for suicidal ideation and attempt in Black girls. We thank them for their important contribution presenting results on suicidal ideation and attempt from three adolescent cohorts of 38,380 non-Hispanic Black and non- Hispanic White youth including: 1) The Adolescent Brain Cognitive Development Study (ABCD, N = 11,842) with data from youth recruited from school systems and including the first four assessment waves conducted between 2016–2022 (age range 9–15, 12.9 ± 0.65) and assessing lifetime suicidal ideation and attempt; 2) The 2021 Youth Risk Behavior Survey (YRBS, N = 16,784), administered to 9th – 12th grade US students (15.7 ± 1.2) attending public and private schools and asking about suicidal ideation and attempt in the past 12 months; and 3) The Children’s Hospital of Philadelphia Emergency Department (CHOP-ED, N = 19,873) cohort, which includes data on 12- to 18-year-old youth (15.3 ± 1.5) assessing lifetime suicidal ideation and attempt at the CHOP-ED between 2013–2020. The overall suicidal ideation and attempt rates were 22.5% and 8.6%. Meta-analysis of all three cohorts showed that sex (Odds Ratio [OR]=1.75, 95% Confidence Interval [95% CI]: 1.13–2.72, P=.01) but not race (OR=1.06, 95% CI: 0.92–1.24, P=.42) was significantly associated with suicidal ideation. In addition, there was a significant sex by race interaction with greater risk in female Black youth (OR=1.26, 95% CI: 1.02–1.55, P=0.03). For suicide attempt, sex (female) (OR=1.81, 95% CI: 1.41–2.33, P<.001) and race (Black) (OR=1.57, 95% CI: 1.37–1.80, P<.001) were significant; however, there were no significant sex-by-race interactions (OR=1.06, 95% CI: 0.80–1.41, P=.67).

These results highlight the increased risk for suicidal ideation and attempt in female youth. The increased risk of suicide attempt but not suicidal ideation among Black youth and the sex by race interaction in suicidal ideation but not attempt highlights potentially different mechanisms for the emergence of these phenotypes in female and Black youth. The lack of differences by race in suicidal ideation but not attempt suggest a pathway that does not include the transition from suicidal ideation to attempt in Black youth and that in Black youth could be more impulsive in nature. In a sample of adolescents, predominantly Black, a latent class of severe impulsivity and aggression was a significant predictor of suicide attempt in females (6). Similar results to those presented by Cooper and Colleagues (5) were obtained in an analysis of 119,654 high-school students from the Youth Risk Behavior Survey from 2007 to 2021 where females, non-Hispanic White and Black students, and those with depressive symptoms had the highest rates of suicidal ideation (7). Suicide attempts were disproportionately increased among non-Hispanic White and Black students and high school seniors. We had previously reported the trajectory of depression symptoms with the highest mean scores and variability over time to be the only trajectory to predict suicide attempt in high-risk youth, offspring of parents with mood disorders, above and beyond psychiatric diagnoses, impulsivity, aggression, and hopelessness (8). We also found younger age and a diagnosis of depression to be important predictors prior to suicide-related behaviors in Black youth in this high-risk sample (9). Suicide-related behaviors outcome was our broader definition including actual attempt, aborted, interrupted, preparatory behaviors, and emergency referrals for suicidal ideation.

There have been several individual, family, neighborhood, and structural-level risk factors identified to drive some of the differences in increased risk for suicidal ideation and attempt by sex and race. Limited access to services in the community, cost, and long waiting times for appointments, are some of the structural barriers that interfere with Black youths’ access to mental health care (10,11). However, evidence also shows that screening and identification of youth at risk increases the likelihood of mental health service utilization and reduction in depression symptoms, especially among Black youth (10). Living in adverse environments, exposure to violence, and racial/ethnic discrimination, are examples of neighborhood-level factors associated with increased risk of suicidal ideation and attempt among Black youth (12–15). Black girls were previously reported to be more likely to experience relationship problems within 24 hours prior to death by suicide, physical health problems, and current mental health problems (16,17). Indeed, a recent study found lower odds of a mental health diagnosis among Black youth suicide decedents compared to White youth; among those aged 10–14 years; however, there was higher odds of a mental health diagnosis among female suicide decedents compared to males (18).

There are several identified risk factors that can be targeted for prevention and interventions approaches to reduce the morbidity and mortality from suicidal ideation and behavior in Black youth and girls. Strengthening coping mechanisms in response to stress, improving access to culturally competent care, and reducing access to lethal means are some examples. We also need to address protective factors associated with reduced risk for suicidal ideation and attempt in general and in Black girls in specific. School connectedness and social support have been reported to be protective against suicidal ideation and attempt among female Black youth (19). However, it is not straightforward how to address the structural- and neighborhood- level problems driving some of the suicide risk in Black youth and females. What we need urgently are bold public policies to break down what seem to be insurmountable barriers to save future generations of Black youth and girls from despair and suicide; and we need them now.