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

Abstract

This cross-sectional study assesses suicide rates in US youths, contrasting them with existing studies on suicide-associated emergency department visits and legislation-based suicide prevention efforts in the Unites States.

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).

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.

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

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).

Figure 2. 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.

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.