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. Author manuscript; available in PMC: 2022 Oct 1.
Published in final edited form as: Public Health. 2021 Sep 20;199:51–56. doi: 10.1016/j.puhe.2021.08.004

Trends and instigators among adolescent suicide in the United States

Mary Labuhn 1, Kathryn LaBore 2, Tooba Ahmed 3, Rashid Ahmed 4
PMCID: PMC8763572  NIHMSID: NIHMS1742555  PMID: 34547557

Abstract

Objectives:

The present investigation examined the role of factors involved in suicide ideation and suicide attempt using a nationally representative sample of United States high school students.

Methods:

Data were collected from students in grades 9–12 as part of the Youth Behavioral Survey (n = 11328). Logistic regression models were used to examine factors associated with suicide ideation and suicide attempt. Variables included demographic characteristics (grade, sex, and race), psychosocial factors (physical fighting, sexual violence, sports participation, bullying, and electronic bullying), and substance use (cigarette usage, marijuana usage and alcohol usage). Results: The factor most associated with suicide ideation was bullying (either electronic or physical), while the factor most associated with suicide attempt was sexual violence followed closely by physical bullying.

Conclusions:

The multitude of instigators, and commonality among gender, ethnicity, and socioeconomic status, give an indication of how to prevent suicide and who to target information regarding the hazards of suicide.

Keywords: suicide ideation, suicide attempt, adolescents

Suicide is one of the top three causes of death among current youth1. Adolescent death by suicide, suicide planning, suicide attempt related injuries, and suicide related hospitalizations are all on the rise 2,3. In an effort to better understand contributing factors to suicide risk, researchers have described suicide on a spectrum. Two particular outcomes of interest include suicidal ideation, ‘thoughts of harming or killing oneself’, and suicide attempts, ‘a non-fatal, self-inflicted destructive act with explicit or inferred intent to die’ 4. While there are substantial number of investigations examining predictors of both suicide ideation and attempt within adolescent psychiatric populations, there is a continued need to understand associated biological and psychosocial factors linked with suicide in nationally representative youth samples 4.

Psychiatric and Psychosocial Factors

Predominate theories of suicide describe suicide ideation and attempts as interrelated through biological, psychosocial, and environmental vulnerabilities5. Some factors are associated with ideation alone while other, sometimes separate, factors may increase the risk of turning suicidal thoughts into action6. Presence of psychiatric diagnosis has been associated with both suicide ideation and attempt in youth samples7,8. In particular, Major Depressive Disorder has been identified as a significant contributor to suicide attempts; 40–80% of adolescents who attempted suicide were diagnosed with depression at the time of their attempt8. Depressive symptoms have also been linked with suicide ideation in youth samples. Individuals who reported a single event of ideation were likely to have had personal depressive symptoms, maternal depression, inappropriate emotional response, and poor social support9. Those with persistent suicide ideation had higher levels of parental depression and increased self-reported depressive symptoms9. Suicide ideation and attempts are also linked with substance use and substance use disorders in youth samples10. Psychiatric substance disorders such as alcohol abuse and dependence have been linked with suicide attempt in adolescent samples11. Use of substances such as cigarettes12, alcohol13, and marijuana13 have been linked with suicide attempts in adolescent samples.

Other theories such as the Interpersonal Theory of Suicide emphasize the role of interpersonal and psychosocial factors. The theory posits that acquired capability for suicide (e.g., reductions in fear and pain sensitivity) when combined with thwarted belongingness and perceived burdensomeness will prompt an individual to shift from suicide ideation to action14,15. Given that establishing a personal identity and connecting with peers is a key developmental task for adolescents, the interpersonal theory of suicide’s emphasis on relationships may be particularly well suited for understanding youth suicide. Initial evidence appears to support the utility of the interpersonal theory of suicide16. Specifically, there are numerous psychosocial factors that many adolescence experiences that may contribute to feelings of thwarted belongingness as bullying, sexual violence, and physical aggression. Within samples of 12 – 17 year-olds, online and in-person bullying was associated with both suicide ideation and attempts17,18,19. A recent meta-analysis of longitudinal studies found that forms of interpersonal violence such as bullying and relationship violence also associated with suicide attempt in adolescents and young adults20. In contrast, physical activity in a social context may have a protective effect. Male and female students who played on sports teams demonstrated a much lower rate of suicide attempt compared to inactive students who did not participate in team sports21. Furthermore, physical violence may increase the risk of suicide attempt Youth aged 13–19 who engage in physical fighting were 4 times more likely to report suicide attempts12,22.

Gender

Existing evidence suggests differential patterns of suicide behavior between male and female adolescents. Adolescent males are 3–4 times more likely to die by suicide, while females are far more likely attempt suicide4,23. While choice of method may be a major reason for a higher male suicide fatality rate, there are cultural components to take into consideration such as female’s willingness to engage in help seeking behaviors and possible underreporting of female death by suicide23,24. Additionally, some evidence suggests that the gap between male and female suicide rates is diminishing emphasizing the continued need to investigate suicide trends related to gender25.

Ethnicity

Historically, when compared to Non-White adolescents, White adolescents are more likely to die by suicide26. Subsequent evidence suggests that patterns of suicide by race may be changing. Rates of death by suicide have increased for black adolescent males27,28. Black females aged 10–15 years old were more likely to report suicide ideation when compared to white females29. Youth suicide in the Hispanic community also appears to be more prevalent than in non-Hispanic communities, although data is not comprehensive4. American Indians/Alaska Natives are currently at the highest risk of attempting and dying by suicide in the United States4.

The Present Study

Understanding correlates of adolescent suicide remains an imperative public health tasks for researchers. While suicide presents a growing threat to adolescent wellbeing, one of the inherent challenges in suicide research is the low prevalence of suicide within adolescent populations. For example, a recent meta-analysis suggested that 4.5% of adolescents reported a suicide attempt within the past year and 7.5% of adolescents reported a suicide plan within the past year30. Hence, identification of useful correlates of suicide requires large representative samples31. The present investigation aims to examine predictors of past year of suicide ideation and attempts in a large sample of adolescents. Variables examined include demographics such as grade, sex, and race, psychosocial factors such as physical fighting, sexual violence, bullying, electronic bullying and sport participation, and substance use including cigarette use, marijuana use and alcohol use.

Method

Participants

This study used nationally representative data collected by the Centers for Disease Control and Prevention (CDC) as part of the Youth Risk Behavior Survey (YRBS) for the 2017 academic year. The target population included students in private and public schools throughout the United States. Wyoming, Washington, Oregon, and Minnesota did not participate in the survey. Territorial and tribal government such as Guam, Northern Mariana Islands, Puerto Rico, the Cherokee Nation, the Navajo Nation, and the Winnebago Tribe of Nebraska were included. Participants retained in this analysis were student in grades 9 through 12 who responded to the mental health and suicide portion of the YRBS (n=11328). Demographic variables included gender, grade level, and race. Detailed information regarding methods and informed consent processes of the YRBS is available through the CDC.

Measures and Procedures

The YRBS collected information on grade, gender, race, mental health and suicide, sexual behavior, substance use, and violence victimization. Suicide ideation was assessed with the dichotomous self-report item “During the past 12 months, did you every seriously think about committing suicide?” (1=yes, 0=no) (Qn26). Suicide attempt was assessed with the self-report item “During the past 12 moneys how many times did you actually attempt suicide?” Response categories included 0, 1, 2 to 3, 4 to 5, and 6 times. Responses were dichotomized into “never” and “one or more times.” (1=attempted suicide at least once, 0=no suicide attempts) (Qn28). In order to predict suicide ideation and attempt, further past year behaviors were analyzed such as: physical fighting (Qn17), sexual violence (Qn20), bullying at school (Qn23), electronic bullying (Qn24). Substance use included past 30 days of: cigarette usage (Qn32), marijuana usage (Qn48), and alcohol usage (Qn42). A possible protection factor, participation in a team sports team (Qn83), was also used. Responses were dichotomized into “no” or “yes”.

Statistical Approach

Descriptive analyses of suicide ideation and suicide attempt were examined according to grade, sex, and race. Using information from the 2017 data set, two logistic regression models were constructed to examine factors associated with suicide ideation and suicide attempt (Table 1). Analyses were weighted by the YRBS weighting variable, which accounted for nonresponses and oversampling of Black and Hispanic students.

Table 1.

Logistic regression analyses examining factors associated with suicide ideation and attempt among youth (grade 9–12) in 2017 in the United States

Parameters Adjusted Odds Ratioa (95% CI)
Model 1:
Suicide ideation versus
No suicide		 Model 2:
Suicide attempt versus
No suicide attempt
Sex Male 1.00 (ref) 1.00 (ref)
Female 1.64 (1.47–1.84)** 1.52 (1.25–1.84)**
Grade 9 1.00 (ref) 1.00 (ref)
10 1.11 (0.96–1.28) 1.05 (0.84–1.32)
11 1.11 (0.95–1.28) 0.73 (0.57–0.93)
12 1.11 (0.96–1.29) 0.70 (0.54–0.90)*
Race White 1.00 (ref) 1.00 (ref)
Native American 1.12 (0.59–2.13) 1.05 (0.32–3.41)
Asian 1.42 (1.11–1.83)* 1.80 (1.16–2.80)*
Black 0.99 (0.85–1.15) 2.13 (1.68–2.69)**
Hispanic 0.94 (0.79–1.12) 1.37 (1.03–1.82)
Physical Fighting 1.26 (1.11–1.42)** 1.87 (1.54–2.27)**
Sexual Violence 1.81 (1.59–2.06)** 2.84 (2.34–3.43)**
Bullying Physical 2.49 (2.18–2.84)** 2.50 (2.02–3.08)**
Electronic 2.19 (1.91–2.52)** 1.92 (1.55–2.39)**
Substance Use Cigarette 1.71 (1.46–2.00)** 2.55 (2.01–3.23)**
Alcohol 1.00 (0.89–1.13) 0.89 (0.72–1.09)
Marijuana 1.71 (1.49–1.96)** 1.93 (1.56–2.40)**
Played on a Sports team 0.72 (0.65–0.81)** 0.83 (0.69–0.99)
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a

Model 1: 1= Yes (n=2006), 0= No (n=9322)

Model 2: 1= Attempted suicide at least once (n=564), 0= No suicide attempts (n=7560)

*

p < 0.01

**

p < 0.001

Results

Risk Factors

Of students surveyed, approximately 52% (5877) were female and 48% (5451) were male. By race/ethnicity, 55% (6243) were White, 25% (2789) were Black, 14% (1539) were Hispanic, 6% (645) were Asian, and 1% (136) were American Indian/Alaska Native (AI/AN). By grade, 9th, 10th, 11th, and 12th grade represented 27% (3018), 25% (2894), 25% (2833), and 23% (2607), respectively. Within the past 12 months, approximately 38% (4245) of youths had gotten into at least one fight, 13% (1473) had experienced at least one incidence of sexual violence, 19% (2014) had been bullied physically, and 15% (1702) had been bullied electronically. Additionally, for substance use, 10% (1172), 37% (4173), 21% (2399) reported cigarette, alcohol, and marijuana use in the last 30 days. Finally, 64% (7314) were part of one or more sports teams.

Prevalence of suicide ideation

Suicide ideation was reported in approximately 18% (2006) of youth in grades 9–12 in the United States (Figure 1a). Females had a significantly higher rate of suicide ideation with approximately 65% (1309) of youth reported to have had thoughts of suicide being female, compared to approximately 35% (697) being male (F1,11311=74.86, p < 0.001). Being in grades 9–12 had no significant relation to suicide ideation. Race and alcohol use also were not significant. Those who had gotten into fights (F1,11311=13.05, p < 0.001), experienced sexual violence (F1,11311=82.48, p < 0.001), and those who were bullied (physically at school, F1,11311=186.79, p < 0.001; electronically, (F1,11311=124.38, p < 0.001) were significantly more likely to have considered suicide. Youth who had used cigarettes (F1,11311=43.08, p < 0.001) or marijuana (F1,11311=59.48, p < 0.001) in the last 30 days were also significantly more likely to have considered suicide. Conversely, youths involved in a sports team (F1,11311=35.37, p < 0.001) were significantly less likely to have considered suicide.

Figure 1.

Figure 1

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Model-adjusted proportions of suicide ideation and attempt among youth (grade 9–12) in 2017 in the United States by sex, physical fighting, sexual violence, bullying at school, electronic bullying, cigarette use, marijuana use, and sports team participation.

Prevalence of suicide attempt

Suicide attempt was reported in approximately 7% (564) of youth in grades 9–12 in the United States (Figure 1b). Females had a significantly higher rate of suicide attempt with approximately 66% (374) youths reported to have attempted suicide at least once being female, compared to approximately 34% (190) being male (F1,8107=17.61, p < 0.001). Those who had gotten into fights (F1,8107=40.30, p < 0.001), experienced sexual violence (F1,8107=114.28, p < 0.001), and those who were bullied (physically at school, F1,8107=72.08, p < 0.001; electronically, (F1,8107=34.34, p < 0.001) were significantly more likely to have attempted suicide. Cigarette (F1,8107=60.11, p < 0.001) and marijuana (F1,8107=35.89, p < 0.001) use also showed significant results, while alcohol use did not. Conversely, youths involved in a sports team (F1,8107=6.61, p =0.013) were significantly less likely to have attempted suicide.

Suicide attempts also differed by race/ethnicity (F1,8107=10.87, p < 0.001) (Figure 2a). For those who attempted suicide, approximately 2% (10) were AI/AN, 5% (27) were Asian, 28% (162) were Black, 53% (302) were White, and 12% (69) were Hispanic. Black adolescents had a significantly higher proportion of suicide attempts than White adolescents. AI/Ans adolescents had the most variable rates, which may be an artifact of small sample size. Suicide attempts were also significantly different by grade (F1,8107=5.37, p = 0.001) (Figure 2b). The proportions of those who attempted suicide were lower in grades 11 and 12 than in grades 9 and 10.

Figure 2.

Figure 2

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Model-adjusted proportions of suicide attempt among youth (grade 9–12) in 2017 in the United States by A) race/ethnicity and B) grade. Error bars are 95% confidence intervals.

Discussion

Suicide ideation

Results indicate that the largest predictor of suicide ideation was bullying (physical or electronic). The contribution of bullying experiences to suicide ideation is consistent with other investigations within adolescent populations17,18,19. Consistent with previous literature12,20,22, other psychosocial variables including sexual violence and physical fighting were also related to increased likelihood of suicidal ideation. Consequences of bullying, sexual violence and aggression may reflect experiences of thwarted belongingness, such that the experience of rejection from peers contributed to increased suicide risk14. In contrast, adolescents who were involved in a sports team were significantly less likely to have thoughts of suicide. This suggests sports participation may serve as a protective factor against suicide. In this sense, the proxy psychosocial variables utilized in this study appear consistent with the interpersonal theory of suicide14. Future investigations should examine thwarted belongingness as a mediational variable on the relationship between sexual violence, physical fighting, and bullying and suicide ideation.

There was also evidence that substance use (cigarette and marijuana) significantly related to suicide ideation. Alcohol was not a significant predictor, which may be due to the social nature surrounding alcohol for adolescents. It is also possible that clinically significant alcohol use consistent with DSM diagnoses may be related to suicide ideation rather than use of alcohol11. While it was beyond the scope of the present study to include clinically significant substance use, further research should clarify the contribution of clinically significant alcohol use as compared to sub-threshold alcohol use. Among race, participants who identified as Asian had a significant link to suicide ideation. There is limited research examining Asian American adolescents’ experiences with suicide ideation32. Research with Asian American college students has linked concepts such as family, cultural difference, and racism as key components related to suicide risk32. Being female was also a significant predictor of suicide ideation. Female suicide ideation is not uncommon, females are more likely to have thoughts of suicide while males are more likely to die by suicide23.

Suicide attempt

Suicide attempt patterns were similar to suicide ideation patterns, though additional factors such as grade and ethnicity were significant. For suicide attempt, sexual violence was the largest predictor, followed by physical bullying. This is consistent with previous literature linking sexual assault33 and bullying17,18,19 with suicide attempts. The present study examined sexual violence within the past year. Previous research suggests that prior victimization is associated with subsequent victimization in adolescent populations34. When combined with results from the present study linking past year of sexual violence with suicide attempts, findings strongly emphasizes the utility of sexual assault prevention as well as improvement in connecting survivors of sexual violence with supportive resources. Consistent with prior research highlighting rising risk for suicide among Black adolescents27,28,29, Black adolescents had the highest proportion of suicide attempt. While there is evidence suggesting that the predictors of suicide attempts are similar for White and Black adolescents28, Black adolescents face unique factors such as discrimination and racism. Previous longitunidal studies have linked perceived discrimination with suicide ideation among samples of Black adolescents35. Future research should aim to differentiate the extent to which establishing and discrimination related correlates associate with suicide in Black adolescent samples. Asian adolescents had the second highest proportions and AI/ANs had the lowest proportions and highest variability. The cause for this is unclear and goes against previously found data suggesting high rates of suicide attempts among AI/AN adolescents4.

While sports participant was associated with significantly lower odds of considering suicide, proportions of attempts were not significantly different. Participation in sports may help reduce thinking about suicide but be less helpful in reducing attempts at suicide. Older students (11–12th grade) had lower proportions of suicide attempts than younger students (9th–10th). This may suggest that the transition to high school may be a particular period of risk. Longitudinal studies examining suicide attempts across the course of high school suggest that there are differential risks associated when comparing 9th graders to 11th graders36.

Limitations

There are limitations to this study. The YRBS study was conducted in 2017, so suicide ideation and attempt trends may have changed in the last three years. To that extent, instigators of ideation and attempt may have changed. This is particularly relevant given the changing social context within the past. For example, the impact of social media and consequences of COVID-19 in youths’ daily lives continues to grow. This may encourage an increase in electronic bullying or increase depressive symptom risk. Additionally, this study is largely cross-sectional limiting the extent to which causal inferences can be made regarding contributors of risk.

Conclusions

Overall, these results suggest that there are factors that contribute to increased likelihood of suicide ideation and attempt. Results from this investigation highlight the role of psychosocial experiences that may interrupt key developmental tasks for adolescents such as establishing meaningful friendship and an autonomous identity. In particular, results support programs designed to reduce and address the effects of bullying, connect sexual violence survivors with support, and mental health interventions designed to consider the unique experiences of Black and Asian youth may be of particular importance. Results also draw attention to protective factors such as sports participation.

Acknowledgements:

Dr. Mark Williamson assisted in data analysis and manuscript editing.

Funding:

Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number T34GM122835. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

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Competing Interests:

None

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