Abstract
This cross-sectional study examines the pattern of suicides from 2015 through 2020 among youth aged 10 to 19 years in 14 US states.
In 2021, the American Academy of Pediatrics declared a state of emergency regarding child and adolescent mental health.1 During the COVID-19 pandemic, US adolescents have been affected by the widespread loss of primary caregivers. Suicide-risk screenings have yielded higher positive rates than during the prepandemic period2; thus, we sought to measure suicide-related mortality in this population.
Methods
Through partnerships with 14 state departments of public health, we collected data from 2015 through 2020 for 85 102 decedents with suicide as the cause of death. MIT COUHES approved the conduct of this research and waived ethical review and the informed consent requirement because the study was not human participant research and used death certificates from deceased individuals.
To assess pandemic-period changes in suicide, we first compared counts of suicides between the prepandemic (2015-2019) and pandemic (2020) periods. Counts were collated for adolescents aged 10 to 19 years3 and across all ages (overall). We then computed the yearly proportion of overall suicides among adolescents to examine how the burden of suicide has shifted across age groups throughout the pandemic. To measure the change in adolescent suicidality between the prepandemic and pandemic periods, we investigated the absolute count of adolescent suicides and proportion of overall suicides that occurred among adolescents. Reflecting the relative burden for adolescents rather than absolute suicidality, the second outcome was chosen to inform resource reallocation decisions in this age group, particularly about mental health, psychiatric services, and emergency care. Additional study details are provided in the eMethods in the Supplement.
Results
Georgia, Indiana, New Jersey, Oklahoma, and Virginia had an increase in absolute count of adolescent suicides during the pandemic. These states, along with California, also had an increase in the proportion of overall suicides among adolescents. In contrast, Montana had a decrease in both absolute count and proportion of adolescent suicides during the pandemic, whereas Alaska had a decrease in proportion only. When data were aggregated across all 14 states, the proportion of overall suicides among adolescents increased during the pandemic. No other pandemic-period changes in adolescent outcomes were statistically significant (Table).
Table. Suicides Among Adolescents and General Population During the Prepandemic and Pandemic Periods in 14 Participating Statesa.
| Alaska | Arkansas | California | Colorado | Connecticut | Georgia | Indiana | Montana | Nebraska | New Jersey | Ohio | Oklahoma | Virginia | Vermont | All 14 states | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No. of adolescent suicides | |||||||||||||||
| 2015- 2019, mean (95% CI) | 22.6 (5.7-29.5) | 32.6 (20.2-45.0) | 204.6 (185.0-224.2) | 92.8 (80.8-104.8) | 18.0 (11.0-25.0) | 87.8 (79.2-96.4) | 62.8 (45.4-80.2) | 21.4 (16.2-26.6) | 21.2 (14.7-27.7) | 32.4 (29.3-35.5) | 111.4 (88.5-134.3) | 54.8 (46.9-62.7) | 67.6 (56.9-78.3) | 5.6 (3.2-8.0) | 835.6 (746.7-924.5) |
| 2020b | 17 | 41 | 220 | 101 | 14 | 106c | 83c | 16d | 20 | 37c | 90 | 67c | 85c | 6 | 903 |
| No. of overall suicides | |||||||||||||||
| 2015- 2019, mean (95% CI) | 198.2 (187.4- 209.0) | 573.4 (532.1- 614.7) | 4360.0 (4204.4- 4515.6) | 1200.2 (1092.2- 1308.2) | 398.6 (379.0- 418.2) | 1455.2 (1298.5- 1611.9) | 1024.0 (952.1- 1095.9) | 275.6 (250.1- 301.1) | 264.6 (222.2- 307.0) | 700.2 (657.3- 743.1) | 1748.4 (1653.7- 1843.1) | 794.6 (762.1- 827.1) | 1145.0 (1101.5- 1188.5) | 98.2 (81.7- 114.7) | 14236.2 (13606.4- 14866.0) |
| 2020b | 204 | 583 | 4048d | 1294 | 340d | 1488 | 1017 | 294 | 281 | 643d | 1642d | 837c | 1152 | 98 | 13921 |
| Proportion of suicides among adolescents | |||||||||||||||
| 2015- 2019, mean (95% CI) | 11.3 (8.5-14.2) | 5.6 (3.9-7.4) | 4.7 (4.2-5.2) | 7.7 (6.9-8.6) | 4.5 (2.8-6.2) | 6.0 (5.7-6.4) | 6.1 (4.8-7.4) | 7.8 (5.5-10.2) | 8.0 (5.80-10.2) | 4.6 (4.3-5.0) | 6.3 (5.3-7.4) | 6.9 (5.8-8.0) | 5.9 (5.2-6.6) | 5.6 (3.6-7.7) | 5.9 (5.4-6.3) |
| 2020b | 8.3 | 7.0 | 5.4c | 7.8 | 4.1 | 7.1c | 8.2c | 5.4d | 7.1 | 5.8c | 5.5 | 8.0c | 7.4c | 6.1 | 6.5c |
Proportions of suicides among adolescents (aged 10-19 years) were calculated as the number of adolescent suicides divided by the number of overall suicides in a given year.
No 95% CIs were included because death certificate counts for a single year (2020) were considered to be the ground truth.
Statistically significant increase between the prepandemic period mean (2015-2019) and the pandemic period (2020).
Statistically significant decrease between the prepandemic period mean (2015-2019) and the pandemic period (2020).
Discussion
Proportion of suicides among adolescents has shifted markedly and heterogeneously across the 14 participating states. Although the study was limited to states with available data, this 14-state cohort included representation from all 10 Department of Health and Human Services regions and comprised 32% of all US residents (33% adolescents). Future research is needed to expand this analysis to the remaining US states. The format of data available from each state varies greatly, but any existing aberrations are unlikely to change the directionality of the findings because of standardization of International Classification of Diseases coding across states.
In accordance with previous work on excess mortality during the pandemic,4 we treated the full year of 2020 as the pandemic period. Although previous studies reported that suicide-related deaths in the broader population decreased during the pandemic,5 we found that adolescents have not experienced the same patterns as adults in the participating 14 states in the same period; specifically, suicides among adults 35 years or older have followed a downward pattern,5 although there is undoubtedly variation across geographic areas and subpopulations. Stratification by age group and geography will be necessary to expose these heterogeneities in mental health outcomes associated with the pandemic. Moreover, given recent evidence that pandemic-period suicidality may be differentially affected by race and ethnicity, especially among youth, future work is needed to capture variability across ethnoracial subpopulations.6
These findings highlight the importance of alleviating the downstream consequences of the pandemic for adolescent well-being. Examples of interventions that may address shifting suicidality among young people in the US include expanding bereavement counseling to cope with the loss of caregivers and implementing more readily available suicide risk assessment solutions.
eMethods.
References
- 1.American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, Children’s Hospital Association . AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health. Accessed December 20, 2021. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/
- 2.Mayne SL, Hannan C, Davis M, et al. COVID-19 and adolescent depression and suicide risk screening outcomes. Pediatrics. 2021;148(3):e2021051507. doi: 10.1542/peds.2021-051507 [DOI] [PubMed] [Google Scholar]
- 3.World Health Organization . Adolescence: a period needing special attention. 2014. Accessed December 20, 2021. https://apps.who.int/adolescent/second-decade/section2/page1/recognizing-adolescence.html
- 4.Rossen LM, Branum AM, Ahmad FB, Sutton PD, Anderson RN. Notes from the field: update on excess deaths associated with the COVID-19 pandemic - United States, January 26, 2020-February 27, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(15):570-571. doi: 10.15585/mmwr.mm7015a4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Curtin SC, Hedegaard H, Ahmad FB. Provisional numbers and rates of suicide by month and demographic characteristics: United States, 2020. Vital Statistics Rapid Release; no 16. National Center for Health Statistics. November 2021. Accessed December 20, 2021. https://stacks.cdc.gov/view/cdc/110369
- 6.Sheftall AH, Vakil F, Ruch DA, Boyd RC, Lindsey MA, Bridge JA. Black youth suicide: investigation of current trends and precipitating circumstances. J Am Acad Child Adolesc Psychiatry. 2021;S0890-8567(21)01365-4. doi: 10.1016/j.jaac.2021.08.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods.