Youth Suicide Is Skyrocketing; Researchers Try to Figure Out Why

Andrew N. Wilner, MD; Oren Miron, MA

Disclosures

August 20, 2019

Andrew N. Wilner, MD: Welcome to Medscape. I'm Dr Andrew Wilner. Today I have the pleasure of speaking with Oren Miron, MA, a research associate in biomedical informatics at Harvard Medical School. The topic we're discussing is a difficult one, that of suicide.

Oren, you are the lead author of a recently published paper in JAMA[1] on adolescent and young adult suicide. Can you tell us why you chose that topic?

Oren Miron, MA: From a personal perspective, a friend of mine in high school was bullied and unfortunately took his life. So I was very connected to the topic.

When I came to the United States, my research was originally focused on autism. However, in looking at data from the Centers for Disease Control and Prevention (CDC) showing an increase in suicide, I realized that I wanted to focus on addressing that as well. We have people doing a great job on behavioral research in this area, but there's not as much when it comes to the quantitative analysis. So we wanted to bring a big-data approach to it.

Wilner: I empathize, because a few months ago I learned that a very good friend, just a little older than me, committed suicide with a gun. I wrote an article about it for Medscape, which led me a little deeper into the topic, including finding that physicians have the highest suicide risk of any profession. What did your findings show about risk factors in adolescents and young adults?

A Rise in Both Female and Male Suicide

Miron: We found that suicide among adolescents and young adults reached its highest recorded level, at least in the past 20 or so years, a period for which we have pretty reliable data for comparison.

We also found that this rise was especially high among adolescent males, which was surprising because previous studies talked more about an increase in females, that they were closing the gap. It's not that the rate of suicide in females is not rising; both male and female suicides are rising in alarming rates. It's just that in the past 4 or so years, males seem to have had a more pronounced increase than they previously did. It's really troubling. We wanted to flesh this out so we could start examining the contributing factors and how to stop it.

Wilner: This is publically available CDC data. I've looked at the charts myself, and when you do, you see the trend lines all going up.

Miron: Yes, this was the CDC national database of all death cases. Obviously, there could be some suicides that aren't detected there. For example, sometimes you don't know if a person fell off the roof or jumped. There's also a potential problem in comparing the rates, because if we see more suicide in recent years, it could also be because more people understand how to differentiate it from accidents. However, the rise was so stark in the past 4 to 5 years that it's pretty certain that this is not just an awareness or misclassification issue.

Wilner: If anything, I think it's probably an underestimate because of drug overdoses. Very often there's not a lot of history to go with that. If the coroner is going to examine the case, they are going to call it a drug overdose unless there's overwhelming evidence to call it a suicide.

Miron: Definitely. In researching the opioid epidemic, I watched a documentary about an addict who said, "I just wanted to end it, so I took 20 pills." He was saved because he was found in time. But if he were, God forbid, to be found dead, then people would likely have said that he just took too much rather than that it was a suicide attempt.

And with pills, it's easier to notice. If you're talking about fentanyl, where one speck will get you high and two specks will kill you, it's very hard to know if somebody used that second speck on purpose.

Looking for Causation in the Suicide Epidemic

Wilner: Do we have the data to know whether this is purely a US phenomenon, or is this happening in Western countries all over the world?

Miron: There isn't as wide of documentation globally, especially in the younger age groups, and you would want to aggregate a lot of data. Of course, the United States is very large. I looked in Israel, where I'm from, and we don't see nearly as much of an effect.

But we know that a lot of things start in America and then move on to other countries. Whether it's modern technology, social networks, or opioid use, it always starts in America, and then other countries imitate it. Hopefully, we will not see this happening in other countries and try to stop it in America as well.

Wilner: I can't help but wonder whether this is due in part to easy access. There are people who believe that you can't do anything about those who are suicidal, that if someone wants to kill themselves, they'll find a way. Maybe for some people, that's true. But I think for a lot of people, there's sort of the crisis of the moment. If you can get them over that crisis, then they're not suicidal anymore and can live normal lives, particularly with some mental health treatment.

To my knowledge, my friend I was telling you about wasn't a gun guy. When I learned that he killed himself with a gunshot wound to the head, I thought that really wasn't typical of him. Like in his case, I wonder if the easy access to things like opioids, fentanyl, and guns is partly responsible for pushing these numbers up.

Miron: Now, especially with the Internet, there's also so much more access to the methods for suicide. Especially when working with teens, there's a lot more you can do to limit their access. An adult can drive his car and find the opioid dealer or buy the gun. However, with the kids, I think it's important to do things like keep the medicine cabinet locked, the gun safe locked. A lot of people consider preventing access to guns in 5-year-olds who would use it on accident, but we also want to do it with 15-year-olds, who may, God forbid, do it on purpose.

However, we didn't just see an increase in those factors you've mentioned; we also saw it in strangulation and other methods. So I don't think that limiting gun access will solve the issue, although there could be a lot of linkage. But especially with the young people, we want to do a better job of enforcing the laws of not giving them access to their parents' guns until they reach the appropriate age, or not giving them access to their parents' opioids. There's been a study that when parents are prescribed opioids, it actually increases the risk that their kids commit suicide.[2]

So again, what we're saying is that we don't want to deny parents treatment for their pain or of their right to bear arms; we just want to make sure that the kids are not able to use it without their parents' consent.

Changing Cultural Perceptions of Suicide

Wilner: This raises another question. I'm sure people are going to wonder: What is the influence of social media? You often hear about children being bullied on social media. You can tell them, "Just don't check Facebook and you won't know," but kids are so attached to this as part of their world, they can't turn it off. It's as bad, if not worse, than real-life bullying.

Miron: It's becoming really bad. We used to tell the parents to just check their kids' Facebook to see if they are being bullied. Now it's happening on Snapchat and Instagram Stories, things that are not accessible and are in the form of posts that disappear. There's also a lot more anonymity. It's much easier for people to just open an anonymous account and start spreading rumors or threats. There was recently a girl who put up an Instagram poll about whether she should kill herself, and people voted in favor, and she unfortunately did that. It's a very extreme case.

Most of these issues have more to do with bullying and with spreading information about suicide, which I think has been glorified way too much by some cultural figures. We used to have a very helpful cultural and religious taboo against suicide. It wasn't considered as beautiful and poetic as some people might say it is.

Wilner: I believe that in the Christian and Jewish religions, for example, suicide is not an option. It is strongly disapproved of. I know that when I was young, if someone committed suicide, it was something you didn't even talk about. It wasn't part of the conversation. It was a stigma.

Miron: And while we don't want to stigmatize the parents who are grieving, and we don't want to blemish the person who unfortunately did that, we do need to be careful about not bringing up the topic too readily to teenagers. We may want to talk with them more about depression before getting to that stage. When we constantly bring up the issue of suicide, we might give ideas to some of them. I think a lot of the work has to be done without presenting that as an option, and instead focus on fighting the depression, fighting that lack of sense in life. You can't ask these kids every week, "Are you going to kill yourself?"

Building Predictive Risk Models

Wilner: Are you planning on pursuing this topic in any upcoming research?

Miron: Yes. It was a very depressing article to put together. We really wanted to start delving into the ways to prevent this rising suicide epidemic, but we realized that it was so stark that we had to just get it out there to let clinicians and researchers know about it.

Now we're working on identifying the risk factors, especially in connection with opioids. We already know that there's increased risk for suicide among not just opioid addicts but also their kids. Because we've seen an increase in suicide in the past 4 years, during which we have also seen an increase in opioid overdoses, we're trying to analyze whether the opioid epidemic is somehow pushing the suicide epidemic. Or maybe it's something that connects to both of them, which is the general despair and lack of purpose that some people experience.

The other thing we're trying to do is develop for doctors a much better risk-prediction tool for individuals. Before I did this research, if you asked me what's the suicide rate for a girl from New Jersey or for an adolescent boy from Alaska, I would have had no idea. I would especially not know that the 18-year-old boy in Alaska would have, for example, a 50 times higher risk than the younger girl from New Jersey.

We're trying to provide that basic kind of risk calculator. Obviously, we can do other things, like putting in medical records and educational records, apply machine learning, and create a very sophisticated analysis. But at the first stage, we want to create these super-easy tools which allow you to go to a website; enter the gender, age, and location; and get a pretty good sense of how much danger that kid is in.

Wilner: That's very interesting, because that shows that there is clearly an environmental factor. This isn't just genetics; it depends on where you live. That has a huge influence on whether suicide is part of your future or not.

Miron: It could also relate to lack of resources, when it comes to counselors or teachers who might notice the problems. That's something we see in a lot of rural areas. I think one of the ways to address this suicide epidemic is to really put more resources into prevention in rural areas that are really horribly affected in a lot of the cases.

Wilner: Oren, I want to thank you very much for sharing these troubling results with Medscape. I look forward to discussing your future results with you.

Miron: I really hope to talk with you about happier findings in the future, especially as it relates to addressing this problem. Thank you, and thank you to all of the viewers.

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