Temporal Trends in Suicide Methods Among Adolescents in the US

Introduction

Deaths due to suicide increased 45.2% in the past 10 years among adolescents in the US,1 with disproportionate increases among youths who are members of minority groups.2,3 Method of suicide is a strong determinant of suicide fatality, and research on temporal trends in suicide methods among decedents is scarce, especially by race. To address concerns regarding increasing suicide rates, we examined temporal trends in suicide methods among adolescents, with attention to variation by sex and race.

Methods

This cross-sectional time series followed the STROBE reporting guideline. Owing to the use of publicly available data from the Centers for Disease Control and Prevention WONDER database, institutional review board approval and informed consent were not necessary according to the Common Rule.

Suicide death data for adolescents aged 10 to 19 years and stratified by sex and race were drawn from the National Center for Health Statistics’ Multiple Cause of Death files from 1999 to 2020.1 Racial data were collected owing to increasing suicide rates among members of minority groups. Racial categories included American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, and White. Ethnicity data were not included in the present study. Method of suicide was categorized as firearm, asphyxiation (including hanging, strangulation, and suffocation), and a single category comprising other methods (poisoning, drowning, fall, fire, and cuts) due to lower base frequency. Locally estimated scatterplot smoothing regression curves with 95% CIs and logistic regression models were used to evaluate the interaction of time (5-year periods) on the association between race and suicide method. Statistical significance was set at P < .05.

Results

From 1999 to 2020, 47 276 adolescents aged 10 to 19 years (3.0% American Indian or Alaska Native, 4.0% Asian or Pacific Islander, 11.0% Black or African American, and 82.0% White; 23.0% female and 77.0% male) died by suicide in the US. Suicide rates increased steadily for male adolescents, from 7.4 to 9.7 per 100 000 population; for female adolescents, from 1.6 to 3.6 per 100 000 population. Among male adolescents who died by suicide, firearms remained the leading suicide method (Figure), but trends differed substantially by race, with firearms increasingly accounting for deaths among racial minority youths. From 2011 to 2020, the proportion of suicide deaths involving firearms increased from 40.0% to 51.0% among Black male adolescents compared with 49.0% to 52.0% among White male adolescents (Table). Among female adolescents, asphyxiation was the leading method since 2000 (Figure). Suicide death by asphyxiation increased from 53.0% in 1999 to 2001 to 74.0% in 2017 to 2020 among American Indian or Alaska Native female adolescents compared with 37.0% to 52.0% among their White counterparts (Table).

Logistic regression models evaluating the association between race and death by asphyxiation vs other methods and between firearms vs other methods, stratified by year and sex, indicated statistically significant interactions. For instance, in 2019 to 2020, Black female adolescents had 1.43 (95% CI, 1.05-1.95) times the odds of suicide death involving asphyxiation vs all other methods compared with their White counterparts, whereas from 1999 to 2003 these odds were 1.06 (95% CI, 0.74-1.52).

Discussion

This time series found that suicide deaths by asphyxiation increased over time among female adolescents who were members of minority groups, whereas firearms remained the predominant method of suicide death among male adolescents. Furthermore, the proportions of suicide deaths involving firearms among Black male adolescents increased at a much faster pace than that among other racial groups.

Prevention of suicide involving firearms through restriction of access remains urgent.4 The results of this study suggest an additional need to expand suicide prevention initiatives. Reducing access to asphyxiation means is difficult outside of institutionalized settings; thus, a focus on reducing the frequency and intensity of suicidal crises is critical. The emergence of suicide as a public health concern among Black or African American and Asian or Pacific Islander adolescents indicates a need for culturally adaptive, structurally competent approaches to ensure access to mental health services.

Limitations of this study include potential errors in suicide mortality certification and underreporting of suicide deaths, especially for members of minority groups.5 Future studies should consider assessing age, state-level differences, and trends of method of suicide deaths, including clinical characteristics and ethnicity of adolescents.6

Back to top Article Information

Accepted for Publication: August 25, 2022.

Published: October 12, 2022. doi:10.1001/jamanetworkopen.2022.36049

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Joseph VA et al. JAMA Network Open.

Corresponding Author: Victoria A. Joseph, MPH, Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, 7th Floor, Room 733, New York, NY 10032 (vaj2118@cumc.columbia.edu).

Author Contributions: Ms Joseph had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Joseph, Martínez-Alés, Gould.

Acquisition, analysis, or interpretation of data: Joseph, Olfson, Shaman, Keyes.

Drafting of the manuscript: Joseph.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Joseph, Keyes.

Obtained funding: Shaman, Keyes.

Administrative, technical, or material support: Joseph, Shaman.

Supervision: Martínez-Alés, Shaman, Gould, Keyes.

Conflict of Interest Disclosures: Dr Shaman reported receiving grants from National Institute of Mental Health during the conduct of the study, partial ownership of SK Analytics with Colombia University, and consulting for BNI. Dr Keyes reported consulting for plaintiffs’ law firms for opioid litigation outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by grant R01 MH121410 from the National Institutes of Health.

Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.