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This article is intended for pediatricians, emergency medicine clinicians, family medicine/primary care practitioners, nurses, psychiatrists, and other members of the healthcare team who treat and manage girls who may be at risk for suicide.
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Associate CME Clinical Director, Medscape, LLC
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In the United States, suicide is the second leading cause of death among youth aged 10 to 19 years, with rates increasing 33% from 1999 to 2014. Although suicide rates are historically higher in male than in female youth, recent national mortality data suggest that this gap may be narrowing. Development of targeted prevention strategies requires understanding disparities in youth suicide rates.
The goal of this cross-sectional study using the most recent national mortality data available through 2016 was to examine trends in suicide rates among US youth aged 10 to 19 years by age group, sex, race/ethnicity, method of suicide, and US regions.
Suicide rates have increased among all youth, but there has been a particularly sharp rise among young girls, new research shows.
A new study conducted by the Centers for Disease Control and Prevention reveals that the suicide rate among girls aged 10 to 14 years tripled from 1999 through 2014. Although males traditionally take their own lives at much higher rates, researchers at Nationwide Children's Hospital found that this sex gap is narrowing.
"Based on recent mortality data showing an increase in female youth suicide rates, we investigated trends among US youth aged between 10 and 19 to better understand if the traditional gap between male and female youth suicide rates is decreasing," lead study author Donna Ruch, PhD, postdoctoral scientist at the Center for Suicide Prevention and Research, the Research Institute at Nationwide Children's Hospital in Columbus, Ohio, told Medscape Medical News.
The study was published online May 17 in JAMA Network Open.[1]
Sex Gap Narrowing
Finding a considerable rise in suicide among girls aged 10 to 19 years, Dr Ruch and team explored whether this also indicates a narrowing of the typically wide gap in rates between male and female youth.
"Consistent with earlier studies, our findings provide evidence of racial/ethnic disparities in youth suicide rates among males and females. The ratio of male-to-female suicide rates decreased for all racial and ethnic categories since 2007, with a significant declining trend across the study period in younger non-Hispanic white youth and older non-Hispanic youth of other races," said Dr Ruch.
"These results expand upon previous reports of a disproportionate increase in the suicide rate among female relative to male youth, and highlight a significant reduction in the historically large gap in suicide rates between sexes," she added.
The cross-sectional study employed period trend analysis of US suicide decedents aged 10 to 19 years from 1975 to 2016.
In the study, 85,051 US youth suicide deaths were identified, including deaths of 68,085 boys and 16,966 girls, from 1975 through 2016. The male-to-female incidence rate ratio (IRR) was 3.82 (95% confidence interval [CI], 3.35-4.35).
Deidentified data were obtained from the publicly available Wide-ranging Online Data for Epidemiologic Research (WONDER) records, in which suicide was the cause of death in this age group.
WONDER population estimates were used to calculate crude suicide rates per 100,000 individuals. Joinpoint regression software assessed these trends by sex and age.
Negative binomial regression was employed to estimate IRRs and corresponding 95% CIs to compare suicide rates within select periods for boys and girls.
Stata/IC software and a 2-tailed significance level of P<.05 were used to conduct the statistical analysis. A chi-squared test was performed to compare male-to-female IRR for each period and to identify statistically significant trends within demographic subgroups.
More Lethal Means
The findings show that hanging or suffocation had significantly increased as cause of death among young women.
"A particularly important finding relates to changes in method of suicide, with hanging and suffocation showing a greater increase as the cause of death among females relative to males," said Dr Ruch.
"Consistent with previous reports of increasing rates of suicide by hanging or suffocation in female youth, the ratio of male-to-female suicide rates by hanging or suffocation declined significantly for both age groups," she continued.
"It's troubling that a growing proportion of females are choosing this more violent and lethal method, since it's well documented that females have higher rates of attempted suicide," said Dr Ruch.
Suicide among female youth showed the greatest percentage increase after a downward trend through 2007 compared with boys, with 12.7% vs 7.1% for individuals aged 10 to 14 years and 7.9% vs 3.5% for those aged 15 to 19 years.
The sex gap significantly decreased in male-to-female IRR for children aged 10 to 14 years (IRR, 3.14; [95% CI, 2.74-3.61] to IRR, 1.80 [95% CI, 1.53-2.12]) and for those aged 15 to 19 years (IRR, 4.15 [95% CI, 3.79-4.54] to IRR, 3.31 [95% CI, 2.96-3.69]).
By race, significant declining trends were also found in the male-to-female IRR in non-Hispanic white youth aged 10 to 14 years (IRR, 3.27 [95% CI, 2.68-4.00] to IRR, 2.04 [95% CI, 1.45-2.89]) and non-Hispanic youth of other races aged 15 to 19 years (IRR, 4.02 [95% CI, 3.29-4.92] to IRR, 2.35 [95% CI, 2.00-2.76]).
Dr Ruch believes this significant reduction in the traditionally wide difference between male and female suicide rates highlights a need for more targeted interventions in which suicide risk by sex is considered.
"The narrowing gap in suicide rates between male and female youth underscores the urgency to identify suicide prevention strategies that address the unique developmental needs of female youth. Future research examining sex-specific risk and protective factors associated with youth suicide and how these determinants can inform interventions is warranted," she said.
Social Media a Factor?
In an accompanying editorial, Joan Luby, MD, and Sarah Kertz, PhD, note that the study shows "an unprecedented escalation" in suicide rates in young girls.[2]
They add that although the study does not shed any light on the reason for the leveling of suicide rates between boys and girls, social media is a "key target of interest."
"While this is an area in need of further well-controlled investigation, a marked increase in the use of social media for peer interaction, with more than 95% of youth now connected to the internet, represents a clear and powerful social change occurring over the same period," they write.
Dr Luby and Dr Kertz also note that "social media use is more strongly associated with depression in girls compared with boys, and cyberbullying is more closely associated with emotional problems in girls compared with boys."
Commenting on the findings for Medscape Medical News, Mary T. Rourke, PhD, director of school psychology concentration at Widener University, Chester, Pennsylvania, and co-director of the Widener Child Therapy Clinic, who was not involved in the study, noted that girls attempt suicide by less lethal means compared with boys.
This, she said, "may color the way we respond to suicidal statements in girls. I think we're going to have to think about that a lot differently in light of these findings, especially regarding our younger girls."
As for the potential influence of social media on the increasing rates of suicide in girls, Dr Rourke said she believes the "jury is out."
"Certainly social media is important, but it's only one aspect of a culture that can be overwhelming. In fact, social media can even be helpful when dealing with a suicide crisis. Clinically, I've had a number of clients who have expressed something on social media and a friend has seen it and shown an adult or a parent has reviewed the child's messages.
"However, younger kids are impulsive, less likely to talk, less likely to show depression and anxiety in a way adults can understand. This may be a way social media plays a role. Because of social media, the means and models of suicide are much more accessible to younger kids. Pair that with higher levels of impulsivity and difficulty communicating their feelings, and it may explain the increasing risk at younger ages. Maybe the sex differences which we've seen in prior generations aren't as relevant considering these newer factors," she added.
One coauthor was supported a grant from the National Institute of Mental Health, National Institutes of Health, and is an unpaid member of the scientific advisory board of Clarigent Health. Dr Rourke has disclosed no conflict of interest.
JAMA Netw Open. Published online May 17, 2019
• This cross-sectional study used period trend analysis of suicides from January 1, 1975, to December 31, 2016, among US youth aged 10 to 19 years.
• The investigators analyzed data for periods defined by statistically significant changes in suicide rate trends and calculated suicide rates using population estimates.
• Use of joinpoint regression allowed evaluation of period trends in suicide rates by sex and age group.
• Negative binomial regression comparing male and female suicide rates within periods allowed estimation of IRRs.
• Of 85,051 youth suicides from 1975 to 2016, 68,085 (80.1%) were in boys and 16,966 were in girls (19.9%), yielding a male-to-female IRR of 3.82 (95% CI, 3.35-4.35).
• Suicide rates for girls followed a downward trend until 2007, but subsequently had the largest significant percentage increase compared with boys (12.7% vs 7.1% for youth aged 10-14 years; 7.9% vs 3.5% for youth aged 15-19 years).
• Across the study period, there was a significant decrease in the male-to-female IRR for youth aged 10 to 14 years (from 3.14 [95% CI, 2.74-3.61] to 1.80 [95% CI, 1.53-2.12]) and for those aged 15 to 19 years (from 4.15 [95% CI, 3.79-4.54] to 3.31 [95% CI, 2.96-3.69]).
• There were significant decreasing trends in the male-to-female IRR among non-Hispanic white youth aged 10 to 14 years (from 3.27 [95% CI, 2.68-4.00] to 2.04 [95% CI, 1.45-2.89]) and among non-Hispanic youth of other races aged 15 to 19 years (from 4.02 [95% CI, 3.29-4.92] to 2.35 [95% CI, 2.00-2.76]).
• Among youth aged 15 to 19 years, there was a significant increase in the male-to-female IRR for firearms (χ2=7.74; P=.02 for sex×period interaction).
• In both age groups, there was a significant decline in the male-to-female IRR of suicide by hanging or suffocation (10-14 years: χ2=88.83 [P<.001] for sex×period interaction; and 15-19 years: χ2=82.15 [P<.001] for sex×period interaction).
• Across the study period, there was no significant change in the male-to-female IRR of suicide by poisoning.
• On the basis of their findings, the investigators concluded that there was a significant reduction in the historically large gap in youth suicide rates between boys and girls, highlighting the urgent need for interventions that consider unique differences by sex and developmental level.
• After a downward trend in suicide rates for both sexes in the early 1990s, rates of youth suicide increased since 2007, as did narrowing of the gap between male and female rates, with the largest percentage increase in younger female individuals.
• All US regions showed similar trends.
• The racial/ethnic disparities in youth suicide rates among boys and girls in this study are consistent with those of earlier studies.
• Rates of suicide by hanging or suffocation and in some racial/ethnic groups among female youth are currently approaching those of male youth.
• This is particularly troubling, as hanging/suffocation is a more violent and lethal method, and therefore suicide attempts by this method are more likely to be successful.
• These findings should encourage clinicians to be even more concerned about suicidal statements or behavior in girls, especially in younger girls, as younger children may be impulsive but less likely to express or manifest depression and anxiety in ways that adults can identify.
• The increasing trend in differences between male and female suicide rates by firearms highlights the ongoing need for prevention strategies intended to restrict access to lethal means.
• The observed increase in female suicide rates might in part be explained by differential increases over time in risk factors for suicide, such as a history of suicidal behavior.
• Rates of hospitalization for suicidal ideation and suicide attempts in youth have increased over time, more so in girls than in boys.
• The investigators recommend additional studies of sex-specific risk and protective factors associated with youth suicide and of how these predictors can inform interventions.
• To improve suicide prevention strategies and interventions, future research should also address distinct mechanisms of suicide in males and females within racial/ethnic groups.
• Study limitations include inability to explain reasons underlying the narrowing of the sex gap in youth suicide, possible effects of variations in cause of death coding systems, and inability to determine change during the study period in accuracy of classification of a death as suicide in youth.
• Data for Hispanic and non-Hispanic categories were not captured before 1990 and were excluded from select states through 1996, warranting caution in interpreting early suicide trends among racial/ethnic groups.
• An accompanying editorial noted that the study did not address the reason for narrowing of the gap in suicide rates between boys and girls, but that social media could be partly responsible.
• The marked increase in the use of social media for peer interaction during the study period, with more than 95% of youth now online, is a clear and powerful social change, the effect of which should be studied further.
• Social media may increase accessibility of suicide methods and models to younger children.
• In addition, there are stronger associations in girls than in boys of social media use with depression, and of cyberbullying with emotional problems.
• During the last 15 years, the gap between male and female rates of suicide among youth aged 10 to 19 years in the United States has decreased significantly, particularly among younger children and for suicide by hanging or suffocation.
• Findings of this cross-sectional study highlight the urgent need for interventions that consider unique differences by sex, race, and developmental level.
• Implications for the Healthcare Team: Clinicians should be even more concerned than previously about suicidal statements or behavior in girls, especially in younger girls, as younger children may be impulsive but less likely to express or manifest depression and anxiety in ways that adults can identify.
• The role of the healthcare team member is to continue to enhance their own knowledge through seeking up to date evidence, guide and support patients to improve outcomes, in collaboration with other members of the healthcare team.
