- The Utah Department of Health and Human Services released a deep study of youth suicides.
- The project used psychological autopsies to understand circumstances behind each death.
- Researchers urge parents to directly ask their children if they have ever thought about suicide.
Suicide is a leading cause of death among young Utahns, ages 10-17, and the state has spent years trying to figure out why teens choose to end their lives.
The Utah Department of Health and Human Services recently released its “Utah Youth Suicide Research Project,” looking deeply at actual youth suicides between 2016 and 2019 to offer insights and recommendations for families, communities, healthcare providers and educators. The goal is to pair data with the stories of those lost to suicide in hopes of crafting prevention that works, including recommendations from Utah’s Suicide Child Fatality Review Committee.
Both findings and recommendations, while based on Utah deaths, are expected to resonate across the nation, as suicide is consistently the second- or third-leading cause of death among young people.
The study identified factors loved ones can’t afford to ignore, including behavior changes that can signal something bad is brewing, relationship breakups, parental struggles, a history of abuse and feeling unseen. Severe mental health issues were not among the major factors.
“Feeling unseen, unlikeable, isolated, or like an outsider — even though many youth had friends they spent time with regularly — was a common theme described by families and peers,” per the report.
“For many young people, a bad argument or a breakup can feel like a disaster and lead to quick, life-altering decisions,” the researchers found, noting two-thirds of them had recently had such a rift or were worried about one. The report said those emotional moments are a time for adults to offer extra support and not brush the pain off as just part of life.
Michael Staley, suicide prevention research coordinator at the state health department’s Office of the Medical Examiner, said the study found parents often notice behavioral change and then “talk themselves out of assuming the worst or addressing it.”
There’s a common perception that friends are more aware when a child is struggling, he said, but in-depth interviews called psychological autopsies showed parents often really knew their children well.
“There were instances where families didn’t know that they were observing a warning sign of suicide, and we have got more public health education to do,” he said. “But in a lot of cases, they did see that things were changing, and they weren’t changing for the better. And either they didn’t know how to ask their child about this, or they just talked themselves out of the worst-case scenario.”
He added, “Nobody wants to think the people they love could possibly be thinking of ending their own life — it’s scary, unbelievable. How could my son or daughter possibly believe the narrative the world would be better off without them? We want families and friends to feel empowered to push through the awkward reaction of ‘Why are you asking me that?’ and have the hard, important conversations: ‘Have you thought of suicide? Do you really believe the world would be better off without you in it?’”
Those questions open doors to honest conversations and opportunities to save lives, said Staley, who also urged families to make an environment safe immediately at any hint of risk by removing means that might lead to impulsive action, such as guns, substances or even belts.
“It’s important not to freak out,” said Staley, who warned that escalates an already fraught situation. Better to respond with something like, “Thanks for telling me that. That probably took a lot of bravery.”
Addressing suicide directly, he said, lets loved ones talk about the child’s value and starts the journey to hope and finding help.
A psychological autopsy
The project has been underway for years, using psychological autopsies conducted by medical examiner staff. Utah’s youth suicides in the study period were 46.5% higher than the national average, per the report. The researchers conducted the “autopsies” through detailed interviews with those closest to the teens who died, including relatives and friends, to understand the “who” and ”why" of young people choosing death.
In a psychological autopsy, questions are asked of the person deemed closest to the one who died, then others who were as close or nearly so are asked the same question to validate findings, Staley said. Besides those ages 10-17, the study included suicides involving 18-year-olds if they had just graduated from high school very recently.
All families with a young suicide in 2016 to 2019 were invited to participate; 108 of the 203 families did. The actual interviews were completed by about mid-2022, after some delays during COVID.
Demographics of teen despair
Here’s some of what the report shows about the youth who died by suicide:
- Three-fourths were male.
- Nearly 80% were ages 16-18.
- Forty percent had an immediate family member die by suicide, often years before their own death.
- One in four previously lost a friend to suicide.
- Nine in 10 lived with parents or guardians and most lived in a middle-income household with adults who had jobs and health insurance.
- Nearly half had been diagnosed with at least one mental illness and 63% of them had seen a therapist, many within two weeks before their death.
- Thirty-seven percent had been disciplined at school, “some very near to the time they died,” and just over 4 in 10 had experienced at least one interaction with law enforcement or the justice system. But most of them had not had either experience.
- A disproportionate number attended an alternative school. Those students had a significantly higher risk profile, Staley said.
- Maltreatment of some sort was common, experienced by 80%, including physical, sexual or emotional abuse. Staley said families were candid about how learning of abuse changed family dynamics and even structure.
- Two-thirds had experienced other types of trauma, too, often years earlier, such as witnessing violence or surviving a natural disaster or seeing grave illness or death in someone they cared about.
- Bullying was “ubiquitous,” per Staley, who said more than 58% had been bullied and 1 in 5 were bullies themselves. But the psychological profiles suggested bullying didn’t appear to those asked to be a driving force in the death itself. Sextortion, on the other hand, while far less common, spiraled quickly and greatly raised the risk.
- The report showed that many young people who died by suicide lived in homes where those around them faced complex mental health or substance use challenges or were grieving loss themselves. There were extreme levels of distress.
Some findings are more counterintuitive. Those who died by suicide were not usually disconnected from others or extremely disengaged, according to those closest to them. More than 90% had someone they could count on in a crisis and nearly two-thirds were said to be “happy with their friendships.” Fewer than 1% reported not having people they liked spending time with. In spite of all that, family members and friends reported that roughly 6 in 10 didn’t feel like they belonged in their community.
Warning signs were there
More than half of the young people showed frequent mood changes, while around 45% had at least one signal something was amiss: They were lonelier or said they felt like a burden or hopeless or trapped.
Some also had changes in sleep patterns and appetite.
Many had just undergone or were pondering a major life change, whether a move, the previously mentioned breakup or heading to college or career. The authors urge families and communities to help youth learn resilience and build social skills that help them handle emotional ups and downs.
The report is careful to note not all of them showed all the signs. It was the pattern of change that most strongly signaled a struggle. The report warns parents and other loved ones that “any noticeable change in a young person’s normal routine or reactions is a signal they may need extra support.”
Friends were more likely to see the small changes, leading the researchers to conclude that young people need to be taught both how to spot such signs, and also the importance of involving a trusted adult.
Change is hard, especially when lots of things seem to be going wrong. The report found that a collision of multiple issues at once — its examples were health, housing and money problems — can create crisis. Communities can step in and help families stabilize. That can save lives.
What educators and clinicians can do
The interviews revealed missed opportunities in schools and primary care. Ninety-one percent had seen a doctor. Schools had tools the teens often didn’t use; just over 1 in 14 of the young people ever asked for help or called a suicide prevention lifeline though they knew about them.
“Our data leads us to believe that suicide prevention programs ought to be more expansive and create more opportunities for engagement, not less,” per the report.
“What we can’t do in a school system is say that, ‘Ooh, we have a suicide prevention program — it’s SafeUT.’ Because that’s only going to work for one segment of students. Schools have to deploy comprehensive strategies,” Staley said.
The report’s recommendations for educational settings include:
- Help those working in schools know both signs of child maltreatment and how to report it.
- Work with local behavioral health leaders to offer “wraparound” services for youth.
- Watch for signs of disengagement or a sense of not belonging.
- Have solid, evidence-based suicide prevention programs in place.
- Provide support for bereaved youth, especially in the wake of a suicide death of a family member or peer.
The report said educators should foster a positive emotional bond for students with teachers and peers. Belonging also includes being invited into activities, rather than being on the sidelines.
“Do students feel they can be their ‘whole self’ without hiding parts of their identity?” the report asks.
The advice for clinicians in healthcare settings is similar, starting with recognizing child mistreatment, traumatic experiences and adversity.
Other recommendations include screening all youth for substance use and abuse and employing evidence-based interventions as needed. Every primary care and emergency setting should screen for suicide risk and if risk is seen, create a safety plan before crisis arises.
Children with significant mental health concerns should receive effective, evidence-based treatment.
Many of the youth who died could have benefitted from improved care coordination across systems. While acknowledging healthcare providers are pressed for time, Staley emphasized that health systems need to train providers to better recognize when young people are struggling with mental health.
Challenges don’t end after the teenage years
”Whatever issues existed when you were 16, 17, 18 don’t get somehow dropped on the floor at the graduation stage. They continue into college ... or on non-college life paths,” Staley said.
In an unrelated media briefing sponsored by SciLine last week, experts talked about suicide risk, disparities and suicide prevention aimed at those of college age.
Suicide risk is high in the young adult group, “among both college students and their same-age peers,” said Dr. Adam Horwitz, clinical psychologist and assistant professor of psychiatry at the University of Michigan. “It’s actually slightly higher among those who are not in college.”
Those in both groups might be undergoing major transitions, like going to college or getting jobs. He said as independence increases, some of the protective factors, like parents nearby or structure can decrease and create vulnerability. “That’s when we sometimes see first onset for different mood disorders come into play.”
He added that student mental health problems surged in the pandemic and have not receded completely.
Suicide rates among young Black adults ages 20 to 24 are now higher than those of white peers, said Jasmin Brooks Stephens, assistant professor and clinical psychologist at the University of California Berkeley. She cited research indicating the lifetime history of suicide attempts are about 4% in the general population, 11% among sexual minorities and 40% among gender minorities.
“A lot of the reasons for this is when we think about our more known and traditional risk factors for suicide ideation, some of those can include what we call thwarted belongingness or this lack of belonging with other individuals,” she said.
She advocates for medical amnesty or similar policies in college to protect students from disciplinary action if they disclose they have suicidal thoughts or substance use during a crisis. Fear of “punitive consequences” can keep a young person from seeking help.
Dr. Christine Yu Moutier, psychiatrist and chief medical officer at the American Foundation for Suicide Prevention, said campus suicide prevention has long been reactive and needs to change so every person on campus at any level or position “knows what to do when they become concerned about a student.”
“Suicide prevention on college campuses, I think, in the past, was a bit of an afterthought. It was reactive in response to suicides or crises that were occurring, and we know that suicide is a complex health outcome,” she said. “A public health approach, when it is applied really robustly, means there will be a true prioritized strategic plan that’s sustained and measuring the impact of all of the multi-tiered approaches.”