Children to young adult suicide rates by sex, race/ethnicity and method 2017–2021—essential data for a community response in the United States

Introduction

Suicide is comprised of emotional, psychological, and social components (1). Unfortunately, suicide rates are increasing across all age groups (1-3). Presently, it is the third leading cause of death in those aged 10 to 24 years, and the second leading cause of death in the youngest of this cohort, ages 10–14 years (4). Females have more suicide attempts compared to males, but males are more likely to die by suicide compared to females (5-7).

Suicide and suicidal behavior can be influenced by social determinants of health (e.g., poverty, low employment opportunities, violence and abuse). Disparity in suicide rates is apparent in groups such as veterans, those who live in rural areas, minorities, middle-aged adults, people of color, and tribal populations. These cohorts carry an excess burden of suicide (8,9). Although, suicide trends and disparity rates have been documented for the youth and young adult (10), there is a parity of data on the suicide rates for this age cohort during the coronavirus disease 2019 (COVID-19) pandemic lockdown.

This period of time is associated with social isolation, loneliness, and hopelessness which may have exacerbated the developmental and transitional challenges of this age cohort (11-15). Therefore, we evaluated deaths by suicide trends (from 2017–2021) for those aged 10–24 years old by sex and race/ethnicity and by sub-groups 10 to 14, 15 to 19, and 20 to 24 years old in order to provide suicide patterns to assist emergency departments, local community leaders and policy makers in developing appropriate and targeted suicide prevention interventions for now and for future pandemics (16). We present this article in accordance with the STROBE reporting checklist (17) (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-54/rc).

Methods

Data sources

Death data (2017 to 2021) were obtained from the U.S. National Vital Statistics System (NVSS) of the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) (18). This study was exempt from human subjects’ research requirements due to data anonymity and was approved as exempt by our institutional review board, with a waiver of consent granted. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

The NCHS compiles information annually from death certificates filed in all 50 states and Washington D.C., and inputs it into the NVSS (19). Causes of death are coded according to the International Classification of Diseases (ICD) revision in use at the time of death, which was the 10th revision (ICD-10) for 1999–2020. The underlying cause of death is defined by the World Health Organization as “the disease or injury which initiated the train of events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury”. Conditions not listed as the underlying cause were defined as contributory causes of death.

ICD-10 codes U03, X60–X84 [suicides by poisoning (X60–X69), suffocation (X70), and firearm (X72–X74)], and Y87.0 were used to identify suicide deaths among those aged 10–24 years old during the study timeframe of 2017–2021. Other means included cut or pierce, drowning, falls, fire or flame, other land transport, struck by trains or automobiles, other specified classifiable injuries, other specified not elsewhere classified injuries, and unspecified injuries (20,21).

Socio-demographic variables included age at death, sex, race/ethnicity, marital status, and college education (some college credit, associate degree, or bachelor’s degree). Other comorbidities including neurological disorders, alcohol abuse, drug abuse, psychoses, and depression were defined using the Elixhauser comorbidity index (ECI) (22).

Statistical methods

Characteristics of suicide decedents were compared across age group, race or suicide method by using non-parametric Kruskal-Wallis tests and Pearson Chi-squared tests. Suicide rates were calculated by age, sex and race/ethnicity, using population estimates from the U.S. Census Bureau’s National Population Projections data (23).

Temporal trends in rates were analyzed using joinpoint regression analysis with the National Cancer Institute’s Joinpoint software (24). Further details on this analysis can be found on the CDC website (https://www.cdc.gov/nchs/hus/sources-definitions/joinpoint.htm). Briefly, joinpoint analysis identifies whether different lines are connected at inflection points or “joinpoints” and determines the number of joinpoints to incorporate. A significant joinpoint at 2019 for suicide rates was identified for the entire study period. Consequently, we reported the average annual percent change (AAPC) for 2017–2021 and the annual percent change (APC) for 2017–2019 and 2019–2021 with their respective 95% confidence intervals (CIs) (25). Trends were described as increasing or decreasing if the APC was significantly different from 0; otherwise, trends were described as stable or level. Data analysis was conducted using SAS software, version 9.4 (SAS Institute, Cary, NC, USA).

Results

Demographics

Between 2017 and 2021, there were 33,911 suicides among youth aged 10–24 years: 8.3% were aged 10–14 years, 34.5% aged 15–19 years, and 57.2% aged 20–24 years. The majority of decedents were male (79.0%). By race/ethnicity, 61.9% were non-Hispanic White (NHW), 12.6% non-Hispanic Black (Black), 17.1% Hispanic, 4.9% Asian, and 2.7% American Indian and Alaskan Native (AIAN). The percentage of male suicides increased with age from 63.8% in those aged 10–14 years to 82.4% in those aged 20–24 years, while the percentage of female suicides decreased with age from 36.2% in those aged 10–14 years to 17.6% in those aged 20–24 years (Table 1).

Comorbid conditions included depression (4.6%), alcohol abuse (2.0%), neurologic disorders (1.7%), and drug abuse (1.3%). Firearms accounted for the most common suicide method (48.8%), followed by suffocation (35.7%) and poisoning (7.7%). Notably, the use of firearms increased with age, from 36.0% in those aged 10–14 years to 51.9% in those aged 20–24 years (P<0.001). Conversely, suffocation decreased with age, from 56.1% in those aged 10–14 years to 31.4% in those aged 20–24 years (P<0.001) (Table 1).

Compared to suicides by poisoning and suffocation, firearms were more likely to involve males (88.6% vs. 50.9% vs. 72.3%) and White youths (66.4% vs. 64.0% vs. 57.1%). Suicides by poisoning were more likely to involve alcohol (8.2% vs. 1.4% vs. 1.5%) and drug abuse (7.4% vs. 0.7% vs. 1.0%) compared to firearms and suffocation (Table 2).

Trends in suicide rate (per 100,000) by age, sex, and race/ethnicity from 2017–2019

During the study period (2017–2021), the overall youth suicide rate per 100,000 remained stable, with an AAPC =+0.93% (95% CI: −2.16% to 3.97%). However, there was a significant increase observed post-2019, rising from 10.19% in 2019 to 11.18% in 2021, with an APC =+4.26% (95% CI: 1.21% to 7.47%). Prior to this, the trend was stable at 10.59% in 2017 and 10.19% in 2019 (APC =−2.36%, 95% CI: −5.29% to 0.63%). This pattern was consistent across age, sex, and race/ethnicity. Notably, the sharp increase during 2019–2021 was driven by youth aged 20–24 years (APC =+5.08%, 95% CI: 2.35% to 7.92%), with rates increasing from 17.09% in 2019 to 18.97% in 2021.

During 2019–2021, the suicide rate among females (APC =+5.25%, 95% CI: 1.26% to 9.47%) increased slightly faster than among males (APC =+4.02%, 95% CI: 1.17% to 6.99%), although male rates consistently exceeded female rates throughout the study period [15.75% (males) vs. 4.36% (females) in 2019 and 17.19% (males) vs. 4.89% (females) in 2021]. Across racial groups, the highest increase was observed among Black youth (APC =+12.99%, 95% CI: 10.08% to 16.06%), with the highest rates observed in AIAN youth (36.97%), followed by White (12.63%), Black (11.52%), Asian (9.60%), and Hispanic (7.85%) youth in 2021 (Table 3). Characteristics of youth suicide over time are presented in Table S1.

Adolescents (10–14 years)

Adolescents aged 10–14 years experienced relatively stable suicide rates from 2017 to 2021, with the rate remaining at 2.89% per 100,000 in 2021 and an AAPC =+2.69%, 95% CI: −2.46% to 7.92% for 2017–2021) in 2021. However, this stability was not apparent when deaths by suicide rates (per 100,000) were reviewed by gender and ethnicity with female deaths by suicides increased from 1.67% in 2017 to 2.38% 2021 with an AAPC of +7.28% (95% CI: 1.5% to 13.23%). This rise was particularly pronounced among Black females (from 1.38% in 2017 to 2.65% in 2021: AAPC =18.57%, 95% CI: 15.93% to 21.30%) and Hispanic females (from 1.19% in 2017 to 2.15% in 2021: AAPC =16.46%, 95% CI: 7.61% to 26.09%), accelerating notably from 2019 to 2021 (APC =22.52%, 95% CI: 19.17% to 26.00% and APC =17.39%, 95% CI: 0.35% to 37.73%, separately) (Table 3 and Figure 1A-1D).

Figure 1 Suicide trends for ages 10–24 years old by age, sex and race. (A-D) Suicide trends for aged 10–14 years old by sex and race. (E-H) Suicide trends for aged 15–19 years old by sex and race. (I-L) Suicide trends for aged 20–24 years old by sex and race. AIAN, American Indian and Alaska Native.

Teenagers (15–19 years)

Among teenagers aged 15–19 years, overall suicide rates remained stable at 11.14% per 100,000 in 2021 (AAPC =−1.97%, 95% CI: −6.51% to 2.63%). However, suicide rates among White youth showed a decreasing pattern (AAPC =−4.22%, 95% CI: −8.07% to −0.36%), driven by White males (AAPC =−4.68%, 95% CI: −8.63% to −0.68%) than White females. This declining trend was interrupted following the COVID-19 pandemic driven by increasing rates among Black youth (APC =+13.37%, 95% CI: 11.68% to 15.10%). Specifically, Black females and males experienced increases from 4.35% to 5.89% (AAPC =8.17%, 95% CI: 0.24% to 16.60%) and from 12.73% to 15.26% (AAPC =5.11%, 95% CI: 1.14% to 9.24%), respectively, with notable rises during 2019–2021 (APC =21.9% and APC =10.5%, respectively) (Table 3 and Figure 1E-1H).

Young adults (20–24 years)

From 2017 to 2021, the suicide rate among young adults aged 20–24 years remained stable at 18.97% per 100,000 (AAPC =−2.46%, 95% CI: −0.58% to 5.46%). However, joinpoint regression detected a significant increase post-2019, rising from 17.09% in 2019 to 18.97% in 2021, with an APC =5.08%, 95% CI: 2.35% to 7.92%. Prior to this, the trend was stable, with rates of 16.96% in 2017 to 17.09% in 2019 and an APC =−0.19%, 95% CI: −2.89% to 2.55%). This pattern was consistent across sex. During the pandemic lockdown period (2019–2021), there was a notable increase observed in Black females (5.61% to 7.24%; APC =+16.62%, 95% CI: 1.18% to 34.37%) and Black males (25.71% to 33.47%, APC =+14.24%, 95% CI: 9.59% to 19.21%).

Unlike other races from 2017 to 2019, Hispanic females experienced an increase in trend before 2019 from 3.79% to 5.13% (APC =+14.16%, 95% CI: 1.50% to 28.29%) and Hispanic males from 17.94% in 2017 to 20.64% in 2019 (APC =+6.91%, 95% CI: 5.60% to 8.25%), but the trend slowed down during the COVID-19 pandemic lock down (APC =+1.06%, 95% CI: −2.36% to 4.62%) (Table 3 and Figure 1I-1L).

Compared to suicides before the pandemic, during the COVID-19 pandemic lockdown time, suicides were more likely to occur among young adults (58.8% vs. 56.3%), Black (14.1% vs. 11.7%), and Hispanic individuals (17.8% vs. 16.7%). Firearms were the predominant method used post-pandemic (52.6% vs. 46.5%), whereas there were no significant differences in comorbidities between the two periods (Table 4).

Discussion

The findings of this study reveal several noteworthy patterns and shifts in youth suicide rates across different demographic groups between 2017 and 2021. Overall, while the youth suicide rate showed stability during the initial part of the study period (2017–2019), a significant increase was observed post-2019, particularly among older adolescents and young adults aged 20–24 years. This upward trend appears to indicate a critical shift in suicide patterns among these age groups (10).

Although Whites continued to comprise the majority of suicides, the rate of White youth deaths by suicide decreased from 2017–2021, while deaths by suicide among Black, Hispanic, and others (AIAN, Asian, other) youth increased. Additionally, from 2017–2021, the use of firearms as the method of suicide increased while suffocation as a method of suicide decreased. Importantly, our trend analysis demonstrated that the COVID-19 lockdown period had a negative impact on deaths by suicides across all age groups where the rate per 100,000 increased from 10.19% in 2019 to 11.18% in 2021 which was an average increase of 4.3% per year from 2019–2021, an increase which was primarily driven by Black females and males.

Although the overall suicide rates among the 10–14-year-old cohort appeared stable at approximately 8%, during the 2019–2021 period, there were notable increases observed among Black and Hispanic females after 2019. Black females demonstrated an increasing trend with an average increase of 22.5% a year for 2019–2021 compared to an average increase of 15% a year noted during 2017–2019. Hispanic females, on the other hand, had a suicide rate that appeared to be slowing for 2017–2019 at an average percent change of 15% per year but then experienced a sharp and significant increase at 17% increase per year in deaths by suicide for 2019–2021.

These trends were also found for the other two age cohorts, 15–19 and 20–24 years old. Among teenagers aged 15–19 years, suicide rates were stable through 2019 but were then followed by significant increases. Notably, while White youth showed declining trends, Black males and females experienced marked increases during 2019–2021.

In young adults aged 20–24-year-old, the initially stable suicide rates also gave way to a pronounced increase after 2019. This increase was driven mainly by Black females and males. Black females’ death by suicide trend went from being stable for 2017–2019 to a sharp and significant increase for 2019–2021. Black males, on the other hand, were experiencing an increasing trend through the study but also had a sharp increase in deaths by suicide for 2019–2021. AIAN males and to a smaller extent Hispanic males also experienced significant increases in their suicide rates.

This updated study on youth suicide provides a granular analysis of the characteristics of children through young adults who died by suicide, highlighting the major racial/ethnic as well as sex disparities in the burden of suicide (10). Since the observed increase in suicide rates occurred post-2019, this time period coincides with the onset of the COVID-19 pandemic and the COVID-19 pandemic lockdown, we suggest that there could be a potential association between the pandemic-related stressors exacerbating existing vulnerabilities or it may have introduced new risk factors among this young age group which will require further study (11-15).

The alarming increase in suicides among the Black youth, especially females, also extends and validates a recent study noting the same devastating trend among Black youth (26). Although the rates were not as high as the Black youth, Hispanics and AIAN youth were also adversely affected during 2019–2021.

The use of firearms increased across the study time frame and was the primary method of suicides among the Black, White, and “other” ethnicities youth and was the second most used method for Hispanic, AIAN and Asian youths. These striking findings provide further evidence that local and national policy makers must work to lower accessibility to firearms as it is known that ease of access to firearms is one of the main contributors to successful deaths by suicide especially among males (7). These patterns were similar to those reported for older age groups denoting that the risk of death by suicide does not necessarily decrease as one ages so finding solutions and building strong community support systems are vital across the age span (8,9,16).

Additionally, results of recent work on the use of high lethal means of suicide suggest that those who select more lethal means of suicide such as firearms may have displayed aggressive behavior in the form of hostility more often prior to their suicide (27,28). Furthermore, the presence of hostility is often due to an individual experiencing unbearable mental pain, difficulties in communication, interpersonal difficulties, impulsivity, and/or decision-making deficits (27,28). These results, along with the recent Surgeon General statement on the use of firearms as a public health emergency, suggest that healthcare workers and community groups should focus their assessments on recognized risks (being male and using more lethal means of suicide) associated with deaths by suicide and work closely with community mental health liaisons as well as local/state policy makers to provide suicide prevention resources (29-33).

Limitations

Identification of suicides relies on cause of death from death certificates which may be subject to misclassification, with the potential for both over and underreporting. Similarly, death certificate race/ethnicity data may have heterogenous sources, also at risk of inaccuracy. Importantly, due to small cell sizes (<10 events) in certain sub-analyses, the trend results may not be significant when in fact they may be. There was a low rate of psychiatric illness reported which may come from underreporting due to lack of diagnosis data within NVSS or the lack of diagnosis in a young age group. It is important to note that diagnoses rates may increase as the United States Preventative Task Force has updated guidelines on screening for anxiety and major depressive disorder for ages 8–18 and 12–18 years old, respectively (34). However, whether an increase in screening is translated to the NVSS reporting is uncertain at this time especially given the current state of underreporting.

Conclusions

Black and Hispanic females as well as Black, Hispanic and AIAN males (particularly those aged 20–24 years) experienced disproportionate increases in deaths by suicides from 2017–2021 most significantly during the COVID-19 lockdown period (2019–2021). The use of firearms increased significantly, accounting for over 50% of suicides during 2019–2021. This finding requires immediate measures to prevent easy access to firearms especially among males as firearms are one the main contributors to their successful suicides. Efforts at the national, state and local levels should focus on developing culturally appropriate suicide prevention interventions and support systems tailored to address the specific needs of these communities.

Acknowledgments

This work was an oral presentation at the American College of Emergency Physicians annual conference which was held in October 2022, San Francisco, CA, USA.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-54/rc

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-54/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-54/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was exempt from human subjects’ research requirements due to data anonymity and was approved as exempt by our institutional review board, with a waiver of consent granted. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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