Dying to Ask for Help: Suicide Trends and Treatment Disparities Among US

Adolescents

Michael A. Lindsey, PhD, MSW, MPH

Executive Director, NYU McSilver InstituteNYU Silver School of Social Work

Aspen Health Innovator Fellow, The Aspen Institute

MHTTC Network

Central East MHTTC Goals

Funded by SAMHSA to:• Accelerate the adoption and implementation of

mental health related evidence-based practices• Heighten the awareness, knowledge, and skills

of the behavioral health workforce • Foster alliances among culturally diverse

practitioners, researchers, policy makers, family members, and consumers

• Ensure the availability and delivery of publicly available, free of charge, training and technical assistance

Central East Region

HHS REGION 3Delaware

District of ColumbiaMaryland

PennsylvaniaVirginia

West Virginia

Introduction

• Rylan Thai Hagan

Carl Joseph Walker-Hoover

2009

Gabriel Taye2017

Seven Bridges

2019

From: Suicide Trends Among Elementary School-Aged Children in the United States From 1993 to 2012. JAMA Pediatrics, 2015;169(7), doi: 10.1001/jamapediatrics.2015.0465

Detroit, Michigan

Suicide among Youth in the United States

Quickstats: Suicide Rates For Teens Aged 15-19 Years, By Sex - United States, 1975-2015. https://www.cdc.gov/mmwr/volumes/66/wr/mm6630a6.htmCash, S. J., & Bridge, J. A. (2009). Epidemiology of youth suicide and suicidal behavior. Current opinion in pediatrics, 21(5), 613–619. doi:10.1097/MOP.0b013e32833063e1

2,200+2nd 111,000+accounted for

>2,200 deaths in this age group in

2017

leading cause of death among young people 12-18 years old

young people were seen in an

emergency department for

self-harm behavior in 2017

In 2017:

Trends in Suicidal Behaviors Among High School-Aged Youth in the U.S.: 1991-2017

Examined four indices of suicide behaviors among U.S. adolescents- - 1 in 5 adolescents are thinking about

suicide (18.8%)- - 1 in 10 has a suicide plan (14.7%)

Key Questions: - - What has been the trend over time

among the indices of suicide behaviors?- - Are there racial and gender

differences?

Lindsey, M. A., Sheftall, A. H., Xiao, Y., & Joe, S. (2019). Trends of Suicidal Behaviors Among High School Students in the United States: 1991–2017. Pediatrics, 144(5). doi: 10.1542/peds.2019-1187

Linear and Quadratic Trends for Suicidal Thoughts and Behaviors by Interactions of Race/Ethnicity and Sex, 1991-2017

Lindsey, M. A., Sheftall, A. H., Xiao, Y., & Joe, S. (2019). Trends of Suicidal Behaviors Among High School Students in the United States: 1991-2017. Pediatrics, 144(5). doi: 10.1542/peds.2019-1187\

Why the Increase in Injury by Attempt among Black Boys?

• May be engaging in increasingly lethal means when attempting suicide

• 2001-2017, 52% of 560 Black adolescent male suicides were by firearms; 34% usedhanging/suffocation.

• During study period, 56% of 204 Black adolescent female suicides were by hanging/suffocation; 21% used firearms.

• Limit access to firearms. And, provide more TREATMENT.

Linear and Quadratic Trends for Suicidal Thoughts and Behaviors by Interactions of Race/Ethnicity and Sex, 1991-2017

Lindsey, M. A., Sheftall, A. H., Xiao, Y., & Joe, S. (2019). Trends of Suicidal Behaviors Among High School Students in the United States: 1991–2017. Pediatrics, 144(5). doi: 10.1542/peds.2019-1187

Why the Acceleration in Attempts among Black Girls?

• Overall, female adolescents:— Experience more interpersonal stress from

cyberbullying and social media use— Experienced a significant increase in sadness or

hopelessness between 2007 and 2017 (from 35.8% to 41.1%)

• Black girls’ experiences with intersectional stigma and discrimination affect Black female youth's mental well-being

• More research is needed

Ruch DA, Sheftall AH, Schlagbaum P, Rausch J, Campo JV, Bridge JA. Trends in suicide among youth aged 10 to 19 years in the United States, 1975 to 2016. JAMA Network Open. 2019;2(5):e193886. doi:10.1001/jamanetworkopen.2019.3886

Are Black Kids Going Right to an Attempt?

Ideation to Action Framework

• The Ideation to Action framework aims to improve risk assessment and theoretical models of suicide

• Literature often takes youth with suicidal thoughts, plans, or attempts and compares them with non-suicidal youth

Klonsky, E. D., & May, A. M. (2014, 2015 & 2016). & Mars, B., et al. (2019). What distinguishes adolescents with suicidal thoughts from those who have attempted suicide? A population‐based birth cohort study. Journal of child psychology and psychiatry, 60(1), 91-99.

Ideation to Action Framework

• Most suicide risk factors are risk factors for ideation, not progression to a suicide attempt

• Most people who experience suicidal ideation do not attempt suicide

• The Ideation to Action framework explores the transition from suicidal thoughts to suicidal actions

Klonsky, E. D., & May, A. M. (2014, 2015 & 2016). & Mars, B., et al. (2019). What distinguishes adolescents with suicidal thoughts from those who have attempted suicide? A population‐based birth cohort study. Journal of child psychology and psychiatry, 60(1), 91-99.

Methods

• Data: 2015 & 2017 National Youth Risk Behavior Survey (YRBS)

• Data analytic sample: Students with suicidal thoughts, a suicide plan, and/or a suicide attempt within the past 12 months (N=4,989)

• Descriptive Statistics (frequencies; chi-square tests)

• Multinomial Logistic Regression (Stata; weights applied)

Results

• Four mutually exclusive groups identified and examined

Results - Demographics

Key Points

Compared to White youth, Black youth were• 3.7 times more likely to attempt suicide only rather than report

suicidal thoughts• 3.3 times more likely to attempt suicide only rather than report

thoughts and plans in combination

• What does this mean in terms of screening and prevention?

• Common warning signs may not be present

Under review, Romanelli et al., 2019

Key Points (cont’d)

• Compared to female adolescents, males were more likely to have suicide attempts only vs the other indicators— More impulsive behavior for boys?— Future research: Consider additional risk factors and

differential symptom expressions that cue providers to intervene in the absence of formulated suicide thoughts and plans

• History of sexual assault/abuse is screened at hospitals, but rarely linked to imminent suicide concern (without expressed suicide ideation and/or plan)

Under review, Romanelli et al., 2019

Why Is This Happening?

Factor 1: Barriers to Treatment

Primacy of Family Support

Toxic Masculinity: We rear boys differently

• “Toxic” Messages• Man up • Fight it off • Be tough

• Boys “externalize” behaviors• Antisocial behaviors and

attitudes mask depression• Misinterpret symptoms as

conduct problem

Lindsey, Brown, & Cunningham, 2017

Lifetime Disorder-Specific Mental Health Service Use by Race/Ethnicity (Merikangas et al., 2011)

Mood Anxiety ADHD Behavior Substance Use

Hispanic .47 (.29-.78) .24 (.09-0.65) .80 (.36-1.80) .75 (.40-1.41) 2.09 (.72-6.11)

Non-Hispanic Black

.23 (.14-.40) .60 (.34-1.08) .58 (.22-1.52) .77 (.40-1.45) 1.56 (.23-10.56)

Other .61 (.22-1.68) .47 (.34-1.08) .32 (.14-.73) .68 (.39-1.20) 1.57 (.40-6.10)

Non-Hispanic White

1.00 1.00 1.00 1.00 1.00

X²₃(p) 36.1 (.000) 14.8 (.002) 8.3 (.040) 3.2 (.361) 2.2 (.525)

Setting-Specific Mental Health Service Use by Race/Ethnicity (Costello et al., 2014)

MH Specialty

General Medical

Human Services

CAMᵇ Juvenile Justice

School Any

AOR95%CI

AOR95%CI

AOR95%CI

AOR95%CI

AOR95%CI

AOR95%CI

AOR95%CI

Hispanic 1.04.52-2.08

.81 .41-1.60

.66.23-1.91

.43.16-1.18

1.14.49-2.61

.51.25-1.03

.75.51-1.12

Non-Hispanic Black

.39**.22-.70

.64.31-1.31

1.39.75-2.59

.36*.17-.74

.67.25-1.84

.95.51-1.75

.63.43-.93

Other .40**.20-.79

1.55.70-3.45

.51.17-1.48

.50.18-1.33

.69.21-2.27

.88.36-2.20

1.17.49-2.78

Non-Hispanic White (Reference Group)ᵃ Analyses were adjusted for all demographic variables in the table and number of disordersᵇ Complementary and alternative medicine*p˂.05, **p˂.01, ***p˂.001

• 465 ninth-graders in Baltimore City (M = 14.78)

• Half of sample had identified MH needs; only 20% rec’d MH treatment

• NETWORK INFLUENCE• + association between

perception of network’s support and SMH service use.

• SMH services for internalizing MH problems higher for youth larger social networks.

• PES in Philadelphia, PA: n=1,621 Black adolescents

• 73% voluntarily arrived

• Odds of a voluntary arrival increased as the level of impairment decreased

• Arrival based on non-urgent reasons

Factor 2: What is the school environment like for Black youth, boys, and youth with disabilities? Disproportionately disciplined.

Students Suspended from School Compared to Student Population, by Race, Sex, and Disability Status, School Year 2013-14

School mental health in context: Poverty-impacted students

A Way Forward: Policy-Level Intervention

Policy-level interventions

Problem Policy InterventionVariability in the quality of care Adoption/implementation of EBPs with a track

record of feasibility and successful outcomesRecognition of symptoms Teacher training on Mental health as a criteria

for certification (e.g., Minnesota); NOT JUST TEACHERS. ALL PERSONNEL.

Universal screening for prevention, early intervention, and health promotion Not without controversy: cultural clashes,

parental autonomy vs. the school’s role, stigma

Funding barriers to providing mental health services and supports

Offset the limited federal and district funding for non-instructional services: Community agency partnerships; Billing to Medicaid

Social and Emotional Learning Standards in Schools

NCSL, 2018

Problem Policy InterventionLimited required promotion of wellness

State legislative mandate to promote social emotional health in schools from Pre-K-12 (only 8 states in the U.S. currently)

The BIGGEST Policy Imperative?

• EVERY SCHOOL SHOULD HAVE A MENTAL HEALTH PROVIDER!

• THE NUMBER OF SERVICE PROVIDERS SHOULD BE PROPORTIONATE TO THE NUMBER OF STUDENTS!

Research, Advocacy and Policy

• Launched April 30, 2019 on Capitol Hill

Congressional Taskforce Members• Bonnie Watson Coleman (NJ-

12), Chair

• Emanuel Cleaver II (MO-05)

• Alcee Hastings (FL-20)

• Eddie Bernice Johnson (TX-30)

• John Lewis (GA-05)

• Ayanna Pressley (MA-07)

• Alma Adams (NC-12)

• Danny Davis (IL-07)

• Jahana Hayes (CT-05)

• Barbara Lee (CA-13)

• llhan Omar (MN-05)

• Frederica Wilson (FL-24)

• Sheila Jackson Lee (TX-18)

• Eleanor Holmes Norton (DC-At Large)

New York State Efforts

• Passed in NY State Senate, March 2019(Senator David Carlucci)

• Passed in NY State Assembly, June 2019(Assembly Member Kimberly Jean-Pierre)

• NY State working to establish a Workgroup on Black Youth Suicide

Questions and Thank You!

Email: Michael.Lindsey@nyu.edu Website: mcsilver.nyu.edu

Appreciation

Contact Us

a program managed by

Central East MHTTC websiteOscar Morgan, Project Director

Danya Institute websiteEmail

240-645-1145

Funding for this presentation was made possible by SAMHSA grant no. 3H79SM081785. The views expressed by speakers and moderators do not necessarily reflect the official policies of HHS; nor does mention of trade

names, commercial practices, or organizations imply endorsement by the U.S. Government.