Adolescent Suicide Myths in the United States

Abstract

In the United States, teen suicide rates tripled over several decades, but have declined slightly since the mid-1990s. Suicide, by its nature, is a complex problem. Many myths have developed about individuals who complete suicide, suicide risk factors, current prevention programs, and the treatment of at-risk youth. The purpose of this article is to address these myths, to separate fact from fiction, and offer recommendations for future suicide prevention programs. Myth #1: Suicide attempters and completers are similar Myth #2: Current prevention programs work. Myth #3: Teenagers have the highest suicide rate. Myth #4: Suicide is caused by family and social stress. Myth #5: Suicide is not inherited genetically. Myth #6: Teen suicide represents treatment failure. Psychiatric illnesses are often viewed differently from other medical problems. Research should precede any public health effort, so that suicide prevention programs can be designed, implemented, and evaluated appropriately. Too often suicide prevention programs do not use evidence-based research or practice methodologies. More funding is warranted to continue evidence-based studies. We propose that suicide be studied like any medical illness, and that future prevention efforts are evidence-based, with appropriate outcome measures.

Full text

M.A.Mosk os et al.: Adolescent Suicide Myths in the United StatesCrisis25 (4), © 2004 Hogrefe & Huber Publishers
Research Trends
Adolescent
Suicide Myths
in the United States
Michelle Ann Moskos
1
, Jennifer Achilles
2
, and Doug Gray
3
1
Univ. of Utah School of Medicine, Department of Pediatrics, Intermountain Injury Control Research Center,
2
University of Utah School of Medicine,
3
University of Utah, Department of Psychiatry,
Child and Adolescent Specialty Clinic, Salt Lake City, UT, USA
Abstract: In the United States, teen suicide rates tripled over several decades, but have declined slightly since the mid-1990s. Suicide,
by its nature, is a complex problem. Many myths have developed about individuals who complete suicide, suicide risk factors, current
prevention programs, and the treatment of at-risk youth. The purpose of this article is to address these myths, to separate fact from
fiction, and offer recommendations for future suicide prevention programs. Myth #1: Suicide attempters and completers are similar.
Myth #2: Current prevention programs work. Myth #3: Teenagers have the highest suicide rate. Myth #4: Suicide is caused by family
and social stress. Myth #5: Suicide is not inherited genetically. Myth #6: Teen suicide represents treatment failure. Psychiatric illnesses
are often viewed differently from other medical problems. Research should precede any public health effort, so that suicide prevention
programs can be designed, implemented, and evaluated appropriately. Too often suicide prevention programs do not use evidence-based
research or practice methodologies. More funding is warranted to continue evidence-based studies. We propose that suicide be studied
like any medical illness, and that future prevention efforts are evidence-based, with appropriate outcome measures.
Keywords: Antidepressants, adolescents, evidence based, school health, suicide
Introduction
The prevention of violence, in particular suicide, is of in-
ternational concern (Cantor, 2000; Weber, 2000). In 1999,
the United States Surgeon General issued a Call to Action
to Prevent Suicide because the most current statistics iden-
tified suicide as the ninth leading cause of mortality in the
United States with nearly 31,000 deaths. Concomitantly,
the World Health Organization (WHO) recognized suicide
as a growing problem worldwide with nearly 1,000,000
deaths and urged member nations to take action (World
Health Organization, 1996). The WHO document, Preven-
tion of Suicide: Guidelines for the Formulation and Imple-
mentation of National Strategies (1996), motivated a part-
nership to seek a national strategy in the United States (In-
stitute of Medicine, 2002). In 2001, the United States
Surgeon General released the National Strategy for Suicide
Prevention: Goals and Objectives for Action, which is a
plan that will guide the nation’s suicide prevention efforts
for the next ten years (Satcher, 2001). This document pro-
vides essential guidance and suggests the fundamental ac-
tivities that must follow–activities based on scientific evi-
dence. The National Strategy emphasized that, “much of
the work of suicide prevention must occur at the commu-
nity level where human relationships breathe life into pub-
lic policy (Satcher, 2001).” In 2002, the Institute of Medi-
cine (IOM) released Reducing Suicide: A National Imper-
ative. The IOM clarifies the medical, social, psychological,
economic, moral, and political facets of suicide and the
need for prevention. Teen suicide rates tripled over several
decades in the United States, but have declined slightly
since the mid-1990s (American Psychiatric Association,
2003; Kachur, Potter, James, & Powell, 1995). Suicide, by
its nature, is a complex problem. Many myths have devel-
oped about individuals who complete suicide, suicide risk
factors, current prevention programs, and the treatment of
at-risk youth in the United States. There are certain myths
that suicidologists encounter in their work with the general
population, health professionals, school administrators,
and other government officials, as well as the media. The
purpose of this article is to address these myths related to
suicide in the United States, to separate fact from fiction,
and offer recommendations for future suicide prevention
programs.
DOI: 10.1027/0227-5910.25.4.176
Crisis 2004; Volume 25 (4): 176–182 © 2004 Hogrefe & Huber Publishers

Myths and Recommendations
Myth #1: Suicide Attempters and
Completers Are Similar
The epidemiology of suicide attempts and completions
vary internationally. In the United States, males are four
times more likely to die from suicide than females, but fe-
males are more likely to attempt suicide than males (Cen-
ters for Disease Control and Prevention, 2003). In 1999,
83% of teenage suicide completers were male (Arias, An-
derson, Kung, Murphy, & Kochanek, 2003). The only state-
wide hospital surveillance study of child and adolescent
suicide attempters in the United States demonstrated that
84% of attempters were female (Andrus et al., 1991). Sui-
cide attempts peak in the teenage years, while suicide com-
pletion peaks in old age (Birkhead, Galvin, Meehan,
O’Carroll, & Mercy, 1993; Centers for Disease Control and
Prevention, 1998; Kachur et al., 1995). The United States
does not have an official source that compiles suicide-at-
tempt data nationwide, therefore, reported rates are specu-
lative (Mancinelli, 2002; Maris, Berman, & Silverman,
2000). However, the average estimated ratio between non-
fatal youth suicide attempters and youth suicide completers
in the United States was 100–200:1(Maris, 2002; McIn-
tosh, 2003). In a smaller study, researchers found that ado-
lescent suicide attempters are a large group, with a 1 year
incidence rate of 130/100,000 suicide attempts among
those with no baseline suicidal behaviors (McKeown et al.,
1998). By contrast suicide completion is a rare event, in-
volving only 1–2/10,000 teenagers each year (Kachur et al.,
1995). While suicide attempts increase the long-term risk
of suicide, the majority of teen suicide completers have
never made a prior attempt (American Psychiatric Associ-
ation, 2003; Brent, Perper, & Moritz, 1993; Maris et al.,
2000). Gender differences can be explained by the choice
of more lethal means by males, and by cultural influences
making it more acceptable for males to complete rather
than attempt suicide (American Psychiatric Association,
2003; Canetto, 1997; Maris et al., 2000; Moscicki, 1994).
Recommendations
It will be important to recognize that suicide attempters and
completers are two different groups, with some overlap.
These two groups will require separate treatment interven-
tions, and outcome measures specific to each group. Cul-
tural influences must also be addressed.
Myth #2: Current Prevention Programs Work
National suicide prevention efforts have focused on school
education programs, teen suicide hotlines, media guide-
lines, and efforts to limit firearm access for at-risk youth
(Gould & Kramer, 2001; Shaffer, 1988). Unfortunately,
these prevention methods have not had a significant impact
in lowering teen suicide rates. Historically, suicide preven-
tion programs have not been rigorously evaluated, and,
consequently, resources have not been focused on high-risk
groups (Hazell & King, 1996; Shaffer, Garland, Vieland,
Underwood, & Busner, 1991). School-based suicide pre-
vention programs have not been demonstrated to effect sui-
cide rates, and educational benefits have been limited to a
few studies (Spirito, Overholser, Ashworth, Morgan, &
Benedict-Drew, 1988). In 2004, an evaluation of Signs of
Suicide (SOS), a school-based suicide prevention program,
documented a reduction in self-reported suicide attempts
for the first time using a randomized experimental design
(Aseltine & DeMartino, 2004). This study was unique, be-
cause it incorporated screening and referral of high-risk
youth in addition to an educational component. Teen hot-
lines are primarily used by females, rather than males, thus
having little effect on the group with the highest risk for
death (Grossman, 1992). Approximately 5% of all teen sui-
cides are believed to be “cluster” suicides (Hazell, 1993).
Cluster suicides involve additional imitative suicides,
based on the idea of a contagion, which may be associated
with the way the media describes suicide (Gould, 2001;
Schmidtke & Hafner, 1988). The Centers for Disease Con-
trol and Prevention (CDC) have developed guidelines for
the reporting of suicide in the media in the United States.
Because the implementation of similar recommendations
for media coverage of suicide has been shown to decrease
suicide rates in Europe, (Etzersdorfer & Sonneck, 1998;
Sonneck, Etzersdorfer, & Nagel-Kuess, 1994) we strongly
support the use of the CDC guidelines for media in the
United States, although their effectiveness warrants exam-
ination. There is general agreement that reducing access to
lethal means can reduce suicide completion rates, in fact,
according to the CDC, restricting access to lethal means
may be one of the most promising underused strategies that
warrant further examination (Centers for Disease Control
and Prevention, 1994, 2003). Unfortunately, a recent study
demonstrated that only 25% of gun owners remove fire-
arms from their home when repeatedly asked to do so by
their teenager’s mental health provider (Brent, Baugher,
Brimaher, Kolko, & Bridge, 2000). In Canada, Leenaars
and colleagues (2003) explored the relationship between
Canada’s Criminal Law Amendment Act of 1977 (Bill C-
51) and Canadian suicide rates; although legislative gun
control correlated with a decrease in suicide rates, this ap-
proach is probably unfeasible in the United States (Lee-
naars, Moksony, Lester, & Wenckstern, 2003).
Recommendations
Suicidologists recommend that future efforts in the educa-
tional system use evidence-based screening tools to identi-
fy youth at risk, and link screening responses to appropriate
treatment referrals. Limitations include the cost of screen-
ing tools used in school settings, as well as the number of
false positives (Satcher, 2001). Educational programs
M.A. Moskos et al.: Adolescent Suicide Myths in the United States 177
© 2004 Hogrefe & Huber Publishers Crisis 2004; Volume 25 (4): 176–182

which consist only of a brief, one-time lecture regarding
risk factors for youth suicide have not been effective (Cen-
ters for Disease Control and Prevention, 1994). Teen hot-
lines may be effective in helping suicide attempters. An
appropriate outcome measure for hotlines could be a reduc-
tion in the number of emergency room visits for suicide
attempts rather than a reduction in the number of suicide
deaths. Reducing access to lethal means may require health
professionals to change their strategy of encouraging the
removal of firearms to encouraging the safe storage of fire-
arms (American Psychiatric Association, 2003; Centers for
Disease Control and Prevention, 2003; Christoffel, 2000).
Recently published data from the Utah Youth Suicide Study
by Gray and colleagues (2002) indicated that the Juvenile
Justice System provides a unique opportunity to identify
youth at risk for suicide. The study found that 63% of youth
suicide completers had contact with Juvenile Justice, usu-
ally multiple minor offenses over many years. Less than
half (46%) of the youths found in the justice system could
also be located in the public educational system. This find-
ing suggests that mental health screening and treatment
should be integrated into the nation’s Juvenile Justice sys-
tems (Gray, Achilles, & Keller, 2002).
Myth #3: Teenagers Have the Highest
Suicide Rate
In the United States, elderly white males have always had
the highest risk for completed suicide (Arias et al., 2003).
Often suicide in the geriatric population is related to a med-
ical disability. However, older adult suicide rates have
stayed relatively constant in the United States, while ado-
lescent and young adult suicide rates have more than tripled
between the 1960s and 1990s (Centers for Disease Control
and Prevention, 2003; Kachur et al., 1995). The CDC con-
siders years of potential life lost (YPLL) to gauge the im-
pact of an illness on a population (Centers for Disease Con-
trol and Prevention, 2003). Teen suicide involves consider-
able YPLL, and for teenagers nationwide, suicide is one of
the leading causes of death (Centers for Disease Control
and Prevention, 2003). In addition, cluster suicides pre-
dominately occur in the teenage population (Gould, Wal-
lenstein, Kleinman, O’Carroll, & Mercy, 1990). Rates of
suicide among minorities are low compared to whites. The
rate of suicide among African American youth in the United
States is increasing faster than any other ethnic group (Cen-
ters for Disease Control and Prevention, 1998). Surprising-
ly, the rise in African American youth suicide in the United
States is concentrated in those with higher socioeconomic
status (Centers for Disease Control and Prevention, 1998).
Recommendations
Future prevention efforts should continue to be focused on
adolescents and young adults, given the social, economic,
and emotional impact of youth suicide. While the white
population has had the highest suicide rates, other ethnic
groups need greater consideration, because of changing
epidemiology.
Myth #4: Suicide Is Caused by Family and
Social Stress
When interviewing families of suicide victims, relatives of-
ten point to an adverse precipitant, such as breaking off a
romantic relationship, an argument with parents, or a dis-
ciplinary action (Shaffer et al., 1996). One feature of ado-
lescent suicide is that it may be precipitated by a psycho-
social stressor associated with a recent loss, rejection, or
disciplinary crisis. However, stressors related to these
events are common in a normal teenager’s life, and suicide
is a rare outcome (Zamekin, Alter, & Yemini, 2001). Stud-
ies have shown that over 90% of teen suicide completers
have psychiatric diagnoses, most commonly a mood disor-
der with comorbid substance abuse or conduct problems
(Brent et al., 1993; Shaffer et al., 1996). Teens who com-
plete suicide have more stress and family dysfunction
(Gould, Fisher, Parides, Flory, & Shaffer, 1996). However,
we know that mental illness runs in families, and either
child psychopathology or parental psychopathology may
account for stressors related to family dysfunction. For ex-
ample, Brent (1994) found that parent-child discord was
associated with adolescent suicide, yet when this study
controlled for proband psychopathology, parent-child dis-
cord made no significant contribution (Brent et al., 1994).
The largest controlled studies conducted to date come to
different conclusions regarding negative interactions be-
tween victims and their parents, and whether history of se-
vere physical punishment plays a role in youth suicide
(Brent et al., 1993; Brent et al., 1994; Gould et al., 1996).
While suicide victims are more likely to come from nonin-
tact families, the overall effect of divorce on suicide risk is
small (Brent et al., 1993; Brent et al., 1994; Gould et al.,
1996). While 19% of youth suicide completers in Utah had
been reported to Child Protective Services, most reports
involved teenagers having physical altercations with their
parents, rather than abuse or neglect of small children
(Gray et al., 2002). The available information leads to the
question of whether the family dysfunction contributes to
mental illness, or whether the mental illness contributes to
the family dysfunction. Separate from family dysfunction,
both child and parent psychopathology have been associ-
ated with an increased risk for suicide in Denmark (Agerbo,
Nordentoft, & Mortensen, 2002).
Recommendations
Suicide “is caused” by an interplay of biological, psycho-
logical, environmental, and social factors. However, it is
essential to screen, identify, and treat mental illness in teen-
178 M.A. Moskos et al.: Adolescent Suicide Myths in the United States
Crisis 2004; Volume 25 (4): 176–182 © 2004 Hogrefe & Huber Publishers

agers, because mental illness is a known risk factor for sui-
cide. Furthermore, the identification and referral for mental
health treatment of any psychopathology in parents of teen-
agers at risk for suicide is needed. Treating either child or
parental psychopathology, or both, should decrease both
parent-child discord and family dysfunction.
Myth #5: Suicide Is not Inherited
Genetics has a critical role in mental illness and suicide. If
an individual who is adopted at birth completes suicide, it
is their biological relatives who are at increased risk for
suicide, not the adoptive family members (Schulsinger,
Kety, Rosenthal, & Wender, 1979). Suicide rates are higher
among monozygotic twins, compared with dizygotic twins
(Roy, Segal, Centerwall, & Robinette, 1991). The genetics
of suicide are complex. For example, some families are at
increased risk for depression over multiple generations,
while other families have increased risk for both depression
and suicide. Perhaps the later families inherit a more viru-
lent form of depression? A study in Denmark confirmed
that youth are more likely to commit suicide if they had a
family history of mental illness or they had been diagnosed
with a mental illness; however, no one psychiatric diagno-
sis versus another in parents was associated with an in-
creased risk for suicide among their children (Agerbo et al.,
2002). Brent raises the possibility of a two-factor genetic
model, where a patient must inherit both a mental illness,
and a second factor, such as impulsivity/aggression (Brent,
Perper, & Goldstein, 1988).
Recommendations
Future suicide prevention efforts need to focus on identify-
ing a phenotype that predisposes to suicide. A more specific
phenotype will help us to identify individuals at risk. Clar-
ifying the phenotype is an integral step in discovering the
genetic basis of suicide, because it is unknown whether risk
for suicide is mediated by a history of mental illness in the
family or the presence of a phenotype that could be asso-
ciated with either suicide or mental illness, or both.
Myth #6: Teen Suicide Represents Treatment
Failure
National studies indicate that very few suicide completers
were in treatment at the time of their death (Shaffer et al.,
1996). According to Gray and colleagues (2002), govern-
ment agency data revealed that only 1% of youth suicide
completers were in public mental health treatment at the
time of their suicide, and only 3% of youth suicide com-
pleters had detectable levels of psychotropic medication in
their blood sample at autopsy. From 1952–1995, the inci-
dence of suicide among adolescents nearly tripled; howev-
er, rates began to level off in the mid 1990s, and are begin-
ning to decline (Centers for Disease Control and Preven-
tion, 2003). Interestingly, this change in suicide rate coin-
cides with the rapid increase in use of antidepressants and
mood stabilizers in children and adolescents (Olfson et al.,
1998). In Sweden, there was a 25% reduction in the overall
suicide rate, which accompanied a four-fold increase in an-
tidepressant use (Isacsson, 2000; Isacsson, Holmgran, Dru-
id, and Bergman, 1997). While there is no proof of a causal
relationship between the use of antidepressants or mood
stabilizers and a decrease in suicide completion, other
known factors affecting suicide completion rates such as
divorce or substance abuse were unchanged (Gould,
Greenberg, Velting, & Shaffer, 2003; Shaffer & Craft,
1999). Moskos and colleagues (2002) conducted a study of
parent and community contacts of teen suicide completers
and found that a lack of appropriate treatment, or compli-
ance with treatment (i.e., use of psychotropic medications)
for mental illness, leads to suicide completion rather than
mental illness alone. Additionally, parents identified the
stigma of mental illness and the denial of mental illness as
the most significant barriers between teen suicide complet-
ers and treatment (Moskos, Achilles, Keller, Workman, &
Gray, 2002). More recently, a study by Olfson and col-
leagues (2003) examined the relationship between regional
changes in antidepressant medication treatment and suicide
rates in the United States, and reported a relationship be-
tween increased antidepressant use and decreased suicide
rates, especially among teenage males. Psychotropic med-
ications can ameliorate symptoms, reduce disability, short-
en the course of several psychological disorders, and pre-
vent relapse (World Health Organization, 2001). However,
in the United States (Druce, Hoff, & Rosenheck, 2000) and
Finland (Laukkala et al., 2001), while there has been a sev-
eral fold increase in antidepressant use in the general pop-
ulation, most individuals with major depression remain un-
treated. Undertreatment is more prevalent among children
and adolescents than young adults (Haarasilta, Marttunen,
Kaprio, & Aro, 2003). A limiting factor in treating psychi-
atric disorders is the lack of psychopharmacologic studies
with children and adolescents. While some psychotropic
medications (i.e., antidepressants) have FDA approved
uses in the pediatric population, many medications ap-
proved for adults are yet to receive adequate trials in
younger age groups. The lack of empirically-based studies,
which exist but were not made public due to proprietary
issues (Zito, Derivan, & Greenhill, 2004), has led to some
controversy regarding the use of certain Selective Seroto-
nin Reuptake Inhibitors (SSRIs) to treat depression in chil-
dren and adolescents (Sood, Weller, & Weller, 2004).
Recommendations
The association between the increase of antidepressant use
and decrease of suicide rates warrants further examination.
We recommend government intervention to require phar-
maceutical companies to study new psychotropic medica-
M.A. Moskos et al.: Adolescent Suicide Myths in the United States 179
© 2004 Hogrefe & Huber Publishers Crisis 2004; Volume 25 (4): 176–182

tions in pediatric populations, and to inform the public of
their findings before these drugs come to public market
(Zito et al., 2004). More research into biological and psy-
chosocial aspects of mental health is necessary to increase
the understanding of the cause, course, and outcomes of
mental illness and to develop more effective treatment op-
tions (World Health Organization, 2001). We also recom-
mend that all pediatric psychopharmacologic studies be
published, including studies with negative results (Whit-
tington et al., 2004; Zito et al., 2004). Public awareness of
the available treatments for psychiatric disorders is vital. It
may not be the mental illness itself, but rather the lack of
treatment or compliance with treatment, which may lead to
suicide completion. Barriers to treatment for mental illness
must be addressed if the teen suicide rate is to be reduced.
These include denial of mental illness, stigma, mental
health insurance parity, and other barriers. Public aware-
ness can reduce the stigma of both the diagnosis and treat-
ment of mental illness (World Health Organization, 2001).
Conclusion
Unfortunately, the six myths of teen suicide outlined above
indicate that evidence-based information is still needed to
combat the high teen suicide rate in the United States. Psy-
chiatric illnesses are often viewed differently from other
medical problems. Research should precede any public
health effort, so that prevention programs can be designed,
implemented, and evaluated appropriately. Too often sui-
cide prevention programs do not use evidence-based re-
search or practice methodologies. More funding is warrant-
ed to continue evidence-based studies in suicide. In accord
with the United States Surgeon General, we support the
position that the public should view mental illness or sub-
stance abuse disorders as a real illness. Public awareness
could close the gap in the perception of mental illness and
physical illness as two distinct separate issues. Increased
public awareness regarding the frequency, treatment, and
recovery process of mental illness, and the human rights of
people with mental illness could reduce barriers to treat-
ment and care (World Health Organization, 2001). Suicidal
persons with underlying mental illness who are seeking
mental health treatment should be viewed as persons who
are pursuing basic health care. Concomitantly, the United
States Surgeon General reports that our nation is facing a
public health crisis in pediatric mental health. This is of
importance for pediatric populations because untreated
mental illness is a known risk factor for youth suicide
(Satcher, 2001). According to the World Health Organiza-
tion (2001), countries have the responsibility to give prior-
ity to mental health in their health planning, as enlightened
mental health policy, legislation, professional training, and
sustainable fiscal resources will facilitate the delivery of
the appropriate mental health services to those who need
them at all levels of health care.
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M.A. Moskos et al.: Adolescent Suicide Myths in the United States 181
© 2004 Hogrefe & Huber Publishers Crisis 2004; Volume 25 (4): 176–182

About the authors:
MichelleAnn Moskos, PhD, MPH, is currently a Research Instruc-
tor at the Intermountain Injury Control Research Center through
the Department of Pediatrics at the University Of Utah School Of
Medicine. Dr. Moskos serves as a consulting epidemiologist for
the Utah Department of Health, the American Association of Sui-
cidology, and the National Suicide Prevention Resource Center.
She has presented at several national conferences as the Co-Prin-
cipal Investigator for the Utah Youth Suicide Study since 2001.
Jennifer Achilles, MA is a fourth-year medical student at the Uni-
versity of Utah School of Medicine. Ms. Achilles was the Study
Coordinator and managed the day-to-day operations of the Utah
Youth Suicide Study from 1992–2001. She has presented at na-
tional conferences and has co-authored several articles on youth
suicide.
Doug Gray, MD is a child and adolescent psychiatrist and an As-
sistant Professor in the Department of Psychiatry at the University
of Utah School of Medicine. For the last 12 years, Dr. Gray has
served as the Principal Investigator for the Utah Youth Suicide
Study. Dr. Gray is the Director of Outpatient Child Psychiatry
Clinical Services at the University of Utah Neuropsychiatric In-
stitute. Dr. Gray is the Chair for the Utah Youth Suicide Task Force.
Address for correspondence:
Michelle Moskos
615 Arapeen Drive Suite 202
Salt Lake City, UT 84102
USA
Tel. +1 801 585-9511
E-mail michelle.moskos@hsc.utah.edu
182 M.A. Moskos et al.: Adolescent Suicide Myths in the United States
Crisis 2004; Volume 25 (4): 176–182 © 2004 Hogrefe & Huber Publishers