*Corresponding Author:

Sheila J. Asghar

Department of Neurology, Louisiana State University Health Sciences Center, 1501 Kings Hwy Blvd, Shreveport, LA 71130-3932, USA, Tel: 318-675-8299; E-mail: sheila.asghar@lsuhs.edu

Key Words: COVID 19, suicide, young adults, teenage girls, screening tools.

This study highlights recent trends of suspected suicide attempts amongst girls aged 12 to 17 from February 21 to March 20, 2021, as compared to the same period in 201 before the pandemic. While there were fewer emergency department visits for suspected suicide attempts between March and April following the declaration of the coronavirus pandemic, by early May 2020 these numbers increased steadily among adolescents aged between 12 to 17, especially girls, and remained elevated. This calls for attention for more awareness to be given to trends in this age group which could indicate a higher level of distress due to ongoing barriers imposed during the pandemic such as physical distancing, mental health treatment barriers, an increase in substance abuse, anxiety about family health and economic problems. Several limitations in the report by Yard et al. [2] were highlighted by the authors including the absence of data on race and ethnicity as well as identification of the young people as LGBTQ (lesbian, gay, bisexual, transgender, and queer (or questioning). Further research into different suicide related trends by subgroups such as American Indian, Alaska Native, Black, Latino, LGBTQ needs to be identified and examined according to Dr. Moutier, chief medical officer at the American Foundation for Suicide Prevention [7]. Screening tools such as the Computerized Adaptive Screen for Suicidal Youth or CASSY tool with a strong validated accuracy for prediction of suicide attempt is being used in pediatric emergency departments as the first universal screen for suicide rick in this age group [12].

Suicide rates continue to be the second leading cause of death in the US among the young (10-14, 15-19, and 20-24 age bracket) [1]. Globally suicides rank as the fourth leading cause of death among 15–29-year-olds in 2019 [2]. According to Ruch et al. [3] since 2007, the average suicide rate for girls between the ages of 10 to 14 years has increased yearly by 13% as compared to boys in the same age group. For the age bracket of 15 to 19 years, the suicide rates for girls have risen to 8 %, while for boys the rate is at 3.5%. A recent report by Yard et al. [4], cited an increase of 50.6% in suspected suicide attempts amongst girls aged 12 to 17 from February 21 to March 20, 2021, as compared to the same period in 2019 before the pandemic. The significance of the study highlights more awareness to be given to trends in this age group which could indicate a higher level of distress.

The figures were provided by the Centers for Disease Control and Prevention (CDC) and calculated using data from the National Syndromic Surveillance Program (NSSP) from weekly Emergency Department (ED) visits for suspected suicide attempts across 49 states and Washington DC. The period covered was from January 1, 2019, to May 15, 2021, and included males and females aged 12 to 25 years, at the three phases of the COVID pandemic, spring, summer, and winter. Although this trend indicated an increase as compared to rates in 2019, the age-adjusted suicide deaths among persons 15 to 23 years old had no significant change. While there were fewer emergency department visits for suspected suicide attempts between March and April following the declaration of the coronavirus pandemic, by early May 2020 these numbers increased steadily among adolescents aged between 12 to 17, especially girls, and remained elevated. According to Dr. Jonathan Singer, president of the American Association of Suicidology, this may follow the pattern of a decrease in suicide deaths in the early part of a disaster or a catastrophe and then an increase [5]. The increase in suspected suicide attempts especially among adolescent girls in early 2021 provides a disturbing picture of the psychological strain that young Americans are under. Several limitations in the report by Yard et al. [2] were highlighted by the authors including the absence of data on race and ethnicity as well as identification of the young people as LGBTQ (lesbian, gay, bisexual, transgender, and queer (or questioning). This limitation was also raised by Dr. Jonathan Singer in the Washington Post [5].

The CDC’s 2019 Youth Risk Behavior Survey, which focused on high school children aged (14 to18 years), found significant differences among various demographics of young people who attempted suicide. Specifically, a higher percentage of black students (12%) as compared to white students (8%) were more likely to attempt suicide. An important identification by the CDC (6) was the probability of more lesbian, gay or bisexual persons likely to have reported having attempted suicide.

 While specific reasons for the increase in suspected suicide attempts remain elusive, the CDC reported that young persons may represent a higher at-risk group due to ongoing barriers imposed during the pandemic such as physical distancing, mental health treatment barriers, an increase in substance abuse, anxiety about family health and economic problems. While suspected child abuse and neglect also increased in 2020, more time spent at home during the pandemic may have alerted parents and family members of a potential suicide attempt hence increasing emergency department visits but decreasing the number of suicide deaths [4].

A factor to be considered is puberty, a time of crucial physical and mental change, when emotions such as depression and anxiety can be exacerbated by the pandemic, especially for females [7].  Risk factors for depression can also include bullying, economic stressors, family discord, trauma, and academic stress.  Bullying and cyberbullying were of concern prior to the pandemic and remain a concern. A study by Hinduja and Patchin [8] did not find a direct correlation between school bullying or cyberbullying and suicide. What was highlighted were those painful personal experiences, both internal and external, combined with the mental harm contributed to school bullying or cyberbullying can lead to suicide. 

Youth with suicidal ideation may include perfectionists, LGBTQ, and those with depression, anxiety, and other mental health disorders. Adolescent females remain a vulnerable group due to their higher rate of suspected suicide attempts than males. Contributing factors can include a lack of community and parental support, substance abuse, a history of sexual or physical abuse, low self-esteem, academic struggles, and a family history of suicide [9]. Early signs of suicidal ideation can present in changes in personality or behavior, that are out of character such as talking about death, suicide, and/or self-harm [10]. Other indications may include indulging in risky or self-destructive behavior, and changes in sleeping patterns and eating habits. They may isolate from peers and/or family and have a sense of worthlessness, hopelessness, shame, and guilt [10].

 The first line of support to decrease suicide rates needs to start at home, school, and in the community. The social stigma associated with suicidal ideation that comes with guilt, fear, and shame, needs to stop as it is this stigma that society holds which can prevent someone vulnerable from seeking the help so desperately needed. Research continues to evidence the vulnerability of young females who remain at a higher rate for suspected attempted suicide. The use of appropriate screening tools for suicide attempt in the Emergency Department may decrease numbers. The ED-SAFE study is the largest suicide intervention trial conducted in the United States with more than 1300 participants with significant suicide risk from 8 emergency departments [11]. The patients received either treatment as usual (TAU), universal screening, or universal screening plus an intervention. The intervention consisted of an expanded suicide screening, provision of a self-administered safety plan in the emergency department and subsequently followed a telephone-based intervention delivered over 52 weeks. An overall drop in suicide attempts by 30% was noted when emergency department patients with attempted suicide are treated, and health care providers check on them periodically in the months post discharge (11). Although the study was based on adult patients, intervention tools such as the Computerized Adaptive Screen for Suicidal Youth or CASSY tool is being used in pediatric emergency departments as the first universal screen for suicide rick in this age group due to its strong, validated classification accuracy for suicide attempt [12].

A prognostic study [13] with a derivation cohort of 2075 adolescents and an independent prospective validation cohort of 2754 adolescents developed and validated the Computerized Adaptive Screen for Suicidal Youth (CASSY) to predict a suicide attempt within 3 months. In this study, the CASSY had a sensitivity of 82.4% for prediction of a suicide attempt at the 80% specificity cutoff established in study [12].

Dr. Moutier [7] further emphasized that it was critical to strengthen care transitions once an individual leaves the Emergency Department, so they do not fall through the cracks. Access to mental health treatment and an increase in trained mental health workers is needed as there continues to be a dire need for both. Strategies are needed to prevent suicide that need to be tailored to the needs of different youth populations including females, black, and ethnics [7] which is one of the biggest limitations of the study Furthermore, different suicide related trends may be experienced by sub groups such as American Indian, Alaska Native, Black, Latino, LGBTQ and this needs to be identified and examined according to Dr. Moutier, chief medical officer at the American Foundation for Suicide Prevention [7].

REFERENCES

1. Curtin SC, Heron M. Death Rates Due to Suicide and Homicide Among Persons Aged 10–24: United States, 2000–2017. U.S Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics. NCHS Data Brief 2019; No.352.
2. World Health Organization Fact Sheets 2021.
3. 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): e93886.
4. Yard E, Radhakrishnan L, Ballesteros M, Sheppard M, Gates A, Stein ZM, Hartnett KP, Kite-Powell A, Rodgers LE, Adjemian J, Ehlman DC, Holland KM, Idaikkadar N, Ivey-Stephenson A, Martinez PD, Law R, Stone DM. Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12–25 Years Before and During the COVID-19 Pandemic — United States, January 2019–May 2021. Morbidity and Mortality Weekly Report, 2021 70, 888 - 894.
5. Chiu A. CDC: ER visits for suspected suicide attempts among teenage girls rose during pandemic. The Washington Post. June 11, 2020. https://www.washingtonpost.com/lifestyle/wellness/teen-girls-suicide-attempts-pandemic-/2021/06/11/567a4f62-cac0-11eb-a11b-6c6191ccd599_story.html (accessed 24 Jul 2021).
6. Centers for Disease Control and Prevention (CDC). CDC releases 2019 Youth Risk Behavior Survey Results; 2020.
7. Rosen NS, Salzman S. Sharp uptick seen in suspected suicide attempts among teenage girls: CDC. ABC News June 11, 2021.
8. Hinduja S, Patchin J. (2018). Connecting Adolescent Suicide to the Severity of Bullying and Cyberbullying. Journal of School Violence 2018; 18:1-14.
9. The Stream: Why are so many teen girls in the US attempting suicide? Live streamed on June 22, 2021.
10.  Cleveland Clinic. Recognizing Suicide Behavior. https://my.clevelandclinic.org/health/articles/11352-recognizing-suicidal-behavior
11. Miller IW, Camargo CA, Arias SA, Sullivan AF, Allen MH, Goldstein AB, Manton AP, Espinola JA, Jones R, Hasegawa K, Boudreaux ED. The ED-SAFE Study. Suicide Prevention in an Emergency Department Population. JAMA Psychiatry 2017 Jun; 74(6): 563–570. Published online 2017 Jun 7. Prepublished online 2017 Apr 29.
12. King CA, Brent D, Grupp-Phelan J et al., Casper C, Dean M, Chernick LS, Fein JA, Mahabee-Gittens EM, Patel SJ, Mistry RD, Duffy S, Melzer-Lange M, Rogers A, Cohen DM, Keller A, Shenoi R, Hickey RW, Rea M, Cwik M, Page K, McGuire TC, Wang J, Gibbons R, for the Pediatric Emergency Care Applied Research Network Author Affiliations. Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth. JAMA Psychiatry 2021; 78(5):540-549.
13. Paquette DW, Brodala N, Williams RC. Risk Factors for Endossesous Dental Implant Failure. Den Clin N Am 2006; 50(3) 361 – 374.

PEER REVIEW

Not commissioned. Externally peer reviewed.

1. Curtin SC, Heron M. Death Rates Due to Suicide and Homicide Among Persons Aged 10–24: United States, 2000–2017. U.S Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics. NCHS Data Brief 2019; No.352.
2. World Health Organization Fact Sheets 2021.
3. 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): e93886.
4. Yard E, Radhakrishnan L, Ballesteros M, Sheppard M, Gates A, Stein ZM, Hartnett KP, Kite-Powell A, Rodgers LE, Adjemian J, Ehlman DC, Holland KM, Idaikkadar N, Ivey-Stephenson A, Martinez PD, Law R, Stone DM. Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12–25 Years Before and During the COVID-19 Pandemic — United States, January 2019–May 2021. Morbidity and Mortality Weekly Report, 2021 70, 888 - 894.
5. Chiu A. CDC: ER visits for suspected suicide attempts among teenage girls rose during pandemic. The Washington Post. June 11, 2020. https://www.washingtonpost.com/lifestyle/wellness/teen-girls-suicide-attempts-pandemic-/2021/06/11/567a4f62-cac0-11eb-a11b-6c6191ccd599_story.html (accessed 24 Jul 2021).
6. Centers for Disease Control and Prevention (CDC). CDC releases 2019 Youth Risk Behavior Survey Results; 2020.
7. Rosen NS, Salzman S. Sharp uptick seen in suspected suicide attempts among teenage girls: CDC. ABC News June 11, 2021.
8. Hinduja S, Patchin J. (2018). Connecting Adolescent Suicide to the Severity of Bullying and Cyberbullying. Journal of School Violence 2018; 18:1-14.
9. The Stream: Why are so many teen girls in the US attempting suicide? Live streamed on June 22, 2021.
10.  Cleveland Clinic. Recognizing Suicide Behavior. https://my.clevelandclinic.org/health/articles/11352-recognizing-suicidal-behavior
11. Miller IW, Camargo CA, Arias SA, Sullivan AF, Allen MH, Goldstein AB, Manton AP, Espinola JA, Jones R, Hasegawa K, Boudreaux ED. The ED-SAFE Study. Suicide Prevention in an Emergency Department Population. JAMA Psychiatry 2017 Jun; 74(6): 563–570. Published online 2017 Jun 7. Prepublished online 2017 Apr 29.
12. King CA, Brent D, Grupp-Phelan J et al., Casper C, Dean M, Chernick LS, Fein JA, Mahabee-Gittens EM, Patel SJ, Mistry RD, Duffy S, Melzer-Lange M, Rogers A, Cohen DM, Keller A, Shenoi R, Hickey RW, Rea M, Cwik M, Page K, McGuire TC, Wang J, Gibbons R, for the Pediatric Emergency Care Applied Research Network Author Affiliations. Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth. JAMA Psychiatry 2021; 78(5):540-549.
13. Paquette DW, Brodala N, Williams RC. Risk Factors for Endossesous Dental Implant Failure. Den Clin N Am 2006; 50(3) 361 – 374.