Suicide Risk in Latino and latina Adolescents

Suicide Risk in Latino and latina Adolescents Yovanska M. Duarte-Velez and Guillermo

Bernal*

Latinos and Latinas are the fastest growing ethnic minority in United States. Hispanics represent 14.1% (40.5 million persons) of the US. population and surpass all other racial/ethnic minority populations in size (US. Bureau of the Census, 2004). Hispanic youth are at a greater risk for suicide ideation and attempts and there are serious disparities in the delivery of mental health services to this population. Hispanics have less access to mental health services than do Whites and are less likely to receive needed care. Further, when they do access care it is frequently of poor quality (US. Department of Health and Human Services, 2001). For the general population, young people are at an increasingly high risk for suicide, which is the cause of 11.7% of aIr deaths among youth and young adults aged 10 to 24 years in the US. (Grunbaum et a1.,2004). Among Latinos and Latinas, the largest proportion of suicides occurs among the young. In fact, suicide is the third leading cause of death for young Hispanics (aged 10 to 24 years) and the seventh leading cause of years of potential life lost before age 75 (Center for Disease Control and Prevention, 2004). Also, Hispanic youth are at a greater risk of suicide behavior than other ethnic groups (Canino & Roberts, 2001). This chapter expands on a previous review in the scientific literature related to suicide behavior among Hispanic adolescents (Duarte-Velez & Bernal, 2007). Conceptual and methodological issues in research are examined and the role of contextual and developmental factors on suicide in part by grants from the National Institute on Mental Health (R24-MH49368) and (ROI-MH67893).

* Work on this article was supported

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82 . ~..

Suicide Among Racial and Ethnic Groups

behavior is discussed. The empirical findings of comparative ethnic minority studies, studies focused on Hispanic youth, and within-group studies are reviewed, as is the role of contextual and developmental factors, and the status of evidence-based treatment for suicidal Hispanic adolescents. Finally, implications for future research are presented. Studies were identified through a comprehensive search of online databases (e.g., Psych Info, Medline) that were published from 1990 to 2006. Studies were selected based on the following criteria: (1) inclusion of outcomes directly related to suicide behavior, such as suicide ideation, suicide attempts, and completed suicide; and (2)reporting Hispanic ethnicity as a research variable (not just as a sample description). Samples were middle or high school students or adolescents 12 to 20 years old.*

D Epidemiology of Suicide Behavior Suicide is the third leading cause of death among young people 15 to 24 years of age, following unintentional injuries and homicide (National Institute of Mental Health, 2001). Also, suicide is the fourth leading cause of death for children aged 10 to 14, with a gender ratio of 3:1 (males:females). Approximately 8.3% to 8.7% of all high school students attempt suicide one or more times each year in the U.S. (Eaton et al., 2006;Grunbaum et al., 2004; Grunbaum et al., 2002;Kann et al., 2000; Kann et al., 1998;Kann et al., 1996). Females consistently demonstrate a higher prevalence of depression, suicide ideation, and suicide attempts than males, even though males are more apt to actually kill themselves. Hispanic adolescents have shown a tendency to be at a greater risk for depressive symptoms, suicide ideation, and suicide attempts than other groups of adolescents in the U.S. (Canino & Roberts, 2001;Hovey & King, 1997;Zayas, Lester, Cabassa, & Fortuna, 2005).

D Diversity among Hispanics in the u.S. Hispanics are a large and heterogeneous group of people who share some cornman characteristics but differ from one another in many aspects (McGoldrick, Giordano, & Garcia-Preto, 2005). The Census Bureau's code list contains more than 30 Hispanic or Latino subgroups. The largest group is Mexican Americans (64%);next are Puerto Ricans (9.57%),** * Two studies included a sample up to age 30. ** The U.S. citizens who live on the island of Puerto Rico (3.8 millions) are not included on

these estimates.

Suicide Risk in Latino and Latina Adolescents

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followed by Cubans (3.55%), Dominicans (2.59%), and Central and South Americans (12.6%), with another 7.6% from Spain and some who did not identify their country of origin (4.9%) (US. Census Bureau, 2004). Key differences among Hispanics are related to the varied circumstances leading to their migration (US. Department of Health and Human Services, 2001). The historical context greatly influences the experience of given population in the US. (Saez-Santiago & Bernal, 2003). Hispanic subgroups also differ in terms of their geographic location in the US., their knowledge of English, and other demographic and socioeconomic characteristics such as education level and family income (Ungemack & Guarnaccia, 1998). Yet, Hispanics share a common language and for many, the experience of migration from their country of origin, acculturation process, racism, and discrimination (McGoldrick, Giordano, & Garcia-Preto, 2005).

D

Conceptual and Methodological Issues in Hispanic Research

Conceptual and methodological issues are almost inseparable in research. The conceptual part of a study entails the basis for structuring the "what, when, and how" of research. The world view of an investigator is at the core of the concepts that will inform the methods (Marin & Marin, 1991). For example, if an investigator assumes a worldview based on universalism (Norenzayan & Heine, 2005), little consideration will be given to ethnicminority issues and concepts. Alternatively, if a cultural or multicultural perspective is assumed, the place of culture, ethnicity, and context will more likely playa prominent role in the primary research question (Burlew, 2003; Marin & Marin, 1991; Potts & Watts, 2003; RogIer, 1999). The use of ethnicity and race as independent variables in research assumes that persons belonging to such groups share some common psychological characteristics (related to personality or psychopathology) associated with culture (Okazaki & Sue, 1998). Theories about which psychological variables associated with culture to explain ethnic group differences in suicide behavior should guide comparative approach. Also, explanatory variables in specific population studies should be specified and directly measured (Okazaki & Sue, 1998). Does the fact that there are similarities among Latino subgroups justify placing them in one broad category, such as "Hispanic," for comparative studies addressing adolescent suicide behavior? Do differences among Latino subgroups justify specific population studies (for example, focusing only on Puerto Ricans); or within-group studies (Puerto Ricans vs. Mexicans vs. Cubans) to address adolescent suicide behavior? Answers to

If

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these questions depend on the research question and the theory investigators may have on the relationship between historical background and contextual factors to explain ethnic differences among Hispanic adolescents. Conceptual considerations on the nature of ethnicity, ethnic identity, race, and context should be reflected in the methodology. Methodological issues, such as study design, sampling, recruitment, retention, accounting for within-group diversity (such as national origin, generational status in the U.S.), measurement (which variables are included and how these are measured), language use, and culturally sensitive aspects of analytical issues require thoughtful and careful consideration in ethnic-minority research (Bernal & Sharron-deI-Rio, 2001). Indeed, as RogIer (1999) recommended, culture should be an integral part of the research enterprise. This "effort should span the entire research process, from planning and pre-testing to instrumentation, to translation of instruments and collection of data, to data analyses and interpretation of findings" (RogIer, 1999,p. 430). Confidence in the findings will depend on the investigators' sensitivity to ethnic and cultural aspects at both the conceptual and methodological level.

D

Role of Contextual and Developmental Factors on Hispanic Adolescent Suicide Behavior

Sociocultural and environmental processes are central to the development of an individual's identity, ability to function in everyday life, and perception of mental illness and mental health (Basic Behavioral Science Task Force of the National Advisory Mental Health Council, 1998).Social context and experiences, combined with biological and psychological characteristics, influence individual psychological strength and vulnerability. Within each culture, nation, and society there are particular histories, legacies, worldviews, opportunities, challenges, and stresses that constitute the framework for individual and group identity (Dana, 1998).Historical experiences of migration and the context of how the different groups of Hispanics were received in the U.S. play an important role in ethnic identity and current health status (Bernal, Trimble, Burlew, & Leong, 2003). Common threads of the Latino identity are Spanish language, physical features (predominantly heterogeneous racially, due to the mixing of races), spirituality, common values and beliefs rooted in a history of conquest and colonization, and familismo (Garcia-Preto, 2005). Familismo is described as a core system of values centered on the family. Indeed, there


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is evidence of a strong link between parental/family variables and adolescent depression (Bernal, Cumba, & Saez-Santiago, 2006). Familismo values of collectivism and interdependence interact and compete with dominant Euro American values of autonomy and individuality (Oyserman, Coon, & Kemmelmeier, 2002), creating issues of intergenerational tension between parents and their children, depending on their varying levels of acculturation. At the microsystem level, familismo reinforces deference to parents, restrictions on adolescent female autonomy, and family unity, while at the mesosystem level, U.S. cultural norms result in increased adolescent autonomy and sexuality (Zayas, Lester, Cabassa, & Fortuna, 2005). Zayas (2005) theorizes that migration, acculturative stress, discrepant levels of acculturation, Hispanic sociocultural factors, socioeconomic disadvantage, traditional gender role socialization, ethnic identity, and adolescent-parental conflict (influenced by family functioning) are all factors that can lead to suicide attempts. From a developmental perspective, Hispanic adolescents seem to be more deeply troubled by such questions as: "Who am I? Who do I want to be?" than by "Who does my family want me to be?" than do their peers of other ethnic backgrounds. This is a common dilemma during adolescence, which seems to be intensified in this group due to the two contradicting cultural traditions surrounding them (i.e., the American mainstream individualism versus the Hispanic culture's collectivism and familismo). Due to the Latino cultural value known as machismo, boys and girls experience different processes of gender role socialization (Beck & Bargman, 1993; Chavez, Edwards, & Oetting, 1989; Garcia-Preto, 2005; Scott, Shifman, On, Owen, & Fawcett, 1988; Tamez, 1981). Divergent expectations, rules, and roles are inculcated into each gender during adolescence. Furthermore, acculturation processes and stress may impact boys and girls in different ways. For example, within machismo's traditional values some aspects of autonomy and sexuality are encouraged for men but not for women (Scott, Shifman, On, Owen, & Fawcett, 1988;Tamez, 1981). Further research is required into the different processes of socialization by gender that could suggest distinct pathways to suicidality for Latinas and Latinos living in the U.S. Despite the fact that acculturating stress may be experienced differently between boys and girls, at some time during development Hispanic adolescents inevitably face the realization that they belong to a minority group. Adolescence is characterized by a search of individual identity, but minority Hispanic adolescents have the additional challenge of defining and integrating their ethnic identity within Euro American society, usually in the face of acculturative stress, racism, discrimination, and oppression (Phinney, 1998; Trimble, Helms, & Root, 2003). Numerous research findings indicate that racism and discrimination result in stress that

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adversely affects physical and mental health (U.S. Department of Human Services, 2001). To summarize, a developmental perspective in the study of Hispanic adolescent suicide behavior places identity, and in particular ethniC identity, at center stage in relation to other important variables such as acculturation, acculturative stress, and other family variables. Alternatively, an ecological perspective highlights the interaction of the social and historical influences (the mesosystem) with the family environment (the microsystem). Furthermore, a gender perspective acknowledges the different socialization of boys and girls that could lead to identifying distinct pathways to suicide behavior. An eco-developmental gender-specific perspective seems to integrate milestones for the understanding of suicide behavior in Hispanic adolescents.

D latino Culture, Sexual-Minority Youth, and Suicidality Latino culture has been characterized

in terms of values related to

spirituality, collectivism, and machismo among other characteristics (Garcia-Preto, 2005; Nagayama Hall, 2001). Within the Latino culture, JudeoChristian values are the predominant moral parameters that represent a continuum of very conservative-traditional to liberal values. Within the conservative-traditional values, a prevalent point of view considers nonheterosexual relationships sinful. Sexuality is a fundamental aspect of human existence. Sexual identity is a milestone of human development. Adolescents within the JudeoChristian tradition that experiment with same-sex attraction are challenged to integrate their sexuality to an apparent ideological contradiction (Ransom, 2004).In this sense, to identify as gay, lesbian, or bisexual (GLB) compromises the incorporation of two opposite parts of the adolescent's identity. This conflict could result in distress not only because of the internal difficulties to conciliate these two fundamental aspects of his/her identity (spirituality and sexuality), but also because of the social implications of assuming a non-heterosexual identity (Ransom, 2004). In the worst scenario, family, religious community, and school peers will show disapproval (rejection, humiliation, criticism) to a non-traditional course of sexual development (Savin-Williams, 2004). One example concerning this internal struggle was captured in the phrase of one Puerto Rican Christian girl in the clinical practice as: "Not being able to express myself is like being dead,"


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Meyer (2003)argues that the concept of minority stress is an elaboration of the social stress theory that "distinguishes the excess stress to which individuals from stigmatized social categories are exposed as a result of their social, often minority position" (p. 675). This concept refers to the enduring and persistent stress that crystallizes in the form of prejudice and rejection and is in turn mediated by particular social circumstances (e.g,. as job discrimination, bullying by peers) quite different from the circumstantial stress that most would experience. If minority stress and identity issues are taken into consideration, it is understandable why adolescents who self-identify as gay show more suicidality, depression, and hopelessness than their counterparts (Safren & Heimberg, 1999). These authors compared 56 GLB youth with 48 heterosexual youth and found that the differences in suicidality, depression, and hopelessness (significantly higher in GLB youth) were consequential to the effect of stress, social support, and coping through acceptance. GLBN orientation (gay, lesbian, bisexual, or not sure) and same-gender sex were identified as risk factors for suicide ideation and attempts among one population-based study (Garafalo, Wolf, et a1., 1999) and one large sample of adolescents (O'Donnell, O'Donell, Wardlaw, & Stueve, 2004; O'Donnell, Stueve, Wardlaw, & O'Donell, 2003). Also, Hispanic ethnicity was a risk factor among these samples, but the combined effect of being Hispanic and non-heterosexual was not explored. Some scholars suggest that persons belonging to diverse minority groups have to deal with the integration of diverse identities, and to manage minority stress of different kinds depending on the social context results in a greater challenge (Meyer, 2003). Also, we argue that the Hispanic's cultural values of spirituality, collectivism, and machismo may result in a more difficult scenario for adolescent development toward a GLB orientation. In conclusion, the integration of GLB sexuality as part of a developing identity represents a set of tasks that increase in complexity given the multiple identities that may be involved (e.g.,racial, ethnic, gender, spiritual, and sexual orientation). Indeed, the acceptance and support expected from family members, the religious community, and peers is challenged when an adolescent is moving toward a non-heterosexual development of sexuality. Being part of both a sexual and an ethnic minority group increases by far the stress experienced, especially when the adolescent's spiritual ideology is in opposition to the expression of a GLB orientation, which could result in increased vulnerability to high-risk behavior such as suicidality. Sexual orientation, as well as ethnicity and race, should be explored in any research related to suicide behavior in adolescents. Also, the impact of religious affiliation or spirituality in dealing with internalized homophobia and minority stress needs to be considered.

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D

Suicide Behavior Prevalence and Risk Factors among Hispanic Youth

Comparative Studies with Representative Sample Table 5.1 presents the comparative population-based studies of suicide behavior among Hispanic adolescents in terms of study source, nature of sample, predictive variables, outcomes, and results. We summarize these studies next. Population-based samples of middle and high school adolescents in the U.S. reflect that being female (Blum et a1., 2000; Garofalo, Wolf, Wissow, Woods, & Goodman, 1999; Grunbaum, Basen-Engquist, & Pandey, 1998; Guiao & Thompson, 2004; Hallfors et a1.,2004) and suffering from depression were significantly and strongly related to suicide ideation and suicide attempts. The Youth Risk Behavior Survey (YRBS) reports suggest that being Hispanic constitutes a risk factor for depression, suicide ideation, and suicide attempts, with Hispanic females at the highest risk (Grunbaum et a1.,2004; Grunbaum et a1.,2002; Kann et a1.,2000; Kann et a1.,1998; Kann et a1., 1996). Different results were found in the National Longitudinal Study of Adolescent Health studies (NLSAH). No significant differences were found for Hispanic ethnicity in suicide behavior (Blum et a1.,2000; Guiao & Thompson, 2004; Hallfors et a1.,2004). However, among females, Latinas reported significantly higher risk for depression than their Euro American peers (Guiao & Thompson, 2004). Blum et a1. (2000) examined the unique and combined contributions of race/ethnicity, income, and family structure to some risky behaviors, including suicidal thoughts or attempts. Those three demographic variables taken together explained less than .5% of the variance in suicide attempts in middle and high school students. The authors concluded that knowing race/ethnicity, income, and family structure provides little predictive power at the indiviciual level and suggest further studies of the more proximal social contexts of young people, including families and communities, in order to better understand what predisposes some young people to increased suicide risk.

Comparative Studies with Large and Small Samples Another set of studies are comparative studies with large and small samples of suicide behavior among Hispanic adolescents. Table 5.2 and Table 5.3 present these studies organized by study source, sample, predictive variables, outcomes, and results.


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In school-based surveys with 6th to 8th graders, Mexican Americans reported a higher prevalence of suicide ideation than their Anglo peers (Olvera, 2001; Roberts, Chen, & Roberts, 1997;Roberts & Chen, 1995;Tortolero & Roberts, 2001). Risk for suicide ideation remained significant among Mexican Americans even after adjusting for other important psychological and sociodemographic variables in a large sample (N = 3,442) from New Mexico and Texas (Tortolero & Roberts, 2001).Mexican American females reported the highest prevalence of suicide ideation (Olvera, 2001; Roberts, Chen, & Roberts, 1997; Roberts & Chen, 1995; Tortolero & Roberts, 2001). Four studies compared Hispanics with African Americans in suicide behavior, three with high school students (Lester & Anderson, 1992; O'Donnell, O'Donnell, Wardlaw, & Stueve, 2004; O'Donnell, Stueve, Wardlaw, & O'Donnell, 2003) and one with middle school students (Walter et a1., 1995). Suicide ideation in high school students was more frequent in Hispanics. In Walter et a1.study (1995)with middle school students evaluating lifetime involvement in suicide intentions/attempts no difference by race/ethnicity group were found. In O'Donnell's sample, suicide attempt was more strongly related to Hispanic ethnicity than suicide ideation. In this study, race/ethnicity was measured by asking the participants, "Are you Black/African American, Hispanic/Latino, Black and Hispanic, Black and white, or other?" Responses were coded into either Hispanic or non-Hispanic. Students that identified as "Black and Hispanic" were labeled as non-Hispanic in the first study (O'Donnell, Stueve, Wardlaw, O'Donnell, 2003). In an effort to differentiate ethnic and racial groups, O'Donnell, O'Donnell, Wardlaw, and Stueve (2004) reanalyzed the O'Donnell et a1. (2003) data. Hispanic remained as one category, but non-Hispanic was separated into Black/ African American, Black and Hispanic, and Other. Those who reported suicide attempts were 17.9%of Hispanics, 16.9%of those who identified as "other," 10% of Black and Hispanic, and 8.1%of Black/African Americans. Some studies focused on suicide behavior in high school students or older adolescents, comparing Whites, Blacks, and Hispanic Americans. In a large sample from Connecticut, researchers Rew, Thomas et a1.(2001) found that the percentage of suicide attempts was significantly higher among Latina girls than in any other ethnic-gender group. Even in a sample of homeless adolescents (aged 12 to 22), significantly more Hispanics (57%) than Whites (31.7%)reported having considered suicide (Rew, Taylor-Seehafer, & Fitzgerald, 2001) Suicidal ideation has also been studied as a common experience in adolescent development in response to normal developmental crisis (Marcenko, Fishman, & Friedman, 1999).The main hypothesis was that if attitudes toward suicide were controlled, ideation would not vary significantly by ethnicity, gender, or psychosocial variables usually associated

TABLE 5.1 Comparative

Population-Based Studies of Suicide Behavior among Latino and Latina Adolescents: Study (Source), Sample, Predictive Variables, Outcomes, and Results Study (Source)

Sample

NLSAH database In-home interview; Blum, Beuhringn, Shew, Beuringer, Sieving, and Resnick (2000)

N = 10,803 White, non-Hispanic = 7,684 (71.1%); Hispanic = 1,355 (12.6%); Black, nonHispanic = 1,734 (16.3%)

NLSAH databaseWave I , In-home interview; Hallford, Waller, Ford, Halper, Brodish, and Iritani (2004)

NLSAH database Wave I; Guiao and Thompson (2004)

YRBS 1992 Southeast Texas; Grunbaum, Basen-Engquist, and Pandey (199B)

Predictive Variables race/ethnicity, income, family structure

N = 18,924 Race: White = 12,429; Black = 4,247; Other = 2,248 (mostly Asian); Ethnicity: Hispanic = 3,230; Non-Hispanic = 15,635

adolescent sex and

N= 3,310 females Euro Americans

ethnicity

drug behavior

Suicidal thoughts or attempts during the past year (ordinally scaled composite measures with no report of specific items used)

Lifetime suicide ideation (ever think about committing suicide? Yes/No) Lifeti me su icide attempt (ever actually attempt? Never/one or more times) Suicide behavior during past year: composite measure of 3 items (suicide

57.7%; African Americans 24.9%; Latinas 11.6%; Asian Americans 3.8'Yo; Native Americans 2%

N = 1,786 Mexican American 65%; nonHispanic White 26%; unknown 9%; Analyses compared Mexican Americans

Outcome

thoughts, number of suicide attempts, and need for treatment

N = 3,365

No significant racial/ethnic differences in suicidal thoughts or attempts were found for younger teens (7th to 9th graders). High school White (14%) and Hispanic youth (13.4%) were more at risk for suicidal thoughts or attempts than Blacks (10.7%). No differences in prevalence were found between Hispanic and White youths. Being female was associated with a greater risk for suicidal thoughts or attempts. No differences were found for "Hispanic ethnicity" and "race/ethnicity" when controlling for SES.Major depression was a strong predictor for suicide ideation and attempt, as was female gender. Increase in risky behavior (sex and drugs) increased the risk for depression, suicide ideation, and suicide attempts.

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No significant ethnic differences in suicidal behavior were found. Latinas reported significantly higher risk for depression than did their Euro American peers, and higher risk for alcohol use than did African- and Asian Americans.

following an attempt)

ethnicity, gender, and su bstance use

Planned suicide and attempted suicide during past year

vs. non-Hispanic White YRBS 1995 Massachusetts; Garofalo, Wolf, et al. (1999)

Results

No ethnic difference within gender category in prevalence of planned or attempted suicide. 15% of males and over 20% of females planned suicide. Attempted suicide was two times greater among females. Use of alcohol, marijuana, and steroids all increased the risk of suicide plans and attempts among Mexican American females.

sexual orientation, drug use, sexual behavior, and violence/ victimization

Planned suicide and attempted suicide during past year

Female gender, GLBN orientation (gay, lesbian, bisexual, or not sure), Hispanic ethnicity, higher levels of violence/ victimization, and more drug use were independent predictors of suicide attempt (P