Results: Medical Examiner's records (n=54) indicate a 4: 1 male:female ratio, and methods: firearms 5 1%, hanging 26%; Juvenile Justice records (n=49) show ...
Utah Youth Suicide Study: Preliminary Results by Doug Gray, M.D.; T. Keller R.N., M.P.H.; L. Haggard, Ph.D.; B. Rolfs, M.D.; J. Achilles, M.A.; D. Tate, M.S.; C. Cazier, M.P.H.; and W. McMahon, M.D. Abstract
Objective: State agency records of all Utah suicide victims, age 13-21 were reviewed for risk factors and prevention opportunities. Method: Data were reviewed from 4 state agencies. Results: Medical Examiner's records (n=54) indicate a 4: 1 male:female ratio, and methods: firearms 5 1%, hanging 26%; Juvenile Justice records (n=49) show 65% had contact, and by age 18 (n=24) 75% have contact, and significantly more offenses than controls; School records (n=3 1) show 47% with record of suspension or expulsion, and 39% with special education evaluation; Child Protective Services review (n=5 1) show 21% with a family referral. Conclusions: Preliminary results suggest this approach contributes to the understanding of youth suicide. Referral to Juvenile Justice is an important risk factor. Introduction U.S. suicide rates have remained steady since the 1950s, but the rate of youth suicide has increased dramatically. For example, the U.S. rate for 15-24 year old youth has risen from 3.5 per 100,000 in 1950, to 7.5 in 1970, and 13.5 in 1990. The trend is to see suicide at younger ages, with the U.S. suicide rate for individuals less than 15 years old increasing 121% from 1980 to 1992 (Kachur, Potter, James, Powell, 1995). There are distinct gender differences in choosing lethal and non-lethal methods. Eighty percent of suicide attempters are female and 80% of suicide completers are male (Canetto, 1997). Suicide rates are generally higher in the western states than in the rest of the country. Recent theories, such as regional differences in age, sex, raciavethnic mix, and firearm availability, have failed to explain this pattern (Centers for Disease Control, 1997). In Utah, suicide is the leading cause of death for males ages 15 to 44 (Rolfs, unpublished Utah data, 1997). Firearms are the most common method of suicide across the nation, among all age groups, and for both males and females (Kachur et al., 1995). Psychological autopsy studies allow researchers to study suicide and can guide future suicide prevention efforts. Studies to date have focused on the diagnoses of youth suicide victims and have found that more than 90% had a psychiatric disorder (Brent et al., 1988). Both male and female suicide completers have high rates of mood disorders. Males frequently have additional diagnoses, most commonly substance abuse or conduct disorder. The studies to date find that only 5-20% of suicide completers are in psychiatric treatment at the time of their death (Brent et al., 1988; Shaffer et al., 1996); current
methods of prevention, such as school education programs and teen hotlines, have not been shown to be effective (Hazel1 and King, 1996; Grossman, 1992). Nationally, suicide experts suggest that we focus our efforts on finding youth who are at risk for suicide and get them into treatment. Unfortunately, the best mechanism to accurately find these young people who are at risk for suicide is unclear. Where are these individuals connected in our community, and how can they be identified? For example, do these youth completers attend school or are they involved with the justice system? Do they seek help from primary care doctors, counselors, or clergy? Which community contacts recognize known suicide risk factors, or try to intervene? When community members try to prevent an individual suicide, and fail, what are the barriers they face? Statewide Effort The Utah Child Fatality Review Committee (CFRC) identified a need to fight the rising epidemic of youth suicide in Utah. Based on the recommendation of the CFRC, the Utah Department of Health organized a committee with representatives from multiple government agencies to study the problem. Due to gaps in the available information and understanding of youth suicide, it became clear that research was necessary before appropriate prevention programs could be developed. Once the study was designed, it was reviewed by national suicide experts who supported the need for this type of research. The study methodology has been presented at local, regional, and national conferences. Cooperation among government agencies was crucial, and
fortunately every Utah agency asked to participate gave full cooperation. The state medical examiner plays a vital role, first in determining the cause of death, then in notifying the research team of each youth suicide. Finally, funding was provided by the Utah Department of Health for the study of all suicides occumng in one year. Methods This is a study of Utah residents, ages 13 to 21, who completed suicide between August 1996 and August 1997. The study was approved by the Institutional Review Boards of both the State Department of Health and the University of Utah. Ethical considerations included protecting the confidentiality of the deceased and surviving family members, respecting the rights of those who choose not to participate in the study, and monitoring the emotional demands of the interviews. The study consists of three phases:
Phase 11 After consent from the "Next of Kin" is obtained, face-to-face interviews are conducted, where applicable, with parents, step-parents, and spouse. Mental health professionals from the research team go to their homes and gather information about the deceased using questionnaires designed for the study. If consent to interview "community contacts" is obtained, the "community contacts" of the deceased are identified for phase 111. After each interview, families were surveyed regarding their response to the research process. This provided information on the emotional reactions to the interview and allowed us to redesign questions during the pilot study.
Phase II
Letter to Next of Kin introducing study Phase I Data are collected from four government agencies: 1) Office of the Medical Examiner, 2) The Juvenile Justice System, 3) The Division of Child and Family Services (Department of Human Services), 4) The Department of Education. The Utah Department of Health has the authority to collect the data from government agencies. Each agency has a statewide data system, except the Department of Education, where data is collected from individual school districts. Care is taken not to identify the cause of death. Interviews do not occur during this phase.
Medid Examinets detenninatimof suicide. Every suicide in Utah aged 1S21 years.
I
Within 3 month
1 Gather govemnt agency 1 dab
Justice
/ I
I Rehse consent
3 months after death
Accept consent
1 NOK interviewed as /
I
/ a communitycontact /
Phase 111 "Community contacts" of the suicide victim are interviewed, including family, friends, school counselors, employers and coworkers, clergy, romantic relationships, medical and mental health care providers, probation officers, coaches, and others. The community contacts are selected for interview according to specific protocols. Each community contact is interviewed with a standard questionnaire covering three areas: I ) An intimacy scale, to evaluate the relationship between the contact and the deceased. 2) A checklist of psychiatric symptoms, in specific categories, exhibited by the deceased. 3) A section reviewing specific barriers to mental
health care experienced by the deceased. The goals of phase I11 are to determine which community contacts are able to recognize risk
factors for suicide and to identify the barriers that may prevent appropriate mental health treatment of high risk youth.
Phase In
Locate Community Contacts
Consent from Community Contacts
Interview Community Contacts
Types of Community Contacts: Siblings Close fiiends Employers/coworkers Clergy Teachers/school counselors Medical and mental health professionals Others
Control Groups Some of the data collected on suicide victims will require comparison with other Utah youth to determine their significance. The Juvenile Justice System and the Division of Child and Family Services each have a statewide database, which will be used to form a control group. Results Participation Phase 1 compliance rates for the four government agencies have been 100% to date. Some of the school records have incomplete data, although efforts have been made to find all of the available data. Phase I1 consent from next of kin is cumntly 60%. Phase 111 pmicipation rates for
community contacts is currently 78%. As families were surveyed regarding their emotional reactions to the research process, they have indicated that participation in the study was helpful, not harmful. Appropriate referrals to community support groups or mental heath services have been made, when indicated. This paper only reviews the data from phase I.
Ofjice of the Medical Examiner Records have been reviewed on 54 consecutive suicides. Gender ratio was 80% male, 20% female. Sixty percent committed suicide at their residence, 4% at school, and 36% at another location. The method used was most commonly firearms (5 1%), followed by hanging (26%), poisoning (17%) and "unspecified" (6%) (see graph below). Type of firearm used was classified as handgun (64%), shotgun (14%), rifle (IS%), and "not listed" (4%). Toxicology was completed on 94% of subjects. Of 41 nonpoisoning deaths with completed toxicology screens (firearm, hanging, or unspecified), eight (20%) had a positive test for alcohol or drugs of abuse. Of nine poisoning deaths (five carbon monoxide, four overdoses) with completed toxicology, three (33%) had a positive test for alcohol or drugs of abuse. In only one case was substance abuse the sole cause of death (heroine overdose). Juvenile Justice System Records have been reviewed on 49 consecutive suicides, with 65% having a record of involvement and 35% having no record. Of those involved in the juvenile justice system, 3 1% had at kast One Since to
Method of Death
hanging
IH poisoning unspecified
i
U t a h Juveniles by N u m b e r o f C r i m i n a l O f f e n s e s Referred to Juvenile C o u r t : Suicide Victims A g e 18 to 21, 8\96-4197 a n d Population A g e 18,
1995
60
1 I
--
= U t a h 1995 P o p u l a t i o n A g e 1 8 U S u i c i d e S t u d y G r o u p A g e 18-21
)
1
50 -P e r c e n t o f 40 Persons
--
30 -20 --
-
-
10 -0
I
0
1
2to3
4or5
6or7
8 or
more N u m b e r o f C r i m i n a l a n d S t a t u s O f f e n s e s R e f e r r e d to J u v e n i l e C o u r t
juvenile justice is age dependent up to age 18, 24 suicide completers over the age of 18 were selected for detailed analysis. This group was compared to a control group of over 40,000 Utah juveniles who turned 18 during 1995 (see bar graph above). The study subjects were significantly different from controls in comparisons of the overall distribution of the number of offenses (Chi-square (d%5) =86.89, p
