From the Editor
She came into our ED feeling overwhelmed. After a recent breakup, she felt suicidal; the academic demands of grade 12 further stressed her. As a clinician, this type of adolescent presentation seems to be increasingly common.
But is it? Many people have opinions. Dr. Tanner J. Bommersbach (of the University of Wisconsin) and his co-authors attempt to shed light on the state of teen mental health with a new and important paper focused on suicidal ideation, plans, and attempts. In the first selection, we examine their American Journal of Psychiatry paper, involving almost 120 000 high school students, drawing on US survey data, and covering a decade and a half. “In this nationally representative sample… significant increases occurred in the percentage reporting past-year suicidal thoughts, suicide plans, and suicide attempts from 2007 to 2021.” We consider the paper and its implications.
In the second selection from BJPsych International, Dr. Rachel Gibbons (of the Royal College of Psychiatrists) writes about suicide. In a controversial paper, she argues that we make too many assumptions about suicide, which colour our research and undermine our understanding of patients. “Embracing the complexity of suicide may not only refine prevention but also deepen our understanding of suffering, resilience, and meaning.”
And in the third selection, playwright Dan O’Brien writes about his brother’s suicide for Esquire. In a deeply personal essay, he discusses his brother’s mental health problems and his parents’ desire to hide them. He wonders what could have been. “I would like to be helpful to some who might read this, if only to deny that the suffering of mental illness is a disgrace, and to assert that such suffering is common and survivable.”
DG
Selection 1: “National Trends in Suicidal Thoughts and Suicide Attempts Among High School Students in the United States”
Tanner J. Bommersbach, Mark Olfson, Taeho Greg Rhee
The American Journal of Psychiatry, 28 May 2025 Online First
In 2021, suicide accounted for approximately 20% of all deaths among 15- to 19-year-olds in the United States, making it the third leading cause of death in this age group. Suicide is believed to be the result of a complex interplay of environmental (i.e., stress, access to means) and individual (impulsivity, mental health, and genetic vulnerability) risk factors, often occurring along a continuum of behaviors that includes suicidal ideation, planning, and attempts. Recent data demonstrate a concerning rise in behaviors along this continuum; among 15- to 19-year-olds, the suicide rate increased 63% from 2007 through 2021. Moreover, suicidal ideation among high school students increased significantly from 2009 to 2019, and self-reported suicide attempts increased from 1991 to 2019, especially among Black adolescents…
Despite the rise in suicide and suicidal symptoms among adolescents, surprisingly little is known about the extent to which the increase has been broad-based or narrowly confined to at-risk groups. A greater understanding of recent trends in behavioral risk factors could inform clinical surveillance strategies. Research thus far has focused on broad trends in suicidal symptoms among age, sex, and racial and ethnic subgroups…Several health-risk behaviors, which commonly emerge in adolescence, are associated with suicidal symptoms. Important examples include substance use, victimization, sedentary activity, body dissatisfaction and unhealthy weight control behaviors, inadequate sleep, and high-risk screen time…
So begins a paper by Bommersbach et al.
Here’s what they did:
- They drew from the Youth Risk Behavior Survey, “a biennial cross-sectional survey of U.S. high school students.”
- The years: 2007 to 2021. (“We selected 2007 as the baseline year because previous research has indicated that 2009 was the turning point when suicidal ideation began to increase among U.S. adolescents, and we sought to capture the period immediately before this rise.”)
- “Suicidal thoughts were defined as seriously considering attempting suicide or making a plan to attempt suicide in the past year. Suicide attempts included ≥1 attempt in the past year.”
- Statistical analysis was done, including multivariate logistic regression identified health-risk behaviors associated with suicidal thoughts and attempts.
Here’s what they found:
- 119 654 students were sampled.
- Demographics. The mean age was 16.0 years. Females represented 49.1%. Ethnically, the majority were White (55.3%); Hispanic (21.6%), and Black were well represented (13.6%).
- Thoughts and plans. “The percentage of students endorsing past-year suicidal thoughts (biennial average percent change or BAPC=2.9%) and suicide plans (BAPC=3.0%) increased significantly across the study period and at a significantly higher rate among females compared to males…”
- Attempts. “The percentage of students endorsing past-year suicide attempts increased significantly across the study period (BAPC=2.2%)…”
- Groups. “The rate of increase in suicidal thoughts was disproportionately high among females, non-Hispanic White and Black students, and students with depressive symptoms, while attempts rose disproportionately among non-Hispanic White and Black students and high school seniors.”
- Substance. “In subgroup analyses, there was a disproportionately large increase in suicidal thoughts and attempts among students who used cigarettes or cannabis.”
A few thoughts:
1. This is a strong paper, drawing on a large dataset collected over several years, and published in a major journal. Importantly, the study included data from the first pandemic year.
2. The main findings in three words: up, up, up. To be more specific, suicide attempts, plans, and ideation all increased over the study period.
3. To put things in perspective: “Nearly 1 in 4 high school students reported past-year suicidal ideation in 2021, and 1 in 10 reported a suicide attempt.” (!!) Ouch.
4. This is one of several studies suggesting mental health problems with youth. Are younger people more willing to talk about their problems than before? Are they experiencing negative effects from technology, COVID, and other things?
5. The authors looked at health-risk behaviours (e.g., experienced bullying recently, ongoing poor sleep, etc.). In fact, they didn’t find much of a difference between those who had multiple such behaviours and those who didn’t. The authors see clinical implications: “The results of our study, demonstrating elevated and rising rates of suicidal thoughts and attempts among students without established behavioral risks, shows how targeted screening based on behavioral risk factors might be increasingly likely to miss individuals with suicidal symptoms.” It’s a reasonable point but – to state the obvious – universal screening is problematic and resource-intensive.
6. Like all studies, there are limitations. The authors note several, including the reliance on self-reporting.
7. Past Readings have looked at youth and adolescent mental health. Last month, we summarized a JAMA paper on public-insured children in the United States, finding: “the percentage of publicly-insured children diagnosed with any mental health or neurodevelopmental disorder increased from 10.7% in 2010 to 16.5% in 2019.” That Reading can be found here:
The full American Journal of Psychiatry paper can be found here:
https://psychiatryonline.org/doi/10.1176/appi.ajp.20240706
Selection 2: “Rethinking suicide prevention: from prediction to understanding”
Rachel Gibbons
BJPsych International, 19 May 2025 Online First
Over the past two decades, suicide prevention efforts have expanded significantly and are likely to have contributed to a 36% global reduction in suicide rates. The field has also seen an extraordinary 8000% increase in publications (PubMed) since 1961. This progress has been linked to reduced stigma, public health interventions that limit access to means, increased research investment, and advances in data gathering and prevention strategies.
Yet, alongside these advances, certain deeply held assumptions appear to shape both research and policy in ways that may constrain rather than enhance our understanding of suicide. Some beliefs – widely accepted but not always strongly supported by evidence – introduce bias into research, limit the effectiveness of interventions and discourage exploration of the complexity of suicide.
So begins a paper by Dr. Gibbons. She focuses on eight questions. Here, we summarize four.
Can we really predict suicide?
“Despite decades of research, our ability to predict individual suicides has not improved. Yet, belief in prediction persists, shaping discourse, research methods and conclusions. Suicidal behaviour arises from a complex interplay of genetic, psychological and social factors. Some acts are impulsive, others carefully concealed. Survivors of serious attempts often report uncertainty about their motives, many with no clear warning signs.”
Suicidal ideation: a warning sign or something more?
“Suicidal ideation is widely seen as a predictor of suicide, yet most who experience it do not die by suicide, and around 60% of those who do never expressed such thoughts. Its low positive predictive value underscores its limitations as a risk assessment tool. Far from rare, suicidal ideation can be part of grief and mourning and reflects an ability to symbolise distress – a capacity often absent in those who die by suicide. When someone expresses suicidal thoughts, they are articulating somatic and psychic pain, offering a crucial opportunity for therapeutic engagement.”
Does mental illness cause suicide?
“The assumption that suicide is caused by mental illness has shaped prevention efforts, placing primary responsibility on mental health services, narrowing the scope of suicide prevention and leaving many deaths unexamined. In England, only 26–27% NCISH of people who died by suicide had contact with mental health services in the preceding year. Similarly, the CDC reported that 54% had no diagnosed mental illness. With one-sixth of the UK population experiencing mental illness at any time and 25% facing a common mental health problem each year, this overlap is unsurprising and inevitable in large-scale studies. Correlation may be mistaken for causation, reflecting Western assumptions that suicide is inherently irrational and tied to mental illness, with a focus on individual over social, cultural or spiritual factors.”
Should suicide prediction and prevention be the primary job of mental health professionals?
“Research shows that mental health professionals overwhelmingly believe that predicting and preventing suicide is a core part of their role, despite strong evidence that suicide prediction is not realistically achievable. This expectation is reinforced by societal pressures, which frame suicide as an outcome of mental illness, assuming it is both individually predictable and therefore preventable.”
She closes with an invitation:
“Suicide remains complex and often enigmatic – acknowledging this is not failure but a step toward more meaningful, compassionate prevention. Clinicians, researchers, and organisations struggle with the tension between expectations and reality, pressured to provide certainty where uncertainty persists. But rather than viewing uncertainty as a barrier, could it be an opportunity? By broadening its focus beyond risk reduction to explore the existential, moral and philosophical dimensions of suicide, the movement can encourage deeper engagement with what it means to be human.”
A few thoughts:
1. This is a well-written essay.
2. She makes good points – including the connection between mental illness and suicide. Suicide is, after all, an action, not a diagnosis.
3. An important comment: “A focus on certainty and control risks reinforcing blame, fear, and scapegoating rather than fostering understanding and support.”
4. To play Devil’s advocate: yes, research may be based on flawed assumptions, but given the notable success of global suicide reduction efforts, should we be tempered in our criticism?
The full BJPsych International paper can be found here:
Selection 3: “Dear Family…”
Dan O’Brien
Esquire, 15 January 2025
We had just recovered from our first bout of Covid, and we were rewarding ourselves with a trip to Cabo San Lucas that we couldn’t really afford. My wife was sunbathing while I strolled with our daughter, nine years old, through the waves along the beach. Returning to our towels, I saw a text on my phone from my brother Tim – ‘Call me’ – and moments later I learned that our older brother Chris was dead.
Perhaps this will be the last time that I feel the need to write about the Thursday afternoon in February 1986 when Chris jumped from a window in the attic of our house in Scarsdale, New York. I was 12, and I witnessed the immediate aftermath: my brother limping toward our front door, barefoot, no jacket, snow matted in the back of his blue sweater and blue jeans, and the back of his mussed blond hair.
That evening, home from the hospital, my mother collapsed in my arms. ‘Nobody can ever know,’ she whispered in my ear. ‘This is a secret we must take to our graves.’
So begins an essay by O’Brien.
He notes the family’s shame. “My parents didn’t provide my brother with any professional help. They denied that he had a problem. His attempted suicide was merely an act of ‘immaturity,’ they said. Within months I developed obsessive-compulsive disorder, and I didn’t receive treatment, either. Instead I tried to treat myself: Writing – confessionally, secretly – allowed me to feel healthy again.” And he describes a complicated relationship with his own parents, one marked by years of estrangement.
He discusses the death. “It appeared that he had been brushing his teeth, leading my mother to suggest that a heart attack or stroke had killed him in a flash.” But the author has his suspicions. “I had been waiting since 1986 to hear that Chris had killed himself. He was hospitalized briefly in the early 2000s, and likely there were other such hospital stays. He didn’t have friends and had never had a romantic relationship, as far as I knew. He was without social support of any kind.”
As the next of kin, he has access to different documents. He writes about getting the toxicology screen. He then outlines different conversations as he seeks to understand what happened. He secures a copy of the suicide note.
“Was my brother’s debilitating depression the result of our unhappy childhood? He was genetically predisposed to depression, surely, but sadly – tragically, it is fair to say – being raised by my parents didn’t help. And being raised by them did not help in the most literal sense: Early intervention and treatment would have changed the course and the quality of my brother’s life – could have possibly saved his life.”
He thinks about his parents. “With my brother’s death, they chose to turn away, once again, from the reality of who he was and how he suffered. It’s too late for Chris. My parents can no longer help him, but they might help the family, they might help themselves, if they could overcome the shame they feel concerning my brother’s depression and suicide.”
He ends the essay by writing about the note – and his brother. “My brother’s note of farewell reveals little. He writes that his death is nobody’s fault, and he asks to be forgiven. I wish that he could read these words and know that he does not need my forgiveness. I did not love him in spite of his suffering; I loved him more deeply because of it.”
A few thoughts:
1. This is a raw and moving essay.
2. It’s tough not to wonder what might have been.
3. There have been many people like Chris over the years. With fading stigma, more families are talking about mental health problems and getting help. But many people like Chris are still shunned by family, friends, and co-workers.
The full Esquire essay can be found here:
https://www.esquire.com/lifestyle/a62925309/brother-suicide-note-dear-family-january-2025
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
Recent Comments