Tuesday, December 7, 2010

Teen Suicide -- the facts

November 15, 2010 (Denver, Colorado) — About 25% of high school students report being bullied, 13% have considered suicide, and 8% have attempted it, according to data from 2007.

Building on this foundation, Shane Fernando, MS, from the University of North Texas Health Science Center, in Fort Worth, explored the link between bullying and suicide in a poster presented here at the American Public Health Association 138th Annual Meeting.

He used data from the Massachusetts Youth Risk Behavior Survey, a standard US Centers for Disease Control and Prevention survey for youth between the ages of 12 and 18 years, to assess the link between bullying and suicide. It asks about mental state (such as feelings of sadness), being "physically hurt by a date or having sexual contact against your will," being the victim of bullying during the previous year, and risk behaviors during the previous 30 days. His analysis was based on complete data from 3095 students.

The responses were stratified into 3 levels: no risk (did not think about or attempt suicide), low risk (thought about committing suicide, planned suicide), and high risk (attempted suicide and attempted suicide with injury).

Fernando found that whites, who constituted about two thirds of the survey population, had the highest rates of victimization — "around 23% for both males and females." Hispanics were the next most likely group to be bullied.
Victims of bullying were twice as likely to be in either the low- or high-risk groups as those who had not been bullied (low-risk odds ratio [OR], 2.1; 95% confidence interval [CI], 1.7 - 2.6; high-risk OR, 1.83, 95% CI, 1.3 - 2.7).
Those who had been physically hurt by a date had a higher chance of being in the low- or high-risk group than those who were not (low-risk OR, 1.44, 95% CI, 0.9 - 2.4; high risk OR, 2.63; 95% CI, 1.7 - 4.1). There were parallel results for youth who had a sexual experience against their will (low-risk OR, 1.42; 95% CI, 1.0 - 2.1; high-risk OR, 2.04, 95% CI, 1.2 - 3.5).

"We saw that as you go up in grade level, the tendency to be bullied decreases." It might be that newness to the environment of high school and smaller physical stature are factors leading to victimization, he said.

"We found that the suicide level was highly correlated with victimization. Hispanics had a 1.5 odds ratio of being in the high-risk category, compared with the low-risk category" (OR, 0.087).

"Feeling depressed, feeling sad, was correlated with being bullied, as was being physically hurt or having sexual contact against your will," Mr. Fernando said.
Cyberspace is the latest arena for bullying. Mr. Fernando believes it is because "it is an easier way to bully someone because you are anonymous."

It also helps to level the playing field; previous manifestations of bullying were often based on physical stature and the group dynamics of power. The anonymity of cyberspace allows even the smallest and weakest students to become bullies, he pointed out.

The link between bullying and suicide led Fernando to say that "we need to address bullying and find measures to reduce the depression and suicidal behavior" that spring from it.

He urged physicians to look for possible signs of victimization, such as sadness or physical marks, among their adolescent patients and ask about it. "Try to bridge the doctor–patient disconnect, and try to make them feel comfortable talking with their doctor about things that may be happening in their life."

With girls, signs of victimization are more likely to take the form of concern with gossip; with boys, it often centers around "making them feel that it is okay to feel challenged or threatened."

Cindy L. Buchanan, PhD, noted the high incidence of rape in the lives of the adolescent girls visiting her clinical practice in Philadelphia, Pennsylvania. "I wanted to find out if these percentages were because they were the ones coming into clinical practice, or was this actually a problem in the community," said the psychologist, who is now teaching at the University of Colorado at Colorado Springs.
She found that the overall rate of suicide attempts was high in Philadelphia. "More shocking than that, if our teens had experienced rape in their lifetime, our total sample is 3 times more likely to attempt suicide. The numbers go up when we look at minority female adolescents in Philadelphia; [they are] as much as 7 times more likely to attempt suicide.

The overall rate for adolescent females who had attempted suicide at least once within the previous 12 months was 14.7%; 12.7% reported being forced to have sex at least 1 time in their lifetime.

The young women who reported a history of being raped were 3.350 times more likely to have attempted suicide (95% CI, 3.034 - 3.700).

Hispanics who had been forced have sex were the most likely to have attempted suicide at least once over the previous year (OR, 7.008; 95% CI, 3.850 - 12.758); African Americans were the least likely (OR, 3.658; 95% CI, 3.215 - 4.162), and whites were in the middle (OR, 5.813; 95% CI, 4.605 - 7.337).

The study did not include those who were successful in their attempts at suicide.
"It makes sense," Dr. Buchanan said. "They have experienced this major, traumatic stress and they are figuring out how to cope with it. My hope is to be able to develop strategies to help them to cope in a more effective manner."

She has developed a Web site, with input from teenage reviewers, in which teenage rape victims can get information "and most importantly, link them to professional help," particularly if they are not ready to talk to a local school counselor.
Physicians need to be aware that many teenage girls "initially have a hard time discussing past history of abuse or rape," Dr. Buchanan reminded meeting attendees. Do not take the first denial of a problem as the final answer; keep that possibility open for future discussions, she advised.

Dr. Buchanan said it often requires time to build trust that will allow the patient to become comfortable talking about an issue that has been bottled up. Often, girls are victimized by a boyfriend or family member, and there might be serious relational consequences from raising the matter publicly.

Dr. Buchanan suggested that physicians try asking other family members or friends if the patient has changed, and if so, when those changes began to occur. "Maybe you can identify a time when things started to look different for them."

She acknowledged that it can be difficult separating out responses to rape/victimization from normal developmental changes that occur during the teenage years. A professional who is experienced in working with teens is best equipped to do so.

Matthew Miller, MD, MPH, a suicide expert from the Harvard Injury Control Research Center, Harvard School of Public Health, Boston, Massachusetts, called Dr. Buchanan's study confirmatory: "We've seen this before."

He is not sure that physicians should necessarily screen for a rape–suicide nexus with their patients. There are no conclusive data demonstrating the utility of this screening, and there is some suggestion that it might even be counterproductive. Dr. Miller said: "It may normalize the idea [of suicide] and have a perverse effect."

The speakers have disclosed no relevant financial relationships.
American Public Health Association (APHA) 138th Annual Meeting: Abstracts 3070.0-3 and 3157.0-1. Presented November 8, 2010

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