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Suicide in young people

by Chris Woodford. Last updated: April 23, 2016.

A winter night. In cold and darkness, she steals her way through the woods, her feet tracing the moon-silvered path dully, mechanically, like the wheels of a train. She follows for a mile or more, glancing occasionally at the moon, its sick white face, glimpsed through dark branches, staring full and hopelessly back like one of those kids on a cancer ward. Then, suddenly, a break in the trees, a deep cutting opening its arms to catch her, the trains thumping through... every few seconds... sudden endless carriages rushing through the windy cutting... and she's high on the giddy footbridge. And she's leaning her elbows on the criss-cross rails. And she's watching the carriages rushing, pushing under her feet. And she's wondering if she has the nerve. And she's feeling sick and bleak as the trains keep cutting through. And she stands there for an hour, wobbling between life and death, that night—the night she finally killed herself.

~

"Global figures for suicide in [adolescents] show that it is the second most common cause of death after road-traffic accidents—it is the third most common cause of death in male adolescents (after road-traffic accidents and violence). Globally, suicide is the most common cause of death in female adolescents aged 15–19 years."

"Self-harm and suicide in adolescents," Keith Hawton, Kate Saunders, Rory O'Connor.

In the forty seconds or so that it took you to read those words...

...someone somewhere in the world has killed themselves. Read them again and someone else will die too. Quietly and hopelessly perhaps, crying themselves to sleep for the final time after punching pill after pill through the foil in the packet. Noisily and angrily, perhaps, jumping off a roof, hurling themselves under a train...

Waiting at London's Waterloo Station one afternoon a few weeks ago, I found myself wondering why the concourse was so packed with people looking angrily at their anxious watches, when a voice came over the station PA: "Due to an 'incident' on the line, all services this afternoon are subject to severe delay and disruption." And, like anyone else who's ever heard the word 'incident' spoken by a train announcer, I thought to myself: suicide. Someone who was alive this morning has become an "incident", a mess to be cleared up, an inconvenience to commuters, a "why-oh-why" story in the local paper.

And I thought to myself: why is suicide so taboo? Why does no-one ever really talk about it? It's like when rabbits die in Watership Down and the others disappear into their burrows without even mentioning it, pretending nothing has even happened. It seemed so bizarre, this conspiracy of silence. And I wondered if it was part of the problem. I wondered if, instead of telling me about the delays to the 15.47 to Portsmouth and the 16.08 to Poole, the announcer could have calmly told me a few facts about suicide instead: "We apologize for the delay to your journey this afternoon. This is due to suicide being the second biggest killer of 15–29-year-olds in the world today. Officially, over 160,000 people under the age of 25 will kill themselves this year—that's over 50 times more than died in the September 11 terrorist attacks (unofficially, that's described as a "gross underestimate"). Anyway, thank you for listening. We apologize for the delay to your journey and any inconvenience this may cause."

I pause, reflect, try to get my head round those numbers. There's a killer in our midst, stalking the youngest and most vulnerable. A new black death. I think of Wilfred Owen's Anthem for Doomed Youth: "What passing bells for these who die as cattle?" I try to picture 160,000 dead young people—the population of a large town or small city—piled high in a field somewhere like foot and mouth carcasses. I try to imagine the tabloid outrage if the world's entire, annual toll of young suicides happened on the same day—the death toll 50 times higher than that of September 11. I find myself growing angry; I wonder how the station announcer stays so calm.

What can we learn from suicide statistics?

"Lies, damned lies, and statistics..." applies just as much to suicide as it does to anything else. Using statistics to understand suicide is fraught with difficulty: different countries define "suicide" differently, many suicides are misclassified as accidents or covered up because of social, cultural, or religious taboos. Bearing that in mind, what sorts of things do the numbers tell us?

The death toll

According to the World Health Organization, something like 800,000 people commit suicide every year (roughly one every 40 seconds) [1]; about 41,000 of them are in the United States. [2] These bald numbers tell us little, though they certainly become much more chilling when we consider the WHO's belief that they represent a "gross underestimate": for every person who commits suicide, 20 more attempt it. If suicides were accurately reported, and everyone who attempted suicide pulled it off, we might be looking at 20 million deaths worldwide each year. Even working with the official figure of 800,000 and only one in 20 suicide attempts proving successful, we still have the population of the Netherlands (17 million) or Australia (23 million)—in effect, an entire country's worth of people—attempting suicide every year. So why don't we sit up and take more notice?

Causes of death

Top 10 leading causes of death for different age ranges in the United States, 2012.

Suicide is the 10th leading cause of death (counting all age groups together) in the United States; homicide, which garners so much more media coverage, ranks a mere 16th. [3] Both pale in comparison with the big boys of death: heart disease (7.4 million deaths worldwide each year) and strokes (6.7 million). HIV/AIDS notches up 1.5 million and road accidents 1.3 million. But if suicide is as underreported as the WHO suggests, 800,000 a year might be 1.6 million or 2.4 million in reality, so it could easily be one of the world's top five killers. If you're the kind of newspaper reader who frets over violent crime, bear in mind that suicide accounts for 50 percent of all violent deaths in men worldwide and a staggering 71 percent of violent deaths in women. [4]

Table: Suicide kills a disproportionate number of young people. This table shows the ten leading causes of death for different age ranges from <1 (left) to >65 (right) in the United States for the year 2012. Suicide is shown by green squares. For ages 10–14, suicide is the third most common cause of death. For ages 15–34, it becomes the second most common cause. From 35–54, it's fourth most common. The blue squares represent unintentional injury; the red squares show death by homicide. Table from Wisqars: Ten Leading Causes of Death and Injury, US Centers for Disease Control and Prevention.

Age

Suicide is more common in older people: in most parts of the world, the over 70s (particularly the widowed and divorced) are most likely to kill themselves. There are important variations, however. In the United States, the peak rate is currently for middle-aged adults, [5] while in the UK, the highest rate is currently for males aged 30-44. [6] Suicide rates are very low in children under 15. Infants at different stages of development can have some unusual ideas about death (for example, that it's reversible), but many psychologists believe children between 6 and 10 can "commit suicide" in the same way as adults (in other words, kill themselves with awareness of what that means).

While high suicide rates in the old and low rates in the young are easy enough to understand, the more surprising statistics are for age groups in between. If childhood suicide is very low, and elderly suicide relatively high, we might suppose that the rate of suicide would increase steadily the older people get—and that's broadly what happens. Yet there are interesting anomalies. What, for example, do we make of the sudden, spectacular leap in suicide rates that begins after puberty, during adolescence and early adulthood, making suicide the second biggest cause of death for ages 15–29 and the biggest single killer of girls aged 15–19? What about the observation that younger people think more about suicide and plan for it more than older people—even though they don't successfully commit suicide anything like as much? According to the US Center for Disease Control and Prevention (CDC), suicidal thoughts and planning and actual suicide attempts are "significantly higher" in young adults (18–29) than in people over the age of 30 [7]: 20 percent of all adolescents now consider suicide and 5–8 percent of them actually attempt it, so the number of young lives touched by suicide, one way or another, is enormous. (Again, there are fascinating differences between boys and girls, with just over 10 percent of female students attempting suicide compared to just over 5 percent of males.) Or how about the fact that the rate of youth suicide has roughly tripled in the last half century? [8] Most of these statistics are based on research carried out in the United States; in some countries, suicide rates are significantly higher in young people than in any other age group. [9]

One of the most worrying findings is that older schoolchildren can be highly suicidal. Research in the United States has found that older teens (grade levels 9–12, ages 14–18) show a worrying fascination with suicide. About one in six (17 percent) say they've considered suicide, one in seven (13.6 per cent) have made a suicide plan, and one in twelve (8 percent) have made an actual suicide attempt. These are relatively small numbers but still frighteningly high percentages. Only one in thirty or so (one person in every classroom) has actually injured, poisoned, or overdosed to the extent that they've needed medical attention. [2] In short, these young people are suicidal but, for the most part, lack what suicidologists call "lethality" (the ability to actually kill themselves).

Chart comparing how many grade 9-12 boys and girls have suicidal thoughts, plans, and mild or harmful suicide attempts.

Chart: Suicidal intentions in students. This chart shows the percentage of adolescent boys and girls (grades 9–12) who have considered, planned, attempted, or made a harmful attempt at suicide requiring medical attention in the United States. Drawn using data quoted in Suicide: Facts at a Glance, 2015 [PDF] from research by Kann L, Kinchen S, Shanklin SL, et al. Youth Risk Behavior Surveillance—United States, 2013. MMWR 2014; 63(ss04): 1–168.

Sex

Since the 19th century, researchers have consistently found significant differences between men and women: the rate at which they attempt suicide, the rate at which they succeed, and the methods they choose. In 1838, Jean-Étienne Esquirol, one of the world's first proper psychiatrists, based at France's pioneering mental hospital, the Sâlpetrière, wrote in Mental Maladies: A Treatise on Insanity, that "the proportion of suicides among men and women, is as three of the former, to one of the latter." [10] In France (and countries such as the UK, Australia, and Germany) that's still true today. In eastern Europe and the former Soviet countries, the disparity is wider, with male suicides outnumbering females by anything from 5:1 (Belarus) to 8:1 (Poland). In low and middle-income countries, the gap closes, with just 1.5 men committing suicide for each woman. [11] According to the CDC, men represent almost 80 percent of all suicides in the United States. Tellingly, however, women are more likely to have suicidal thoughts and to attempt suicide.

Chart comparing male and female suicide methods, suggesting males opt for more violent (and therefore more successful) techniques.

One simple explanation for the discrepancy is that men pick more violent methods of suicide and therefore succeed much more often than women, even though they make far fewer attempts: death by gunshot is the most common suicide method for men, while poisoning is the (much less effective) method chosen by most women. [12] (Having a gun in the home carries a "significantly greater risk" of someone using it to commit suicide, no matter what type of gun or how safely it's stored. [13])

The gender difference appliances equally to girls and older women: in the United States, 84 percent of youth suicides are boys and only 16 percent girls. In the study of suicidal tendencies in school children, girls score significantly higher than boys on all categories (considered, planned, attempted, or harmed by suicide).

Chart: Men tend to pick more violent suicide methods than women, which is one reason why more men kill themselves: violent suicide attempts are more likely to be successful. Data from US Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, quoted in NIMH: Suicide in the U.S.: Statistics and Prevention.

Country

Emile Durkheim was one of the first people to argue that broad social conditions play a major factor in suicide. On the face of it, that might offer a possible explanation for the huge disparity in suicide rates that we see worldwide. But even a glance at the World Health Organization's striking interactive world suicide atlas suggests there is likely to be no single, simple explanation for the huge variation in suicide rates across the world.

This fascinating map shows very high suicide rates in rapidly developing countries such as India. Indeed, a recent paper titled The changing global face of suicide, by Michael Phillips and Hui Cheng, published in The Lancet in 2012, revealed that low- and middle-income countries account for an astonishing 84 percent of the world's suicides (India and China make up almost half of all suicides alone). Why the differences? Why does Canada have a conspicuously lower rate of suicide than the United States? Why is the French rate of suicide twice the rate in nearby Britain? How do we explain the very low rates of suicide in North Africa and the Middle East compared to the very high rates in East Africa? Why does Australia—surely a happy, go-lucky, sunny kind of a place?—have a far higher suicide rate than its Pacific island neighbors?

Chart comparing suicide rates per 100,000 and ratio of male to female suicide in 15 typical countries.

Chart: There are wide variations in the suicide rate around the world. This chart shows (blue bars, left y-axis) the number of suicides per 100,000 people in 15 typical countries. The orange diamonds (right y-axis) show the ratio of male to female suicides in those countries; the orange line shows the mean value of just over three to one. Drawn using data from WHO's Global Health Observatory (GHO).

As Durkheim argued, the differences turn out to be due to complex interactions of social, religious, and cultural factors. For example, Muslim countries tend to have officially low rates because suicide is still treated as a criminal offense (so may be misclassified or under-reported); China has particularly high suicide rates in rural areas where agricultural workers have ready access to poisonous pesticides; the United States has high rates of male suicide correlated with high levels of gun ownership; and rapidly industrializing nations are in a period of huge social upheaval. Australia has high rates of aboriginal suicide—and it's a country to which people migrate, and therefore, perhaps, lack a sense of belonging and social connection (critically important factors that help to prevent against suicide).

Even within a country, there can be startling variations in the suicide rate, for example, due to ethnic variations. In the United States, Latinos commit suicide more than white people, while blacks (until recently) had a much lower rate. Young Native Americans and Alaskans have an extremely high suicide rate (1.5 times the national average) largely, it's been argued, because of their difficulty in integrating into modern America, high rates of substance abuse and child abuse, and high levels of gun ownership. Mixed-race adults report the highest levels of suicidal thoughts. Among students, Hispanics show significantly higher rates of contemplating, planning, attempting, or harming themselves in a nonfatal suicide attempt than either white or black students. [14]

Time

Every study of suicide is a snapshot of the problem; suicide rates are fluctuating from year to year. Even so, it's possible to chart changes in the suicide rate over time. In the United States, broadly speaking, the rate increased from the 1960s to the late-1980s, declined until 2000, and has since risen again to its 1980s peak. The rate of youth suicide tripled in the second half of the 20th century. [15] Since 2000, the youth suicide rate has held roughly steady, suicides in the elderly have declined somewhat, but there have been very significant increases in the mid-age brackets 25–44 and 45–64. The biggest increases have been among white people and Native Americans; blacks, Asians/Pacific islands, and Hispanics have held steady.

References

Why can't society discuss and address the epidemic of suicide in young people?

"The pain of severe depression is quite unimaginable to those who have not suffered it, and it kills in many instances because its anguish can no longer be borne. The prevention of many suicides will continue to be hindered until there is a general awareness of the nature of this pain."

William Styron, Darkness Visible

Trying to understand why so many young people commit suicide is hard. But then trying to understand why anyone commits suicide isn't easy. There are a whole variety of reasons why people end their lives prematurely and often very violently. Certain people are much more likely to kill themselves than others; doctors, dentists, vets, and farmers—with ready access to the tools of "self-murder"—top the list. Not surprisingly, mental illness is the most significant factor of all: many people who commit suicide suffer from an untreated illness, perhaps a mood disorder such as depression or bipolar disorder (the illness formerly known as manic depression, a roller-coaster ride of epic highs and crushing lows) or an eating disorder such as anorexia or bulimia. Brain biology plays a major role in mood disorders: cursed with badly wired brains, some people need chemical help to sort themselves out. "Negative life events" as the psychologists call them (things like lost jobs, bereavements, and the end of relationships) play a key role too; psychotherapy proves especially effective there. Together, medication and psychotherapy make a great team. Mental illnesses are often as treatable as physical problems like gallstones or broken bones.

But most people with broken bones don't die. Thousands of young people are not dying of broken bones every year. So what makes mental illnesses and suicide so different?

If the media are to be believed, there's always been something distinctly hip about dying before your time. And I don't just mean Kurt Cobain. Take a trip to the Tate and study the romantic, oil-painted portrayals of Thomas Chatterton, the self-poisoned poet, draped suggestively over a sofa, or Ophelia, Hamlet's unrequited love, floating glassy eyed between the weeds, and you'll see what I mean: romanticizing suicide is nothing new. But it's a long, long way from wallowing in the melancholy of a Tindersticks lyric to being wheeled into A&E with a blanket pulled over your head. If young people committed suicide simply because it was cool, they'd be dying in their millions. Studies have estimated that only five per cent of suicides in young people are copycat deaths. That's five per cent too many, of course, and it shows that insensitive and sensational media coverage can do more harm than good. But it also shows we have to look elsewhere for an explanation.

Painting of poet Thomas Chatterton by Henry Wallis in 1856

Photo: Suicide romanticized? Thomas Chatterton, poet and forger, is believed to have committed suicide at the age of just 17. This famous portrait painted by Henry Wallis in 1856 heightened his credibility as a romantic figure, but it's highly misleading and disingenuous: we see nothing of the pain or despair that drove him to take his own life.

If it's not a matter of copycat killing, why are so many young people ending their lives so prematurely? There seem to be a whole raft of things that can make one young person more likely to attempt suicide than another. Alcohol and drug use are thought to play an important role; both affect your ability to reason, both can act as depressants, both can make you less inhibited and more likely to actually kill yourself if you're feeling suicidal in the first place. Young men are ten times more likely to use drugs to relieve stress. And drugs, in particular stimulants like cocaine and speed, can tip the balance in people who are already genetically hard-wired for mental illnesses such as bipolar disorder. But drugs are far from the only reason for the surge in young deaths. Puberty is also happening earlier now, bringing adolescence and depression to a younger age group ill-equipped to cope.

No man—or woman—is an island. And people don't always commit suicide purely because of the things going on inside their heads. Ever since French sociologist Emile Durkheim wrote his groundbreaking book Suicide in 1897, psychiatrists and psychologists have recognized the importance of wider social factors, both in causing suicide and in helping to prevent it. It comes as no surprise that high suicide rates often go hand-in-hand with high unemployment rates, for example. And young people from broken homes or families in which there's a high level of stress (due to parental unemployment, mental illness, or alcohol abuse, for example) are also more likely to attempt suicide, as are young people who have suffered physical or sexual abuse. Those at particular risk include young gay and bisexual men (estimated to be two to six times more likely to commit suicide than straight men) and people in prison or young offenders' institutions. Sometimes social factors can have a surprising effect. For example, suicides went up by nearly 20 per cent in the month following Princess Diana's funeral, while episodes of self-harm increased by 44 per cent. Equally, though, social factors can protect against suicide. People strongly integrated into social groups, such as devout church-goers, are much less likely to kill themselves.

So why do more young men kill themselves than young women? Again, the picture is complex. In the United States, women are two to three times more likely to attempt suicide than men, but men are four times more likely to actually kill themselves. The reason is partly due to the different types of mental illness that women and men typically suffer from and partly because men choose more violent methods of suicide that are more likely to succeed. Another crucial problem identified by researchers is that men and boys—because of social pressures to be "strong", "macho" or whatever—seem to find it much harder to ask for help when they're having a bad time.

Generic illustration of alcohol abuse: bottles and cans in a recycling dumpster

Photo: Alcohol abuse (and a history of alcohol or substance abuse in your family) puts you at greater risk from suicide. Alcohol abuse is also strongly connected with violence, itself one of the leading causes of death among young people. According to the World Health Organization: "Harmful drinking among adolescents is an increasing concern in many countries."

So what do we do about all this?

According to The Samaritans (a British charity that provides a sympathetic ear at the end of the phone to anyone who needs it): "There are no quick and easy solutions to the complex problems of suicide in our society today. Perhaps a starting point is to consider our response to the emotional distress that we see in the people around us." Our response means all of us. It means the World Health Organization, who have declared that it's essential for the world "to break the taboo surrounding suicide"—a major global problem that is currently slaughtering far more young people than war and AIDS. It means governments providing health care that kids and young people can actually relate to; member countries of the World Health Organization have set themselves the target of reducing the global suicide tally by 10 percent by the year 2020. It means bridging the gap between the health care that's available and the people who need it (a 1999 study by the Mental Health Foundation in London found that half the people surveyed had no idea who to contact if someone they knew needed psychiatric help). And it means us too—you and me.

Because ending the taboo of suicide means not mumbling apologetically about "incidents" on rail lines or going quiet or changing the subject, but talking openly about mental illness as easily and comfortably as we talk about the common cold. A third of us will suffer from some sort of mental illness at some point in our lives. That means us, our friends, and our families. Most of us will go on to lead normal lives, because in most cases mental illness is no big deal: it is as normal, common and treatable as physical illness provided people get the help and support they need, when they need it.

I come back to the question that's been haunting me since I started working on this article: why are so many young people killing themselves? Not because "suicide is painless", as the Manics once sang—how painless is it having your stomach pumped in A&E because you screwed up an overdose?—but because for some people, sometimes, life becomes acutely and unbearably painful. Not because killing themselves was a quick and easy solution to a simple problem, but because, in most cases, they had a history of personal or family problems and untreated depression or another mental illness. People kill themselves because, at the moment when they decide to take their own life, they can see no alternative. They may or may not be ill, but they're not in their right mind either. And no-one sees it and no-one helps them in time. No-one asks them the right questions, so no-one gives them the right answers.

On average, in England, one person dies from suicide every hour. Maybe one of your friends, maybe one of mine. Maybe there's not much you or I can do to stop people dying of TB (the world's biggest killer). Maybe we can't stop people killing one another in wars. But where suicide—the black death—is concerned we can all make a difference, just by being there.

Getting help – call a suicide hotline

Every year, 800,000 people die from suicide (World Health Organization).

Are you thinking of joining them? If you're feeling suicidal, please get help. Now.

A person's hand holding a telephone.

Call the National Suicide Prevention Lifeline (in the United States), The Samaritans (in the UK), or Befrienders (in 40 countries worldwide). They're not going to judge you or argue. Someone on the end of that phone line will listen patiently. They will try to understand. And they will try to help you.

If you think a friend is contemplating suicide, the best thing you can do is talk to them about it, rather than skirt round the issue. You may have spotted the warning signs already. These can include dramatic personality changes, withdrawal from pleasant activities, strange sleep or eating patterns, taking unnecessary risks or giving away personal possessions. Never be tempted to play psychiatrist; you may make things worse. But mental health professionals agree on one thing: asking suicidal people directly about their plans is one of the most helpful things you can do. You won't make matters worse; you may save someone's life. Try to find out how serious the situation is. For example: Do they really think they'd be better off dead? Have they made suicide attempts in the past? Have they drawn up a definite plan to commit suicide? How will they do it? When? What, if anything, would hold them back? If you think they're at serious and imminent risk of committing suicide, get help immediately. If the threat is less serious, help your friend find a qualified counselor (their GP/physician is probably the place to start) or suggest they talk about their problems with someone they trust.

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Woodford, Chris. (2002/2016) Suicide in Young People. Retrieved from http://www.explainthatstuff.com/suicideinyoungpeople.html. [Accessed (Insert date here)]

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