One in five high school students seriously considered attempting suicide in 2023, according to data from the Centers for Disease Control and Prevention (CDC).
This staggering statistic corresponds with a growing rate of youth suicide in the United States, which is one of the leading causes of death in adolescents and young adults. Suicide deaths among 10- to 24-year-olds increased by 62% from 2007 to 2021. Research released this summer found that suicide is rising dramatically in preteens as young as 8 years old as well, with an 8.2% annual increase from 2008 to 2022.
No sole data point will accurately predict suicide. There are countless information sources that we have yet to tap into.
Christine Cha, PhD
The trend is even more alarming regarding Black children and teens. The suicide rate among Black youth ages 10-17 increased by 144% between 2007 and 2020, the fastest-growing rate among racial groups. Black preteens ages 8-12 experience the highest rates of suicide compared with other racial groups as well.
The COVID-19 pandemic contributed to the worsening numbers. “There was what’s been called a secondary pandemic,” says Christopher Pittenger, MD, PhD, Elizabeth Mears and House Jameson Professor of Psychiatry at Yale School of Medicine (YSM). “Youth mental health struggles were already at crisis levels, and woefully underserved, prior to the pandemic – and then they exploded as an area of enormous need.”
The CDC identified several factors that have contributed to worsening mental health for teens over the past decade. These include concerns about violence and safety, persistent sadness or hopelessness, and suicidal thoughts and behaviors; female and LGBTQ+ students are disproportionately affected.
Yale’s focus on youth suicide research
Historically, youth suicidality has been an understudied area of research, a reality which the Center for Brain and Mind Health (CBMH) at YSM is focused on addressing. Founded in 2022, CBMH was created to integrate Yale’s neuroscience research with clinical care; the center’s five co-directors, including Pittenger, have identified youth suicidality as a pressing area where such integration would be beneficial. Their efforts reflect a national strategy to reduce mental health disparities in young people, which experts have declared a national emergency.
“In pediatric mental health, things are worse than they’ve ever been, and there’s a greater need to understand mental well-being in children and specifically problems with suicidality,” says James McPartland, PhD, Harris Professor in the Yale Child Study Center, director of the Yale Developmental Disabilities Clinic, and a CMBH co-director. “We really thought that this could be a domain where far-reaching improvements could be made.”
To this end, in partnership with the Child Study Center, the CBMH has recruited a specialist in youth suicide research as its first faculty hire. .Christine Cha, PhD, clinical psychologist, associate professor in the Yale Child Study Center, and honorary associate research professor at Teachers College, Columbia University, joined CBMH on September 1 as the inaugural core faculty member, with plans to extend her research program on youth suicide risk and prevention that she has conducted for the past 15 years.
Who is at greatest risk for suicide?
One focus for Cha is the pursuit of innovative suicide risk detection methods. “No sole data point will accurately predict suicide,” says Cha. “There are countless information sources that we have yet to tap into.”
Tied to this, Cha’s research team at Columbia examined patients’ reaction times, mood fluctuations, and reasons for nondisclosure during clinical assessments. Recent initiatives in Cha’s lab, spearheaded by Ilana Gratch, have included the examination of micro expressions and voice quality of young adults when responding to clinical questions. Beyond targeting adult and adolescent populations, work in her lab led by Nathan Lowry has expanded the scope to preadolescents, given the alarming suicide trends in these younger age groups. Ultimately, this line of work may yield tools that help identify at-risk patients across the lifespan in order to help clinicians identify opportunities for intervention.
“Even the best treatments in the world will fall short unless we know precisely who would benefit from them most and how,” Cha says.
Nationally, many are working toward the same goal, with a commitment to identify at-risk youth by increasing screening measures for patients receiving health services of any kind. The American Academy of Pediatrics now recommends universal suicide screenings for youths above age 12, meaning that preteens and teens should be screened for suicide risk even when seeking health care for unrelated concerns. These screenings involve asking questions such as “in the past few weeks, have you wished you were dead?” or “in the past week, have you been having thoughts about killing yourself?”
Two years ago, physicians at Yale New Haven Health System launched a zero-suicide initiative in the pediatric emergency department and the inpatient psychiatric unit at the Children’s Day Hospital by providing educational training on suicide screenings for health providers.
“We know that kids who attempt suicide are more likely to have been seen in some sort of medical placement within the last month,” says Pamela Hoffman, MD, assistant professor of child psychiatry at YSM and psychiatrist in the pediatric emergency department at Yale New Haven Children’s Hospital. “So, we need to screen people who come in who aren’t flagged for behavioral health, who might be here for a football injury or a sore throat, or they might be here needing STI (sexually transmitted infection) testing, and they happen to be suicidal. The only way that we can find them is to be able to ask the question.”
Important as such screenings are, they don’t always provide a reliable assessment of a child or adolescent’s risk for death by suicide. A patient screens positive on a suicide screening tool when they answer “yes” to questions asking if they’ve had suicidal thoughts or behaviors, but even with a positive screen, it’s not always clear to the health care professionals providing these screenings what kind of treatment and follow-up are needed.
“With suicide, a ‘positive screen’ doesn’t mean that this person is really going to die by suicide,” says Yann Poncin, MD, assistant professor of child psychiatry and child and adolescent psychiatrist at Yale New Haven Hospital. “Whom do we identify as really, really being at risk? We don’t know. It’s very hard to do.”
These clinical challenges are precisely what motivate Cha and her lab’s work in this area. “We aim to discern which information sources from patients can complement and augment our current ability to predict who’s at greatest risk,” Cha says.
Intervening on the psychology of suicide
Cha also investigates the underlying psychological experiences of teens and preteens who are considering suicide. She studies factors such as adolescents’ views and orientations toward death, which can include a sense that “death is a viable escape from pain,” and their ability to simulate their own future life in a concrete way.
“We’ve been asking teens to describe discrete events that might happen within the next five to ten years of their lives, and measure how detailed and textured these imagined events are,” Cha says. “It’s hard to generate hope for something you can’t imagine in the first place. Perhaps helping them imagine their future in a realistic and mentally tangible way lays a foundation for hope.” With the intention to improve adaptive qualities of future thinking, Pauline Goger, PhD, and Rachel Nam from Cha’s research team continue to test both the strengths and limits of future thinking as an intervention target.
Another area of potentially impactful research is developing effective educational measures for the families of suicidal youth.
“It’s not just about what’s within the person, but also around the person,” Cha says. “My colleagues and I been looking at what the quality of the family environment is and exploring ways to approach parents and guardians of teens to coach them — on parenting and its effect on their child, and ways to support them emotionally when they’re having a challenging time.”
Involvement of the family, in Poncin’s experience, is a vital component of care when it comes to children and teens experiencing suicidal thoughts and behavior. “There should be no situation where a child would have suicidal thinking and not have a parent be informed or involved in the safety planning,” he says. Complementing this observation is Cha and her trainee Angela (Page) Spears’ National Institute of Child Health and Development-funded examination of self-reported risk from multiple stakeholders such as youth and their parent/guardians.
Cha is enthusiastic about the opportunities for collaboration across their different disciplines of brain and mind research as she continues her work on interventions for suicidal youth.
“There are particular conditions of populations that are prone to elevated suicide risk,” McPartland says. “By collaborating with [Cha]… we can make far-reaching progress in multiple fields.”
From Cha’s perspective, “This is the chance to make it count. To connect with experts on different topics and methodological approaches to pursue innovative, pragmatic, and impactful solutions,” she says. “There’s a lot to gain from a little humility. It’s a matter of staying open to what we in mental health care may be missing, engaging in generative conversations, and centering the projects on vulnerable populations who may stand to benefit the most.”