Epidemiology of adolescent suicide

Adolescent Suicide

Epidemiological Approach to the Study of Male Adolescent Suicide in Idaho

Throughout history suicide has remained an enigma in cultures that are far and different from each other. The act of taking one's life has been a representation of religious beliefs, cultural attitudes, and the answer to pain and suffering. Although suicide is mainly frowned upon in the western world is such countries as Japan and India the act of suicide is a requirement of honor and social acceptability and the passage of time has seen the emergence, and rejection, of varying attitudes toward suicide. For example, during the persecution of Christians by the Romans an acceptable practice of a Christian woman to prevent herself from being "deflowered" by a Roman soldier the act of suicide was not only accepted but expected as well. In fact the Romans and Greeks both were of the opinion that suicide was a responsible and socially acceptable and sometimes necessary course of action. Socrates drank hemlock in the company of his friends and in certain parts of rural India it is still permissible for the wife of a deceased husband to commit suicide by throwing herself onto his funeral pyre. What is important to remember is that suicide places the victim in a voluntary position wherein facilitation of the act is determined by the individual him or herself and, for the suicide there is no question of symmetry or consent. For these individuals suicide may well be a rational argument to end one's life in the context of prolonged physical pain or metal anguish. On the other hand, however, there are numerous situations wherein ambiguity rings clear and the act is a reflection of an emotional dysfunction wherein the ability to rationalize outside the constraints of the illness lead to suicide. In other words, the powers of reasoning have been suspended. In fact affective mod disorders that lead to suicide, or evoke the desire to commit suicide, must be treated in the same vein.

If suicide is both culturally influenced and psychologically determined the question becomes one of differentiation. Although this particular philosophical debate is beyond the scope of this paper mention must be made by way of consequential interests. The leading question, therefore, is suicide a defensible action given certain contextual situations. For example, does the death of one person become socially and morally correct if the act ensures the continuance of life for a greater number of people? Continuing this example further consider a soldier who constantly risks his/her life for the well-being of others. Should the bomb explored and the soldier be killed does society consider the person's death an act of suicide? Can one actually question the morality of the soldier who was in full possession of the knowledge of the risks involved? Most would agree that even St. Thomas, who was vehemently opposed to the act of suicide, would deem the act excusable when the primary intent of the action is altruistic. In other words a socially and morally unacceptable action completed in principle is morally acceptable if an obligation exists to exercise an action benefiting the larger majority.

The act of suicide must also be looked at from the viewpoint of a natural or unnatural response to pain. As a side bar note it is interesting to point out that animals suffering from extreme pain do not actually commit suicide. The haunting question is, therefore, what is the defining feature in man that permits the act of suicide to emerge? Is it because, right or wrong, man has the ability to make the argument on a hypothetical level, to reason, and to logically arrive at a conclusion? If this is the case, what tempts or causes man to be illogical in decisions ending in suicide? Or, what influences are so strong that rational man decides that suicide is the only probable answer to a dysfunctional situation? The answer, of course, lies in the epidemiology of the construct of suicide itself, namely risk factors that are sociodemographic, psychiatric, biological, familial, and situational.

The remainder of this paper will take a more epistemological look at the issue of suicide, especially male teen suicide with respect to the phenomenon existing in the state of Idaho. The secondary phase of the report will pay particular attention to the role of the nursing profession in suicide rate reduction. The end product, or result, will be the formulation of a testable hypothesis seeking to determine whether or not the nursing profession is equipped to become a forcible entity in lowering the rate of male teen suicide in Idaho through preventative programming.

The Epidemiology of Teen Male Suicide. By broad definition epidemiology refers to the study of an event occurrence or phenomenon from a causative stance. As such the goal of epidemiological studies is to uncover the relationship that exists between exposure to various environmental conditions that can produce a certain medical illness whether the illness is neuro-biological, sociological, or psychological. Epidemiological research investigations study the distribution and determinants of various health-related states and events with respect to specified populations (Last, 1983). In the end, epidemiological studies apply the results of the research investigations to help control the health problem being investigated. Basically there are two types of epidemiological studies, namely, descriptive and analytical wherein descriptive studies are concerned with existing health-related variables and absent of a testable hypothesis and not set up to test causality in any manner. On the other hand analytical studies are designed to examine the existence of hypothesized associations and relationships, and focus on measuring the effects of a specific health related risk factor or factors (Bailar, 1997). The health-related topic of this assignment, adolescent male suicide in Idaho is basically an analytical meta analysis study wherein research pertaining to an identified group of individuals (male teens) is examined with respect to mortality rates for the whole population. As the study does not examine the relationship between exposure to certain elements impacting upon the rate of male teen suicide in Idaho the information garnered will be useful for generating a scientific hypothesis to test the efficacy of preventative treatment programs for the purpose of lowering male teen suicide rates in Idaho along with the usefulness of the nursing profession in the preventative program. The testable hypothesis is, therefore, based on the research question of whether or not preventative measures can be implemented to lower the rate of male teen suicide in the state of Idaho. In order to accomplish a meta analysis study with respect to male teen suicide in Idaho and the possible impact of nursing involvement certain reporting criteria must be met. They are as follows:

1. Clear identification of the study population (male teens in Idaho) and related groups (nurses);

2. Extracting and applying the results of other studies in a clear and straightforward fashion;

3. Making sure that what is being extracted from other studies is comparable across the board and the results are expressed consistently; and, if possible,

4. Assess the results of all studies review statistically.

As the current project is an epidemiological approach to the study of male teen suicide in Idaho a statistical analysis is not required.

Teen Suicide. Death, regardless of occasion or reason is an emotional burden for all to carry. Even in modern times the questions as to why someone commits suicide has no easy answer. Unfortunately those who endure unbearable pain, physical or psychological, the act of living is a tremendous burden to carry. The primary risk or epidemiological factors surrounding the suicide phenomenon are generally identified as major depression, severe personality disorders, the male gender, substantive abuse, the elderly, previous suicide attempts, living alone and physical illness. In the United States suicide is most prevalent among the elderly and young (15-24) (CDC, 2003). In addition, according to Shafer and Hicks (1993) among the youth group between 0.01 and 10% will attempt the act. This is a staggering number when one considers the birth rate in the United States to be 4,019,280 in 2002 (CDC, 2003). Simple mathematics equates this to a completed suicide population of young people between 40,192 and 401,928 per year.

As stated in the previous paragraph Every year between 4,000 teenagers between the ages of 15 and 400,000attempt suicide and approximately 5-6,000 complete the act and the number of suicides might be even higher because some families report the suicides as accidents or murders (Klagsburn, 1976). In addition, for the past 20 years suicide now ranks as the third leading cause of death among people ages 15 to 24, trailing only accidents and homicides" (Worsnop, 1991). According to several research studies the primary cause of male teen suicide is depression.

Only in the past two decades, have depression and suicide been taken seriously as an illness that involves the body, mood and thoughts. Not only does depression affect the way a person eats and sleeps, feels about themselves, and the way they think of the things around them but also strongly linked to teen suicide. Adolescent suicide is now responsible for more deaths in people between ages 15 to 19 than cardiovascular disease or cancer (Blackman, 1996). Teen suicide has more than tripled since the 1960's (Santrock, 2003). Despite this alarming increased suicide rate, depression in this age group is largely under-diagnosed and can lead to serious difficulties in school, work, and personal adjustment, which may continue into adulthood. How prevalent are mood disorders and when should an adolescent with changes in mood be considered clinically depressed? Brown (1996) gives the reason why depression is often overlooked in adolescents is that it is a time of emotional turmoil, mood swings, gloomy thoughts, and heightened sensitivity. Adolescence is often a time of rebellion and experimentation. Blackman (1996), observed that the "challenge is to identify depressive symptomatology which may be superimposed on the backdrop of a more transient, but expected developmental storm." (p. 52)

For numerous teens, the symptoms of depression are directly related to low self-esteem stemming from increased emphasis on peer popularity and/or peer isolation. On the other hand for some teens, depression arises from poor familial relationships, including decreased family support and perceived rejection from their parents (Lewis and Lewis, 1996). Oster and Montgomery (1996) stated "when parents are struggling over marital or career problems, or are ill themselves, teens may feel the tension and try to distract their parents" (p 2). This distraction might well include increased disruptive behavior, self-inflicted isolation and even verbal threats of suicide. Many times parents wrapped up with their own conflicts and busy lives fail to see the changes in their teens, or they simply refuse to admit their teen has a problem. In today's society, the family unit can be quite different from the stereotypical one of the 1950's where the father worked and the mother was the homemaker. Today, with single parent families and families where both parents are working full time, the teen may harbor feelings of being "second fiddle" in the hierarchy of importance. Great stress is placed upon teens today starting in early childhood which significantly contributing to the strain and depression they experience. Most enter daycare at an early age and continue into preschool. At one end of the spectrum, teens are pushed by parents to excel in sports and academics and on the other end there are teens that are never given direction or goals by their parents. Those pressured to excel oftentimes become overwhelmed by what is expected of them and succumb to using drugs and alcohol as a form of escape and possibly feel the only way out is that of suicide. Those teens without direction and lack of interest on the part of their parent's also increase the likeliness of drugs and alcohol activity as a means of escape (Lasko 1996). These adolescents might contemplate and even attempt suicide as a way of either drawing attention to themselves or to end their lives because no cares about them anyway.

Regardless of the reason for teen suicide the issue is a reality and no other state has been burdened than Idaho with respect to teen suicide -- especially male teen suicide. Epidemiologically the haunting question is not only why but also what can be done to avert the continuing tragedy?

Male Teen Suicide in Idaho. When most Americans think about Idaho images of open fields, vast national forests, mountains, lakes, and a tranquil lifestyle come to mind. Idaho holds for most individuals the impression of being a magnificently empty natural space, one that depicts rugged Western authenticity. As such the visitor, though media or actual travel, would never think that such an addictively satisfying place would be plagued by a high male teen suicide rate. Yet, Idaho ranks second in the nation with reported adolescent suicide deaths (Idaho Department of Welfare, 2003) and the rate of male suicides in Idaho is four times that of females and the chosen method used to complete the act of suicide is the firearm. In addition a survey conducted by the Idaho Department of Education produced reporting data revealing information that showed 2,330 Idahoans aged 18 and older attempted suicide within a twelve month period in 2001 (Idaho Department of Education. 2001). This in and of it self is staggering knowing that the population of Idaho is roughly 1,293,000. Upon closer inspection data gathered by the CDC (2003) shows that Idaho has four unique populations susceptible to the act of suicide, namely Native American males ages 15-24, teenage males ages 15-17, working age males ages 18-64 and elderly males aged 75 and older. Of these four groups the teen male group (ages 15-17) have the overall highest suicide rate: 22.5 per 100,000 between 1999 and 2001 (CDC, 2003). This is followed by the Native American male group with a reported suicide rate of 21 per 100,000. However, over a ten-year period, 1992-2001, Native American males (15-24) committed suicide more frequently than all other reported groups: 115.8 per 100,000.

Although nationally suicide is the third highest cause of death for teens, in Idaho it is the second highest cause of teen deaths. In addition, between 199 and 2001 15- to 17-year-old teen males completed the suicide act five times higher than female teens of the same age bracket (U.S. Department of Health and Human Services, 2001). However, the same is not true for attempted suicide as females teens in grades 9 through 12 attempted suicide twice as much as male teens (Idaho Department of Education, 2001). Continuing further the collected data supports the fact that of the teen male population in Idaho, Native American males between the ages of 15 and 17 have the highest rated of suicide. Those factors supporting the increase of suicide and suicide attempts can be generally attributed to mental disorders, substance abuse aggressive and impulsive behavior patterns, and easy access to firearms (Idaho Department of Health and Welfare, 2003). Knowing that teen male suicide in Idaho is extremely high by way of national averages the need for preventative programming is crucial.

Preventative Programming. The very first step in establishing a teen preventative program to deal with the suicide phenomenon is the ability to recognize the warning signs and risk factors of possible suicide actions. Most professionals, including those in the State of Idaho, recognize that preventing suicide begins first with recognizing the warning signs presented below followed by an understanding of the risk factor involved:

1. A previous suicide attempt.

2. Very noticeable changes in personality, mood structure, and behavior.