CDC Guidance for Community Assessment and Investigation of Suspected Suicide Clusters, United States, 2024.

This report is the second of three reports in the MMWR supplement updating CDC's guidance for investigating and responding to suicide clusters. The first report, Background and Rationale - CDC Guidance for Assessing, Investigating, and Responding to Suicide Clusters, United States, 2024, describes an overview of suicide clusters, methods used to develop the supplement guidance, and intended use of the supplement reports. The final report, CDC Guidance for Community Response to Suicide Clusters, United States, 2024, describes how local public health and community leaders can develop a response plan for suicide clusters. This report provides updated guidance for the approach to assessing and investigating suspected suicide clusters. Specifically, this approach will guide lead agencies in determining whether a confirmed suicide cluster exists, what concerns are in the community, and what the specific characteristics are of the suspected or confirmed suicide cluster. The guidance in this report is intended to support and assist lead agencies and their community prepare for, assess, and investigate suicide clusters. The steps provided in this report can be adapted to the local context, culture, capacity, circumstances, and needs for each suspected suicide cluster.

CDC Guidance for Community Response to Suicide Clusters, United States, 2024.

This is the third of three reports in the MMWR supplement that updates and expands CDC's guidance for assessing, investigating, and responding to suicide clusters based on current science and public health practice. The first report, Background and Rationale - CDC Guidance for Communities Assessing, Investigating, and Responding to Suicide Clusters, United States, 2024, describes an overview of suicide clusters, methods used to develop the supplement guidance, and intended use of the supplement reports. The second report, CDC Guidance for Community Assessment and Investigation of Suspected Suicide Clusters, United States, 2024, describes the potential methods, data sources, and analysis that communities can use to identify and confirm suspected suicide clusters and better understand the relevant issues. This report describes how local public health and community leaders can develop a response plan for suicide clusters. Specifically, the steps for responding to a suicide cluster include preparation, direct response, and action for prevention. These steps are not intended to be explicitly adopted but rather adapted into the local context, culture, capacity, circumstances, and needs for each suicide cluster.

Background and Rationale - CDC Guidance for Communities Assessing, Investigating, and Responding to Suicide Clusters, United States, 2024.

To assist community leaders in public health, mental health, education, and other fields with developing a community response plan for suicide clusters or for situations that might develop into suicide clusters, in 1988, CDC published Recommendations for a Community Plan for the Prevention and Containment of Suicide Clusters (MMWR Suppl 1988;37[No. Suppl 6]:1-12). Since that time, the reporting and investigation of suicide cluster events has increased, and more is known about cluster risk factors, assessment, and identification. This supplement updates and expands CDC guidance for assessing, investigating, and responding to suicide clusters based on current science and public health practice. This report is the first of three in the MMWR supplement that describes an overview of suicide clusters, information about the other reports in this supplement, methods used to develop the supplement guidance, and the intended use of the supplement reports. The second report, CDC Guidance for Community Assessment and Investigation of Suspected Suicide Clusters - United States 2024, describes the potential methods, data sources and analysis that communities can use to identify and confirm suspected suicide clusters, and better understand the relevant issues. The final report, CDC Guidance for Community Response to Suicide Clusters - United States, 2024, describes how local public health and community leaders can develop a response plan for suicide clusters. The guidance in this supplement is intended as a conceptual framework that can be used by public health practitioners and state and local health departments to develop response plans for assessing and investigating suspected clusters that are tailored to the needs, resources, and cultural characteristics of their communities.

Disparities and Trends in Middle School Students' Suicidal Thoughts and Behaviors: Results From the Youth Risk Behavior Survey, 2015-2019.

PURPOSE: To examine trends and racial and ethnic disparities in early adolescent suicidal thoughts and behaviors in the years immediately prior to the COVID-19 pandemic. METHODS: This study used pooled data from Centers for Disease Control and Prevention's middle school Youth Risk Behavior Survey (n = 127,912) between 2015 and 2019. Three dichotomized measures of suicide-related behaviors were assessed: suicidal thoughts, planning, and attempts. Weighted prevalence estimates with 95% confidence intervals were calculated for each survey year. Linear trends examined disparities in the prevalence of suicidal thoughts and behaviors, overall and by student demographic characteristics. Main effects odds ratios compared estimates among racial and ethnic minority adolescents with non-Hispanic White students, controlling for sex and grade. RESULTS: Significant linear increases were observed for the percentage of middle school students who reported seriously thinking about suicide (18.2%-22.3%), ever making a suicide plan (11.8%-14.7%), and ever attempting suicide (6.9%-9.3%). Racial and ethnic minority students, other than non-Hispanic Asian, showed higher odds of suicidal thoughts and behaviors compared with non-Hispanic White students. DISCUSSION: Findings indicate a need for comprehensive suicide prevention to address health equity and disparities in suicide-related behaviors among middle school-aged adolescents.

Suicidal Thoughts and Behaviors Among High School Students - Youth Risk Behavior Survey, United States, 2021.

Suicide is the third leading cause of death among high school-aged youths aged 14-18 years. The 2021 suicide rate for this age group was 9.0 per 100,000 population. Updating a previous analysis of the Youth Risk Behavior Survey during 2009-2019, this report uses 2019 and 2021 data to examine high school students' reports of suicidal thoughts and behaviors. Prevalence estimates are reported by grade, race and ethnicity, sexual identity, and sex of sexual contacts. Unadjusted logistic regression models were used to calculate prevalence differences comparing 2019 to 2021 and prevalence ratios comparing suicidal behavior between subgroups across demographic characteristics to a referent group. From 2019 to 2021, female students had an increased prevalence of seriously considered attempting suicide (from 24.1% to 30%), an increase in making a suicide plan (from 19.9% to 23.6%), and an increase in suicide attempts (from 11.0% to 13.3%). In addition, from 2019 to 2021, Black or African American (Black), Hispanic or Latino (Hispanic), and White female students had an increased prevalence of seriously considered attempting suicide. In 2021, Black female students had an increased prevalence of suicide attempts and Hispanic female students had an increased prevalence of suicide attempts that required medical treatment compared with White female students. Prevalence of suicidal thoughts and behaviors remained stable overall for male students from 2019 to 2021. A comprehensive approach to suicide prevention with a focus on health equity is needed to address these disparities and reduce prevalence of suicidal thoughts and behaviors for all youths. School and community-based strategies include creating safe and supportive environments, promoting connectedness, teaching coping and problem solving, and gatekeeper training.

Suicides Among American Indian or Alaska Native Persons - National Violent Death Reporting System, United States, 2015-2020.

Compared with the general U.S. population, American Indian or Alaska Native (AI/AN) persons, particularly those who are not Hispanic or Latino (Hispanic) AI/AN, are disproportionately affected by suicide; rates among this group consistently surpass those among all other racial and ethnic groups (1). Suicide rates among non-Hispanic AI/AN persons increased nearly 20% from 2015 (20.0 per 100,000) to 2020 (23.9), compared with a <1% increase among the overall U.S. population (13.3 and 13.5, respectively) (1). Understanding characteristics of suicide among AI/AN persons is critical to developing and implementing effective prevention strategies. A 2018 report described suicides in 18 states among non-Hispanic AI/AN persons only (2). The current study used 2015-2020 National Violent Death Reporting System (NVDRS) data among 49 states, Puerto Rico, and the District of Columbia to examine differences in suicide characteristics and contributing circumstances among Hispanic and non-Hispanic AI/AN populations, including multiracial AI/AN. Results indicated higher odds across a range of circumstances, including 10 of 14 relationship problems (adjusted odds ratio [aOR] range = 1.2-3.8; 95% CI range = 1.0-5.3) and six of seven substance use problems (aOR range = 1.2-2.3; 95% CI range = 1.1-2.5), compared with non-AI/AN persons. Conversely, AI/AN decedents had reduced odds of having any current known mental health condition, any history of mental health or substance use treatment, and other common risk factors (aOR range = 0.6-0.8; 95% CI = 0.2-0.9). Suicide is preventable. Communities can implement a comprehensive public health approach to suicide prevention that addresses long-standing inequities affecting AI/AN populations (3).

Rural-Urban Comparisons in the Rates of Self-Harm, U.S., 2018.

INTRODUCTION: This study compares rural and urban differences in the rates of nonfatal self-harm in the U.S. in 2018. METHODS: Nationwide Emergency Department Sample and Census data were analyzed to calculate the RR of emergency department visits for self-harm between rural and urban residents. The analyses were conducted in 2021. RESULTS: Among a weighted total of 488,000 emergency department visits for self-harm in the U.S., 80.5% were urban residents, and 18.3% were rural residents. In both settings, poisoning was the most common mechanism for self-harm, followed by cutting. Firearm-related self-harm and suffocation each accounted for <2% of total self-harm cases. Overall, the age-adjusted emergency department visit rate for self-harm was 252.3 per 100,000 for rural residents, which was 1.5 (95% CI=1.4, 1.6) times greater than the rate for urban residents (170.8 per 100,000 residents). The rates of self-harm among rural residents were higher than those of urban residents for both male and female residents, for all age groups except people aged ≥65 years, and by all mechanisms. CONCLUSIONS: Comprehensive suicide prevention strategies tailored to rural communities may mitigate the rural-urban disparity in morbidity from suicidal behavior.

Suicidal Thoughts and Behaviors Among Adults Aged ≥18 Years - United States, 2015-2019.

PROBLEM/CONDITION: Suicidal thoughts and behaviors are important public health concerns in the United States. In 2019, suicide was the 10th leading cause of death among persons aged ≥18 years (adults); in that year, 45,861 adults died as a result of suicide, and an estimated 381,295 adults visited hospital emergency departments for nonfatal, self-inflicted injuries. Regional- and state-level data on self-inflicted injuries are needed to help localities establish priorities and evaluate the effectiveness of suicide prevention strategies. PERIOD COVERED: 2015-2019. DESCRIPTION OF SYSTEM: The National Survey on Drug Use and Health (NSDUH) is an annual survey of a representative sample of the civilian, noninstitutionalized U.S. population aged ≥12 years. NSDUH collects data on the use of illicit drugs, alcohol, and tobacco; initiation of substance use; substance use disorders and treatment; health care; and mental health. This report summarizes data on responses to questions concerning suicidal thoughts and behaviors contained in the mental health section among sampled persons aged ≥18 years in all 50 states and the District of Columbia. This report summarizes 2015-2019 NSDUH data collected from 254,767 respondents regarding national-, regional-, and state-level prevalence of suicidal thoughts, planning, and attempts by age group, sex, race and ethnicity, region, state, education, marital status, poverty level, and health insurance status. RESULTS: Prevalence estimates of suicidal thoughts and behaviors varied by sociodemographic factors, region, and state. During 2015-2019, an estimated 10.6 million (annual average) adults in the United States (4.3% of the adult population) reported having had suicidal thoughts during the preceding year. The prevalence of having had suicidal thoughts ranged from 4.0% in the Northeast and South to 4.8% in the West and from 3.3% in New Jersey to 6.9% in Utah. An estimated 3.1 million adults (1.3% of the adult population) had made a suicide plan in the past year. The prevalence of having made suicide plans ranged from 1.0% in the Northeast to 1.4% in the Midwest and West and from 0.8% in Connecticut and New Jersey to 2.4% in Alaska. An estimated 1.4 million adults (0.6% of the adult population) had made a suicide attempt in the past year. The prevalence of suicide attempts ranged from 0.5% in the Northeast to 0.6% in the Midwest, South, and West and from 0.3% in Connecticut to 0.9% in West Virginia. Past-year prevalence of suicidal thoughts, suicide planning, and suicide attempts was higher among females than among males, higher among adults aged 18-39 years than among those aged ≥40 years, higher among noncollege graduates than college graduates, and higher among adults who had never been married than among those who were married, separated, divorced, or widowed. Prevalence was also higher among those living in poverty than among those with a family income at or above the federal poverty threshold and higher among those covered by Medicaid or the Children's Health Insurance Program than among those with other types of health insurance or no health insurance coverage. INTERPRETATION: The findings in this report highlight differences in the adult prevalence of suicidal thoughts, plans to attempt suicide, and attempted suicide during the 12 months preceding the survey at the national, regional, and state levels during 2015-2019. Geographic differences in suicidal thoughts and behavior varied by sociodemographic characteristics and might be attributable to sociodemographic composition of the population, selective migration, or the local cultural milieu. These findings underscore the importance of ongoing surveillance to collect locally relevant data on which to base prevention and intervention strategies. PUBLIC HEALTH ACTION: Understanding the patterns of and risk factors for suicide is essential for designing, implementing, and evaluating public health programs for suicide prevention and policies that reduce morbidity and mortality related to suicidal thoughts and behaviors. State health departments and federal agencies can use the results from this report to assess progress toward achieving national and state health objectives in suicide prevention. Strategies might include identifying and supporting persons at risk, promoting connectedness, and creating protective environments.

Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12-25 Years Before and During the COVID-19 Pandemic - United States, January 2019-May 2021.

Beginning in March 2020, the COVID-19 pandemic and response, which included physical distancing and stay-at-home orders, disrupted daily life in the United States. Compared with the rate in 2019, a 31% increase in the proportion of mental health-related emergency department (ED) visits occurred among adolescents aged 12-17 years in 2020 (1). In June 2020, 25% of surveyed adults aged 18-24 years reported experiencing suicidal ideation related to the pandemic in the past 30 days (2). More recent patterns of ED visits for suspected suicide attempts among these age groups are unclear. Using data from the National Syndromic Surveillance Program (NSSP),* CDC examined trends in ED visits for suspected suicide attempts† during January 1, 2019-May 15, 2021, among persons aged 12-25 years, by sex, and at three distinct phases of the COVID-19 pandemic. Compared with the corresponding period in 2019, persons aged 12-25 years made fewer ED visits for suspected suicide attempts during March 29-April 25, 2020. However, by early May 2020, ED visit counts for suspected suicide attempts began increasing among adolescents aged 12-17 years, especially among girls. During July 26-August 22, 2020, the mean weekly number of ED visits for suspected suicide attempts among girls aged 12-17 years was 26.2% higher than during the same period a year earlier; during February 21-March 20, 2021, mean weekly ED visit counts for suspected suicide attempts were 50.6% higher among girls aged 12-17 years compared with the same period in 2019. Suicide prevention measures focused on young persons call for a comprehensive approach, that is adapted during times of infrastructure disruption, involving multisectoral partnerships (e.g., public health, mental health, schools, and families) and implementation of evidence-based strategies (3) that address the range of factors influencing suicide risk.

Circumstances Associated With Suicides Among Females-16 States, United States, 2005-2016.

BACKGROUND: Suicide rates in the United States have been consistently increasing since 2005 and increasing faster among females than among males. Understanding circumstances related to the changes in suicide may help inform prevention programs. This study describes the circumstances associated with suicides among females in the United States using the National Violent Death Reporting System. METHODS: We analyzed the circumstances of suicides occurring from 2005 to 2016 in 16 states (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin) among females aged 10 years and above. We compared the percentages of circumstances reported for the entire sample, by age group, and by race/ethnicity. Trends in changes in the leading circumstances were analyzed using Joinpoint regression. RESULTS: From 2005 to 2016, there were 27,809 suicides among females 10 years and older in the 16 states. Overall, the 2 leading precipitating circumstances were current mental health problem and ever treated for mental health problem. The leading circumstances differed by demographics. Joinpoint analysis showed inflection points in reports of job problems, financial problems, and non-intimate partner relationship problems during 2005-2009. During 2010-2016, downward inflections were seen in reports of job problems and financial problems and upward inflections in substance abuse problems and a recent or impending crisis. CONCLUSIONS: These findings show changes by age group and race/ethnicity in the circumstances associated with suicides among females in the 16 states have occurred. Studying these shifts and identifying the most salient circumstances among female suicide decedents may help prevention programs adapt to different needs.

Suicidal Ideation and Behaviors Among High School Students - Youth Risk Behavior Survey, United States, 2019.

Suicide is the second leading cause of death among high school-aged youths 14-18 years after unintentional injuries. This report summarizes data regarding suicidal ideation (i.e., seriously considered suicide) and behaviors (i.e., made a suicide plan, attempted suicide, and made a suicide attempt requiring medical treatment) from CDC's 2019 Youth Risk Behavior Survey. Results are reported overall and by sex, grade, race/ethnicity, sexual identity, and sex of sexual contacts, overall and within sex groups. Trends in suicide attempts during 2009-2019 are also reported by sex, race/ethnicity, and grade. During 2009-2019, prevalence of suicide attempts increased overall and among female, non-Hispanic white, non-Hispanic black, and 12th-grade students. Data from 2019 reflect substantial differences by demographics regarding suicidal ideation and behaviors. For example, during 2019, a total of 18.8% of students reported having seriously considered suicide, with prevalence estimates highest among females (24.1%); white non-Hispanic students (19.1%); students who reported having sex with persons of the same sex or with both sexes (54.2%); and students who identified as lesbian, gay, or bisexual (46.8%). Among all students, 8.9% reported having attempted suicide, with prevalence estimates highest among females (11.0%); black non-Hispanic students (11.8%); students who reported having sex with persons of the same sex or with both sexes (30.3%); and students who identified as lesbian, gay, or bisexual (23.4%). Comprehensive suicide prevention can address these differences and reduce prevalence of suicidal ideation and behaviors by implementing programs, practices, and policies that prevent suicide (e.g., parenting programs), supporting persons currently at risk (e.g., psychotherapy), preventing reattempts (e.g., emergency department follow-up), and attending to persons who have lost a friend or loved one to suicide.

National Trends in hospitalizations for self-directed violence related to opioids and/or depression - United States, 2000-2015.

This study examined national trends in self-directed violence in the context of changes in opioid use and depression to better inform prevention measures. Using 2000-2015 National Inpatient Sample (NIS) data, we identified 625,064 hospitalizations for self-directed violence among persons aged ≥10 years in the United States. Based on whether co-listing opioid related diagnosis and depression, we categorized hospitalizations for self-directed violence into four comorbid categories as 1) related to opioids alone; 2) related to depression alone; 3) related to both opioids and depression; and 4) related to neither opioids nor depression. Census population estimates served as the denominator for calculating hospitalization rates for self-directed violence. Hospitalization rates for self-directed violence related to opioids doubled from 5.1 per 100,000 persons in 2000 to 11.0 in 2015. The rate of increase was highest for self-directed violence related to both opioids and depression, which increased 9.4% annually during 2000-2011 and then decreased 4.3% annually during 2011-2015. Hospitalizations for self-directed violence related to depression alone remained the predominant category, accounting for approximately 60% of hospitalizations for self-directed violence; the rates among females aged 10-24 years were the highest among all subgroups, and rose 7.8% annually since 2011 reaching 93.2 per 100,000 persons in 2015. These findings highlight the importance of assessing the risk for self-directed violence among patients misusing opioids and the importance of treating opioid use disorder and depression, particularly when they co-occur. Prevention and treatment of depression is especially important for young females.

Suicides Among Lesbian and Gay Male Individuals: Findings From the National Violent Death Reporting System.

INTRODUCTION: Information regarding the epidemiology of suicide among lesbian and gay male individuals is limited, and comprehensive information is needed. This study seeks to describe the characteristics and precipitating circumstances of suicide among lesbian and gay male decedents when compared with non-lesbian and non-gay male decedents. METHODS: An analysis was conducted of National Violent Death Reporting System data from 18 U.S. states for the years 2003-2014. Sociodemographic characteristics and precipitating circumstances of suicide among lesbian and gay male decedents were compared with non-lesbian and non-gay male decedents. Logistic regression analysis was conducted to examine the association between precipitating circumstances and suicide by sexual orientation. The analysis was conducted in December 2017. RESULTS: There were a total of 123,289 suicide decedents from 18 states participating in National Violent Death Reporting System during 2003-2014; of those, 621 (0.5%) were identified as lesbian, gay, bisexual, or transgender. The majority of lesbian, gay, bisexual, or transgender decedents were identified as gay male (53.9%), followed by lesbian (28.0%), transgender (10.4%), and bisexual (7.5%). The analysis revealed several differences by age, mechanism of injury, and precipitating circumstances, including intimate partner problems among lesbian decedents, suicide planning and intent for both lesbian and gay male decedents, and mental health problems among gay male decedents. CONCLUSIONS: Findings highlight differences in the characteristics of suicide among lesbian and gay male and non-lesbian and non-gay male decedents. It is important for suicide prevention efforts to be culturally sensitive and consider the needs of sexual minority populations.

Suicide Among Persons With Dementia, Georgia, 2013 to 2016.

INTRODUCTION: Findings from studies examining the relationship between dementia and suicide have been inconsistent. This study examined the characteristics, precipitants, and risk factors for suicide among persons with dementia. METHODS: Data from the Georgia Alzheimer's Disease and Related Dementia registry were linked with 2013 to 2016 data from Georgia Vital Records and Georgia Violent Death Reporting System. Descriptive statistics were calculated and logistic regression was used to examine risk factors for suicide. RESULTS: Ninety-one Georgia residents with dementia who died by suicide were identified. Among decedents with known circumstances, common precipitants included depressed mood (38.7%) and physical health problems (72.6%). Suicide rate among persons with dementia was 9.3 per 100 000 person-years overall and substantially higher among those diagnosed in the past 12 months (424.5/100 000 person-years). Being male, dementia diagnosis before age 65, and a recent diagnosis of dementia independently predicted suicide, but not depression or cardiovascular diseases. CONCLUSION: Prevention strategies that identify at-risk individuals, provide support, and ensure continuity of care for persons diagnosed with dementia may help reduce suicide in this population.

Efforts and Opportunities to Understand Women's Mortality Due to Suicide and Homicide Using the National Violent Death Reporting System.

Women's mortality due to violent deaths is a public health issue that has received national attention. Many data systems only collect death certificate data, which provide very limited information about the circumstances surrounding a violent death. The Centers for Disease Control and Prevention's (CDC's) National Violent Death Reporting System (NVDRS) is the first and only surveillance system to capture data from death certificates, coroner/medical examiner reports, and law enforcement reports allowing for a more comprehensive picture and targeted prevention efforts. The system currently operates in 40 states, the District of Columbia, and Puerto Rico; however, with additional funding from the Consolidated Appropriations Act of 2018, this surveillance system will fully expand to cover all 50 states. A number of analyses have been conducted using NVDRS data to compare suicide and homicide among women with men; however, only a handful of studies have been conducted among subgroups of women. The present study provides an overview of NVDRS while highlighting a few key analytic studies with implications for suicide and homicide prevention/intervention among women. Data from the 2014 NVDRS Surveillance Summary are also presented to emphasize the unique opportunity to use NVDRS data to study the characteristics of suicide and homicide among women. The summary includes data from 18 states that were collected statewide. This information can provide state and local public health experts with essential data on female suicide and homicide, not provided in other surveillance systems, to help shape prevention and intervention efforts.

Vital Signs: Trends in State Suicide Rates - United States, 1999-2016 and Circumstances Contributing to Suicide - 27 States, 2015.

INTRODUCTION: Suicide rates in the United States have risen nearly 30% since 1999, and mental health conditions are one of several factors contributing to suicide. Examining state-level trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. METHODS: Trends in age-adjusted suicide rates among persons aged ≥10 years, by state and sex, across six consecutive 3-year periods (1999-2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to examine contributing circumstances among decedents with and without known mental health conditions. RESULTS: During 1999-2016, suicide rates increased significantly in 44 states, with 25 states experiencing increases >30%. Rates increased significantly among males and females in 34 and 43 states, respectively. Fifty-four percent of decedents in 27 states in 2015 did not have a known mental health condition. Among decedents with available information, several circumstances were significantly more likely among those without known mental health conditions than among those with mental health conditions, including relationship problems/loss (45.1% versus 39.6%), life stressors (50.5% versus 47.2%), and recent/impending crises (32.9% versus 26.0%), but these circumstances were common across groups. CONCLUSIONS: Suicide rates increased significantly across most states during 1999-2016. Various circumstances contributed to suicides among persons with and without known mental health conditions. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: States can use a comprehensive evidence-based public health approach to prevent suicide risk before it occurs, identify and support persons at risk, prevent reattempts, and help friends and family members in the aftermath of a suicide.

Suicidal Ideation and Attempts Among Students in Grades 8, 10, and 12 - Utah, 2015.

Suicidal thoughts and behaviors among youths are important public health concerns in Utah, where the suicide rate among youths consistently exceeds the national rate and has been increasing for nearly a decade (1). In March 2017, CDC was invited to assist the Utah Department of Health (UDOH) with an investigation to characterize the epidemiology of fatal and nonfatal suicidal behaviors and identify risk and protective factors associated with these behaviors, among youths aged 10-17 years. This report presents findings related to nonfatal suicidal behaviors among Utah youths. To examine the prevalence of suicidal ideation and attempts among Utah youths and evaluate risk and protective factors, data from the 2015 Utah Prevention Needs Assessment survey were analyzed. Among 27,329 respondents in grades 8, 10, and 12, 19.6% reported suicidal ideation and 8.2% reported suicide attempts in the preceding 12 months. Significant risk factors for suicidal ideation and attempts included being bullied, illegal substance or tobacco use in the previous month, and psychological distress. A significant protective factor for suicidal ideation and attempts was a supportive family environment. UDOH, local health departments, and other stakeholders are using these findings to develop tailored suicide prevention strategies that address multiple risk and protective factors for suicidal ideation and attempts. Resources such as CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices (2) can help states and communities identify strategies and approaches using the best available evidence to prevent suicide, which include tailored strategies for youths.

Suicides Among American Indian/Alaska Natives - National Violent Death Reporting System, 18 States, 2003-2014.

Suicide disproportionately affects American Indians/Alaska Natives (AI/AN). The suicide rate among AI/AN has been increasing since 2003 (1), and in 2015, AI/AN suicide rates in the 18 states participating in the National Violent Death Reporting System (NVDRS) were 21.5 per 100,000, more than 3.5 times higher than those among racial/ethnic groups with the lowest rates.* To study completed suicides across all ages of AI/AN, NVDRS data collected from 2003 to 2014 were analyzed by comparing differences in suicide characteristics and circumstances between AI/AN and white decedents. Group differences were assessed using chi-squared tests and logistic regression. Across multiple demographics, incident characteristics, and circumstances, AI/AN decedents were significantly different from white decedents. More than one third (35.7%) of AI/AN decedents were aged 10-24 years (versus 11.1% of whites). Compared with whites, AI/AN decedents had 6.6 times the odds of living in a nonmetropolitan area, 2.1 times the odds of a positive alcohol toxicology result, and 2.4 times the odds of a suicide of a friend or family member affecting their death. Suicide prevention efforts should incorporate evidence-based, culturally relevant strategies at individual, interpersonal, and community levels (2) and need to account for the heterogeneity among AI/AN communities (3,4).

Characteristics of and Precipitating Circumstances Surrounding Suicide Among Persons Aged 10-17 Years - Utah, 2011-2015.

In 2015, suicide was the third leading cause of death among persons aged 10-17 years (1), and in Utah, the age-adjusted suicide rate was consistently higher than the national rate during the past decade (2). In January 2017, the Utah Department of Health (UDOH) invited CDC to assist with an epidemiologic investigation of suicides among youths aged 10-17 years during 2011-2015 to identify precipitating factors. CDC analyzed data from the Utah Violent Death Reporting System (UTVDRS), National Vital Statistics System, and additional information collected in the field. During 2011-2015 in Utah, 150 youths died by suicide. Approximately three fourths of decedents were male (77.4%) and aged 15-17 years (75.4%). During this period, the unadjusted suicide rate per 100,000 youths in Utah increased 136.2%, from 4.7 per 100,000 population (2011) to 11.1 (2015), whereas among youths nationwide, the rate increased 23.5%, from 3.4 to 4.1. Among suicide decedents with circumstances data available, more than two thirds (68.3%) had multiple precipitating circumstances, including mental health diagnosis (35.2%), depressed mood (31.0%), recent crisis (55.3%), and history of suicidal ideation or attempt (29.6%). CDC's technical package of policies, programs, and practices to prevent suicide supported by the best available evidence can be used as a suicide prevention resource (3).

Sexual Orientation Discordance and Nonfatal Suicidal Behaviors in U.S. High School Students.

INTRODUCTION: Studies among adults have documented association between sexual orientation discordance and some suicide risk factors. However, studies examining sexual orientation discordance and nonfatal suicidal behaviors in youth are rare. This study examines the association between sexual orientation discordance and suicidal ideation/suicide attempts among a nationally representative sample of U.S. high school students. METHODS: Using sexual identity and sex of sexual contact measures from the 2015 national Youth Risk Behavior Survey (n=6,790), a sexual orientation discordance variable was constructed describing concordance and discordance (agreement and disagreement, respectively, between sexual identity and sex of sexual contacts). Three suicide-related questions (seriously considered attempting suicide, making a plan about how they would attempt suicide, and attempting suicide) were combined to create a two-level nonfatal suicide risk variable. Analyses were restricted to students who identified as heterosexual or gay/lesbian, who had sexual contact, and who had no missing data for sex or suicide variables. The association between sexual orientation discordance and nonfatal suicide risk was assessed using logistic regression. Analyses were performed in 2017. RESULTS: Approximately 4.0% of students experienced sexual orientation discordance. High suicide risk was significantly more common among discordant students compared with concordant students (46.3% vs 22.4%, p<0.0001). In adjusted models, discordant students were 70% more likely to have had suicidal ideation/suicide attempts compared with concordant students (adjusted prevalence ratio=1.7, 95% CI=1.4, 2.0). CONCLUSIONS: Sexual orientation discordance was associated with increased likelihood of nonfatal suicidal behaviors. Discordant adolescents may experience unique stressors that should be considered when developing and implementing suicide prevention programs.