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To examine suicidal ideation, suicide attempts, lethality of suicide attempts, and the relationship between psychiatric disorder and recent attempts in newly detained juveniles.
The sample included 1829 juveniles, aged 10 to 18 years, sampled after intake to a detention center in Chicago, IL. Interviewers administered the Diagnostic Interview Schedule for Children (DISC) to assess for thoughts of death, suicidal ideation, suicide plans, lifetime suicide attempts, number of attempts, age at first attempt, attempts within the last 6 months, method of suicide attempts, and psychiatric disorder.
More than one-third of juvenile detainees and nearly half of females had felt hopeless or thought about death in the 6 months prior to detention. Approximately 1 of 10 (10.3%, CI: 7.7% – 12.8%) juvenile detainees had thought about committing suicide in the past 6 months, and 1 of 10 (11.0%, CI: 8.3% – 13.7%) had ever attempted suicide. Recent suicide attempts were most prevalent in females and youth with major depression and generalized anxiety disorder.
Fewer than half of detainees with recent thoughts of suicide had told anyone about their ideation. Identifying youth at risk for suicide -- especially those suffering from depressive and anxiety disorders -- is a crucial step to preventing suicide.
Suicide is the third leading cause of death in young people aged 15 to 24 years, affecting 9.5 per 100,000 adolescents in 2003.1 Suicide among youth has nearly doubled since 1950, increasing at a faster rate than among groups 25 years and older.2 Suicide is an even greater risk in incarcerated youth; available national data suggest that prevalence rates of completed suicide are between 2 and 4 times higher among youth in custody than among youth in the community.3, 4 Incarcerated youth have characteristics commonly associated with increased risk for suicide,5 such as high rates of psychiatric disorder6 and trauma.7, 8 Conditions associated with confinement, such as separation from loved ones,9 crowding, 10 locked sleeping rooms,4 and solitary confinement,10, 11 may also increase risk for suicide.
It is important to study youth immediately after arrest and detention. Detention provides the first opportunity in the juvenile justice system to systematically screen youth for risk of suicide. Screening for current and prior suicidal ideation and behavior is critical for prevention. A recent national study of 79 suicides among incarcerated and detained youth found that over two-thirds of the suicide victims had made prior attempts, reported suicidal ideation, made suicidal threats, or physically harmed themselves.5
Although studies have examined suicidal behaviors in youth in long-term correctional facilities,12, 13 youth in residential facilities,14 and youth formally processed by the juvenile justice system,15 few large-scale investigations have examined detained youth in the United States. Findings vary widely. Prevalence rates of current suicidal ideation vary from 14.2% to 51%.8, 16–20 Racial and ethnic differences in suicidal ideation also vary across studies; some reported higher prevalence rates of ideation in non-Hispanic whites than African Americans and Hispanics,16, 19 while others reported no racial/ethnic differences.18, 20, 21 Similarly, some studies reported higher prevalence rates of ideation in females than males,16, 18, 19 while others found no gender differences.21, 22
The variation in prevalence rates across studies of detained youth is likely due to differences in sampling and measurement. The largest study of detained youth examined 18,607 admissions to detention, not individuals; youth may have been admitted more than once.16 The largest study of individual detainees sampled a combination of 451 youth held in detention and 1350 youth incarcerated in long-term facilities.19 However, findings were not reported by subsample, and combining the subsamples is problematic because youth in detention and youth in prison have different patterns of suicidal behavior.5 For example, in detained youth 40% of completed suicides occur within 3 days of admission. In contrast, in youth in long-term facilities, over 72% of completed suicides occur after 3 months.5
Variation in prevalence rates is also due to differences in measurement. Although all prior studies use questionnaires to assess suicidal ideation and behavior, they used a variety of self-administered8, 16, 17, 20–22 and group-administered measures.19
There are several key omissions in the literature. First, many of the samples were too small or homogeneous to examine differences by race/ethnicity and gender.17, 18, 21 Examining racial/ethnic and gender differences is important because suicidal ideation and attempts vary by these characteristics in the general population.23–26 Understanding demographic differences in suicide risk in detained youth also helps to identify culturally relevant and gender-specific interventions that are most needed.
Second, only three studies examined prevalence rates of suicide attempts in juvenile detainees;18, 19, 22 past suicide attempts are powerful predictors of future attempts.5 Moreover, due to methodological differences in the studies, these rates vary widely. Rohde et al.27 reported a lifetime attempt rate of 19.4%, whereas Morris et al.19 reported a past-year attempt rate of 15.5%. Esposito et al.22 reported lifetime, past-year, and past-month attempt rates of 33%, 29%, and 26%, respectively.
Finally, to date, few studies of detained youth have examined the relationship between psychiatric diagnosis and suicide risk. It is important to determine which youth are most at risk for suicide. Psychopathology is consistently linked with risk for suicide in adolescents28 and is prevalent in detainees.6, 29 Depression,15, 27 anxiety,27 substance use,15, 19 and behavioral disturbances (in boys)27 have all been identified as correlates of past suicide attempts in youth involved in the justice system. The few studies that examined psychiatric disorders and suicide in detained youth relied on small samples27 or examined a limited range of disorders.18, 19
To our knowledge, this is the first large-scale epidemiologic study of detained youth in the United States that uses a comprehensive, standardized interview to assess suicidal ideation, suicide attempts, the lethality of suicide attempts, and a wide range of psychiatric disorders. Using data from the Northwestern Juvenile Project, we examine prevalence rates of suicidal ideation and behaviors; the relationship between recent suicide attempts and psychiatric disorders; and differences by gender and race/ethnicity.
Participants were part of the Northwestern Juvenile Project, a longitudinal study of 1829 youth (aged 10–18 years) detained between 1995 and 1998 at the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago, IL. The randomly selected sample was stratified by gender, race/ethnicity (African American, non-Hispanic white, Hispanic), age (10–13 years or 14 years and older), and legal status (processed as a juvenile or as an adult) to obtain enough participants to examine key subgroups (e.g., females, Hispanics, and younger children).
During data collection, the CCJTDC received approximately 8500 annual admissions (John Howard Association, unpublished data, 1992). The CCJTDC is used solely for pretrial detention and sentences less than 30 days. It houses detainees younger than 17 years, although youth up to age 21 years are detained at CCJTDC if prosecuted for an arrest that occurred when they were younger than 17 years. Like juvenile detainees nationwide 30, approximately 90% of the CCJTDC detainees are male, and most are racial/ethnic minorities (77.9% African American, 5.6% non-Hispanic white, 16.0% Hispanic, and 0.5% from other racial/ethnic groups). The age and offense distributions of the CCJTDC detainees are similar to those of detained juveniles nationwide 31.
We chose CCJTDC (which includes Chicago and surrounding suburbs) for 3 reasons. First, nationwide, most juvenile detainees live in and are detained in urban areas 32. Second, Cook County is ethnically diverse and has the third largest Hispanic population of any county in the United States 33. Third, the CCJTDC’s size ensured that enough participants would be available.
No single site can represent the entire country because jurisdictions differ in their options for diversion. Nevertheless, Illinois’ criteria for detaining juveniles are similar to those of other states. Detainees were eligible to participate regardless of psychiatric morbidity, alcohol or other drug intoxication, or fitness to stand trial. Within each stratum, names were selected using a random-numbers table. The final sampling fractions ranged from 0.018 to 0.689.
Project staff explained the project to participants in their units and assured them that anything they told us (except acute suicidal or homicidal risk) would be confidential. Data are protected by a Federal Certificate of Confidentiality and Title 28 Code of Federal Regulations, Part 22. Participants signed an assent form or consent form, depending on their age. The Northwestern Institutional Review Board, the Centers for Disease Control and Prevention Institutional Review Board, and the US Office of Protection from Research Risks waived parental consent, consistent with Federal Regulations. We nevertheless tried to contact parents; however, despite repeated attempts, none could be found for 43.8% of the participants. In lieu of parental consent, youth assent was overseen by a participant advocate who represented the interests of the participants.
Of the 2275 names selected, 4.2% refused to participate. There were no significant differences in refusal rates by sex, race/ethnicity, or age. Some youth processed as adults were counseled by their lawyers to refuse participation; in this stratum, the refusal rate was 7.1%. Twenty-seven youth left the detention center before we could schedule an interview; 312 were not interviewed because they left while we were attempting to locate their caretakers. Eleven others were excluded: 9 became physically ill and could not finish the interview, 1 was too cognitively impaired to be interviewed, and 1 appeared to be lying. The final sample was 1829. This sample size allows us to reliably detect disorders that have a base rate in the population of 1.0% or greater with a power of 0.80.34
The final sample comprised 1172 males (64.1%) and 657 females (35.9%), 1005 African Americans (54.9%), 296 non-Hispanic whites (16.2%), 524 Hispanics (28.7%), and 4 from other racial/ethnic groups (0.2%). The mean age of participants was 14.9 years, and the median age was 15 years.
Participants were interviewed for 2 to 3 hours in a private area, almost always within 2 days of intake. Female participants were interviewed only by female interviewers. Interviewers were trained for at least a month; most had a master’s degree in psychology or an associated field and experience interviewing high-risk youth. One-third of our interviewers were fluent in Spanish. We maintained interviewer consistency throughout the study by monitoring scripted interviews with mock participants. Additional information on our methods can be found in the article by Teplin et al. (2002).
We used version 2.3 of the Diagnostic Interview Schedule for Children (DISC),35, 36 the most recent English and Spanish versions then available. The DISC 2.3 assesses the presence of the following DSM-III-R disorders in the past 6 months: major depressive episode, dysthymia, mania, hypomania, panic, separation anxiety, overanxious, generalized anxiety, obsessive-compulsive, schizophrenia, attention-deficit/hyperactivity, oppositional defiant, conduct, marijuana use, alcohol use, and other drug use. The DISC 2.3 has specific questions that assess thoughts of death, suicidal ideation, suicide plans, lifetime suicide attempts, number of suicide attempts, age at first suicide attempt, suicide attempts within the last 6 months, and method of suicide attempts. For analyses including psychiatric diagnoses, we excluded items related to suicidal ideation and behavior from the diagnostic algorithms for major depression (major depression - modified) and dysthymia (dysthymia - modified) to avoid inflating the relationship between them.
The DISC 2.3 is highly structured, contains detailed symptom probes, and has acceptable reliability and validity.35, 37–40 Additional information on our use of the DISC 2.3 has been published elsewhere.6, 41
Because selected strata were oversampled, we used sample weights, based on the CCJTDC population, to estimate descriptive statistics and model parameters that reflect the CCJTDC population. Weighted analyses were conducted using Stata, version 9.0. Taylor series linearization was used to estimate standard errors.42, 43 Logistic regression was used to assess demographic differences in the prevalence rates of suicidal ideation and behaviors and for the predictive models.
Table 1 shows the prevalence rates of suicidal ideation and behavior by gender and race/ethnicity. Results are summarized by type of suicidal ideation and behavior:
More than one-third of the sample had ever felt that life was hopeless. Significantly more females than males ever felt hopeless (Odds Ratio [OR] = 1.43, 95% Confidence Interval [CI] = 1.10 – 1.86).
More than one-third of the sample had thought more than usual in the past 6 months about death and dying. Among males, significantly more Hispanics (OR = 1.97, CI = 1.26 – 3.09) and African Americans (OR = 1.64, CI = 1.09 – 2.47) than non-Hispanic whites had thoughts of death and dying. During the past 6 months, approximately one-fifth of youth had thought about death and dying for at least 2 weeks.
Approximately 10% of our sample had thought about suicide in the past 6 months. Significantly more females than males had thought about suicide (OR = 2.27, CI = 1.56 – 3.29). Among females, more Hispanics than African Americans had thought about suicide (OR = 1.91, CI = 1.22 – 2.99). Among males, significantly more non-Hispanic whites than African Americans endorsed thoughts of suicide (OR = 2.37, CI = 1.36 – 4.12).
Nearly 4% of our sample had thought “a lot” about suicide for at least 2 or more weeks in the past 6 months; significantly more females than males had such ideation (OR = 2.63, CI = 1.53 – 4.53). Among females, significantly more Hispanics than non-Hispanic whites had thought about killing themselves for 2 or more weeks (OR = 4.47, CI = 1.48 – 13.47). Among males, significantly more non-Hispanic whites than African Americans had thought about suicide for 2 or more weeks (OR = 3.84, CI = 1.66 – 8.87).
Nearly 6% of the sample developed a specific plan for suicide in the past 6 months. Significantly more females than males had a plan (OR = 2.17, CI = 1.32 – 3.57).
Nearly 5% of the sample told someone in the past 6 months about having suicidal ideation. Among those who endorsed suicidal ideation in the past 6 months, 46.1% had told someone about their suicidal thoughts. Significantly more females than males had told someone about their suicidal thoughts (OR = 2.32, CI = 1.35 – 3.97). Among males, significantly more non-Hispanic whites than African Americans (OR = 2.80, CI = 1.32 – 5.95) or Hispanics (OR = 4.88, CI = 2.21 – 10.77) told someone that they were thinking about suicide.
Eleven percent of the sample had made at least 1 suicide attempt. Participants who had ever attempted suicide had made, on average, 2 attempts (range, 1–11; SD, 0.15). The average age at first suicide attempt was 12.7 years (range, 5–17; SD, 0.24). Significantly more females than males had attempted suicide (OR = 3.44, CI = 2.33 – 5.08). Among females, significantly more non-Hispanic whites (OR = 2.65, CI = 1.63 – 4.28) and Hispanics (OR = 1.64, CI = 1.10 – 2.53) had attempted suicide than African Americans. Among males, significantly more non-Hispanic whites than African Americans (OR = 2.12, CI = 1.21 – 3.71) and Hispanics (OR = 2.17, CI = 1.10 – 4.28) had attempted suicide.
Approximately 3% of the sample had attempted suicide in the past 6 months. Significantly more females made suicide attempts in the past 6 months than males (OR = 3.54, CI = 1.91 – 6.57).
Table 2 shows that 283 participants had ever attempted suicide. Most common methods were cutting (26.9%), drug overdose (23.8%), and jumping (20.7%). Less common methods included hanging (9.5%), firearms (3.7%), and ingestion other than drugs (1.8%). Approximately 14% used methods other than those specifically listed by the DISC 2.3, e.g., running into traffic. Significantly more males than females attempted suicide by jumping (OR = 5.62, CI = 1.97 – 16.04). Among males, significantly more Hispanics attempted suicide with firearms than African Americans (OR = 18.06, CI = 3.90 – 83.53).
Table 3 shows that, controlling for gender, age, and race/ethnicity in separate analyses of individual disorders, nearly all of the disorders significantly increased the odds of a recent suicide attempt. We tested for interactions between gender and each of the disorders associated with a recent suicide attempt. Overanxious disorder increased the odds of making a suicide attempt, but less so for females than for males (OR = 0.19, CI = 0.47 – 0.77, p < .05). We also tested for interactions between race/ethnicity and each of the disorders associated with a recent suicide attempt. Generalized anxiety disorder significantly increased the odds for a recent attempt for both Hispanics (OR = 58.83, CI = 13.60 – 247.52) and African Americans (OR = 4.96, CI = 1.02 – 24.00); however, it increased the odds significantly more for Hispanics than African Americans (OR = 10.09, CI = 1.64 – 73.00).
In a regression analysis containing gender, age, and race/ethnicity along with all the disorders that were individually associated with suicide attempt, major depressive episode – modified (OR = 3.21, CI = 1.05 – 9.81) and generalized anxiety disorder (OR = 3.40, CI = 1.51 – 7.67) significantly increased the odds of having made a recent suicide attempt.
One of every 10 newly detained youth has a history of attempted suicide. Because suicide attempts are a powerful predictor of future attempts,5 detained youth are at greater risk than youth in the general population.28 25, 26, 44, 45
Risk varied by demographic characteristics. Females have a higher risk for suicide than males, a finding consistent with prior studies of detained youth16, 18, 19 and a study of delinquency among youth in the general population.46 The association with recent suicide attempts persists even after controlling for current psychiatric disorders, which also tend to be more prevalent among girls.6
Our study confirms and extends what is currently known about racial/ethnic differences among detained youth;16, 19, 22, 27 non-Hispanic whites generally have higher risk for suicide than youth of color. We did, however, find a few exceptions. Among females, Hispanics were the most likely to have suicidal ideation. Studies of youth in the general population have also found that Hispanic females have higher prevalence rates of suicidal ideation and behavior than non-Hispanic white47–49 and African American50, 51 females. Suicidal ideation and behavior appears to be highest in U.S.-born Hispanic females from traditional Hispanic families, who may have difficulty coping with contrasting social role expectations at home and among peers.52, 53
We also found that significantly more African American and Hispanic males had thoughts about death in the past 6 months than non-Hispanic whites. It is unclear if and how concern about death among African American and Hispanic males is related to risk for suicide. Such concern may result from a greater likelihood of having lost siblings and peers to violent death compared with non-Hispanic white males.54, 55 These findings also may reflect an awareness of their own heightened risk of mortality. In our sample, African American and Hispanic males are at substantially greater risk of an early violent death than non-Hispanic whites.56
The most common methods for recent suicide attempts – cutting and drug overdose – are also the most common in the general population.28 A striking finding was that Hispanic males who attempted suicide were more likely to use a firearm than African American or non-Hispanic white males. This finding is of particular concern because half of all completed suicides by young men in the general population involve firearms.57
Many psychiatric disorders were associated with having made a recent suicide attempt. At minimum, detainees who are in any type of distress must be considered at risk for self harm. When accounting for comorbidity in a multivariate model, however, only major depression (modified) and generalized anxiety disorder remained significant predictors. These internalizing disorders are often the most difficult for correctional staff to identify; affected youth tend to be compliant and cause little trouble. Anxiety disorders were also more strongly associated with a recent suicide attempt for males and Hispanics, groups that are less likely to be detected in detention as needing services. Although preliminary, these findings suggest that suicide risk is manifested differently in males and females and race/ethnicity, and that we need gender-specific and culturally relevant interventions for detained youth.18, 46
A few limitations to the study are noteworthy. Because our measure of suicidal ideation and behavior was part of a larger diagnostic module, our data were not as comprehensive and detailed as clinical measures of suicidal ideation and behavior (e.g., Suicidal Behaviors Interview,58 the Suicidal Ideation Questionnaire,59 the Scale for Suicidal Ideation,60, 61). Using an interview instead of a self-report questionnaire may underestimate the prevalence of suicidal ideation. In contrast, the turmoil of recent detention may increase participants’ suicidal symptoms or their awareness of symptoms. Although we had a large and diverse sample, our statistical power limited analyses of racial/ethnic differences for uncommon behaviors, such as the method of suicide attempts. Furthermore, correlational analyses do not infer causality. Finally, findings may generalize only to juvenile detainees living in urban areas. Despite these limitations, our findings have implications for research and for clinical services.
We suggest several directions for future research:
Our findings highlight two clinical implications: First, juvenile detention facilities must systematically screen for suicide risk. Juvenile detention centers often provide the first opportunity to systematically screen youth for risk for suicide and to provide interventions, yet the majority of facilities do not perform sound screening for “emergent risk.”66 A recent study found that facilities that screen all juveniles within 24 hours of arrival had lower prevalence rates of serious suicide attempts than those that screen only juveniles considered at risk for suicide.67 Fewer than half of the detainees with recent suicidal thoughts had shared this with someone else. Juvenile justice facilities cannot rely on juvenile detainees to inform staff that they are contemplating suicide.67 Identifying youth at risk for suicide is a crucial step to preventing suicide, both in detention centers and after youth return to their communities.
Second, psychiatric services in detention must be increased. Youth with psychiatric disorders, especially depression and anxiety, may be at particular risk for suicide attempts. Detention center staff should be trained to recognize depressive and anxiety disorders in detainees, and refer affected youth for psychiatric services. The competent assessment and treatment of psychiatric disorders in detained youth will prevent untimely deaths.
This work was supported by National Institute of Mental Health grants R01MH54197 and R01MH59463 (Division of Services & Intervention Research and Center for Mental Health Research on AIDS) and grants 1999-JE-FX-1001 and 2005-JL-FX-0288 from the Office of Juvenile Justice and Delinquency Prevention. Major funding was also provided by the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration (Center for Mental Health Services, Center for Substance Abuse Prevention, Center for Substance Abuse Treatment), the NIH Center on Minority Health and Health Disparities, the Centers for Disease Control and Prevention (National Center on Injury Prevention & Control and National Center for HIV, STD & TB Prevention), the National Institute on Alcohol Abuse and Alcoholism, the NIH Office of Research on Women's Health, the NIH Office on Rare Diseases, Department of Labor, The William T. Grant Foundation, and The Robert Wood Johnson Foundation. Additional funds were provided by The John D. and Catherine T. MacArthur Foundation, The Open Society Institute, and The Chicago Community Trust.
This study could not have been accomplished without the advice of Ann Hohmann, Ph.D., Kimberly Hoagwood, Ph.D., Heather Ringeisen, Ph.D., Grayson Norquist, M.D., and Delores Parron, Ph.D., Celia Fisher, Ph.D., and the generous cooperation of everyone working in the Cook County and State of Illinois systems. Finally, we thank the participants for their time and willingness to participate and our field interviewers for their commitment to excellence.