What is already known on this topic

Suicide is a leading cause of death among young people worldwide and an international public health concern.1 While research has established common risk factors that may serve as key components of suicide prevention strategies (eg, past suicidal behaviour, psychiatric disorders, substance abuse), little is known about specific antecedents of youth suicide. Knowing what factors precede youth suicide can help frame targets for intervention and identify promising sites for suicide prevention.

Methods of the study

The authors collected data from the Office for National Statistics about people aged 10–19 years who died by suicide in England or were a resident of England. The researchers took a novel approach in analyzing suicide deaths reported between 1 January 2014 and 30 April 2015 by multiagency sources such as coroners, police and the National Health System, identifying antecedents relevant to suicide, including abuse, bullying, bereavement, academic pressures, self-harm and physical health. Report data were collected for 90% (130/145) of youth suicides during the study period.

What this paper adds

• This is the first national investigation in England to combine available sources to establish antecedents of suicide most relevant for young people aged 10–19 years.

• These data underscore misconceptions that only youth with mental illness are at risk for suicide as 61% of individuals who killed themselves had no reported mental health diagnoses. Moreover, only a low percentage of youth were on psychotropic medications (23%) or antidepressants (15%), which may reflect underdiagnosis and treatment or a consequence of regulatory restrictions on the use of antidepressant medications in children and adolescents.2 These results also highlight the need for implementation of broad-based suicide prevention activities in multiple settings including healthcare systems, schools, social service and the justice system.

• Some findings revealed critical opportunities for rescue. Twenty-seven percent of youth expressed their suicidal ideation in the week prior to death and 16% on the day of death. This finding is consistent with previous studies3 and demands better education of young people, parents, school personnel and healthcare providers about how to recognise and respond to warning signs of suicide.

• Over one-third of the youth who killed themselves had a medical illness, most often a young person-specific condition such as asthma or acne. Without comorbid psychiatric diagnoses, these young patients struggling with these additional risk factors, may easily pass through the healthcare system undetected, highlighting the importance of suicide risk screening in all medical settings.

• Academic pressures were experienced by 51% (35/69) of students who died by suicide, 25 of whom (71%) experienced pressure within 3 months prior to death. Four deaths occurred on an exam day or the following day. School administrators, teachers and parents should be proactive in implementing programs that teach students adaptive strategies for coping with academic stress.

Limitations

As the authors point out, the analyses are uncontrolled, the potential for recall and ascertainment bias exists, multisource information can result in non-equivalent data capture and other important antecedents may have not been present in the available data sources.

What next in research

More research on the effectiveness of upstream interventions that mitigate important risk factors and prevent suicide is needed.4 Future research comparing youth who died by suicide and received mental health treatment before death with those who did not receive care may aid prevention efforts. Understudied antecedents of suicide risk, such as academic pressures and physical health warrant further exploration.

Do these results change your practices and why?

Yes. It is the responsibility of all who come in professional contact with youth to learn how to detect and effectively respond to the warning signs of suicide. Although mental healthcare systems are well recognised sites for suicide prevention, only one-third of decedents had a psychiatric diagnosis and even less were treated for these concerns. Consequently, it is incumbent on public health decision makers to create policies and practices that target sites where intervention can take place within the broader healthcare system (emergency departments, inpatient medical units and primary care settings), as well as outside the healthcare system. Programs like the Garrett Lee Smith Memorial Suicide Prevention Programs, which include gatekeeper training and suicide risk screening activities among other approaches, have been associated with reductions in suicide and suicide attempts, and could become systematised in England.5 With education, community-based intervention strategies and sustained commitment, everyone can save lives.