September 17, 2007

Youth Suicide Rates Up? Not So Fast

The headlines read, "Highest increase in youth suicide" and "girls aged 10-14 increased 75%."  And of course, the only explanation anyone seems to want to debate is antidepressants: was it too many prescriptions, or too few?   And self-righteous indignation all around.

Well, I did something apparently no one else cares to do: I looked up the individual suicides.  They are individuals, right?  With different reasons for doing things?  And guess what?  I have another explanation:  Ohio. 


The year in question is 2004, the most recent year the data is available.  I focused on girls aged 10-14, because that's what the majority of the news articles focused on.  Most reports described an increase of 75%, from 56-94.  I actually found 98 total suicides in this group.

If antidepressants had any effect-- in either direction-- then the increase should have been spread out throughout the country. 

Most states had very few suicides in this demographic.  Maine had zero.  North Carolina had 1.  Oregon, 1.  Florida, 1.  Etc.  These small numbers are generally unchanged from 2003.  California, which had the one of the highest absolute number of suicides, had 6 in 2003, and 7 in 2004.

If you look at Ohio, however, you see something interesting.  In 2003, there were no suicides.  In 2004, there were 11. 

Indiana was next: 0 in 2003, 6 in 2004. 

This, of course, speaks to the problem of medicine’s over-reliance on epidemiology.  People are different, and even “matched controls” have such variability that association studies are often nearly useless.  This is even more true in psychiatry.  Suicide is not an involuntary pathogen, it is a complex, volitional behavior whose causes can only be meaningfully investigated at an individual level.  

I have to go back and look closely at all the states' data, etc.   But it seems to me that when two small states account for almost half of the entire increase in the suicides, we should stop talking about antidepressants and maybe go find out what the hell happened over there?


The conclusion I immediatel... (Below threshold)

September 17, 2007 11:28 AM | Posted by Jim Lipsey: | Reply

The conclusion I immediately came to, but which may be incorrect, is that this boils down to differences in reporting practices from state to state. Perhaps Ohio and Indiana don't have the biggest problem. Maybe they're the states that treat this issue with increasing concern and thus are now tracking it more carefully.

Given the apparent epidemic of runaways who end up in California after fleeing abusive homes only to then be preyed upon by drug dealers or coerced into prostitution, it seems suspect that only 6 or 7 suicides are reported in this state. For instance, are intentional drug overdoses in some states often incorrectly documented as accidental overdoses?

From U.S. census data, it appears there are roughly 10 million girls who are 10-14. Getting a correct count for incidents that affect 50-100 of them is very difficult, so percentage difference are highly susceptible to changes in reporting practices.

One other theory: how are the suicides being attempted? Do states with fewer actual suicides have a greater percentage of failed attempts? Is there a difference in how suicidal girls in the Midwest make attempts compared to girls in other regions?

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At the risk of sounding cal... (Below threshold)

September 17, 2007 1:37 PM | Posted by Sally: | Reply

At the risk of sounding callous, can the death of 50 - 100 out of 10 million really be called a national health emergency?

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Good catch. Sounds like it... (Below threshold)

September 17, 2007 3:48 PM | Posted by Stomper: | Reply

Good catch. Sounds like it may be a non-event.

I'd be interested in any explanations offered by the specific sources of this data in Ohio and Indiana. Most likely, this change simply reflects a change in data-gathering and/or reporting.

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Heh, Ohio and Indiana? Almo... (Below threshold)

September 17, 2007 5:39 PM | Posted by Ernunnos: | Reply

Heh, Ohio and Indiana? Almost sounds like someone's recreating the movie "Heathers". Veronica Sawyer (Winona Ryder) and Jason Dean (Christian Slater) live in Sherwood, Ohio, a small town on the Ohio-Indiana border. (Which in real life doesn't have a high school.) They start killing the popular kids (the "Heathers") and making the murders look like suicides. It's a great satire on how society inadvertently glorifies suicide.

Alone's response: this is actually my point. 11 people in Ohio, all 13 or 14? Suggests to me that they knew each other, or at least had some common link. Let's say that turns out to be true; can you really say the suicide rate is up if 11 people collectively chose to commit suicide? By example: Did Colorado become more violent-- a higher murder rate-- because two kids killed a lot of people?

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The size and population of ... (Below threshold)

September 17, 2007 11:35 PM | Posted by Stephany: | Reply

The size and population of the state matter statistic-wise, and might I bring into the discussion electoral votes per state? because it's the same thing--try to figure it out.

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funny i thought of heathers... (Below threshold)

September 17, 2007 11:59 PM | Posted by Philip Dawdy: | Reply

funny i thought of heathers and other possible cultural drivers when i wrote about this two weeks ago. knowing that many in this age group were from two states does indeed make you wonder what kind of overlaps there may have been esp if these were the girls who hanged themselves that the cdc was pointing to.

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Adsense Ban is crying for y... (Below threshold)

September 18, 2007 9:07 AM | Posted by Adsense: | Reply

Adsense Ban is crying for you!

Alone's response: wait, not enough Adsense?

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More ammunition for the “bl... (Below threshold)

September 18, 2007 9:51 AM | Posted by Ben Hansen: | Reply

More ammunition for the “black box warning linked to increased suicides” debate…

See Table 29, “Studies assessing Suicidal thoughts and behavior” on page 106 of the Agency for Healthcare Research and Quality Final Research Review published January 2007,
“Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression.”

Twelve studies are cited. None show any difference between any of the SSRIs, and none show any advantage of SSRIs over older “first generation” antidepressants. Only 4 of the 12 studies compared antidepressants to placebo, and in all 4 of these studies, PLACEBOS OUTPERFORMED ANTIDEPRESSANTS. Summarized below.

Fergusson et al., 2005.
Meta-analysis: SSRIs vs. placebo.
Results: Higher risk of suicide attempts for SSRI-treated patients.

Gunnell et al., 2005.
Meta-analysis: Citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, all vs. placebo.
Results: Increased risk of nonfatal suicide attempts compared with placebo; no difference in risk among drugs.

Pedersen, 2005.
Retrospective cohort study: Escitalopram vs. placebo.
Results: Higher rate of nonfatal suicide attempts for escitalopram than for placebo.

Aursnes et al., 2005.
Meta-analysis of unpublished Paroxetine data.
Results: Higher rate of suicides for paroxetine than for placebo.

Read the AHRQ report here:

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Girls 14 and under do not c... (Below threshold)

September 18, 2007 10:25 AM | Posted by Sara: | Reply

Girls 14 and under do not commit suicide in very high numbers at all. If there are only 50-100 it should be possible to get some anecdotal information on each and every one of them frankly, like whether or not they were on or had ever taken psychotropic drugs, and I'm not just talking antidepressants -- how about stimulants or antipsychotics too while we're asking. Unless we know the individual circumstances of these suicides it is ridiculous to draw conclusions based on one epidemiological factor.

Alone's response: Exactly.

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Hey, I liked your blog for ... (Below threshold)

October 24, 2007 10:49 PM | Posted by brad: | Reply

Hey, I liked your blog for a while, and figured i had some recent relevant info on this post.
A few days ago a kid (from ohio) jumped in front of a train in suicide(notes left and the such to determine suicide) but whats interesting is a couple months ago a girl died by wandering on train tracks b/c she was drunk. This story got a lot of press at my small college town. Interesting he killed himself by train which ive never heard of anyone else commiting suicide by train

Alone's response: please send me a link to the story if you can, this is really helpful information.

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