Suicide is the second-leading cause of death among youth and young adults ages 10 to 24 in the United States.¹ In 2016, the rate of suicide among persons ages 15 to 24 was 13.15 per 100,000 individuals.² According to the 2015 national Youth Risk Behavior Survey, 17.7 percent of youth in grades 9 through 12 reported seriously considering suicide in the previous 12 months, 8.6 percent of youth reported making at least one suicide attempt in the previous 12 months, and 2.8 percent reported a suicide attempt that required medical treatment.³

Suicide contagion is the process by which one suicide facilitates the occurrence of another through direct or indirect awareness of the prior suicide. Two main types of suicide clusters have been discussed in the literature: mass clusters, which are media-related (suicides are grouped in time but not space), and point clusters, which are local (suicides are contiguous in time and space).^4,5

Emergency clinicians are often primary points of contact for persons at elevated risk for suicide, and they have the ability to alter a patient’s clinical course. It is imperative that frontline providers learn to recognize the risk factors, provide proper screening, and refer patients for treatment. There is strong evidence that emergency departments and emergency physicians are critical to such injury prevention and intervention efforts.⁶

Types of Contagion

In adolescents, many studies have demonstrated a strong association between major depression and suicide. In a recent large U.S.-based longitudinal study, the relative risk of exposure to suicide was 2.96 to 7.67 depending on the relationship (friend or family member) to the person who attempted suicide.⁷

Bullying has been identified as increasing the risk of suicidal behaviors, particularly in youth with underlying suicide risk factors (eg, mental health problems, substance use, early childhood adversity such as abuse, and other psychosocial stressors). Bullying can be physical, verbal, or relational (eg, rumors and social exclusion). The Centers for Disease Control and Prevention (CDC) reported that, in 2013, 23.7 percent of boys and 15.6 percent of girls were bullied at school, while cyberbullying was experienced by 21 percent of girls and 8.5 percent of boys.⁸ Increases in suicidal ideation and/or suicide attempts are observed in both bullies and victims.

Media exposure has been investigated as a source of suicide contagion. Traditionally, this has been divided into fictional and nonfictional exposure to suicide, with books, newspapers, television, and radio being the major sources of content. Recently, the internet, with multiple social platforms and news outlets, has greatly increased the opportunity for individuals to be exposed to fictional and nonfictional suicides.

The association between nonfiction reporting and suicidal behavior is stronger. This is particularly true of teenage observers, especially when the subject of the report is similar to the observer in terms of age, sex, and nationality. When reporting suicides, the news media often oversimplifies the causes, attributing the act to single factors, such as financial disasters, broken relationships, or failure in examinations. What is often overlooked is the most common factor leading to suicide: mental illness.⁹ This style of reporting can increase the risk of suicide contagion. It has also been noted that the suicide of a celebrity, along with the amount, duration, and prominence of coverage, proportionally increases the suicide rate.¹⁰ The risk for suicide contagion as a result of media reporting can be minimized by factual and concise media reports of suicide, which is in accordance with CDC recommendations.^10,11

The internet offers adolescents social contact through websites, social media, forums, video imaging/sharing, and blogs. The internet has the potential to offer support and protect adolescents’ mental health by reducing social isolation, increasing self-esteem, and offering crisis support as well as outreach and access to therapy.

Unfortunately, information on the internet may have both positive and negative effects, as there is also a potential for harm with access to pro-suicide sites, communities encouraging suicide, and increased contact with suicidal individuals, which can result in contagion through normalization of suicide, cyber suicide pacts, and descriptions of how to commit suicide.¹²

Screening for Suicide Risk in Emergency Departments

Starting in 2010, The Joint Commission recommends all medical patients in hospitals be screened for suicide risk. Although “at-risk” patients may be seen in primary care or inpatient settings, for more than 1.5 million youth, the emergency department is their only point of contact with a health care provider. Screening in the emergency department may also be more acceptable to patients and their families and, in many cases, is nondisruptive to workflow.

In 2012, three pediatric emergency departments developed a brief instrument for the emergency department. The Ask Suicide-Screening Questions tool recommends asking four less-specific questions before moving to the all-important, “Are you having thoughts of killing yourself right now?” More information about the Ask Suicide-Screening Questions tool may be found on the National Institute of Mental Health website at www.nimh.nih.gov/labs-at-nimh/asq-toolkit-materials.

Risk Reduction

The CDC has developed a conceptual framework for the prevention and local containment of suicide clusters.¹³ The recommendations advocate for a coordinated interdisciplinary approach led by a community coordinating committee composed of representatives from the school district, municipal government, mental health services, medical facilities, emergency medical services, academia, clergy, parent organizations, survivor support groups, and the media. Emergency departments should coordinate with the community coordinating committee to ensure timely patient referral for appropriate counseling.

When suicide is the cause of death of an emergency department patient, the attending emergency physician may have an opportunity to shape media coverage. Whenever possible, emergency physicians communicating with reporters should sensitize them to the problem of suicide contagion and remind or familiarize them with the CDC’s recommended reporting best practices designed to prevent additional deaths.

Teen Suicide Resources

National resources are available to assist communities in providing support to those affected by adolescent suicide. Nonprofit organizations have focused resources on the increasing incidence of cyberbullying and on disadvantaged youth. States also have online resources available that contain a wealth of information. There is a list on resources with links at www.acep.org/SuicideContagionInAdolescents.

References

1. 10 leading causes of death by age group, United States–2016. Centers for Disease Control and Prevention website. Accessed April 16, 2019.
2. 2016, United States suicide injury deaths and rates per 100,000. Fatal injury reports 1981-2016. Centers for Disease Control and Prevention website. And data generated by the WISQARS fatal injury reports, national, regional and state, 1981-2017. Accessed and generated on April 15, 2018.
3. Youth risk behavior surveillance system results: suicide-related behaviors. Centers for Disease Control and Prevention website. Accessed April 16, 2019.
4. Ting SA, Sullivan AF, Boudreaux ED, et al. Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993-2008. Gen Hosp Psychiatry. 2012;34(5):557-565.
5. Joiner TE. The clustering and contagion of suicide. Curr Dir Psychol Sci. 1999;8(3):89-92.
6. Zonfrillo MR, Melzer-Lange M, Gittelman MA. A comprehensive approach to pediatric injury prevention in the emergency department. Pediatr Emerg Care. 2014;30(1):56-62.
7. NanayakkaraS, Misch D, Chang L, et al. Depression and exposure to suicide predict suicide attempt. Depress Anxiety. 2013;30(10):991-996.
8. Kann L, Kinchen S, Shaklin SL, et al. Youth risk behavior surveillance–United States, 2013. MMWR Suppl. 2014;63(4):1-168.
9. Robertson L, Skegg K, Poore M, et al. An adolescent suicide cluster and the possible role of electronic communication technology. Crisis. 2012;33(4):239-245.
10. Stack S. Media coverage as a risk factor in suicide. J Epidemiol Community Health. 2003;57(4):238-240.
11. Pirkis J, Blood RW. Suicide and the media. Part I: reportage in nonfictional media. Crisis. 2001;22(4):146-154.
12. Caruso K. Stop saying ‘committed suicide.’ Say ‘died by suicide’ instead. Suicide.org website. Accessed April 16, 2019.
13. O’Carroll PW, Mercy JA, Steward JA, et al. CDC recommendations for a community plan for the prevention and containment of suicide clusters. MMWR Suppl. 1988;37(6):1-12.