By Hannah Critchfield
The debate to reopen schools for in-person learning has highlighted an alarming idea – that students are not just falling behind academically, but at a heightened risk of death by suicide.
“One of our local superintendents recently shared with me that the suicide rate among teens is higher than the COVID rate of death in their county,” Sen. Deanna Ballard, a Republican from the 45th district, recently told CBS 17, though she declined to name the superintendent or county. Ballard did not respond to NC Health News’ requests for comment.
The pandemic has undoubtedly taken a grave toll on the mental health of young people. Nationally, the proportion of child emergency room visits for mental health crises increased last year compared to 2019, according to a recent report from the Centers for Disease Control and Prevention. Rates of suicidal thoughts and suicide attempts in children also appears to have spiked during some months of 2020.
These grim figures have led many to fear that suicide in young people is also on the rise in North Carolina.
But does data bear this out in North Carolina?
Looking at the data
North Carolina currently lacks data for deaths by suicide in young people in 2020. The state doesn’t have a comprehensive electronic death registry – meaning it has a slower system for reporting deaths than all but two other states.
Without this figure, trying to assess the extent of suicides in young people during the pandemic is like looking for clues in a game with missing pieces. But some metrics are available.
Children in North Carolina were hospitalized for self-harm injuries, including suicide attempts, slightly less last year than in 2019, according to data obtained by information request from the state Department of Health and Human Services.
In contrast to death reporting, North Carolina does have a faster registry of what’s happening in emergency departments. The NC DETECT system collects information from all of the state’s emergency departments, tracking what types of complaints are being reported in people showing up for care. In 2020, the year the pandemic began, there were 2,971 emergency room visits for self-harm in kids between the ages of 10 and 18. In contrast, there were 3,134 emergency hospital visits for kids in this same age group in 2019.
Last year’s emergency room data may still slightly increase, however, as “much of the data for December 2020 are still being reported,” according to DHHS spokesperson Sarah Lewis Peel.
Self-harm is not suicide
Self-harming behavior, also referred to as self-injurious behavior, is the act of harming oneself on purpose. It can include an array of behaviors, from cutting to attempted suicide. It’s one of the reasons the data are limited. Suicide attempts are not necessarily predictive of who will die by suicide, according to experts who study it. For instance, women are more likely to attempt suicide, but men are more likely to die by it because they tend to use more lethal means.
“People who make suicide attempts are more likely to die by suicide than people who haven’t made attempts,” explained Ryan M. Hill, researcher and professor of pediatric psychology at Baylor College of Medicine. “So it’s certainly a risk factor. But it’s very difficult to predict. There are kids who don’t make previous attempts but still die by suicide later on.”
Janel Cubbage, a suicidologist, Bloomberg fellow at Johns Hopkins School of Public Health, and a member of the American Association of Suicidology, echoed this.
“Ninety percent of people who have attempted suicide do not go on to die by suicide,” she said.
Fears not realized
Existing studies that have analyzed suicide during the pandemic have not found evidence that deaths by suicide are increasing overall.
“Obviously, along with many of my colleagues, at the beginning of the pandemic I was concerned that suicide would increase,” said Cubagge. “But the preliminary data that we have so far, do not show that. With the jurisdictions reporting so far, suicide is generally down, or had no change.”
Studies from federal agencies and states that have data on suicides over the last year – such as Massachusetts, Utah, Maryland and the Department of Veteran Affairs – have come to the same conclusion.
Possible disparities by race
However, suicide data can sometimes paint a vastly different picture when broken down by race, researchers found. A recent study in Maryland found that suicides in general hadn’t increased within the state during the pandemic, but suicides in Black people in the first few months of lockdown doubled when compared to the average for the previous three years.
“Though overall there has not been an increase in suicide in the jurisdictions that have reported, I think one of the big takeaways from this is that it’s still very important to look at trends in different populations and identify disparities that have developed, or worsened during the pandemic,” said Cubagge, one of the authors of the Maryland study. “I think it drives home this point that we are all in the same storm, but we are not all in the same boat.”
North Carolina’s self-harm data did not reveal similar trends. Across all races, youth went to the emergency room for self-harm injuries less in 2020 than in 2019 – the only exception was among kids in the “unknown” racial category, where self-harm visits jumped from 55 to 68.
Indigenous youth are often lumped into that “unknown” category in research. Within North Carolina, there are eight state-recognized American Indian tribes, the largest American Indian population east of the Mississippi River. Members of these communities have long alleged that they can end up categorized as “unknown” due to poor data collection.
Different months, different stressors
It’s possible suicide attempts in North Carolina may have increased during certain points in the pandemic, but not others. A team of researchers at Baylor College of Medicine and the University of Houston recently analyzed youth emergency department visits for suicidal ideation and attempts at a large pediatric hospital in Texas during 2020 to those from the previous year.
They found a “more complicated story” than expected, according to Hill, one of the authors of the study.
“We didn’t see a universal increase across 2020,” he said. “When we looked month-by-month, we found that there were some months where we did see an increase in reported suicidal behavior, and some months where there wasn’t a noticeable change from 2019.”
The times when youth were reporting more frequent suicidal thoughts lined up with times where there were particularly high levels of “community concerns” or fears about the pandemic, according to Hill.
There was a significant spike in the rate of suicidal ideations in March, at the beginning of the pandemic, and then again in June, when Texas cases were beginning to rise to dire levels. Reports of recent suicide attempts were higher in February, March, April and July 2020 than they were in those same months in 2019. But other months showed no discernable change from that time in the previous year.
The Maryland study that looked at suicide among Black people found that deaths by suicide increased only between May 5 and May 7, what researchers called the “progressive closure period.”
Numbers for North Carolina’s emergency room visits are not available at this granular level – NC DHHS was not able to break the data provided to NC Health News down by month.
‘Unsupported by the data”
Suicide is never caused by just one thing — another thing that can make it so difficult to predict, and so frightening for loved ones who worry a child is at risk. Researchers who attempted to study suicide over the last year said they were careful not to attribute blame to the pandemic because there are so many confounding factors.
“There was COVID-related stress in 2020, but there was also stress around politics that was different from 2019,” said Hill. “You’re seeing all of the stresses and the strains that youth are experiencing, and the skills that they have to manage them.”
Drawing a connection between youth suicide and any one factor — school closures, social isolation, or academic and financial stress — is a nebulous, incomplete exercise, experts said, and ignores the opaque nature of suicide death.
“Suicide is complex,” said Cubbage. “This narrative that suicide is increasing due to the pandemic is not only unsupported by the data at this time, it also completely ignores the disparities impacting minority groups before the pandemic — and the impacts of the racial and political landscape in our country over the past year.”
A troubling trend
It’s also difficult to parse out what changes are due to the pandemic, and what can be attributed to a larger troubling trend — that youth suicides have been on the rise over the last few years. The national rate of suicide in young people increased 57 percent between 2007 and 2018, according to the CDC.
“Even before the pandemic, we’ve been seeing an increase in youth suicides,” said Virginia Hamlet Rodillas, hotline manager for National Alliance on Mental Illness NC, which operates a statewide helpline.
In North Carolina, suicide is now the second-leading cause of death in children ages 10 to 17, according to a 2019 report from the organizations N.C. Child and the N.C. Institute of Medicine. Their data found that the number of children who died by suicide in the state in 2017 was double what it was a decade earlier, and that suicide in Black teens in the state has been rising at a disturbing rate.
Stressors that can place someone at risk for suicide have undeniably increased during the pandemic, and Hamlet Rodillas said it’s bearing out in her work.
“Before the pandemic, we might get one or two suicidal callers a year,” said Hamlet Rodillas, who also manages the NAMI on Campus program in North Carolina. “Since the pandemic we’ve been having at least one person a month calling us in that situation. Most of them are younger people.”
She noted that their organization runs a helpline – meant to provide support, not emergency response – and that crisis hotlines like the National Suicide Hotline may be receiving an even higher number of calls.
‘A lot of misinformation’
Still, experts said it’s important to keep in mind that an increases in suicidal ideation in young people, much like suicide attempts, do not necessarily mean there’s been a spike in suicide deaths.
“I think there are a lot of myths about suicide, which contributes to misinformation that I’ve seen circulating around like, ‘Oh, hotline utilization has increased, suicides must be up,’” said Cubbage. “Really, suicide ideation, suicide attempt and suicide deaths are distinctly different.”
Many hotlines are reporting significant increases in the calls they’re receiving, which Cubbage said is good – it means people are reaching out for help and support.
“But I think people conflate increases of hotline utilization with increases in suicide deaths,” she said. “It’s not supported by the data at this time.”
One of the reasons it’s so hard to draw a throughline between suicidal thoughts and suicide death is a somewhat counterintuitive reality – suicide, even while increasing in the years before the pandemic, is relatively rare.
“At any point in time, one in 20 people is thinking about suicide,” said Cubbage. “That’s five percent of the population. An even smaller number of people in that subset of the population goes on to make a suicide attempt, and an even smaller number of people within that subset go on to die.”
Not an ‘either-or situation’
Youth suicide deaths during the pandemic need further study, said everyone who was contacted for this story. We won’t know the true scope of loss during this period for quite some time, at least not until the CDC releases national health statistics for 2020 later this year.
Until then, experts who study suicide recommend checking in on family and friends as we wait out the remainder of the pandemic, and remaining wary of anecdotes.
“Anecdotes do not necessarily represent what the data show,” said Cubbage. “Unfortunately, it also seems that suicide has been politicized as a reason to push for reopening schools in-person or end the guidance to stay at home.
“I don’t think this is an either-or situation,” she added. “I think that we can follow guidance to help mitigate the COVID-19 pandemic and we can also do things to help reduce people’s risk for suicide and keep them safe. “
If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (800-273-TALK).
If you would like mental health support, referrals, or information, dial the NAMI NC HelpLine at 1 (800) 950-6264 (1-800-950-NAMI) between 10 a.m.- 6 p.m. EST, Monday through Friday.