Suicide is the third leading cause of death among children and adolescents aged ten to 19 in the United States ( 1 ). Suicide attempts during adolescence are often followed by additional morbidity, such as additional attempts, indicating great need for mental health services ( 2 ). However, few studies have examined mental health service use among youths with suicidal behaviors. Most such studies are based on data from either clinical samples ( 2, 3, 4 ) or completed suicide cases ( 5, 6, 7, 8 ) rather than on data from nonclinical samples of youths at risk of suicide. Previous research indicates that mental health service use among youths with depression and suicidal behaviors is nonetheless low ( 5, 9, 10, 11 ).
In a study of 2,482 adolescents in the National Longitudinal Study of Adolescent Health who had suicidal ideation or behavior, Pirkis and colleagues ( 10 ) found that only one-third were receiving psychological counseling. A Canadian study of 435 adolescent suicides completed in Quebec between 1992 and 1996 found that although 78% of the victims had used medical services in the period before their suicides, only 12% had received services for psychiatric problems ( 5 ). A school survey of 17,193 adolescents in Minnesota found that adolescents with the most severe suicidal thoughts and behaviors were usually aware of their need for help but were less likely to seek it than adolescents with less severe suicidality ( 12 ). The circumstances associated with severe suicidal ideation may discourage treatment seeking by those with the highest treatment needs.
Youths who attempt suicide are a special population with regard to both their mental health service needs and their help-seeking behavior. Predisposing characteristics, enabling resources, and need are factors that help to determine adults' use of health services ( 13 ). However, children's pathways to mental health services are different in that they do not usually make service use decisions by themselves ( 14 ). Parents, teachers, and even police play an important role in both identifying the mental health problem and obtaining professional treatment for the child ( 15, 16, 17, 18 ). The decision to seek mental health services for an adolescent and the type of treatment subsequently received are particularly susceptible to the community and environmental context in which the decision is made.
Race-ethnicity, gender, age, and foreign nativity are strong predictors of service use ( 19, 20, 21, 22 ), but there is decidedly less research on the social and environmental factors affecting mental health help seeking. Disparities in family income, insurance, and neighborhood characteristics can help to predict whether services are used ( 19, 23 ). The parent-child relationship, social factors, and involvement in clubs or sports teams can also influence an adolescent's ability to secure mental health services through alternative channels ( 24, 25, 26, 27 ).
Few studies have examined adolescents' use of various types of mental health services within a socioenvironmental context or have used a representative, population-based national sample of adolescents at risk of suicide. This study aimed to describe characteristics of adolescent suicide attempters in the context of their family, community, and environment; examine patterns of mental health service use by type of service accessed; and identify important factors that influence decisions about mental health service use among adolescents.
Methods
National survey sample and data
The data used in our analyses were drawn from the adolescent subsample of the 2000 National Household Survey on Drug Abuse (NHSDA), which is representative of all noninstitutionalized adolescents aged 12–17 in the United States. Suicide attempters, our study population of interest, were defined by a positive response to one item: "In the past 12 months, have you tried to kill yourself?" Of the 19,430 adolescents in the survey, 877 answered "yes," and they constituted the study sample. Sixty-six percent (N=579) of the 877 youths were white, 11% (N=96) were African American, 16% (N=140) were Hispanic, and 7% (N=64) were from other racial-ethnic groups. Most were female (70%, N=614), and most were between the ages of 14 and 17 (78%, N=684). Compared with youths in the survey who did not attempt suicide, a greater proportion of suicide attempters were not living with both parents (37%, N=324).
Data collection consisted of computer-assisted personal interviews conducted in respondents' homes. All information obtained was self-reported by adolescents. For questions about suicide attempt, substance use, and other sensitive issues, audio computer-assisted self-interviewing was used to increase the rate of honest reporting ( 28 ). Further details on the sampling design and study procedures of the original study, including its consent procedures, are available elsewhere ( 28 ). Analyses were carried out in full compliance with New York State Psychiatric Institute Institutional Review Board requirements.
Measures
Mental health service use. The mental health services used by adolescents in the past 12 months fell into three categories: inpatient, outpatient, and school-based services. Inpatient services included overnight stays in a hospital or residential treatment center to receive treatment or counseling for emotional or behavioral problems not caused by alcohol or drugs. Outpatient services included services received at a partial day hospital, day treatment program, or mental health clinic or center or treatment received from a private therapist, psychologist, social worker, counselor, pediatrician, or family doctor for these problems. School-based services included consultations with school counselors or psychologists or regularly scheduled meetings with teachers to deal with these problems.
The service use outcome variable is the type or types of service used, a Guttman scale measure ( 29 ) that divides adolescents who had used any type of treatment services in the past 12 months into three mutually exclusive subgroups: inpatient service use (those who used inpatient mental health services, with or without any other types of services), outpatient service use (those who had used outpatient mental health services with or without school services but not inpatient services), and school-based service use only. Adolescents in the sample of suicide attempters who had not used any mental health services formed the reference group.
Demographic characteristics. Information on age, gender, ethnicity, and nativity was obtained in the survey. Three age groups were used—12–13, 14–15, and 16–17 years. Race-ethnicity was categorized as white, African American, Hispanic, or other. Adolescents who answered no to the question, "Were you born in the U.S.?" were considered foreign born.
Family characteristics. Family income was a four-category variable based on adolescent-reported annual household income. Health insurance was categorized as Medicare or Medicaid, other insurance, or no insurance. Residential instability is a measure of the frequency with which a respondent had moved or changed residences (coded yes for respondents who reported that they had changed residences three or more times during the past five years). A dichotomous variable derived from survey items about the parental figures residing in the respondent's household documented whether or not the child was living with both parents. A variable addressing the child's ability to talk with parents was included. Respondents who disagreed with the statement "There is no one I can talk to about serious problems" and reported that they could talk to their mother, father, or guardian about such problems were coded yes. Respondents were also asked to report the number of children under age 18 in their family.
Community characteristics. Neighborhood supportiveness is a scale-based variable derived from two survey items that asked about the degree to which people in the respondent's neighborhood help each other out and visit each other's homes. The internal consistency of this scale was found to be .52. Neighborhood quality is a scale-based variable created from four ordinally coded survey items addressing crime, drug selling, street fights, and the frequency with which residents moved in and out of the respondent's neighborhood. Internal consistency of this scale was .73. Population density is categorized as not a Metropolitan Statistical Area (MSA), an MSA with less than one million residents, or an MSA with one million or more residents (high population density).
Individual characteristics. Extracurricular activities was a dichotomous variable that was coded yes for youths reporting any participation in such activities in the year before the interview—for example, any school- or community-based clubs, after-school programs, community or volunteer groups, team sports, band or choir, or music programs. Criminal justice system involvement was a lifetime measure and was based on a positive response to one of two survey questions—ever being arrested or booked for breaking the law and having been on parole or probation status in the past year.
Individual spirituality was measured by a scale consisting of two items, each coded from "strongly agree" to "strongly disagree": "My religious beliefs are a very important part of my life" and "My religious beliefs influence my decisions." The internal consistency of this scale was .85. Self-perceived health was measured with the question: "Would you say your health in general is very good, good, fair, or poor?" Respondents reporting either fair or poor health were coded as having poor self-perceived health.
Measures of past-year psychopathology were adapted from the Diagnostic Interview Schedule for Children (DISC) Predictive Scales (DPS) ( 30 ), a screening measure derived from the National Institute of Mental Health's DISC Version IV ( 31 ). The DPS includes only the DISC items that are most predictive of DSM-IV diagnoses ( 32 ). Psychometric data on the DPS are reported elsewhere ( 30 ). Information on 11 DPS symptom clusters, including seven anxiety symptom clusters, one depressive symptom cluster, and three disruptive behavior symptom clusters, was used in the analyses for this study. A symptom cluster is derived from DSM-IV criteria for a particular disorder, not including criteria related to impairment or symptom duration. The cutoff points for the clusters were selected on the basis of previous methodological research ( 33 ).
The anxiety symptom clusters assessed included the social phobia, separation anxiety disorder, agoraphobia, panic disorder, generalized anxiety disorder, specific phobia, and obsessive-compulsive disorder symptom clusters. The number of anxiety symptom clusters found for each individual was used as a measure of his or her overall level of anxiety problems. Probable depression was assessed using the depressive symptom cluster of the DPS. The disruptive behavior symptom clusters assessed included the oppositional defiant disorder, attention-deficit hyperactivity disorder, and conduct disorder symptom clusters. The count of disruptive behavior symptom clusters for each individual was used to measure the overall level of disruptive behavior problems. Dependence on and abuse of substances were measured according to DSM-IV criteria ( 32 ). A dichotomous variable was created to indicate whether the respondent either abused or was dependent on alcohol or an illicit drug or had nicotine dependence.
Data analysis
Bivariate analyses compared the three service user groups with the reference group (adolescents who had attempted suicide but who had not received any treatment services in the past year) in relation to individual, family, and community factors. Chi square tests were used for categorical variables, and analysis of variance was used for continuous variables. Bonferroni correction was used to adjust the significance levels to .017 (.05/3) for multiple pairwise comparisons in bivariate analyses. All tests were two-tailed.
Multinomial logistic regression analysis was applied to the four-category outcome variable (type of service used or no service used). Major sociodemographic variables, family income, insurance, depression, and other variables found to be significant predictors (p<.05) in bivariate analyses were included in the model. Regression analyses were conducted hierarchically. Sociodemographic, family, and community factors were first added to the model, followed by the anxiety problems and probable-depression variables, and then by the disruptive behavior problems and substance use disorder variables. Variables were entered into the model in this fashion to assess the independent effect of factors when previously entered variables were controlled for and to explore the mediating effects of the variables being entered. All analyses were weighted to account for the complex sampling design of the national survey data. Analyses were conducted with SUDAAN, version 8.0 ( 34 ).
Results
Bivariate analysis
Less than half of the suicidal adolescents (45%, N=393) had received any mental health services in the year before the interview. Of those who had, 86 (22%) received inpatient services, 234 (59%) used outpatient services but no inpatient services, and 73 (19%) received only school-based services.
Characteristics of the service use groups and of those who did not receive services (reference group) are reported in Table 1 . White adolescent suicide attempters were significantly more likely than those from other racial-ethnic groups to receive either inpatient or outpatient services. With regard to factors at the family level, adolescents who received inpatient services were less likely than those in the reference group to be living with both parents. At the individual level, adolescents who received inpatient or outpatient services had higher levels of anxiety and disruptive behavior problems than those in the reference group and were more likely to have a substance use disorder. Those who received outpatient services were more likely to have probable depression. In addition, adolescents who received inpatient treatment were more likely than those in the reference group to have prior involvement with the criminal justice system and to report poorer perceived health. Adolescents who had received only school-based services differed significantly from those who received no services in being more likely to be engaged in extracurricular activities.
Table 1 Characteristics of adolescents who reported a suicide attempt in the past year, by past-year use of three types of services
Multinomial logistic regression
Results of the logistic regression analyses are shown in Table 2 . Adolescents from racial-ethnic minority groups were significantly less likely than whites to receive inpatient services; the adjusted odds ratios (AORs) were .2 for African Americans (p<.01), .3 for Hispanics (p<.01), and .2 for other racial-ethnic groups (p<.05). Adolescents from single-parent families were significantly more likely than those from dual-parent households to receive inpatient services (AOR=2.6, p<.01). Poor self-perceived health also contributed significantly to the receipt of inpatient treatment (AOR=2.6, p<.05). Two other factors contributed marginally to inpatient service use: foreign nativity (p=.0546) and disruptive behavior problems (p=.0512).
Table 2 Multinomial logistic regression predicting three types of service use among adolescents who reported a suicide attempt in the past year
Like inpatient service use, outpatient service use was found to be positively associated with being white. Compared with white youths, both African-American and Hispanic youths were 60% less likely to receive outpatient services (AOR=.4 for both, p<.05 and p<.01, respectively). Anxiety and disruptive behavior problems were also positively associated with use of outpatient services—AORs of 1.3 (p<.05) and 1.6 (p<.001), respectively. After control for other factors, male adolescents appeared to be less likely than females to receive outpatient services (AOR=.6; p<.05). Adolescents with moderately high family incomes ($40,000–$74,999) were more likely to receive outpatient services (AOR=1.9, p<.05) than those with low family incomes ($0–$19,999), and adolescents with high family incomes (≥$75,000) were nearly three times as likely to receive these services (AOR=2.8, p<.01) as those with low family incomes.
Suicidal adolescents who reported no participation in extracurricular activities were significantly less likely to use outpatient services (AOR=.6, p<.05) than those who reported participation. Finally, adolescents with Medicare or Medicaid were more likely than those without insurance to receive outpatient mental health services (AOR=2.3, p=.0503).
The findings of the logistic regression analyses with regard to use of school-based services were similar to those of the bivariate analyses: use of school-based services was significantly associated with participation in extracurricular activities.
Discussion
This study examined use of inpatient, outpatient, and school-based services among adolescent suicide attempters in relation to individual, family, and community factors. Unlike previous studies, this study used a population-based and nationally representative sample of adolescents who reported a suicide attempt.
Consistent with previous research ( 20, 35 ), this study found that significant racial-ethnic disparities with regard to utilization of mental health services exist among adolescents, even when service need and other related factors are taken into account. Our study found these disparities to be particularly pronounced with regard to use of inpatient and outpatient services.
Previous studies found that externalizing problems are strong predictors of outpatient mental health service use and that the treatment needs of adolescents who have only internalizing problems are more likely to remain unmet ( 14 ). The study reported here confirms these findings. The strength of the association between anxiety problems and inpatient service use diminished when disruptive behavior problems and substance use disorder were taken into account, suggesting that the presence of overt behaviors may prompt help seeking for the adolescent by parents and other guardians who witness these behaviors, whereas the symptoms of adolescents' internalizing disorders are not as easily noticed by adults.
On the other hand, some measures suggestive of lower adolescent quality of life, such as being from a single-parent family, poor perceived health, and criminal justice system involvement, seem to be associated with increased inpatient service use. A recent study concluded that the costs of mental health services for adolescents often fall on the juvenile justice and other social service systems, although these systems are "not primarily designed to provide psychiatric services" ( 36 ). Inpatient mental health services may be more accessible for adolescents who have already received care from the state as a result of previous justice system involvement because these services may be more readily available within correctional facilities rather than at specialty mental health treatment facilities ( 37 ).
Another result of these analyses that is worth mentioning is a trend indicating that foreign-born adolescents are more likely to receive mental health treatment in inpatient settings. However, they were not found to be more likely than native-born adolescents to use outpatient or school-based services. This may indicate a lack of knowledge among immigrant families about the range of service types available. Huang and colleagues ( 38 ) found that foreign-born, noncitizen children were four times more likely than nonimmigrant children to lack health insurance and to report no visits to a mental health specialist in the previous year. Low acculturation and linguistic isolation of parents are thought to act as barriers to health care use by immigrant children ( 38 ). Our results may also indicate a lack of awareness of depressive, anxious, or suicidal behavior among immigrant families and perhaps equally low recognition of the need to secure mental health services early. Generally, inpatient services become necessary when the severity of symptoms warrants inpatient care.
Adolescents' access to mental health services outside of school differed by race-ethnicity and family income level, but similar disparities were not evident in use of school-based services. Previous studies have found that non-specialty mental health services, such as those provided in school-based settings, are used fairly frequently by adolescents who do not use or have access to inpatient or outpatient care ( 39, 40, 41, 42 ). A recent study of a school-based suicide prevention program found that although Latino youths were less likely than others to use follow-up services outside their schools, use of school-based services did not differ by race-ethnicity ( 43 ). Although our sample of youths receiving school-based services only was small (N=73), our findings support those of previous studies. The impact of sociodemographic factors was not as strong at the school-based service level in this sample, indicating that school-based mental health services may be accessed more readily by adolescents of varied backgrounds. However, school-based service use was predicted by participation in extracurricular activities. This finding may have important implications for depressed youths who are less engaged in social activities and therefore less likely to participate in these programs.
Young people may be hesitant to seek professional help for suicidal thoughts and behaviors, and thus their need for help may not be immediately apparent. Thus school-based health services, along with teachers and other staff in schools, can play an important role in the early identification of those who may need mental health services ( 44 ). Rickwood and colleagues ( 15 ) also noted that professionals who may act as gatekeepers to mental health services for adolescents include teachers, school counselors, and general practitioners. Not only do schools offer troubled youths a "point of engagement to address educational, emotional, and behavioral needs" ( 40 ), but teachers and school counselors are also uniquely placed to identify troubled youths through ready comparison with their peers. In addition to providing easier access, school settings are also more likely to integrate programs that reduce suicide risk, such as substance abuse prevention and mental health services, and thus promote mental health treatment efforts on a variety of fronts ( 40 ).
It is important to note that schools are not the only point of entry to care for suicidal adolescents and that adolescents often use more than one type of mental health service for their problems. This highlights the importance of integrating mental health services across various community institutions to better detect, treat, and follow up with suicidal adolescents regardless of where they seek care. Integrated mental health service models have already proven successful in the United States, Australia, Canada, the United Kingdom, and Finland ( 45, 46, 47, 48 ). In the school setting, mental health service integration among agencies promotes adolescents' receipt of appropriate services, maintenance of treatment gains, and improved school performance ( 40, 44, 48 ).
This study has a few limitations that deserve mention. All information was obtained by self-report from the adolescent respondents, and information for variables such as income and insurance status may not be as accurate as that obtained from parent reports. The measures of anxiety problems, probable depression, and disruptive behavior problems may not be adequately robust, because impairment and duration of symptoms were not taken into account. We were also unable to measure internal barriers to obtaining services that were perceived by the adolescent, such as embarrassment or stigma ( 49 ). However, our findings provide a better understanding of the levels of external factors that affect the decision to use mental health services among adolescents.
Conclusions
Only 45% of the suicide attempters in this sample reported receiving any mental health treatment, indicating substantial unmet need for these services among suicidal youths. Therefore, school and community settings may play an integral role in both identification of service needs and provision of services ( 43, 50 ). Factors that are usually viewed as affecting children's use of services, such as race-ethnicity, nativity, insurance, family income, and household structure, may not play as strong a role in limiting or promoting access to services for adolescents in a school-based setting—a substantiated finding that we believe warrants future research. Improving the quality of and access to school-based programming, as well as continuing to better integrate and evaluate mental health services across inpatient, outpatient, and other community-based sectors may help lower the level of unmet mental health service need in this vulnerable population.
Acknowledgments and disclosures
Work on this article was supported by a grant to Dr. Wu from the American Foundation for Suicide Prevention. The authors thank David Shaffer, M.D., for his valuable comments on a draft of this article.
The authors report no competing interests.
Footnote
Dr. Wu is affiliated with the Departments of Psychiatry and Epidemiology, Ms. Katic is with the Department of Epidemiology, and Dr. Liu is with the Department of Biostatistics, all at Columbia University, 1051 Riverside Dr., Unit 43, New York, NY 10032 (e-mail: [email protected]). Dr. Fan and Ms. Fuller are with the Division of Child Psychiatry, New York State Psychiatric Institute, New York City.
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