Focus on the state of mental health in the United States is arguably higher than ever. A recent Evernorth analysis of commercially-insured customer data shows there is reason for concern – particularly when it comes to the health and safety of children and adolescents. Suicidal ideation and suicide attempts exceed pre-pandemic levels across all age groups, but the largest increase occurred in those aged 17 and under. Our data shows a 14% increase in suicide-related diagnoses in children and adolescents, accounting for 35% of all customers with these diagnoses.
Our analysis calls attention to this important public health issue with the goal of raising awareness for all health care stakeholders, including families, plan sponsors, providers, policymakers, and communities. Independently and collectively, we must work to prevent, identify and protect children and adolescents from crisis situations. Understanding which youth are at higher risk can aid in early detection and interventions.
The sharpest rise of suicidal signs and behaviors occurred in children and adolescents
Compared to other age groups, children and adolescents had seven times the rate of increase in suicide ideation (21% vs. 3%) and six times the rate of increase in suicide attempts (26% vs. an average of 4%) from 2020 to 2021. In addition, they were the only age group that showed a rise in suicide attempts from 2019 to 2020, with a cumulative jump of 39% from 2019 to 2021, compared to a 2% increase among those aged 18-25 and 3% increase among those aged 26 and older. Typically differences are seen when comparing the young adult and adult populations, but this latest analysis shows similar trends among these age groups, and a stark difference in those age 17 and under.
Suicidal Ideation Trends by Age Group (%)
Suicidal Attempt Trends by Age Group (%)
These findings are in line with our recent report about increasing cases of depression among this age group, as well as other research linking suicidal thoughts with key social issues that greatly affect America’s youth, including internet and social media addiction, cyberbullying, and negative attitudes toward those who identify as LGBTQ+.
Female and Asian/Pacific Islander youth demonstrate a significantly higher rate of suicide-related behaviors
Females age 17 and under are most at risk with more than twice the rate of increased suicidal ideation (26% vs. 12%) and more than five times the rate of increased suicide attempts (33% vs. 6%) from 2020 to 2021, compared to males. Females also represent the majority of children and adolescents with suicide risk, accounting for 68% of youth with suicidal ideation and 79% of youth diagnosed with suicide attempt in 2021.
Suicidal Ideation Year-over-year Trend by Gender (%)
Suicidal Attempt Year-over-year Trend by Gender (%)
Asian/Pacific Islander youth demonstrated significantly higher rates of increased suicidal ideation than other ethnic populations. In fact, they were the only ethnic group that showed a spike in this diagnosis from 2019 to 2020. They also had the highest rate of increase from 2020 to 2021, experiencing suicidal ideation at more than twice the rate of white youth (43% vs. 19%).
Suicidal Ideation Year-Over-Year Trend by Race/Ethnicity (%)
In terms of suicide attempts, Asian/Pacific Islander youth experienced a 55% rise from 2019 to 2020, which was four times the rate of increase observed in white youth (13%), while other ethnicities saw a decrease. While all ethnic groups showed an escalation of suicide attempts from 2020 to 2021, Asian/Pacific Islander youth had the highest rate with an increase of 39%.
Suicide Attempt Year-Over-Year Trend by Race/Ethnicity (%)
Although they demonstrated the largest percentage increases of suicide-related behaviors, Asian/Pacific Islander youths represent only 3% of those in this age group with suicidal ideation and 5% of those with suicide attempts in 2021. These behaviors actually occur more often among white youth, who account for roughly four-fifths of suicidal ideation diagnoses (80%) and attempts (79%).
2021 Suicidal Ideation Distribution by Race/Ethnicity (%)
2021 Suicide Attempt Distribution by Race/Ethnicity (%)
Youth demonstrating signs of suicidal behavior are more likely to have serious health conditions
Children and adolescents with suicide-related behaviors had a significantly higher prevalence of nine behavioral health and six physical health conditions, compared to other youth. The behavioral health conditions were 2.9 to 49.5 times more prevalent, while the physical health conditions were 1.4 to 4.0 times more prevalent.
2021 Prevalence of Behavioral Health Conditions for All Youth and Youth with Suicide-Related Diagnoses
| Behavioral Conditions | All Youth | Youth With Suicide-Related Diagnoses |
|---|---|---|
| ADHD | 4.6% | 23.0% (5.0X) |
| Autism | 1.5% | 4.4% (2.9X) |
| Anxiety | 5.9% | 67.3% (11.5X) |
| Alcohol Dependence | 0.03% | 1.5% (49.5X) |
| Bipolar | 0.3% | 11.4% (45.7X) |
| Eating Disorder | 0.4% | 5.1% (13.1X) |
| Schizophrenia | 0.04% | 1.9% (47.0X) |
| Depression | 4.4% | 80.3% (18.3X) |
| Drug Dependence | 0.1% | 4.5% (40.9X) |
2021 Prevalence of Physical Health Conditions for All Youth and Youth with Suicide-Related Diagnoses
| Physical Condition | All Youth | Youth with Suicide-Related Diagnoses |
|---|---|---|
| Asthma* | 4.3% | 7.8% (1.8X)** |
| Cancer | 0.15% | 0.21% (1.4X) |
| Cardiac-related | 0.07% | 0.14% (2.1X) |
| Type 2 Diabetes | 0.5% | 1.8% (4.0X) |
| Type 1 Diabetes 2 | 0.3% | 0.6% (1.8X) |
| Low Back Pain | 1.8% | 5.4% (2.9X) |
Youth at risk of suicide are more likely to have been prescribed antidepressants
From 2019 to 2021, there was a significant increase in antidepressant prescriptions among those aged 17 and under. Of those diagnosed with either suicidal ideation or attempt, more than one-third (36%) had a psychotropic drug prescribed during the year of the diagnosis, which is more than three times the prescription rate for all youth (10%). Psychotropic prescription drugs include anti-anxiety medications, antidepressants, antipsychotics, mood stabilizers and stimulants.
Many at-risk youth are getting care preceding suicide attempts
Among those youth who were diagnosed with a suicide attempt in 2021, 87% had utilized health care services within three months prior to the event, with 54% having used at least one behavioral health service and the remaining 33% using medical services only.
2021 Health Care Utilization Among Youth with a Suicide Attempt Diagnosis within 3 Months Prior to the Event (%)
Evernorth’s analysis identified key trends regarding health service use, which reveals potential touchpoints for additional behavioral health and suicide risk screening protocols. Children and adolescents received care for a number of behavioral health conditions, including those related to major depressive disorder, neuroses, acute adjustment disorder and childhood mental health disorders.
Compared to major depressive disorder, neuroses are typically milder conditions with depression or anxiety symptoms. An acute adjustment disorder is an unhealthy or excessive emotional or behavioral reaction to a stressful event or change in a person's life within three months of it happening. Common childhood mental disorders include attention-deficit/hyperactivity disorder (ADHD), anxiety, and behavior disorders.
Among youth who received behavioral health care in the three months before the suicide attempt:
- 91% used mental health/substance use disorder services, most commonly related to major depressive disorder, acute adjustment reaction and childhood mental disorders.
- 88% used Evaluation and Management (E/M) services, most commonly related to major depressive disorder and acute adjustment reaction.
- 54% had at least one emergency department (ED) visit, most commonly related to poisoning, depressive neuroses and major depressive disorder.
- 49% had a prescription for a psychotropic drug.
Among those who received medical care in the three months before the suicide attempt:
- 68% used E/M services, most commonly related to COVID-19 exposure, immunization encounters, acne diagnoses and poisoning.
- 48% had at least one ED visit, most commonly related to poisoning, depressive neuroses and major depressive disorder.
Characteristics of those who did not access care during the three months before the suicide attempt include the below, and suggest a lack of access or under-diagnosis.
- More likely to be male and twice as likely to be Black compared to those who received behavioral health services.
- Less likely to have any behavioral health-related diagnoses.
- Less likely to have any pharmacy costs.
Risk factors identify opportunities for early interventions
Understanding risk factors can help us better anticipate and address the needs of youth who are in danger of suicide and self-harm. These factors should be considered in predictive models and other early identification systems to better connect youth to the care they need before an incident occurs.
Given that a majority of youth who attempted suicide received some form of health care prior to the event, there is significant opportunity for clinicians to help avert a possible crisis with routine screening and family engagement. Clinicians can intervene by helping parents and guardians have conversations about suicide with children at risk. Providing an age-by-age conversation guide can help them start the discussion. In addition, bringing attention to risk factors can help parents and guardians understand what to look for and create a sense of urgency in seeking help. The 988 Suicide and Crisis Lifeline should be heavily promoted with families and youth at risk.
Health plan sponsors can work with clinicians and health care facilities to establish an ecosystem with connected behavioral, medical and pharmacy care (such as a “medical neighborhood” model) to enable a coordinated response when a child is identified as at risk. These connections can be particularly helpful when risk factors appear in ED and primary care settings.
A collaborative investment by plan sponsors and clinicians in focused crisis support services is critical to managing suicide risk. Real-time notification to health care plans of related-ED use can enable those plans to remind parents and guardians of available support and resources at the time of their child’s crisis.
These cooperative actions should also help identify and address any social determinants of health that may potentially hinder access to needed behavioral health and crisis support services. Plan sponsors and local providers should also help address any stigma surrounding depression and mental health treatment by normalizing conversations about these topics with children and their parents and guardians, so they will feel more comfortable to seek help and support.
All of these efforts can help improve outcomes for children and adolescents at risk for suicide-related behaviors. Encouraging the use of behavioral outpatient care earlier can help prevent the onset of more serious problems, including suicide, and improve lives.
*Suicidal thoughts or actions have been noted as potential side effects for certain Asthma medications.
**This higher prevalence is in line with research that suggests a potential link between asthma and suicidal ideation and attempts.
This comparative study examined the medical, behavioral and pharmacy claims data for the calendar years of 2019 to 2021 for approximately 9 million customers with either a large commercial health insurance plan or individual or family health insurance plan. The population of interest included 31,698 unique customers, including 27,729 diagnosed with suicidal ideation and 3,969 customers diagnosed with suicide attempt.
The age group assessed runs from age 5 to 17.
