The continuing rise in the suicide rate of our youth lbr the past two decades has made it imperative to take a closer look at this problem in order to find solutions. Interpersonal, familial, cultural, and sociological factors have been suggested as explanations for this increase, but no clear reason has emerged. Although the bulk of our knowledge focuses on suicide in general, relatively little has been written on racial and ethnic factors in youth suicide, especially in blacks and Hispanics. Most research has been done on adult populations and. for this reason, much of our knowledge of adolescents must be extrapolated.
In the past 8 years, the author and colleagues at the Lincoln Medical and Mental Health Center in the South lironx. New York, have noticed a steady increase in admissions of adolescents to the inpatient pediatric wards lor suicide attempts (D. R. H.. unpublished data. 1988). In 1985. 111 teens were admitted: in 1984. 125: in 1985. 15, 000 and the number has risen yearly thereafter. The patients come from the South Bronx, which has a population of approximately 500 000 people (1980 census) and the following ethnic/racial representation: 50% Hispanic. 42% black. 6% while, and 2vo from other ethnic backgrounds. The population has a mean age ol 24.5 years, with one out of three being under the age of 18.
In general, the suicide rate among whites is higher than among blacks.1 Approximately 22% of all adolescents in the New York City metropolitan area are black, yel blacks account for only 10% of suicides in this age group. The suicide rate in (he Hispanic and Asian minority communities is similar to that of whites.
During the past 25 years, suicide has become less common in middleaged and older groups but more common in the voting. The increase has been greatest (threefold) among while males between 15 and 24 years of age. with an increase being noted every year. The rate of increase for black males during this period, however, has not been as great, and there has been only a very small increase in the suicide rate for females across all ethnic groups.
Shaffer and colleagues2 addressed the subject of ethnicity. They noted suicide rales in whites to be higher than in blacks at all ages, with greater differences identified in southern states. Monk and Warshaur3 compared completed and attempted suicide rates among blacks, whites, and Puerto Ricans in Manhattan. They found that Puerto Rican men had the highest rate of completed suicide - two (o three times that of either of the other two groups. White women had rates for completed suicide as high as those lor white men and three times as high as for black women. They suggest that the difference, in part, pertains to differential reporting and classification of death among blacks and whiles.
SUICIDE IN BLACK ADOLESCENTS AND YOUNG ADULTS
Frederick1 is one of the few suicide researchers who has focused on minority groups. He has noted that the percentage increase in suicide among young nonwhite males, specifically blacks, has surpassed that of while males even though the actual overall rale of completed suicide among white males is higher.
The completed suicide rate in young people, ages 15 to 19 and especially the 19 to 24 age range, is of great concern. The increase in rates over the past decade or so for adolescent and young adult males has exceeded 70%. The rate for nonwhites, including blacks, has shown a remarkable rise of more than 75% among those aged 15 to 19 and 2U to 24 over the past 12 years.4
Frederick found a 70% or more increase in suicide rates in adolescents and young adult males in the previous decade and notes the greater increase among black males. However, it was emphasized that data reflected a relatively small number of minorities (100 black males in the 15 to 19 age range) compared with the predominant group (1305 white males). In contrast to the shift in suicide rates among black males, the rates for their female counterparts were much lower than for white females (17% compared with 55%). Frederick also noted relatively little difference in the method of suicide between the two racial groups in the 10- to 14-year-old range for both females and males. Firearms and explosives were most commonly used, followed by hanging and ingestion of lethal substances. In the 15- to 19-ycar-old range, a greater proportion of black males, as compared with white males, died by hanging, drowning, or jumping from high places. In contrast, white males used firearms or died from carbon monoxide poisoning. Without respect to race, a higher proportion of females in middle to late teenage years (15 to 19) committed suicide by poison, although a majority used firearms.
Hayes and Johnson5 looked at suicide among blacks and whites in the military. They had also noted that completed suicide rates for young urban blacks between the ages of 20 and 55 were twice that for a comparable white group in the civilian sector. However, a US Army study, conducted by Datei and Johnson6 in 1975 and 1 97b. showed the ratio oï suicide rates for males of the two groups to be the reverse oi those in the civilian community. The highest concentration of all suicides in the army is in the 20- to 24-year-old group. Similar treatment of the two groups by the military was suggested as a reason for similarity in suicide rates.
Hendin7 cited a statistical study that showed suicide to be a serious problem among blacks: suicide was found to be twice as frequent among New York black males between 20 and 55 years of age as it was among white males in the same age range. Family violence and violence in the communities of black victims were viewed as significant causal factors.
Bagley and Greer12 criticized Hendin's study and reported a comparable study of their own. The criticism of Hendin's work pertained to his failure to use an unbiased method of case Unding and the lack of control subjects. Hendin's argument that black suicide reflects the strains of ghetto life was viewed as invalid because in almost all age groups the suicide rate among whites is higher than the rate among blacks. The Bagley and Greer epidemiologic study of 25 black suicides (2 were completed) was conducted in England. These subjects were more migratory than those of Hendin and perhaps different in other sociological aspects. Bagley and Greer found that those who attempted suicide:
* suffered more acute situational reactions than did controls.
* were younger controls, and
* were more likely to be discharged without psychiatric referral.
They also found that being black was a significant predictor oï repeated attempts in those individuals who did not receive psychiatric and social support at the time of the initial suicide attempt.
Gibbs9 found that black youth were relatively worse off in 1980 than they were 20 years earlier in relation to unemployment, delinquency, substance abuse, teenage pregnancy, and suicide. Baker10 cited a number of significant findings drawn from a study of 5b (17 males and 59 females) suicide attempted. Female attempters were younger, and 54% had made a prior attempt and had a diagnosis of either affective illness (55%) or an adjustment reaction with depressive features (51%). Seventy-six percent of the male attempters had a prior psychiatric history, and 59% had a psychotic diagnosis.
Davis11 also commented on the rising rate of suicide among young blacks, particularly in the 1960s and 1970s. This rate has risen so that it is nearly as high as that of their white peers. Whereas white suicide increases in diteci relation with increasing chronological age. suicide among blacks reaches its peak in the youthful years. Current statistics fail to reflect a dramatic or significant increase in the suicide rate of black women. Regionally, rates of suicide of blacks are highest in the North and West and lowest in the South.
In an attempt to explain attempted suicide in young adult urban black males (the high riskhigh rale group, aged 20 to 50). Kirk and Zucker12 set out to test the hypothesis that in the suicidal black population, black consciousness and group cohesiveness would be lower and depression would be higher. Young inner city black males with a history of suicidal attempt in the previous 6 months and matched controls were studied. The findings supported only the hypotheses regarding the lower level of black consciousness.
Bush13 developed strategics that use a family perspective for assisting blacks who consider, plan, and attempt suicide. This exploratory study tests the hypothesis that the precipitating events among blacks are more likely to be the loss or threatened loss oi a love partner in the context of a negative value orientation and intragroup pressures than among white suicide attempters.
In a review of suicides of blacks and whites, Seiden14 emphasized the democratic distribution. In recent vears (before 1972). the suicide rate of 15- to 19-year-old nonwhile females had exceeded the toll for their white iemale peers, and at 20 to 24 years of age the nonwhile male has. ai limes, surpassed the white male rate. Seiden recommends studies to determine whether urban ghetto life. social stains integration problems, militant activities, police community relations, and work training programs act as suicide prevention lactors.
SUICIDE IN HISPANIC YOUTH AND ADOLESCENTS
When reviewing the literature on suicidal behavior in Hispanic adolescents, one is immediately struck by the serious dearth of publications in this area. Much oi the material reported here came from personal communications. It must be underscored that the Hispanic population is not homogeneous and what may be characteristic for one subgroup may not be for another. The three Hispanic subgroups most representative of New York City's Hispanic population are Puerto Ricans. Dominicans, and Cubans: Mexican Americans generally reside in the five southwestern slates, ie, Arizona. California. Colorado. New Mexico, and Texas.15
Zayaslb notes thai Hispanics are neglected in literature that focuses on suicides. Socioeconomic disadvantages, traditional gender role, socialization, acculturation, cultural identity, and intergcnerational conflict were factors thai had some bearing on suicidal attempts among Hispanic adolescent females. In terms ol dynamic understanding, Zayas recommends thai family variables that buffer or increase risks oi suicide in Hispanic teens need to be assessed. Family Iunior and "lamilism" (family centeredness and cohesiveness) arc highlighted. Hc suggests that these values can mitigate suicidal behavior. However, multiple stresses arc associated with poverty conditions, including substandard housing, unemployment, crime victimization, and poor healthcare and education. Manx Hispanic youth feel pressured lo acculturale, enduring conflicts bel ween Hispanic and dominant societal values. Intergcnerational tension, gender role colili ici. and language barriers heighten the risks oi succumbing to behavioral and psychotic disorders. I hose adolescents who are able to adapt to their new culture and still maintain ties and receive support from the old culture arc afforded considerable protection.1" The report by Smith el al1' compared suicides among whites and Hispanics in five southwestern states and found that suicides occurred at a younger age lotMexican Americans. In fact. 52.9' A of all Hispanics in their study who committed suicide were under the age of 25. compared with 17.5? of whites in the same age group. A shortcoming of this study, however, was that the authors identified subjects by surnames rather than using actual ethnic identification.
In a study oi Puerto Rican immigrants in the mid- to late 1950s. Trainman18 identified a syndrome. "suicidal fit." among Puerto Rican women. Precipitating factors included depression, recent break-up with boyfriend or husband, low levels of acculturation, and considerable psychosocial stress. Most of these women were young adults, and the suicides were impulsive acts. Zayas warns that Trainman's population may have been different from the one we see today.
Bluestone and Purdy (unpublished dala. 1977) noted depressive reactions in the form of suicide attempts among Puerto Rican women in the Bronx. Attempting suicide often appeared to be the women's only perceived outlet for culturally generated anger and frustration. Korin and Dycheh) suggested that suicidal attempts in Hispanic adolescent females are rooted in a motheradolescent conflict. The need for continued closeness and loyally lo lhe mother and the need to respect Hispanic traditions are coupled with the intensification and fulfillment of sexual needs. Tensions mount and conflict is heightened, often followed by an explosive act. The suicide attempt, then, is the adolescent's reaction to the struggle between her own rights and lier attempts to define her personal destiny. These investigators underscored two components to successful therapeutic intervention:
* meeting with families prior to hospital discharge and providing them with information about follow-up outpatient treatment and the availability of Spanish-speaking therapists, and
* identifying the mother's fear of failure and humiliation as a parent and providing insight-oriented and supportive treatment.
Monk and Warshaur1 point Io migration as a factor in the high attempt rates for Puerto Ricans. Most Puerto Ricans over the age of 17 are migrants, and numerous studies have revealed higher rates of completed suicide for migrants than nonmigrants. As a rule, however, recent immigration seems to be a factor. Thus, although migration may be important in Puerto Rican suicidal behavior, it is more likely that other factors arc crucial. The harshness and sequalae of poverty are illustrative: Puerto Ricans are the poorest of the three ethnic groups in East Harlem.
Puerto Rican men have the highest rate of completed suicide among all the groups of Hispanies and the second highest rale of attempts. Only Puerto Rican women make more attempts. The high number of suicide attempts by Puerto Rican women (4) times the annual number of completed suicides) is striking. Their rate is nearly twice that of Puerto Rican men and nearly three limes that ol white or black women.
A comparison of suicide rates lor Mexican Americans and whites revealed an increased rate in both groups over a 20-year period, with a greater increase in whites.20 The investigators viewed lam i I ism and fatalism in the Mexican American culture as protectors against stress: these factors accounted for the lower suicide rate (as compared with whites). Familism is associated with the Catholic religion, which is itself associated with low suicide rate. Fatalism allows the individual to accept whatever happens but may also be associated with depression.
In the author's study, 25 randomly selected first-time hospitalized attempted were compared with 22 randomly selected nonsuicidal matched controls who were admitted to the hospital for the first time with a chronic illness. The absence of black males was striking in that 42% of the population of the hospital catchment area are black. A higher incidence of depression, greater psychosocial stress, and more financial concerns characterized the suicide attempters. who were predominately Hispanic females. During the period of the study, no suicidal black males were hospitalized although some were referred before and after the formal study.
A representative case from each adolescent subgroup illustrates the differences in the underlying dynamics of each category.
A black 14-year-old girl had been sexually molested lor years by her stepfather before lolling her mother. "The mother's immediate response was io throw the stepfather out of the house. Subsequently, the girl's grades began to decline and truant behavior became frequent. She often stayed out late ai night; sometimes she failed to return unni the following morning. Eventually, she uns broughl io lhe Adolesceni Day Treatment Center, a program designed for special educai ion and psychotherapeutic intervention, but she was never able to make maximal use of the program. About a year aller entering lhe program, she became involved with a hoy. became pregnant, and then experimented with household drugs in an attempt to abort. Two months aller a spontaneous abortion, she attempted suicide by taking acetaminophen, aspirin, and alcohol. There were a number of her mother's relatives and friends in the home at the lime of lhe incident. Ii seemed she was making sure that someone would know about the attempt.
When examined at the hospital, the patient was slightly depressed, bui there was an absence of suicidal ideations and no evidence ol psychosis. She was referred to an inpatient program and subsequently underwent outpatient treatment. Unfortunately, she soon left the clinical program.
It was apparent that this adolescent had developed a masochistic lifestyle, picking up boyfriends who humiliated and beat her. Although she talked frequently about goals and plans to reach those goals, she never made any substantial changes and continues to drift.
An 18-year-old black male presented at the hospital after the formal study had been completed. He was broughl to the emergency room alter ingesting diet pills, cough syrup, and two vials ol crack in a suicide attempt - his third attempt in 5 years. All three attempts required hospitalization. He has been unable to sustain himself in a meaningful therapeutic relationship, drilling in and out of city shelters and living on the streets. Al times, he would go to the apartment where his mother lived with four smaller children, but he would leave after several days when he needed money for crack. I Ie would then steal furniture or household appliances to leed his habit. On mental examination at his third hospitalization, he admitted his addiction to crack: he staled that he had to have it at any cosi. He also admitted to sporadic suicidal and homicidal urges but denied these urges at this interview. He told of experiencing command hallucinations to kill as recently as a lew days prior to admission. He was oriented to lime, place, and person: content of thought centered on his constant arguments with his siblings and his mother. His mood was mildly to moderately depressed: ailed was not unusual. Insight and judgment were quite poor. He did not appear to be grossly psychotic, suicidal, homicidal, hallucinating, or delusional al the ini en few.
After 4 days in the hospital, this patient left against medical advice: he walked out dressed in a hospital robe and pajamas. Al a follow-up visit to his home 7 months later, his mother revealed that he had rarely been there since leaving the hospital and thai his whereabouts was unknown. The mother revealed he had made another suicide attempt (the fourth) within that 7-month period. He tried to throw himself in Iront of a subway train. Some waiting passengers restrained him. and transit police had him hospitalized and then called his mother. He was diagnosed as having schizophrenia (chronic undifferentiated type) and substance abuse disorder (crack).
A 15-year-old Hispanic male was brought to the emergency room alter he had tried to hang himself with shoelaces at a correctional facility. He was discharged from the hospital the following day, at which time he denied suicidal ideations. (An evaluating team determined that hospitalization was not indicated.) The following night he was found in the bathroom with an improvised rope (fashioned from tape) with which he was trying to hang himself. He spoke of being upset about a court appearance the following day.
The examining psychiatrist described the patient as alert and oriented. Mis mood was marked with anger and anxiety: affect was appropriate. He was reluctantly cooperative but answered questions appropriately with apparent relevance. I Ie stated that he did not really want to kill himself but when he thought about the situation he was in. hanging himself was the first thing that came to mind. Poor impulse control as well as poor insight and judgment was obvious.
The patient was admitted to the hospital: continuous observation was recommended because of his impulsiveness and unpredictability. Thioridazine was prescribed to reduce his anxiety. The patient was seen daily by a child psychiatrist and referred for outpatient treatment upon discharge.
Following discharge from the hospital, this patient went back to the correctional facility. He continued to be quite difficult to control and was placed in a special support dormitory with a 2:1 staff to inmate ratio. At one point, hewas sent to the local state adolescent hospital for a week, where he calmed down but refused to lake prescribed medication alter discharge. Because he was depressed and possibly suicidal, low dosages of thorazine and Imipramine were offered to him, but he refused to Uike the medication. Approximately 5 months after the original hospitalization. he remains in the correctional facility. because of his sudden explosive behavior, a counselor is present at all times. Twice he lashed out at other inmates, hurting them badly and breaking one of his fingers in the attack. He refused to wear a casi, refused to be seen by a therapist, and refused to take medication until he was allowed to control the amount oi medication and the time of day it would be given to him (thorazine 200 mg once daily at 5 PM) His diagnosis is still unclear. Borderline personality. explosive personality, and antisocial disorder are all being considered.
A 16-year-old Hispanic female was admitted to the hospital ward through the emergency room after she had taken an overdose of ibuprofen and theophylline following an argument with her father about her boyfriend. According to the patient, she had been dating a 19-yearold I lispanic youth who did not meet with her lather's approval. Her boyfriend was suspected of drug dealing. The patient slated that the boyfriend was not dealing any moie, and she complained that her lai her threatened to beat up or kill the boyfriend if he went near her. On the day prior to admission the father saw them both in the house. A violent argument ensued, and the patient left her father's house to go to the boyfriend's home. Before doing this, she ingested the pills mentioned. Several hours later she came home and started vomiting repeatedly. The lather called an ambulance, and she was laken to the hospital.
The patient staled that she had had suicidal thoughts before but had never acted on them. The patient's mother died of cancer 2 monihs previously, and she was very upset by her mother's death. She expressed regret at having taken the pills and promised never to do it again. Examination on the ward revealed a small attractive 16-year-old Hispanic female who looked 2 to 5 years older than her stated age. Speech was coherent, relevant, and goal directed. She was alert and cooperative. She appeared to have a mild agitated depression: affect was of formal. She denied and showed no sign of hallucinations, delusions, or suicidal or homicidal ideation. Insight and judgment were fair. She was oriented to time, place, and person.
The patient said she first began to consider suicide at age 1 5 but made the first attempt shortly alter mother died by slashing her wrists. The current attempt was her second. She denied that either parent ever made suicide attempts but said the lather was a heavy drinker. She and her mother used to fight and argue constantly about her failure to help out with household duties: lights with her lather centered around the boyfriend. At follow-up 5 weeks after hospital discharge, the patient was again living with her father, who had "accepted" the boyfriend. Both the patient and the boyfriend came to the clinic for the followup interview and both agreed to come back if necessary for further discussions. At follow-up. the patient was only mildly depressed, clung to her boyfriend, and seemed eager to come for help. She planned lo return to school (10th grade) at the beginning of the next semester. Our diagnosis was adjustment disorder with mixed emotional features.
Because of the dearth of research on the subject, our present knowledge of black and Hispanic adolescent suicide behavior is limited and often must be extrapolated from suicidal behavior in the general adolescent population. During the past 20 years, suicidal behavior has been occurring more frequently and in more intense and dangerous ways in this group.21 Some aspects of the problem are specific to each subgroup, ie, both genders of blacks and llispanics. A number of studies have shed light on different phases of the problem, but in other cases we are still awaiting answers.
Black males between 20 and 55 years of age have a very high suicide rate. Some see the rise in the black young adult rate as an alarming factor with ominous overtones. This suicidal behavior seems to be related to the young black male's inability to establish his vocational, racial, social, and gender role identity during these years. The fact that the rate eventually levels off for black males but continues climbing in white males suggests that at some point black men come to terms with these conflicts one way or another. A study by (ones et al22 may give some important clues as to why the rate of suicide in black males in the 20 to 55 age range is so high, despite the fact that the two groups of black males they studied were different in age and perhaps socioeconomically also. Jones and his colleagues conducted a questionnaire survey of black and while psychiatrists on the subject of psychotherapy with black males. The investigators found that the major reason for which men in the 50- to 40-year-old range sought treatment were depression and work-related problems. Aggressionpassivity was a common conflict, and racism was often a causative factor in their pathology.
The black iemale adolescent, on the other hand, presents a different problem for study. Rates of completed suicide for black female adolescents arc consistently lower than rates for other comparable subgroups. What protects the young black female from suicide? Again. there is no clear answer, but certain clues emerge that warrant further investigation. The black female usually has closer ties to her mother and her grandmother, who is usually strong and is accessible. The grandmother is often willing to take pressure off her daughter, whether this is in the form of caring for the daughter's child or providing a respite from the world's "pain." The younger woman also has the supportive network of the extended family and the church, and she is generally not reluctant to reach out to these sources for help.
Hispanic adolescents, both male and female, not only have the problem of racial and ethnic discrimination and the culture of poverty, as do black adolescents, they also have additional problems related to acculturation and language. The Hispanic female is caught between two worlds - the old world of Hispanic traditions where the woman is expected to be dependent, homebound, passive, and virginal and the new world of late 20th century America where a woman is expected to value other characteristics, many of which are opposite to those of the old world. Yet. it is striking that despiie the inordinately high number of Hispanic females who make suicide attempts, very few the. One factor clearly operating here is that the attempts are made using relatively low-lethal methods. The scenario usually involves an argument with a boyfriend or with a parent (usually the mother) over a boyfriend. The typical argument is a dispute over courting rules or household chores. Two or three days after hospitalization for the suicide attempt, the patient is released and is given an appointment with a child adolescent psychiatry clinic. Fewer than une third keep this appointment, however, and denial from patient and family usually gels stronger as time goes on.
New techniques to deal with the dynamics of the problem include scheduling home visits, selling up school programs and hotlines, and encouraging increased involvement with churches and other types of social interaction. Early contact with families. even in the emergency room, must be arranged because families are most receptive immediately after the suicide attempt.
"The high-risk suicidal adolescent must be targeted. The adolescent who is depressed, psychiatrically disturbed, acting out. learning disordered, or drug and alcohol addicted presents the greatest risk. Males are at higher risk for completed suicide than females. Access to firearms must be eliminated, as ? his highly lethal method of suicide is being used more frequently, particularly among nonwliite urban male adolescents.
Finally, both Hispanic and black male adolescents have extremely high homicide, accident, and drug addiction rates: the rates are higher than those found among white males. If the number of victimprecipitated homicides (therefore actual suicides), suicides disguised as accidents, and drug overdoses (intentional and unintentional) could be determined, the rate of suicide in black and Hispanic males would be much higher. These selfdestructive behavior patterns are directly associated with suicide and should be the target of future investigation.
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