1 EXECUTIVE SUMMARY
This report is intended for the review of Eric Braverman, Corporate Executive Officer of the Clinton Foundation.
One of the most prevalent health issues affecting the world today is suicide. In particular, suicide acts as a leading cause of death for teenagers and adolescents around the world. The World Health Organization estimates that every forty seconds, someone commits suicide (WHO). Global data show that suicide acts as the second highest cause of death in adolescents aged 15 through 19, behind road traffic accidents. Furthermore, these data have shown that suicide is the most common cause of death for females aged 15 through 19 and the third most common cause of death for males aged 15 through 19.
This report aims to examine the suicide rates of three countries: the United States, South Korea, and Russia. These countries represent radically different cultures and livelihoods. Nevertheless, in all of these countries, the adolescent suicide rate is medium to high, indicating a need to research adolescent suicide.
The Clinton Foundation prides itself on the ideal of prevention to promote better health and wellness worldwide, therefore it makes the perfect candidate to take the lead in helping prevent adolescent suicide worldwide. The Foundation already has programs aimed at improving the well-being of young children, so the next logical step is to improve the well-being of adolescents, especially those at risk for suicide (“Our Work”).
This report intends to reveal the differences in the methods that adolescents use to commit suicide in these different countries, as well as determine the main causes of adolescent suicide in each of these countries, analyze these causes, and synthesize a strategy for suicide prevention. After researching the suicide prevention policies of these countries and reviewing research on suicide prevention, it has been found that suicide prevention will increase by implementing more efficient suicide screening methods, restriction of means of suicide, raising suicide awareness in communities, and bullying prevention in schools.
2 SUICIDE IN THE UNITED STATES
2.1 PREVALENCE AND METHODS
In 2000, the United States reported 1616 adolescents aged 15 through 19 committed suicide. 1347 of the deaths reported being male, and 269 being female, leading to a male death rate of 13.0 per 100,000 persons aged 15 through 19 and 2.7 female deaths per 100,000 (Wasserman). Even worse, in 2010, the total suicide rate for those aged 15 to 24 was 10.5 for every 100,000 people ("Facts and Figures"). The three most common methods of suicide among adolescents are firearms (56% for males, 30% for females), suffocation (24% for males, 21% for females), and poisoning (13% for males, 40% for females) (“Facts and Figures”). Data from the Center for Disease Control showed that since 2000, the rate of suicide for adolescents continuously increased. This doesn’t take into account the even higher rate of suicide attempts in American adolescents. A recent nationwide poll of American high school students in both public and private schools showed that “16% of students reported seriously considering suicide, 13% reported creating a plan, and 8% reporting trying to take their own life in the 12 months preceding the survey” (Suicide in the U.S.: Statistics and Prevention). With 14.8 million high school students currently enrolled, this means that 2,368,000 high school student potentially have planned suicide, 1,924,000 created a plan, and 1,184,000 actually attempted suicide within the last twelve months, a figure that can hardly be ignored. A collection of 128 surveys comprising 513,188 adolescents revealed that 9.7% of these adolescents actually attempted suicide in their lifetime, with 6.4% making an attempt in the previous year and 6.3% attempting to commit suicide within the month before the surveys. These same surveys showed that suicide rates for females were twice as high as those for males (Evans et al.). These statistics clearly reveal that adolescent suicide marks a major problem in America.
2.2 RISK FACTORS
In the United States, a plethora of causes and risk factors for adolescent suicide exists. One of the leading suspected causes of adolescent suicide is adverse childhood experiences. Examples of these include emotional abuse, physical abuse, sexual abuse, parental separation or divorce, mental illness in household, and household substance abuse (alcohol abuse, etc.). A study done using the Adverse Childhood Experiences (ACE) score, a scoring system developed by researchers in the 1990’s at Kaiser Permanente’s San Diego Health Appraisal Clinic and approved by Kaiser Permanente, the Emory University School of Medicine, and the Of?ce of Protection from Research Risks, National Institutes of Health (Felitti et al.), showed that 14.3% of those surveyed attempted suicide and experienced emotional abuse, 7.8% had experienced physical abuse, 9.1% experienced sexual abuse, 7.0% had household substance abuse, 10.8% had an incarcerated family member, and 6.6% had separated or divorced parents. Compared to those surveyed who answered no to any of these categories, the risk for suicide increased up to five-fold (Dube et al.).
Another commonly researched risk factor of adolescent suicide is bullying. The 2007 Bureau of Justice Statistics’ Indicators of School Crime and Safety Report revealed that 28% of youth aged between 12 and 18 were bullied in school within the past six months. In a study conducted by Sameer Hinduja and Justin W. Patchin of American youth from 6th to 8th grade, 19% of respondents reported having attempted suicide. Of those responding, those who reported having been victims of bullying were 1.7 times more likely to attempt suicide than those who did not report being bullied (Hinduja and Patchin). Furthermore, a collection of three surveys of high school students by Jennifer Kaminski and Xiangming Fang, taken from the first wave of the National Longitudinal Study of Adolescent Health from 1994-1995, the 2005 Youth Risk Behavior Surveillance System, and the 2004 Youth Violence Survey yielded similar results. In the first survey, those who reported experiencing victimization of some form had an odds ratio of 3.8 for suicide ideation, those in the third survey had a lesser odds ratio of 1.7. The second data set is unique in that it was set up to put those who experienced victimization against those who did not. Those who reported victimization had “2.4-fold (95%CI = 1.91-2.92) greater odds of reporting suicidal ideation and 3.3-fold (95% CI = 2.64-4.22) greater odds of reporting suicidal behavior than students who had not been victimize by peers” (Kaminski and Fang). Kaminski and Fang state the following:
Our ?ndings provide support for the ‘‘conventional wisdom’’ espoused by the media that peer victimization experience may increase adolescents’ risk for suicide. Consistent with the ?ndings of previous smaller studies, victimization by peers was associated with greater reporting of suicidal ideation and behavior in representative and diverse samples of US adolescents. The signi?cant association between suicide and victimization by peers was unique, beyond the risk attributable to age, sex, race/ethnicity, or depressive symptoms (Kaminski and Fang).
As the researchers themselves say, bullying and suicide are interconnected.
A research survey of high school youths in 2004 showed that 28% of high school students surveyed met criteria for major depression, a commonly known risk factor for suicide. Females were twice more likely to attempt suicide or have suicidal thoughts than males, with major depression being the largest factor for increased risk of suicide attempts for females and previous attempts at suicide having the largest increase in risk for suicide in males. This shows that depression is a major factor in suicide and should not be ignored (Hallfors et al.).
A recent theory concerning the rationale for adolescent suicide, The Interpersonal Theory of Suicide, hypothesizes that two main lines of thought lead to suicide, Thwarted Belongingness and Perceived Burdensomeness. According to this theory, Thwarted Belongingness is the thought that one is alone, further divided into two categories, Loneliness and Absence of Reciprocal Care. These include previously stated risk factors such as abuse and loss of family. This boils down to a social isolation that provides a reliable predictor of suicide ideation and attempt. When an individual receives too little social interaction, it damages his/her “need to belong.” This leads into the second category in the Interpersonal Theory of Suicide, Perceived Burdensomeness. The two subcategories of Perceived Burdensomeness are Liability and Self-Hate. Liability is the thought that one’s death is worth more to others than one’s life. Self-hate results from low self-esteem and self-shame and self-blame. These lead to what is called Acquired Capability of Suicide, which subdivides into Lowered Fear of Death and Elevated Physical Pain Tolerance. Many past studies were used in the construction of this theory and reasonably back up these claims (Van Orden et al.).
3 SUICIDE IN SOUTH KOREA
3.1 PREVALENCE AND METHODS.
In 2011, the Korea National Statistical Office reported suicide as the fourth largest cause of death in the country, with suicide accounting for 6.2% of all deaths in the country, with a 31.7% death rate out of all attempts (National Statistics Office Report). Suicide is the leading cause of death of South Koreans aged 15-19, with 6.8 out of 100,000 individuals committing suicide. South Korea is also the leader in suicide rates among the Organization for Economic Cooperation and Development countries (OECD, 2011). Unlike the United States, suicide by firearms accounted for very few of the suicides of Korean adolescents, instead, the most common method of adolescent suicide in Korea was falling from a great height (47.2%), followed by hanging/suffocation (37.0%), and drug/pesticide intoxication (9.4%). In terms of gender, jumping is the most common method for both male and female Koreans. Male Korean adolescents were also more likely to attempt suicide than females, counter to the global trend (Park et al.).
3.2 RISK FACTORS AND CAUSE
Many Korean researchers have linked depressive symptoms and adolescent suicide in Korea. These studies show that 87% of youth admitted to the emergency room from 1998-2002 manifested psychiatric symptoms, with 66% of the individuals eventually diagnosed as clinically depressed (Lee). However, other studies show that only a small percentage of individuals with depression commit suicide. This leads to the other common signs and risk factors of youth suicide in Korea (Lee).
A risk factor for suicide that appears to be unique to South Korea compared to other countries is academic stress (Cho et al., 2002; Moon, 2006). A majority of suicidal Korean high school students reported that the largest stressor on their lives to be academics related stress, including low academic achievement, difficulties with career choice, high amounts of school work, and lack of sleep (Lee, Hong, and Espelage). Another study showed that receiving results from university entrance exams acted as a major trigger for suicide attempts (Kim & Chun, 2000). Of particular concern, the lack of sleep due to academic pressures has been the subject of whole studies. Most Korean schools start classes at 07:00-08:00 and end between 16:00 and 18:00. On top of this, a large majority of Korean adolescents will attend night schools for extra after-school tuition, with these programs ending between 21:00 and 24:00 (Kang et al). To counteract the low amounts of sleep during the weekday, many adolescents have vastly increased sleep durations on the weekends, which relate to an increased risk of suicide, as inconsistent and small sleep schedules have been linked with increased stress and depressive symptoms. This possibly is due to the chance that insufficient sleep negatively affects the regulation of the prefrontal cortex, an important component of emotional regulation (Kang et al).
Internet addiction has also become a risk factor of suicide in Korea. The country has emerged as the most wired country in the world. A study showed that Korean students from 6th to 8th grade who spent more than three hours on the internet a day were at higher risk for suicide ideation. A study done in 2005 showed that among students who scored high on the Internet Addiction Scale created by in 1998, the rate of suicide ideation was four times greater than those who scored low on the scale. This backs up other studies that have come to similar conclusions (Kyunghee et al).
4.1 PREVALENCE AND METHODS
Russia has one of the highest teenage suicide rates in the world. For Russians aged 15-24, there were 25.8 suicides per 100,000 individuals in 2006. In 2009, just over 1700 adolescents aged 15-19 had committed suicide in Russia. Statistics on the method of suicide in Russia showed that hanging was the most frequent method of suicide in the country, at 49.5%, followed by poisoning by drugs, 12.7%, and jumping, 9.5% (Kokkevi et al).
4.2 RISK FACTORS AND CAUSES
Alcohol abuse is commonly considered to be one of the greatest risk factors for adolescent suicide in Russia. Many cases have occurred where alcohol poisoning due to binge drinking was related to a suicide. Alcohol also acts a depressant, leading to a higher risk of suicidal behavior in adolescents with depression or other psychologically damaging disorders. Further, the impairment of judgment caused by alcohol can result in suicidal behavior. Stress due to poverty and high divorce rates have lead many youths to use alcohol as a coping mechanism. Because alcohol has a low price and high prevalence in Russia, it is not difficult for youths to purchase it. Research by Maria T. Kaylen and William Alex Pridemore shows that outside of regional location, the only variable that strongly correlated with youth suicide was heavy drinking (Kaylen and Pridemore).
Due to the recent increase in teenage suicides in Russia, some researchers have looked at media coverage and social networking as risk factors for suicide. In early 2012, a rash of teenage suicides received notable media attention, following which came a string of copycat suicides. These media reports were often very graphic, showing the bloody bodies of those who committed suicide. Journal reports went into extreme detail about the methods and locations of the suicides. Furthermore, in Russia, there are multiple online social media websites that allow adolescents to plan out and discuss suicide, one of which is Russia’s leading social media site, known as Vkontakte (Vickers).
Due to the collapse of the Soviet Union in the late 20th century, the number of abandoned or orphaned children in Russia increased significantly. A study done in Russian orphanages showed a high rate of physical and sexual abuse (19.1% and 12.3% respectively). One third of these orphans reported already having sexual intercourse before the age of 15 and one half reported using drugs over the course of their lifetime. These factors correlated with an increased risk of suicidal ideation and attempt. This study reinforces previous studies into the relationship between the lack of parental influence in adolescence and risk of suicide (Zapta et al).
5 PREVENTION PLAN
Due to the multitude of methods of suicide, there cannot be one foolproof plan to prevent suicide, but there are many strategies that can be used to reduce the risk of suicide worldwide. These strategies consist of better programs to recognize mental illness, increasing suicide screening programs in schools, restriction of means of suicide such as firearms, and increasing awareness of suicidal behaviors in schools.
Restricting access to many methods of suicide, such as firearms, has shown a decreased rate in the use of that method in suicide attempts. This shows that restricting access to methods of suicide is a viable option to reduce adolescent suicide. Take South Korea, for example, where gun laws are very strict. Very few firearm related suicides occur in South Korea, showing that gun restrictions do have a positive effect on suicide prevention. Another restriction that should be implemented is access to roofs and balconies of tall buildings via fences, railing, and other barriers. This will prevent many people from gaining access to high jumping points where suicide is possible, lowering the number of deaths by jumping significantly.
However, physical restriction of suicide methods cannot work alone, it is through better school screenings for suicidal behavior and campaigns to reduce bullying and remove the stigma around mental illness that we will likely see the best results. One very effective policy is screening for suicidal behavior in schools, where adolescents spend a large portion of their time. Research has shown that this is an effective method of suicide prevention; however, many schools do not screen for suicidal behavior because of concerns that screening adolescents and educating them on signs of suicidal behavior actually increases the risk of suicide ideation. These fears are largely unfounded, as studies have shown that exposure to suicide-related content does not increase the risk of suicide ideation (Joe and Bryant). As part of the screening process, school faculty need in-service training to recognize the signs and symptoms of suicidal behavior and have the motivation to reach out to the student if they are showing signs (Joe and Bryant). Finally, schools need to implement more frequent and detailed suicide-related questionnaires so that faculty can intervene with students who show a high risk of suicide ideation. While this method relies more on help seeking behaviors rather than prevention itself, a life is saved either way (Mann et al).
Related to schools, campaigns to reduce bullying and teach acceptance and understanding of others need to receive more attention and funding. As this report has shown, bullying and abuse are strong factors in suicide ideation and risk. Take, for example, the Amanda Todd case. Todd committed suicide after being bullied and manipulated by not only and older man but her peers (Szalavitz). Unfortunately, Todd’s case is not an outlier when it comes to adolescent suicide. Bullying lowers the self-esteem of the victim and often leaves them with feelings of being isolated, two subcategories of the Interpersonal Theory of Suicide that can lead to actual attempts if the bullying continues for an extended period of time. This calls for more anti-bullying campaigns in schools. Many researchers believe that bullying stems from the fear of the unknown (Mann et al). If a student is homosexual or a minority, they are an unknown to the bully and mob psychology leads to the near dehumanization of these victims. Campaigns that teach tolerance and understanding can make major inroads to cut down on bullying and prevent suicide.
As this report has shown, mental illness is a major risk factor for suicide, and oftentimes goes untreated. Studies have shown that training primary care physicians to better recognize and diagnose symptoms of mental illnesses increase the likelihood of treatment and prevention. In addition, treatment methods such as pharmacotherapy and psychotherapy show promising results in reducing suicide ideation in depressed individuals. Administration of selective serotonin reuptake inhibitors (SSRIs) to depressed individuals in the United States and Europe has decreased suicidal behaviors in those individuals. Unfortunately, the administration of SSRIs can have a negative effect on the individual depending on the SSRI, requiring strict monitoring of individuals under these SSRIs for the first several months after administration (Mann et al). Cognitive and interpersonal psychotherapy have also shown promise in reducing repeated attempts at suicide in depressed individuals, in some cases halving reattempt rate in individuals receiving extra care compared to those who receive normal care (Mann et al).
Youth suicide is a tragic worldwide issue that until recently has gone largely unnoticed and untreated. However, with the resources available to the Clinton Foundation, anti-bullying campaigns can be started worldwide as well as campaigns to urge adolescents to seek help if they are experiencing suicidal thoughts. From the point of view of someone who has been a victim of bullying and experienced suicidal thoughts, these methods of prevention are promising, some of which have actually helped me. This report shows what needs to be done, and the Clinton Foundation should be one of the organizations to help prevent these tragedies from occurring in the future.
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