Suicide remains a leading cause of death among adolescents. A new study among US high school students has found that suicidal behavior is significantly associated with externalizing behaviors and violence exposure. The new study, appearing in the American Journal of Preventive Medicine, published by Elsevier, is the first to assess this association at the state level.

Although access to firearms and other weapon use contribute to suicide risk, the underlying risk for, and correlates of, firearm use among US adolescents is understudied. A cross-sectional study using data from 1991 to 2021 on 234,588 adolescents from the Youth Risk Behavior Survey examined the associations between externalizing behaviors, violence exposure, firearm carrying, and suicidal behavior to provide an assessment of the ways in which broader violence risk factors may increase the risk for injurious self-harm.

Externalizing behaviors are characterized by aggressive and disruptive behaviors that can be harmful to others or the social environment. Examples of externalizing behaviors and violence expression are threatening others with a weapon, starting a physical fight, and committing sexual violence.

First author Victoria A. Joseph, MPH, Department of Epidemiology, Columbia University Mailman School of Public Health, says, "We found significant associations between suicidal behavior and externalizing behaviors and violence exposure, with higher magnitudes of associations among those with a suicide attempt requiring medical treatment. The association between externalizing behaviors and violence exposure and injurious suicide attempt also varied over time and by sex."

Firearm-based suicide rates have increased among adolescents in recent years, suggesting a growing urgency to examine dynamics surrounding firearms and their role pertaining to suicidal behavior. Access to firearms and suicide rates in the US vary by state.

Ms. Joseph explains, "Suicide deaths are more prevalent among individuals who live in rural areas due in part to firearm access, isolation, and limited access to mental health services. State-level variations of suicide rates are heavily driven by suicide deaths involving firearms."

The study's researchers evaluated trends from data available from 16 states (ID, IL, IA, LA, MI, MS, MT, NE, NH, NM, NY, OK, PA, UT, VA, and WV) on carrying a gun or other weapon. They found that among adolescents with an injurious suicide attempt in 2021, state-level differences in weapon access emerged.

Ms. Joseph notes, “Although the prevalence of suicide involving firearms is higher in the West, surprising trends emerged such as low prevalence of weapon access among those with an injurious suicide attempt in gun ownership states such as Montana and high prevalence in states with low gun ownership such as New York. It should be noted that sparse data at the state level hindered the assessment of trends over time in every state. Due to variations in suicide rates, gun laws and weapon access in the US, state-level assessments of suicide risk and interventions are essential.”

Lead investigator of the study Katherine M. Keyes, MPH, PhD, Department of Epidemiology, Columbia University Mailman School of Public Health, concludes, “Firearm injury is a leading cause of morbidity and mortality among young people in the United States, including through suicidal behavior. Youth who carry weapons and have higher risks of engaging in physical violence also have a higher risk of self-inflicted violence, underscoring the need for stronger firearm protections to protect youth health.”