cates and medical examiner's reports were used to ... The medical examiner tested 41.6%. (57/137) of .... factors such as availability and social ac- ceptability. [.
Public Health Briefs
10.
11.
12.
13.
14.
young adulthood of former school absentees and school dropouts. Youth Soci. 1984; 13:325-352. Johnston LD, O'Malley PM, Bachman JG: Highlights from Drugs and American High School Students 1975-1983. Rockville, MD: NIDA, 1984. Miller JD, Cisin IH, Gardner-Keaton H: National Survey on Drug Abuse: Main Findings 1982. Rockville, MD: NIDA, 1983. Rootman R, Smart RG: A comparison of alcohol, tobacco and drug use as determined from household and school surveys. DrugAlcoholDependence. 1985;16:89-94. Johnston LD, O'Malley PM, Bachman JG: National Trends in Drug Use and Related Factors among American High School Students and Young Adults, 1975-1986. Rockville, MD: NIDA, 1987. Kandel DB: Developmental stages in adolescent drug involvement. In: Lettieri D,
15. 16. 17.
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Sayers M, Pearson HW (eds): Theories on Drug Abuse. Rockville, MD: NIDA, 1980; 120-127. Easterlin RA: Birth and Fortune: The Impact of Numbers on Personal Welfare. Chicago: University of Chicago Press, 1987. Ryder NB: The cohort as a concept in the study of social change. Am Soc Rev. 1965; 30:843-861. Bachman JG, Johnston LD, O'Malley PM, Humphrey RH: Explaining the recent decline in marijuana use: Differentiating the effects of perceived risks, disapproval, and general lifestyle factors. J Health Soc Behav. 1988;29:92-112. Bachman GB, Johnston LD, O'Malley PM: Explaining the recent decline in cocaine use among young adults: Further evidence that perceived risks and disapproval lead to reduced drug use. JHealth Soc Behav. 1990;31:173-184. New York State Department of Education: The State of Learning. Statewide Profile of
20.
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the Educational System. Albany, NY: State University of New York, 1990. National Institute on Drug Abuse: Annual Data 1988. Data from the Drug Abuse Warning Network. Rockville, MD: NIDA, 1989b. Office of National Drug Control Policy; Leading Drug Indicators. White Paper. Washington, DC: Executive Office of the President, 1990. Wilson WJ: The Truly Disadvantaged. Chicago, IL: University of Chicago Press, 1987. Son S, Model SW, Fisher GA: Polarization and progress in the Black community: Earnings and status gains for young Black males in the era of affirmative action. Sociol Fonrm 1989;4:309-327. Brunswick AF: Young Black males and substance use. In: Gibbs JT, Brunswick AF, Connor ME, etal (eds): Young, Black, and Male in America. Dover, MA: Auburn House Publishing Co., 1988;166-187.
Surveillance of Attempted Suicide among Adolescents in Oregon, 1988 Jon K Andnus, MD, David W. Fleming, MD, Michael A. Heumann, MPH, James T. Wassell PhD, David D. Hopkhns, MS, and Jane Gordon, PhD
Introduction
.......
Nationally, suicide is the third leading cause of death among adolescents and young adults.1 For each completed suicide, 30 to 200 suicides are attempted, but not completed.2-' Ten percent of adolescents who attempt suicide make further attempts within 1 year, and 31% do so within 2 years.7'8 In Oregon, suicide among teenagers is second only to motor vehicle injuries as a cause of death, accounting for 16% of deaths in Oregonians ages 13 to 19.9,10 In 1987 the Oregon legislature mandated the reporting of all attempted suicides among persons younger than 18 years. This paper summarizes the first year (1988) of information from this surveillance system and compares the characteristics of adolescents who attempted suicide in 1988 with those who completed suicide in Oregon during the 10-year period 1979 to 1988.
Methods ..............
Beginning January 1988, each Oregon hospital (n = 70) was required to report to the Oregon Health Division information on all adolescents younger than 18
years who attempted suicide. An attempted suicide was defined as self-inflicted injury or condition specified by the medical provider as having fatal intent, treated at a hospital or a hospital emergency department. Information collected by the hospital included demographics, date and place of attempt, family living situation, history of previous suicide attempts, use of alcohol, results of blood alcohol testing if done, and method of attempt. This information, without name identifiers, was sent monthly to the Health Division. For comparison, state death certificates and medical examiner's reports were used to identify all Oregon adolesJon K. Andrus and James T. Wassell are with the Epidemiology Program Office of the Centers for Disease Control, Atlanta, Ga. David W. Fleming, Michael A. Heumann, David D. Hopkins, and Jane Gordon are with the Oregon Health Division, Office of Health Status Monitoring, Portland, Ore. Requests for reprints should be sent to Jon K. Andrus, MD, Pan American Health Organization, HPM/EPI 7th Floor, Room 714, 525 23rd Street, NW, Washington, DC 20037. This paper was submitted to the journal August 27, 1990, and accepted with revisions March 6, 1991.
American Journal of Public Health 1067
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to 35 000; and urban were those with greater than 35 000 population. Population data were obtained from the Bureau of the Census and the Center for Population Research and Census at Portland State University. For attempters, we used 1988 mid-year population estimates for denominators to calculate annual incidence rates. For completers, we used 1984 population estimates. Annual incidence rates were calculated for completers using 10 years of data from 1979 to 1988. This methodology was chosen after we had compared the characteristics of completers from 1979 to 1983 with those from 1984 to 1988 and found no differences by age, sex, race, or method of attempt. Data were analyzed using Dbase, EPIINFO, and SAS. Exact confidence limits were calculated using methods based on Fisher's Exact Test.
Resudts
cents 10 to 17 years old who committed suicide in Oregon during the years 1979 to 1988. A completed suicide was defined as a person who died as a result of intentional self-inflicted injuries as determined by the medical examiner. In this study, the term adolescent means 10- to 17-year-olds. Adolescents
1068 American Journal of Public Health
who attempted suicide but were not successful are termed attempters, adolescents who committed suicide are termed completers, and incidence rates are expressed per 100 000 population of 10- to 17-year-olds. Rural counties were those with less than 15 000 population; suburban were those with populations of 15 000
In 1988, 644 Oregon adolescents ages 10 to 17 years were reported to have attempted suicide, an annual incidence rate of 214 per 100 000. There were no attempted suicides in children younger than 10 years. Of attempters, 87.7% were aged 14 to 17 years, 83.5% were female, 84.9% were White, and 19.8% were urban residents (Table 1). Only 9.5% (61/644) of the attempters had blood alcohol tested. Of those tested, 50.8% had detectable blood alcohol levels. The medical examiner tested 41.6% (57/137) of the completers for blood alcohol. Of completers tested, 35.1% had documented detectable blood alcohol at the time of their death. From 1979 to 1988, 137 Oregon adolescents committed suicide, an average annual incidence rate of 4.6 per 100 000. The ratio of the average annual incidence rates of attempters to completers was 47:1. The average annual incidence rates for both attempted and completed suicide was lowest for 10 to 11 year olds and highest for 16 to 17 year olds (Table 2). Compared with attempters, completers were more than 20 times more likely to be male and 2 times more likely to be White (Table 1). There were no statistically significant differences between attempters and completers by residence, place of attempt, day of the week, or season when the self-inflicted injury occurred. Attempters more frequently used drug overdose as a method, while completers more frequently used firearms (Ta-
August 1991, Vol. 81, No. 8
Public Health Briefs
been hampered by a lack of central registries.6'11 Results of limited surveys of high school students vary and have estimated that 5% to 15% of adolescents attempt suicide.1""5 Our study showed that adolescent suicide attempts are common in Oregon and that statewide surveillance is feasible. In this study, method and outcome were found to be inextricably linked. Thus the factors influencing one must also influence the other. Whether desired outcome determines method or the method available at the time of attempt determines outcome urgently needs clarification. For some adolescents who attempt suicide, selection of method may be paramount, and outcome will depend on method. For others, desired outcome may be decided first and selection of method will depend on that decision. Successful intervention is critically dependent on which of these two dynamics is operating. Securing firearms in a locked cabinet may not be helpful if a despondent adolescent will merely search for another lethal weapon. However, this intervention would be quite effective if the result were that an alternate, less lethal method would be used. Additional study is needed to determine factors influencing choice of method and to identify situations in which selection of method is not solely dependent on desired outcome, but is also influenced by other factors such as availability and social acceptability. [
ble 3). Gunshot wounds and hanging were strong predictors of fatal outcome. These two methods were used by 89.1% (122/ 137) of the completers compared with 2.2% (14/644) ofthe attempters (odds ratio [OR] = 366.0, 95% confidence interval
[CI] = 162.8-844.8).
We performed a logistic regression analysis including the method, sex, race, season, residence, day of the week, and age. Choice of method was the strongest predictor of outcome (P < .0001). Although sex had the only other statistically significant predictor coefficient (P = .002), it had little effect on the predicted probability of outcome. The univariate association of sex with outcome was primarily due to an association of sex with method. Combining data from attempters and completers showed that lethal methods were more likely to be chosen by males: 90.9% (30/ 33) of the hangings and 79.6% (82/103) of the shootings. In contrast, among those using stabbing or lacerations, 20.9% (14/ 67) were male; and among the drug overdosers, 13.0% (64/492) were male.
Discussion In 1988, one adolescent suicide attempt with injuries severe enough to require emergency care was reported for every 467 Oregon adolescents. The ratio of attempted to completed suicide rates for those adolescents was 47:1. The overwhelming predictor of outcome was method used. Generally, adolescents who shot themselves died, while those who overdosed on drugs or lacerated themselves lived. Collection of accurate prevalence or incidence data for attempted suicide has
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1. McGinnis JM. Suicide in Americamoving up the public health agenda. Suicide Life Threat Behav. 1987;17:18-32. 2. Weissman M. The epidemiology of suicide attempts. Arch Gen Psychiatry. 1974; 30:737-746. 3. American Academy of Pediatrics, Committee on Adolescence. Suicide and suicide attempts in adolescents and young adults. Pediatrics. 1988;81:322-324. 4. Spirito A, Start L, Fristad M, et al. Adolescent suicide attempters hospitalized on a pediatric unit. J Pediatr Psychol. 1987; 12:171-189. 5. Garfinkle B, Froese A, Hood J. Suicide attempts in children and adolescents.AmJ Psychiatry. 1982;139:1257-1261. 6. Shaw KR, Sheehan KH, Fernandez RC. Suicide in children and adolescents. Adv Pediatr. 1987;34:313-334. 7. Hawton K, O'Grady J, Osborn M, et al. Adolescents who take overdoses: their characteristics, problems, and contacts with helping agencies. Br J Psychiatry. 1982;140:118-123. 8. McIntire M, Angle C, Wikoff R, et al. Recurrent adolescent suicide behavior. Pediatrics. 1977;60:605-608. 9. Oregon Health Division. Reporting teenage suicide attempts in Oregon. Commun Dis Sum 1988;37:1-2. 10. Oregon Health Division Report. Teenage suicide in Oregon, 1983-1985. Portland; October 1986. 11. Eisenberg L. The epidemiology of suicide in adolescents. Pediatr Ann. 1984;13:4754. 12. Smith K, Crawford S. Suicidal behavior among "normal" high school students. Suicide Life Threat Behav. 1986;16:313325. 13. Harkavy JM, Asnis G. Suicide attempts in adolescence: prevalence and implications.
NEngI JMedL 1985;313:1290-1291. 14. Centers for Disease Control. Results from the national adolescent student health survey. MMWR 1989;38:147-150. 15. Schwartz RH, Wirtz P. Suicide attempts by high school students. Am J Psychiatry.
Acknowledgments The authors would like to thank Rocke Klockner, Joyce Grant-Worley, and Brent Marsden of the Oregon Health Division for their support during this study.
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1988;145:537.
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