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National Trends in the Prevalence of Suicidal Ideation and Behavior Among Young Adults and Receipt of Mental Health Care Among Suicidal Young Adults

Published:November 06, 2017DOI:https://doi.org/10.1016/j.jaac.2017.10.013

      Objective

      This study examined national trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults.

      Method

      We examined restricted data from 145,800 persons aged 18 to 25 years who participated in the 2009 to 2015 National Surveys on Drug Use and Health. Descriptive analyses and bivariable and multivariable logistic regressions were applied.

      Results

      Among US young adults during 2009 to 2015, the 12-month prevalence of suicidal ideation increased from 6.1% to 8.3%, the 12-month prevalence of suicide plan increased from 2.0% to 2.7%, and 12-month prevalence of suicide attempt increased from 1.1% to 1.6%. After adjusting for personal factors and changes in residing county’s population characteristics, we found upward trends in suicidal ideation among non-Hispanic whites and Hispanics, an upward trend in suicide plan among young adults overall, and an upward trend in suicide attempt among those without major depressive episodes (MDE). Among young adults with MDE, the prevalence of suicide attempt remained high and unchanged. During 2009 to 2015, trends in receipt of mental health care remained unchanged among most suicidal young adults and declined slightly among uninsured suicidal young adults. The annual average prevalence of receipt of mental health care was 36.2% among suicidal young adults.

      Conclusion

      During 2009 to 2015, suicidal ideation, suicide plan, and suicide attempt increased among young adults overall, but receipt of mental health care among suicidal young adults did not increase. Our results suggest that effective efforts are needed for suicide prevention and promotion of mental health care among young adults.

      Key words

      Death by suicide and suicidal ideation and behavior (e.g., suicide plan or attempt) among young adults are major public health concerns.

      Centers of Disease Control and Prevention. Understanding suicide. Available at: http://www.cdc.gov/violenceprevention/pdf/suicide_factsheet_2012-a.pdf. Accessed April 2, 2014.

      Piscopo K, Lipari RN, Cooney J, Glasheen C. Suicidal thoughts and behavior among adults: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review. Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.htm. Accessed December 1, 2016.

      • Han B.
      • McKeon R.
      • Gfroerer J.
      Suicidal ideation among community-dwelling adults in the United States.
      • Nock M.K.
      • Borges G.
      • Bromet E.J.
      • et al.
      Cross-national prevalence and risk factors for suicidal ideation, plans and attempts.
      The crude death rate by suicide among this population increased by 23.2%, from 11.86 to 14.61 per 100,000 between 2009 and 2015.

      Centers for Disease Control and Prevention. Injury Prevention and Control: WISQARSTM. Available at: https://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html. Accessed January 6, 2017.

      In 2015, about 14% of young adults with suicidal ideation attempted suicide.

      Piscopo K, Lipari RN, Cooney J, Glasheen C. Suicidal thoughts and behavior among adults: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review. Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.htm. Accessed December 1, 2016.

      Young suicide attempters often have long-term mental, physical health, and social problems that last into their later adulthood.
      • Goldman-Mellor S.J.
      • Caspi A.
      • Harrington H.
      • et al.
      Suicide attempt in young people: a signal for long-term health care and social needs.
      Furthermore, although many deaths by suicide occur in the absence of prior attempts,
      • Bostwick J.M.
      • Pabbati C.
      • Geske J.R.
      • McKean A.J.
      Suicide attempt as a risk factor for completed suicide: even more lethal than we knew.
      suicide attempt remains the strongest known predictor for death by suicide.

      US Department of Health and Human Services (HHS). Office of the Surgeon General and National Action Alliance for Suicide Prevention. The 2012 National Strategy for Suicide Prevention: goals and objectives for action. Available at: http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf. Accessed October 15, 2014.

      Action Alliance for Suicide Prevention. A prioritized research agenda for suicide prevention: an action plan to save lives. Available at: http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/Agenda.pdf. Accessed August 1. 2014.

      One recent study reported that the 12-month prevalence of major depressive episodes (MDE) increased from 8.8% in 2005 to 9.6% in 2014 among young adults, but there were few changes in mental health care during 2005 to 2014.
      • Mojtabai R.
      • Olfson M.
      • Han B.
      National trends in the prevalence and treatment of depression in adolescents and young adults.
      These results indicate a growing number of young people with untreated depression.
      • Mojtabai R.
      • Olfson M.
      • Han B.
      National trends in the prevalence and treatment of depression in adolescents and young adults.
      Depression is often associated with suicidality.
      • Bruce M.L.
      • Have T.R.T.
      • Reynolds C.F.
      • et al.
      Reducing suicidal ideation and depressive symptoms in depressed older primary care patients.
      • Nakagawa A.
      • Grunebaum M.F.
      • Oquendo M.A.
      • et al.
      Clinical correlates of planned, more lethal suicide attempts in major depressive disorder.
      • Coryell W.
      • Young E.A.
      Clinical predictors of suicide in primary major depressive disorder.
      • Nock M.K.
      • Borges G.
      • Bromet E.J.
      • Cha C.B.
      • Kessler R.C.
      • Lee S.
      Suicide and suicidal behavior.
      • Nock M.K.
      • Green J.G.
      • Hwang I.
      • et al.
      Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Prevalence and correlates of suicide attempts among adults with suicidal ideation in the United States.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Mental health treatment patterns among adults with recent suicide attempts in the United States.
      • Curtin S.C.
      • Warner M.
      • Hedegaard H.
      Increase in suicide in the United States, 1999-2014. NCHS data brief, no 241.
      However, it is unknown whether there have been recent changes in the national prevalence of suicidal ideation and behavior among US young adults.
      Mental health care can reduce suicide risk among adults with suicidal ideation and behavior.
      • Bruce M.L.
      • Have T.R.T.
      • Reynolds C.F.
      • et al.
      Reducing suicidal ideation and depressive symptoms in depressed older primary care patients.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Mental health treatment patterns among adults with recent suicide attempts in the United States.
      • Hoertel N.
      • Franco S.
      • Wall M.M.
      • et al.
      Mental disorders and risk of suicide attempt: a national prospective study.
      • Han B.
      • Kott P.S.
      • Hughes A.
      • McKeon R.
      • Blanco C.
      • Compton W.M.
      Estimating the rates of deaths by suicide among adults who attempt suicide in the United States.
      American Psychiatric Association
      Practice Guideline for the Assessment and Treatment of Suicidal Behaviors.
      • Brown G.K.
      • Jager-Hyman S.
      Evidence-based psychotherapies for suicide prevention.
      • While D.
      • Bickley H.
      • Roscoe A.
      • et al.
      Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after observational study.
      Some studies have shown that receipt of mental health care increased among the US adult population during 2004 to 2005 and 2013 to 2014.
      • Creedon T.B.
      • Cook B.L.
      Access to mental health care increased but not for substance use, while disparities remain.
      • Mark T.L.
      • Yee T.
      • Levit K.R.
      • Camacho-Cook J.
      • Cutler E.
      • Carroll C.D.
      Insurance financing increased for mental health conditions but not for substance use disorders, 1986-2014.
      However, recent national trends in mental health care among suicidal young adults have not been examined.
      Using nationally representative data, this current study examined the following questions:
      • 1.
        What are the recent trends in the 12-month prevalence of suicidal ideation, suicide plan, and suicide attempt among US young adults overall? Do they vary by sociodemographic factors and mental disorders?
      • 2.
        What are the trends in the 12-month prevalence of receipt of mental health care among suicidal young adults in the US?
      Understanding these questions may help inform and target suicide prevention efforts aimed at young adults. These results may be useful to clinicians, policy makers, college and workplace professionals, families/peers, and the general public.

      Method

       Data Sources

      We examined restricted-use data from 145,800 persons aged 18 to 25 years who participated in the 2009 to 2015 National Surveys on Drug Use and Health (NSDUH). NSDUH provides nationally representative data on suicidal ideation and behavior and mental health treatment among the civilian, noninstitutionalized population aged 18 or older in the United States. NSDUH used a stratified, multistage area probability sample that was designed to be representative of both the nation as a whole and for each of the 50 states and the District of Columbia.
      Data were collected by interviewers during in-person visits to households and noninstitutional group quarters. Audio computer-assisted self-administered interviewing was used, providing respondents with a private, confidential way to record answers. The annual mean weighted response rate of the 2009 to 2015 NSDUH was 62.0%. Details regarding NSDUH are provided elsewhere.

      Piscopo K, Lipari RN, Cooney J, Glasheen C. Suicidal thoughts and behavior among adults: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review. Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.htm. Accessed December 1, 2016.

      Substance Abuse and Mental Health Services Administration: National Survey on Drug Use and Health. Available at: http://www.samhsa.gov/data/population-data-nsduh/reports. Accessed December 1, 2016.

      To better understand factors associated with trends in suicidality, we linked the Area Health Resource Files’ (AHRF)

      Health Resources and Services Administration. Area health resources files. Available at: https://datawarehouse.hrsa.gov/topics/ahrf.aspx. Accessed July 10, 2017.

      relevant county-level variables (residing county’s unemployment rate, percentage of persons in poverty, the number of deaths by suicide, suicide rate, and status of mental health professional shortage area [whole, part, or no county]) to the 2009 to 2015 NSDUH respondents’ individual records for the corresponding year based on the Federal Information Processing Standards (FIPS) state and county codes. For example, a recent study reported contagion effects of suicidal behaviors
      • Ursano R.J.
      • Kessler R.C.
      • Naifeh J.A.
      • et al.
      Risk of suicide attempt among soldiers in army units with a history of suicide attempts.
      ; thus, we examined the impact of deaths by suicide in the residing county on suicidality among young adults.

       Measures

       Suicidal Ideation With or Without Suicidal Behavior

      The 2009 to 2015 NSDUH questionnaires asked adult respondents if at any time during the past 12 months they had thought seriously about trying to kill themselves. Those who reported that they had suicidal ideation were asked if they had made any plans to kill themselves and if they had tried to kill themselves in the past 12 months.
      • Han B.
      • McKeon R.
      • Gfroerer J.
      Suicidal ideation among community-dwelling adults in the United States.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Prevalence and correlates of suicide attempts among adults with suicidal ideation in the United States.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Mental health treatment patterns among adults with recent suicide attempts in the United States.
      These suicidality measures are similar to those used in other national surveys.

      Miller GK, Piscopo KD, Batts K, et al. Measurement of suicidal thoughts, behaviors, and related health outcomes in the United States: comparison of NSDUH estimates with other data sources. Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-DR-N20Suicide-2015/NSDUH-DR-N20Suicide-2015.htm. Accessed July 10, 2017.

       Indicators of Mental Disorders That May Be Related to Suicidal Ideation and Behavior

      The 2009 to 2015 NSDUH assessed whether a respondent had an MDE, alcohol use disorder, or cannabis use disorder in the past year based on DSM-IV criteria.
      American Psychiatry Association
      Diagnostic and Statistical Manual of Mental Disorders.
      Nicotine dependence among cigarette smokers was assessed using the Nicotine Dependence Syndrome Scale.
      • Shiffman S.
      • Waters A.
      • Hickcox M.
      The Nicotine Dependence Syndrome Scale: a multidimensional measure of nicotine dependence.
      The 2009 to 2014 NSDUH also asked adult respondents if they were told by a doctor or other health professional that they had an anxiety disorder in the past year. These measures have demonstrated good validity and reliability.
      • Jordan B.K.
      • Karg R.
      • Batts K.R.
      • et al.
      A clinical validation of the National Survey on Drug Use and Health Assessment of Substance Use Disorders.
      Substance Abuse and Mental Health Services Administration
      Reliability of key measures in the National Survey on Drug Use and Health (Office of Applied Studies, Methodology Series M-8, HHS Publication No. SMA 09-4425).

       Mental Health Care and Substance Use Treatment

      NSDUH asked adult respondents to report whether they received inpatient or outpatient mental health treatment and whether they received prescription medications for mental health problems in the previous year. Inpatient treatment included services received at a psychiatric hospital, psychiatric unit of general hospital, medical unit of general hospital, or other type of hospital for mental health treatment. Outpatient treatment included services received at a community mental health center, private therapist’s office (psychologist, psychiatrist, social work, or counselor) for mental health treatment, physician’s office (nonpsychiatrist) or outpatient medical clinic for mental health treatment, or day treatment program or other type of facility for mental health treatment. Because adults with substance use treatment also tended to receive mental health treatment,
      • Brennan P.L.
      • Kagay C.R.
      • Geppert J.J.
      • Moos R.H.
      Predictors and outcomes of outpatient mental health care: a 4-year prospective study of elderly Medicare patients with substance use disorders.
      we assessed whether young adults received past-year substance use treatment.

       Sociodemographic Characteristics

      Since sociodemographic characteristics are associated with prevalence of suicidal ideation and behavior and receipt of mental health care,
      • Han B.
      • McKeon R.
      • Gfroerer J.
      Suicidal ideation among community-dwelling adults in the United States.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Prevalence and correlates of suicide attempts among adults with suicidal ideation in the United States.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Mental health treatment patterns among adults with recent suicide attempts in the United States.
      this study examined age, gender, race/ethnicity, family income, marital status, health insurance, employment status, and school/college enrollment.

       Statistical Analyses

      All analyses were conducted for young adults aged 18 to 25 years. Between 2009 and 2015, for each examined year, descriptive analyses were conducted to estimate the 12-month prevalence of suicidal ideation, suicide plan, and suicide attempt among young adults, overall and by sociodemographic factor and mental disorder.
      Multivariable logistic regression models were applied to examine trends in suicidal ideation, suicide plans, and suicide attempts among young adults after controlling for covariates. Similar models were applied to assess trends in mental health care among suicidal young adults. For multivariable models, we examined potential interactions among examined factors, including interactions between survey year and all other covariates. Backward stepwise procedures were applied to remove nonsignificant interactions. This study used SUDAAN
      Research Triangle Institute
      SUDAAN Release 11.0.1.
      • Bieler G.S.
      • Brown G.G.
      • Williams R.L.
      • Brogan D.L.
      Estimating model-adjusted risks, risk differences, and risk ratio from complex survey data.
      software to account for the complex sample design and sample weights of NSDUH data.

      Results

       Trends in the Prevalence of Suicidal Ideation

      The 12-month prevalence of suicidal ideation among young adults in the United States increased from 6.1% in 2009 to 8.3% in 2015 (Table 1) and increased significantly for nearly all demographic and clinical subgroups examined. During 2009 to 2015, it increased from 7.0% to 10.0% among those aged 18 to 20 years, from 5.4% to 7.3% among those aged 21 to 25 years, from 5.0% to 7.2% among men, from 7.1% to 9.4% among women, and from 6.1% to 9.0% among non-Hispanic whites.
      Table 1Trends in the Prevalence of Suicidal Ideation Among US Young Adults by Sociodemographic Factor, Mental Disorder, and Mental Health Care (N = 145,800)
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use NSDUH data files must be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      Characteristics12-Month Prevalence of Suicidal Ideation, Weighted Percentage (Standard Error)p Value for Trend
      2009

      n = 22,600
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use NSDUH data files must be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2010

      n = 22,700
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use NSDUH data files must be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2011

      n = 22,800
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use NSDUH data files must be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2012

      n = 22,400
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use NSDUH data files must be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2013

      n = 22,100
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use NSDUH data files must be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2014

      n = 16,300
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use NSDUH data files must be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2015

      n = 17,000
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use NSDUH data files must be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      Overall6.1 (0.20)6.7 (0.22)6.8 (0.25)7.2 (0.23)7.4 (0.24)7.5 (0.25)8.3 (0.26)<.0001
      Age, y
       18−207.0 (0.32)7.9 (0.38)8.2 (0.41)8.7 (0.41)9.6 (0.44)9.0 (0.44)10.0 (0.45)<.0001
       21−255.4 (0.25)5.9 (0.27)5.9 (0.28)6.2 (0.27)6.1 (0.28)6.6 (0.31)7.3 (0.32)<.0001
      Sex
       Male5.0 (0.26)5.9 (0.30)6.1 (0.32)6.4 (0.31)6.8 (0.35)6.5 (0.35)7.2 (0.36)<.0001
       Female7.1 (0.30)7.4 (0.32)7.5 (0.34)8.0 (0.33)8.0 (0.33)8.5 (0.37)9.4 (0.39)<.0001
      Race/ethnicity
       Non-Hispanic white6.1 (0.26)6.7 (0.27)6.9 (0.29)7.4 (0.29)8.2 (0.32)8.2 (0.34)9.0 (0.38)<.0001
       Non-Hispanic African American6.3 (0.53)7.1 (0.64)7.3 (0.66)6.3 (0.54)5.0 (0.49)5.3 (0.54)6.1 (0.54).0276
       Non-Hispanic other6.8 (0.85)7.5 (0.91)8.7 (1.10)7.3 (0.85)8.8 (0.89)8.1 (0.89)9.6 (0.92).0539
       Hispanic5.4 (0.48)5.9 (0.55)5.5 (0.53)7.0 (0.60)6.5 (0.56)6.8 (0.59)7.4 (0.62).0034
      Major depressive episode
       Yes34.2 (1.46)37.7 (1.47)35.3 (1.62)36.4 (1.41)39.2 (1.50)40.4 (1.58)38.1 (1.48).0103
       No3.6 (0.16)3.8 (0.18)4.2 (0.20)4.4 (0.20)4.3 (0.20)4.1 (0.20)4.8 (0.22)<.0001
      Anxiety disorder
       Yes19.7 (1.39)23.5 (1.63)22.6 (1.59)21.6 (1.43)23.8 (1.44)26.5 (1.42)N/A.0035
       No5.2 (0.19)5.8 (0.22)5.9 (0.24)6.2 (0.23)6.2 (0.24)5.9 (0.24)N/A.0059
      Alcohol use disorder
       Yes11.4 (0.69)12.6 (0.78)13.0 (0.82)14.3 (0.82)13.9 (0.89)13.7 (0.97)16.8 (1.06)<.0001
       No5.0 (0.20)5.5 (0.22)5.8 (0.24)6.0 (0.23)6.5 (0.24)6.6 (0.25)7.3 (0.26)<.0001
      Nicotine dependence
       Yes9.7 (0.62)11.7 (0.74)10.3 (0.68)11.3 (0.71)12.0 (0.85)10.0 (0.77)14.5 (0.98).0023
       No5.4 (0.21)5.8 (0.23)6.2 (0.27)6.5 (0.24)6.7 (0.25)7.1 (0.26)7.5 (0.25)<.0001
      Cannabis use disorder
       Yes14.5 (1.23)18.5 (1.43)16.1 (1.31)16.7 (1.31)20.4 (1.84)17.7 (1.66)22.9 (1.87).0007
       No5.6 (0.20)5.9 (0.21)6.3 (0.25)6.6 (0.23)6.7 (0.23)6.9 (0.24)7.5 (0.25)<.0001
      Receipt of any mental health care
       Yes19.0 (0.97)22.1 (1.11)20.0 (1.06)21.3 (0.98)23.4 (1.13)24.3 (1.22)25.5 (1.24)<.0001
       No4.4 (0.19)4.8 (0.19)5.1 (0.22)5.3 (0.22)5.2 (0.22)5.2 (0.22)6.0 (0.24)<.0001
      Note: Boldface estimates significantly differed from the corresponding 2009 estimate (p < .05). N/A = not available (the 2015 National Surveys on Drug Use and Health [NSDUH] broke substance use disorder trend and did not collect anxiety disorder data).
      a Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use NSDUH data files must be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      Suicidal ideation increased from 34.2% in 2009 to 38.1% in 2015 among individuals with MDE and from 3.6% to 4.8% among those without MDE, from 11.4% to 16.8% among those with alcohol use disorder, from 5.0% to 7.3% among those without alcohol use disorder, from 14.5% to 22.9% among those with cannabis use disorder, and from 5.6% to 7.5% among those without cannabis use disorder. It increased from 19.0% to 25.5% among individuals with receipt of mental health care and from 4.4% to 6.0% among those without receipt of mental health care.

       Trends in the Prevalence of Suicide Plans

      The 12-month prevalence of suicide plan among young adults in the United States increased from 2.0% in 2009 to 2.7% in 2015 (Table 2) and increased in many, but not all, subgroups examined. It increased from 2.5% to 3.6% among those aged 18 to 20 years, from 2.3% to 3.2% among women, and from 1.7% to 2.7% among non-Hispanic whites. Suicide plan increased from 0.8% to 1.4% among those without MDE, from 4.0% to 5.8% among those with alcohol use disorder, from 1.6% to 2.3% among those without alcohol use disorder, from 1.6% to 2.4% among those without nicotine dependence, and from 1.7% to 2.4% among those without cannabis use disorder. It increased from 7.8% to 10.6% among persons with receipt of mental health care and from 1.2% to 1.6% among those without receipt of mental health care.
      Table 2Trends in the Prevalence of Suicide Plans Among US Young Adults by Sociodemographic Factor, Mental Disorder, and Mental Health Care (N = 145,800)
      Characteristic12-Month Prevalence of Suicide Plans, Weighted Percentage (Standard Error)p Value for Trend
      2009

      n = 22,600
      2010

      n = 22,700
      2011

      n = 22,800
      2012

      n = 22,400
      2013

      n = 22,100
      2014

      n = 16,300
      2015

      n = 17,000
      Overall2.0 (0.12)1.9 (0.12)1.9 (0.13)2.4 (0.14)2.5 (0.14)2.3 (0.14)2.7 (0.16)<.0001
      Age, y
       18−202.5 (0.21)2.4 (0.20)2.4 (0.20)3.3 (0.28)3.3 (0.26)3.0 (0.27)3.6 (0.31)<.0001
       21−251.6 (0.14)1.7 (0.15)1.7 (0.16)1.8 (0.14)2.0 (0.16)1.9 (0.16)2.1 (0.18).0039
      Sex
       Male1.6 (0.16)1.7 (0.16)1.6 (0.16)2.1 (0.18)2.1 (0.20)1.9 (0.19)2.2 (0.21).0031
       Female2.3 (0.19)2.2 (0.18)2.3 (0.20)2.6 (0.20)2.9 (0.21)2.8 (0.22)3.2 (0.23).0002
      Race/ethnicity
       Non-Hispanic white1.7 (0.14)1.9 (0.14)1.9 (0.17)2.4 (0.17)3.0 (0.20)2.7 (0.21)2.7 (0.20)<.0001
       Non-Hispanic African American2.3 (0.37)2.3 (0.36)2.1 (0.33)2.6 (0.36)1.4 (0.26)1.8 (0.31)2.3 (0.35).3967
       Non-Hispanic other2.6 (0.56)1.6 (0.42)2.4 (0.71)2.5 (0.63)2.0 (0.43)2.4 (0.44)3.3 (0.52).3964
       Hispanic2.2 (0.32)2.0 (0.30)1.7 (0.26)1.9 (0.30)2.1 (0.30)1.8 (0.28)2.7 (0.43).2385
      Major depressive episode
       Yes15.1 (1.13)13.1 (1.00)11.7 (0.99)12.5 (0.96)16.9 (1.15)14.8 (1.10)14.0 (1.02).3183
       No0.8 (0.08)1.0 (0.09)1.1 (0.11)1.4 (0.11)1.1 (0.10)1.1 (0.11)1.4 (0.12).0006
      Anxiety disorder
       Yes8.6 (1.00)9.0 (1.02)8.3 (1.10)7.5 (0.87)10.4 (1.08)10.9 (1.02)N/A.0557
       No1.5 (0.11)1.6 (0.12)1.6 (0.12)2.0 (0.13)1.9 (0.13)1.6 (0.14)N/A.0936
      Alcohol use disorder
       Yes4.0 (0.41)3.9 (0.43)4.1 (0.50)5.5 (0.53)5.7 (0.61)5.4 (0.65)5.8 (0.67).0002
       No1.6 (0.12)1.6 (0.12)1.6 (0.13)1.8 (0.14)2.0 (0.14)1.9 (0.13)2.3 (0.16)<.0001
      Nicotine dependence
       Yes3.8 (0.43)4.1 (0.46)4.1 (0.44)4.7 (0.48)5.0 (0.56)4.1 (0.55)5.1 (0.59).0611
       No1.6 (0.12)1.6 (0.12)1.6 (0.13)2.0 (0.14)2.1 (0.14)2.1 (0.14)2.4 (0.16)<.0001
      Cannabis use disorder
       Yes5.7 (0.89)6.1 (0.84)4.9 (0.66)6.1 (0.90)7.3 (1.06)6.6 (1.03)7.6 (1.13).0697
       No1.7 (0.12)1.7 (0.12)1.8 (0.13)2.1 (0.13)2.2 (0.14)2.1 (0.14)2.4 (0.15)<.0001
      Receipt of any mental health care
       Yes7.8 (0.69)8.0 (0.72)7.7 (0.76)7.9 (0.63)10.2 (0.82)9.5 (0.80)10.6 (0.85).0006
       No1.2 (0.11)1.2 (0.10)1.2 (0.11)1.6 (0.13)1.4 (0.11)1.4 (0.12)1.6 (0.14).0075
      Note: Boldface estimates significantly differed from the corresponding 2009 estimate (p < .05). N/A = not available (the 2015 National Surveys on Drug Use and Health broke substance use disorder trend and did not collect anxiety disorder data).

       Trends in the Prevalence of Suicide Attempts

      The 12-month prevalence of suicide attempt among young adults in the United States increased from 1.1% in 2009 to 1.6% in 2015 (Table 3) and increased in a few of the subgroups examined. During 2009 to 2015, it increased from 1.0% to 1.6% among non-Hispanic whites, from 0.7% to 1.4% among those with full-time employment, and from 0.8% to 1.5% among those with private health insurance. During 2009 to 2015, the 12-month prevalence of suicide attempt increased from 0.4% to 1.0% among individuals without MDE, from 2.7% to 4.2% among those with alcohol use disorder, from 0.8% to 1.3% among those without alcohol use disorder, from 1.0% to 1.5% among those without cannabis use disorder, and from 0.6% to 0.9% among those without receipt of any mental health care. In addition, Table S1, Table S2, Table S3 (available online) present trends in the prevalence of suicidal ideation, suicide plans, and suicide attempts by family income, employment status, health insurance, and school/college enrollment status.
      Table 3Trends in the Prevalence of Suicide Attempt Among US Young Adults by Sociodemographic Factor, Mental Disorder, and Mental Health Care (N = 145,800)
      Characteristic12-Month Prevalence of Suicide Attempts, Weighted Percentage (Standard Error)p Value for Trend
      2009

      n = 22,600
      2010

      n = 22,700
      2011

      n = 22,800
      2012

      n = 22,400
      2013

      n = 22,100
      2014

      n = 16,300
      2015

      n = 17,000
      Overall1.1 (0.09)1.2 (0.09)1.2 (0.10)1.5 (0.12)1.3 (0.10)1.2 (0.10)1.6 (0.13).0013
      Age, y
       18−201.4 (0.14)1.5 (0.15)1.6 (0.16)2.2 (0.25)1.9 (0.19)1.5 (0.17)2.1 (0.24).0139
       21−250.9 (0.12)0.9 (0.11)0.9 (0.13)1.1 (0.12)0.8 (0.10)1.1 (0.14)1.4 (0.15).0142
      Sex
       Men1.0 (0.14)1.0 (0.12)1.0 (0.12)1.3 (0.16)1.1 (0.14)1.0 (0.14)1.3 (0.16).0962
       Women1.3 (0.12)1.4 (0.14)1.5 (0.17)1.7 (0.17)1.4 (0.14)1.5 (0.15)2.0 (0.19).0042
      Race/ethnicity
       Non-Hispanic white1.0 (0.11)1.0 (0.10)1.1 (0.11)1.3 (0.13)1.3 (0.12)1.1 (0.12)1.6 (0.16).0004
       Non-Hispanic African American1.6 (0.31)1.1 (0.23)1.8 (0.31)2.0 (0.32)1.0 (0.21)1.3 (0.27)1.5 (0.27).6864
       Non-Hispanic other1.1 (0.28)1.5 (0.43)1.8 (0.65)1.5 (0.44)1.3 (0.31)1.4 (0.31)1.8 (0.42).6875
       Hispanic1.2 (0.25)1.7 (0.26)1.0 (0.20)1.6 (0.33)1.4 (0.27)1.5 (0.27)1.8 (0.33).2828
      Major depressive episode
       Yes9.5 (0.97)7.3 (0.76)6.1 (0.73)7.7 (0.80)7.7 (0.82)7.6 (0.81)7.3 (0.77).0769
       No0.4 (0.05)0.6 (0.07)0.8 (0.09)0.9 (0.10)0.6 (0.07)0.6 (0.08)1.0 (0.10).0001
      Anxiety disorder
       Yes5.2 (0.82)5.9 (0.87)5.1 (0.83)4.7 (0.75)4.7 (0.70)5.6 (0.76)N/A.8597
       No0.9 (0.09)0.9 (0.08)1.0 (0.09)1.2 (0.11)1.0 (0.10)0.9 (0.10)N/A.3392
      Alcohol use disorder
       Yes2.7 (0.36)2.4 (0.34)2.5 (0.36)4.1 (0.49)2.9 (0.41)3.6 (0.48)4.2 (0.59).0030
       No0.8 (0.09)0.9 (0.09)1.0 (0.10)1.0 (0.11)1.0 (0.10)0.9 (0.09)1.3 (0.12).0026
      Nicotine dependence
       Yes2.4 (0.36)2.8 (0.38)2.8 (0.39)3.3 (0.42)3.2 (0.44)2.4 (0.41)3.8 (0.50).0795
       No0.9 (0.09)0.9 (0.08)0.9 (0.10)1.2 (0.12)1.0 (0.09)1.1 (0.11)1.4 (0.13).0007
      Cannabis use disorder
       Yes3.5 (0.69)4.4 (0.72)2.7 (0.48)4.5 (0.82)4.1 (0.78)4.0 (0.75)4.3 (0.88).4376
       No1.0 (0.09)1.0 (0.08)1.1 (0.10)1.3 (0.11)1.1 (0.10)1.1 (0.10)1.5 (0.12).0007
      Receipt of any mental health care
       Yes5.3 (0.60)5.4 (0.55)4.5 (0.54)5.4 (0.58)5.0 (0.55)5.9 (0.64)7.0 (0.73).0549
       No0.6 (0.07)0.7 (0.07)0.8 (0.09)0.9 (0.11)0.7 (0.08)0.6 (0.08)0.9 (0.10).0270
      Note: Boldface estimates significantly differed from the corresponding 2009 estimate (p < .05). N/A = not available (the 2015 National Surveys on Drug Use and Health broke substance use disorder trend and did not collect anxiety disorder data).

       Trends in the Prevalence of Suicidal Ideation and Behavior After Controlling for Covariates

      Multicollinearity was not found in final multivariable models. However, we identified significant interaction effects between year and race/ethnicity on suicidal ideation (p = .0002) and between year and MDE status on suicide attempt (p = .0037). Stratified multivariable logistic regression analyses showed upward trends in suicidal ideation among non-Hispanic white young adults (adjusted odds ratio [AOR] = 1.08, 95% CI = 1.05−1.10; p < .0001) and Hispanic young adults (AOR = 1.06, 95% CI = 1.02−1.11; p = .0098). The adjusted prevalence of suicidal ideation in 2015 among non-Hispanic whites and Hispanics was 1.3 to 1.4 times higher than that in 2009 (Table 4).
      Table 4Multivariable Logistic Regression Models Showing Trends in the 12-Month Prevalence of Suicidality Among Young Adults in the United States (N = 145,800)
      OutcomeAdjusted Odds Ratio

      for Year
      Adjusted for personal characteristics: age, sex, family income, employment, marital status, health insurance, school/college enrollment; major depressive episode, alcohol use disorder, nicotine dependence, and cannabis use disorder; and changes in population characteristics of the residing county: unemployment rate, percentage of persons in poverty, number of deaths by suicide, and mental health professional shortage area.
      (95% CI)
      p ValueModeled Prevalence

      (%)
      Adjusted for personal characteristics: age, sex, family income, employment, marital status, health insurance, school/college enrollment; major depressive episode, alcohol use disorder, nicotine dependence, and cannabis use disorder; and changes in population characteristics of the residing county: unemployment rate, percentage of persons in poverty, number of deaths by suicide, and mental health professional shortage area.
      2009 (95% CI)
      Modeled Prevalence

      (%)
      Adjusted for personal characteristics: age, sex, family income, employment, marital status, health insurance, school/college enrollment; major depressive episode, alcohol use disorder, nicotine dependence, and cannabis use disorder; and changes in population characteristics of the residing county: unemployment rate, percentage of persons in poverty, number of deaths by suicide, and mental health professional shortage area.
      2015 (95% CI)
      Adjusted Risk Ratio
      Adjusted for personal characteristics: age, sex, family income, employment, marital status, health insurance, school/college enrollment; major depressive episode, alcohol use disorder, nicotine dependence, and cannabis use disorder; and changes in population characteristics of the residing county: unemployment rate, percentage of persons in poverty, number of deaths by suicide, and mental health professional shortage area.


      2015 vs. 2009 (ref) (95% CI)
      Suicidal ideation
       Non-Hispanic white1.08 (1.05–1.10)<.00016.0 (5.56–6.57)8.4 (7.71–9.17)1.4 (1.23–1.58)
       Non-Hispanic African American0.98 (0.92–1.03).34736.1 (5.14–7.13)6.2 (5.02–7.63)1.0 (0.77–1.37)
       Non-Hispanic other1.03 (0.96–1.09).42697.5 (5.87–9.41)9.0 (7.32–10.95)1.2 (0.87–1.67)
       Hispanic1.06 (1.02–1.11).00985.5 (4.61–6.47)7.3 (6.08–8.63)1.3 (1.03–1.71)
      Suicide plan1.06 (1.03–1.10).00021.9 (1.69–2.17)2.6 (2.24–2.89)1.3 (1.10–1.61)
      Suicide attempt
       Adults with MDE1.00 (0.94–1.06).93128.8 (7.00–10.94)7.7 (5.98–9.78)0.9 (0.61–1.26)
       Adults without MDE1.11 (1.05, 1.17).00010.4 (0.28–0.47)1.0 (0.78–1.27)2.7 (1.87–3.97)
      Note: Significant odds ratios and risk ratios are in bold. MDE = major depressive episode.
      a Adjusted for personal characteristics: age, sex, family income, employment, marital status, health insurance, school/college enrollment; major depressive episode, alcohol use disorder, nicotine dependence, and cannabis use disorder; and changes in population characteristics of the residing county: unemployment rate, percentage of persons in poverty, number of deaths by suicide, and mental health professional shortage area.
      Stratified multivariable logistic regression analysis showed an upward trend in suicide attempts among young adults without MDE (AOR = 1.11, 95% CI = 1.05−1.17; p = .0001). The adjusted prevalence of suicide attempts in 2015 among those without MDE was 2.7 times higher than that in 2009 (Table 4). Among young adults with MDE, the prevalence of suicide attempts remained high and unchanged. In addition, we found an upward trend in suicide plans among young adults (AOR = 1.06, 95% CI = 1.0−31.10; p = .0002). The adjusted prevalence of suicide plans in 2015 among young adults was 1.3 times higher than that in 2009 (Table 4).

       Trends in Receipt of Mental Health Care Among Suicidal Young Adults

      Multicollinearity was not found in final multivariable models. However, we identified a significant interaction effect between year and health insurance status on receipt of mental health care among suicidal young adults (p = .0034). Stratified multivariable logistic regression analyses showed a slightly downward trend in receipt of mental health care among suicidal young adults without health insurance (AOR = 0.92, 95% CI = 0.85−0.99; p = .0259) (Table 5).
      Table 5Multivariable Logistic Regression Models Showing Trends in Receipt of Mental Health Care Among Suicidal Young Adults in the United States
      OutcomeAdjusted Odds Ratio for Year
      Adjusted for personal characteristics: age, sex, family income, employment, marital status, health insurance, school/college enrollment; major depressive episode, alcohol use disorder, nicotine dependence, cannabis use disorder, and past-year substance use treatment; and changes in population characteristics of the residing county: unemployment rate, percentage of persons in poverty, number of deaths by suicide, and status of mental health professional shortage area.
      (95% CI)
      p ValueModeled Prevalence (%)
      Adjusted for personal characteristics: age, sex, family income, employment, marital status, health insurance, school/college enrollment; major depressive episode, alcohol use disorder, nicotine dependence, cannabis use disorder, and past-year substance use treatment; and changes in population characteristics of the residing county: unemployment rate, percentage of persons in poverty, number of deaths by suicide, and status of mental health professional shortage area.


      2009 (95% CI)
      Modeled Prevalence (%)
      Adjusted for personal characteristics: age, sex, family income, employment, marital status, health insurance, school/college enrollment; major depressive episode, alcohol use disorder, nicotine dependence, cannabis use disorder, and past-year substance use treatment; and changes in population characteristics of the residing county: unemployment rate, percentage of persons in poverty, number of deaths by suicide, and status of mental health professional shortage area.


      2015 (95% CI)
      Adjusted Risk Ratio
      Adjusted for personal characteristics: age, sex, family income, employment, marital status, health insurance, school/college enrollment; major depressive episode, alcohol use disorder, nicotine dependence, cannabis use disorder, and past-year substance use treatment; and changes in population characteristics of the residing county: unemployment rate, percentage of persons in poverty, number of deaths by suicide, and status of mental health professional shortage area.


      2015 vs. 2009 (ref) 95% CI
      Suicidal adults, n = 10,600
       Private health insurance only1.03 (0.98–1.09).209636.5 (31.96–41.22)40.2 (35.52–44.98)1.1 (0.91–1.33)
       No insurance0.92 (0.85–0.99).025927.0 (22.38–32.16)18.2 (12.49–25.71)0.7 (0.44–1.03)
       Medicaid0.98 (0.91–1.06).591342.9 (35.57–50.59)35.7 (29.45–42.53)0.8 (0.64–1.08)
       Other0.91 (0.77–1.07).233636.3 (20.74–55.41)33.2 (24.59–43.20)0.9 (0.51–1.64)
      Adults with suicidal ideation only, n = 6,8000.97 (0.93–1.02).230231.3 (27.36–35.45)27.3 (23.80–31.04)0.9 (0.72–1.06)
      Adults with suicidal ideation and suicide plan only, n = 1,9001.03 (0.94–1.13).523937.6 (30.66–45.16)40.9 (33.56–48.62)1.1 (0.81–1.45)
      Adults with suicide attempt, n = 2,0001.00 (0.92–1.08).964550.1 (42.84–57.27)49.2 (41.53–56.89)1.0 (0.79–1.23)
      Note: Significant odds ratios are in boldface.
      a Adjusted for personal characteristics: age, sex, family income, employment, marital status, health insurance, school/college enrollment; major depressive episode, alcohol use disorder, nicotine dependence, cannabis use disorder, and past-year substance use treatment; and changes in population characteristics of the residing county: unemployment rate, percentage of persons in poverty, number of deaths by suicide, and status of mental health professional shortage area.
      After adjusting for covariates, receipt of past-year mental health care remained stable among those with past-year suicidal ideation only, those with past-year suicidal ideation and suicide plans only, and those with past-year suicide attempts (Table 5). During 2009 to 2015, the annual average prevalence of receiving mental health care was 36.2% among suicidal young adults, 27.3% among those with suicidal ideation only, 40.9% among those with suicidal ideation and plans only, and 49.2% among those with suicide attempts.

      Discussion

      Using recent nationally representative data, this study examined trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults in the United States. Among US young adults during 2009 to 2015, consistent with increases in death by suicide,

      Centers for Disease Control and Prevention. Injury Prevention and Control: WISQARSTM. Available at: https://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html. Accessed January 6, 2017.

      our multivariable analyses suggest upward trends in suicidal ideation among non-Hispanic whites and Hispanics, an upward trend in suicide plans among overall young adults, and an upward trend in suicide attempts among those without MDE. Importantly, these upward trends were not associated with examined personal factors or changes in residing county’s population characteristics. Other correlates of suicidality outcomes did not change over time.
      Death by suicide has been reported to be a relatively rare event. Using NSDUH data and national mortality files, one recent study estimated that among US suicide attempters aged 18 to 25 years, the overall 12-month suicide case fatality rate was 1.1%.
      • Han B.
      • Kott P.S.
      • Hughes A.
      • McKeon R.
      • Blanco C.
      • Compton W.M.
      Estimating the rates of deaths by suicide among adults who attempt suicide in the United States.
      Our results identified groups at increased risk for suicidality, however, that could be the focus of targeted preventive and treatment interventions. Comprehensive approaches are needed to address individual, family/peer, community, and societal-level factors, to focus on public health prevention, and to strengthen the resiliency and well-being of the US young adult population.
      Suicidal ideation and behavior most commonly occur in people with depressive disorders, but they also occur in individuals with other psychiatric disorders or without psychiatric disorders.
      • Nock M.K.
      • Borges G.
      • Bromet E.J.
      • Cha C.B.
      • Kessler R.C.
      • Lee S.
      Suicide and suicidal behavior.
      • Nock M.K.
      • Green J.G.
      • Hwang I.
      • et al.
      Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Prevalence and correlates of suicide attempts among adults with suicidal ideation in the United States.
      • Hoertel N.
      • Franco S.
      • Wall M.M.
      • et al.
      Mental disorders and risk of suicide attempt: a national prospective study.
      Some studies have shown strong associations between depressive disorders and suicidal ideation and behavior.
      • Han B.
      • McKeon R.
      • Gfroerer J.
      Suicidal ideation among community-dwelling adults in the United States.
      • Goldman-Mellor S.J.
      • Caspi A.
      • Harrington H.
      • et al.
      Suicide attempt in young people: a signal for long-term health care and social needs.

      US Department of Health and Human Services (HHS). Office of the Surgeon General and National Action Alliance for Suicide Prevention. The 2012 National Strategy for Suicide Prevention: goals and objectives for action. Available at: http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf. Accessed October 15, 2014.

      • Nock M.K.
      • Borges G.
      • Bromet E.J.
      • Cha C.B.
      • Kessler R.C.
      • Lee S.
      Suicide and suicidal behavior.
      • Nock M.K.
      • Green J.G.
      • Hwang I.
      • et al.
      Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents.
      Similar to these findings, we found that the prevalences of suicidal ideation, suicide plans, and suicide attempts were consistently higher each year during 2009 to 2015 among young adults with MDE than their counterparts without MDE, suggesting that MDE continues to be an important risk factor over time and that the risk of suicide attempts attributable to MDE remains high.
      Moreover, a recent study suggested that remission of one specific disorder (e.g., MDE) may be insufficient to reduce suicide risk if an adult has co-occurring psychiatric disorders.
      • Hoertel N.
      • Franco S.
      • Wall M.M.
      • et al.
      Mental disorders and risk of suicide attempt: a national prospective study.
      Consistent with these findings, among young adults without MDE in 2014, we found that those with anxiety disorders were 3.2 times more likely to have suicidal ideation and were 5.4 times more likely to attempt suicide than those without (data not shown). We found the prevalences of suicidal ideation, suicide plans, and suicide attempts were higher each year during 2009 to 2015 among young adults with nicotine dependence, alcohol use disorders, cannabis use disorders, or anxiety disorders than among those without the corresponding disorders. We also found increases in suicidal ideation among young adults with anxiety disorders and specific substance use disorders and in suicide plans and attempts among those with alcohol use disorders. Clinicians should screen for suicidal ideation and behavior among young adults with mental disorders.
      Also, we found increases in suicidal ideation, suicide plans, and suicide attempts among young adults without MDE. Because of their rarity, deaths by suicide are unlikely to account for the lack of upward trends in suicide attempts among young adults with MDE. Furthermore, our results identified increases in the prevalences of suicidal ideation, suicide plans, and suicide attempts among young adults without specific substance use disorders. Thus, our results are an important reminder that the risk of suicide is not confined to those with psychiatric disorders.
      A recent study by the Institute of Medicine has found increasing levels of reported stress among young adults.
      Committee on Improving the Health, Safety, and Well-Being of Young Adults, Board on Children, Youth, and Families, Institute of Medicine, National Research Council
      It is essential to develop and to deliver community-based programs that can build resilience through social connections, promote effective coping skills, and reduce suicide risk in the broad-based young adult population.
      • Caine E.D.
      Forging an agenda for suicide prevention in the United States.
      • Caine E.D.
      Suicide and social processes.
      Although mental health care can reduce suicide risk among suicidal young adults,
      • Bruce M.L.
      • Have T.R.T.
      • Reynolds C.F.
      • et al.
      Reducing suicidal ideation and depressive symptoms in depressed older primary care patients.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Mental health treatment patterns among adults with recent suicide attempts in the United States.
      • Han B.
      • Kott P.S.
      • Hughes A.
      • McKeon R.
      • Blanco C.
      • Compton W.M.
      Estimating the rates of deaths by suicide among adults who attempt suicide in the United States.
      American Psychiatric Association
      Practice Guideline for the Assessment and Treatment of Suicidal Behaviors.
      • Brown G.K.
      • Jager-Hyman S.
      Evidence-based psychotherapies for suicide prevention.
      • While D.
      • Bickley H.
      • Roscoe A.
      • et al.
      Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after observational study.
      our results show that most suicidal young adults did not receive mental health care in the past year. During 2009 to 2015, receipt of mental health care did not increase among suicidal young adults. A recent study found that the prevalence of receipt of mental health care among suicidal college students did not differ from their non−college-attending peers.
      • Han B.
      • Compton W.M.
      • Eisenberg D.
      • Milazzo-Sayre L.
      • McKeon R.
      • Hughes A.
      Prevalence and mental health treatment of suicidal ideation and behavior among college students aged 18-25 years and their non-college-attending peers in the United States.
      Among suicidal individuals, low perceived need for mental health treatment might contribute to their low prevalence of receipt of mental health treatment.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Prevalence and correlates of suicide attempts among adults with suicidal ideation in the United States.
      • Han B.
      • Compton W.M.
      • Gfroerer J.
      • McKeon R.
      Mental health treatment patterns among adults with recent suicide attempts in the United States.
      These suicidal young adults do not recognize that suicidal ideation and behavior are warning signs for needing mental health care.
      Better understanding the reasons for low mental health treatment rates despite the presence of suicidality is important for informing and designing future prevention efforts. Efforts are needed to promote effective public awareness programs about mental disorders and mental health care and help identify suicidal ideation and behavior in a wide range of settings including schools, universities, emergency departments, primary care settings, and the criminal justice system.
      • Caine E.D.
      Forging an agenda for suicide prevention in the United States.
      • Caine E.D.
      Suicide and social processes.
      Because young adults may not disclose their suicidal ideation and behavior, effective efforts are needed for suicide prevention and intervention among young adults.
      This study has several limitations. NSDUH did not collect on the onset time and severity of suicidality, methods of suicide attempts, and the timing of receipt of mental health care. NSDUH did not examine whether suicidal ideation and behavior occurred before or after mental health treatment was received. NSDUH is a self-reported survey and can be subject to recall bias and underreporting sensitive and often stigmatized behavior (e.g., suicide plans or attempts) due to social desirability bias. Finally, because NSDUH did not cover young adults who had been continuously homeless and were not living in shelters for the entire past 12 months, institution residents, and active duty military personnel, our study might have underestimated suicidal ideation and behavior among young adults.
      Despite these limitations, this study provides timely and valuable estimates on national trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults. We found upward trends in suicidal ideation among non-Hispanic whites and Hispanics, an upward trend in suicide plans among young adults overall, and an upward trend in suicide attempts among those without MDE. During 2009 to 2015, receipt of mental health care among suicidal young adults did not increase. Our results identified groups at increased risk for suicidality that could be the focus of targeted preventive and treatment interventions. Comprehensive approaches are needed to address individual, family/peer, community, and societal level factors, to focus on public health prevention, and to strengthen the resiliency and well-being of the US young adult population.

      Supplemental Material

      Table S1Trends in the Prevalence of Suicidal Ideation Among US Young Adults by Additional Sociodemographic Factors (N=145,800
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use National Surveys on Drug Use and Health data files has to be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      )
      Characteristics12-Month Prevalence of Suicidal Ideation, Weighted Percentage (Standard Error)p value for trend
      2009

      n=22,600
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use National Surveys on Drug Use and Health data files has to be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2010

      n=22,700
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use National Surveys on Drug Use and Health data files has to be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2011

      n=22,800
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use National Surveys on Drug Use and Health data files has to be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2012

      n=22,400
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use National Surveys on Drug Use and Health data files has to be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2013

      n=22,100
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use National Surveys on Drug Use and Health data files has to be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2014

      n=16,300
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use National Surveys on Drug Use and Health data files has to be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      2015

      n=17,000
      Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use National Surveys on Drug Use and Health data files has to be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      Family income, $
       <20,0006.5 (0.40)6.9 (0.38)7.8 (0.50)7.6 (0.41)8.0 (0.46)8.0 (0.46)9.4 (0.50)<.0001
       20,000-49,9995.8 (0.36)6.6 (0.37)6.6 (0.38)7.1 (0.39)6.9 (0.39)7.2 (0.42)7.4 (0.42).0027
       50,000-74,9996.0 (0.52)5.9 (0.54)7.1 (0.63)6.7 (0.62)7.2 (0.66)7.0 (0.69)7.6 (0.71).0341
       ≥75,0005.8 (0.42)6.9 (0.53)5.3 (0.41)7.1 (0.50)7.5 (0.51)7.5 (0.56)8.5 (0.57)<.0001
      Employment status
       Full-time employment4.3 (0.26)5.1 (0.31)5.1 (0.32)6.2 (0.34)5.9 (0.33)6.1 (0.37)6.9 (0.37)<.0001
       Part-time employment6.6 (0.37)7.7 (0.47)7.5 (0.43)7.3 (0.46)8.2 (0.48)8.4 (0.51)8.7 (0.49).0003
       Unemployment8.4 (0.67)8.4 (0.70)10.6 (0.83)10.2 (0.74)9.6 (0.78)9.6 (0.82)11.8 (1.05).0089
       Not in the labor force6.8 (0.50)6.8 (0.46)6.6 (0.52)7.2 (0.49)7.9 (0.54)7.8 (0.55)8.9 (0.58).0005
      Health insurance
       Private insurance only5.3 (0.27)6.0 (0.29)6.3 (0.34)6.6 (0.30)6.8 (0.32)7.1 (0.31)7.8 (0.27)<.0001
       No insurance6.3 (0.36)7.1 (0.41)7.6 (0.45)7.8 (0.50)8.2 (0.49)7.3 (0.53)8.3 (0.68).0037
       Medicaid8.3 (0.64)7.7 (0.57)7.2 (0.58)8.3 (0.63)7.4 (0.60)8.5 (0.64)9.2 (0.61).1095
      School/college enrollment
       Full-time college enrollment5.3 (0.34)6.4 (0.36)6.3 (0.43)6.4 (0.40)7.3 (0.45)7.0 (0.43)7.4 (0.46).0001
       Part-time college enrollment7.3 (0.84)7.1 (0.79)8.7 (0.91)9.2 (0.92)8.5 (0.93)8.1 (0.87)10.2 (1.08).0388
       No enrollment, college graduate3.9 (0.56)4.9 (0.71)4.2 (0.60)4.1 (0.57)4.3 (0.63)4.5 (0.63)4.3 (0.60).8913
       No enrollment, non-college graduate6.3 (0.31)6.7 (0.34)7.2 (0.36)7.8 (0.36)7.8 (0.38)7.9 (0.41)8.9 (0.43)<.0001
       High school enrollment8.6 (1.04)8.3 (0.97)8.1 (0.94)8.5 (1.08)8.7 (1.01)9.3 (1.20)11.1 (1.44).1090
      Note: Estimates in boldface type significantly differed from the corresponding 2009 estimate (p<.05).
      a Substance Abuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-use National Surveys on Drug Use and Health data files has to be rounded to the nearest 100, which is intended to minimize potential disclosure risk.
      Table S2Trends in the Prevalence of Suicide Plan Among US Young Adults by Additional Sociodemographic Factors (N=145,800)
      Characteristics12-Month Prevalence of Suicide Plan, Weighted Percentage (Standard Error)p value for trend
      2009

      n=22,600
      2010

      n=22,700
      2011

      n=22,800
      2012

      n=22,400
      2013

      n=22,100
      2014

      n=16,300
      2015

      n=17,000
      Family income, $
       <20,0002.2 (0.25)2.2 (0.22)2.5 (0.29)2.7 (0.30)2.8 (0.28)2.7 (0.26)3.4 (0.32).0008
       20,000-49,9991.8 (0.20)2.1 (0.21)1.8 (0.19)2.2 (0.20)2.1 (0.23)1.9 (0.21)2.2 (0.26).2838
       50,000-74,9991.8 (0.30)1.3 (0.25)2.0 (0.34)1.8 (0.33)2.5 (0.38)1.7 (0.30)2.3 (0.40).1244
       ≥75,0001.9 (0.25)1.8 (0.27)1.3 (0.21)2.4 (0.29)2.5 (0.34)2.8 (0.37)2.7 (0.33).0006
      Employment status
       Full-time employment1.2 (0.14)1.3 (0.16)1.2 (0.15)1.9 (0.18)1.7 (0.17)1.8 (0.21)2.2 (0.20)<.0001
       Part-time employment2.1 (0.22)2.0 (0.22)2.0 (0.24)2.5 (0.30)2.6 (0.29)2.5 (0.31)2.6 (0.27).0180
       Unemployment3.3 (0.42)2.6 (0.37)3.6 (0.53)4.1 (0.53)3.9 (0.55)3.7 (0.56)3.9 (0.65).1003
       Not in the labor force2.3 (0.32)2.7 (0.31)2.1 (0.30)2.1 (0.28)2.9 (0.34)2.4 (0.30)3.3 (0.38).0657
      Health insurance
       Private insurance only1.5 (0.14)1.4 (0.14)1.6 (0.16)1.8 (0.16)2.3 (0.19)2.1 (0.19)2.4 (0.20)<.0001
       No insurance2.0 (0.21)2.2 (0.25)2.1 (0.26)3.1 (0.34)2.7 (0.27)2.4 (0.34)2.5 (0.37).0510
       Medicaid3.8 (0.51)2.9 (0.36)2.7 (0.38)2.6 (0.34)2.3 (0.33)2.8 (0.34)3.6 (0.51).9803
      School/college enrollment
       Full-time college enrollment1.4 (0.16)1.7 (0.19)1.6 (0.22)1.9 (0.25)2.3 (0.25)1.9 (0.22)2.3 (0.28).0011
       Part-time college enrollment2.3 (0.51)2.1 (0.45)2.1 (0.44)2.4 (0.44)2.7 (0.55)1.7 (0.37)3.2 (0.55).4274
       No enrollment, college graduate0.7 (0.20)1.0 (0.32)0.9 (0.30)1.0 (0.33)1.1 (0.31)1.0 (0.27)0.8 (0.23).7149
       No enrollment, non-college graduate2.3 (0.21)2.0 (0.18)2.3 (0.21)2.8 (0.22)2.7 (0.23)2.7 (0.24)3.0 (0.25).0010
       High school enrollment3.6 (0.82)3.5 (0.71)2.6 (0.48)3.1 (0.57)3.5 (0.61)3.8 (0.75)4.9 (1.07).2740
      Note: Estimates in boldface type significantly differed from the corresponding 2009 estimate (p<.05).
      Table S3Trends in the Prevalence of Suicide Attempt Among US Young Adults by Additional Sociodemographic Factors (N=145,800)
      Characteristics12-Month Prevalence of Suicide Attempt, Weighted Percentage (Standard Error)p value for trend
      2009

      n=22,600
      2010

      n=22,700
      2011

      n=22,800
      2012

      n=22,400
      2013

      n=22,100
      2014

      n=16,300
      2015

      n=17,000
      Family income, $
       <20,0001.5 (0.20)1.4 (0.18)1.7 (0.24)1.6 (0.22)1.6 (0.20)1.6 (0.20)2.1 (0.27).0720
       20,000-49,9991.0 (0.15)1.3 (0.17)1.0 (0.14)1.6 (0.23)1.4 (0.19)1.3 (0.19)1.3 (0.17).1515
       50,000-74,9990.7 (0.17)0.7 (0.18)0.9 (0.20)1.1 (0.28)0.9 (0.20)1.1 (0.29)1.5 (0.31).0145
       ≥75,0001.0 (0.20)0.9 (0.19)0.9 (0.17)1.4 (0.22)0.8 (0.15)0.8 (0.18)1.6 (0.26).1419
      Employment status
       Full-time employment0.7 (0.13)0.8 (0.12)0.7 (0.10)1.3 (0.19)0.9 (0.12)1.0 (0.15)1.4 (0.17).0005
       Part-time employment1.0 (0.15)1.1 (0.16)1.2 (0.16)1.3 (0.21)1.2 (0.20)1.0 (0.17)1.2 (0.20).5237
       Unemployment2.1 (0.34)1.5 (0.26)2.4 (0.43)2.6 (0.41)2.2 (0.38)2.0 (0.37)3.0 (0.50).0867
       Not in the labor force1.3 (0.24)1.7 (0.23)1.4 (0.25)1.3 (0.23)1.4 (0.22)1.6 (0.27)2.0 (0.32).1629
      Health insurance
       Private insurance only0.8 (0.11)0.7 (0.08)0.8 (0.09)1.0 (0.13)0.9 (0.12)1.0 (0.12)1.5 (0.17)<.0001
       No insurance1.3 (0.17)1.4 (0.19)1.6 (0.24)2.0 (0.29)1.6 (0.20)1.2 (0.22)1.4 (0.24).8538
       Medicaid2.0 (0.35)2.2 (0.32)2.0 (0.32)1.9 (0.31)1.7 (0.26)2.1 (0.32)2.5 (0.34).3631
      School/college enrollment
       Full-time college enrollment0.8 (0.11)1.0 (0.14)0.7 (0.12)1.1 (0.18)0.8 (0.14)0.9 (0.16)1.0 (0.19).3693
       Part-time college enrollment1.2 (0.38)1.2 (0.31)1.2 (0.27)1.3 (0.33)1.2 (0.39)0.7 (0.21)1.8 (0.47).6067
       No enrollment, non-college graduate1.4 (0.17)1.3 (0.15)1.7 (0.20)2.0 (0.21)1.7 (0.19)1.7 (0.19)2.0 (0.19).0136
       High school enrollment1.6 (0.38)2.0 (0.57)1.6 (0.40)2.0 (0.46)2.4 (0.48)2.0 (0.53)3.7 (1.02).0415
      Note: Estimates in boldface type significantly differed from the corresponding 2009 estimate (p<.05). Estimates on suicide attempt among college graduates aged 18-25 without college enrollment were suppressed due to low precision.

      References

      1. Centers of Disease Control and Prevention. Understanding suicide. Available at: http://www.cdc.gov/violenceprevention/pdf/suicide_factsheet_2012-a.pdf. Accessed April 2, 2014.

      2. Piscopo K, Lipari RN, Cooney J, Glasheen C. Suicidal thoughts and behavior among adults: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review. Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.htm. Accessed December 1, 2016.

        • Han B.
        • McKeon R.
        • Gfroerer J.
        Suicidal ideation among community-dwelling adults in the United States.
        Am J Public Health. 2014; 104: 488-497
        • Nock M.K.
        • Borges G.
        • Bromet E.J.
        • et al.
        Cross-national prevalence and risk factors for suicidal ideation, plans and attempts.
        Br J Psychiatry. 2008; 192: 98-105
      3. Centers for Disease Control and Prevention. Injury Prevention and Control: WISQARSTM. Available at: https://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html. Accessed January 6, 2017.

        • Goldman-Mellor S.J.
        • Caspi A.
        • Harrington H.
        • et al.
        Suicide attempt in young people: a signal for long-term health care and social needs.
        JAMA Psychiatry. 2014; 71: 119-127
        • Bostwick J.M.
        • Pabbati C.
        • Geske J.R.
        • McKean A.J.
        Suicide attempt as a risk factor for completed suicide: even more lethal than we knew.
        Am J Psychiatry. 2016; 173: 1094-1100
      4. US Department of Health and Human Services (HHS). Office of the Surgeon General and National Action Alliance for Suicide Prevention. The 2012 National Strategy for Suicide Prevention: goals and objectives for action. Available at: http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf. Accessed October 15, 2014.

      5. Action Alliance for Suicide Prevention. A prioritized research agenda for suicide prevention: an action plan to save lives. Available at: http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/Agenda.pdf. Accessed August 1. 2014.

        • Mojtabai R.
        • Olfson M.
        • Han B.
        National trends in the prevalence and treatment of depression in adolescents and young adults.
        Pediatrics. 2016; 138: e20161878
        • Bruce M.L.
        • Have T.R.T.
        • Reynolds C.F.
        • et al.
        Reducing suicidal ideation and depressive symptoms in depressed older primary care patients.
        JAMA. 2004; 291: 1081-1091
        • Nakagawa A.
        • Grunebaum M.F.
        • Oquendo M.A.
        • et al.
        Clinical correlates of planned, more lethal suicide attempts in major depressive disorder.
        J Affect Disord. 2009; 112: 237-242
        • Coryell W.
        • Young E.A.
        Clinical predictors of suicide in primary major depressive disorder.
        J Clin Psychiatry. 2005; 66: 412-417
        • Nock M.K.
        • Borges G.
        • Bromet E.J.
        • Cha C.B.
        • Kessler R.C.
        • Lee S.
        Suicide and suicidal behavior.
        Epidemiol Rev. 2008; 30: 133-154
        • Nock M.K.
        • Green J.G.
        • Hwang I.
        • et al.
        Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents.
        JAMA Psychiatry. 2013; 70: 300-310
        • Han B.
        • Compton W.M.
        • Gfroerer J.
        • McKeon R.
        Prevalence and correlates of suicide attempts among adults with suicidal ideation in the United States.
        J Clin Psychiatry. 2015; 76: 295-302
        • Han B.
        • Compton W.M.
        • Gfroerer J.
        • McKeon R.
        Mental health treatment patterns among adults with recent suicide attempts in the United States.
        Am J Public Health. 2014; 104: 2359-2368
        • Curtin S.C.
        • Warner M.
        • Hedegaard H.
        Increase in suicide in the United States, 1999-2014. NCHS data brief, no 241.
        National Center for Health Statistics, Hyattsville, MD2016
        • Hoertel N.
        • Franco S.
        • Wall M.M.
        • et al.
        Mental disorders and risk of suicide attempt: a national prospective study.
        Mol Psychiatry. 2015; 20: 718-726
        • Han B.
        • Kott P.S.
        • Hughes A.
        • McKeon R.
        • Blanco C.
        • Compton W.M.
        Estimating the rates of deaths by suicide among adults who attempt suicide in the United States.
        J Psychiatr Res. 2016; 77: 125-133
        • American Psychiatric Association
        Practice Guideline for the Assessment and Treatment of Suicidal Behaviors.
        American Psychiatric Association Press, Washington, DC2003
        • Brown G.K.
        • Jager-Hyman S.
        Evidence-based psychotherapies for suicide prevention.
        Am J Prev Med. 2014; 47: S186-S194
        • While D.
        • Bickley H.
        • Roscoe A.
        • et al.
        Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after observational study.
        Lancet. 2012; 379: 1005-1012
        • Creedon T.B.
        • Cook B.L.
        Access to mental health care increased but not for substance use, while disparities remain.
        Health Aff (Millwood). 2016; 35: 1017-1021
        • Mark T.L.
        • Yee T.
        • Levit K.R.
        • Camacho-Cook J.
        • Cutler E.
        • Carroll C.D.
        Insurance financing increased for mental health conditions but not for substance use disorders, 1986-2014.
        Health Aff (Millwood). 2016; 35: 958-965
      6. Substance Abuse and Mental Health Services Administration: National Survey on Drug Use and Health. Available at: http://www.samhsa.gov/data/population-data-nsduh/reports. Accessed December 1, 2016.

      7. Health Resources and Services Administration. Area health resources files. Available at: https://datawarehouse.hrsa.gov/topics/ahrf.aspx. Accessed July 10, 2017.

        • Ursano R.J.
        • Kessler R.C.
        • Naifeh J.A.
        • et al.
        Risk of suicide attempt among soldiers in army units with a history of suicide attempts.
        JAMA Psychiatry. 2017; 74: 924-931
      8. Miller GK, Piscopo KD, Batts K, et al. Measurement of suicidal thoughts, behaviors, and related health outcomes in the United States: comparison of NSDUH estimates with other data sources. Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-DR-N20Suicide-2015/NSDUH-DR-N20Suicide-2015.htm. Accessed July 10, 2017.

        • American Psychiatry Association
        Diagnostic and Statistical Manual of Mental Disorders.
        Fourth Edition. American Psychiatry Association, Washington, DC1994
        • Shiffman S.
        • Waters A.
        • Hickcox M.
        The Nicotine Dependence Syndrome Scale: a multidimensional measure of nicotine dependence.
        Nicotine Tob Res. 2004; 6: 327-348
        • Jordan B.K.
        • Karg R.
        • Batts K.R.
        • et al.
        A clinical validation of the National Survey on Drug Use and Health Assessment of Substance Use Disorders.
        Addict Behav. 2008; 33: 782-798
        • Substance Abuse and Mental Health Services Administration
        Reliability of key measures in the National Survey on Drug Use and Health (Office of Applied Studies, Methodology Series M-8, HHS Publication No. SMA 09-4425).
        SAMHSA, Rockville, MD2010
        • Brennan P.L.
        • Kagay C.R.
        • Geppert J.J.
        • Moos R.H.
        Predictors and outcomes of outpatient mental health care: a 4-year prospective study of elderly Medicare patients with substance use disorders.
        Med Care. 2001; 39: 39-49
        • Research Triangle Institute
        SUDAAN Release 11.0.1.
        RTI International, Research Triangle Park, NC2015
        • Bieler G.S.
        • Brown G.G.
        • Williams R.L.
        • Brogan D.L.
        Estimating model-adjusted risks, risk differences, and risk ratio from complex survey data.
        Am J Epidemiol. 2010; 171: 618-623
        • Committee on Improving the Health, Safety, and Well-Being of Young Adults, Board on Children, Youth, and Families, Institute of Medicine, National Research Council
        Bonnie R.J. Stroud C. Breiner H. Investing in the Health and Well-Being of Young Adults. National Academies Press (US), Washington, DC2015
        • Caine E.D.
        Forging an agenda for suicide prevention in the United States.
        Am J Public Health. 2013; 103: 822-829
        • Caine E.D.
        Suicide and social processes.
        JAMA Psychiatry. 2015; 72: 965-967
        • Han B.
        • Compton W.M.
        • Eisenberg D.
        • Milazzo-Sayre L.
        • McKeon R.
        • Hughes A.
        Prevalence and mental health treatment of suicidal ideation and behavior among college students aged 18-25 years and their non-college-attending peers in the United States.
        J Clin Psychiatry. 2016; 77: 815-824