Editor's note: Resources for any person who is feeling depressed, troubled or suicidal are listed at the bottom of this article.
Preliminary findings from the Centers for Disease Control and Prevention's epidemiological investigation into youth suicides in Santa Clara County have shed some light on factors -- including mental-health issues and problems at school -- that played a role in the suicides of Palo Alto teenagers over the past 13 years.
The Santa Clara County Public Health Department, which on behalf of the Palo Alto school district formally filed a request for the CDC to conduct the study, released the agency's preliminary report on Tuesday. It is an early, incomplete analysis, subject to change, with a final report due out later this year.
The report was compiled by a team of five staff members from the Centers for Disease Control and the Substance Abuse and Mental Health Services Administration (SAMHSA) who spent two weeks in Palo Alto this February talking with organizations and people who work on suicide prevention and youth mental health as well as poring through county and local data, the report states. While the initial scope was limited to 2008 to 2015, the researchers expanded their data analysis to 2003 in response to community requests to consider an earlier youth suicide cluster in Palo Alto.
The majority of the report takes a countywide view, with the team examining data related to 232 suicides. However, the team also analyzed Medical Examiner reports to draw out locally specific data. In Palo Alto, these reports indicate that mental-health problems, previous or current treatment for mental illness, a recent crisis and problems at school precipitated the suicides of at least 25 percent of the Palo Alto youth, ages 10 to 24 years old, included in the study.
The report also identifies "current depressed mood," a previous suicide attempt and leaving a suicide note as precipitating circumstances among Palo Alto youth who died by suicide.
Those youth were less likely to tell someone about their plans than in other Santa Clara County cities. Less than a quarter of the Palo Alto youth had told someone they intended to die by suicide, the researchers found.
The CDC also found that more than half of all Santa Clara County youth who died by suicide during this time period had a recent crisis within two weeks of death, pointing to the vital importance of widespread training, awareness and education around suicidal risks and behavior. Recent crises youth experienced included problems with intimate partners, such as a breakup or argument with a family member; release from a medical facility, such as after a psychiatric hospitalization; legal problems; a suicide attempt; drug or alcohol use; and school problems, such as failing classes or getting suspended, the report states.
Current mental-health problems were also reported in 46 percent of the Medical Examiner reports, according to the CDC. The most common mental-health diagnosis was depression, followed by anxiety and bipolar disorder.
About a quarter of those who died were receiving treatment at the time of their deaths, and 41 percent had received treatment previously.
Young men were particularly vulnerable countywide. They were significantly less likely to have reported a current mental-health problem or to have received treatment than young women, the researchers found. The suicide rate for male youth is also greater than for female youth in Santa Clara County, as well as statewide and nationally.
The report notes that the many circumstances and factors that are associated with both fatal and non-fatal suicidal behavior "underscores the complex nature" of youth suicide.
"Factors associated with fatal and non-fatal suicidal behavior were found at the individual (e.g., mental health problems, sexual orientation, drug and alcohol use, past suicidal behavior), interpersonal (e.g., arguments, bullying, intimate partner, and family problems), and community level (e.g., connectedness to school, meaningful engagement at school)," the report states. "This suggests that suicide prevention efforts should take a multi-faceted approach to suicide prevention and should include programs, activities, and outreach that target factors at multiple levels beyond those that focus on risk factors at the individual level."
Despite the intense national spotlight that has been focused on Palo Alto over the last several years in the wake of several teenage deaths by suicide, the CDC's report indicates that Palo Alto school-district students are actually faring better than some of their peers.
Data from the 2013-14 California Healthy Kids Survey (CHKS) indicate that far fewer Palo Alto Unified high school students seriously considered suicide and reported mental distress than in three other county school districts for which the CDC reviewed data (Santa Clara Unified, Gilroy Unified and East Side Union High School District in San Jose). Only 12 percent of responding Palo Alto Unified high school students had seriously considered suicide in the 12 months before taking the survey, compared to 18 percent in Santa Clara, 20 percent in Gilroy and 20 percent in East Side Union. Palo Alto Unified also had the lowest percentage of high school students who had experienced mental distress in the previous year 20 percent compared to Santa Clara's 32 percent, Gilroy's 30 percent and East Side's high of 34 percent.
High school students from all four districts who had considered suicide and reported mental distress, though, shared many characteristics. They were significantly more likely to have missed school in the past month (due to either falling behind in school work; feeling bored at school; or feeling sad, hopeless or angry), experienced bullying and victimization, used alcohol or drugs in their lifetime, engaged in binge drinking in the last month and self-identified as gay, lesbian or bisexual, the CDC found.
These students were also less likely than their peers to think that an adult or teacher cared about them and to have a high level of school connectedness, according to the CHKS data. Forty-one percent of suicidal high school students in Palo Alto said they felt a teacher or adult in school cares about them, compared to 67 percent of students who hadn't considered suicide.
In Palo Alto, 76 percent of students who had considered suicide reported feeling sad or hopeless almost every day for two weeks or more.
The top reasons these students missed school, in order, were illness (including physical problems); lack of sleep; feeling very sad, hopeless, anxious, stressed or angry; falling behind in schoolwork or feeling unprepared for an assignment; and feeling bored or uninterested in school.
The report also identifies bullying as a crucial problem for schools to address to better support struggling students. Just over half of all suicidal students in Palo Alto reported in the survey that they had been psychologically bullied at school.
In comparing Santa Clara County with other California counties, the team of researchers found that Mendocino, Humboldt, Lake, Shasta and Yuba counties all have significantly higher youth suicide rates all double or more the local rate. The highest is Mendocino at 16.2 per 100,000, according to the report.
Santa Clara County's youth suicide rate from 2003 to 2014 was almost the same as California's. Since 2003, Santa Clara County has also had a consistently lower rate than the nation, according to the report.
While still at a preliminary stage, the CDC's report offers "initial, broad" recommendations for how to address youth suicide.
Unsurprisingly, education, awareness and decreasing stigma around mental health are all central to these early recommendations. Given the fact that many youth who died by suicide had experienced some sort of recent crisis, the report suggests that those who live, work and are in close contact with young people should be "familiar with signs of distress so they are able to recognize and intervene with a youth in crisis."
Suicide-prevention efforts should also focus on "encouraging help-seeking behavior, and ensuring access to quality care," the report states. In communities where few youth were receiving treatment at the time of their death (this problem is more urgent in San Jose, Milpitas and Santa Clara than in Palo Alto), an effort "should be made to understand and identify barriers to help-seeking," the report reads.
Communities should also identify strategies to help young people feel more comfortable disclosing and seeking help during a suicidal crisis, including forging stronger relationships between students and teachers or other adults.
"Connections between youth and a teacher or another adult, feeling connected to school, and meaningful opportunities at school were found to be protective factors for suicidal ideation," the report states. "Enhancing relationships between youth and a teacher or another adult could provide opportunities to identify at-risk youth and provide ways for youth to seek help prior to and during a crisis.
"Activities to enhance the relationship between youth and a teacher or other adult should be implemented in tandem with educational programs focused on recognizing warning signs for suicide and how to respond to a suicidal individual."
Given the fact that suicide affects a diverse range of ethnicities and races, "both messaging and mode of delivery of prevention materials should consider linguistic and cultural differences," the report reads. The report also suggests offering programs and outreach targeted at young men, given the data that indicates they are at higher risk of suicide and yet less likely to seek help when struggling.
Palo Alto Unified Superintendent Max McGee wrote in a message to families on Tuesday that the preliminary findings "affirm our current efforts, validate available data, and offer important recommendations to help us persist in our work to address youth suicide" which he called an "urgent health issue."
"As a school district, we've taken numerous steps in all of our schools to support youth well-being including passing new Board policies to promote mental and physical health, hiring additional staff members who are experts in the field of mental health, and implementing programs and initiatives to support our families and students," he wrote. "We will continue to collaborate very closely with other organizations and professionals including the Santa Clara County Public Health Department (SCCPHD), the City of Palo Alto, Project Safety Net (PSN), mental health experts, and parent, student, and community groups to review the recommendations and consider future policies and programs to address the findings and recommendations."
In a message announcing the report's release, Sara Cody, health officer and public health director for the county health department, cautioned that the purpose of Epi-Aid investigations is to provide short-term, emergency assistance for an urgent public health problem. They are not research and do not involve the collection of any new data, she wrote.
"This approach means that the Epi-Aid will answer some, but not all, possible questions about suicide and suicidal behaviors in our community. When questions come up that the Epi-Aid is not designed to answer, we will work with community partners on these issues and connect them with others, such as researchers, who may be able to address these questions through additional analyses or new data collection," wrote Cody, who is also a Palo Alto school district parent.
The final, more comprehensive report will include an analysis of trends in youth suicide and related behaviors countywide, and data permitting, in cities and school districts, according to Cody. The team will also have access to data from a recent survey that youth well-being collaborative Project Safety Net conducted to ensure that the CDC hears input from more community members than those who were able to meet with the CDC team in February.
The final report will also look at whether recent media coverage of youth suicide met established media guidelines, and compare local youth suicide prevention efforts to evidence-based recommendations. The final report will likely to include additional recommendations regarding suicide-prevention strategies at the school, city and county level.
"One of the first steps in reducing the stigma around depression and other mental health issues, including what may lead to a suicide, is to know the facts," Cody wrote. "This preliminary report begins to provide the facts about youth suicide in Santa Clara County. Individuals, schools, community organizations, businesses and government organizations, as well as the news media, all have a role to play in reducing stigma and preventing suicide in our community."
Project Safety Net will hold a meeting on Wednesday, July 27, 4-6 p.m. at Rinconada Library, to discuss the report and hear an update from the county health department. To RSVP, click here.
Any person who is feeling depressed, troubled or suicidal is urged to call 1-800-784-2433 to speak with a crisis counselor. People in Santa Clara County can also call 1-855-278-4204.
People can also reach trained Crisis Text Line counselors by texting "HELLO" to 741741.
Links below provide more resources where one can receive help: