Editor's note: Resources for any person who is feeling depressed, troubled or suicidal are listed at the bottom of this article.
The Centers for Disease Control and Prevention (CDC) released Friday a much-anticipated final report on its investigation into youth suicide in Santa Clara County, offering an exhaustive, epidemiological look at what experts and others have called a critical public health issue.
Although the Santa Clara County Public Health Department formally filed a request for the CDC to conduct the study on behalf of the Palo Alto school district, the investigation examined trends, risk factors and other data on youth ages 10 to 24 years old throughout Santa Clara County from 2003 to 2015.
The goal of its investigation and the accompanying 200-plus page report, the CDC wrote, is "to provide specific, and actionable, public health recommendations that can be used by community stakeholders to mitigate the public health problem."
Santa Clara County Health Officer Sara Cody, also a Palo Alto parent, wrote in a message Friday that the report offers a "starting point, a foundation upon which we can build our understanding of how to best prevent suicide.
"Suicides are complex and there is never just one reason why someone dies by suicide," she wrote. "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."
In a message sent to the Palo Alto school district community Friday morning, Superintendent Max McGee reiterated the district's ongoing efforts to prevent and better understand youth suicide.
The CDC's report "affirms our school district's current efforts, validates available data, and offers important recommendations to help us persist as a community to address suicide and youth well-being," McGee wrote.
The report includes pages of analysis of suicide rates, emergency department visits, perceptions about suicide from surveys, a catalogue of existing suicide-prevention programs and an analysis of the impact of media coverage on youth suicide, among other topics.
The nature of the type of investigation the CDC conducted, called an epidemiologic assistance study, or "Epi-Aid," is quick and short-term. They are not "research studies," the CDC noted, and mostly rely on existing rather than newly collected data. Here, the CDC primarily examined existing data, but also visited Palo Alto last February to meet with mental health experts, organizations and community leaders. Palo Alto youth-wellbeing collaborative Project Safety Net also conducted its own survey on perceptions about youth suicide and mental health, and provided the results to the CDC. The collaborative has said it plans to release those results publicly.
Factors involved in youth suicide
Key findings of the report include that for nearly all of the youth who died by suicide, there were known circumstances that precipitated their death, including a recent crisis, current mental health problem, history of treatment for mental illness or history of suicidal thoughts or ideation. This finding, though unsurprising, highlights "the importance of and potential for intervention," Cody wrote.
Among those who had "current" mental health problems, the most common diagnosis was depression, the CDC found, followed by anxiety disorders, bipolar disorder and self-injury.
Several young people from Palo Alto who died by suicide had "severe" mental health problems, including schizophrenia, psychosis and chronic and severe depression. Among those who died by suicide and had made prior attempts, several had been admitted multiple times to a hospital for suicidal behavior, the report states, or had "attempted suicide multiple times."
In Palo Alto, 25 percent or more of young people who died by suicide also saw similar precipitating circumstances, the CDC found. Those include relationship problems with an intimate partner, school-related behavioral issues and release from a hospital or rehabilitation facility.
The study also considered whether the Palo Alto youths who died of suicide had known one another. It found that even though two youths were identified as having been aware of other youth suicides, there was "no indication that other suicide deaths played a contributory role."
The two individuals, the study noted, "had other precipitating circumstances indicated in their medical examiner reports, including past suicide attempt/suicide ideation, depressed mood and social isolation."
Across all cases, there were common warning signs, including withdrawing from friends, family and previously enjoyed activities; increased substance use; "agitation and reckless behavior;" sleeping too much or too little, extreme mood swings and "putting affairs in order."
The CDC found that Palo Alto saw the highest youth suicide rate in the county -- 14.1 per 100,000 residents -- between 2003 and 2015, the time period covered by the report. It was followed by Morgan Hill, Sunnyvale, Santa Clara and San Jose. Santa Clara County's overall youth suicide rate of 5.1 per 100,000 was similar to the state's, the CDC found.
However, the rates of suicide among youth in the county and state are lower than the national rate among youth.
Youth suicide has increased in Santa Clara County since 2003, mirroring trends in California and the United States as a whole, Cody noted in her message. The CDC also found that deaths by suicides are more common among men and 20 to 24 year olds. Young men were also significantly less likely than young women to have received treatment or to have a current mental health problem at the time of their death, according to the report.
Programs, recommendations on preventing suicide
The CDC also reviewed programs, activities, protocols and other efforts focused explicitly on suicide prevention, several of which were identified as being evidence-based. The majority of programs the CDC reviewed -- 65 percent -- came from the Palo Alto school district.
However, it is "unclear," the CDC wrote, "if programs and policies currently being used are effective in achieving the community's goals."
The study surveyed 51 different programs aimed at preventing suicide and found that in most cases, it's nearly impossible to gauge effectiveness. Less than one third of programs and activities were evaluated for process or outcome measures, the study noted.
"Current evaluation of efforts were limited, focusing primarily on the total number of people reached or general, often anecdotal, assessments of program acceptability," the study states. "Therefore it is not possible to determine whether 99 programs and activities being used in Santa Clara County are effective or whether they are reaching adolescents and young adults at risk for suicide."
The new study also found that when it comes to youths visiting an Emergency Department due to either a suicide attempt or suicidal ideation (having thoughts of suicide) Palo Alto patients tend to be younger than those across the county. In Palo Alto, there was a higher proportion of patients from the 15-to-19 age group than in the rest of the county (52 percent versus 48 percent, respectively) and a lower proportion from the 20-to-24 age group (27 percent versus 32 percent).
Furthermore, Palo Alto youth were more likely than those elsewhere in the county to visit an emergency room because of suicidal ideation (71 percent versus 60 percent) and less likely to to do so because of a suicide attempt or a self-injury, the study found (34 percent in Palo Alto, compared to 50 percent in the rest of the county).
In addition to surveying recent trends, the report offers a series of recommendations for preventing youth suicides -- recommendations that affirm existing programs and suggest where new ones should be pursued.
Given the connection between mental health problems and youth suicide, the CDC stressed the need for ensuring that young people have access to quality mental health services. Such care, the report states, should "incorporate evidence-based treatment modalities as part of a comprehensive and coordinated prevention approach."
In addition, the study encourages primary care physicians in Santa Clara County to get educated about ways to recognize and effectively treat depression and suicidal behavior among youth. And because several youths who died of suicide in Santa Clara County had severe mental health problems such as "schizophrenia and hallucination," the report recommends that county stakeholders consider "engaging in focused suicide prevention efforts for this high-risk population."
"Prevention efforts would include interventions, such as the combined use of psychopharmacology and psychotherapy, such as cognitive behavior therapy, and early detection and identification of youth with symptoms of schizophrenia and other severe mental illness," the report reads.
Given previous suicide attempt has been identified as one of the strongest predictors of suicide, the county should also focus on support for and follow-up with young people after they are hospitalized or treated for suicidal behavior, the CDC wrote. Ensuring young people leaving hospitals see a "continuity of care" -- a planned transition back into school, treatment options and follow-up services -- is critical, the report states.
Given the scarcity of inpatient psychiatric services for adolescents in Santa Clara County -- only one hospital in San Jose that opened last summer currently offers beds for young people in crisis -- this continuity is at risk, the CDC wrote, encouraging the county to "consider how to work with current mental health service providers and hospitals in nearby counties to overcome the current gap in access to inpatient pediatric psychiatric beds within the county."
The report also encourages strategies to strengthen parent-youth relationships and notes that child abuse and neglect had been identified by the Developmental Assets Survey in Palo Alto as "significant risk factors" for suicide attempt. Fortunately, the report states, "child abuse and neglect is preventable and preventing child abuse and neglect can lower the incidence of multiple health problems and risk behaviors during adolescence and young adulthood."
A strong connection to school is another broadly known protective factor for young people. The CDC encourages schools in the county to consider programs that "focus on building youth connection to schools as part of a comprehensive and coordinated prevention approach." These should also include "social-emotional learning programs" that improve "emotional regulation, problem solving, help seeking, coping skills, and conflict resolution, and can be implementation to entire student groups."
"In general, increasing knowledge only is unlikely to result in behavior change," the report states. "Suicidal youth have, in other communities, been identified as having challenges with problem-solving, coping, and cognitive skills."
The CDC recommends a strategic, data-driven approach to suicide prevention, writing: "use of multiple programs and strategies as part of a comprehensive and coordinated prevention approach may be more effective than using single, unconnected, programs."
In her message, Cody reiterated that the report is a baseline that must inform deeper analysis — and action.
"Some, but certainly not all, of our questions about youth suicide and suicidal behaviors have been addressed by this report. Undoubtedly, we will need to continue to work with community partners, mental health professionals and researchers to support further analyses or collect new data to explore areas not addressed," she wrote. "Regardless, we all must continue the work to find solutions and prevent suicide in our community, among our youth and at every stage of life."
A hot-button topic — the role that media coverage can play in suicide prevention, both positive and negative — is explored in the report. Overall, media organizations "deviate(d)" from established guidelines for reporting on suicide, the CDC found in a review of 438 local and regional stories. While over time there was "sustained improvement" in following some guidelines, by 2015, only 40 percent of articles the CDC examined included at least one suicide prevention hotline number, according to the CDC.
The most common departure from the guidelines across all years examined, according to the CDC, was a description of method of suicide used.
The CDC suggests that "continued partnership with media and news outlets, and engagement that is not reactionary or in response to any individual death or individual media article, may be needed to avoid re-emergence of poor reporting practices."
Staff Writer Gennady Sheyner contributed to this story.
• Read the full CDC report here.
Any person who is feeling depressed, troubled or suicidal can call 1-800-784-2433 to speak with a crisis counselor. People in Santa Clara County can call 1-855-278-4204. Spanish speakers can call 1-888-628-9454.
People can reach trained counselors at Crisis Text Line by texting 741741.
Links below provide more resources where one can receive help: