Predictors of suicide and associated factors in Texas high school adolescents

Abstract Suicide is the second leading cause of death among 10–24-year-olds in the United States with suicide rates in this age group increasing by more than 57% between 2007 and 2018. Texas, in particular, is one state that has a fairly notable increase in suicide with such deaths occurring once every two hours in the state. This study aims to explore the predictors of suicide and the factors associated with suicidality in Texas high school adolescents. Data come from the Youth Risk Behavior Surveillance Survey (YRBSS) which monitors health behaviors that significantly contribute to the leading causes of death, disability, and social problems among youth and adults in the United States. A multivariable logistic regression analysis was used to explore the associations of suicidality as the outcome of interest and several behavioral characteristics. Our study found that females (OR = 2.01; 95% CI: 1.71–2.36) and students who identify as lesbian, gay, bisexual (LGB) or unsure of their sexuality (OR = 1.98; 95% CI:1.55–2.52) were at significantly increased with for suicide. Race and grade were not found to be significant factors. Drug use, sexual activity, and school-based violence or violence-related behaviors also contributed to an increased risk of suicide. Using data from a nationally-representative sample, this study evaluated risk factors associated with negative mental health outcomes described as suicide with respect to the state of Texas adolescents. Our findings underscore the need for strategies to reduce the risk that sexual-, violence-, substance-, and health-related behaviors and their co-occurrences have on negative mental health outcomes


Introduction
Suicide is one of the leading causes of death for American teens, and depression is a condition that afflicts millions of adolescents in the United States (Grant et al., 2020;National Institute of Mental Health, 2022).It is the second leading cause of death among 10-24-year-olds in this country with suicide rates in this age group increasing by more than 57% between 2007 and 2018 (Berk et al., 2021;Shain et al., 2016).Suicide most often occurs when an individual feels hopeless and believes there are no other options available.Although it has been recognized as an imminent public health epidemic, many adolescents are at a higher risk for self-injurious thoughts and behavior-which includes suicide ideation (SI), suicide attempts (SA), and non-suicidal self-injury (NSSI).
Texas, in particular, is one state that has a fairly notable increase in suicide with such deaths occurring once every two hours in the state (Texas Health and Human Services, 2020).Since 2000, the suicide mortality rate in Texas has increased 36% and as of 2019, suicide was the 11th leading cause of death statewide (Texas Health and Human Services, 2020).Texas adolescents, in particular, have shown a notable increase in death by suicide which, as of 2019, was the second leading cause of death for individuals ages 15-34 (Texas Health and Services, 2020).
A limited number of studies have assessed suicidality in Texas adolescents.Examining trends in suicide attempts in adolescents showed that females and non-Hispanic white patients had the highest frequency of visits to the emergency department in Central Texas due to suicide attempts (Barczyk et al., 2019).When evaluating predictors of suicidality in Texas adolescents, heavy substance use (Johnson et al., 2018) and homelessness (Reingle Gonzalez et al., 2018) were shown to increase suicidal behaviors.School bullying, feeling unsafe at school, and being threatened or injured at school also contribute to suicidal behaviors; however, a reduction in suicidal behaviors were seen in Texas adolescents who belonged to a community (Olcoń et al., 2017).This study aims to explore the predictors of suicide and the factors associated with suicidality in Texas high school adolescents.

Materials and methods
The Youth Risk Behavior Surveillance Survey (YRBSS) monitors health behaviors that significantly contribute to the leading causes of death, disability, and social problems among youth and adults in the United States.The YRBSS survey is administered biennially to a representative sample of students in grades 9-12 that measures the prevalence of health-risk behaviors including, but not limited to, behaviors that contribute to unintentional injuries and violence; alcohol and other drug use; and, sexual behaviors that contribute to HIV infection, sexually transmitted diseases, and unintended pregnancies (CDC, 2013).As Texas began including one or the other of the sexual minority questions in the 2017 survey cycle, data from the 2017 and 2019 Texas YRBSS high school cycles were utilized for this study.Data analyzed using SAS 9.4 were representative of statewide samples for 2017 and 2019 with overall response rates of 62% and 54%, respectively.The model also incorporates complex survey sample designs, including stratification, clustering, and weights which were all provided in the data.

Demographics
Race was determined using the 7-level variable from race and ethnicity questions: American Indian Alaska Native, Asian, Black or African American, Hispanic/Latino, Native Hawaiian/Other Pacific Islander, White, or Multiple Races.

Gender and sexual identity
Sex was assessed by the question "What is your sex" with responses categorized as "Male" or "Female."Sexual identity and sex of sexual contacts were both used to identify sexual minority adolescents.Sexual minority youth defined by sexual identity include those who identify as gay, lesbian, and bisexual (LGB) and those who are not sure about their sexual identity.Sexual minority youth defined by sex of sexual contacts include those who have had sexual contact with only the same sex or with both sexes (CDC, 2020).Additionally, responses to the question "Which of the following best describes you" as "Heterosexual (straight)", "Gay or lesbian", Bisexual", and "Not sure" were taken into consideration when determining sexual identity.

School-based violence or violence-related behavior
Discrete responses to the following questions were dichotomized: carrying a weapon such as a gun, knife, or club on school property; not attending school due to safety concerns and feeling unsafe at school or on the way to or from school; ever threatened or injured by someone with a weapon such as a gun, knife, or club on school property; involvement in a physical fight; and ever bullied on school property or electronically.Physical sexual violence was characterized by having ever been physically forced to have unwanted sexual intercourse, forced to do unwanted sexual things at least once during the past 12 months, forced to do unwanted sexual things while dating or going out with someone during the past 12 months, or physically hurt by someone while dating or going out during the past 12 months at least once.

Healthy diet and physical activity
Healthy diet was assessed by dichotomizing responses to questions about food eaten or drank in the past seven days.Respondents were categorized as "No" if they did not drink 100% fruit juices such as orange juice, apple juice, or grape juice, or did not eat fruit, green salad, potatoes, carrots or other vegetables.Physical activity was assessed and categorized as "Yes" if respondents were physically active at least one day for a total of at least 60 minutes per day during the past seven days, went to physical education at least one day in an average week while in school, or played on at least one sports team in the past 12 months.

Sexual behavior
Sexual behavior was dichotomized based on responses to "Have you ever had sexual intercourse," "How old were you when you had sexual intercourse for the first time," "During your life, with how many people have you had sexual intercourse," "During the past three months, with how many people did you have sexual intercourse," "Did you drink alcohol or use drugs before you had sexual intercourse the last time," "The last time you had sexual intercourse, did you or your partner use a condom," "The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy," and "During your life, with whom have you had sexual contact?"

Substance use and chemical dependency
Current and any history of substance use and chemical dependency was assessed for cigarettes or electronic cigarettes, vaping or electronic vaping, use of tobacco products, alcohol consumption, marijuana and synthetic marijuana use, prescription pain medicine use, and drug use.Responses were dichotomized to "Yes" or "No."

Mental health and well-being
Suicidality as the main outcome of interest was dichotomized to "Yes" or "No" based on affirmative responses to any of the questions that assessed mental health and well-being: 1) feeling so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities; 2) having ever seriously consider attempting suicide in the last 12 months; 3) making a plan to attempt suicide in the last 12 months; 4) attempting suicide at least once in the last 12 months; and, 5) having attempted suicide resulting in an injury, poisoning, or overdose in the last 12 months that had to be treated by a doctor or nurse.

Analytical approach
All analyses were conducted using SAS 9.4.This study employed the use of multivariable logistic regression analysis with a binary outcome to investigate the relationship between discrete responses and explanatory variables (measures) among sample survey data.To account for nonresponse and sample selection probabilities, sample weights, primary sampling units, stratum and cluster variables were included to account for complex survey design.

Results
Table 1 depicts the prevalence for each situation that used to define suicidality in this study, which encompasses depressive symptoms, and suicide ideation, planning, and attempts.More than onethird (36.8%) reported feeling sad or hopeless for two or more weeks in a row that usual activities were stopped.Although the majority of our sample reported no suicide ideation (81.7%), no plans (85.2%), no attempts or attempts with serious injury (88.9% and 96.2%, respectively), we found significant differences between the two groups of adolescents in each situation depicted.
The weighted sample included 4,145 Texas high school adolescents, of which 671 (16.2%) were found to identify as a sexual minority and nearly 53% identified as female.Additional demographic characteristics of respondents are described in Table 2.The proportion of sexual minorities experiencing suicidality from 2017 to 2019 slightly increased by 0.1 percentage points from 227 of 2,113 (10.7%) to 219 of 2,032 (10.8%), respectively.Contrastingly, there was a similar increase of 2.3 percentage points in suicidality amongst heterosexual adolescents from 659 of 1,768 (37.3%) in 2017 to 676 of 1,706 (39.6%) in 2019.Bivariate analyses produced significant associations between suicidality and many of the health-, substance-, violence-, and sexually-related metrics which are also detailed in Table 2.
For this study, a multivariable logistic regression model was used to examine the associations between the behavioral characteristics and suicidality as the outcome of interest.The results of the model can be found in Table 3. LGB adolescents and those unsure of their sexuality are almost twice as likely to experience suicidality (OR = 1.98, 95% CI: 1.55-2.52).Females are also twice as likely to experience suicidality than males (OR = 2.01, 95% CI: 1.71-2.36).Race was found to be of no significance but, interestingly among this sample, American Indian and Native Hawaiian adolescents were found to be 1.28 times more likely to experience suicidality than Whites (95% CI: 0.60-2.74)whereas Black adolescents had the lowest risk of suicidality when compared to Whites (OR = 0.98; 95% CI: 0.76-1.27).
Several of the school-related factors were found to be significant: carrying a weapon such as a gun, knife, or club on school property (OR = 1.91; 95% CI: 1.11-3.26);feeling unsafe at school or to or from school (OR = 1.77; 95% CI: 1.42-2.20);carrying a gun at school (OR = 0.75; 95% CI: 0.60-0.94);and, having been threatened or injured with a weapon such as a gun, knife, or club on school property (OR = 1.54; 95% CI: 1.16-2.05).Involvement in a physical fight increases an adolescent's odds of suicidality by 1.43 (95% CI: 1.16-1.78).Adolescents who reported having ever been physically forced to have unwanted sexual intercourse or forced to do unwanted sexual things are at a significant risk of suicidality (OR = 2.16; 95% CI: 1.71-2.74).Those who reported being bullied at school or electronically are more than two times more likely to experience suicidality (OR = 2.27; 95% CI: 1.70-3.10).
Substance use and chemical dependency increases the odds of suicidality: drug use (intravenous drug use, heroin, methamphetamines, steroid pills or shots, various forms of cocaine, ecstasy, sniff glue or aerosols) constitutes are risk of 1.32 (95% CI: 1.10-1.60);the use of prescription pain medicine without a doctor's prescription or differently than how it was prescribed raises the risk of suicidality to 1.29 (95% CI: 0.97-1.69);marijuana or synthetic marijuana use presents a risk of 1.18 (95% CI: 0.96-1.45).Sexual activity was found to be a significant predictor of suicidality (OR = 1.27; 95% CI: 1.01-1.60).

Discussion
This study aimed to explore the predictors of suicide and the factors associated with suicidality in Texas high school adolescents.We believe the findings from this study can be used to inform targeted interventions for Texas adolescents who are experiencing suicidality for varying reasons including substance use, interpersonal violence, and risky sexual behavior.

Demographics
Differences in suicidality amongst the sexes-male and female-have been found to be overwhelmingly significant.Consistent with prior research (Miranda-Mendizabal et al., 2019), we found that females were more likely to experience suicidality.Our study did not seek to explore the phenomenon of the gender paradox; however, it is evident Texas high school students would benefit from the implementation of gender-specific suicide prevention and/or mental health interventions.The gender paradox of suicide that males are more likely to end their lives by suicide and use deadly force undoubtedly exists today, but more and more females are considering ending their lives by suicide, attempting to, and successfully doing so (Canetto & Sakinofsky, 1998;Ruch et al., 2019).
Our findings show that Texas LGB students are significantly at risk for suicidality.An abundance of evidence suggests that LGB people are more likely to attempt to take their own lives in their youth when compared to heterosexuals (De Lange et al., 2022;Ream, 2019).We hypothesize that the increase in suicidality from 2017 to 2019 stems from a lack of protections in schools for socially-minoritized groups coupled with increasing calls to pass discriminatory legislature in Texas.As a result, many LGB students are subjected to harassment, bullying, and physical assault-all of which are risk factors for suicide (Russell et al., 2021).Among the raciallyminoritized groups, we did not find race to be a significant predictor of suicidality; however, we did find that African-Americans were the least likely to experience suicidality.In the last decade, suicide trends for African-American youth have risen, particularly among females and those aged 15-17 (Sheftall et al., 2022).While this is incredibly alarming, there is an imminent need to develop culturally-appropriate behavioral health interventions and treatments and to better understand the historical experiences that contribute to the risk of suicide in these minoritized groups.

Interpersonal violence, substance use, and sexual activity
Interpersonal violence occurs when one person uses power and control over another person through physical, sexual, or emotional threats or actions, economic control, isolation, or other kinds of coercive behavior.In fact, early exposure to interpersonal violence has been found to present higher risks of suicide attempts and suicide death in youth and young adults (Castellví et al., 2017).In a recent study of suicide in Harris County, Texas, researchers found that interpersonal violence was noted in nearly one-third of suicide cases, with more than 86 per cent between intimate partners; partner violence was a dominant factor noted for male suicides (DeMello et al., 2022).Adolescents who experienced school bullying and cyberbullying had higher odds of experiencing suicidal ideation; those subjected to school bullying alone had higher odds of experiencing suicidal ideation, while those exposed to only cyberbullying had two times the odds of experiencing suicidal ideation (Baiden & Tadeo, 2020).We recommend future research to examine what factors contribute to the stressors associated with interpersonal violence between intimate partners and/or peer-to-peer lateral violence.
The association of suicide and substance is well documented in the literature.Suicide by drug overdose among teenagers, especially females, has significantly heightened in recent years.There are more cases of opioid prescription for females than males due to higher cases of chronic pain in females (Singh et al., 2019).Our study supports the increased risk of female substance users' suicidality, as females are more likely to end their lives by less-violent means.Methamphetamine was named the top drug threat in Texas by three DEA teams in 2019, perhaps due to the increased supply and purity in Texas P2P (phenyl-2-propanone) meth (Maxwell, 2020).P2P meth has become an increasingly more accessible and cost-efficient drug in Texas, making it even more accessible to adolescents (Dickson et al., 2021;Loza et al., 2020).In our sample of Texas adolescents, it is evident that the tailored interventions are needed to address substance use-particularly in communities where accessibility is higher and those at risk for suicide (Van Horne et al., 2021).
Risky sexual behaviors (RSBs) can be defined as high-risk sexual activity that increases one's risk of contracting a sexually transmitted infection (STI) and/or sexually transmitted disease (STD), or that leads to an unintended pregnancy.Our study found that there is a positive association between Texas teens' engagement in RSBs and suicidal behaviors such that Texas teens who partake in RSBs are increasingly at risk for suicidality.Our findings are consistent with past studies conducted that deduced adolescents that engaged in sexual activity and have more sexual activity make suicide attempts and experience suicide ideation (Burge et al., 1995;Smith et al., 2020), those who had unprotected sexual intercourse and had more sexual partners experience suicide ideation and make suicide attempts (Baiden et al., 2021;Smith et al., 2020), and that increased rates of RSBs, and early initiation of sexual intercourse are associated with suicidal behaviors (Husky et al., 2013).

Conclusion
Using data from a nationally representative sample, this study evaluated risk factors associated with negative mental health outcomes described as suicide with respect to the state of Texas adolescents.Our findings underscore the need for strategies to reduce the risk that sexual-, violence-, substance-, and health-related behaviors and their co-occurrences have on negative mental health outcomes.Perhaps, future research could investigate the specific needs of culturally-and racially-competent interventions tailored for targeted adolescents, age-groups and subpopulations.

Limitations
This study is not without limitations.First, our definition of suicidality is a composite of five variables that assess mental health and well-being.We relied on affirmative responses by our sample population to any of the five variables, which were then used as a binary outcome.Second, while the YRBSS is a standardized questionnaire, we were unable to delve deeper into the underlying causes of suicidality within our study sample.Thus, future research-particularly, those employing qualitative designs, should aim to understand the psychopathological and personality characteristics of suicidal and non-suicidal adolescents.You are free to: Share -copy and redistribute the material in any medium or format.Adapt -remix, transform, and build upon the material for any purpose, even commercially.The licensor cannot revoke these freedoms as long as you follow the license terms.
Under the following terms: Attribution -You must give appropriate credit, provide a link to the license, and indicate if changes were made.You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

No additional restrictions
You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.

Cogent Psychology
and dialog with, expert editors and editorial boards • Retention of full copyright of your article • Guaranteed legacy preservation of your article • Discounts and waivers for authors in developing regions Submit your manuscript to a Cogent OA journal at www.CogentOA.com

Table 2 . (Continued)
a Percentages incorporate population survey weights.b Statistically significant at p < .05. c Statistically significant at p < .001.