DE GRUYTER International Journal of Adolescent Medicine and Health.

2017; 20170036

Review
Zebib K. Abraham1 / Leo Sher2,3

Adolescent suicide as a global public health issue

1
Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, NY 10029, USA, Phone:
+212-241-6500, E-mail: zebib.abraham@mountsinai.org
2
Icahn School of Medicine at Mount Sinai, New York, NY, USA
3
James J. Peters Veterans’ Administration Medical Center, New York, NY, USA

Abstract:
Youth suicide is a major global mental health problem. This review looks at the epidemiology, risk and pro-
tective factors associated with youth suicide, and global strategies to address this important issue. To better
understand factors contributing to youth suicide, global gender differences in suicide were examined. Global
rates of suicide amongst young men are higher than young women. However, there are anomalously higher
rates of female youth suicide in India and China, and possible causes of this are examined further. It is likely
that underestimation of youth suicide is a major factor affecting the accuracy of suicide epidemiology. Risk
factors for youth suicide are varied. Psychiatric factors include various psychiatric illnesses, substance use (par-
ticularly amongst refugee and homeless youth). Psychosocial risk factors include family conflict, physical and
sexual childhood abuse, isolation, socioeconomic disadvantage, discrimination and acculturation. Vulnerable
populations are at increased risk, including refugee/immigrant/indigenous youth, those in foster care and
homeless youth. Protective factors can include family cohesion and strong interpersonal relationships, as well
as increased access to care. Global strategies to prevent youth suicide include reducing lethal means to suicide
and reducing harmful media reporting. Various psychosocial interventions may be helpful, including individ-
ual support, and family, school and community based interventions. Strategies can also increase evaluation of
psychiatric disorders and access to care, as well as promote psycho-education and reduce stigma against mental
illness.
Keywords: global mental health, prevention strategies, risk factors, vulnerable populations, youth suicide
DOI: 10.1515/ijamh-2017-0036
Received: February 23, 2017; Accepted: April 7, 2017

Epidemiology of youth suicide

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Youth suicide is a major global mental health problem (Table 1) [1]. Data from a 2014 World Health Organization
(WHO) report on global suicide showed that in 2012, youth suicide accounted for 8.5% of all deaths in those
aged 15–29 years, and was the second highest cause of death in this age group. The statistics are worse in
higher income countries, with youth suicide accounting for 17.6% of deaths in this group, and in South East
Asian countries where suicide accounts for 16.6% of deaths in this group [1]. Youth suicide, on a global scale,
is a complex issue with many risk factors.

Table 1: Adolescent suicide in select countries [1].

Country Crude suicide rates per Age-standardized rates, Age-standardized rates,
100,000, ages 15–29, 2012 per 100,000, all ages, 2000 per 100,000, all ages, 2012
(Male/female) (Male/female) (Male/female)
Argentina 21.9/5.3 20.6/5.1 17.2/4.1
Canada 14.6/5.2 17.2/4.9 14.9/4.8
China 2.7/5.9 17.4/21.7 7.1/8.7
Egypt 2.4/1.3 3.1/2.1 2.4/1.2
France 11.8/3.2 23.3/7.4 19.3/6.0
Germany 12.0/3.1 17.5/5.2 14.5/4.1
Hungary 18.1/3.4 43.1/10.6 32.4/7.4
India 34.9/36.1 26.2/20.3 25.8/16.4
Israel 7.4/1.8 10.6/2.6 9.8/2.3

Zebib K. Abraham is the corresponding author.

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Japan 25.7/10.8 28.1/9.9 26.9/10.1

Lithuania 46.5/6.5 79.3/15.0 51.0/8.4
Mexico 8.9/3.1 6.5/1.1 7.1/1.7
Philippines 6.4/2.2 3.9/1.4 4.8/1.2
South Africa 4.5/1.0 6.1/1.0 5.5/1.1
United States 20.4/4.7 16.2/3.8 19.4/5.2

Gender di昀ferences in the epidemiology of adolescent suicide

Youth suicide rates have fluctuated over the years, and often differ between genders. Between the 1970s and
1990s, male adolescent suicide rates were shown to have increased in comparison to female adolescent suicide
rates, in countries like England and Italy. Meanwhile, both male and female rates increased in the Nether-
lands, Spain and Australia [2]. Age and gender comparisons were made amongst global youth suicides in the
2014 Centers for Disease Control (CDC) report on suicide. The CDC report showed the ratio of male to female
completed suicide in the 15–29 year age group was greater in high income counties compared to lower income
countries. Most Asian countries showed equal male and female youth rates of suicide. However, two frequently
cited studies showed that in India and China, female youth suicides were greater [1].
In one widely cited study in India, mortality in those aged 10–19 years old was studied in the rural com-
munity of Vellore in South India. From the period of 1992 to 2001, data were prospectively collected on 108,000
people. Male deaths due to suicide were between 24% and 31% during this period, and female deaths due to
suicide were between 36% and 73%. This study has been widely cited as evidence of a trend of increased female
youth suicide [3].
In another widely cited study from China, mortality data from 1995 to 1999 were collected and analyzed.
Causes of death were examined across gender and age, as well as rural and urban settings. Data showed that
suicide was the leading cause of death in those aged 15–34 years old. Suicide rates in women across all ages
and settings was 25% higher than in men. This difference was due to the high rates of suicide in rural women
ages 15–34. Suicide rates in young rural women was 66% higher than in young rural men [4].
There are several explanations for the increased rates of female adolescent suicide in both of these regions.
In both of these rural communities in India and China, there was likely less social support for young women.
Without such support, impulsive actions may have become more likely under acute stressors [5]. In the widely
cited study on Chinese suicide rates, it is postulated that Chinese culture has no strong religious or legal pro-
hibitions against suicide, and therefore suicide may seem a more acceptable option in times of crisis [4]. In
both India and China, women can face low social status, limited opportunities, domestic violence, which may
contribute to mental health disorders. Finally, the ready availability of toxic pesticides and lack of immediate
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emergency care increase the lethality of suicide attempts [5].

Factors a昀fecting suicide reporting

Accurate suicide data may be limited by how deaths are classified, lack of data, and societal and cultural differ-
ences. It is possible that adolescent suicide rates are underestimated. When looking at the epidemiology of
global youth suicide, different countries have different obstacles to measuring rates of suicide. Underreporting
often occurs secondary to stigma and shame [6]. One example is religious stigma, which can prevent reporting
of suicide. A study in Bolivia on suicide showed that many cases seem to be misclassified secondary to cultural
and religious stigma. Religious burials could be prevented if suicide was suspected [7]. In some countries, legal
issues prevent reporting of suicide. In Pakistan, for example, suicide is a criminal act [8].
It can be difficult to distinguish accidental deaths or other causes of death from suicide. Different countries
use different registration systems and have different degrees of surveillance [1]. Death certificates are signed
by legally authorized personnel (doctors, police officers, etc.), and these personnel follow routines specific to
their own country [9]. Quality data on suicide rates requires several elements, including a national standard
for registering causes of death, a willingness for officials at every level to acknowledge suicides, and medical
examiners who impartially and thoroughly register causes of death [1]. For example, in situations of drowning
or overdose, there is uncertainty in whether death is accidental or suicidal. Medical examiners may be more
cautious and classify death as accidental (as a classification of suicide would legally require establishing an
intent to die). One small study compared how English and Danish coroners classified the same 40 cases, and
Danish coroners were found to report more of these cases as suicides. Different cultures may have different
methods that they would classify as suicide [10].

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One example of difficulties with the reporting and classification of suicide is amongst “Aboriginal groups”.
In 1995, the Royal Commission on Aboriginal People in Canada estimated 25% of Aboriginal deaths classified
as accidental may have been due to suicide. Australian death classifications are limited by lack of data in remote
regions and lack of understanding of methods that are culturally specific. Cultural differences may also affect
how people respond to survey instruments. Surveying in schools may limit data as some youth do not attend
school. Race itself affects the procedures of classifying deaths. In one retrospective study, Canadian Aboriginal
suicide victims were more likely to get blood alcohol levels drawn [11].

Risk factors for adolescent suicide

Globally, there are common risk factors for youth suicide, including prior psychiatric conditions, psychosocial
risk factors, trauma, cultural and community factors and indigenous or displaced status.

Psychiatric risk factors

Psychiatric risk factors for suicide include a family history of suicide, psychiatric illness and substance use
disorders [1]. While many people who suffer from depression and substance use disorders are not suicidal,
those people with suicidal behavior often have psychiatric comorbidity.
Substance use is a significant risk factor, with alcohol or other substance use found in 25%–50% of all suicides
[12]. Especially with older adolescent males, affective disorders, substance use and conduct disorder can lead
to increased risk [13], [14]. Substance use has been shown to be a risk factor for suicide. Unaccompanied male
refugee youth may be more at risk of substance use problems [15]. Substance use has been shown to be increased
amongst homeless youth [16].
Additional risk factors include previous suicide attempts, conduct disorder, personality disorder, bipolar
disorder, psychotic disorders. Of these risk factors, prior attempts are the strongest predictor for future attempts
in youth [13], [14].

Psychosocial risk factors

Psychosocial risk factors for suicide can include abuse, a sense of isolation, family conflict, personal violence,
socioeconomic disadvantage, discrimination and acculturation [1].
Psychosocial stressors can leave youth feeling isolated and lonely. Those who lack support and close rela-
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tionships will feel isolated when experiencing these stressors, and are more likely to be negatively affected [1].
A study of Egyptian youth examined perceived parenting style and adolescent suicidal intent. Suicidal intent
was associated with “less caring” parental styles. Youth who perceive less care from parents feel more alienated,
and this alienation may lead to feelings of rejection, hopelessness, and increased suicidal behaviors [17].
Abuse and trauma can worsen depression and suicidality. This abuse can range from torture, to bullying in
schools, sexual, emotional and physical abuse within families and communities, institutional care and neglect
[1]. Child maltreatment is associated with increased post-traumatic stress disorder (PTSD), depression, suicide
and substance use [18]. Physical and sexual childhood abuse are associated with adolescent suicidality [19].
In particular, one study found that childhood physical abuse, and specifically violent sexual abuse were risk
factors for future suicidality [20].
Acute triggers for suicidal actions can be arguments, humiliations, family conflict and domestic violence
[3], [21]. It has been long noted that adolescents display more impulsivity overall [22].
Socioeconomic disadvantage is another possible risk factor. Evidence on income inequality as a risk fac-
tor for suicide is inconsistent. However, a case control study in New York City showed fatal injuries were more
likely to be suicidal in neighborhoods with greater income inequality, specifically in those aged 15–34 years [23].
Another case control study found that social disadvantage was an independent risk factor for serious suicide
attempts in those aged 13–24 years [24]. One study examined the WHO mortality data in 53 different countries,
to see if suicide rates increased after the 2008 global economic crisis. Previous data had show associations be-
tween economic downturns and subsequent increased unemployment and increased suicide rates, particularly
in working age men. This study found that in 27 European and 18 American states, increases were seen in male
suicide rates in 2009. Specifically, European men aged 15–24 years had the largest increase in suicide rates [25].
Discrimination can be a suicide risk factor. Those who experience discrimination continuously experience
rejection, stigmatization, violence and loss of freedom, which can lead to suicidal behavior. This has been noted

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in lesbian, gay, bisexual and transgender (LGBT) populations, bullied youth, those imprisoned/detained, and
displaced populations [1].
Additional vulnerable youth populations have increased psychiatric morbidity and increased suicide risk.
Youth offenders and juvenile delinquents in the US have an estimated 60%–70% prevalence of psychiatric disor-
ders [26]. Youth in the foster care system in the US have an estimated 80% of children with conditions requiring
mental health services [27]. Finally, homeless youth lack any sort of social support at all. Homeless youth often
have histories of abuse and high rates of suicidal ideation and suicide attempts [28].
In a study looking at global youth suicide rates from 1965 to 1999, high rates of suicide were found in non-
European countries, as well European countries “in transition” (developing European countries, and former
USSR countries). Cultural, psychosocial and economic factors likely contribute to this historical difference in
youth suicide. Also, it is possible that physicians focus on the psychosocial problems and stressors that youth
face may differ in these countries [9].

Community and cultural risk factors

There are a wide variety of cultural, societal, social and religious factors which can affect youth suicide risk.
These factors are specific to each country or group of people. The cultural and community context people
live in impose risk factors, on a larger scale than individual mental illness, family, or individual experience. In
countries affected by ongoing war or sudden natural disasters, the risk of suicide increases. These circumstances
affect the physical and mental health and financial security of citizens on a fundamental scale. While conflict
and disasters threaten the ability to feel safe, be well fed, sleep and stay healthy, the actual affects on suicide
mortality numbers are not clear [1].
Cultural dynamics and family conflict can increase risk of youth suicidality. One example is the stigma of
unwanted pregnancies [7]. However, in some cases the cultural emphasis on family and religious factors can
be protective for suicide [1].

Indigenous and displaced populations at risk

People who are displaced or indigenous are at increased risk of exposure to war and acculturation, which
can increase suicide risk. Peoples at risk include indigenous groups, refugees, asylum seekers, those held in
detention centers, those who are internally displaced and emigrants [1].
Indigenous groups have been noted to have higher rates of youth suicide. The Australian Bureau of Statistics
reported that from 2001 to 2010, the rates of suicide were higher amongst indigenous people. Specifically, rates
were highest (compared to non-indigenous people) in females aged 20–24 and males aged 25–29 years [29].
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Rates of youth suicide have been noted to be higher amongst indigenous populations in the US, Canada and
New Zealand. Indigenous youth, particularly males, can have higher rates of suicide and attempts [30].
Cultural issues unique to indigenous groups have been hypothesized to affect suicide rates, including loss of
identity, denial of traditions, environment degradation, loss of cultural autonomy, violence and lack of employ-
ment. Cultural deterioration affects the individual sense of self. Indigenous youth are also affected by unequal
social and economic standing. Youth susceptible to suicide may be at greater risk when they are in the position
of being “less well off” than those around them. Amongst indigenous groups, alcohol abuse is also a major risk
factor. Alcohol use can increase impulsivity and worsen mental disorders, leading to suicidal behavior [30].
While refugees, asylum-seekers and migrants are likely to have an increased risk for suicide, rates are not
fully known due to the scarcity of reliable data. These groups are exposed to genocide, imprisonment, trauma,
death, violence. Refugees endure arduous physical journeys and fear of apprehension while seeking asylum.
Even after the relocation process, refugees face discrimination, economic destitution and decreased access to
work and health care [31]. Refugee youth also face lack of family and community support, social isolation and
cultural displacement. Adolescents coming to a new country as immigrants, refugees, or asylum seekers are
developing their own identity yet have to take on the role of mediating a new culture for their families [32].
Refugees/asylum-seekers may be particularly anxious about personal information affecting their legal sta-
tus, and may be less likely to trust mental health providers. Practical issues of language barriers and under-
standing of what to tell mental health providers also affects access to care, and therefore can increase suicide
risk [33].
Recent investigations show possibly increased rates of suicide amongst displaced populations. In 2013, the
CDC released a report of suicide and suicide ideation amongst Bhutanese refugees to the US, from the period
of 2009 to 2012 [34]. Suicides amongst Bhutanese refugees had increased from 2009 to 2012, compared to prior
years. There were 16 suicides reported during this period, with an annual age-adjusted suicide rate calculated to

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be 24.4/100,000. Not only had suicides increased amongst this group in the US, their rate of suicide which was
higher than the average global and US annual suicide rates [34]. However, this report calculated that pre-arrival
and post-arrival suicide rates were similar for Bhutanese refugees. The CDC investigated possible causes of the
increased suicide rate amongst the current Bhutanese refugee population by randomly surveying 423 Bhutanese
refugees. This investigation found unemployment, family conflict, anxiety and depression were associated with
those who expressed suicidal ideation [34]. These findings spurred further research, including a small study
of Bhutanese refugees resettled in the US from 2008 to 2012. This study utilized 14 “psychological autopsies”,
investigating the prior lives and circumstances of Bhutanese refugees found to have committed suicide. Unem-
ployment, lack of services and social support and separation from family appeared to be contributing factors
[35].
Similarly, the Commonwealth and Immigration Ombudsnman released a report on suicide and suicide
ideation amongst immigrants to Australia, in the national detention network. Between 2010 and 2012, five sui-
cides were confirmed, and suicide was the leading cause of premature death amongst this population. It is
likely that displaced populations are at greater risk of suicide [36].

Protective factors
Looking across cultures and societies, various protective factors exist for youth. These protective factors can
include family relations. In cultures where the family unit is emphasized, the “familial self” is valued over
“individuality” [37]. Family cohesion can be protective [38], [39], and connections to family can reduce social
isolation and loneliness [40]. Across cultures, strong interpersonal relationships are protective [1].
On an individual level, healthy coping strategies are protective [1]. Youth with more problem solving skills
and better conflict resolution skills may be more protected from suicidal thoughts [41].
Religious and cultural beliefs may be protective as well [1]. These beliefs often discourage suicide and sup-
port the principle of preservation of life. Suicide rates have been shown to be lower in religious countries ver-
sus secular countries. It is unknown if these differences are due to underreporting due to stigma or actually
decreased suicide rates. It is possible that because religion promotes increased social cohesion and morally
prohibits suicide, it is a protective factor [42], [43].

Global strategies for suicide prevention

Regarding the epidemiology of youth suicide, the risk factors and protective factors, the question of what can
be done to prevent youth suicide arises [1]. Specific global strategies include limiting access to legal means of
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suicide, decreased media reporting of suicides, increased public understanding of mental illness and suicide,
increased psychiatric training for providers, increased access to psychiatric care and decreased psychosocial
stressors leading to suicide.

Reducing access to lethal means

Strategies that decrease access to lethal means of suicide include detoxification of domestic gas and pesticides,
and decreased access to guns. Suicide can often be an unpredictable and impulsive act, and reducing access to
immediate means of suicide can reduce suicide rates [1].
Pesticide poisonings are a major method of suicide globally, and decreasing access to toxic pesticides may
decrease suicides. In a global, systematic review of fatal pesticide self-poisoning, it was estimated that one third
of suicides in 2002 were due to pesticide ingestion. Percentages in non-Western countries were much higher.
The review goes on to recommend international strategies for restricting the sale of pesticides. The WHO, did
in fact, launch a global initiative in 2005 to decrease pesticide suicides. Obstacles to pesticide restriction have
been the financial benefits for pesticide companies and for increasing crop production. The authors recommend
policies that would phase out the most toxic of pesticides, as well as cost-effective alternatives to pesticide use.
Also, increased medical training in rural areas could help improve the medical response to pesticide poisonings
[44], [45]. In Bolivia, pesticide poisoning was the most common method of suicide [7]. In the well-cited study of
youth suicide in rural southern India, it was hypothesized that controlling the availability of pesticides within
rural communities (not having these chemicals in homes, or in unlocked storage) could also decrease suicides
[3]. This would require national and international strategies to regulate pesticide storage and availability.
Detoxification of domestic gas was also seen as a global target for reducing youth suicide. When domestic
gas was detoxified in Switzerland, the overall suicide rate decreased [46]. Detoxification of domestic gas in

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Japan was shown to decrease the use of gas for suicide, and did not show increased use of alternative methods
[47]. Global initiatives can target regulations of domestic gas, by requiring less toxic chemicals, and have legal
measures requiring licensure and inspection.
In the US, ingestion of medications are a common method of attempting suicide. Ibuprofen and ac-
etaminophen are the most commonly used, and antidepressants and atypical antipsychotics are the most com-
monly linked to death. Access to medications for overdose can be appropriately reduced by educating pediatri-
cians about suicidality amongst adolescent patients, and helping primary care doctors counsel parents. Some
benefit was found from limiting the size of analgesics that can be purchased [48].

Modifying media reporting

Reduced sensationalized media reporting can decrease copycat suicides. Reporting on suicide can affect ado-
lescents and young adults in particular [49]. It has been hypothesized that media coverage distributes technical
information about certain methods and makes these methods more appealing. Studies suggest that reporting
that focuses on details of suicide, reporting that is repetitive, and suicides that are presented dramatically all
can affect the individual viewer more. In Taiwan, patients who had attempted suicide by inhaling fumes from
charcoal burning reported being influenced by media reports. When subway suicides increased in cities like
Toronto or Vienna, restrictions on reporting of subway suicides led to a decrease in subway suicides [50]. Sui-
cides amongst teenagers increased more than adult suicides after media reporting on suicide [51]. The WHO
developed guidelines for reporting suicide in news media in 2000 [1]. These guidelines need to be implemented
globally to help combat affects of sensationalized media reports.

Psychosocial interventions
Global initiatives can include psychosocial interventions. Overall, reducing discrimination, isolation, abuse,
violence and family conflict could help reduce youth suicide. Interventions to promote family support and
positive relationships for youth may be protective. Vulnerable youth face stressors that increase risk of psychi-
atric illness. Interventions that target vulnerable youth populations can include preventative early childhood
and family interventions, individual therapy and medical interventions, school-based and community inter-
ventions and multi-systemic interventions [26].
Social relationships are necessary for the well-being of youth. Vulnerable youth populations often face stres-
sors without support. Family and community support promote healthy development and positive well-being
amongst youth [26], and programs that help maintain or establish this kind of support may be beneficial.
For refugee youth, increasing social support, and promoting supportive relationships in schools and com-
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munities can be protective [52]. Migrants can often end up in a low socio-economic status after resettling [15].
These youth and their families often struggle with long-term unemployment, poor housing quality and limited
public services [15], therefore policies that promote the socio-economic well-being of immigrants and refugees
may be effective.

Reducing psychiatric risk factors

The CDC recommends prevention strategies that target psychiatric risk factors, on the level of whole popula-
tions, then at risk groups, and then individuals. “Universal” prevention strategies target whole populations by
increasing access to care, promoting mental health and decreasing stigma, and improved national surveillance
including accurate classifications of suicide deaths. Many countries have limited mental health resources [1].
Effective care and easier access to this care could reduce youth suicide. Prevention should include reducing
stigma against mental disorders and providing more support to those who seek help for suicidal thoughts [41].
“Selective” prevention strategies target at-risk groups by helping those exposed to trauma, conflict, disaster
and training “gatekeepers” to recognize those with suicidal feelings (health care workers, educators, police,
etc.). National suicide prevention strategies need to be developed (and are already in 28 countries), which work
through healthcare, education, employment, social welfare, the law, and more, and are evidence-based prac-
tices specific to each country. “Indicated” prevention strategies target at risk individuals by providing increased
support [1].
Youth suicide can be reduced by treating adolescents with previous suicide attempts, alcohol and drug use
disorders, personality disorders, conduct disorders, bipolar disorder and other psychotic disorders, depression
and anxiety [1]. Suicide risk increases with each psychiatric co-morbidity, and therefore treating psychiatric
disorders can decrease suicide rates.

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Treating psychiatric illness in non-Western countries requires an understanding of the spiritual and cul-
tural context in which mental illness is understood [26]. Therefore, when promoting mental awareness and
treatment, programs must be culturally-specific [53], [54]. Culturally appropriate care is complex. Providers
must understand that in different cultures, mental health itself is conceptualized differently, symptoms may be
understood differently and be ascribed different meanings, views on treatment may differ, and perceptions of
those with “mental illness” differs [26].
Specific treatment strategies include trauma-focused cognitive behavioral therapy which has been shown in
several randomized control trials to be effective in reducing depressive and PTSD symptoms in youth exposed
to trauma [55].

Mental health education

Global initiatives include mental health education which can reduce stigma and also improve health literacy.
Australia, for example, has been able to reduce youth suicide, in part through education programs at several
levels, online resources, training professionals. It is important to educate families and adolescents about mental
health and suicide, so that at-risk youth are identified and willing to access care. Early detection strategies are
helpful in identifying those youth at risk, but may be limited by stigma [56].
One important example of the necessity of mental health education is when a student commits suicide.
Many schools that experience a student suicide do not have a strategy to address such a situation, and therefore
prevent more suicides. However, national level strategies are available, that can help schools address student
bodies after a student suicide [56]. Such interventions can reduce the emotional distress directly after a suicide
and hopefully prevent more suicides [57].

Initiatives to help vulnerable populations

There are also global initiatives to combat youth suicide amongst indigenous communities, refugees and asy-
lum seekers. Vijayakumar [31] suggests that culturally geared tools for accurately assessing suicidality in these
populations are required first [58]. Once suicidality is assessed in this cultural context, guidelines can be de-
signed to target suicidal behavior. One example is the Inter Agency Standing Committee (IASC) guidelines for
mental health in refugees, and includes emotional support for new refugees, early education on host country,
early provisions, maintenance of connections to family, friends, non-governmental organizations (NGOs), and
media efforts to positively portray refugees [59]. These are some examples of international guidelines that could
better target suicide risk in a vulnerable population. Culturally relevant intervention strategies for indigenous
communities include gate keeper training and mental health education [60]. Policies can be implemented to
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maintain social connections in communities affected by conflict or disaster.

Strategies to reduce suicide amongst LGBT youth can involve reducing stigma, prejudice, individual and
institutional discrimination [61].

Conclusions
Ultimately, youth suicide is an important global problem that needs more attention. To reduce youth suicide,
social changes are needed improve the conditions of vulnerable groups, to change stigma against mental illness
and facilitate access to mental health care. In particular, recent conflicts in the world have increased violence,
economic destitution, trauma, and worsened discrimination and access to care. Youth who face these stressors
are at increased risk of psychiatric comorbidity and suicide. Policy changes are needed on a local, national, and
international level to reduce risk factors for suicide and also identify and treat those at risk.

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