Utah Health Status Update:

CDC Investigation Shows Youth Suicides in Utah Increasing
Special Edition 4 (December 2017)

•  The UDOH requested an Epi-Aid
from the CDC to assist in investigating the 141.3% increase in the youth
suicide rate from 2011 to 2015.
•  From 2011–2015, 150 Utah youth
aged 10–17 died by suicide.
•  78.0% were male
•  35.2% had a mental health diagnosis
•  31.0% had a depressive mood at
the time of suicide
•  29.6% had a history of suicide
ideation or suicide attempt
•  55.3% experienced a recent crisis
•  23.9% disclosed intent to die in the
past month
•  47.2% left a suicide note
•  Of the 40 cases that included
information on the decedent’s sexual orientation, six (15.0%) were
identified as sexual minorities
•  20.5% had a history of cutting or
had evidence of recent cutting
•  12.6% of decedents had experienced a technology-related restriction prior to their death
•  For the 3,005 ED visits and 690 hospitalizations for self-inflicted injury
among Utah youth aged 10–17 during
2011–2014, the predominant method
of injury was poisoning (72.4%), followed by cutting/piercing (23.0%).
•  Approximately 19% of youth aged
10–17 considered or planned suicide
in the past year and 8.6% reported a
suicide attempt.
•  Risk factors for suicide ideation and
attempt included being bullied at
school or online, substance use in
the previous month, being female,
in 10th grade, non-White, and low
parental education.
•  Supportive family environments, community environments, school environments, and peer environments all
reduced the odds of suicide ideation.

The Utah Department of Health (UDOH) Violence and Injury Prevention
Program (VIPP) observed a 141.3% increase in the youth suicide rate from
4.6 per 100,000 population in 2011 to 11.1 per 100,000 population in 2015
for ages 10 to 17 years (Figure 1). As a result, the UDOH requested shortterm epidemiologic assistance, known as an Epi-Aid, from the U.S. Centers
for Disease Control and Prevention (CDC) to assist in investigating the
observed increase. Epi-Aids are carried out by a team of Epidemic Intelligence Service (EIS) officers who provide an independent investigation
of an urgent public health problem.1 Along with UDOH staff, the Epi-Aid
team identified the following objectives to guide the investigation:
1.  Characterize the epidemiology of, and trends in fatal and non-fatal
suicidal behaviors among Utah youth aged 10–17 years that occurred
from 2011 to 2015.
2.  Identify risk and protective factors for fatal and non-fatal suicidal
behaviors among Utah youth aged 10–17 years.
3.  Identify the three most utilized suicide prevention initiatives in Utah
by school district (QPR, Hope Squads, and Hope for Tomorrow) and
compare these programs to evidence-based initiatives and national
recommendations for suicide prevention.

Youth Suicide Trends

Figure 1. Rate of suicides by year, youth aged 10–17, Utah and U.S., 1999–2015
Utah

16.0

U.S.
11.1

14.0

Rate per 100,000 Population

KEY FINDINGS

12.0

8.1
6.9

10.0
5.0

8.0

5.4

5.3

4.7
3.4* 3.4*

6.0

5.9

5.8

5.7

4.0

4.6

4.6

3.0*

4.2

4.0
2.0

8.5

3.1

3.3

3.1

2.9

2.7

3.0
3.0

2.7

2.9

3.1

3.0

3.4

3.5

3.7

4.0

2.4

0.0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
* Insufficient number of cases to meet the UDOH standard for data reliability; interpret with caution.
Source: Utah Office of Vital Records and Statistics

The Epi-Aid team analyzed data from multiple sources, including the UDOH
Office of the Medical Examiner, the Utah Violent Death Reporting System, the
Prevention Needs Assessment survey, emergency department and hospitalization data, as well as curricula from school-based suicide prevention initiatives.
From 2011–2015, 150 Utah youth aged 10–17 died by suicide; 78.0% of
decedents were male. Firearms and suffocation were the most common
methods of suicide. About one-third (35.2%) of decedents had a mental

 health diagnosis and nearly a third (31.0%)
had a depressive mood at the time of suicide.
Approximately 30% had a history of ideation
or suicide attempt. More than half of decedents
(55.3%) had experienced a recent crisis. Nearly
one-quarter (23.9%) disclosed their intent to die.
Almost half left a suicide note (47.2%). Forty
investigative narratives included information
on the decedent’s sexual orientation; of these, six
(15.0%) were identified as sexual minorities. One
in five decedents (20.5%) had a history of cutting
or had evidence of recent cutting. A surprising
finding was that 12.6% of decedents had experienced a technology-related restriction prior
to their death. This included mobile phones,
tablets, gaming systems, or computers being
taken away by a parent or guardian (Table 1).

The 2015 Prevention Needs Assessment survey (PNA) was analyzed to
determine risk and protective factors for youth suicide. Among youth
less than age 18 in grades 8, 10, and 12, approximately 19% considered or
planned suicide in the past year and 8.6% reported a suicide attempt. Significant risk factors for suicide ideation were being bullied at school or online
and substance use in the previous month. Multiple logistic regression identified being female, in 10th grade, non-White, and low parental education as
risk factors for suicide ideation and attempt. Youth in the TriCounty Health
District also were at higher risk. Students who reported participating more

Suicide Ideation and Attempt Characteristics

Table 2. Odds ratios of characteristics of suicide ideation and attempt among
youth less than age 18 in grades 8, 10, and 12, Utah, 2015
Suicide Ideation
Characteristic

Youth Suicide Decedent
Characteristics

Number

Percent

Suicide Attempt

Odds Ratio (95% Confidence Interval)

SEX

Table 1. Precipitating circumstances for suicide
decedents aged 10–17 years, Utah, 2011–2015
Mental health diagnosis
Mental health treatment
Current depressed mood
Sexual minority (N=40*)
History of ideation or attempt
Suicidal thoughts (ideation)
Suicide attempts
Recent crisis
Family relationship problems
Intimate partner problems
School problem, legal problem, or
suicide of friend
Disclosed intent in past month
To friend
Parents/guardian
Left a suicide note
Technology-related restrictions
Cutting and history of cutting

facility was lower if the patient was Hispanic in both the ED (OR=.45)
and hospital (OR=.12).

n

50
42
44
6
42
26
23
82
31
15

%

35.2
84.0
31.0
15.0
29.6
18.3
16.2
55.3
21.4
10.6

19 13.4
34
14
11
67
18
30

23.9
41.2
32.4
47.2
12.6
20.5

* Information for this circumstance was only available for N=40 decedents.
Source: Utah Violent Death Reporting System

There were 3,005 emergency department (ED)
visits and 690 inpatient hospitalizations for
self-inflicted injury among Utah youth aged
10–17 during 2011–2014. The majority of
suicide attempts were among non-Hispanic
White females. The predominant method of
injury was poisoning (72.4%), followed by cutting/piercing (23.0%). The majority of youth
seen in the ED (60.3%) were discharged to
home or self-care and 24.5% were transferred
to psychiatric care. The likelihood of being
transferred from a hospital to a psychiatric

Male

12,706

46.7

Reference Group

Reference Group

Female

14,507

53.3

2.15 (1.96–2.37)

2.46 (2.16–2.79)

10–14

13,111

48.0

Reference Group

Reference Group

15–17

14,218

52.0

1.33 (1.18–1.50)

1.07 (0.91–1.26)

8th

13,206

48.3

Reference Group

Reference Group

10th

10,616

38.9

1.42 (1.24–1.63)

1.21 (1.01–1.45)

12th

350

12.8

1.11 (0.95–1.29)

0.72 (0.57–0.91)

21,988

80.8

Reference Group

Reference Group

5,208

19.2

1.33 (1.19–1.48)

1.79 (1.57–2.04)

17,479

66.5

0.51 (0.47–0.55)

0.42 (0.36–0.48)

8,792

33.5

Reference Group

Reference Group

Less Than High School

1,561

6.5

1.88 (1.55–2.28)

2.89 (2.30–3.63)

High School Graduate or
Some College

7,707

32.2

1.50 (1.35–1.66)

1.78 (1.54–2.07)

14,649

61.3

Reference Group

Reference Group

Bear River

3,610

13.2

0.73 (0.60–0.88)

0.80 (0.64–1.00)

Central

1,496

5.5

0.79 (0.62–1.02)

0.90 (0.60–1.36)

Davis

2,545

9.3

0.84 (0.67–1.06)

0.86 (0.62–1.17)

Salt Lake

7,325

26.8

Reference Group

Reference Group

San Juan

192

0.7

0.81 (0.57–1.17)

1.20 (0.62–2.30)

Southeast

836

3.1

0.80 (0.55–1.17)

1.05 (0.68–1.62)

Southwest

2,450

9.0

0.83 (0.69–0.99)

0.93 (0.73–1.17)

826

3.0

0.67 (0.54–0.84)

0.56 (0.40–0.79)

1,877

6.9

1.03 (0.78–1.36)

1.35 (0.96–1.88)

439

1.6

1.34 (1.15–1.57)

1.57 (1.33–1.85)

3,426

12.5

0.95 (0.78–1.16)

1.11 (0.88–1.40)

671

2.5

0.58 (0.39–0.86)

0.52 (0.41–0.65)

1,636

6.0

1.04 (0.84–1.31)

1.11 (0.87–1.43)

AGE GROUP (YEARS)

GRADE LEVEL

RACE
White
Non-White
RELIGIOUS ATTENDANCE*
Religious
Less Religious
PARENT EDUCATION LEVEL

College Graduate
LOCAL HEALTH DISTRICT

Summit
Tooele
TriCounty
Utah County
Wasatch
Weber-Morgan

* Based on a question asking “How often do you attend religious service or activities?” Responses of “never” and
“rarely” were categorized as less religious and “attends 1–2 times per month” and “about once a week or more” were
categorized as religious.
Highlighting indicates statistical significance at a p-value <0.05.
Source: Utah Prevention Needs Assessment

 frequently in religious activities and those from
Bear River, Southwest, Summit, and Wasatch
Health Districts had lesser risk (Table 2).
Supportive social environments were found to
be protective for suicide ideation and attempts.
Supportive social environments are characterized by ones in which youth feel involved, valued, and able to ask for and receive help when
they need it. Supportive family environments
had the biggest impact on reducing suicide
ideation (OR=.72), followed by community
environments (OR=.82), school environments
(OR=.85), and peer environments (OR=.93) all
reduced the odds of suicide ideation (Table 3).
The Epi-Aid team also reviewed three youth
suicide prevention programs in Utah: QPR,
Hope Squad, and Hope for Tomorrow.
•  The Question, Persuade, Refer (QPR)
program is designated by the Suicide
Prevention Resource Center (SPRC) as
an evidence-based suicide prevention
program. QPR improves knowledge
about suicide, gatekeeper self-efficacy,
gatekeeper skills, and knowledge of suicide prevention resources. To learn more
about QPR, visit www.qprinstitute.com.
•  Hope Squad is not currently designated
by the SPRC as an evidence-based suicide
prevention program. However, a pre- and
post-test of trainees found members to
be active in providing help, support, and
assistance to fellow peers in their schools.
To learn more about Hope Squads, visit
http://hope4utah.com/hope-squad.
•  Hope for Tomorrow is not currently designated by the SPRC as an evidence-based
suicide prevention program. However,
the program was found to help increase
knowledge about mental illness and
recognition of signs and symptoms of
mental illness. To learn more about Hope
for Tomorrow, visit www.namiut.org/
families-caregivers/schools/item/104hope-for-tomorrow.
For additional information about this
topic, contact Michael Friedrichs, Utah
Department of Health, (801) 538-6244,
email: mfriedrichs@utah.gov; or the
Office of Public Health Assessment, Utah
Department of Health, (801) 538-9191,
email: chdata@utah.gov.

Positive Social Environments

Table 3. Odds ratios of positive social environments and suicide ideation and
attempt among youth less than age 18 in grades 8, 10, and 12, Utah, 2015
Total
Sample Overall
Size
Mean

Suicide Ideation

Supportive Family Environment

13,442

9.37

0.72 (0.70–0.74)

Supportive Community Environment

13,482

7.46

0.82 (0.80-0.83)

0.79 (0.76-0.81)

Supportive School Environment

26,728

14.15

0.85 (0.83–0.87)

0.85 (0.83–0.87)

Supportive Peer Environment

13,365

17.80

0.93 (0.92–0.94)

0.91 (0.90–0.92)

Characteristic

Suicide Attempt

Odds Ratio (95% Confidence Interval)
0.71 (0.68–0.73)

Highlighting indicates statistical significance at a p-value <0.05.
Source: Utah Prevention Needs Assessment

The Epi-Aid team made several recommendations:
•  Increase access to evidence-based mental health care for youth
•  Strengthen family relationships
•  Promote connectedness at various levels of the socio-ecologic
framework
•  Identify and provide support to youth at risk of suicidal behaviors
•  Prevent other forms of violence in this population
•  Reduce access to lethal means
•  Teach coping and problem solving skills
•  Consider comprehensive and coordinated suicide prevention
programs that address multiple risk and protective factors simultaneously
•  Conduct ongoing comprehensive evaluation of suicide prevention
programs
Given the paucity of data on sexual orientation, yet its potential importance in understanding risk and protective factors for suicide and other
health disparities, the UDOH is making efforts to include questions on
this topic in the Student Health and Risk Prevention (SHARP) surveys.
Recognizing the need to address suicide prevention efforts in Utah, the
Utah State Legislature has passed a number of bills related to suicide
prevention education, means restriction, training, access to treatment
and the creation of several positions in state agencies to address this issue.
For example, in 2015, SB 175 “School Safety & Crisis Line” sponsored
by Senator Thatcher created a student safety and crisis tipline, in 2016,
HB 440 “Suicide Prevention & Gun Data Study” sponsored by Representative King required a study to be conducted related to suicide prevention and firearms, and in 2017, HB 346 “Suicide Prevention Programs”
sponsored by Representative Eliason, created a position at the Office
of the Medical Examiner to study suicide deaths and provided for the
award of grants that focus on suicide prevention efforts targeting youth.
There is a strong partnership between state, community-level agencies,
and private partners, including the Suicide Prevention Coalition, that
are working on making the Epi-Aid team recommendations actionable.
For more information about what is being done in the state, and how to
get involved, visit utahsuicideprevention.org.
References

1. Epidemiologic Assistance (Epi-Aids). Epidemic Intelligence Service. CDC.
Accessed at https://www.cdc.gov/eis/epiaids.html.