Ethnic Differences in Risk Factors For Suicide Among American High School Students, 2009: The Vulnerability of Multiracial and Pacific Islander Adolescents

Abstract

This study compared self-reported risk factors for suicide among American high school students in the last decade. Data from the 1999-2009 Youth Risk Behavior Surveys was analyzed by 8 self-reported ethnicity groups across 6 suicide-related items: depression, suicide ideation, suicide planning, suicide attempts, and suicide attempts requiring medical attention). Native Hawaiian/Pacific Islander adolescents had the higher prevalence of risk factors for suicide. Multiracial adolescents were also at high risk for suicide-related behaviors, with a risk comparable to American Indian/Alaska Native adolescents. Overall, Native Hawaiian/Pacific Islander, multiracial, and American Indian/Alaska Native adolescents reported a significantly higher risk for suicide-related behaviors compared to their Asian, Black, Hispanic, and White peers. The ethnic disparities in risk factors for suicide dictate a need to understand the vulnerability of the Pacific Islander, American Indian, and growing multiracial adolescent populations, in an effort to develop and implement suicide prevention strategies.

Full text

Ethnic Differences in
Risk Factors For Suicide
Among American High
School Students, 2009: The
Vulnerability of Multiracial
and Pacific Islander
Adolescents
Shane Shucheng Wong, Jeanelle J. Sugimoto-Matsuda,
Janice Y. Chang, and Earl S. Hishinuma
This study compared self-reported risk factors for suicide among American high
school students in the last decade. Data from the 1999–2009 Youth Risk Behavior
Surveys was analyzed by 8 self-reported ethnicity groups across 6 suicide-related
items: depression, suicide ideation, suicide planning, suicide attempts, and suicide
attempts requiring medical attention). Native Hawaiian=Pacific Islander adolescents
had the higher prevalence of risk factors for suicide. Multiracial adolescents were also
at high risk for suicide-related behaviors, with a risk comparable to American
Indian=Alaska Native adolescents. Overall, Native Hawaiian=Pacific Islander,
multiracial, and American Indian=Alaska Native adolescents reported a signifi-
cantly higher risk for suicide-related behaviors compared to their Asian, Black,
Hispanic, and White peers. The ethnic disparities in risk factors for suicide dictate
a need to understand the vulnerability of the Pacific Islander, American Indian, and
growing multiracial adolescent populations, in an effort to develop and implement
suicide prevention strategies.
Keywords adolescence, ethnic differences, high school students, mental health, minority health,
risk factors, suicide
INTRODUCTION
Suicide is a major public health concern for
American adolescents. As the third leading
cause of death among youth 14 to 18 years
of age, it accounts for 11 percent of
all deaths in this age group (Centers for
Disease Control and Prevention, 2010).
Unfortunately, completed suicides reflect
only a small proportion of suicide-related
thoughts, behaviors and injuries among
youth. There are many risk factors, from
depression and suicide ideation to suicide
planning and suicide attempts, that predict
Archives of Suicide Research, 16:159–173, 2012
Copyright #International Academy for Suicide Research
ISSN: 1381-1118 print=1543-6136 online
DOI: 10.1080/13811118.2012.667334
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suicide completion. These thoughts and
behaviors are important to assess beginning
in adolescence, given that depression at an
early age of onset is a significant predictor
of suicide completion, the probability of
transitions from suicide ideation and plans
to attempts is high, and as one of the stron-
gest predictors of future completed suicide,
suicide attempts tend to peak between 16
and 18 years of age (Gould, Greenberg,
Velting et al., 2003; Kessler, Borges, &
Walters, 1999; Mann, Waternaux, Haas
et al., 1999).
Unfortunately, little is known about
suicide risk factors among ethnic minorities
(Colucci & Martin, 2007). In particularly,
an emerging issue is the prevalence of
health-risk behaviors among multiracial
youth, a minority population of 6.8 million
according to the 2000 Census and currently
the fastest-growing demographic group in
the United States (United States Census
Bureau, 2001, 2010). A growing literature
attests empirically to the emotional-,
health-, and behavior-risk problems of this
population, including substance abuse and
violence (Choi, Harachi, Gillmore et al.,
2006). However, other studies have
demonstrated conflicting findings with no
elevation of risk behaviors among multi-
racial youth (Danko, Miyamoto, Foster
et al., 1997; Johnson & Nagoshi, 1986).
Furthermore, very few studies investigating
risk factors for suicide among multiracial
adolescents were found. These investiga-
tions, based on data a decade or more
ago, suggest that multiracial adolescents
are at an elevated risk for suicide (Olvera,
2001; Roberts, Chen, & Roberts, 1997;
Udry, Li, & Hendrickson-Smith, 2003;
Whaley & Francis, 2006). There has yet
to be any national studies comparing multi-
racial adolescents to their peers on a range
of suicide risk factors, including suicide
attempts.
Another important issue is the ethnic
disaggregation of the Asian and Pacific
Islander (API) populations, which numbers
14.6 million in the United States (United
States Census Bureau, 2010). Due to gener-
ally low rates of health-risk behaviors
reported for aggregated API youth, includ-
ing a recent study on risk factors for
suicide, this population has been described
as a ‘‘model minority’’ group—implying that
API adolescents do not require targeted
support for success in society (Centers for
Disease Control and Prevention, 2009;
Grunbaum, Lowry, Kann et al., 2000;
Schuster, Bell, Nakajima et al., 1998). How-
ever, conclusions drawn from such research
are likely to be misleading given the hetero-
geneity of the population. Recent studies on
the disaggregated API population have
indeed shown that the prevalence of
health-risk behaviors differ significantly
between Asians and Pacific Islanders (Choi,
2008; Sasaki & Kameoka, 2009).
The few studies on suicide among Pacific
Islanders have reported elevated suicide rates
compared to their peers in the United States
(Booth, 1999; Wong, Klingle, & Price, 2004;
Yuen, Andrade, Nahulu et al., 1996). More
recent studies within the State of Hawaii sug-
gest that suicidal thoughts and behaviors are
indeed significantly higher among Native
Hawaiian adolescents compared to their
non-Hawaiian peers (Else, Andrade, &
Nahulu,2007;Yuen,Nahulu,Hishinuma
et al., 2000). On the other hand, the risk fac-
tors for suicide among the Asian American
population appears lower, although the litera-
ture is not entirely conclusive (Evans, Haw-
ton, Rodham et al. 2005; Kisch, Leino, &
Silverman, 2005; Shiang, Binn, Bongar et al.,
1997). To date, no studies on risk factors for
suicide using national samples of disaggre-
gated Asian and Pacific Islander adolescents
have been reported.
In 1999, the Centers for Disease
Control and Prevention (CDC) began cod-
ing Asians and Native Hawaiians=Pacific
Islanders as two separate ethnic categories
for the Youth Risk Behavior Survey
(YRBS), and introduced the ‘‘multiple
(Hispanic)’’ and ‘‘multiple (non-Hispanic)’’
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ethnic groups. We test the hypothesis that
multiracial and Pacific Islander adolescents
are at significantly higher risk for suicide in
comparison to their peers.
METHODS
Sample Description
Demographic and suicide-related
response data were utilized from the
1999, 2001, 2003, 2005, 2007, and 2009
YRBS, a nationally representative survey
of high school students administered every
2 years. A total of 88,532 school question-
naires were completed by students from
1999 to 2009. Table 1 presents the sample
description. The average age of respon-
dents was 16.2 years old.
Measures
Demographics. Gender, grade level, year
and ethnicity were provided by the data.
In the 1999 to 2003 surveys, ethnicity was
identified by responses to the following
question: ‘‘How do you describe yourself?’’
Respondents were allowed to select one or
more answers from six response options:
‘‘American Indian or Alaska Native, Asian,
Black or African American, Hispanic or
Latino, Native Hawaiian or Other Pacific
Islander, or White.’’ In the 2005 to 2009
surveys, this question was broken down
into two questions: ‘‘Are you Hispanic or
Latino?’’ and ‘‘What is your race?’’ For
the latter, respondents were allowed to sel-
ect more than one answer from the five
response options: ‘‘American Indian or
Alaska Native, Asian, Black or African
American, Native Hawaiian or Other
Pacific Islander, or White.’’ Students who
checked Hispanic=Latino and one or more
other responses comprised the Multiracial
Hispanic group, and students who checked
more than one response but not Hispanic=
Latino constituted the Multiracial non-
Hispanic group. Ethnicity categories will
henceforth be abbreviated to American
Indian, Asian, Black, Hispanic, Multiracial
(Hispanic), Multiracial (Non-Hispanic),
Pacific Islander, and White.
Risk Factors for Suicide. Five YRBS ques-
tions concerning different risk factors for
suicide were recoded into 6 responses each
with a binary answer:
1. Depression: ‘‘During the past 12
months, did you ever feel so sad or
hopeless almost every day for two
weeks or more in a row that you
stopped doing some usual activities?
Yes, No.’’
2. Suicide ideation: ‘‘During the past 12
months, did you ever seriously consider
attempting suicide? Yes, No.’’
3. Suicide planning: ‘‘During the past 12
months, did you make a plan about
how you would attempt suicide? Yes,
No.’’
4. Suicide attempt: ‘‘During the past 12
months, how many times did you actu-
ally attempt suicide? 0 times, 1 time, 2
or 3 times, 4 or 5 times, 6 or more
times.’’ To calculate the prevalence of
suicide attempts, the response choices
were recoded into binary choices: 0
times were recoded as ‘‘0,’’ and 1 or
more times was recoded as ‘‘1.’’
5. Severe suicide attempt among all youth:
‘‘If you attempted suicide during the
past 12 months, did any attempt result
in an injury, poisoning, or overdose that
had to be treated by a doctor or nurse?’’
The three choices were: ‘‘Did not
attempt suicide,’’ ‘‘Yes,’’ and ‘‘No.’’ To
calculate the prevalence of severe sui-
cide attempts requiring medical atten-
tion, ‘‘Did not attempt suicide’’ and
‘‘No’’ were recoded as ‘‘0,’’ and ‘‘Yes’’
was recoded as ‘‘1.’’
S. S. Wong et al.
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7. Severe suicide attempt only among those
who attempted: This variable was based
on the same question as ‘‘severe suicide
attempt’’ above, but recoded: ‘‘No’’ was
recoded as ‘‘0,’’ and ‘‘Yes’’ was recoded
as ‘‘1.’’ ‘‘Did not attempt suicide’’ was
recorded to be a missing score. This
response is different from response 5
because it studies the prevalence of
severe suicide attempts only among
those who made an attempt, rather than
among all youth who were administered
the questionnaire.
Data Analyses
Analyses were conducted using SAS
Version 9.2. YRBS weights based on gender,
ethnicity, and grade level were applied to
provide representative prevalences of ado-
lescents in the United States. Prevalence of
TABLE 1. Sample Description
Unweighted count Unweighted %Weighted %
e
Ethnicity
a
American Indian 1,053 1.2 0.9
Asian 2,953 3.4 3.3
Black 19,597 22.4 14.2
Hispanic 17,242 19.8 10.3
Multiracial (Hispanic) 5,975 6.8 4.6
Multiracial (Non-Hispanic) 2,589 3.0 4.2
Pacific Islander 770 0.9 0.8
White 37,114 42.5 61.7
Gender
b
Female 44,833 50.8 49.3
Male 43,366 49.2 50.7
Grade Level
c
9th Grade 21,741 24.7 29.0
10th Grade 21,825 24.8 26.1
11th Grade 22,313 25.3 23.4
12th Grade 22,153 25.2 21.5
Year
d
1999 15,349 17.3 17.4
2001 13,601 15.4 15.4
2003 15,214 17.2 17.2
2005 13,917 15.7 15.7
2007 14,041 15.9 15.9
2009 16,410 18.5 18.5
Total 88,532 100.0 100.0
Note.
a
Ethnicity (weighted): v
2
[7, N¼87,293] ¼8,514.4, p<.0001.
b
Gender (weighted): v
2
[1, N¼88,199] ¼3.1, p¼.08.
c
Grade Level (weighted): v
2
[3, N¼88,032] ¼280.3, p<.0001.
d
Year (weighted): v
2
[5, N¼88,532] ¼1.2, p¼.94.
e
Weighted based on ethnicity, gender, and grade level.
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suicide-related responses were calculated
based on the four demographic variables:
ethnicity, gender, grade level, and year. Uni-
variate and multiple logistic regression
analyses were utilized. Given the large sam-
ple size, substantial statistical power, and
multiple comparisons, alpha was set at
<.0001, 2-tailed test.
RESULTS
Table 2 reports the prevalence and 95%
confidence interval for each suicide-related
response by ethnicity, gender, grade level,
and year. Between 1999 and 2009, 28.0%
of high school students responded that, in
the 12 months preceding the survey, they
had experienced feelings of sadness and
hopelessness for two weeks that caused
them to stop doing some usual activities;
16.7%responded that they had seriously
considered attempting suicide in the past
year; 13.5%responded that they had made
a plan about how they would attempt sui-
cide in the past year; 7.8%responded that
they had actually attempted suicide at least
once in the last year, of which 30.3%of
those who attempted suicide required medi-
cal attention; and overall 2.3%of all high
school students made a suicide attempt that
required medical attention in the past year.
By gender, females reported higher
rates of depression symptoms, suicide idea-
tion, suicide planning, suicide attempts, and
suicide attempts requiring medical attention
(overall). However, among only those who
attempted suicide, males reported a higher
proportion of suicide attempts that
required medical attention. Results by high
school grade level indicated that younger
students reported higher rates of suicidal
ideation, planning, and attempts. However,
there were no significant differences
among grade levels for depression and
severity of suicide attempts among those
who attempted in the past. By year, the pre-
valences decreased over the last decade,
except for severe suicide attempts among
only those who attempted suicide, which
remained relatively constant.
To investigate the differences in sui-
cide-related responses by ethnicity, we first
conducted a logistic regression with eth-
nicity as the categorical independent vari-
able. Overall, there was a significant
difference (p<.0001) by ethnicity for
depression, suicide ideation, suicide plan-
ning, suicide attempts, and severe suicide
attempts overall (see Table 2). Severe sui-
cide attempts among only those who
attempted was statistically significant only
at the p<.001 level.
Using the five suicide-related questions
that were significantly different by ethnicity
(p<.0001), we conducted pair-wise com-
parisons for all ethnic groups and com-
puted the odds ratios (see Table 3). The
ratio is more than 1.0 when the first group
(first column of Table 3) in the comparison
is at greater risk than the second group
(first row of numbers in Table 3), and the
ratio is less than 1.0 when the first group
is at lower risk. For example, Pacific Islan-
ders had a statistically significant 1.78-fold
increased risk of depression as compared
to Whites. If the two groups are at equal
risk, their odds ratio is not significantly dif-
ferent from 1.0 (evaluated here at the
alpha <.0001 level, 2-tailed test).
To determine the overall pattern of
results (see Table 3), a calculation for each
ethnicity was made by comparing the num-
ber of the odds ratios significantly greater
than 1.0 against the number of ratios signifi-
cantly less than 1.0. This was done for each
ethnicity in comparison to the other seven
ethnicities, on each of the five suicide ques-
tions significantly different by ethnicity.
Pacific Islanders had the highest proportion
of ‘‘greater than’’ vs. ‘‘less than’’ odds ratios,
(21:0), whereas Whites had the lowest
proportion (2:27). Ratios of the ethnic
groups were as follows: Pacific Islander ¼
21:0; Multiracial (non-Hispanic) ¼20:0;
American Indian ¼15:0; Multiracial
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TABLE 2. Prevalences and 95%Confidence Intervals of Risk Factors for Suicide by Ethnicity,
Gender, Grade Level, and Year
Depression %
95%CI
Suicide
ideation %
95%CI
Suicide
plan %
95%CI
Suicide
attempt %
95%CI
Severe
attempt
among all
youth %
95%CI
Severe attempt
among only those
who attempted %
95%CI
Ethnicity
American Indian 32.7 23.3 19.6 16.2 5.9 39.0
28.4–37.0 19.7–26.9 15.5–23.7 13.0–19.4 3.2–8.6 25.4–52.4
Asian 26.4 17.2 16.2 7.9 2.5 32.4
23.9–28.8 15.2–19.2 14.1–18.2 6.3–9.4 1.6–3.4 23.1–41.7
Black 28.2 13.2 10.2 7.9 2.6 34.9
27.2–29.1 12.5–14.0 9.5–10.9 7.2–8.6 2.1–3.0 30.7–39.2
Hispanic 33.9 16.1 13.8 10.3 2.9 29.1
32.7–35.0 15.1–17.1 12.3–15.2 9.6–11.1 2.4–3.3 24.6–33.6
Multiracial (Hispanic) 37.0 20.4 16.5 10.9 3.6 33.3
35.2–38.7 18.8–22.1 15.2–17.9 9.7–12.2 2.9–4.3 27.6–39.0
Multiracial
(Non-Hispanic)
35.0 27.2 21.6 13.1 4.1 31.8
31.8–38.2 24.3–30.1 19.0–24.2 11.2–15.0 2.9–5.3 22.9–40.7
Pacific Islander 37.9 25.7 23.4 17.4 6.5 40.4
33.5–42.3 21.5–30.0 18.8–28.0 13.0–21.8 3.1–9.9 25.8–55.0
White 25.5 16.3 13.0 6.6 1.8 28.2
24.8–26.3 15.7–16.9 11.9–14.0 6.1–7.0 1.6–2.0 26.0–30.5
Gender
Female 35.3 21.3 16.3 10.3 2.8 27.5
34.5–36.1 20.6–22.0 15.4–17.1 9.7–10.8 2.5–3.0 25.3–29.7
Male 20.8 12.2 10.7 5.4 1.8 35.4
20.2–21.5 11.7–12.7 9.9–11.5 5.0–5.8 1.6–2.0 32.3–38.6
Grade Level
9th Grade 28.1 17.2 14.0 9.4 2.8 30.4
27.1–29.1 16.3–18.0 13.0–15.1 8.7–10.1 2.4–3.1 27.3–33.5
10th Grade 28.3 17.6 14.5 8.8 2.5 28.3
27.4–29.2 16.8–18.4 13.6–15.4 8.2–9.5 2.2–2.7 25.6–31.0
11th Grade 27.9 16.4 13.2 6.9 2.1 31.4
27.0–29.0 15.5–17.2 12.2–14.3 6.3–7.4 1.8–2.4 27.8–35.1
12th Grade 27.2 15.1 11.4 5.3 1.6 29.8
26.3–28.2 14.3–15.8 10.5–12.4 4.9–5.8 1.3–1.8 26.1–33.6
Year
1999 28.3 19.3 14.5 8.3 2.6 31.0
26.9–29.6 18.1–20.4 13.2–15.9 7.3–9.3 2.0–3.2 24.9–37.2
2001 28.3 19.0 14.8 8.8 2.6 29.9
26.9–29.6 17.8–20.3 13.7–15.9 8.0–9.7 2.3–3.0 26.9–32.9
(Continued )
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(Hispanic) ¼13:4; Hispanic ¼8:14; Asian ¼
3:14; Black ¼3:26; and White ¼2:27.
Therefore, these findings show a higher
prevalence of suicide risk factors for
suicide-related behaviors among Pacific
Islander, American Indian, and both
Multiracial adolescent groups compared to
the Hispanic, Asian, Black, and White
groups.
Finally, multiple logistic regression
analyses were conducted to examine two-
way demographic interactions with
ethnicity for each of the suicide-related
responses, to determine whether the
prevalence of self-reported risk factors for
suicide changed for ethnicity across the
values of gender, grade level, or year. For
example, the first model entailed ethnicity
as a main effect, grade level as a main
effect, and the ethnicity-gender interaction
effect with depression as the dependent
measure. Results show that five two-way
interaction effects were statistically signifi-
cant (p<.0001; see Table 4).
1. #1: Over the past decade, suicide
planning generally decreased for most
ethnicities, but American Indian, Asian,
Hispanic, White, and Multiracial (non-
Hispanic) youth showed a peak in
prevalence in 2003.
2. #2&#3: Over the past decade, severe
suicide attempts both overall and
among only those who attempted gen-
erally remained constant or decreased sli-
ghtly for most ethnicities, but American
Indians showed sharp decreases while
Asian, Hispanic, Pacific Islander, and
TABLE 2. Continued
Depression %
95%CI
Suicide
ideation %
95%CI
Suicide
plan %
95%CI
Suicide
attempt %
95%CI
Severe
attempt
among all
youth %
95%CI
Severe attempt
among only those
who attempted %
95%CI
2003 28.6 16.9 16.5 8.5 2.6 33.0
26.7–30.5 16.1–17.6 13.0–20.0 7.4–9.5 2.0–3.1 28.0–38.0
2005 28.5 16.9 13.0 8.4 2.3 28.4
27.1–29.8 15.9–17.8 12.1–13.8 7.5–9.3 1.9–2.7 24.2–32.6
2007 28.5 14.5 11.3 6.9 1.9 28.3
27.1–29.8 13.3–15.6 10.3–12.2 6.2–7.7 1.6–2.3 24.7–31.9
2009 26.1 13.8 10.9 6.3 1.9 30.6
24.8–27.4 13.1–14.6 10.0–11.7 5.7–7.0 1.6–2.3 26.9–34.4
Total 28.0 16.7 13.5 7.8 2.3 30.3
27.4–28.6 16.2–17.1 12.7–14.2 7.5–8.2 2.1–2.5 28.5–32.2
Depression
Suicide
ideation
Suicide
planning
Suicide
attempt
Severe attempt
overall
Severe attempt for
those who
attempted
Probabilities (pvalues) of Univariate Logistic Regressions
Ethnicity <.0001 <.0001 <.0001 <.0001 <.0001 .0007
Gender <.0001 <.0001 <.0001 <.0001 <.0001 <.0001
Grade level .1008 <.0001 <.0001 <.0001 <.0001 .2678
Year <.0001 <.0001 <.0001 <.0001 <.0001 .1768
Note. Bolded numbers indicate the prevalence of the suicide risk factor in each specified demographic group.
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TABLE 3. Odds Ratios for Pair-Wise Comparisons by Ethnicity
Suicide-related
item White Black Asian Hispanic
Multiracial
(Hispanic)
American
Indian
Multiracial
(Non-Hispanic)
Pacific
Islander
Pacific Islander
Depression 1.781.561.701.19 1.04 1.26 1.13 –
Ideation 1.782.271.661.801.35 1.14 0.93 –
Plan 2.052.681.581.911.541.25 1.11 –
Attempt 3.002.452.471.831.721.09 1.40 –
Severe attempt 3.752.612.692.341.85 1.10 1.62 –
Multiracial
(Non-Hispanic)
Depression 1.571.371.501.05 0.92 1.11 – 0.88
Ideation 1.922.451.791.951.451.23 – 1.08
Plan 1.852.421.431.731.391.13 – 0.90
Attempt 2.151.751.771.311.23 0.78 – 0.72
Severe attempt 2.321.621.66 1.451.15 0.68 – 0.62
American Indian
Depression 1.421.24 1.36 0.95 0.83 – 0.90 0.80
Ideation 1.561.991.46 1.581.18 – 0.81 0.88
Plan 1.642.141.26 1.531.23 – 0.88 0.80
Attempt 2.752.252.271.681.57 – 1.28 0.92
Severe attempt 3.412.382.442.131.68 – 1.47 0.91
Multiracial
(Hispanic)
Depression 1.711.491.641.14 – 1.21 1.09 0.96
Ideation 1.321.681.24 1.34– 0.85 0.690.74
Plan 1.331.741.02 1.24– 0.81 0.720.65
Attempt 1.751.431.441.06 – 0.64 0.81 0.58
Severe attempt 2.031.41 1.45 1.27 – 0.59 0.87 0.54
Hispanic
Depression 1.491.311.43– 0.87 1.06 0.95 0.84
Ideation 0.99 1.260.92 – 0.750.630.510.55
Plan 1.07 1.400.83 – 0.810.660.580.52
Attempt 1.641.341.35 – 0.94 0.600.770.55
Severe attempt 1.601.11 1.15 – 0.79 0.470.690.43
Asian
Depression 1.04 0.91 – 0.700.610.74 0.670.59
Ideation 1.07 1.36– 1.08 0.81 0.69 0.560.60
Plan 1.301.70– 1.21 0.98 0.79 0.700.63
Attempt 1.21 0.99 – 0.74 0.690.440.560.40
Severe attempt 1.39 0.97 – 0.87 0.69 0.410.60 0.37
(Continued )
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Multiracial (Hispanic) youth showed
peaks in prevalence in 2003.
3. #4&#5: Across grade levels, both
suicide attempts and severe suicide
attempts overall generally decreased
slightly for most ethnicities, but Asians
and Pacific Islanders showed an increas-
ing trend.
DISCUSSION
This study fills a scientific gap of knowledge
regarding youth risk factors for suicide
among ethnic minorities, by comparing
multiracial youth to monoracial youth, and
by disaggregating the heterogeneous Asian
and Pacific Islander ethnic group. Our find-
ings support the conclusion that multiracial
and Pacific Islander adolescents are groups
at high-risk for suicide. The first hypothesis
of greater risk status for multiracial adoles-
cents compared to their monoracial peers
is supported by our results. Both groups
of multiracial adolescents, similar to Amer-
ican Indians, had at least 13 odds ratios sig-
nificantly greater than 1.0. For example,
both groups of multiracial adolescents were
more likely to report depression symptoms,
suicide ideation, suicide planning, and sui-
cide attempts in the past year compared to
White and Black youth (OR: 1.32–2.45;
p<.0001). Notably, non-Hispanic multira-
cial youth reported a significantly higher
prevalence of suicide ideation and planning
compared to Hispanic multiracial youth
(OR: 1.45, 1.39; p<.0001).
The second hypothesis of greater risk
status of Pacific Islanders compared to
Asians is strongly supported. Compared
to Asians, Pacific Islander adolescents
were more likely to report depressive
symptoms, serious consideration of suicide,
suicide planning, suicide attempts, and sui-
cide attempts requiring medical attention
TABLE 3. Continued
Suicide-related
item White Black Asian Hispanic
Multiracial
(Hispanic)
American
Indian
Multiracial
(Non-Hispanic)
Pacific
Islander
Black
Depression 1.14– 1.10 0.770.670.81 0.730.64
Ideation 0.78– 0.730.800.590.500.410.44
Plan 0.76– 0.590.710.580.470.410.37
Attempt 1.23– 1.01 0.750.700.450.570.41
Severe attempt 1.44– 1.03 0.90 0.71 0.420.620.38
White
Depression – 0.870.96 0.670.580.710.640.56
Ideation – 1.280.94 1.02 0.760.640.520.56
Plan – 1.310.770.93 0.750.610.540.49
Attempt – 0.820.82 0.610.570.360.470.33
Severe attempt – 0.700.72 0.630.490.290.430.27
Note: The odds ratio is more than 1.0 when the first group (first column of Table 3) in the comparison is at
greater risk than the second group (first row of numbers in Table 3), and the ratio is less than 1.0 when the
first group is at lower risk. For example, Pacific Islanders had a statistically significant 1.78-fold increased risk
of depression as compared to Whites. The odds ratios on the upper-left of the table are reciprocals (1=odds
ratio) of the bottom-right odds ratios. For example, Pacific Islanders had a 1.78-fold increased risk for
depression as compared to Whites (upper-left of table), and Whites had 0.56 the risk for depression as compared
to Pacific Islanders (bottom-right of table). 1=0.56 ¼1.78.
p<.0001.
S. S. Wong et al.
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TABLE 4. Prevalences of Significant Two-Way Interaction Effects (p<.0001)
1999 (%) 2001 (%) 2003 (%) 2005 (%) 2007 (%) 2009 (%)
A. Suicide Planning: Ethnicity Year
American Indian 24.3 20.0 26.5 13.8 14.7 17.0
Asian 17.9 18.1 24.5 13.3 10.8 12.6
Black 11.7 10.3 10.4 9.6 9.5 9.8
Hispanic 15.8 13.3 17.9 13.5 10.4 10.1
Multiracial (Hispanic) 25.1 19.1 16.0 16.3 15.3 15.1
Multiracial (Non-Hispanic) 24.2 17.9 26.7 26.4 15.3 13.2
Pacific Islander 29.5 23.3 26.9 28.1 21.3 13.2
White 12.4 15.3 16.2 12.5 10.8 10.3
B. Severe Suicide Attempt Overall: Ethnicity Year
American Indian 15.4 6.6 3.6 5.4 2.2 1.9
Asian 1.9 2.4 5.5 1.9 2.1 1.4
Black 2.9 3.3 2.9 1.9 2.3 2.5
Hispanic 2.5 3.3 4.5 2.6 1.9 1.8
Multiracial (Hispanic) 4.6 3.9 3.7 4.1 3.8 2.8
Multiracial (Non-Hispanic) 4.9 3.6 4.4 1.6 3.3 4.2
Pacific Islander 4.6 3.2 13.9 9.9 1.4 3.8
White 1.9 2.3 1.6 2.0 1.5 1.6
C. Severe Suicide Attempt Among Only Those Who Attempted: Ethnicity Year
American Indian 80.1 33.8 30.6 33.8 15.5 19.7
Asian 27.0 24.5 39.2 28.1 38.0 34.1
Black 39.0 38.0 40.9 29.4 29.9 31.4
Hispanic 19.7 27.4 43.1 25.3 21.7 26.1
Multiracial (Hispanic) 35.5 29.1 52.5 34.2 33.2 28.5
Multiracial (Non-Hispanic) 39.4 30.2 25.1 13.9 30.1 33.5
Pacific Islander 21.8 18.2 74.5 51.6 14.9 39.5
White 28.5 29.4 24.7 28.8 26.8 31.4
Grade 9 (%) Grade 10 (%) Grade 11 (%) Grade 12 (%)
D. Suicide Attempt: Ethnicity Grade Level
American Indian 18.7 18.6 16.2 8.0
Asian 7.9 6.0 8.0 8.7
Black 8.5 8.2 7.2 7.3
Hispanic 11.5 12.0 8.8 7.4
Multiracial (Hispanic) 12.2 10.9 8.6 9.3
Multiracial (Non-Hispanic) 16.9 14.0 10.5 9.4
Pacific Islander 12.9 17.5 15.9 24.2
White 8.2 7.9 5.9 3.8
E. Severe Suicide Attempt Overall: Ethnicity Grade Level
American Indian 6.6 5.4 8.7 2.0
Asian 2.5 1.1 1.9 3.6
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(OR: 1.58–2.69; p<.0001). Indeed, Pacific
Islander adolescents endorsed the highest
risk for suicide-related responses by eth-
nicity, with 21 out of 35 odds ratios signifi-
cantly greater than 1.0 overall.
Our findings demonstrate that multira-
cial adolescents are at relatively high risk of
suicide, with a risk comparable to that of
American Indian youth. The literature has
recognized American Indian adolescents as
an at-risk population, but empirical research
has only recently emerged to suggest similar
vulnerabilities among multiracial youth.
Such studies have found that multiracial
adolescents report higher rates of poor
mental health and academic adjustment,
and greater risk behaviors, such as substance
use and violence (Choi, Harachi, Gilmore
et al., 2006; Cooney & Radina, 2000; Olvera,
2001; Roberts, Chen, & Roberts, 1997;
Udry, Li, & Hendrickson-Smith, 2003;
Whaley & Francis, 2006). Given the con-
tinuing growth of the multiracial popula-
tion, there is a vital need to understand the
mental health concerns of this youth group.
This is also the first national study to
show that by ethnicity, Pacific Islander
adolescents are at the highest risk for sui-
cide in the United States. Over 1 in 6
(17.4%) Pacific Islander adolescents
reported a suicide attempt in the past year
and nearly 1 in 15 (6.5%) made a suicide
attempt that required medical attention—
prevalences more than double the national
rates of 7.8%and 2.3%, respectively.
Compared to Asians, Pacific Islander youth
endorse significantly greater risk factors
suicide. This finding is consistent with pre-
vious literature illustrating considerable dif-
ferences in health-risk behaviors between
the two API ethnic groups (Choi, 2008;
Sasaki & Kameoka, 2009; Wong, Klingle,
& Price, 2004).
It is critical to explicate the root causes
for these findings. Further research is
needed on how culture and cultural identi-
fication influence methodological and
psychological issues of risk factors for sui-
cide. For example, methodologically, a
lower prevalence for Asians may be par-
tially due to shame in self-disclosure of risk
factors for suicide. From a psychological
perspective, the higher rates for Pacific
Islanders, including Native Hawaiians,
may be related to issues of acculturative
stress and cultural conflict.
As immigrants from their native
islands, non-Hawaiian Pacific Islanders
residing in the United States have had to
overcome cultural and socioeconomic bar-
riers that cause acculturative stress and loss
of ethnic identity. For Native Hawaiians,
similar to other indigenous peoples, coloni-
alism (e.g., loss of the ‘aina or land, over-
throw of the monarchy by the United
States), ‘‘foreign’’ diseases, and a dramatic
shift to more individualistic values have
had a devastating inter-generational effect
on the family structure, health, and well-
being of Native Hawaiians (Blaisdell, 1993).
Indeed, investigations into the higher youth
suicide rates among aboriginals in Canada
TABLE 4. Continued
Grade 9 (%) Grade 10 (%) Grade 11 (%) Grade 12 (%)
Black 2.4 2.9 2.5 2.4
Hispanic 3.2 3.3 2.8 1.8
Multiracial (Hispanic) 3.1 3.3 3.5 3.0
Multiracial (Non-Hispanic) 3.8 4.7 4.2 3.7
Pacific Islander 2.8 10.2 5.3 9.2
White 2.6 2.0 1.6 1.0
S. S. Wong et al.
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and indigenous Polynesians in New
Zealand suggest risk factors including his-
torical oppression, and disruptions to a
developing sense of personal and cultural
persistence (Beautrais & Ferusson, 2006;
Chandler, Lalonde, Sokol et al., 2003;
Kirmayer, Brass, & Tait, 2000).
Native Hawaiians have the shortest
life expectancy in their own homeland as
compared to the other major ethnic groups
in Hawaii (Park, Braun, Horiuchi et al.,
2009). Moreover, there is a disproportio-
nately high prevalence of psychiatric symp-
toms and disorders among Native
Hawaiian youth, and risk factors for suicide
may be a manifestation of this psychologi-
cal distress (Andrade, Hishinuma, McDer-
mott et al. 2006; Conwell, Duberstein, &
Cox, 1996). Notably, a series of psychologi-
cal autopsies of Pacific Islander and Hawai-
ian youth who committed suicide found
that the act of suicide was often preceded
by emotions described as depression, with
the act itself having connotations of an
appeal to older family members (Else,
Andrade, & Nahulu, 2007).
A different set of reasons may underlie
the risk factors for suicide among multira-
cial adolescents, as suggested by the
decrease in suicide attempts with grade
level, a trend that contrasts the increase
seen among Pacific Islanders. The most
common explanation for the high preva-
lence of health-risk behaviors among multi-
racial adolescents is their struggle with
positive identity formation, an important
developmental factor for reducing risk
and enhancing resiliency (Lalonde, 2006).
The most common subcategories within
the multiracial population are White and
Black, White and Asian, White and Ameri-
can Indian, and White, and ‘‘some other
race’’—a box checked mainly by
Hispanics (United States Census Bureau,
2001). Because of their multiple heritages,
multiracial youths may face greater dif-
ficulty forming a positive ethnic identity,
due to feelings of ambivalence and=or
divided loyalties between two or more sets
of cultural values. Indeed, a recurring theme
in interviews with multiracial adolescents
was a sense of inauthenticity and shame
with regard to identity (Bowles, 1993). This
lack of positive identity formation may
lead to social isolation and low self-esteem
(Gibbs, 1987; Root, 1992). In addition,
peer acceptance may be a salient stressor
for multiracial youths due to their poten-
tially ambiguous racial status and the
absence of a natural peer group (Root,
1992). The need to be accepted has been
theorized to cause increased engagement
of high-risk behaviors in this population
(Gibbs, 1987). Finally, family dynamics
may play a role, with one study finding that
multiracial boys are less communicative
and emotionally close with their fathers
(Radina & Cooney, 2000).
A few limitations should be noted
given the nature of the YRBS as self-
reported secondary survey data. First, we
were not able to control for socioeconomic
status, and thus unable to investigate
whether these ethnic disparities were due
to socioeconomic stressors or other psy-
chosocial influences. Second, the YRBS
data set does not include corroborating
objective data to supplement the self-report
data. However, given the underestimation
of internalizing disorders by parents and
teachers, self-report data are important
in determining difficulties being experi-
enced by adolescents. Third, although the
present study examined cross-sectional pre-
valences across time, the data were not
linked per youth, thus precluding risk fac-
tor analyses involving longitudinal growth
modeling and group trajectories. Fourth,
the YRBS is administered only in schools,
and therefore, may not capture data from
youth who are absent, suspended or
dropped out from school—an adolescent
subgroup at higher risk for suicide (Gould,
Fisher, Parides et al., 1996). Thus, the
prevalence of risk factors of suicide
reported in the present study are likely to
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170 VOLUME 16 NUMBER 2 2012
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be under-estimates of the population rates.
And fifth, the YRBS fails to disaggregate
within each of the Asian, Pacific Islander,
and multiracial populations. Studies of
Asian subgroups have already demon-
strated that ethnic subgroups within these
categorical umbrellas may show diverging
trends of youth risk behavior prevalence
(Choi, 2008; Mayeda, Hishinuma, Nishi-
mura et al., 2006). Our findings also show
that within the multiracial population,
those identifying as part-Hispanic reported
a lower prevalence of suicide ideation and
planning compared to their non-Hispanic
multiracial peers. Additional studies should
be conducted to better understand suicide
across ethnic subgroups.
Despite these limitations, given our
findings of significant ethnic disparities in
youth risk factors for suicide, further
research should focus on identifying alter-
able risk and protective factors that that
may be unique to certain populations. Of
particular importance in the context of eth-
nicity, cultural identification, and adjustment
is to assess and intervene from a
strengths-based, positive youth develop-
ment approach whereby constructs such as
resilience play a more prominent role
(Werner & Smith, 2001). Furthermore,
research is also needed on the intersection
between culture and methodology, such as
socio-cultural influences that may discour-
age self-disclosure and contribute to ethnic
disparities in risk factors for suicide. Further
knowledge of the determinants of youth sui-
cide will greatly enhance the development of
culturally responsive prevention interven-
tions and policies to eliminate youth suicide
and ethnic disparities in mental health.
AUTHOR NOTE
Shane Shucheng Wong, Department of
Psychiatry and Behavioral Sciences, Division
of Child and Adolescent Psychiatry, School
of Medicine, Stanford University, Stanford,
California; Asian=Pacific Islander Youth
Violence Prevention Center (APIYVPC),
Department of Psychiatry, University of
Hawaii at Ma
¯noa, Honolulu, Hawaii, USA.
Jeanelle J. Sugimoto-Matsuda, Janice Y.
Chang, and Earl S. Hishinuma, Asian=
Pacific Islander Youth Violence Prevention
Center (APIYVPC), Department of Psy-
chiatry, University of Hawaii at Ma
¯noa,
Honolulu, Hawaii, USA.
This manuscript was supported by
the Centers for Disease Control and
Prevention (CDC; R49=CCR918619-05;
Cooperative Agreement #1 U49=
CE000749-01), University of Hawaii at
Ma
¯noa, Department of Psychiatry, and
the Stanford University Medical Scholars
Program (Mr. Wong).
The contents of this article are solely
the responsibility of the authors and do
not necessarily represent the official views
of the funding agencies. The authors would
also like to express their appreciation to the
researchers and administrators of the
Asian=Pacific Islander Youth Violence
Prevention Center (APIYVPC) and
Department of Psychiatry, University of
Hawaii at Ma
¯noa.
Correspondence concerning this article
should be addressed to Shane Shucheng
Wong, Department of Psychiatry and
Behavioral Sciences, Division of Child &
Adolescent Psychiatry, Stanford University
School of Medicine, 401 Quarry Road,
Stanford, CA 94305. E-mail: wongss@-
stanford.edu
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