Exam stress linked to teen suicide

"First detailed study into 130 [teen] suicide cases in England finds range of common anxieties," The Guardian reports, citing factors including exam stress, bullying and bereavement.

The study into teenage suicide also found there was a history of self-harming in half of suicide cases in young people.

Researchers identified multiple factors that might have contributed to the deaths.

These include having experienced bereavement, relationship problems or breakdown; having long-term physical health problems, including asthma and acne, family problems, self-harm, bullying, and alcohol or drug use.

It's unclear if any single factor was a cause of death. It could be possible that in many cases multiple risk factors triggered suicidal thinking and behaviour.

However, we cannot be sure that these factors contributed to the deaths of the children and young people involved in all cases. This is partly because they are very common.

For example, the study showed that 27% of those who died had experienced exam stress or other academic pressures, but we don't know what proportion of under-20s in the general population also experience exam stress.

One striking fact is that in 54% of cases there was a previous history of self-harm. And one in four had talked about suicide in the week before they died.

It's important to get help quickly if you are thinking about self-harming and suicide, or think a friend or relative may be affected by similar thinking and behaviour. Seek advice from your GP. 

Where did the story come from?

The study was carried out by researchers from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, based at the University of Manchester, and was funded by the Healthcare Quality Improvement Partnership. 

It was published in the peer-reviewed journal The Lancet Psychiatry on an open-access basis, so it's free to read online.

Coverage in the UK media was widespread. Different organisations chose to highlight different factors from the report, perhaps reflecting their own interests.

For example, The Sun reported that, "The Internet played a role in a quarter of recent teen suicides in England", while the Daily Mail stated that, "Drugs linked to one in three teen suicides". The Times, The Guardian and The Daily Telegraph highlighted exam stress.

Not all news stories were clear that these factors cannot be seen as direct causes of suicide.

For example, most teenagers have exam stress and develop acne, and many dabble in drugs and alcohol. But, thankfully, most teenagers don't kill themselves.

The Guardian did the best job of explaining the study findings and putting them in context. 

What kind of research was this?

This was a consecutive case series where researchers tried to collect relevant documents and information about every death by suicide in a person under 20 that occurred in a 16-month period.

They wanted to see how many deaths had been preceded by one of a number of recognised "antecedents", or factors linked to suicide, and whether the child or young person had been in touch with health or social care services or the criminal justice system.

Case studies can help to identify factors associated with an outcome, but they cannot tell us whether those factors actually contribute to it.

In this case, they can tell us how many people had records of specific factors in their history, but not whether those factors contributed to their death.

What did the research involve?

The researchers contacted coroners' offices in England, as well as other bodies that may investigate child deaths, to ask to be notified of any deaths by suicide or possible suicide that happened between January 1 2014 and April 30 2015.

They checked the reports for factors previously identified as being linked to suicide and calculated how many deaths were linked to each factor.

The researchers had information from the Office for National Statistics that 145 children or young people died by suicide or possible suicide during the study period.

However, the coroners did not provide copies of the inquest recording or documents in all cases, so these could not be included in the study.

Other information sources included reports from Local Child Safeguarding Children Boards, NHS Trusts, the Prison and Probation Ombudsman, and the Independent Police Complaints Commission.

The researchers collected data about a number of pre-set factors linked to suicide in general, or in young people in particular.

They presented their figures as proportions, and looked for differences between male and female children and young people, and under and over-18s.

What were the basic results?

Of the 130 people who died by suicide or possible suicide in the study period, 70% were male.

Deaths were more common among over-18s than younger people (79 deaths in people aged 18 or 19, and 66 in people younger than 18). Most (57%) had some contact with health, social care or justice agencies.

The researchers identified many different factors that have been linked to suicide. These are some of the more commonly reported factors:

• recent relationship problems or relationship break-up (58% total)
• expressing suicidal ideas (57%)
• previous self-harm (54%)
• any diagnosis of mental illness (39%)
• physical health condition (36%)
• bereavement (28%)
• academic pressures (27%)
• excessive alcohol use (26%)
• illegal drug use (29%)
• bullying (22%)

We do not know if these factors caused people to take their own lives or contributed to their decision to do so.

However, they may help families, schools and doctors to be alert to children or young people who are struggling with life, especially if several of these factors are involved.

How did the researchers interpret the results?

The researchers say they found "a complex pattern of stresses and adverse events" before the suicides took place.

Of the factors that affect young people specifically, they singled out academic pressures, which they said were often unrecognised at the time, and bullying, which was more often face to face rather than online.

They also point to "suicide-related internet use", by which they mean searching online for suicide methods or posting suicidal thoughts online, in 25% of people.

Regarding the perhaps surprising finding that physical health conditions were common, they say that acne and asthma, which were most commonly reported, could both lead to social isolation or withdrawing from social activities.

They point out that, "Many of these factors are common in young people in general and on their own cannot be used to predict suicide risk."

They suggest some "long-term" stresses, such as child abuse, substance misuse or mental illness in the family, could be worsened by later experiences such as bereavement or bullying, before a "final straw" pressure such as exam stress or a relationship break-up finally leads to suicide.

They go on to say that this pattern "could offer opportunities to intervene" if society as a whole has a better understanding of the pressures that can lead to a young person taking his or her life.

Conclusion

Any death in a child or teenager is devastating for friends and family, but suicide is perhaps especially hard to bear. Thankfully, it is uncommon – young people are less likely to take their lives than older people.

There are about 4.4 deaths for every 100,000 people among 15 to 19-year-olds, compared with 15.1 for every 100,000 people aged 40 to 44.

However, because young people are also less likely to die of other causes, suicide among young people is a leading cause of death in this age group. Better understanding of the stresses that can lead to suicide are crucial for helping avert these deaths.

It is striking that more than half of young people in this study had previously harmed themselves or expressed suicidal ideas. This suggests that many troubled youngsters are showing signs that suicide is a possible risk before their deaths.

There are some drawbacks with this study, which are acknowledged by the researchers. The sources for the information – for most cases, coroner inquests – are not designed to be used for research. Inquests don't look systematically at all the possible factors that might contribute to a death.

People giving evidence may be looking for a reason for the death, so may mention factors such as academic pressure, which were not necessarily a contributing cause. Other factors, such as sexual abuse, may be kept secret and not come to light.

Because this is a case series study, we don't know how common any of these factors are in a comparable group of young people who did not take their own lives. This means we can't say that these factors are more common among young people who die by suicide.

For example, most young people experience relationship problems or break-ups in their teenage years. For the vast majority, this does not lead to suicide.

Although the newspapers focus on particular factors, such as exam stress or internet use, any one of an array of factors can contribute to someone feeling unable to cope with life.

The key message is that everyone needs to be alert for children and young people who are under pressure, especially if they have self-harmed or talked about suicide.

Read more advice about spotting possible warning signs of suicidal thinking and behaviour.

You can contact Samaritans in the UK online or by phoning 116 123.